COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD '■■ . i' .•,',•.-..- . '..•.','»;i:<;at;J^'*ft.-!>nl.;>. tlP"^ V^ i^ p ^ TH£ • V^ HEALTH SCIENCES LIBRARY PRACTICAL TREATISE DISEASES OF THE UTEEUS OVARIES AND FALLOPIAN TUBES Digitized by the Internet Archive in 20.10 with funding from Open Knowledge Commons http://www.archive.org/details/practicaltreatisOOcour PRACTICAL TREATISE DISEASES OF THE UTERUS OVARIES AND FALLOPIAN TUBES A. COUETY PROFESSOR OF CLINICAL SURGERY, MONTPELLIER TRANSLATED FROM THE THIRD EDITION BY HIS PUPIL AGNES M'LAEEN, M.D., M.K.Q. O.P.I. WITH PREFACE BY J. MATTHEWS DUNCAN, M.D., LL.D., F.R.S.E. OBSTETRIC PHYSICIAN TO ST BARTHOLOMEW'S HOSPITAL LONDON J. & A. CHURCHILL NEW BURLINGTON STREET 1882 " La prkcision du diagnostic et l'oppoetunite du teaitement sont les seulfe gabants de succes dans la pratique." PEEFACE In recent times gynsecology has been developed in a very remarkable manner; and while there can be no doubt that, on the whole, the luxuriant growth is healthy and beneficent, it is also certain that much of it, both in theory and in practice, is rank and doomed to destruction, or at least oblivion. Too little of the spirit and method of science has as yet permeated gynsecology, and in this respect its state may be contrasted vtdth that of the nearly allied department of obstetrics. This modern development of gynsecology began in France in the earlier years of this century, and a kind of medical enthusiasm soon appeared, which gradually grew and overspread Great Britain, Germany, and America. It would be hard now to say where the still growing enthusiasm is most prevalent. It has extended over the whole world, and several unassailable statistical statements have been made (Dr James E. Chadwick), which render it probable that nowhere does gynsecology thrive so vigorously as in the United States of America. New hospitals, books, journals, societies, practitioners, specially de- voted to it, are now to be found in all parts of the globe in greater or less number, and can be counted and valued ; and those of the great French nation hold a distinguished place. Among books devoted to diseases of women none has been, or is, more important than that of Professor Courty, of Montpellier. It is the carefully elaborated and repeatedly revised work of a man at once imbued with the science and immersed in the practice of gynsecology, of one who has long Hved in a centre of general science and learning, amidst an abounding population, and who enjoys the great advantage of combining in his sphere of practical activity both hospital and private patients — two classes which differ in their circumstances and in their aspects for observation, favorable and unfavorable to the student. It is certainly a boon to the English -speaking peoples to have Courty's work translated ; for the great mass of medical men are, un- VI PREFACE fortunately, ignorant of French, or not familiar enough with that language to enable them to use the book in its original form. This translation of a work on women has been, with striking appro- priateness, executed by a woman doctor. I have had the privilege of her friendship since her childhood, and know her excellent qualities. She has already, by original work, shown her competence in an im- portant respect for this now completed task of translation. But she is, in addition, specially qualified, having studied in the University of Montpellier, under Dr Courty among others, and having, subsequently to her graduation, been for a considerable time his assistant in practice. Moreover, since she settled in Edinburgh, Dr M'Laren has, in her own practice, maintained her familiarity with the diseases treated of in this book. Courty^s work has, since its first publication, been recognised everywhere as an exponent of French doctrine. In France its position is attested by the sale of two editions, numbering, I am told, 10,000 copies, and by the appearance of another, the third edition. It is from this third edition that this translation has been made. The translation is not a simple reproduction in English of the chapters of the third French edition, for it has been abridged by omissions planned by the author himself. As it now appears it is a treatise on the dis- eases of the uterus. Fallopian tubes, and ovaries, with an introductory chapter on the anatomy, physiology, and teratology of the organs of generation. I recommend to the careful study of my professional brethren a book which has already been crowned by the institute of France. J. MATTHEWS DUNCAN. CONTENTS INTRODUCTION ON THE ANATOMY, PHYSIOLOGY, AND TERATOLOGY OP THE ORGANS OP GENERATION PAGE The Ovaries and Pallopian Tubes — tlie Uterus — Ligaments and Append- ages of the Uterus — Changes in the Uterus at Diiferent Stages — Structure of the Uterus — the Vagina and Vulva — Development : Comparison of the Genital Economy in the Two Sexes — Anomalies . 3 PART I GENERAL SURVEY OP UTERINE DISEASES CHAPTER I Diagnosis of Uterine Diseases in General — Presumptive Signs furnished by the Symptomatology of Uterine Diseases — Certain Signs furnished by Direct Exploration . . . . .95 CHAPTER n Treatment of Uterine Diseases in General — Indications to be Pulfilled in the Treatment of Uterine Diseases — Methods of Treatment and Various Medications — Means of PulfiUing Indications in the Treat- ment of Uterine Diseases ...... 151 CHAPTER III General Characteristics of Uterine Diseases — Their Frequency — Predis- posing Causes — General and Local Symptoms — ^Complications — Prognosis — Classification ...... 233 Vlll CONTENT.? PART II UTERINE DISEASES IN DETAIL CHAPTER I PAGE Functional Disorders. — Menstruation — Amenorrhcea — Retention of the Menses — Deviation of the Menses and Supplementary Menstruation — Dysmenorrhcea — Uterine Neuralgia — Uterine Hseraorrhage . 257 CHAPTER II Changes of Position — Displacements — Deviations — Flexions^Inversion . 343 CHAPTER III Morbid States without Neoplasm — Fluxion — Congestion — Engorgement — Metritis — Ovaritis and Salpingitis — Peri-uterine Inflammation — of Leucorrhcea in General and Uterine Catarrh in Particular — Hyper- trophy and Atrophy — Granulations and Fungosities^Ulceration and Ulcers of the Uterine Cervix ..... 460 CHAPTER IV Organic Alterations — Fibrous Tumours — Polypi and Moles — Tubercle — Cancer ......... 648 CHAPTER V Diseases of the Uterine Appendages — Pelvic Hamorrhages and Peri- uterine Hematocele — Cyst of the Ovary and Genito-pelvic Tumour — Sterility ........ 714 Index ......... 803 :2 a. be o I g .-§ 5 r§ ^ § ® C3 m ;^ s^i 1"% 'u 5^ ^/T o-S a> ^'i -1^ -(-> -e^^'S (D ^ S3 P CO (D rQ c3 ■^ ^ O =+-1 r-i ■*^5^ a -(J view of llopian s with t c 1§ a ■| a> CS Tj CO Qi £ +3 00 T « 1 - S to , 13 c ON THE DISEASES OF THE UTERUS, OVAEIES AND FALLOPIAN TUBES INTRODUCTION ON THE ANATOMY, PHYSIOLOGY, AND TERATOLOGY OF THE ORGANS OF GENERATION THE OVAEIES AND FALLOPIAN TTJBES — THE UTEEUS — LIGAMENTS AND AP- PENDAGES OF THE UTEETJS — CHANGES IN THE UTEEUS AT DIFFEEENT STAGES — STEUCTUEE OF THE UTEEUS — THE VAGINA AND VULVA — DE- VELOPMENT : COMPAEISON OF THE GENITAL ECONOMY IN THE TWO SEXES — ANOMALIES. Before entering on the pathology of the uterus and ovaries, it is indispensable to know their anatomy and physiology thoroughly. This preliminary study is more necessary with regard to these organs than any others, because till within the last few years it has been very superficial. I do not refer merely to the organic structure of the uterus and its mucous membrane, to the histology of the ovaries, their func- tions, and all the points of anatomy and physiology relative to irritation, menstruation, conception, pregnancy, &c., on which light has only been thrown by modern investigations ; but even the position, direction, volume, and mutual relationship of these organs, with the modifications which they undergo according to age and various circumstances, have been described in a most imperfect manner till quite recently. This is due to the fact that there are no other organs whose position, form, size and structure are so variable. Age, exercise or rest, menstrua- tion or pregnancy, not to speak of various morbid conditions, modify the anatomical characters so much, that differences between writers are easily accounted for. INTRODUCTION The Ovaries and Fallopian Tubes The ovai-ies and Fallopian tubes constitute the internal genital economy. Ovaries} — The ovaries (ovaria) are the organs in which the ova, i.e. the female germs, are formed. The ovum is not complete till fecundation has taken place, i.e. the union of the female with the male germs produced by the testicles. Hence the name testes tmiliehres given to the ovaries, to recal the analogy existing between organs whose products have an analogous destination. The ovaries lie in the cavity of the pelvis, on each side of the uterus, in the posterior fold {meso- varinm) of the broad ligament (Fig. 1) ; but this position is variable : at birth they are on a level with the iliac fossa, and only descend into the pelvis at the tenth year. These organs are very mobile, their position not being, so to speak, fixed. Certainly they are enclosed in the posterior fold of the broad ligament, behind the Fallopian tubes and in front of the rectum, from which they are usually separated by the inferior circumvolutions of the ileum ; their superior surface corre- sponds with the central fold and with the intestinal circumvolutions ; their inferior surface with the posterior surface of the broad ligaments and with the utero-sacral ligaments ; their superior and posterior border is convex and free, and is in relationship with the small intestines. They are, however, at the same time so mobile that they may undergo all the displacements to which they are liable from the neighbouring organs, and which may be divided into four classes — 1. Displacements owing to the laxity of the posterior fold, very limited, generally momentary ; transverse and vertical. 2. Displacements due to the laxity of the broad ligaments, usually momentary, produced by fulness of the bladder, on which the ovaries rest, and which pushes them back above the utero-sacral ligaments. 3. Displacements caused by enlargement of the uterus, which drags the ovary successively from the pelvis into the hypogastric, the umbilical, the lumbar and, after delivery, into the iliac regions. 4. Lastly, accidental or morbid displacements, such as hernise, which take place through the natural orifices or through lacerations. The form of the ovary is that of an ovoid slightly flattened, pre- senting two surfaces (an antero-superior and a postero-inferior), two borders (the superior free, the inferior adherent), two extremities (one * See Klcbs, Die Eierstoclcseier der Wirhelthiere, in Virchoio^s ArcMv, 18G1, Bd. XX i, p. 3()2, and 13d. xxviii, p. 301. Schron, Beitrage zur Kenntniss zur Anatom. u. Physiol, der Eierstoclces der Sailgethiere (Zeitschr. von Siebold u. Kolliker, Bd. xii, 18()3, pp. 409 and 420). Grohe, Uebcr den Bau u. das Wachdhum des mensclilichen Eierstoclces u. ueher einige hranhJiafte Storungen derselben, in VircJiow''s Archiv, 1863, Bd. xxvi, p. 271, and Bd. xxviii, p. 570. Pfliiom this we may judge of the facility with which multi- locular cysts are developed and of the early age at which they may be observed. It is only in proportion as they are developed that the ovarian vesicles project beyond the cortical substance of the ovary, forming on one side a projection on its free surface, and on the other penetrating more and more deeply into the bulbous portion, where they were erroneously supposed to take their origin. The ovisac is spherical, attaining a size of 15 millimetres or more in diameter; it hollows out for itself a cavity in the ovary, the wall of which has been mistaken for its supposed external membrane. Its proper envelope, semi-trans- parent, grey or reddish, resistant and capable of being enucleated from the ovary to which it is only attached by fibrous tissue and small vessels, is composed of laminar fibres or fibrous tissue, of fusiform bodies, of embryo-plastic nuclei, of amorphous granular matter, of cells pecuHar ' Sappcy, Anat. Dcscrij^livc, p. 031. Paris, 1804.. Kolliker has counted more than GOOO on each ovary {Mih-oscop. Anat. Leipzig, 1852). ANATOMY, PHYSIOLOGY AND TERATOLOGY 7 to the ovisac, and of abundant capillaries.^ The ovisac is supplied with blood by two or four arterioles, which spread over its surface in a delicate network. The memhr ana granulosa or epithelium of the ovi- sac, formed of one or more layers of hemispherical cells, has a thickness of from 1 to 2 hundredths of a millimetre, except at one point where there is a thickness of 60 hundredths of a millimetre and which has received the name of cumulus or discus proligerus, because it bears the germ. The ovum^ lies in the centre of the cumulus and accordina; to the f J^ s <^ ^ \ ^' '^'^-Vjii'rMsrVfte 'isT-, ''Ttef; '^-m-w.'^ :^\ i3 r-// Fig. 3. — Vertical section of the ovary of the cat during gestation. Injected. Magnified 60 diameters. 1, cells of the non-vascular cortical layer ; 2, cortical cells presenting the first rudiment of the memhr ana gerviina- tiva, and the first trace of a vascular circle ; 3, commencing enlargement of follicle, separation of the memhrana germinativa of the ovum, and continuation of this membrane into the adjoining portion of the follicle ; 4, formation of proligerous disc. Vascular network of follicle ; 5 to 8, follicles at various periods of development ; 9, small follicle from which the section has only removed a disc from the zona pellucida of the ovum ; 10, half-opened follicle, the ovum of which has escaped by the section ; 11, intact portion of the follicular wall, through which the zona pellucida is seen ; 12, central vein of corpus luteum ; 13, peripheric artery of corpus luteum : the branches of this artery surround the polygonal cells of the corpus luteum; 14, large vessels of ovarian stroma (after Schroen). ^ Courty, De Vcsxif et de son developpeinent, p. 55. Montpellier, 1845. Eobin, Memoire sur les modifications de la viuqueuse uterine, p. 160. ^ I prefer this name to that of ovule for designating the female germ ; the latter gives a false idea, since Baer, who invented it, meant it to convey a distinction as incorrect as subtle between the ovum of birds and that of the mammalia : the latter having, according to him, an ovum in an ovum, or an ovum raised to the second power. In both cases there is an ovum in question, which 8 INTKODUCTION observations of Schrcen, Robin, &c., at the nearest point to the arterioles which ramify in the Graafian vesicle.^ The ovum is a spherical vesicle of from one to two tenths of a milli- metre, with a very fragile envelope (zona pellucida of Baer or vitelline membrane of Coste) and granular contents {germ or cicatricula in birds), alone or surrounded by a more or less considerable quantity of vitellus, presenting in its centre the nucleus of tlie cell (germinal vesicle of Purkinje) and its nucleolus (germinal spot of Wagner), discovered by Coste in the germinal vesicle of the human ovum. Two ova may be found exceptionally in one ovisac (Baer, Bischoff, Bidder), and certain anomalies have been observed by Davaine ^ in birds. Under the influence of the ovarian congestion produced by the natural matu- FiG. 4 Fig. 5. Fio 4. — Formation of corpus luteum of the ovary (natural size). A, section of tlic ovary : a, recently emptied follicle filled with blood (thrombus of extravasation), surrounded by a thin yellow layer ; 6, empty follicle, puckered in front, with a smaller thrombus and a thicker wall ; c, retro- gressive metamorphosis in more advanced stage. B, exterior surface of the ovary and point where the recent rupture of the follicle has taken place ; the thrombus projects outside. Fig. 5. — Section of two corpora lutea of natural size. 1, in fresh condition, eight days after conception ; 2, in the fifth month of pregnancy, a, tunica alhuginea ; b, stroma of ovary ; c, fibrous membrane of follicle, thickened and puckered (internal Inyer) ; d, sanguineous clot within this membrane ; e, discoloured clot ; /, fibrous membrane, forming the boundaiy of the corpus luteum. does not differ from the other as to the germ, and which is only distinguished by the quantity of nutritive matter added and by the shell which protects it. ' The ovum has often seemed to me to be placed in the superficial and prominent point of the vesicle, opposite tlie little vascular trunks which spread by iiTadiation over tlie ovisac. This is shown very clearly in the beautiful woodcuts which Gerbe lias drawn so conscientiously for Coste's great work ; I liave not, liowcvor, prosecuted my researches on this point so far as to be able to affirm that it is always so. " Cornptes rendus de la Socicte de biologic. Paris, 18(50. ANATOMY, PHYSIOLOGY AND TERATOLOGY 9 ration of the vesicle and by the accompanying erectile phenomena manifested externally by menstruation, or under the influence of the congestion produced by sexual excitement, the quantity of fluid in the ovisac increases rapidly, stretches the walls, renders them thin, and gradually suspends the circulation in the part which is most superficial and least resistant. A kind of linear ulceration with rupture of the ovisac follows at this point : the ovum is expelled in the middle of the cumulus proligerus, and received by the fimbriated extremity of the Fallopian tube. A work of reparation then commences in the tissue of the ovisac, passing through remarkable phases, and characterised by the persistence, during a longer or shorter period, of an organic production which gradually diminishes in volume, and which, on account of its colour, has received the name of yellow body, corpus htteum (Malpighi ^), or, as signifying more exactly the cicatricial act of which it is the indica- tion, the more correct name of ovariule (Robin) . This organic product is a hypertrophic thickening of the membrane of the ovisac, the cells of which multiply and increase in such enormous proportions as to cause a puckering of the membrane, and a considerable projection towards the surface of the ovary. These cells are simultaneously invaded by a granular product, of fatty nature and yellow colour, at least in woman, which is the real cause of the colour of the ovariule in the human species. In cystosarcomata of the ovary I have seen this product invade the membrane of several vesicular cysts, and give rise to considerable masses of yellow matter. Then comes the period of reabsorption ; the yellow body atrophies and shrivels up so much that in its place there remains only a depressed cicatrix with the trace of the rupture of the ovisac and a grey or slaty coloration. The development of the Graafian follicles and of the ova takes place in the ovary not only after puberty and during sexual activity but even before this period and during fcetal life. In 1836 Carus an- nounced that ova were to be found in the ovaries of the foetus. But the Graafian vesicles were considered to be independent of each other, and the ovary in consequence diff'erent from other glands. The recent researches of His and Pfliiger prove that probably it is not so, and that the ovary resembles the testicle and other secreting organs. In 1838 Valentin 2 announced that the ovary in embryos is cana- liculated. In 1863 Pfliiger demonstrated this tubular structure. KoUiker^ confirmed the fact by his researches on the embryos of cats, cows and women. In the ovaries of young embryos cordlike glandular filaments are certainly seen, sometimes in the form of a club with a blind end. They are composed of a superficial layer of little cells analogous to epithelium cells, precursors of the granular membrane of the Graafian follicle, and of a thick mass of larger cells which will become ova. The development also takes place from the superficial part of this ' Mefovarium, after the ovum (Raclborski). 2 Mailer's Archiv, 1838, p. 531. ^ Handhuch Gewebelehre,-5ie Anfl, 1867. Leipzig. 10 INTRODUCTION gland, where it is least considerable, to the deep part, where it is most so. The transition of the glandular filaments containing ova into Graafian follicles or sacs takes place even in the embryo; it com- mences in the interior, and advances slowly to the surface, so that Fig. 6. — Transverse section of the ovary of a liuman embryo at six months, magnified six diameters, a, external layer of glandular substance, with glandular filaments cleaned by means of a brush ; 6, internal layer of the same substance, with ovisacs separated or in course of isolation ; c, stroma of the hilus (medullaiy substance) ; d, mesovarium, divided near the broad ligament (after His). whilst the medullary portion increases, the tolerably thick glandular or cortical portion presents an inferior zone of follicles, separated or in process of separation. The separation of follicles is effected by the production of fibrous tissue forming partitions, and by that of new cells of epithelium lining them. The multiplication of these partitions divides the entire tube into isolated sections, each smaller than the preceding, and each containing only one ovum enveloped in a layer of epithelium. In proportion as the follicle increases in size it becomes filled with fluid, and the granular membrane, with its proligerous disc containing the ovum, remains against the wall. The vascular wealth of the ovary in the foetus is remarkable, and is proportioned to the importance of the formation of this multitude of ovigenic or proli- gerous cells. In after life there are probably periods when physiolo- gical impulses of normal fluxionary movements singularly accelerate the evolution of ova. Thus at birth it is probable, as llouget has affirmed and as the secretion of milk which occurs so frequently at that time would seem to indicate, that a hypertrophic ovarian con- gestion takes place, as if there were a general impulse towards the development of the whole being. A similar impulse, the most remark- able of all, occurs at puberty. Movements of less importance take place at each monthly period. They cease entirely after the meno- pause when the organ atrophies. This retrogressive atrophy makes ANATOMY, PHYSIOLOGY AND TERATOLOGY 11 great progress in old age. Measurements of the ovary, taken by Puecli at different ages, confirm the variations in the size of this organ in these various circumstances. Fig. 7. — Elementaiy structure of the ovary in the human embiyo. — A, in the embryo of six months, magnified 400 diameters. 1, two ova surrounded by an epithelial layer, one of them presents a prolongation by which it was probably united to another ovum as in Fig. 2, which represents two ova united by a cord of protoplasm (primitive ova) with their epithelium ; 3, primitive ovum with two nuclei (germinal vesicles). B, in an embryo of seven months, magnified 400 diameters. 1, superficial layers of the ovary with voluminous glandular tubes, composed each of an epithelial layer and of a mass of ova, those nearest the surface being smaller than those deeply situated in the glandular substance of the organ ; 2, ovigenic sacs of the deep layer of the glandular substance at the time of separation, two little sacs are represented completely isolated, and two others (glandular tubes) each containing two ova (after Kolliker). The diflFerences in the aspect of the ovary at various epochs of life are due to the different phenomena which characterise the normal evo- lution of the Graafian vesicles. The imperfection of this evolution before puberty, the frequency of this development and the almost periodical ruptures during the age of sexual activity, the atrophy and disappearance after the menopause, give to the surface of the ovary, during the successive ages of embryo life, childhood, youth, maturity, and old age, various aspects ; at first it is elongated, then ovoid, smooth, or indented, with mingled projections and cicatrices, dotted with circumscribed spots of various colours — white, blue, or yellow — till finally it has the appearance of a wrinkled, shrunken, shrivelled membrane. 12 INTRODUCTION It will readily be perceived, by the size, length, and tongue-like shape of the ovaries in the embryo (Eig. 8), by their dimiuu- FiG. 8. — The uterus and its appendages, and tlieir relations with the neigh- bouring organs, at the end of the fifth month or beginning of the sixth, natural size. External view : 1, bladder, urachus, and umbilical arteries ; 2, uterus ; 3, rectum ; 4, ovaiy, relatively very large, almost as long as the Fallopian tube ; 5, Fallopian tube, the broad portion of which is prominent from early life ; 6, round ligament. Owing to the defective development of the pelvis at this age these organs are situated above the brim in place of being contained in the pelvic cavity. Cavities : 1, bladder ; 2, uterus, on the anterior surface of which the trunk of the arhor vitce is seen extending to the fundus ; the isthmus, which ought to separate the cavity of the body from that of the cervix, cannot be distinguished ; 3, vaginal orifice of the uterus ; 4, vagina, the folds of which are well marked ; 5, posterior surface of the uterus ; 6, rectum ; 7, ovary ; 8, Fallopian tube ; 9, pubic symphysis ; 10, labia minora and majora ; 11, vaginal orifice ; 12, anus. Fig 9. — Ovary and fimbriated extremity of Fallopian tube in a woman wlio died diiring menstruation (after Farre ad nat.) I, broad ligament ; o, ovary; r, r, old yellow bodies, remains of (Jraafian follicles ruptured and cicatrised ; /, l)road portion of the Fallopian tube ; i, limbriated ex- tremity applied to tlic ovary. ANATOMY, PHYSIOLOGY AND TERATOLOGY 13 tive size and their slightly flattened form in the child, by their in- creased size, ovoid appearance, and the formation of globular projec- tions on their surface at puberty (Figs. 1, 13, 14), in the adult during menstruation (Fig. 9) and in the pregnant woman (Fig. 10), by the return to smaller dimensions at the period of the menopause (Fig. 11), and, lastly, by their complete atrophy in old age (Fig. 12), that these organs, originating in little bands along the inner borders of Tig. 10. — Ovary during pregnancy, and external view of yellow body (corpus luteum) (after Coste). the Wolffian bodies, hollowed out after the manner of blind tubes like the testicles, becoming later on vesicular by the occlusion and the Fig. 11. — Ovary at the menopause. Fig. 12. — Ovary in old age. partitioning of these tubes, are congested and hypertrophied during the whole period of maturation of the ova and of sexual activity, to be reduced to a kind of shell or shrivelled, shrunken web after the extinction of the reproductive faculty. Fallopia?i ttibes. — Contained in the central fold, the tubes may undergo displacements analogous to those of the ovaries. Passing off from the uterus in a transverse direction, each tube describes in its external half a curve, the concavity of which looks backwards, inwards, and downwards, and by its terminal swelling it turns towards the ovary. Its axis, though straight near the uterus, before long presents flexuosities recalling those of the vas deferens at its origin. Its medium length is 12 centimetres. Its diameter increases with its distance from the uterus : it is hardly more than 15- tenths of a milli- metre at the opening and in the thickness of the uterine walls, whilst it is 4 millimetres near the uterus, from 5 to 6 at the central part, from 14 INTRODUCTION 7 to 8 at its external extremity, and from 18 to 20 at the circumference of the terminal infundibulum. Therefore, even supposing the diameter of the uterine orifice to be enlarged, it is not the less impossible to catheterise the Fallopian tube. There is not, however, the same diffi- culty about the penetration of liquids that there is about solids, there- fore an injection may penetrate from the uterine cavity into the Fallopian tube. The external orifice, ostium ahdominale, opens in the Fig. 13. — Fallopian tube and ovary. O, ovary turned downwards and back- wards ; Od, istbmus of the tube ; Od', broadest part of this canal ; J, fimbriated extremity ; Oa, abdominal orifice of the tube, Fo, ovarian fringe ; io, inf undibulo-ovarian ligament ; Ro, organ of Eosenmiiller. centre of a kind of fringed funnel, called the fimbriated extremity/. It is not uncommon to observe accessory fimbriated extremities on the external third of the Fallopian tube, i. e. other orifices besides the normal one, communicating, like it, with the canal of the oviduct, and forming consequently a condition unfavorable to the preservation and transport of the fecundated ovum, and therefore a cause of sterility.^ The Fallopian tube is composed of a double muscular tunic, the internal of circular, the external of longitudinal fibres, following all its flexuosities, and apparently formed by a prolongation of the uterine fibres. These are tide cause of the vermicular, peristaltic movements, analogous in every way to those of the intestine, which it is easy to see in the females of the mammalia at the time of ovulation. Besides these intrinsic muscles, the Fallopian tube is surrounded by an ex- trinsic superficial layer of muscular bundles, which do not follow the flexuosities of this canal, but run in a perfectly straight direction, are continuous with those of the utero-ovarian and tubo-ovarian liga- * Richard, Anatomie des trompes de I'uterus, Theses de Paris, 1851. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 15 ments, as well as with those of the hilus of the ovary, determine the adaptation of the fimbriated extremity to this latter organ, and form part of the general system of the extrinsic muscular envelope common to the uterus and its appendages which will be described hereafter. Fig. 14. — Section of right Fallopian tube in an adnlt nulliiDara (after Richard). a, uterine orifice of the tube ; h, narrowest part of the canal, con'esponding to the uterine end of the tube ; c, canal in the body of the tube, origin of the large folds continuing into the fimbnated extremity ; d, opened fim- briated extremity filled with folds, which are continuous with those of the canal of the tube ; e, tubo-ovarian fringe and furrow of the same name ; f, ovary ; g, round ligament. The internal membrane of the Fallopian tube is a mucous membrane furnished with very remarkable longitudinal folds, most marked in the centre, but equally distinct at the two ends, on the one side on the internal surface of the fimbriated extremity, on the other in the uterus at each of the superior angles. Henning has found in the tubal mucous membrane glands which are short, bursiform, simple, or dichotomous ; some present a swelling in the form of a cluster, others show circumvolutions analogous to those of the intestine and sudori- parous glands, and are arranged parallel to the mucous membrane. They are especially numerous on a level with the abdominal extremity. The epithelium of this mucous membrane is vibratile, the cilia moving from the ovary towards the uterus. The Fallopian tubes have a double action to fulfil : on the one hand they convey the spermatozoa to the ovule to be fecundated, and on the other hand they transmit this ovule to the uterus, where it ought normally to be developed. We may presume that the transport of the ovule is effected in part by the vibratile cilia of the tubal mucous membrane. 16 INTRODUCTION The Uterus The uterus is a hollow organ designed for gestation. In shape it is like a cone flattened from before backwards, having, consequently, two surfaces (one anterior and one posterior) and lateral borders. The base or fundus is above, the apex below. The flattening is not equal on the two surfaces ; the anterior alone is almost flat, the poste- FiG. 15. — Uterus of an adult nullipara (posterior surface), a, body of the uterus ; c, cervix ; r, isthmus or contraction indicating the junction of tlie body with the cervix ; s, fundus ; Z I, lateral borders ; //, Fallopian tubes ; V, insertion of vagina ; i, vaginal portion of cervix ; o, external orifice. rior is convex, and, as it were, divided into two parts by a projection running the whole length of the median line. The isthmus, a slight annular depression situated on the surface of the organ immediately below the middle, more marked before and on the sides than behind, is the external vestige of its division into two unequal parts, an upper one, the hody, larger and cone shaped, a lower one, the nech, cylindrical and slightly swollen in the middle. Volume. — If we take into account neither individual varieties nor functional variations the following are the dimensions in round numbers : Length . Breadth . Thickness 0-060 m. to 0-070 m. 0035 „ to 0.045 „ 0-020 „ to 0-025 „ I may mention that the length may reach 80 millimetres without the existence of any morbid condition; that the breadth from one Fallopian tube to the other is the most difficult to determine either in the patient or on the cadaver, whilst the thickness, or the antero-posterior diameter, measured at its culminating point, is nor- mally the least varial)le and the one in which it is easiest to discover pathological changes. ANATOMY, PHYSIOLOGY AND TERATOLOGY 17 Weight. — The weight of the uterus is on an average an ounce and a half, but it varies, as do also the form and the size in different physiological conditions of the organ. direction. — The vulva is almost in the plane of the inferior strait, projecting a little beyond it below. The vagina commences by being in the same axis, but as it rises it has a tendency to follow the curve of the sacrum ; as for the uterus, it is in the axis of the superior strait, by which it is evident that it forms a continuation of the vagina by making an angle at the point of union of the two organs. The axes, even of the body and neck of the uterus, are not absolutely the same, the neck following slightly the curve of the sacrum, or the axis of the Fig. 16. — Central vertical section showing the direction of the uterus and chief relations of this organ, u, uterus ; w, vagina opened ; v, the bladder opened ; i, urethra opened ; r, rectum opened ; o, anterior peritoneal or utero- vesical cul-de-sac ; t, posterior peritoneal or utero-vagino-rectal cul-de-sac. It is easily seen that these culs-de-sacs are situated on very different levels. n, connection of the vagina with the uterus and utero-vaginal circular cul-de-sac ; a, connection of the bladder with the uterus ; c, recto- vaginal septum, thin above, m, where the walls of the vagina and rectum are almost contiguous, thick below at p, where it forms the perineum ; s, left half of the symphysis pubis. pelvis proper passing in front of the vagina, the body inclining a little forwards, so that its fundus looks towards the anterior abdo- minal wall and its axis is perpendicular to the level of the brim. There is in fact normally, as a rule, a slight anteversion, and even anteflexion, the uterus having a tendency to fall forwards rather than backwards. The fundus of the uterus generally inclines to the right, especially during pregnancy. Is this owing to the sigmoid flexure being to the left ? Mauriceau and Freund think that the relative shortness of the right appendages is the effect and not the cause of this inclination, which is congenital. Relations. — The uterus is situated in the pelvis behind the bladder. The body is free and smooth, and covered in front by the peritoneum, ^ 1 18 INTEODUOTION which adheres closely to it in the upper part, less so below, and on a level with the isthmus is reflected on the posterior surface of the bladder. This vesico-uterine cul-de-sac is situated high up in the child, lower in the adult, and low down in the multipara and in the old woman, owing to the differences which age and parturition cause in the relative proportions of the body and neck. It may vary to a certain extent independently of these conditions ; as a rule, however, it corresponds with the isthmus. Below this point the anterior surface of the cervix is in immediate contact with the lower and posterior part of the bladder, to which it is attached by cellular tissue. The bladder adheres to the cervix for a length of 14 milUmetres. It is adherent to the vagina by all the surface corresponding to the vesical trigone, and by a portion of the vesical walls beyond the trigone, i. e. by almost the whole of its fundus, and by all the breadth of the anterior vaginal wall, a space almost quadrilateral in form and extending from 27 to 30 millimetres in every direction (Fig. 18 b, b). Fig. 17. Fig. 18. Fig. 17. — Exact relations of the bladder with the utems and vagina (after Dubois). m, uterus ; c, cervix ; u, u, ureters ; t, ti'igone of bladder ; a, a, line of connection between the bladder and cervix ; the quadilateral space enclosed in the dotted lines, r, u, u, r, including the trigone, repre- sents the surface of attachment of the bladder to the vagina. Fig. 18. — Vei-tical antero-posterior section of the uterus, i, isthmus separating the cavity of the body from that of the cervix ; a, anterior lip of the cervix ; p, posterior lip ; /, posterior vagino-uterine cul-de-sac ; va, va, vagina ; b, b, connections of the urinary bladder with the anterior surface of the cervix ; r, reflexion of the peritoneum from the posterior surface of the uterus and vagina to the rectum ; c, commencement of the utero-lumbar suspensory ligaments. ANATOMY, PnySIOLOGY AND TERATOLOGY 19 The result of a great number of measurements taken at all ages, both in the state of vacuity and of gestation, is that the distance between the opening of the ureter at the posterior angle of the trigone and the insertion of the vagina at the cervix, while very variable, is on an average from 1 to 3 centimetres. The distance between this opening and the free portion of the cervix is still more variable as it depends on the size and length of the cervix. The distance between the ureter and the margin of the uterus is equally variable, since the ureter is sometimes at some distance from it, whilst in other circum- stances, as at the end of gestation, it is in immediate contact with the uterine border, as shown by the fact that the ureter and uterus may be torn or ulcerated at the same point, as occurred in a case of fistula after delivery which came under my own observation. When the bladder is empty the anterior surface of the uterus is bent over it, forming a slight curve with the concavity looking forwards and down- wards. When it fills, this surface rises and is directed in turn forwards and upwards. When it is distended the uterus may be com- pressed by it against the sacro-vertebral angle, or if the hgaments are relaxed may even be turned backwards, its base looking towards the concavity of the sacrum, and may become fixed in this position when such a displacement occurs at the commencement of pregnancy or after delivery.^ The posterior surface of the uterus is covered in all its extent by the peritoneum, which, as it passes over the utero-sacral ligaments, forms at the sides Douglases folds, whilst in the middle line it extends to the upper part of the posterior vaginal wall to form, by its reflection on to the rectum, the recto-vaginal cul desac (I^ig. 18 r). The posterior surface assumes alternate positions exactly the reverse of the anterior surface, according as the bladder is full or empty. It looks towards the rectum, being generally separated from it by circumvolu- tions of the small intestine, though exceptionally it may rest upon it when raised and pushed towards it by the distension of the bladder or by one of the pathological conditions which will occupy our atten- tion when studying displacements of the womb. The upper margin is in relation with the circumvolutions of the small intestine, of which it somewhat retains the impression. In the majority of women it does not reach the level of the brim (Sappey). However it extends beyond the horizontal plane, passing immediately above the symphysis of the pubis, which allows of its being examined by palpation in the greater number of patients. The lateral borders correspond with the interstices of the two peritoneal folds, anterior and posterior, which, as they leave the uterus, form the broad ligaments. They are continuous with those of the vagina. Both are in immediate relation with the numerous vessels which enter these two organs. The lower extremity projects into the cavity of the vagina, which encircles it. It is a little lower before than behind, and the posterior utero-vaginal cul-de-sac has in consequence a greater depth than the anterior one (Fig. 18). * Sappey, Anat. descript., t. iii, p. 661. Paris, 1864 ; Comte, Bulletin de la Societe anatoviique, 1826, t. i, p. 49. 20 INTRODUCTION This extremity, often iucorrectly designated as the neck, is the vaginal portion of the neck (Fig. 15). Normally it looks downwards and backwards, and this direction may be exaggerated to such an extent that the axis of the neck may form a right angle with the vagina, its vaginal portion resting on the posterior wall of this membranous canal. Sometimes it hardly projects ; at other times it does so considerably ; on an average it is from 10 to 12 millimetres long. Its slightly rounded form may be flattened, or, on the contrary, be elongated till it becomes conical. A transverse orifice divides it into two lips, united right and left by thick commissures. The projection and size of these lips are un- equal. The anterior is the more prominent, the lower and the easier to find, owing to the cervix being directed backwards ; the posterior, however, has a larger surface on account of the vaginal insertion being higher behind than before. This circumstance, added to the difference in length of the two walls of the vagina (the posterior being the longer), should remind us to pass the finger or sound along the pos- terior wall in order to make sure of reaching the cervix (Eig. 18). Ligaments and Appendages op the Uterus The study of these ligaments is very important from a double point of view, whether we consider them as a means of suspension of the uterus, or whether we study the consequences resulting from the partitioning produced by their presence in the pelvic excavation. I. Means of suspension. — They are of two kinds : some suspend the uterus by its fundus and by its sides, others by its neck.^ The former are the broad ligaments and the round ligaments ; the latter are the utero-sacral ligaments and the suspensory ring. A. 1. The broad ligaments are the two lateral parts of the double peritoneal fold which, continued from the bladder to the uterus to be reflected afterwards from the uterus to the rectum, contains within its folds the uterus in the centre with its appendages on either side and divides the pelvis into two unequal parts, the one anterior, vesical, the other posterior, recto-intestinal. Commencing from the lateral margins of the uterus, they become continuous with the peritoneum which covers the brim and pelvic cavity, and are reflected below before touching the floor of the pelvis, the anterior fold towards the bladder, the posterior lower down on to the utero-sacral ligaments, whilst above they are subdivided into three secondary folds, the anterior containing the round ligament, the middle the I'allopian tube, and the posterior the ovary and its ligament (Figs. 1, 20). They are not formed merely by a fold of peritoneum, for this serous membrane is lined throughout their whole extent with a muscular layer, to which I shall call atten- ' See P'ig. 20, p. 22, where these ligaments are represented in a newly bom child, seen from before ; and Fig. \, front, where they are seen from behind in ail adult. ANATOMY, PflYSIOLOGY AND TERATOLOGY 21 tion in describing the contractile organs of the uterus. A|)art, how- ever^ from their contractility they may be said to contribute in main- FiG. 19. — Horizontal section of tlie pelvis of a woman, aged twenty (after Le Gendre). The section, which is made at 1 cm. above the pubis, passes through the ilium about the middle of the coxo-femoral articulation, on a level with the upper borders of the bladder and uterus, the fundus of the latter being divided. The bladder is but slightly distended, the rectum is pushed a little to the right of the sacrum and enveloped by the peri- toneum, except the portion which is adherent to this bone. The uterus on its posterior surface is in contact with the bladder. It presents a deviation from its normal position, as is often observed on the cadaver. The fundus, which is strongly inclined to the left instead of to the right as is usual, fits into the cotyloid cavity of the same side ; the deviation is such that the body of the utems occupies all the left side of the true pelvis. Besides this lateral deviation there is a considerable anteflexion of the body. The distance which separates the anterior surface of the uterus from the abdominal wall is about 7 cm. In the right side of the pelvic cavity are seen the uterine appendages in their normal order of super- position ; the round ligament with the Fallopian tube below, and quite behind and to the outer side the ovary, n, peritoneum ; a, upper border of the bladder ; B, angle of union of the fundus with the neck of the uterus ; M, fundus of the uterus, divided ; H, right ovary ; i, round ligament ; J, Fallopian tube ; L, broad ligament of the right side ; K, fibrous tissue between the rectum and fundus uteri ; c, rectum ; n, meso- rectum ; d, sacrum ; E, head of the femur ; g, cotyloid cavity ; E, fibrous capsule of the coxo-femoral articulation ; o, femoral vein ; p, femoral artery; a, crural nerve; b, epigastric artery and vein; c, c, lymphatic ganglia'; i, inguinal canal ; Q, sciatic nerve ; I, gluteal vessels ; F, gluteus maximus ; s, s, gluteus medius ; t, gluteus minimus ; u, v, x, T, z, fascia lata, sartorius, right rectus, iliacus and psoas muscles ; d, pyramidalis muscle ; e, rectus abdominis muscle ; /, internal oblique muscle ; g, ob- turator internus muscle ; h, levator ani muscle ; j, sacro-sciatic ligament ; K, superior gemellus muscle ; m, aponeurosis of the exteraal oblique muscle. taining the uterus in position ; when they are cut in the dead body the uterus is seen to obey the laws of gravity^ and to incline to the side towards which the pelvis inclines, whilst it reassumes its proper 22 INTRODUCTION place as soon as their continuity is once more effected by means of a Fig. 20. — General view of the internal genital organs of a child at birth. 1, bhidder with the urachus above and on each side the umbilical arteries ; 2, 2, round ligaments ; 3, body of the uterus bent forwards ; 4, 4, Fallopian tubes ; 5, 5, ovaries, above which is seen on each side an ascending longi- tudinal projection of peritoneum, near Douglas's fold, formed by the ovarian vessels and the superior round ligament, which raises the serous membrane ; 6, 6, Douglas's peritoneal folds covering the utero-lumbar ligaments ; 7, rectum. This woodcut is intended to show all the means of suspension of the uterus, including the broad ligaments and the superficial muscular layer lining them, a common envelope embracing the womb and its appendages, and connecting them simultaneously with the anterioi', posterior, and lateral portions of the pelvis. It shows at the same time the position and form of these organs peculiar to the foetus and infant, suture.^ Repeated pregnancies, together with other causes, produce considerable relaxation in these organs. 2, The round ligaments, originating in smooth muscular fibres from the whole extent of the sides of the womb, and especially from its ' Sappey, Traite d'anatomie, t. iii, p. (551. Paris, 18G4. ANAT0M7, PHYSIOLOGY AND TEEATGLOGY 23 upper half, pass off from its lateral angles or from the extremities of the fundus in front of and a little below the Fallopian tubes, are en- veloped on each side by the anterior fold of the broad ligament, reach, at their outer extremity, the brim of the pelvis, and from there, being deflected inwards, the abdominal orifice of the inguinal canal, having traversed which, they are inserted by some of their fibres into its inferior wall, by others into the spine of the pubis, and by others, again, into the upper part of the labia majora. They evidently contribute to maintain the fundus of the uterus in a forward position ; if too short, they may determine anteversion or anteflexion ; if too long, they let the uterus fall or become retroflexed ; if unequal, they may favour lateral flexion (Fig. 20). B. The means of suspension of the cervix are more certain and more resistant than those of the body. They consist of the posterior liga- ments and the anterior adhesions of the uterus to the bladder. 1. The posterior ligaments arise from the sides of the posterior surface of the uterus at the union of the body and neck, or rather at the point where the vagina is inserted, and are formed of muscular fibres which are continuous with those of the organ itself and pass under the posterior layer of the broad ligament. Covered by the peri- toneum, which being reflected from the broad ligament above them to descend from there into the utero-rectal cul-de-sac forms in this manner the fold of Douglas, they pass outwards to be inserted immediately to the inside of the sacro-iliac symphysis at the third sacral vertebra, and often above as far as the promontory or the anterior and lateral part of the last lumbar vertebra, which has led Huguier' to designate them as utero-lumbar in place of utero- sacral ligaments. It is these ligaments which prevent the cervix from descending, even in the majority of multiparse, unless gentle but sustained traction is made on the two lips. 3. The anterior adhesions of the uterus to the bladder (Fig. 18) are not less important as means of suspension. These adhesions evidently prevent the cervix, if not from falling or from being dragged forwards towards the pubis in cases where the utero-sacral liga- ments are relaxed or torn, at least from inclining backwards towards the sacrum ; for even when the bladder is distended by urine, as its base is only moderately developed, the uterus, in place of being pushed back as a whole towards the sacrum, is raised, and its fundus which looked forwards is directed upwards and then bat3kwards and some- times even it may be completely retroverted towards the sacrum. As the result of these two means of suspension (Douglases ligaments embracing the posterior and upper part of the cervix, and the adhesions with the bladder the anterior and upper part) the cervix may be said to be suspended by two half rimjs ; the one posterior, preventing it from inclining forwards and downwards ; the other anterior, pre- venting it from inclining backwards, which complement each other and form a real suspensory ring which maintains the upper third of the cervix in a sufficiently fixed position in the pelvic cavity (Figs. 1, ' Allongemeiits hijpertrophiqiies du col, p. 80. Paris, 1859. 24 INTRODUCTION 18). At the same time it results from the point of attachment of this double half ring that the free portion of the cervix below and the whole body above may oscillate and, under the influence of various kinds of pressure, incline in different directions without the portion of the cervix embraced by this ring leaving the centre of the pelvis. The uterus cannot descend unless the posterior half ring is relaxed ; it cannot rise unless the anterior half ring is stretched; but it may oscillate in all directions round this double half ring as round a suspensory ring. We cannot judge better of the nature, direction and extent of these movements than by provoking them by means of the finger introduced into the vagina : in pushing the cervix backwards we perceive that the body is directed forwards ; in pushing it to the right the fundus is directed to the left, and vice versa ; in other words, the fundus by a swinging motion is always directed in the opposite direction from the cervix. II. Division of the pelvic cavity. — The ligaments are not less im- portant as regards the divisions which they establish in the pelvic cavity than as means of suspension. The vast folds which have just been described under the name of broad ligaments divide the pelvis proper into two unequal compartments : the one anterior, occupied in great part by the bladder ; the other posterior, containing the rectum and the utero-vagino- rectal cavity. So that whilst the uterus at the brim is connected with the bladder in front, behind it is separated from the rectum by a large cavity. This, which may be called the uterovagino-recLal cavity, is very deep, especially in mulliparae. When no adhesion limits its extent, either from before backwards from the vagina to the rectum, or from one side to another between and below the folds of Douglas, this cavity may attain great dimensions; for the dimensions are those of the pelvic cavity itself, exclusive of the thick- ness of the rectum, vagina and bladder, which occupy very little space in a state of vacuity. I have often measured this cavity in various directions, the antero-posterior, and even the transverse diameter, may exceed eight centimetres if the folds of Douglas are stretched ; if they are left in their natural position there may be a space of five or six centimetres between them ; as to the depth of the cavity, from the upper border of the uterus to the bottom of the vagino- rectal cul-de-sac there is from fifteen to eighteen centimetres j taken below the utero- sacral ligaments it measures from five to nine centi- metres. Into this cavity the small intestine may descend in a state of health, in various diseases the ovary may be dragged there by its own weight, and in extreme retroflexions the fundus of the uterus may fall even below the ligaments of Douglas ; and lastly, it is there that sanguineous, serous and purulent efl'usions are formed, and that fibri- nous adhesions take place in hematoceles and retro-uterine peritonitis. To the right and left of the bladder are superficial fossae ; to the right and left of the retro-uterine cavity, behind the ligaments of the ovary and above the folds of Douglas, are two deeper and more extensive fossaj, where tubo-ovarian and uterine adhesions are often formed after inflammations of the ovary and Fallopian tubes. Secondary longi- ANATOMY, PHYSIOLOGY AND TERATOLOGY 25 tudinal fossae, or rather grooves, separate the upper margins of the small folds and are also frequently the seat of inflammatory sero- purulent adhesions and effusions. It is useless to describe the relations of these peritoneal surfaces with the abdomino-pelvic viscera, or the Pig. 21. — Eelations of the viscera contained in the female pelvic cavity (after Tillaux). L F, ligament of the Fallopian tube ; L o, ligament of the OA'ary ; L E, round ligament ; E, rectum ; s, sacrum ; s P, symphysis pubis ; u, uterus ; u s, utero-sacral ligament ; v, bladder. continuity of this peritoneal covering with that of the iliac fossa, Fal- lopian ligament, &c. It is important, however, to remember them in order to account for the extension of inflammation to various points not only of the retro-uterine peritoneal cavity bat also of the iliac and hypogastric portions of the peritoneum, which may be aff'ected by suppuration, or may give rise to a purulent collection contained within septa of new formation. It is also important to remember that these broad ligaments contain a more or less abundant and dense cellular tissue within their folds in addition to the muscular tissue lining them. Their two smooth surfaces are in relation, the anterior with the 26 INTRODUCTION bladder, the posterior with the rectum ; it is at right angles from the latter that the two folds of Douglas arise, which cover the utero-sacral ligaments. There are four borders — superior, inferior, internal, and ex- ternal. The superior is subdivided into three small folds. The inferior is in relation with the subperitoneal cellular tissue of the pelvis and CTJ TTT M.U Fig. 22. — Section of the uterus and broad ligaments perpendicular to the large axis of the womb at 2 centimetres from its base (after Tillaux). B, pelvic wall; cu, uterine cavity; ll, broad ligament; MU, uterine mucous membrane ; P, P, peritoneum ; tu, uterine tissue ; vu, utero- ovarian veins. with the superior perineal aponeurosis. The internal is very wide (Fig. 2£), the two folds being separated from each other by the thick- ness of the uterus ; it is in relation with the uterine artery and the utero-ovarian plexuses, venous and lymphatic ; it is continuous with the inferior border on the lateral portions of the vagina (Fig. 23, l s p), having the same relations with the veins and lymphatics, and allowing of the recognition by vaginal touch of phlebitis, lymphangitis, tumours and purulent collections formed in this ligament. The external is in relation with the walls of the cavity ; it is very thin, the two folds of peritoneum being in close proximity ; a horizontal section of the broad ligaments and of the uterus at about an inch from its base shows very clearly the difference in thickness of the two borders (Fig. 22). The cellular tissue with which this vast peritoneal fold is lined is loose and abundant, especially below where it is continuous with the cellular tissue covering the upper perineal aponeuroses and levator ani (Fig. 23) and with that which covers the lateral surfaces of the bladder, the peritoneal lining of the abdominal wall at the hypogas- trium and of the internal iliac fossa. Consequently an inflammation of the broad ligament may be propagated in any of these various regions, or an abscess of this ligament may open into the vagina, bladder, rectum, into the ischio-rectal fossa, at the top of the sacro- sciatic groove, or may appear at the hip with the sacral plexus and the sciatic nerve or may reach the abdominal wall on a level with the Fallo- pian ligament, above or below the crural arch or even at the obturator foramen. Pelvi-peritonitis is most frequently posterior (retro-uterine cavity) ; it may be anterior or it may surround the uterus on all sides ANATOMY, PHYSIOLOGY AND TERATOLOGY 27 rising to a greater or less height, to the brim or even above the cavity, according to the height of the adhesions or new membranes which hmit it, and may open into the rectum, into a part of the intestine, the sigmoid flexure or even the cfccum, or at the abdominal wall above the crural arch, on a level with the hernial fossse. Abscess of the broad ligament is lateral, on one or other side of the uterus and vagina, pushing back these organs towards the opposite side without Fig. 23. — Transverse section of the pelvis, showing the three cavities (after Beigel). 1. cp, peritoneal cavity ; 2. lsp, sub-peiitoneal space ; 3. esc, sub- cntaneous space ; v, vagina ; ua, levator ani ; p, peritoneum ; u, uterus. extending all round, and making an exit for itself by all the communi- cations which may be established from the pelvic cellular tissue through the natural orifices to outside the pelvis, at the iliac fossa, hip, thigh, &c. Thus the broad ligaments, besides being a means of suspension for the uterus, are of capital importance in the physiological and patho- logical history of this organ, of its appendages, and of the peri-uterine regions ; they give the key to the differential diagnosis of hematoceles, pelvi-peritonitis, peri-uterine phlegmons, abscesses of the broad liga- ments, phlebitis, peri-uterine angioleucitis and adenites of the same region, both in a puerperal and non-puerperal condition. They cannot be too much studied or too well known. 28 INTRODUCTION Changes in the Uterus at Different Ages In the genital organs of women, and especially in the uterus, the volume, form, external aspect, cavities, structure, all the anatomical conditions in fact, vary from age to age. External aspect. — The size of the organ, which is small in the foetus and child, increases considerably at puberty, as do all other parts of the generative system : but it is very inferior in the nullipara to what it is in the multipara, and it diminishes in old age under the influence of the retrogression and atrophy which follow the menopause. The form, which is almost cylindrical in the foetus, gradually assumes the aspect peculiar to it, in proportion as the body undergoes its normal development : so that at puberty in the nullipara, but espe- cially in the multipara, the resemblance of the uterus to a small inverted gourd becomes very striking. Its position, direction, and relations change also with age on account of the difference of develop- ment which exists from one period of life to the other, not only between the various parts of the genital organs, but also between those of the pelvis. The pelvic cavity being but slightly developed in childhood, the uterus, like the bladder, is higher above the brim at this age than in the adult, and is generally inclined, and even curved, forwards (Figs. 9, 28). Fig. 24. — The utenis and its appendages in the foetus at the end of the fourth month, natural size. A, external view : a, a, ovaries relatively voluminous, almost as long as the Fallopian tubes ; b, b, oviducts ; c, c, round ligaments ; d, uterus ; e, vagina ; /, vaginal orifice. B, cavities : a, branches of the arbor vita extending to the fundus ; b, vaginal portion of the uterus ; c, vagina. It is, however, especially in the antagonism of the body and neck that the most remarkable differences are to be seen from one age to another. In the child the neck is very large, the body very small. The neck is almost cylindrical. The body is triangular, more flattened than in the adult ; its superior border is straight or slightly concave, a vestige of the coalescence of the uterine cornua ; its lower extremity is con- tinuous with the neck without any line of demarcation. The isthmus is indicated at this age less by a contraction than by a change of direc- ANATOMY, PHYSIOLOGY, AND TERATOLOGY 29 tion between the neck and the body ; for the result of Boullard's ^ researches, confirmed by my own observations, is that there is very Fig. 25 — Uterus at the commencement of the seventh mouth, opened, of ' natural size, a, fundus with thin walls ; h b, orifices of the Fallopian tubes ; c, arbor vitse ; d, neck, remarkable for the relative thickness of its walls. frequently, if not always, anteflexion of the body on the cervix. (Fig. 28.) In the girl at puberty, and still more in the adult, the body is Fi&. 26. Fig. 26. — Uterus at birth, natural size ; external view, a, body ; h, neck, very- large, rendered clearly distinct from the body by the formation of the isthmus ; c, vaginal portion of the neck ; d, d, Fallopian tubes ; e, e, round ligaments. Cavities : h, cavity of the body showing the arbor vitse. The fundus a and the walls are relatively thin ; c, neck, the walls of which are very thick ; d, vaginal portion of the cervix ; e, vagina. Fig. 27. — Section of uterus at seventh year, open, of natural size, o, fundus ; 6, body, the cavity of which still shows a trace of the internal longitudinal fold resulting from the union of the two primitive uteri, and forming a continuation of the arbor vitse of the neck ; c, neck still longer than the body and with thicker walls ; d, vaginal portion of the neck ; e, vagina. developed more than the neck, and becomes slightly curved, especially behind. The upper border is often straight, sometimes even it is almost convex ; its union with the neck is well marked by an isthmus. The neck, in place of remaining cylindrical, has assumed the form of a ' Quelques mots sur I'utenis. Theses de Paris, 1853, No. 87. 30 INTRODUCTION small barrel, contracted above, tapering below, and is shorter. The anterior flexion of the body on the neck diminishes, according to Cusco,^ in consequence of the unequal development, which being greater on the anterior than on the posterior surface, helps to straighten the organ. Still, a slight degree of anteflexion or rather inclination forwards often continues, not only in the girl after puberty, but in the married woman, provided she has never been pregnant. In the nullipara the characteristics of virginity remain, with the exception of a slight increase in the size of the whole of the organ, caused doubtless by the exercise of a new function. We may also admit some difference in the vaginal portion of the neck : it often loses its slightly conical shape, and becomes rather flattened. The cases in which the neck is normal must be distinguished from those in which it is quite conical. In the latter cases coitus does not modify the conicity Fig. 28. — Uterus of a foetus at birtli, side view seen in its relations, showing the normal anteflexion natural during fatal and infantile life (after Boullard and Bourgery). a, body of the uterus flexed forwards ; fe, fundus of body looking forwards ; c, neck, relatively very large ; d, section of the peritoneum ; e, cervix ; /, vagina ; g, hymen ; I, Fallopian tube, behind which the ovary is seen ; j, bladder ; k, rectum ; n, symphysis pubis. in the least ; on the contrary, it persists and is even increased to a certain extent, owing to the penis being apt to pass below the neck and so increase the depth of the posterior utero-vaginal cul de-sac, and is one of the most unmistakable causes of sterility. In cases where the cervix is of normal shape, the pressure deter- mined by the penis during coitus is made on this organ, and gradually diminishes the convexity so as slightly to flatten it and render the two 1 De V anteflexion et de la retroflexion de I'uterus. These de coiicours, pp. 18, 21. Paris, 185.S. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 31 lips more distinct. These characters are very nearly those of Roe- derer's ^ uterus virgineus. In the primipara, and still more in the multipara, the body is much larger than the neck ; besides increasing in size it changes in form and becomes convex in every direction, especially at its superior border. Generally it becomes quite straight, sometimes, on the contrary, the flexion increases. In this case, however, the flexion is not exclusively forwards ; it may be backwards or to one side, according to the direc- tion in which the determining cause has acted on a uterus in which the consistency may have been diminished, whilst the size has been in- creased by pregnancy and parturition. In old women atrophy of the organ takes place. This is more active in the body than in the neck, restoring in some degree the rela- tive proportion of these two parts to what it was in the child, or at least before the period of sexual activity. Like Cruveilhier,^ I have Fig. 29. Fig. 30. Fig, Fig, 29. — Mould of the uterine cavities in a virgin o£ seventeen years. c, cornua o£ the uterus, ceratine portion of the body ; cb, inferior segment of the body ; ha, isthmus ; ad, neck, with impression of the folds of the arbor vitce and the lateral depression of the column, t, Fallopian tubes, slight contraction at the point of union of their cavity with that of the body (after Guyon). 30. — Mould of the uterine cavities in a multipara, triangular form of the cavity of the body, enlargement and deformity of the uterine cornua, enlargement of the inferior segment of the body which blends with them. ab, isthmus ; ad, neck, with double depression (after Guyon). remarked that the obliteration of the vaginal portion of the neck is very common. Internal conformation. — The cavities of the uterus are very small, but they still differ considerably in their size and form in the child, the 1 Icones uteri huniani. ' Anat. descript., t. ii, p. 474. Paris, 1866. 32 INTRODUCTION nullipara and multipara. They form together a sort of canal flattened from before backwards, constricted at the isthmus and widening out in the body as it approaches the fundus. According to Sappey,i their length is : In the nullipara about 52 millimetres, the body measuring 22, the neck 25, the isthmus 5. In the multipara about 57 millimetres, the body measuring 28, the neck 24, the isthmus 5. I think these measurements rather exaggerated, especially that of the body in the multipara when there is no disease. Apart from this, the difference in the relative length of the body and neck, the latter of which is the greater in the nulHpara and the former in the multipara, is in harmony with the difference in size of the two parts seen externally- (Figs. 29, 30, 34, 35). The other two dimensions are very small, especially the distance separating the anterior from the posterior surface. On this account it is very difficult to move the sound in either direction. The cavity of the body, which hardly exists in the foetus, becomes triangular after puberty. The walls are flat, and applied one against the other, unless a little mucus is interposed between them. The borders are convex, and are directed towards each other in such a way that the convergence of their convexity towards the centre diminishes to an equal extent the uterine cavity. Therefore a slightly curved sound when introduced into this cavity cannot easily be moved from one side to the other, still less be rotated upon itself. The superior angles, very acute, present the last folds of the mucous membrane of the Fallopian tubes, and it is the very close proximity of these folds which forms the only obstacle to the passage of a fluid from the cavity of the body into that of the Fallopian tubes. The inferior angle, less acute, corresponds with the os internum. In the multipara the cavity of the body is distinguished by different characters — greater capacity and an interval between the two surfaces, or at least the possibility of separating them and of moving the sound between them ; superior angles less acute. The form is triangular, but the margins are very seldom convex, sometimes they are straight, often concave, hence the marked increase of the cavity circumscribed by them. This latter tendency seems to be more marked when the number of pregnancies has been considerable, and when they have occurred in quick succession. The cervical cavity, large in the child, is fusiform, flattened from before backwards, presenting consequently two walls, two borders and two orifices. The walls are unequal, traversed from top to bottom by a vertical projection, from which secondary oblique and ascending projections are given off, an arrangement which has received the name of arbor vita (Figs. 29, 32, 35, 38). The posterior tree only becomes visible a few millimetres above the inferior orifice ; it increases in size, and deviates to the left in proportion as it approaches the superior orifice. The anterior tree is, on the contrary, directed towards the right. ' Op. cit., p. 664. ANATOMY, PHYSIOLOGY AND TERATOLOGY 33 Consequently the two cervical walls fit into each other in place of one being applied one against the other, as in the cavity of the body. These kind of columns are analogous to the columnee carnese of the Fig. 31. — Transverse sections taken from the upper half of the cervix, showing the dovetailing of its walls, especially of the two longitudinal projections, which may be said to be the trunks of the arbor vitce, and consequently the mechanism for the occlusion of the isthmus or os internum (after Guy on) . 1, virgin uterus at sixteen years old ; 2, uterus in a nullipara ; 3, uterus in a multipara. Exceptionally there are two posterior projections, but only one anterior and median. heart. It is to Guyon ^ that we owe the knowledge of their fitting into each other, and of several other facts relative to the study of the uterine cavities. The OS intermtm is a true strait of 5 millimetres in length, in which the arbor vitse, stripped of their branches, dovetail into each other so well that, owing to the narrowness of the orifice, they fill it entirely and make it difficult for the sound to enter ; but this resistance over- come, it enters easily into the cavity. The sensibility of this orifice and the circular arrangement of the bundles of muscles v^'hich form a veri- table sphincter at this point, in addition to the narrowness of the opening and the dovetailing of the posterior and anterior columns, increase the difficulties experienced, in the case of certain morbid con- ditions or of virgins, in passing the sound from the cavity of the neck into that of the body (Figs. 29, 35). At other times, on the contrary, as the result of other morbid conditions, nothing is easier than to pass through this orifice (Fig. 32). As a rule, a catheter of 2 milli- metres in diameter will enter it. After the menopause the os internum gradually contracts, and in some women is at last obliterated. The OS externum, is broader, though occasionally it is rounded and narrow. This narrowness may be more or less marked, even reach- ing the degree at which it is known as atresia, which is really im- perf oration or obliteration. Then the retention of mucus or of menstrual blood increases the capacities of the cavities, as may be seen in the accompanying figure taken from Guyon (Fig. 32 eh, ad). Often, too, in such a case the projection of the uterus into the vagina is conical, and the orifice may be at the summit of this cone or on one of its sides a little in front or a little behind. Gene- rally, however, it is in the form of a slit, on which, in the foetus and infant, we can see the starting-point of the trunks of the arbor vita, which gives to this opening a form somewhat similar to that of the ^ Mhide sur les cavitSs de I'uierus a I'etat de vacuite. Theses de Paris, 1858. Hagemann {Archivfiir Gynecologie, Bd. v, p. 295) has arrived at the some results. 3 34 INTRODUCTION mouth (Guyon). These projections are effaced with age so as to reduce the orifice to a straight line, the margins of which are in contact in the child and adult nullipara. The latter differs from the former in Fig. 32. — Mould of the uterine cavities in a nullipara forty-two years of age. There was a well-marked contraction of the os externum. Its form is the same as that of the uterus in the virgin (Fig. 29), but the cornua are broader, the cervico-uterine isthmus is dilated, the upper segment of the body and the cervical cavity are more developed (after Guyon). the slight flattening of the cervix, the lips of which seem to allow the orifice to open more easily. In the multipara the slit is open, irregular, 1 2 Fig. 33. — Differences in the vaginal portions of the cervix in the nullipara, 1 ; and in the multipara, 2. and indented by cicatrices consequent on lacerations caused at de- livery. To sum up, there are differences in the uterus of a nullipara and that of a multipara which should prevent their being confounded. 1st. Externally, the uterus of the multipara is less fixed, it has a less elevated position and a more marked variability of inclination than the uterus of a nullipara. Its two surfaces and its upper border are rounded. The vaginal portion of the neck is less conical and less elongated. The orifice is longer, the lips irregular and indented, open- ANATOMY, PHYSIOLOGY AND TERATOLOGY 35 ing easily and allowing the entrance of the point of the finger. The uterus is larger ; all its diameters have increased, especially the longi- FiG. 34. — Differences in the external conformation of the uterus in a nullipara, 1 ; and in a multipara, 2 (after Dubois). tudinal one. The increase of size, and especially of length, is shown Fig. 35. — Differences in form and size of the uterine cavities. The nullipara 1 ; and the multipara, 2 (after Dubois) . more in the body than in the neck. The walls of the organ have acquired a greater thickness. 2nd. Internally , the cavity of the body is increased and has changed in shape : its borders, in place of being convex, have become concave. The superior angles are no longer funnel-shaped. The openings of the Fallopian tubes are broader. The cavity of the neck is proportionally shorter and rather broader. The os internum is more open, and allows 36 INTEODUOTION the sound to penetrate more easily. The axis of the two cavities is less frequently curved forwards, and when it is curved either forwards, backwards, or to one side, it is more easily rectified by the introduc- tion of an instrument, unless there are adhesions or some morbid condition. Structure of the Uterus The structure of the uterus is not analogous to that of any other organ. The walls are thick, but not equally so throughout. Hardly exceeding 8 millimetres at the opening of the Fallopian tubes, they are as a rule, according to Sappey,^ 10 millimetres thick at the fundus and from 12 to 15 anteriorly and posteriorly and at the lateral borders. 1. Its arteries are the ovarian from the aorta and the uterine from the internal iliac, without counting those of the round ligaments arising from the epigastric. They enter the uterus by its borders, not without anastomosing considerably, describing numerous flexuosities and cork- screw windings, which have led to their being compared to the helicine arteries of the erectile tissues generally and of the cavernous bodies of the penis in particular. 2. Its veins, which are voluminous and almost without valves, anastomose largely and are adherent to the tissue of the organ, forming during pregnancy dilatations known as sinuses. They emerge along the lateral borders and form two vast plexuses contained in the folds of the broad ligaments and, without joining the veins of these Hgaments which flow into the epigastric or external iliac, they empty themselves, some into the internal iliac, others into the vena cava on the right and the renal vein on the left, being marked during the whole length of their course by a plexus analogous to the pampiniform plexus in man. 3. Its lymphatic vessels, studied especially during pregnancy or after delivery by Mascagni, Cruveilhier and others, have lately been investi- gated by Leopold^ in the unimpregnated uterus in woman, as well as in the female mammalia, and by Lucas Championniere^ in the uterus after delivery. Whether they arise from the mucous membrane or from the muscular wall, the hypertrophy of which they share in pregnancy, these lymphatic vessels are divided, like the veins, into two principal groups on each side ; the inferior, which come from the cervix, open into the lateral pelvic glands ; the superior into the lumbar ganglia. Cham- pionniere has discovered that the lymphatics of the cervix unite in vessels of various sizes at the union of the body and cervix ; generally there is one much larger than the others ; they emerge at this level into the lateral cellular tissue at the base of the broad ligaments fol- lowing the course of the blood-vessels and at once join one or two little ganglia which are not constant but which, when wanting, are replaced by a lymphatic network which forms a real and important ' Op. cit., p. 665. ' Archivfilr Gynecologic, Bd. vi, p. 1. Berlin, 1873. •■' Lymphatiques ut<'-rins et Lymphangite uterine. Paris, 1870. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 37 vascular plexus. The largest at last reach the posterior subperitoneal surface of the broad ligament, and from there pass to the deep pelvic and sacral ganglia, sometimes even reaching an inguinal and obturator ganglion. The lymphatics of the body arise chiefly from the portion which adjoins the placental surface ; they anastomose with those of the ovaries and Fallopian tubes and, following the utero-ovarian venous plexus, they accompany these vessels to the vascular plexuses and lumbar ganglia where they end. It is impossible to attach too much importance to the exact knowledge of the lymphatics of the uterus and its appendages. In the sites indicated by anatomists I have frequently observed kernels of inflammatory induration, which could be nothing else than retro-uterine adenitis, and this opinion has occasionally been confirmed by autopsies. I am more and more convinced every day of the important part played by angioleucitis, adenitis and even peri- uterine adenomata, not only in the history of uterine and peri-uterine phlegmasia in puerperal maladies, but in a number of others accom- panied by deep and continuous pain, which otherwise would be inexplicable. 4. The nerves of the uterus and ovaries, according to Pranken- hauser, arise directly and indirectly from the cceliac plexus through the intervention of the renal plexus which, through its inferior gan- glion, is distributed to the ovaries and spermatic ganglia. The aortic plexus by its upper part (superior mesenteric plexus) supplies these spermatic ganglia, which would be more correctly designated genital ganglia. These ganglia, four in number, receive two large branches from the great sympathetic and give off a great number of nerves to the ovaries. Below the origin of the inferior mesenteric artery is the great uterine plexus (lumbo-aortic), which descends to 1 centimetre from the division of the aorta and is formed of the principal branches of the genital ganglia with the addition of small branches proceeding from the four lumbar ganglia of the great sympathetic. On the pro- montory it is divided into hypogastric plexuses, which are joined by branches from the terminal ganglia of the sympathetic and are situated behind the rectum, on the inner side of the pelvic vessels, and are dis- tributed to the lateral borders of the cervix uteri. Each hypogastric plexus measures from 7 to 10 centimetres, and in its course supplies branches to the mesorectum, to the mesentery of the sigmoid flexure, and to the ureter. There is a large cervical ganglion on each side of the neck, easily discovered in the newly-born even without prepara- tion, but covered in adults by the pelvic fascia and superimposed nerves. It extends downwards as far as the folds of Douglas, and measures, in the empty uterus, about 2 centimetres in length and 1 in breadth, and during pregnancy 5 centimetres in length and 2 or 3 in breadth. The greater number of the uterine nerves arise from these two ganglia, the rest coming directly from the hypogastric plexus. The cervico-uterine ganglia receive their afferent branches not only from the hypogastric plexuses, but also from the second, third and fourth sacral pairs. They supply branches not only to the uterus 38 INTRODUCTION but also to the vagina, bladder and rectum. Besides these principal ganglia there are on each side two small ones for the urethra and bladder, the latter sending some branches to the anterior surface of the uterus. The nervous branches from the cervico-uterine ganglia enter the cervix horizontally ; passing upwards they pierce the inferior portion of the body obliquely, whilst above, along the borders of the uterus, they run almost vertically, uniting with each other in the thickness of the ante- rior and posterior walls ; they also anastomose with the ovarian nerves. The ramifications of the uterine nerves may be traced as far as the mucous membrane in the neck, but this cannot be done in the case of the body. Prankenhaiiser has found motor fibres in the uterine plexus but he has not been able to discover sensory fibres. It seems impossible to distinguish the filaments arising from the cerebro-spinal and ganglionic systems. 5. The serous envelope of the uterus is nothing else than the peri- toneum, which, being reflected from the posterior surface of the bladder to the anterior surface of the body of the womb, covers all the posterior surface of the fundus including the nech and the upper part of the posterior vaginal wall and extends right and left over the broad ligaments. 6. The uterine mucous membrane was for a long time unknown. It was Coste^ who demonstrated at the same time its existence, its struc- ture and its hypertrophy into the decidua during pregnancy. I helped to make this discovery known and to develop it twenty years ago.- Since then Robin has described the histology of this membrane,^ and other writers have studied the formation of the decidua and the regeneration of the uterine mucous membrane.'* The mucous membrane of the uterus is different in the body and in the neck. In the body it is attenuated toward the angles, where it is con- tinuous with that of the neck and of the Fallopian tubes. It is thickest towards the centre, varying from 3 to 6 millimetres, according to Coste. The free surface is smooth, without wrinkles, ' Memoire sur la formation de la caduque dans I'ceuf humain. Comptes rendus des seances de I'Academie des Sciences de Paris, t. xv, 1842, and t. xxiv, 1847. Traite general du developpement. Paris, 1848. ^ De I'ceuf et de son developpement dans I'espece humaine, p. 127. Montpellier, 1845. 3 Ch. Robin, Memoire pour servir a I'histoire anatomique et pathologique de la membrane muqueztse uterine, de son mucus et des ceufs, ou mieux glandes de Naboth, see Archives generales de viedecine, t. xvii and xviii. Paris, 1848. * Colin, Etude a I'ceil nu sur la surface interne de I'uterus apres I'accouche- tnent dans I'etat physiologique, dans I'etat pathologique, et en particidier dans la fievre puetperale. Theses de Paris, 1847, No. 229 ; see also A. Richard, De la m,uqueuse uterine. Paris, 1848; Ch. Robin, iHc?>ioire sm* les modifications de la muqueuse uterine pendant et apres la grossesse ; see Memoir es de I'Aca- demie de medecine, t. xxv, p. 81, Paris, 1861 ; Ercolani, Delia struttura della caduca uterina, Boloi^na, 1874 ; Leopold, Studien ilber die Uterusschleimhant wdhrend Menstruation, Schwangerschaft u. Wochenbett ; the paper is accom- panied by a larije nutnber of figures representing sections of the mucous membrane magnified in these various states. Archiv fiir Gyncecologie, Bd. xi, pp. 110, 443, &c. Berlin, 1877. ANATOMY, PHYSIOLOGY AND TERATOLOGY 39 papillae or villosities, but perforated with a multitude of orifices which are the mouths of as many follicles or tubular glands, and covered Fig. 37. Fig. 36, — Internal mucous membrane of a uterus, the anterior wall of which has been partially removed (after Coste). p p, tissue proper, in which numerous vascular orifices are seen, resulting from section of the vessels ; m m, mucous membrane, the regularly striated appearance of which is remarkable, as well as its rose colour. The little vennicular body placed below the uterus is a small gland ; t, initial extremity, ending in cul-de- sac ; 0, terminal extremity, presenting a narrow orifice opening upon the internal surface of the uterine cavity. Fig. 37. — General view of the glands or flexuous follicles of the \iterine mucous membrane. d(Z(Z, simple or double cti/-cZe-sao of these follicles ; a a a, thin cup-shaped orifice opening on to the surface of the mucous membrane. with conical cells of from 3 to 4 hundredths of a millimetre, with pyramidal base furnished with vibratile cilia smaller than the vibratile epithelium cells of the Fallopian tubes which are not less than 7 hundredths of a millimetre. This epithelium, vibratile in the empty uterus, becomes tesselated during gestation, when the mucous mem- brane becomes the decidua. The tubular glands, slightly flexuous and cylindrical, adhere by their blind end which is sometimes bifid to the subjacent tissue; they open on the surface of the mucous mem- brane into a little cup surrounded by a kind of vascular polygon, and are lined with nucleated epithelium. Their diameter is about equal to the twelfth part of their length, and the space separating them is about equal to their diameter. They participate in the general hyper- trophy of the organ during pregnancy. The tissue between the follicles is formed of occasional fibrous bundles (cellular, laminar or connective tissue), of fibro-plastic elements, especiallv of nuclei, cells. 40 INTRODUCTION fusiform bodies and of a great deal of granular amorphous matter. Thus the framework of the membrane is in the embryonic state and in every stage of development. The uterus is the only organ in which we constantly find a tissue in process of organisation. This pecu- liarity is in direct relation with the modifications in size and structure which are necessitated by the fulfilment of its functions ; it determines at the same time a special direction for its morbid processes ; it explains several obscure points in its pathology; it helps also in the search after therapeutical remedies and may explain the occasional unexpected effects produced by them. At the menstrual period the mucous membrane greatly increases in thickness, it becomes congested and remains gorged with blood till the hsemorrhage is established, or rather till it has ceased. Its surface is puffed out and furrowed with wrinkles which resemble the cerebral circumvolutions. The glands participate in this congestion which is almost a temporary hyper- trophy. Their secretion, generally insignificant, becomes consider- able, especially before and after the hsemorrhage. In the neck the mucous membrane is very adherent as in the body, but it is thinner, having a thickness of only 1 or 2 millimetres ; it is wrinkled, lined with ciliated epithelium formed of a substratum analogous to that of the mucous membrane of the body, and in which embryonic elements, such as the fibro-plastic fusiform bodies, pre- dominate : lastly, it is furnished abundantly with secreting organs, regarded formerly as simple follicles with ampullary blind ends and constricted neck, but lately described by Sappey as racemose glands with two or three branches and subdividing to terminate in a cul-de-sac. These glands are found in the uterine and vaginal orifices as well as in the cavity of the neck. They are remarkable for their size in their whole course. Their orifices are seen at the bottom of the grooves which separate the branches of the arbor vita. They secrete a thick and very viscous mucus, alkaline like that of the body, the reverse of the vaginal fluid which is acid. This mucus in accu- mulating forms in the foetus, and often in the adult, especially during pregnancy, a very adherent gelatinous cylinder which fills up the cavity of the neck. These glands frequently become the seat of a partial or total dilatation, which transforms them into a kind of cyst known as Naboth's eggs. These cysts, as they grow, become em- bedded in the muscular coat. The glands of the neck are the organs which specially produce uterine leucorrhcea. Although more acces- sible than the follicles of the body to our means of treatment because nearer to us, they are not any more amenable to the action of the means employed, owing to their position at the bottom of the rugged grooves into which they open between the ramifications of the arbor vita. Fig. 38, taken from Tyler Smith,^ gives an idea of the difliculty there is in reaching them. The muscular envelope, or what has been called the tissue proper of the uterus is very complicated. Super-position of deep layers, intersection of superficial bundles, a vascular development peculiar to ' On Pathology and Treatment of Leucm-rlicea, p. 25. London, 1855. ANATOMY, PHYSIOLOGY AND TERATOLOGY 41 erectile organs, all contribute in giving this organ a texture rendered more difficult of description by the fact that till now anatomists Fig. 38. — General view of the transverse or oblique ramifications of one of the two median columns of the mucous membrane which constitute the anterior and posterior arbores vita in the cervical canal of a virgin, magnified nine diameters. have hardly taken into account the facts gathered from development, from comparative anatomy and from the musculo-vaKSCular conditions of erectility which alone could throw any light on this study. At present we know the structure of the uterine tissue, the elements which enter into its composition, the wealth and special arrangement of its blood-vessels, and the super-position and the mutual relations of the majority of the muscular bundles which characterise the texture of the womb. The essential elements of the tissue of the uterus are smooth mus- 42 INTEODUCTION cular fibres, incorrectly called fibre-cells, muscular fibres of organic life characterised by the presence of a nucleus not exceeding 7 hun- dredths of a millimetre in length and 5 thousandths of a millimetre in width in the unimpregnated uterus, but attaining, during gestation, ten times the length and five times the width and allowing of the pene- tration of a few fatty granulations. The hypertrophy of the organ during pregnancy does not consist merely in the increased size of the elements already existing ; there is also a formation of new muscular elements and, in addition to the growth of contractile fibres, is added that of the fibrous or connective tissue which joins them together. Fig. 39. — Smooth muscular fibres of the unimpregnated uterus (after Tarre). Fig. 40. — Fibre-cells of the utenis in state of gestation (after Wagner). After delivery atrophy brings these elements back to their normal condition. This peculiarity characterises the muscular membrane of the uterus as well as its mucous membrane. If the muscular tissue Fig. 41. — Progress of involution or disintegration and renewal of uterine fibres after delivery. Process of fatty degeneration (after Heschl). has not, like the mucous membrane, the faculty of development carried to the point of renewal, it is always, like the latter, to a certain extent in process of development, and consequently has the characteristic of anatomical instability, thus forming a striking contrast to the stability of all other organs. This special property of the uterine tissue plays an important part in the development of its diseases, imprints a special ANATOMY, PHYSIOLOGY AND TERATOLOGY 43 character on its pathology and exercises a marked influence on its therapeutics. It is now agreed that the contractile bundles are composed of three layers of elementary fibres. The deep layer is formed of two orbicular muscles arranged in concentric curves, which converge right and left around the orifice of the Fallopian tubes as a central point, and to which Ruysch gave the name of detrusor placentcB, attributing to them the function of loosening the placenta. At the isthmus which unites the cavity of the body with that of the neck this layer is formed of simple circular bundles, intersecting at acute angles and constituting a con- strictor, the presence of which accounts for the occlusion of the uterus during gestation and explains its tendency to contract at this point like a sphincter, the difficulty often experienced in passing the sound, and the difference between the resistance presented by this orifice and the dilatability of the os externum and cervical cavity either during pregnancy or in certain morbid conditions, and lastly, the frequent obliteration of the os internum after the menopause. Helie^s^ recent researches have confirmed the truth of this descrip- tion. The central layer seems to be the thickest and most inextricable. According to Pajot^ it is composed principally (in the upper regions of the anterior and posterior surfaces where it can be studied) of muscular bands in loops which cover one another. The superficial layer, on the contrary, is most easily studied in the unimpregnated uterus, especially in children. As Rouget has observed, these organs preserve the traces of the primitive forms till puberty, the uterine cornua are still distin- guishable under the thin muscular layer which covers them, the tissue proper of the uterus is only slightly developed, the connections of the superficial layers with neighbouring membranes are more marked, and these membranes themselves are thin, transparent and free from the adipose tissue which afterwards invades them, and thus present them- selves to the observer under the most favorable conditions for study. The right and left segments of the uterus have doubtless, hke the Fallopian tubes, longitudinal fibres and layers of circular fibres which are a continuation of those of the oviducts. In addition, however, to these special fibres, which are found in much greater number on the two lateral halves of this organ than on the Fallopian tubes, there are doubtless common fibres which complete the fusion of these two halves in order to make one central organ having one cavity. Above these muscular layers there is a common envelope, also muscular, forming a broad contractile apparatus, uniting the movements of the womb with those of the Fallopian tubes, ovaries, broad ligaments, round ligaments and ligament of the ovarian vessels, i.e. with the so-called uterine appendages. If we spread the genital organs of a child on a piece of glass, it is 1 Journal de la section de medecine de la Societe academique du departement de la Loire-Inferiexire, t. Ix, p. 125. Nantes, 1864. Becherches sur la disposi- tion des fibres musculaires de I'uterus developpe par la grossesse, avec mi atlas de dix planches. Paris, 1865. 2 Dubois et Pajot, Traite complet de I'art des accouchements, p. 437. Paris, 1860. 44 INTRODUCTION easy to observe that in the human species, as in the mammalia, the uterus and its appendages are contained in the thickness of a broad muscular membrane, to which the peritoneal ligaments are only sub- sidiary. It is easy to follow the continuity of the muscular bundles of this membrane with the upper layer of the uterine tissue so well described by Deville.^ Fig. 42. — General view of the vascular structures of the internal genital organs in woman, in their relations with the superficial muscular system (after Rouget). The vagina, uterus and appendages are seen from hehind. Vascular system, — b, bulb communicating on the one side with the spongy tissue of the clitoris, and on the other with the venous plexus of the vagina ; PV, semi-circular enlargement of the vaginal venous plexus ; PC, cervi co-uterine plexus ; PU, uterine plexus ; SP, helicine arteries of the body of the uterus ; h, helicine arteries of the hilum of the ovary. Mus- cular structures : VP, insei-tion of the muscular bundles of the vagina into the pubis ; V8, bundles of fibres of the same muscular layer from the region of the sacro-iliac symphysis ; us, bundles of uterine muscular fibres accompanying the preceding, and constituting in great part the posterior fold of the broad ligaments ; TIE, retro-uterine ligaments ; Li, inguinal or pubic round ligaments spreading over the whole anterior surface of the uterus ; LO, ligament of the ovary ; LS, superior or lumbar round liga- ment which accompanies and envelopes the ovarian vessels ; a, bundles of muscular fibres from the ligament of the ovary lo, spreading over and interlacing with bundles of fibres b, from the lumbar ligament ls, within the thickness of the ovary and beyond in the fold of the Fallopian tube before their attachment to this tube and to the fimbriated extremity ; a', bundles of fibres from the ovary, forming, with those coming directly from the superior ligament, the tubo-ovarian fringe. ' See Cazcaux, Traitc theorique et pratique sur I'Art dcs Accouchcments, p. 108, 3rd edit. Paris, 1«50. ANATOMY, PHYSIOLOGY AND TERATOLOGY 45 Eouget^ set out with the double fact that the superficial muscular tunic of the hollow viscera does not always by any means mould itself exactly on their form and dimensions, and that the muscles of organic life at their terminal extremity are constantly in connexion with some portion of the locomotor economy of animal life, bones, tendons, aponeurosis and even muscles. He then studied the arrange- ment of the superficial contractile envelope of the genital organs in the vertebrate animals as well as in woman. He succeeded in this way in demonstrating that the broad ligaments are not a simple fold of peritoneum, but an expansion of the lateral portions of the uterus, or rather of the subjacent muscular folds, with the serous folds adhering to them very closely, and made up of bundles of smooth fibres, which interlace, forming a network. The central portion of the membrane formed by the whole thickness of these folds at their point of inter- section is nothing more than the external layer of the muscular envelope of the uterus. On the median line of the womb down its whole length may be seen the decussation of the muscular bundles from one side to the other (vertical fibres), indicating the meeting and crossing of the two lateral muscular organs (Pig. 42). In this way the bundles derived from the pubic round ligament (li) spread out in the form of a fan throughout the length of the uterus and interlace with those of the opposite side. The insertions to the sacrum and iliac region (ue, vs, us) are found in the utero-sacral ligaments and the posterior fold of the broad ligament. The bundles of fibres dependent on the ovarian ligament, mesovarium (lo) and central fold arise chiefly from the posterior surface of the uterus ; the fibres with numerous and elongated nuclei, which intermingle in the stroma of the gland and enclose the Graafian vesicles in the meshes of their net- work, are probably only their continuation. Another portion of the fibres of the mesovarium runs along the lower border of the ovary, and, having reached the external extremity, helps to form the muscular cord attaching the fimbriated extremity to this gland {a'). Lastly, some fibres are detached from the upper border of the utero-ovarian ligament to mingle with the muscular groundwork of the fold of the Fallopian tube, pnding in this tube and the fimbriated extremity. The fibres which constitute the means of insertion of the superficial muscular envelope of the uterus at the lumbar region (superior round ligament), in place of being narrowed into a band, are spread out like a membrane, envelope the vascular cord of the ovarian vessels, traverse it, rise with it to the lumbar region, and are gradually lost in the fascia propria, by means of which they are fixed to the posterior wall of the trunk. At their termination some of these fibres radiate into the posterior fold of the broad ligament towards the uterus, others, raising the peritoneum in the form of a fold, are deflected outwards on a level with the ovary, and are attached to the fimbriated extremity (h), whilst the greater number, accompanying the vessels to the hilum 1 Recherches sur les organes crectiles de lafemme, et sur I'appareil musculaire tiOio-ovarien, see Journal de pliysiologie of Brown-Sequard, t. i, p. 263. Paris, 1859. 46 INTRODUCTION of the ovary, seem partly to penetrate into the parenchyma of this gland, partly to cross its erectile bulb, and, continuing their course into the fold of the Fallopian tube, are lost in the contractile envelope of the latter, intermingling with those which arise from the ovarian ligament. The discovery of this superficial muscular layer explains the mechanism of the application of the oviduct to the ovary at the moment of dehiscence, an important phenomenon the cause of which was un- known. The direction of the two kinds of muscular fibres which, arising from the lumbar region and the uterus, embrace the whole length of the Fallopian tube and fimbriated extremity (lo, ls, a b, a' b), perfectly explains the movements executed by these organs when in- clining backwards and inwards, the possibility of the flexion of the tube on itself, and the application of the fimbriated end to the surface of the ovary (Fig. 42) . The mechanism, in fact, is exactly similar to that by which the opening of a bag purse is closed, the edges of which pucker up when drawn together by traction upon the strings which pass through rings attached at intervals round the mouth of the bag (fig. 43). The movements of the fimbriae, which, so to speak, sweep the surface of the ovary, and the peristaltic contractions of the Fallopian tube, receive the ovum and carry it to the uterus (Fig. 44). The movements of the uterus are also due to the morbid or spas- modic contractions of this superficial layer of muscular fibres. Patients are aware of this by the sensations they sometimes experience. These Fig. 43. — Muscular tubo-ovarian arrangement in the rabbit (after Eouget). The muscular membranes of the ovary l and of the Fallopian tube T form a double fold, the borders of which, brought together by muscular contraction, enclose the ovary and fimbriae which are thus brought into close contact ; s, upper round ligament, the muscular fibres of which descend from the lumbar region towards the ovaiy and the fimbriated extremity ; o, ovary ; u, uterus. sensations are not to be confounded with the spasmodic action propa- gated to other organs which produces such various effects, e.ff. the globus hystericus. They are so marked that we must admit their reality and attribute them to the partial or total contraction of the superficial muscular envelope. When I add that this contraction is itself the starting point of the erection of the ovary and uterus, that these movements and this erection are probably directly connected with ovulation, menstruation and venereal orgasm, it will be at once ANATOMY, PHYSIOLOGY AND TERATOLOGY 47 understood what importance is to be attached to thein in appreciating the various impressions experienced by women and the subjective phenomena of uterine diseases. Fia. 44. — Ovary and fimbriated extremity of Fallopian tube in a woman who died during menstruation (after Farre, ad. nat.). I, broad ligament ; o, ovary ; r r, old corpora lutea, traces of Graafian vesicles previously mptured and cicatrised ; /, broad portion of the Fallopian tube ; i, fimbriated extremity applied to the ovary. The tissue proper of the uterus is erectile as well as contractile. It is to Kouget^ that we owe the demonstration of this fact also. According to this observer, every erectile organ is nothing more than a muscular organ in which the blood brought by the arteries may be temporarily retained in the capillaries or in the veins transformed into cavernous sinuses and retiform plexuses ; the immediate cause, there- fore, of erection is to be found in the contraction of the muscular fibres, the primary element of all erectile orgasm. He also observed in the branches of the tubo-ovarian arteries an arrangement exactly similar to that which he had remarked in the helicine arteries of the corpus cavernosum. He discovered that the uterus and ovary each possess a true corpus spongiosum (Kg. 42), and that they may be the seat of phenomena analogous to those of erection. In fact, he de- monstrated that, besides the intrinsic muscles of the uterus which may participate in the production of these phenomena, the fibres of the tubo-ovarian muscular membranes have such intimate relationship with the corpora spongiosa of the uterus and ovary, and especially with their efferent vessels, that at the moment of contraction the meshes of the network through which the veins make their way being drawn tighter in every direction, the latter are necessarily compressed and the passage of blood more or less completely obstructed. The erectility of these organs and the part that it plajs in ovulation, menstruation and copulation, can be proved by producing an artificial erection in these organs on the dead body. Normally, the uterus and ovaries after ^ BecliercJies sur le type des organes genitaux et de leurs ajopareils muscu- laires. Inaugural thesis. Paris, 1855. INTRODUCTION death, if unimpregnated, sink into the pelvic cavity, and even when freed from the mass of intestines weighing on them, the uterus, unless supported bj the bladder and rectum, yields to every movement com- FiG. 45. — General view of the vascular formations of the internal genital organs. PV, semi-circular enlargement of the vaginal plexus ; PC, cervico- uterine plexus ; sp, helicine arteries of the body of the uterus ; h, helicine arteries of the hilum of the ovary. municated to it, bending and falling when no longer held up. In such circumstances, if, after having placed the pelvis in hot water, we inject the ovarian veins till the corpora spongiosa of the ovary and uterus are filled, we shall see the body of the uterus (as soon as it is distended by the injection) plainly straightening itself in the axis of the neck and rising in the pelvic cavity, executing a movement, that is to say, quite analogous to that of the pendent portion of the penis when it straightens itself into the axis of the portion fixed to the pubis and rises towards the abdomen. This change of position is accompanied by a marked change of size and form ; the uterus becomes more convex in front, but especially behind; its borders, previously attenuated become round ; and the walls of the uterine cavity separate sensibly at the same time, as Gunther and Kobelt have shown in the case of the walls of the urethra. Analogous, although less marked phenomena occur simultaneously in the ovary, whilst the Pallopian tube undergoes no change of any kind. As for the vagina, there seems to be no portion which can properly be said to be erectile, unless it be the plexus of broad veins which ANATOMY, PHYSIOLOGY AND TERATOLOGY 49 runs along its lateral borders, and the sometimes circular plexus which surrounds the first portion only of this canal. Doubtless, as Rouget remarks, sexual excitement in women is fre- quently limited to the erectile structures of the bulbs and clitoris ; but when it is complete — when venereal erethism reaches its summum of intensity — it must exceed these limits and extend to the essential organs of the genital function, in which is then developed the special voluptuous sensation which announces the accomplishment of the sexual act which the organs of copulation have only prepared. The Vagina and Vulva The vagina is a membranous canal extending from the neck of the uterus, which it embraces, to the vulva, from which it is separated by the hymen and vulval ring. It is in great part situated in the pelvic cavity, the curve of which it follows pretty closely, having an oblique direction from above downwards and from behind forwards which crosses the axis of the perineal strait, so that its lower extremity is in a plane anterior to the axis of this strait. It forms, therefore, with the uterus which is placed almost in the direction of the axis of the superior strait, an angle with an anterior sinus corresponding to the bladder and a posterior convexity in relation with the rectum. The aper- ture of the angle varies according to the vacuity or fulness of the bladder. Its length is from 10 to 12 centimetres, measuring it from the vulval ring; the anterior wall, according to Sappey, is only 75 milli- metres, whilst the posterior is 95 millimetres ; its width varies accord- ing to the individual, the age, virginity, pregnancy, &c. It varies also at different points, being narrow at the vulval orifice and increasing gradually from below upwards or from before backwards as far as the neck of the uterus. The dilated portion which surrounds the cervix is called the cul-de-sac or sinus, and is divided into anterior, posterior and lateral ; the posterior is the deepest, and often conceals morbid states of the vagina or of the corresponding cervical lip which are both difficult to diagnose and to cure. When left to themselves the anterior and posterior walls are in imme- diate contact, so that in place of being cylindrical the vagina, in a state of repose, is really flattened. The anterior surface is in relation with the urethra, and at the base of the bladder with the ureters (Figs. 16, 17, 18) ; its posterior surface with the perineum, rectum, and with the peritoneum to an extent of from 10 to 15 millimetres (recto- vaginal cul-de-sac) ; its borders with the levator ani muscles (which may com- bine their action with that of the constrictor), with the perineal or upper pelvic aponeurosis, with abundant adipose cellular tissue, and with the inferior portion of the broad ligaments. Above, the vagina adheres to the neck throughout the extent of the central third of the latter, leaving the posterior lip more exposed than the anterior and the posterior sinus broader than the anterior. Below it terminates in the vulval ring, the elastic tissue of which, with the constrictor and the 4 50 INTRODUCTION bulb, together constitute the narrowest part of the vagina and present a greater obstacle to the introduction of the penis than the hymen, may offer so much resistance during delivery as to require incision, and become the seat of a spasmodic contraction, with or without fissure, similar to that of the anus. To this vulval ring is attached the hymen, apparently formed by the apposition of the vaginal UliW Fig. 46. Fig. 47. Fig. 46. — Horizontal section of soft parts on a level with the inferior strait of the vagina, showing its walls in contact. Va, vagina ; Ua, urethra ; R, rectum and levator ani (after Cniveilhier). Fig. 47. — B, anterior vaginal wall, the posterior having been removed ; Ou, meatus ; above, anterior column foiTned by two enlargements diverging towards the base ; Oue, os externum ; *, section of the utero- vaginal cul-de- sac. mucous membrane (intermediary formation) to the vulval mucous membrane (external formation), and which, like all orifices placed on the borders of two different embryogenic fields, may be imperforate. As a rule, the hymen has an annular or semi-lunar form ;^ it is destroyed by coitus, leaving no other trace than the carunculce myrtiformes.- ' Roze, De Vhymen. Inangui-al thesis. Strasbourg, 1865. We shall consider these various anomalies aftenvards. ■■^ Puech has seen the singular case of a lady who never had a hymen, and who after delivery had four caruncidw myrti/orme^. ANATOMY, PHYSIOLOGY AND TERATOLOGY 51 The internal surface of the vagina is remarkable for the transverse ridges of its mucous membrane known as rugse, which reach their greatest height in the middle portion, where they form on each wall a median projection bearing the name of the column, extending from top to bottom, more prominent on the anterior than on the posterior wall and more marked near the vulval orifice, where it is sometimes double (Pig. 47), than near the uterine insertion, where it almost dis- appears. These columns and rugse, probably traces of the double vagina, give rise to grooves which become reservoirs for virulent matter and seats of syphilitic or blennorrhagic contagion. The average thickness of the vaginal walls is from 3 to 4 millimetres. The external coat is fibro-cellular and thin ; the middle one is muscular and thick, formed of a superficial layer of longitudinal fibres inserted below into the ischio-pubic rami, above into the utero-sacral ligaments and into the uterus itself, and covers a deep layer of fibres intercrossing obliquely or circularly. The inner coat or mucous membrane, also thick, varying in colour according to age and reflected above on to the vaginal portion of the cervix, is furnished with a great number of papillae and covered with pavement epithelium, which stops abruptly at the os externum and is renewed throughout the whole extent of the mucous membrane with surprising activity in certain pathological conditions accompanied by leucorrhoea. It is remarkable that the vagina not only is susceptible of great expan- sion and is dilated during pregnancy and delivery, but that it positively hypertrophies during pregnancy, its tissues sharing with those of the uterus, though to a smaller extent, the property of alternate hypertrophy and atrophy, in order to meet the exigencies of their special functions. The vagina seems to me to be without secreting organs properly so called. After having passed the vulval ring or circular insertion of the hymen, which is the limit of the richly glandular apparatus of the vulva, we must reach the vaginal surface of the cervix before encountering new secreting organs. The fluid which exudes from the vaginal mucous membrane, carrying with it epithelial debris, is always acid. It not only has a strong acid smell, but it powerfully reddens litmus paper. The vulva is limited externally by the labia majora, the cutaneous surface of which is covered with hairs implanted obliquely and the mucous surface of which presents the orifices of numerous follicles, as well as several rows of sebaceous glands.^ Below the skin and super- ficial fascia is to be found a sac, which is serous, according to Broca,^ and fatty according to Alph. Guerin,^ belonging to the mo7is veneris as • According to C. A. Martin and Leger {Archives generales de Medecine, 1862) the secreting apparatus of the external genital organs in woman is constituted solely (with the exception of the vulvo- vaginal glands) of sebaceous racemose glands and some sudoriparous glands which are only found on the external or cutaneous surface of the labia. The mvicipai'ous follicles of the vestibule of the meatus and of the urethra are only mucous crypts. 2 Bulletin de la SocUtn anatomique, Mars, 1851. Morpain, lEtudes anato- miques et patlwlogiq^ies des grandes Ihvres. These de Paris, 1852, No. 278. He has adopted the ideas of Broca. ^ Maladies des organes genitaux externes de la femme, p. 243. Paris, 1864. 52 INTRODUCTION much as to the labia majora, extending from the external inguinal ring to the level of the descending ramus of the pubis, separated above ♦ ill'- '"rV-'Ip^iftTi Fig. 48. Fig. 49. Fig. 50. Fig. 48, — Transverse and vertical section of the nymphse, — sebaceous glands (after Cruveilhier). Fig. 49.— General view of the sebaceous glands of the vulva, under surface natural size (Martin and Leger). Fig. 50.— Sebaceous glands of the labia majora opening into a hair-sac, 20 diameters (Martin and Leger). from that of the opposite side by a median sac, really serous, which prevents friction of the skin on the pubis, and not passing beyond the anterior half of the labium majus. The labia majora in uniting form the anterior commissure, below which is the clitoris. Behind and below they are flattened before uniting to form a posterior commissure, called ihtfourchette. Between the anterior commissure, and especially between the clitoris and the orifice of the vagina, is the vestibule. Between the posterior commis- sure and orifice of the vagina is the fossa navicularis. The nymphse, situated within the labia which they occasionally exceed in their middle portion, are forked before and above, i. e. below the anterior commissure, so as to form a kind of hood or foreskin for the clitoris. They enclose a great number of sebaceous glands at this point. They may be so hypertrophied as to exceed the labia majora to a certain extent and become very troublesome under some circumstances, e. g. in riding. Both surfaces are covered witli mucous membrane, the ANATOMY, rflYSIOLOGY AND TERATOLOGY 53 internal having an innumerable quantity of little glands, generally arranged in three or four concentric rows. The meatus urinarius is situated 1 \ centimetres behind and below the clitoris ; in virgins, as a rule, it is a mere slit, but in lascivious women it is open, owing to the erectile turgescence all round the orifice. Sometimes it is half closed by a kind of inferior median ridge continuous with a prominent inferior tubercle, occasionally double (Fig. 47), the termination of the anterior column of the vagina and serving as a guide in catheterism. The meatus is generally on a line with the vestibule when it is easily discovered. According to Alph. Guerin, however, in women who have had precocious intercourse the vulva is pushed backwards and the meatus concealed under the symphysis of the pubis. Sometimes the vaginal orifice is gradually dilated without any laceration of the hymen taking place. Generally, however, only traces of this membrane are found after the first coitus. These vestiges are known by the name of carunculse myrtiformes; they vary in number, size, and form, according to the individual conditions and the amount of violence used. There are generally four or five, most frequently one inferior and always two lateral, at the base of which the orifices of Cowper's glands are seen. The secreting organs of the vulva are the sebaceous and piliferous follicles and the muciparous glands. The sebaceous and piliferous follicles are excessively numerous, and are only observed on the mons, on the labia majora and minora, and in the genito-crural folds. The follicles of the nymphas are simply seba- ceous. The muciparous glands are grouped within the nymphse, nearer the entrance of the vagina. Some, already described by several authors, notably by Eegnier de Graaf^ and more recently by Eobert,^ have been called by Huguier^ isolated muciparous follicles. The others form a true gland, designated by this author as the vaginal follicular body or vidvo-vaginal gland. The isolated muciparous folli- cles are collected especially at three or four points round the vaginal orifice ; at the vestibule, between the clitoris and the urethra {vestibular follicles) ; circularly round the meatus, on the surface of the central tubercle which limits this opening below (urethral follicles) -, at some distance from the meatus and on its sides (urethro-lateral follicles') ; lastly, sometimes on the lateral portions of the vaginal entrance, imme- diately below the hymen or upper carunculce myrtiformes {lateral follicles of the vaginal entrance) (Fig. 51). The vulvo-vaginal glands described by Duverney, Bartholin, Garen- geot, Morgagni, Cowper, and lately by Tiedmann* and Huguier^ are 1 Traite des parties des femmes qui servent a la generation, p. 120, in I'Histoire anatomique des parties genitales de I'homme et de lafemme. Bale, 1649. 2 De I'injlammation des follicules muqueux de la vulve. Arch. gen. de med., August, 1841. 3 Memoirs sur les maladies des appareils secreteurs des organes genitaux externes de lafemme {Memoires de I'Academie de onedecine, t. xv, p. 527, et seq.). ^ Von den Duverneif sclien, Bartholin' schen oder Cowper' schen Driisen des Weibes. Heidelberg, 1840. See also Knox, Lond. Med. Gaz., vol. xxiii. » Op. cit. Paris, i841. 54. INTRODUCTION conglomerate or racemose glands, situated right and left of the entrance of the vagina, small before puberty, greatly developed in voluptuous Fig. 51. Fig. 52. Fig. 51. — Muciparous follicles of the vulva, a, vestibular follicles ; h, lateral urethral follicles ; c, central urethral follicles ; d, lateral follicles of the entrance of the vagina; e, orifice of the excretory duct of the vulvo- vaginal gland. Fig. 52. — Vulvo-vaginal gland and its excretoiy duct (after Huguier), a a, section of the labium and nympha ; b, the gland ; c, its excretory duct ; e, its orifice in the vulvo-cai'uncular sinus, a dii'ector is introduced ; /, bulb of the vagina ; g, ischio-pubic ramus. women, surrounded immediately by a fibro-vascular envelope in relation with the transverse artery of the perineum, placed between the vagina and its bulb (to which they lie close) on the inner side, the ischio- pubic ramus, which is 1 centimetre to the outside, the central apo- neurosis of the perineum situated behind and above, and the super- ficial aponeurosis in front and below. They are bounded on all sides by resistant layers, so that pus formed internally can hardly escape into either the rectum or the vagina nor run together as in abscesses of the labia. The excretory duct, 2 centimetres long, opens at the union of the lower fourth with the upper three-fourths of the vaginal orifice, beyond the hymen or lateral canmculre myriiformes, at the base of the groove which separates the external surface of these carunculse from the internal surface of the nympha?, where it may often be recognised by a red border. Excitation of the clitoris, the corpora cavernosa and the bulb of the vagina greatly increases the secretion of the vulvo-vaginal glands. The mucus secreted by the follicles and the vulval glands is acid, that which is secreted by the vestibular and peri-urethral follicles has ANATOMY, PHYSIOLOGY AND TERATOLOGY 55 always seemed to me more acid than that which is secreted by the vulvo- vaginal gland. Development — Comparison of the Genital Economy in the TWO Sexes Development^ takes place from different embryonic points, which are more or less independent of each other in their evolution. The external generative organs (the vulva and its dependencies) are developed from the external layer of the blastoderm ; the internal generative organs arise from the middle blastodermic layer. Hence anomalies may be produced in one of these formations to the exclusion of the other. There is even a point of central formation, which is neither the external layer nor the intermediate blastema, but the septum established in the primitive cloaca formed by the rectal cul-de-sac and the bladder which has been previously derived from the latter under the form of the hollow pedicle of the allantois ; the vagina is developed at this point, which explains a relative independence between the anomalies of this portion of the generative system and those of other parts. In short, each of these portions, especially the internal one, presents in its turn several centres of formation, equally endowed with a relative inde- pendence each of the other, and capable of undergoing, each by itself, arrests in development, alterations in type or differences of direction, ■which multiply the number of anomalies and which may carry dis- similarities in the development of different parts of the same economy as far as that difference of sexual character which constitutes herma- phrodism. A few words will suffice to explain this. At the beginning the development of the internal generative organs takes place around the Wolffian bodies.^ These bodies atrophy towards the end of the second month, leaving probably, as traces in the adult, those vestiges of organs in connection with the testicles or ovaries known by the names of vas aberrans in the male and the organ of Eosenmiiller in the female. Whilst the Wolffian bodies atrophy, new organs are developed in the same region. These are the kidneys, the ovaries or the testicles, the oviducts or the spermatic ducts, &c. I. Along the inner border of the Woliiian body there is a fusiform enlargement which, increasing gradually in size and diminishing in length, forms the first rudiment of the testicle or ovary. Along its external border, parallel and attached to its excretory duct, but quite * See Kiissmaul's work, Yon dem Mangel, Verhmnmenmg tind Verdoppelung der Gebai-mutter, Wuvizhnvg, 1839 ; as well as the work of M. Lefort, Des vices de conformation de I'literus et du vagin, &c., Paris, 1863, and that of Guyon, Des vices de conformation de I'urethre cliez I'homme, Paris, 1863 ; see also Albers, Die weibliche Cloakbildung in Monatsschrift fiir Geburtsh, und Frauen- hranhheiten, Berlin, 1860, Bd. xvi, 4« Heft ; and Ko-lliker, EntivicJcehmgsge- schiclite der Menschen und der lioheren Thiere. Leipsig, 1861. - Follin, Becherches sur les corps de Wolff. Paris, 1850. 56 INTRODUCTION independent of the tubes, tliere is a second organ, at first a simple solid cord, later hollowed into a canal, known by the name of Miiller's duct. The excretory canal of tlie Wolffian body and Miiller's duct Fig. 53. Fig. 54. Fig. 53. — Wolffian body (after Coste). c v, Wolffian body ; s, excretory canal of Wolffian body ; o, future ovary or testicle ; t, future oviduct or sperm- duct called Miiller's duct ; m, future uterus ; the figure placed alongside shows the fjlandular structure of these organs. Fig. 54. — Wolffian body and internal uro-genital system of the human embryo after the fortieth day (after Coste). cv, Wolffian body ; o, ovary or testicle ; s, excretory canal of Wolffian body ; t, sperm-duct or oviduct, Miiller's duct ; m, future uterus ; c, suprai'enal capsule ; r, kidney ; u, ureter ; v, bladder ; gi, large intestine, rectum. both run into the cloaca. Now, according to Rathke and Kobelt, whilst the sperm-duct is developed from the excretory canal of the Wolffian body, the oviduct proceeds from Miiller's duct. In the first period of intra-uterine life there is a time when distinc- tion of sex is impossible. This confusion is owing to similarity of form, which soon disappears in the internal as well as in the external organs. If Miiller's duct atrophies, Wolff's excretory duct forms a sperm- duct, and is united, by means of tubes afterwards transformed into the epididymis, with the germinative organ which becomes the male generative organ or testicle. If Miiller's duct is developed it forms an oviduct, develops at its extremity a Fallopian tube, and remains distinct from the germinative organ, /. e. from the ovary. As for the germinative organ, it is united to the sperm-duct by efferent vessels (epididymis), or it remains isolated from Miiller's duct, with the excpj^tion of the interposition of a certain number of atrophied \\ olffiaa ducts (organ of Rosenmiiller), according as it is testicle or ovary. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 57 Thus, the Wolffian body never entirely disappears either in the male or female; its elements atrophy. In the male the remains of its tubes, besides the part which they have taken in the formation of the epididymis, frequently become small epididymous cysts, and form pro- bably the corpus imiomivahim of Giraldes,^ the vasa aherraniia of Fig. 55. — Figure showing the organ of Rosenmliller. Superior right angle of the uterus (Ut) and portion of the hroad ligament (LI) with oviduct and ovary, seen from behind ; Od, isthmus of the oviduct ; Od', largest portion of this canal ; J, fimbriated extremity ; Oa, abdominal orifice of Fallopian tube ; Fo, fimbrise ; 0, ovary turned downwards ; Lo, ovarian ligament ; io, infundibulo-ovarian ligament ; ip, infundibulo-pelvic ligament divided at its pelvic insertion ; Po, parovarium or organ of Eosenmiiller, exposed to view by the ablation of a portion of the posterior fold of the broad ligament ; *, vascular branch which follows the border of the ovary. Haller. In the female the Wolffian body becomes the organ of Eosenmiiller, its central tubes end in the hilum of the ovary, the outer ones disappear or atrophy and remain the analogues of the rasa aberrantia ; the excretory duct of the Wolffian body disappears by atrophy, and is found in this state, in the cow for example, on each side of the uterus as far as the vagina, where it terminates under the name of Gsertner's canal. Therefore, according to the formof development affected by Miiller's ducts or the Wolffian ducts, an oviduct or sperm-duct is produced, and concurrently with it an ovary or testicle. I. One of these forms of development may appear on one side, whilst another is produced on the opposite side, the result of which would be a lateral hermaphrodism. 2. The two forms of development may appear incompletely and simul- taneously on the same side (but much less frequently so, especially I Becherches anatomiques sur le corps innomine, Journal de Brown- Seqiiard, i. iv, p. 1. 58 INTRODUCTION as regards the germinative organ), so that on this side there may be produced a testicle and an oviduct or an ovary and a sperm- duct, and even a testicle and an ovary superimposed, a phenomenon to which has been given the name of double or vertical hermaphro- dism ; only we must remember that it is easy to be led into error in this case by the persistence of the Wolffian duct or of Gsertner's canal. 3. Lastly, one of these forms of development may take place in all the deep organs, which will be, for example, all male, whilst the opposite development is effected in the superficial organs which are female, the result of w^iich would be transverse hermaphrodism. As regards this transverse hermaphrodism, the independence of the development of the external and internal generative organs, which are produced in two fields of formation quite different from each other, shows that it may occur comparatively frequently.^ Now, in order to understand how Miiller's ducts when transformed into oviducts, are developed into Fallopian tubes and uterus, and how the continuity of these organs is estabUshed with the vagina and external generative system, we must remember that development proceeds simultaneously on the intermediate blastema and on the internal and external layers of the blastoderm. On the internal layer this development takes place early. The allan- tois produced by budding from the anterior surface of the rectal cul- de-sac continues attached to the rectum by its pedicle. This pedicle is hollowed out into a canal (urachus), which widens at its point of origin in the rectum into a reservoir (the bladder) ; so that at this period the bladder and rectum form a true cloaca in which the genito-urinary canals terminate, similar to that on the exterior which precedes the formation of the anus and urogenital orifice. In pro- portion as the uterus is formed by the apposition of Miiller's ducts the cloaca is divided, allowing the formation of the vagina either in the blastema interposed by this division between the bladder and the rectum, as is supposed by Eathke who thinks the lower part of the uterus is developed in the same way or by the prolongation of Miiller's two ducts, which themselves form a double vagina below a double uterus. I think the most probable hypothesis to be that which limits to the uterine cervix the formations depending on Miiller's ducts, and which supposes the vagina to be developed from the tissue the inter- position of which between the rectum and the bladder has previously ettected the separation of these two reservoirs, or in its lateral borders. I will give my reasons presently. . However that may be, we can in any case say with certainty that Miiller's ducts, during the development of their lower portion whilst approaching each other and in proportion as they descend, pass through three periods characterised by — 1, complete separation and division; 2, reunion in the median line; 3, complete fusion. Eunning along the external border of the excretory canal of the "WollKan body, Miiller's duct changes its direction lower down and * Geoffroy Saint-llilaiie, Traite de Uraiologie. Paris, 1836; L. Lefort, op. cit., 1). 174. ANATOMY, PHYSIOLOGY AND TERATOLOGY 59 describes a half circle round this canal, coming in front and to the inner side of it to meet its fellow of the opposite side to which it becomes attached and united in the median line. J. Y. Meckel observed, in embryos of from eight to nine weeks, absolute equality in calibre and the absence of any line of demarca- FiG. 56. — Development of the internal genito-urinaiy organs in a human embryo older than the preceding (after Coste). c, suprarenal capsules ; r, kidneys ; o, ovaries ; u, ureters ; /, Fallopian tubes ; m, uterus ; I r, round ligament ; v, bladder. tion between the rudimentary oviduct, uterus, and vagina. According to Kiissmaul, however, at about three months the womb can easily be distinguished from the vagina by a somewhat greater thickness and consistency ; the very fine oviducts begin to become flexuous, and are about a third longer than the corresponding uterine cornu. The sepa- ration between the oviduct proper and the uterine cornu is marked by the insertion of a fibro-muscular cord, afterwards to be known as the round ligament. Meckel justly compares this organ to the suspensory- ligament of the testicle {^g^ihernacuhim testis of Hunter). Wrisberg designates it the cremaster of the womb, and Eathke confirms the analogy by the study of its development in the embryo. Between the testicle or ovary on one side and the pubis on the other extends on each side a kind of ligament, destined to become more or less muscular, having connections with the inguinal canal, the scrotum or labium. The presence of this organ determines, in the scrotum or labium, the peritoneal prolongation known as the tunica vaginalis in man, canal of Nuck in woman, the obliteration of which takes place after birth, partially in the one, completely in the other. Its ulterior changes bear a relation to the displacements of the testicle and ovary. The testicle, descending into the scrotum, pushes before it the gubernaculum which covers it and which is transformed principally ijito the cremaster ; the ovary, descending only into the 60 INTEODUCTION pelvic cavity, preserves its relations witli this organ which, adhering to the oviduct at its point of intersection with this canal and there modifying the direction or the number of its contractile fibres, becomes the uterine ligament of the ovary in its upper portion and the round ligament of the uterus in its lower portion. The portion of the ovi- duct placed above it forms the Fallopian tube, that below it the womb. The two uteri are recognisable for a long time after their union by the projection of the cornua of which the Fallopian tubes are a continua- tion. Gradually the fundus rises slightly between these two cornua but for a long time without the organ losing the traces of its primi- tive duplicity. Tlie womb at the same time becomes more volumi- nous, more cylindrical, and the body may be distinguished by the enlargement of the upper part. This portion, however, remains in a state of comparative inferiority ; for, owing to the length of the neck, it does not reach the third of the total length of the organ in a foetus at term. To sum up : two cords at first solid (Miiller's ducts), separated above by the width of the vertebral column and of the Wolffian body, are united below back to back. The part situated above the point of union and Hunter's ligament will form the Fallopian tube, the part below will constitute the uterus. Each of these cords is hollowed into a distinct cavity, then the partition separating the two disappears from above downwards, and the uterine canal, at first double, becomes finally single. II. Between the internal generative economy, the development of which we know, and the external generative economy, the formation of which we shall presently study, there is an organ of transmission, the vagina, intermediate in function as in position. The notions which we have as to its evolution are somewhat hypothetical, for they are deduced partly from direct observation by embryology, partly from indirect observation by teratology. We have seen that, within the external fold of the blastoderm while still imperforate, there is a true cloaca or cavity common to several hollow organs. This cloaca is the termination at first of the rectum behind, then of the bladder (dila- tation of the hollow pedicle of the allantois) before, and finally of the excretory canals of the Wolffian bodies, of Miiller's ducts and of the ureters laterally. The communication between the rectum and bladder is limited above by a band or elevation, indistinct at first, but which, becoming more and more marked, descends from above downwards under the form of a flattened membrane, and gradually separates the intestinal cavity completely from the reservoir of the urine. It is in the central blastema forming the division between these two reservoirs that the vagina is soon afterwards developed ; it has not been determined whether it is developed from above downwards or from below upwards, but it is certainly produced from two lateral canals, communicating above with the uterine necks (the probable ter- mination of Miiller's ducts) and below with the vulva where may be found a double hymeneal orifice, and destined, like several other pairs of organs, to unite together, the absorption of the partition reducing them ANATOMY, PHYSIOLOGY AND TERATOLOGY 61 to a single canal extending from the uterine orifice (which has also become single) to the vulval ring developed in the midst of the cutaneous formations. Now, if the membranous band destined to separate the rectum from the bladder is not formed, an abnormal communication^ (cloaca) will persist between the two organs. If formed incompletely and hollowed into a vagina, a double communication will remain, giving rise to a double congenital fistula (vagino- vesical and vagino-rectal). If the vesico-rectal septum is formed but not hollowed out, there will be no vagina ; if hollowed out imperfectly, there will be a partial vagina ; the superior or inferior portion may be in turn alone developed, or two parts may exist simultaneously, the one superior, the other inferior, between which there may be at a variable height, a transverse partition, thick or thin, imperforate or perforate. Lastly, if the primitive double vaghia is developed normally in the vesico-rectal septum, but if the development is arrested there, a double vagina will persist, co- existing or not with a similar arrest of development in the uterus. If the two canals are united incompletely the malformation will be limited to a partial longitudinal partition between the right and left portions of the vagina; if the union is complete, but if the cavity has not enlarged to its normal extent, there will be a congenital narrowness. III. The external generative economy ^ot% not begin to be developed till after the first formations of the internal generative organs, particu- larly the Wolffian bodies. In an embryo of thirty-five days an accumu- lation of blastema may be seen on the external tegument near the caudal extremity. The result is a simple oval, central eminence, from which afterwards a secondary formation of buds is seen to arise, destined to form a series of appendages. This eminence is soon hollowed out in the centre by a longitudinal depression which, by corrosion of the tegumentary fold, soon becomes an external linear orifice, getting deeper and deeper and terminating (when evolution progresses regularly) by communicating with the cloaca of which we have spoken and afterwards with the vesical, vaginal and rectal cavities which finally become distinct and independent. Later on two rounded eminences are developed from each side and towards the upper part of this slit, destined to form the corpora cavernosa of the penis in the male, the clitoris and nymphse in the female. They are united at first by their upper or dorsal surface, leaving a lower half-groove between the opposed surfaces. This half-groove persists in the forma- tion of the female economy; in that of the male it is closed below by a kind of raphe, which converts the primitive half- canal into a com- plete one, the urethra. The malformation known as hypospadias results from the arrest of development in this line of union. Below these eminences two others are developed, which in the male form the scrotum, in the female the labia. Lastly, a transverse parti- tion is developed lower down, which ultimately becomes the perineum separating the anus from the vulva. ^ Puecli has wi'itten a good paper on the uro-genital cloaca. Montpellier Medical, Jan. and Feb., 1868. 62 INTRODUCTION It is by the disappearance of the tissue situated between the rectal cul-de-sac, the vagina, and the bladder on one side, and the external integument on the other, that the three cavities — intestinal, genital Fig. 57. — Development of the anus and external genital organs in a human embryo of thirty- five days (after Coste). i, intestine, on the sides of which two white masses are seen (Wolffian bodies) ; below is the section of the urachus and umbilical arteries and veins ; lower still, the cutaneous fold slightly turned back over the ano-genital orifice. The latter consists in a simple slit in the centre of an ovular eminence, m i, inferior mem- brane ; q, caudal prolongation. and urinary — open externally. If this development does not proceed regularly and completely on a level with the anal depression, the rectal cul-de-sac will not open, and there will be an imperforate rectum. When an analogous phenomenon occurs in the vaginal portion, there will be a more or less extensive obliteration of that part of the vagina which joins the vulval ring or simple imperforation of the hymen. Comparison of the generative organs in the two sexes. — The reader would wish me, I think, to follow up the description of the develop- ment of the uterus and its appendages by some observations on the independence of the different zones in which the genital economy is developed, and on the analogies between the different parts of this economy in the male and female. These considerations may not only throw some light on the diagnosis of sexual anomalies in general, and help in determining particular cases, but they may also lead to more frequent and immediate applications to the various morbid states of the genital organs than one would at first be apt to think. The direct observation of the development of the embryo shows that the genital economy may be divided into three zones, which must be considered as three distinct seats of organic evolution, each developed independently of the others, and tending to produce one system destined for the accomplishment of a single function. Of these three zones the two outer are principal, the middle or intermediate one is secondary. The former are the internal and external genital organs, the latter is the means of union between the two. The middle zone is simple : the vagina is developed between the ANATOMY, PHYSIOLOGY AND TEEATOLOGY G3 vulval ring belonging to the external zone and the neck of the uterus belonging to the internal zone, almost in the same way that the oeso- phagus is developed between the cul-de-sac of the stomach pierced by the cardiac orifice and the cephalic cul-de-sac developed into the buccal Fia. 58. I'iG. 59. Fig. 58. — Development of the anus and external genital organs in a human embryo of from thirty-five to forty days (after Coste). o, urachus and pedicle of the umbilical vesicle, the umbilical vessels of each side ; c, cutaneous fold of the umbilical cord wide open ; i, intestine ; g, central projection produced by the development of the genital economy. If this projection is seen in front, as in the annexed figure, two lateral eminences will be observed above, the origin of the future corpora cavernosa ; below, two smaller eminences, the origin of the future scrotum or labia. On the median line above, a slit between the points of origin of the corpus caver- nosum ; lower down, an opening, the uro-genital orifice ; lower still, a second opening, the anus. Fig. 59. — Development of the external genital organs in an embiyo a . little older than the preceding, the sex of which, however, cannot yet be dis- tinguished, p, corpus cavernosum (penis or clitoris), below which i-uns a central groove terminating in the uro-genital orifice ; b, scrotum or labia not yet united in the median line ; a, anus. and pharyngeal cavity. The external zone is complex, but this com- plexity depends only on its structure, and not on the difference of the seats of evolution, its whole development being effected at one and the same point in the embryo. The internal zone is more complicated still, for the character of this complication exists in the multiplicity of the centres of formation, the ovaries being developed along the internal border of the Wolffian bodies, whilst the Pallopian tubes and the uterine cornua are formed along their external border, the Pallopian tubes above, the cornua below the point where the oviduct, considered as a whole, crosses Hunter's ligament. These various centres of formation are precisely the points at which development may be arrested separately, or where a deviation of the plastic act may be manifested. Therefore the anomaly may affect the ovary, Pallopian tube or cornu on both sides or on one. It may extend to several of these organs at once. The whole internal zone may be affected or the intermediate or external one. The two former 64 INTRODUCTION zones may even be affected to the exclusion of the third, or the latter may alone be affected ; for the two former are situated in the blastema between the serous and raucous folds, and the third in the serous fold transformed into the cutaneous envelope. Now, my teratological studies have led me to consider these primordial embryonic folds as vseats in which very frequently the action of the cause which brings about an arrest of development is exhausted; between these points there seem to be limits which cannot be passed by any known terato- logical cause.^ As for the analogies which embryology, in concert with relations, connections, structure, vascularisation, innervation and functions, permits us to establish between the various portions of the genital economy, male and female,^ I shall confine myself to their enume- ration. In the external economy the analogy is striking between — The scrotum The penis .... The bulb of the urethra The glands of the urethra . Cowper's (bulbo-urethral) glands and the labia majora, ,, „ clitoris, „ ,, bulb of the vagina, „ those of the vulva, „ Bartholin's (bulbo-vulval). In the internal economy it is easily demonstrated between — The testicles ..... and the ovaries, The cremasters . . . . • „ ,, roiind ligaments, The vasa deferentia . . . . „ ,, Fallopian tubes, rT,\. ^ i. -i. e i.-u A c ( The body of the uterus, with the glands The lower extremity of the vasa deter- ) e -.•' , ", ., ,. J i.1, • • 1 -1 < or its mucous membrane and its entia and their vesiculse semmales -^ muscular richness. The ejaculatory ducts opening on the^ ^^^ ^^^ ^^^,^.^ ^^^^. ^^^.^^^ ^^^ vemmontanum, separated by the f ,^,,^^^^,^ , its glandular agglo- utriculus and surrounded by the I meration •' ^ "» prostate ..... .J Lastly, the intermediary organ is represented by — The membranous portion of the urethra") „„, ,, „ „„„:„„ • „„.^„„ ^ i and the vagina in woman, in man ......) ° This last analogy may seem strange without a little reflection. It is, however, easily justified. The vagina, in fact, is developed in the blastema between the rectum and bladder immediately above the central perineal aponeurosis, by the formation, in the vesico-rectal par- tition, of a canal which goes to meet the vulval slit on the one side ' Memoire sur I'absence complete du vagin, de Vuterus, des trompes et des ovaires, &c., with remarks on the absence or arrest of development of the various paiis of the genital economy of the female and general considerations on teratological laws ; in the Mcmoires de VAcadimie des sciences et lettres de Montpellier, t. ii, p. 321. Montpellier, 1853. ^ It is curious and very interesting to pursue these researches on the analogy between the various parts of the vascular system, the nerves, muscles, apo- neuroses and glands, and to verify the wonderful concordance existing between the elements which correspond in the male and female. ANATOMY, THYSIOLOGY AND TERATOLOGY 65 and the cervix on the other. It is identically at the same point and in the same way that the membranous portion of the urethra in man is formed, in front of the urethral crest (junction of the two sperm- ducts), behind the groove of the penis which is soon converted into a canal by an inferior line of union extending to the bulb where is also found a falciform fold, the boundary line between cutaneous and inter- mediary formations, and where, when catheterism is practised on the male, the catheter is frequently arrested before penetrating the mem- branous portion. A consequence which results from the latter analogy seems, at first sight, very paradoxical, namely, that in man there is no proper urethral canal whilst there is one in woman. In man, the canal by which the urine flows from the bladder is nothing but the analogue of the vagino- vulval canal in woman developed in another way and put to other uses. In man, the urinary passages properly so called terminate at the neck of the bladder. The canal into which they open belongs, by its origin and destination, to the genital economy. It is certainly, and above all, the propulsor of the semen. It only lends itself to the excretion of the urine which passes through it from one end to the other, traversing successively its prostatic (cervix), membranous (vagina), and bulbo-spongiose (vestibule) portions — a new proof of the differences of structure or of destination which nature can imprint on organs fundamentally identical.^ The aim of such research after analogies leading to such results is chiefly to satisfy the mind and to lead it to the philosophy of science ; it may, however, also lead to some practical applications. The physiolo- gist does not undertake the study of organic analogies because he desires to force a resemblance between dissimilar organs, but because it is interesting to observe how these various parts are gradually formed and differentiated from each other, although their embryonic identity was such that it was impossible to predict their future condition ; also, because the knowledge of these analogies leads to unexpected anatomi- cal and physiological interpretations stamped with the most living reality ; and lastly, because exact and useful resemblances may be deduced from a pathological point of view between organs proved to be anatomically analogous. Anomalies The majority of permanent teratological conditions in the genital, as in all the other organs of the economy, represent transitory embry- ^ In 1849 I pointed out all these analogies, developing them in a paper entitled, Des differences que presente V organisation dih corps liumain dans les deux sexes, which was published in the Annales cliniques de Montpellier, 1855. My colleague and friend, Professor Rouget, had on his side heen led to adopt similar conclusions, especiallj with reference to the cervix and prostatic portion of the urethra. See his Becherches sur le type des organes genitaux et de leurs appareils musculaires. Paris, 1855. 5 66 INTRODUCTION onic states. Eoerster,^ Kiissmaul,^ Leon Lefort/ and Klob* have based the natural classifications which they have made of these mal- formations on this idea. This scientific interest^ however, is not the only one which leads us to say a few words on the anomalies of the genital economy of woman. The cases of vaginismus, impotence, dysmenorrhcea, and sterility, which are simply dependent on a tera- tological condition of the genital organs, are so common that every day in practice we have additional proof of the necessity there is for the physician to know exactly the normal disposition of the sexual organs, what I may call their physiological form, so as to be able to distinguish it without difficulty from the alterations in form, size, situation and relations which suffice to prevent the accomplishment of their functions, and to seize easily the indications that must be fulfilled in order to correct these anomalies and bring them back to their normal conditions or conditions resembling their normal develop- ment. With a little experience we can often guess at the existence of these monstrosities by subjective signs and, if the development of the sexual economy and the arrests of development to which it is exposed are present to the mind, we can easily diagnose them by the objective signs which are detected by methodical examination. In giving a teratological description of the various zones of the genital econoyny in woman, I shall omit a multitude of facts which are only interesting as mechanical causes of more or less serious derangements in the accomplishment of their functions, while I shall place in the hand of the physician a clue which will enable him easily to find his way through the labyrinth of anomalies which suffice to produce the most serious func- tional disorders and become the startiag-point of diseases the real cause of which was for long, and is even now, too frequently misunderstood. I. General Anomalies of the Generative System These anomalies may be characterised by an absence or imperfection of formation, by an excess of development, or by a defect or deviation of the plastic process. The first kind is equivalent to absence of sex or neutrality in the individual, the second to real hermaphrodism by substitution or excess, the third to an apparent hermaphrodism. 1. Neutrality. — There may be absence, rudimentary state, imper- fection or arrest of development with persistence of the embryonic form of all the organs constituting the three zones of the generative system, or of all the organs of one of the three zones, or of some, or of even one only of these organs, the consequence of which is a condition which makes it impossible for the individual to accomplish functions devolving on organs which do not exist, and which is equivalent to the 1 Manuel d'anatomie pathologique, translated by Kaula, p. 440. Strasbourg, 18o3. 2 Von dem Mangel, Verhummerung u. Verdoppelung der Gebdrmutter. Wui-tzburg, 1859. ^ Des vices de conformation de V uterus et du vagin, p. 23 and followins:. Paris, 18(33. * Pathologische Anatomie der weiblichen Sexualorganen. Vienna, 1864. ANATOMY, PHYSIOLOGY AND TERATOLOGY 67 absolute privation of sex^ assimilating the woman so affected to tliose females amongst insects (bees, ants, &c.) designated as neuters, owing to the absence, rudimentary condition or congenital atrophy of their sexual economy. This condition may produce incapacity for repro- duction owing to the absence of germination, and the impossibility of forming a germ or ovule, or it may lead to relative impotence owing to the difficulty or obstacles, sometimes quite insurmountable, which alterations in form and position of the organs produced by these arrests of development put in the way of coitus, of the subsequent meeting of ■ the male and female element, and of fecundation; or lastly, there may be germinative impotence, impossibility of fecunda- tion and incapacity for gestation, owing to the absence of the uterus itself. I have seen individuals inscribed in the civil register as women, some of them having the marks of a feminine organisation, but in whom the generative functions, by an arrest of development affecting part or the whole of the sexual economy, were so annihilated as to assimilate them to those animals known as netiters. As one of many interesting cases of this kind which I have seen and have been able to examine, there was one on which I had to give an opinion based on subjective signs alone (the subject refusing to be examined) taken from what the patient herself said and from the testimony of persons who knew her. I found in these signs proofs which enabled the tribunals to declare nullity of marriage on the ground of error as to the sex of one of the parties.-^ 3. True Jiermaplirodlsm, common in the lower animals and in almost all vegetables (under the name of gynandry or androgyny), was till lately believed to be only apparent in the human kind. Two cases, however, are now recorded, one by Rokitansky and another by Heppner, which prove to a certainty that the simultaneous presence of organs characteristic of both sexes may be found in the same in- dividual, not only the one on one side the other on the other, but both simultaneously on the same side. There is no longer any doubt either as to the mode in which the testicle and ovary, sperm duct and oviduct, are formed. Eokitansky,^ in 1869, presented to the Medical Society in Vienna the results of the autopsy of a person named Hoffmann, in whom he found two ovaries with their Pallopian tubes, a rudimentary uterus and one testicle with vas deferens containing spermatozoa. This individual, who had men- struated regularly, had an imperforate penis and a bifid scrotum ; there was absolute sexual indifference. Heppner,^ of St. Petersburg, has published the interesting results ^ Courty, Detnande en nullite de 'tnariage, fondee sur le defaut de caracteres sexuels feminins ; consultation medico -leg ale et considerants du jugetnent. Montpellier medical, t. xxviii, p. 473 ; Montpellier, 1872 ; and Annales de Gynecologic, t. ii, pp. 325, 410. Paris, 1874. ^ Centralblatt fiir die medicinische Wissenschaften, 361-1111, Union medicale, 3rd series, t. vi, p. 498. Quoted by Maurice Laugier, Nouveau dictionnaire de medecine et de chirurgie pratique, t. xvii, p. 505. 3 Sur I'hermaphrodisme vrai dans I'espece humaine, trad, pai- Doiimic, Gazette medicale de Paris, 1872, p. 29. 68 INTRODUCTION of the autopsy of a hermaphrodite of six weeks, preserved in alcohol for several years. He found in this child, together with a complete internal generative apparatus (ovaries and Fallopian tubes, uterus and vagina opening into the urethra), two glands which microscopical examination proved most clearly to be two testicles. There was a penis and a hypospadic prostate, but neither vesicula seminales nor vasa deferentia. Thus there may be excess of formation, not in the external and median zones which are never double and in which a male de- velopment can only be substituted for a female, or vice mrsd^ but in the inner or deep zone, where the male and female germinative organs may exist simultaneously, not only the one to the right and the other to the left, but both on the same side and even both on both sides, which is the extreme case of bi-sexual hermaphrodism, or hermaphro- dism by excess. In most cases, in place of finding male and female organs on both sides or on one side, we observe male organs on one side and female organs on the other, or male organs in one of the zones, or in a part of one of the zones, and female organs in another. Fig. CO.— Apparent female hermaphrodism owinj? to the abnormal development of the clitoris, obliteration of the vagina and descent of the ovary into the labium (after Anger). The first fig. represents the hermaphrodism before the operation ; the second after, c, clitoris ; sv, sound in the vulval orifice ; o, ovary ; u, urethra ; Va, vagina formed by operation. or in a part of another zone. When a more or less complete male organism on the one side co-exists with a more or less complete female ANATOMY, PHYSIOLOGY AND TEEATOLOGY 69 organism on the other, this anomaly is called lataral hermaphrodism. When the genital economy of one sex is developed on both sides in one of the zones, and the genital economy of the other sex in another zone, this anomaly is called transverse hermaphrodism. Lastly, when there is co-existence on one side only of an organ of one sex in one of the zones with an organ of the other sex in the same zone, or if the deep zone belong to one sex and the central or superficial zone to the other (case included in the preceding), it is called vertical or double herma- phrodism. True herma])hrodism, therefore, may be simple or double, unilateral or bilateral. From a physiological point of view it will be seen that it is not possible for a hermaphrodite to effect self-fecundation nor to assume the sexual functions of both sexes alternately with another hermaphrodite, as do the lower animals when similarly organised ; in fact, this apparent wealth is in reality poverty. When there is an excess of organs in any individual this excess always coincides with a Fia. 61. — Marle-Magdeleine Lefort. Section of the pelvis showing the genital organs, s, sound passing through the principal orifice helow the clitoris ; V, vagina ; o, ovary ; t, Fallopian tube ; u, uterus ; Lr, round ligament ; c, clitoris ; L, labia. defect, an imperfection or an absence of formation in these organs. The arrest of development which always accompanies these singular 70 INTRODUCTION anomalies affects not only the additional organs, but also the organs of the primitive or fundamental sex — all the organs, in fact, in the zone in which the teratological condition is manifested, and frequently those in the other zones also. 3. Apparent hermaplirodism. — In most cases the hermaphrodism is apparent. If the testicles have not descended from the abdominal cavity, if the penis has remained smaU, the two halves of the scrotum sepa- rated, the bulbo-spongiose groove open and communicating directly with the membranous portion, and if the urethra terminates in hypo- spadias, the cryptorchis, the species of vagina of the intermediary zone, and the arrest of development in the external zone which preserves the appearance of a vulva, concur in giving to the whole of this sexual organism a feminine aspect. If, on the contrary, the ovaries have descended by the inguinal canal, as has been the case, if the bulbo- cavernous groove be closed, the labia united, the clitoris hypertrophied, the beard developed and the breasts arrested in their development, the woman in many respects will have the appearance of a man (rigs. 60 and 61) . Lastly, while certain organs have preserved a feminine appear- ance, others by union and hypertrophy may have assumed a masculine character, so that the most unexpected results of apparent hermaphro- dism may be presented, making the determination of sex a matter of great difficulty. This is seen in the history of a certain number of so- called hermaphrodites recorded in the archives of science, among others in that of Marie-Magdeleine Lefort (Fig. 61), The reflections suggested by the knowledge of these general anoma- lies will naturally find their place in the history of sterility, which is the usual consequence of these teratological conditions. II. — Anomalies of the Ovaries Absence, — Of all the anomalies of the generative organs the absence of both ovaries is not only that which occurs most rarely, but also that which is most frequently accompanied by other anomalies of other portions of the generative system. In two thirds of the cases in which absence of the ovaries has been observed the vagina, uterus and Fallopian tubes were also absent ; in the remaining third the uterus existed but was imperfectly developed, presenting after puberty the characteristics of fcctal or infantile life. A case recorded by Depaul is the only one which leaves any doubts as to this. Notwithstanding what has been said by Scanzoni this anomaly is not marked by external signs : there is no example of the chin being covered by a beard or the voice being rough and masculine. It is not correct either to say that the breasts are rudimentary, although Busch and Cripps have observed one case of arrested development ; they were of the usual size in seven other cases. The absence of symptoms indicating ovulation, with the existence of concomitant anomalies in the uterus and vagina, are the only grounds we can have during life for diagnosing or rather presuming on the existence of this anomaly. At other times the absence occurs only on one side, generally on the left ; ANATOMY, THYSIOLOGY AND TERATOLOGY 71 in this case the uterus has usually, if not always, but one cornu (Fig. 62), the horn corresponding to the missing ovary being also absent or reduced to a cord. In twelve cases of this anomaly the ovarian function vi-as exercised normally, with regular menstruation, pregnan- cies and children of both sexes. Rudimentary development. — Two features characterise this anomaly, which is much more frequent than absence of the ovaries : — 1. The small size of the organ. 2. The absence of Graafian vesicles at ma- turity. From a physiological as well as from an anatomical point of view two forms may be distinguished ; in the first the organ is in outline audits structure incomplete; in the second it has the foetal organisation, i. e. the form, size, and vesicles proper to that age. These two forms occur sometimes with a normal conformation of the uterus, sometimes with an anomaly of this organ. The anomalies Fig. 62. — Left unicorn uterus, absence of tlie broad ligament, right ovaiy and Fallopian tube, c tr, cervix uteri ; o, left ovary ; T, left Fallopian tube, fimbriated extremity. The right border of the rounded uterus (u) is covered with peritoneum (Klebs, Handbuch der pathologischen Anatomie. Berlin, 1873, 4«= Lieferung, S. 761.) with which they are most frequently seen to coincide are complete absence of the uterus, apparent absence of this organ, infantile uterus and hermaphrodism. Rudimentary ovaries, though rarely, do some- times coexist with a uterus normally formed. In a preparation in the Heidelberg Museum, described by Kiissmaul, a rudimentary state of the ovaries is seen in a woman whose uterus is 5 centimetres long and 3^ broad ; the vagina is replaced by a fibrous cord 3^ centimetres in length and 2 lines in width, and presenting no trace of a canal, except 72 INTRODUCTION in the upper part. Eoubaud, in an analogous case, observed that all the other genital organs were normal. At other times only one of these organs is in a rudimentary con- dition, either when the corresponding uterine horn is atrophied (Granville, Mayer of Triburg, Stolz, Forster, Rosenburger and others), or when it is normally developed (Morgagni, Behling, Lalle- mand, Blot, Scanzoni, Forster). The rudimentary condition of the two ovaries produces the same consequences as the absence of these organs ; when only one is atrophied menstruation and fecundation take place as usual. Division. — Without referring to varieties of form and size which do not hinder function, we shall only mention the depressions and notches which these organs sometimes present in their borders, in adults as well as in infants. Sometimes single, sometimes multiple (from three to six), these notches are generally superficial. At other times the notch is much deeper and accompanied by a considerable separation of the borders, so that in place of a slit the ovary is really divided into two segments. Klebs and Gintrac have seen cases where the two segments of the ovary were united by a kind of isthmus. F. Winckel, in his plates, represents an ovary divided into two almost equal parts, on one of which an accessory ovary is seen retained by a peritoneal fold and having a Graafian follicle; a similar accessory ovary, also furnished with a serous pedicle and with a Graafian vesicle, is repre- sented in another plate. Beigel has met with this anomaly eight times in 350 autopsies and Winckel eighteen times in 500. In fact, the ovary may be composed of two parts entirely separated, &s was proved by the preparation presented by Grohe, in ]863, to the Congress of Stettin -^ the right one was normal and well developed, whilst on the left there were two small ovaries, one of which was suspended to the uterus, as usual, by the hgament belonging to it, the other, situated farther off, was enclosed in a peritoneal fold. The woman to whom these ovaries had belonged had had three children, and the three ovaries had all performed their function, as the autopsy showed. Ectopias. — There are two kinds — lumbar and abdominal or in- guinal. The lumbar ectopias described by Puech (1855)^ are arrests of migration, occurring from the eighth to the tenth week of embryonic life, i. e. when these organs, as well as the Fallopian tubes, occupy the lumbar region normally. In the cases quoted the ovary and the Fallopian tube were not in any way attached to the uterus ; in one the latter organ was absent; in the other only the right horn was ^ Monatsschriftfiir Geburtslcund, &c., 1864, Bd. xx, p. 67. Since then, in 1864, Khebs observed three ovaries in one woman. De Sinety and Olsliausen have publislied analogous cases, but the most remarkable has been drawn by Winckel (Die Pathologie der Weiblichen Sexualorganen in Lichtdruclcabbildungen, &c. Leipzig, 1872). There were three ovaries and three ovarian ligaments. The third ovary and its ligament were on the anteiior surface of the uterus, touch- ing the fundus of the bladder, without any peritoneal inflammatory adhesion. It was found in a woman of seventy-seven who, although married, had never had a child. . ' Compte rendu de I'Acad. des sciences, 22 octobre, 1855. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 73 wanting. Inguinal ectopias, which are much more common, may be considered, on the contrary, as excesses of migration, having for prin- cipal agents the various elements which concur in the constitution of the round ligament. The smooth muscular fibres and those with transverse striae coming from the abdominal muscles then intervene and, acting in the manner of the gtibemaculum testis, drag the Pal- lopian tube and ovary after the round ligament. May not the non- adherence of this ligament to the oviduct where it joins the uterine horn, favour this displacement ? The canal of Nuck, which has its maximum of development from the fourth to the sixth month of intra- uterine life, contains these organs at that time, and the descent is completed by the retraction of the elements of the round ligament. The ovaries may descend, like the testicles, into the inguinal canal and cross the external orifice, even reaching the labium. The persistence of the canal of Nuck, the narrowness of the pelvis and the elongated form of the ovaries favour this ectopia. I shall not add more now, as I shall have occasion to recur to the subject in connection with hernia of the ovary. III. Anomalies of the Fallopian Tubes They sometimes affect the whole organ, sometimes only the body of the oviduct or the fimbriated extremity. Fig. 63. — Eight unicorn uterus : absence of broad ligament, of ovary, and of Fallopian tube on left side. Mattbews Duncan, Obstetrical Journal, vol. i, p. 784. 74 INTEODUOTION Absence. — The complete absence of the Pallopian tubes is very rare, only occurring when the uterus is entirely wanting. Unilateral absence has been observed in cases of unicorn uterus, conjointly with that of the ovary (Fig. 63). Radimentari/ development. — The Tallopian tubes may be represented by traces only, or by more or less developed cords. In the condi- tion of traces they are found under the form of muscular layers occupy- ing the upper border of the corresponding peritoneal fold. One would say that the Fallopian tube itself was absent, and that only traces of its external longitudinal muscular tunic existed. More frequently they are observed in the condition of solid cords, in whole or in part, a disposition which can only be connected with arrested development, for it depends on im])erforation of Miiller's ducts and it coexists with other anomalies of the same kind, such as complete absence of the uterus, embryonic uterus, unicorn uterus with rudimentary horn and, lastly, complete absence of the cavity of a uterus apparently normal. In other cases the tubal canal appears well developed but is imper- forate, an anomaly which coexists with the absence or embryonic development of the uterus, or with the atrophy of the horn in cases of unicorn uterus. In other cases congenital imperforation only affects the fimbriated end. Baillie, Eeynaud, Guerard and Besnier have seen cases of this kind. Lastly, there may be a striking inequality in the length of the two Fallopian tubes. Puech has observed such a case in a woman married for ten years and sterile ; the right Fallopian tube was of the ordinary length, fourteen centimetres, whilst the left was only six. Vices of conformation. — The Fallopian tubes sometimes have an apparent shortness depending on the shortness of their longitudinal muscular tunic and on the more numerous and deeper folds which are the consequences of it. It is not uncommon to find contractions at some point of their course, and at other times dilatations, either primitive or consecutive to the existence of a constriction situated below and which forms, especially when obliterated by thick mucus, a more or less efficient obstacle to the progress of fluids from the Fallopian tube or ovary towards the uterus. But it is principally the fimbriated extremity which is subject to a number of varieties ; sometimes the widening of the tubal canal on a level with the abdominal extremity is slight and its opening is surrounded with very short fringes ; sometimes the fimbriated end is greatly enlarged, and forms below a sort of canal, which is in close communication with the ovary and the margins of which are furnished with broad fringes. At other times supernumerary fimbriae are to be seen, as described by Ilichard and to which I have ah'cady referred (p. 14), to the number of from one to three on the same Fallopian tube, appearing always to have their seat on the upper wall of the tube and presenting a single opening. Puech, in an autopsy, saw two on each tube placed symmetrically. Ectopias. — They may be lumbar or inguinal. With reference to the former we have nothing to add to what has been already said of lumbar ectopias of the ovary. As for the latter, considering the close ANATOMY, PHYSIOLOGY AND TERATOLOGY 75 relations of the Fallopian tube and ovary there is no difficulty in understanding that hernia of the ovary cannot occur without the Fallopian tube accompanying this latter organ. As for hernia of the Fallopian tube occurring alone, a few cases of which have been quoted by Schiller, Voigt, Mayer, Scholler and Berard, they are produced by a mechanism analogous to that of ovarian ectopias. lY. Anomalies of the Uterus The anomalies of the uterus are numerous and varied, but at the same time easy of interpretation. 1. Miiller's ducts may be undeveloped or atrophied, in which case, if the ovaries are also wanting, there will be complete absence of the internal genital organs} 2. Want of development or atrophy may only affect the portion of tlie two tubes destined to form the body of the uterus ; there may be a vagina. Fallopian tubes and ovaries, but the uterus itself may be absent — uterus deficiens? 3. One only of the ducts may be atrophied or incompletely developed. Fig. 64. — Unicorn utenis of a child, seen from behind (after Pole), a, right unicorn uterus (left half of uterus is not developed) ; &, right Fallopian tube ; c, left Fallopian tube ; d, d, ovaries ; e, bladder ; /, vagina, in which is seen the uterine orifice. the other continuing its evolution ; the uterus may be only half an organ and there may be only one Fallopian tube, the other half being in a rudimentary condition, in fact one horn only has been developed — uterus unicornis (Fig. 64). ^ I have quoted a case of this kind : Memoires de VAcademie des sciences et lettres de Montpellier (Section of Sciences), t. ii, p. 321. Montpellier, 1853. Co'mptes rendus de VAcademie des sciences de Paris, 26 Sept., 1853. 2 Cases are on record known in which absence of the uterus co-exists with that of the ovaries and Fallopian tubes (Busch, Colombi, Courtj, Klinkosch, Quain) ; othere with absence of Fallopian tubes only (Boyd, Food, Otto, - Fig. 100. — Hymen perforated like rose Fig. 101. — Puckered hymen with of a waterin<'-can. central orifice. 92 INTRODUCTION The fifth (Fig. 101) is a puckered hymen with a central orifice (Roze) . The sixth and seventh (Figs. 102 and 103) are hymens with a circular, or rather polygonal, central orifice, with from four to six lips, which are a kind of carunculse (Roze). Fia. 102. — Hymen witli polygonal orifice and four camnculae. Fig. 103. — Hymen with polygonal orifice and sis canmculse. The eighth (Fig. 10-t) is a hymen with a circular opening, but with serrated edges (Ledru). It is singular that in these cases the circumference of the meatus was also serrated. Fio. 104. — Hymen with serrated borders. Fig. 105. — Horse-shoe hymen. ANATOMY, PHYSIOLOGY AND TEEATOLOGY 93 The ninth (Pig. 105) is a semilunar hymen, but the upper angles are broader and prolonged towards the upper border of the vulval ring, which has led to its being called a horse-shoe hymen (Roze). I have recently seen one of these thick, resistant hymens, very broad and allowing of considerable dilatation, in a virgin of thirty affected with a myoma of the body of the uterus with marked descent of the anterior vaginal wall (Courty). The tenth (Fig. 106) is a hymen with a circular orifice situated to the left side (Roze), probably belonging to a double vagina imperforate on the right side. The eleventh (Fig. 107) is a hymen with two orifices or biperf orate Fig. 106. — Hymen perforated at left Fig. 107. — Biperforate hymen, side. (Roze), the orifices being probably vestiges of the primitive duplicity which extends from the two uterine horns to the two hymeneal orifices, passing through the double vagina (Courty). The twelfth (Fig. 108) is a hymen with two well-marked openings, almost equal, observed in a young girl, who menstruated regularly and without pain, in whom the inter-hymeneal septum extended from 1 to 2 centimetres into the vagina, being a vestige of the inter-vaginal septum which had not entirely disappeared (Courty). The thirteenth (Fig. 109) is a biperforate hymen, one of the orifices being smaller than the other, without any trace of median vaginal septum, observed by myself in an old maid, and at another time in a married woman of twenty-six affected with membranous dysmenorrhoea without any symptom of teratological condition of the uterus. The septum was applied against the right vaginal wall, and had a direction and position which made it certain that the left orifice only had been used in copulation. She was not aware of the anomaly till I discovered it (Courty). 94 INTBODUCTION Fig. 108. — Biperforate hymen with Fig. 109. — Biperforate hymen with equal orifices, with prolongation unequal orifices, of the inter-hymeneal septum to 1 or 2 centimetres into the The fourteenth (Fig. 110) is the hymen with double semilunar orifice, equal on both sides, forming the continuation of a double vagina represented in Fig. 65 (Eisenmann). Fig. 110. — Biperforate hymen, forming the continuation of a double vagina and double uterus. PAET I GENERAL SURVEY OF UTERINE DISEASES CHAPTER I DIAGNOSIS OF UTERINE DISEASES IN GENERAL — PRESUMPTIVE SIGNS FURNISHED BY THE SYMPTOMATOLOGY OF UTERINE DISEASES — CERTAIN SIGNS FURNISHED BY DIRECT EXPLORATION. It is constantly said that diseases of the uterus are far more common now than formerly ; but this is an error which can be easily accounted for. Our forefathers recognised these diseases less frequently because they knew less about them, and because they often ascribed to other causes the serious and even fatal results produced by them. Sometimes they successfully treated the morbid symptoms, and so got rid of the disease without being aware of its existence ; and, indeed, we know that a certain class of these affections will really yield to simple hygienic measures. It is, then, of the first importance, before entering on the study of individual diseases, to gain a general view of the symptoms which all uterine maladies possess in common, and which may reveal or conceal the true state of the case, according to the attention and skill of the observer. We must point out that uterine diseases have many of these common symptoms, which indeed were almost the only ones formerly known ; and in certain cases it is quite possible to apply a similar, if not identical, treatment to them, with reasonable chance of success. We must also indicate the measures by which morbid conditions de- pending on uterine diseases, as well as the diseases themselves, can be ameliorated or cured. This introduction will help us to understand how our forefathers failed to recognise these diseases, and how they sometimes cured them without having suspected their existence ; and it will also give us the key to the errors into which several gynecologists of the first half of this century fell, in supposing a simple morbid state to be the prime factor in all uterine pathology. They arrived at too hasty conclusions from the new means of investigation put into their hands by the inventive spirit of the age, and did not see that if the ancients erred in ignoring the great mass of uterine diseases, they themselves were almost equally wrong in simplifying its pathology to the extent of embracing all in one type of malady. Lisfranc and his disciples found the explanation of all uterine diseases in congestion, Yalleix in displacements. Those who followed Blatin and Tyler Smith thought leucorrhoca the great evil, while Recamier 96 GENERAL SURVEY OP UTERINE DISEASES and his school talked of ulcerations and granulations. The more modern teachers, like Bennet, Nonat and even Aran, although recog- nising distinctions in the morbid states, were inclined to trace them all to the common source of inflammation. From this exclusive pathology came equally exclusive therapeutics. Those who saw congestion everywhere kept their patients in bed ; those who only discovered displacements applied mechanical treatment only. Some directed all their attention to curing leucorrhoea as the cause of any ailment, and thus concentrated their efforts on the destruction of ulcerations by caustics or the actual cautery. Others, again, devoted themselves resolutely to subduing inflammation by bleeding, baths and emollients. Thus it appears that uterine medicine has passed through the same stages as all other branches of medical knowledge. From ignorance and chaos emerged crude ideas, which in their turn gave birth to systematic knowledge. Let us hope that by going to the root of the matter, by a thorough and complete study of these diseases, we shall at length reach a really scientific mastery of their various species and true nature. ^ The false idea that, because uterine diseases had common symptoms, they must also share a common nature, led to equally erroneous con- sequences in identical treatment for all cases. The differentiation of their various kinds will, on the contrary, teach us to treat them, not all alike, but each by a special method founded on the indications furnished both by the origin and manifestations of the disease. We must therefore master the symptoms common to all uterine diseases, not only for the sake of a general diagnosis, but that we may be on our guard against analogies that are only apparent, and may recognise, in spite of misleading resemblances, the true differences that characterise each variety. The interest of this general study of diseases of the womb is thus intensified. Our diagnosis will not be formed simply by the considera- tion of certain symptoms which indicate the presence of uterine mis- chief; it will depend on a proper interpretation of these symptoms, or of groups of symptoms variously arranged, as the pathognomonic expres- sion of each type of disease. So also we shall not be satisfied with a general line of treatment, but shall make a point of studying each separate indication, so that from the character of the chief symptoms we may deduce the appropriate remedies. From such simultaneous study of diagnostic signs and therapeutic means we ought to acquire, on the one hand, a comprehensive knowledge of uterine diseases, and we shall also have prepared for ourselves a safe pathway with many finger-posts, to guide us aright as to the diagnosis and treatment of each particular malady. " By their almost latent state, their great variety of symptoms (often very transitory), their sympathetic effects on all parts of the economy, and their immense influence on the nervous system, uterine diseases are peculiarly apt to lead medical practitioners into errors of diagnosis." Thus wrote Lisfranc, who dedicated seventy-four pages to pointing out DIAGNOSIS 97 such diagnostic errors, with illustrations from his own observations.^ I have myself seen mistakes made by practitioners of excellent standing which would have been simply incredible without such evidence. For example, I remember one case where a previous pregnancy was asserted while the conical cervix ought to have suggested sterility. I have seen cases of leucorrhoea mistaken for blennorrhagia, and the peace of house- holds consequently destroyed. The best way of escaping such errors is to understand their cause. It is certain that the majority of medical men can diagnose the diseases of other organs better than those of the uterus ; and hence we may be sure that there are real difficulties in the way. These are partly due to the fact that the uterine symptoms are not always the most prominent, that they are frequently slowly developed, and sometimes do not attract the patient^s attention, while disorders of the alimentary canal or nervous system demand more notice and cause more evident suffering. How often is one consulted for neuralgia or hysteria; for symptoms manifested in the stomach, the heart, or the liver; for digestive troubles — anorexia, nausea, diarrhoea, and for all the train of evils depending on poverty of blood — anaemia, chlorosis, emaciation and exhaustion, but the natural and symptomatic manifestations of an un- recognised uterine malady ! The explanation lies in the fact that the uterus exercises a most powerful influence over the whole economy, and that very often an apparently insignificant disorder affecting this organ is felt throughout I ^r~^ the body to a quite disproportionate extent, causing troubles in neigh- bouring organs, functional derangements of the various systems, and in fact a result greatly exceeding its cause. Most frequently the gravest effects are felt in the general health and not in local symptoms. Such appearances may naturally mislead the invalid, but they ought rather to put a skilled physician on his guard, and suggest to him the existence of the morbid state that they only thinly veil. They should lead him to ask questions which may help towards the confirmation of his suspicions and the discovery of additional local symptoms, which should end in the direct examination of the organs in which disease really centres. > It is of importance to proceed step by step, and to pass from j v general to local symptoms ; to ascertain the condition of the principal I functions and their derangements, before proceeding to investigate the troubles more immediately connected with the uterine system. In this way the practitioner not only provides himself with the guidance of a sure clue which keeps him from losing himself in the chaos of morbid conditions, gradually leads him away from mere functional and symptomatic derangements, and brings him closer to the original cause of all these evils ; but at the same time he is enabled to carry the sufferer^s mind along with his own, and to make her realise the true origin of her troubles. It is essential that the patient should be led steadily to the convic- tion at which the physician has already arrived, for this conviction is ' Cliniqne chirurgicale de la Pitie, vol. ii, p. 182. Paris, 1842. 7 98 GENEKAL SUKVEY OF UTERINE DISEASES the only meaDS by wliicli he can hope to make her understand the necessity for a local examination and agree to submit to this painful trial. This point is the more important, as a woman^s decision on this matter will be entirely governed by the fact that she is or is not convinced that she is suffering from disease of the womb. Women are so much afraid of polypi, cancers, and ulcerations — which sum up their ideas of all uterine maladies — that the reasonable terror inspired by these affections will not only remove their repugnance to an exami- nation, but will make them earnestly desire it. Even the less sensible women will feel their instinct of modesty overborne by their desire of self-preservation, and I can assert that — putting aside the members of religious orders, among whom it is often impossible to obtain any examination of the genital organs — I have never yet met with one woman, even unmarried, who has refused to allow an examination when she was thoroughly convinced that her malady was really in the womb. Then of course the direct exploration by sight and touch reveals signs absolutely pathognomonic ; and these, in combination with the symptoms already noted, enable us to determine absolutely the exact seat and form and usually also the exact nature of the disease. I believe I cannot better explain the various steps towards a dia- gnosis than by following exactly the order in which patients should be interrogated and examined. Experience has taught me the value of such a method in teaching a tolerably difficult subject. In dogmatic teaching synthesis may be preferable, but in chnical instruction I prefer analysis. Let us imagine a patient of the kind most commonly met with ; let us first ascertain of what she specially complains ; let us review all the more general symptoms in their order of frequency, and then let us come gradually to local symptoms ; then demonstrate the best modes of examination, and finally enumerate the various indications which we may expect to find. All general and local symptoms related by the patient or observed by the physician, without direct examination, are rational or sub- jective ; they form a basis of probability or presumption. What we learn by direct examination are sensible or objective symptoms ; they form a basis of certainty. The latter are to be sought only subse- quently to the former, unless we find in the first instance sufficient reason for immediate examination. PfiESUMPTivE Signs Indicating Uterine Disease General Symptoms. — Whenever a change of condition as well as of function takes place in the womb, as at puberty, at each menstrual epoch, during pregnancy, and at the menopause, there is a tendency towards a morbid uterine condition which in turn will react painfully on the whole system. A pathological change of considerable impor- tance may take place, and may long remain unnoticed, whilst the PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 99 most insignificant functional disorder is sufficient to disturb the whole economy. It is very striking to observe the disproportionate magni- tude of this general disturbance compared to the insignificance of the change which has produced it. It is therefore from ignorance as well as from modesty that the majority of women suffering from chronic disease of the womb complain of symptoms which seem to indicate a malady in no way connected with this organ. Some complain of nervous troubles, giddiness and neuralgia ; others of nausea and of disorders of digestion; the majority of weakness and exhaustion. In short there are almost always func- tionaFdisturbances of the nervous and digestive systems, which in turn tend to produce various morbid cachexise, just as in the beginning of pregnancy we have vomiting, dyspepsia and nervous disturbance, and these are apt to be followed by ansemia, chlorosis and emaciation. But we must remember that symptoms can do no more than sound the tocsin of alarm ; we must not expect them to indicate precisely the site of the lesion, and still less to explain the cause of the suffering. We must therefore first ascertain whether these pathological con- ditions are symptomatic or idiopathic. To do this we must not only -assure ourselves of organic integrity side by side with functional derangement, but we must endeavour to identify the original cause of disturbance, and to fix upon any special indications which may enable us to trace up the connection with the uterine system. In studying general symptoms I will follow the usual order of their appearance. I. Disorders of digestion. — Every practitioner must have had patients who came to consult him for gastric derangement and dys- pepsia, when the real source of trouble lay in the womb ; and I have known such cases treated by distinguished physicians for the cure of a malady that never existed. Indeed, this whole class of disorders — gastralgia, nausea, dyspepsia, anorexia, perverted appetite, oesophageal constriction, the globus hystericus, ho.., ho,. — these are of all others the symptoms which most frequently accompany uterine diseases, and more especially affections of the body of the womb. In such cases these alone are complained of because these alone are felt. The first and most common of such derangements is an increasing difficulty of gastric digestion. This is not a true dyspepsia. There is a good appetite, and the intestinal functions are healthy ; but gastric digestion is slow, and is accompanied by discomfort and epigastric tenderness, with distension and a sense of suffocation from the flatu- lent development of gases, which lead to frequent inodorous eructa- tions, obliging women to loosen their dresses and to avoid the least pressure on the epigastrium. Sometimes a desire for food returjis very soon after a meal, but this is purely factitious. Digestive inertia and pain is often succeeded by real dyspepsia of a nervous type, in- volving much suffering and great delay in the accomplishment of diges- tion, with sensations of weight and pain, swelling at the epigastrium, bitter regurgitation, headache, exhaustion, iijcapacity for work, and a sense of sinking which cannot be removed by food. This type of dyspepsia is purely nervous and symptomatic of uterine disease, 100 GENERAL SURVEY OF UTERINE DISEASES while it has not the characteristics of true idiopathic dyspepsia. The tongue is clean and normal, not dry, neither edged nor spotted with red, and rarely furred. This in itself is an important diagnostic sign. In the third stage this kind of indigestion is marked with want of appetite and a tendency to nausea, sometimes with actual vomiting of food, either before, during, or after meals. This symptom occasionally leads the sufferer to believe herself pregnant. Digestive troubles of this kind do not merely indicate uterine disease ; they suggest further, that it is the body and not the neck of the womb that is involved. Ovarian disease is also more apt than affections of the cervix to produce these digestive and nervous derangements. In addition to these we may find, though more rarely, a derangement of the biliary secretion, described by Bennet^ and Aran.^ This affection causes enlargement of the liver and gall-bladder, and produces fits of sharp pain, which begin in the hepatic region but extend over the chest, breast and right shoulder. They are accompanied by bilious vomiting and diar- rhoea, with excessive sensibility in the epigastric and right hypochon- driac regions. These attacks occur most frequently a few days before the menstrual period, and are accompanied very often by slight jaun- dice. Bennet thinks they are purely symptomatic of dyspepsia, but. Aran considers them to be true hepatic colics, due to a biliary lithiasis, which seems connected with urinary lithiasis, especially at the menopause. II. Nervous disorders may be produced by uterine disease (1) directly, i. e. by sympathetic irritation of the nervous system ; (2) iw- directly, by means of impoverishment of the blood and general con- stitutional debility. Indeed, these morbid phenomena may alternately act as cause and effect, for the poverty of blood may be due to defects of innervation as well as of digestion. They react both on the sensory and motor functions, whether in the domain of voluntary or involuntary organic life. Large account must also be taken of disorders of sensa- tion, which may take the form of (1) anaesthesia; (2) visceral neuralgias ; (3) neuralgia of the usual type. (1) Ancesthesia may affect many parts of the epidermis, but is especially frequent in the lower limbs. Sometimes it invades the genital organs, the clitoris and vagina, which are then no longer capable of being excited, and even the uterus itself, which falls into a state of inertia, the sexual life of the woman being thus prematurely brought to a close. I have seen several examples of this kind, where sexual desire and pleasure in coitus were entirely lost after the begin- ning of uterine disease. (2) These nervous affections attack not only tlie bladder and rectum, which are close to the uterus, but also remote organs, such as the liver, the intestinal canal, the stomach, and more especially the heart, so ' A practical treatise on Inflammation of the Uterus, its Cervix and Ajy[^endage8, and on its connection with other Uterine Diseases, 4th edition. London, 1861, p. 119. ' Logons cliniques sur les maladies de Vuterus et de ses annexes. Paris, 1858, p. 141. PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 101 that cardiac suffering and palpitation alarm the patient extremely, and make her fear tiie existence of an aneurism or otiier organic lesion. (3) Neuralgia, however, is the commonest of all these disorders, not only in the lumbar and abdominal regions, where it might possibly be supposed to be propagated from the uterus, but also in more distant parts, and specially intercostal neuralgia on the left side, which makes the patient fear that her heart is affected, and trifacial neuralgia, which causes the sensation of a nail being driven into the skull in the parietal region, as described by Sydenham. Intercostal neuralgia is often associated with pain in the breast, shoulder and arm of the same side, and if with lumbago sciatica and facial neuralgia it may suggest to the patient the fear of hemiplegia. It is not rare to find either hypersesthesia or anaesthesia affecting one half of ihe body only, being, in fact, a kind of hysteric hemiplegia affecting sensation, as in other cases it may affect motion. Uterine disease may also manifest itself by sympathetic pains in the breast extending to the axillae and causing a feeling of swelling and a particular kind of erethism often experienced during menstruation and pregnancy. These sympathetic pains in the breast are very common, especially during menstruation, sometimes sharp, sometimes dull, the mammary glands being occasionally so swollen that it is impossible to bring the arm close to the side. Hysteria, which seems to be a natural point of transition between disorders of sensation and of motion, since it includes both, is not exclusively connected with the uterus or the ovaries, nor even with the whole genital system. It is a chronic nervous affection characterised by two kinds of symptoms ; on the one hand we have various perma- nent symptoms, such as anaesthesia, or it may be hyperaesthesia, or neuralgia, spasms, convulsive cough, or paralysis of different kinds; on the other hand we have intermittent symptoms, attacks coming on at irregular intervals, characterised by the globus hystericus, a sensation of suffocation, or a loss of consciousness accompanied by various dis- orders of sensation and motion, and generally terminating in a fit of ciying or in polyuria. This nervous affection often accompanies uterine disease, but it may be developed independently of this cause ; indeed, physicians of great authority tell us it may be met with in men. Nevertheless, it cannot be denied that the uterus or ovary, whether or not in a normal condition, is most generally the starting-point, if not the seat, of this affection. We need no further proof of this than the extreme frequency of hysteria among women, especially among those of a passionate nature who exercise self-restraint; and the same thing is demonstrated by the voluptuous character of the convulsive move- ments accompanying such attacks, as regards not only those of the arms and eyes, but especially of the pelvis, even in the case of virgins wholly ignorant of sexual relations. If, helped by the light wliich recent researches have thrown on the physiology of the nervous system, we endeavour to discover the relative share of influence exercised by the nerves and by the uterus on hysteria, we must admit that the disease is really a neurosis, that is to say, that it is due to a 102 GEXEEAL STJEVET OF UTEEIXE DISEASES general derangement of innervation^ in -vrhicli the -whole nervous system partakes with effects varying in form and in degree according to the exciting cause and to the special idiosyncrasy in each case.^ But we must remember that these symptoms, so varied in detail and yet so similar as a whole, are only manifestations of the reflex action of brain or spinal cord, the starting-point having been irritation in some other organ, generally in the generative system. This irritation and its influence transmitted to the nervous centres (analogous to the aura ejjileptica) is often overlooked, while yet producing endless phenomena of sensation or motion, affecting sometimes the whole economy and sometimes only the various parts of the reproductive system in which it took its rise. Thus hysteria is not properly speaking a disease of the uterus or ovaries, but functional derange- ments of these organs may be an exciting if not a primary cause of it. I say functional derangement rather than disease ; for usually it is some condition of pain, excitement, or irritation, nervous or vascular, in some part of the genital organs that forms the starting point of hysteria in pale, nervous and emaciated women, who already are pre- disposed to it. Sometimes marriage is sufficient to develop this con- dition, which in its turn produces hysteria. On the other hand, when there is real uterine disease the patient may be irritable, neuralgic and even partially paralysed, but she will seldom complain of the glohus hystericus, or suffer from any really serious hysterical fits or convulsions. In fact true hysteria is one of the rarest of the nervous disorders occurring as general symptoms of uterine disease. Spasms, tonic or clonic, muscular rigidity, contractions or convul- sions, may occur incidentally more frequently in the involuntary than in the voluntary muscular system- May not vesical tenesmus, vomiting, spasmodic dyspncea, cardiac palpitations, 5:c., be attributed to this cause ? Of such nature also is the little dry cough which Aran ^ calls *' the uterine cough," which differs essentially from the loud and noisy hysterical cough that somewhat resembles pertussis, and which I think Trousseau ^ is right in attributing to the convulsive motion of the muscles of the larynx and diaphragm. This uterine cough is rare except in cases of great debility and exhaustion ; and consequently it is a symptom which should arrest the attention of the physician. He must decide whether it is nervous and merely sym- ptomatic of uterine disease, or due to the commencement of pul- monary tuberculosis. ' Coete, Be I'hysterie consideree principalement au point de vue de sa nature et de ses causes. These de Montpellier, 1863, Xo. 6. See also Rouget, Physiologic des actions reflexes, introduction to the French translation of Paralysis of the Lower Limbs, by Brown-Sequard, 1864. And Brown-Sequard, Arch. geyi. de viedecine, Jannary, 18o6 ; Causes organiques et mode de pro- duction des affections dites hysteriques, Gazette medicale de Paris, 18-i6 ; Lemons sur les maladies du systeme nerveux, Bourneville, 4* fascicule. Paris, 1873. ' Op. cit., p. 1 16. ' CUnique med. de I'Hotel-Dieu de Paris, t. ii, p. 205, 2* edit. PRESUMPTIVE SIOxNS INDICATING- UTERINE DISEASE 103 Motor paralysis is very rare as a ng'vous symptom of uterine dis- ease. Aran ^ has denied its existence. It certainly must not be con- founded with a numbness of the side of the body corresponding to a lesion of the generative system, nor with the immobility to which a patient may be driven by the intense pain occasioned by the slightest movement ; nor even with more or less complete paralysis of the lower limbs, which may arise from mischief in the pelvis causing compression of the great nervous trunks. But besides these direct results of organic lesions acting mechanically on those parts of the nervous system with which they are in contact, we may have indirect and sympathetic disturbance manifested in the motor nerves. No one doubts the existence of hysterical paralysis ; why may we not have similar states produced by a suffering condition of the uterus and ovaries which could itself develop hysteria ? I have seen two very remarkable instances, one of hysterical and the other of uterine paraplegia. The paralysis need not be general, nor affecting the upper limbs, as Aran contends, in order to be regarded as sympathetic. Indeed, a reflex paralysis, starting from the uterus, is more likely to affect the lower parts of the body. Lisfranc^ mentions the case of a lady suffering from paraplegia, who had been treated without benefit for a supposed affection of the spinal cord, but whose condition began to improve only when attention was paid to a chronic metritis, which was the real cause of the paralysis. He gives another case of para- plegia, where the cure of this affection kept step exactly with the relief of the uterine malady. Nonat^ relates several similar cases, and shows that when the uterine disease is unilateral the paralysis is so also. These last cases seem to me to present some difficulties. I must refer readers to his own work, and also to the theses of his pupils, Esnaulf*^ and Vallin.^ Brown-Sequard^ refers to these cases, and mentions having been consulted in 1855 by a young lady for extreme weakness, amounting to paraplegia, at each menstrual period. Sen- sibiKty was normal ; there were no symptoms of hysteria and no para- lysis of the bladder or rectum. There was dysmenorrhoea, congestion and anteflexion of the uterus, which was enlarged and very sensitive, the tenderness extending to the broad ligaments, &c. The womb was supported by an abdominal bandage, and in a few days there was a marked improvement; in less than a fortnight the paralysis disap- peared, though it had lasted for six months and had been treated by strychnia, galvanism and hydropathy, as well as iron and other tonics. At present I have a young girl under my care who had suffered for I Op. cit., p. 147. - Clinique chirurgicale de la Pitie, vol ii, p. 199. Paris, 1842. ^ Traits pratique des maladies de I'uterus et de ses annexes, p. 381. Paris, 1860. '' Des paralysies symptomatiques de la metrite et du phlegmon periuterin These de Paris, 1857, No. 206. * Des paralysies symijathiques des maladies de I'uterus et de ses annexes. These de Paris, 1858, No". 33. « Lessons on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities, London, 1861, p. 11. 104 GENERAL SUEVEY OF UTERINE DISEASES more than a year from violent hypogastric pains, sometimes associated with hysteralgia and purulent vaginal leucorrhoea, and at other times complicated with similar symptoms in the rectum and bladder, with retention of urine, which was loaded with deposits. This condition was accompanied by complete paralysis of the lower limbs, which with- stood every kind of treatment, general and local, but is now disap- pearing as the pelvic and uterine pains are gradually yielding to the influence of atropine injected subcutaneously into the hypogastrium. Not long ago I was consulted by a lady affected with paraplegia, who was on her way to Balaruc; a chronic metritis was discovered, appro- priately treated and cured, the paralysis also disappearing without the help of the Balaruc waters. Hunt, Romberg, Wolf, Mayer and others have mentioned similar cases. Brown-Sequard asks. What causes such paraplegia? We cannot admit that in the majority of cases it is due to compression of the nerves of the lower limbs, because the increased size of the organ is not sufficient to produce such an eff'ect. Besides, sensibility is very little, if at all, affected. We must therefore conclude that the uterine disease produces the paraplegia by a special action on the spinal cord, and that, therefore, such paraplegia has all the characters of reflex paralysis. In such cases the cure of the paralysis must depend on that of the uterine malady, and our main duty is, therefore, to be able to diagnose this latter disease and treat it appropriately. III. Disorders of nutrition. — Derangements of the digestive and nervous systems naturally bring about an impoverished state of the blood and impaired nutrition. Anaemia, chlorosis and general debility are, therefore, constantly present in women who have been ill for some months, and may be taken as general symptoms of uterine disease. Chlorosis occurs specially in ill-nourished young women who have probably already suffered from it at puberty and during pregnancy, so that it is rather developed than originated by the uterine disease. Anamia is most common among older women, among those suffering from serious diseases, such as cancer, fibroid tumours and polypi, where repeated and profuse haemorrhages have occurred. It is less a morbid affection than a direct or indirect result of the uterine malady. Repeated losses have impoverished the blood and deprived the economy of needful materials for repair ; suppuration and insuffi- cient assimilation have weakened the patient ; these are followed by loss of colour in the skin, transparency of tissues, local oedema, a frequent weak pulse, general debility and, in fact, symptoms resem- bling those that follow after delivery or after some serious operation. Chlorosis, anaemia, or chloro-anaemia are not only accompanied by general debility, but by constantly increasing emaciation, until the dyspepsia and uterine disease are properly treated. Even where no special pain exists the patient acquires a very characteristic attitude, constantly stooping forwards, the head and limbs bent in a manner usually seen only in old age. The features are drawn and have a look of suffering, which is all the more striking because the patient is PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 105 SO thin ; the flesh is soft and flabby, the countenance wanting in expression, the complexion pale and faded, especially where there has been long standing and abundant leucorrhoea ; this paleness with loss of flesh and earthy complexion is difierent from the colourlessness of anaemia, the sickly green hue of chlorosis, and the pale yellow of cancer. It is to this very characteristic appearance that we give the name Qi fades uterina. Emaciation does not always exist ; on the contrary, there is some- times corpulency. This is chiefly the case among those women in whom amenorrhoea takes the place of leucorrhcea or haemorrhage ; and the constitution seems to get accustomed to the change. Is it pos- sible that the blood which should have formed the catamenia is used up in the economy to produce this unhealthy stoutness ? We cannot affirm that it is so, but there is no doubt of the embonpoint which becomes obesity, and which leads some women to believe themselves pregnant ; whilst others, when suffering greatly, are forced to listen to the congratulations of friends on their excellent health. As the uterine disease becomes cured this unhealthy stoutness disappears, and with it its various accompanying discomforts. Should the obesity persist it may be treated by vapour baths, resolvents, tonics, exercise, diet of roast meat and green vegetables, in addition to the admin- istration oifucus vesiculosus, and these measures will generally bring the body back to its normal condition. Local Symptoms. — These are found in the neighbouring organs, or in the uterus itself or its appendages. 1. In the neighbouring organs. — The rectum and bladder will almost always be found affected. A. Functional derangements of the rectum may accompany disturb- ance of the rest of the alimentary canal. Though frequent they do not always exist ; and sometimes instead of resulting from uterine dis- ease they may produce it. If coincident, the two react upon and aggravate each other. Many women who are habitually constipated have diarrhoea just before the menstrual period, or during its course. Though this symptom requires no treatment it is worthy of notice, as showing the close inter-dependence of the various pelvic organs. Another very important point is habitual constipation, which is so common among women that in certain cases it may be looked on as the cause of the uterine malady. We must therefore find out whether the constipation was habitual and to what extent it existed before the disease of the womb. There are cases in which it has neither increased nor diminished since that period, in others it has increased so much that it helps to keep up and continue the uterine disturbance by the irritation and congestion which it causes in the pelvis. Constipation does not necessarily accompany uterine disease. The derangement of the digestive functions may produce diarrhoea; but this is not common and is generally followed by constipation. Con- stipation is all the more frequent because it may be perpetuated by a mechanical cause. In prolapsus and various displacements, esi)ecially retroversion and retroflexion, as well as in cases of tumours (whether 106 GENERAL SURVEY OF UTERINE DISEASES uterine, periuterine, or ovarian), the rectum suffers from pressure which impedes the circulation. In cases of metritis, uterine catarrh, ovarian or periuterine inflammation, congestion of the rectum is not due only to blood stasis but to an extension of the inflammation, in which case diarrhoea sometimes alternates with constipation. How- ever, the first effect of congestion is generally obstinate constipation, which is one of the most common and most serious symptoms of every uterine disease. The mass of hardened scybala can be evacuated only after enemata and repeated efforts, and the faeces are often coated with mucus, a sign of enteric inflammation. The constipation may last for two or three weeks or end in painful diarrhcea with tenesmus, lasting several days ; and sometimes even this will not occur without the use of purgatives. The accumulation of fseces and consequent distension of the intestine bring on a kind of paralysis, the retained mass becomes partly decomposed and some of its elements may be reabsorbed. The effect of this form of blood poisoning, to which Barnes gives the name of Copramia, may be seen in the sallow, dirty hue of the skin, the ill-smelling cutaneous secretions, in dyspepsia, flatulence, pyrosis, and in fact in endless disorders of nutrition and innervation. Sometimes the paralysis and obstruction of the intestine go so far as to resist all treatment ; I have seen several women die from simple constipation. In spite of constipation the sufferer may be tormented by an argent desire to go to stool, owing to pressure being exercised on the rectum by the uterine tumour. This desire becomes so strong that women make violent expulsive efforts, the only result of which is the excretion of some bloody mucus, with tenesmus and intolerable straining. In this way habitual constipation increases uterine disease both directly and indirectly. It almost always leads to haemorrhoids, anal fissure, contraction of the sphincter and violent pains during defsecation, which may persist for a long time afterwards. Such violent efforts cannot be made without painful reaction on the uterus, and the patient dreads the effects so much that she is apt to let the constipation go on unless constantly watched. B. Derangements in the functions of the bladder and urinary systein are various. The urine is often clouded, especially in the case of patients who have a displacement or hypertrophy of the uterus, which then presses on the bladder or urethral canal; particularly when any new irritation arises in the womb, or an increase of old inflammatory symptoms reacts on the bladder. Patients usually complain of frequent desire for micturition, often accompanied with dysuria and sometimes with strangury and hsematuria. The bladder in fact often shares the morbid condition of the uterus ; there may be congestion or even inflammation, and perhaps catarrh of the mucous membrane; the urethra may be red, swollen and bleeding ; the meatus congested and inflamed, and sometimes the seat of small vascular tumours of which I shall speak subsequently. Any pressure on the bladder from the abdominal or pelvic viscera is very painful. The state of the urine corresponds to these morbid conditions and requires examination. We find more or less viscous. PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 107 flaky, mucous, or muco- purulent deposits, which may coincide or alternate with deposits of white powdery triple phosphates. These muco-purulent and saline deposits are signs of vesical catarrh which often accompanies uterine catarrh. Is Aran right in thinking that much of the pain felt by women suffering from uterine disease is due to these deposits and to the irritation caused by their presence in the bladder and their passage through the urethra? Catarrh of the bladder with irritation and inflammation of its mucous membrane and that of the urethra is a still more likely cause of much suffering. Sometimes the abnormal condition of the urine is due to the kidney itself. The secretion may not only be very much increased under the influence of violent pain or hysteria, giving rise to the excretion of a large quantity of transparent " nervous^' urine, but the secretion may itself be altered, containing brick-red deposits of uric acid or urates. There is sometimes a tendency to the renal lithiasis to which I have already called attention as being coincident with hepatic lithiasis. In these cases, it seems to me, there is a rheumatic if not a gouty diathesis. II. Symptoms in the utems. — It is desirable to ascertain at once how the various reproductive functions have been performed, especially menstruation and pregnancy. As regards menstruation, we must learn the date of its appearance, the character of each monthly period and its frequency and duration, the quantity of the discharge, and the presence or absence of pain, with any particulars relating to the meno- pause. If dysmenorrhoea has existed from the first it suggests me- chanical obstruction, whereas if it supervened after marriage or after miscarriage it is more probably due to cervicitis. It is important to learn everything relating iojjrevioiis prec/nancies, as well as to each delivery. Sterility is a fact of still greater importance in the history of uterine disease. If a woman has been married for several years without having become pregnant the probability is that something is wrong; there may be some malformation, or the sterility may be due to functional disturbance or to disease. In nine cases out of ten I have discovered the cause of the sterility in a malformation, or in a morbid condition of the cervix, and very frequently I have been able to remedy it. Uterine symptoms are of two kinds — pain and excessive discharges. Pain is the cry of the suffering organ. Of all local symptoms it is the first to attract attention. It is, however, sometimes absent ; but even in such cases it can be elicited by slight causes, and it is always of great importance. We must study pain from three points of view — 1. Its form of expression. 2. Its seat. 3. Its type. When studying its form and mode of production we must distinguish between spontaneous pain and that artificially elicited. Spontaneous pain is rare if we limit the term to pain caused directly by organic disease, but we ought to include pains induced by changes of posture which give rise to tension. Spontaneous pain does, how- ever, occur frequently enough, even when the patient is in bed with all the muscles at rest and with no exciting cause dependent on neigh- 108 GENERAL SUEYEY OF UTERINE DISEASES' bouring organs. Such pain is almost always the symptom of acute disease and generally of inflammation, such as occurs in acute hy- persemia, congestion^ metritis, or ovaritis (whether puerperal or not), but most especially in perimetritis and hematocele. In some cases this pain persists, even after the disease has passed into a chronic state ; but as a rule spontaneous pain, strictly speaking, disappears at this stage, and is only excited by pressure or concussion dependent on movements. Although patients generally suffer least when in bed, there are instances where less pain is felt when walking or standing. When the dorsal decubitus causes pain we may suspect retroversion, retroflexion, a tumour, or a retro-uterine hematocele. Many patients suffering from chronic metritis or congestion, or even from simple hypertrophy with relaxation of the uterine ligaments, experience con- siderable pelvic pain when lying down, especially if the bed slopes downwards towards the foot. I have known several invalids who, not content with making the bed quite horizontal, have instinctively taken the precaution of placing a pillow under the nates, so that, the pelvis being higher than the shoulders, the uterus escapes all pressure from the abdominal viscera. The lateral decubitus, with semi-flexion of the limbs, is sometimes adopted to avoid the pain referred to, but this lateral position may cause other pains. If these are felt on the side on which the patient is lying the lesion will be there also, whether its seat be in the ovary, uterus, or connective tissue, the pain being pro- duced by pressure on organs extremely sensitive from their patholo- gical state and exposed by their position to pressure from neighbour- ing viscera. If, on the contrary, pain is felt in the other side, it is due either to the dragging of the diseased uterus on the ligaments and appendages of that side, or to an inflammatory condition with abnormal adhesions, in which case it may depend on dragging caused even by the weight of a healthy uterus. Some patients find that the least fatiguing position is that of pronation — either lying on the stomach or on elbows and knees ; this is almost a certain sign of retroflexion. Spontaneous pain may be felt more in sitting than in lying, as in cases of uterine hypertrophy, hematocele, or perimetritis. The patient cannot remain seated for long without experiencing a j)ainful sensation at the anus and perinseum similar to that caused by haemorrhoids, urgent desire to go to stool, or a disagreeable and sometimes burning heat in the perinseum with a feeling of fulness and weight in the pelvis. These pains sometimes become so intense that the patient, not being able to remain sitting in the ordinary way, will rest in Turkish fashion, or throw the weight on the heels placed below the opposite tuberosities, or finally lie down to escape this discomfort. Sometimes the sitting position makes the patient feel as if a hard body pressed on the anus or perinaeum ; at other times it is as if such a hard body pressed painfully upwards on the uterus and abdominal viscera. This sensation may be felt under various circumstances, especially in pelvic peritonitis ; but I have often seen it when the uterus alone was affected; it is rarely absent with hypertrophy of the cervix, especially when this coincides with fungous granulations or metritis. In such PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 109 cases the sufferer not only avoids sitting long, but takes great care not to sit down abruptly, knowing that by so doing she would produce the pain I have just described, which may be so severe as sometimes to induce syncope. Standing seems to cause pain which neither the position nor the special disease can always account for. In cases of displacement, it is natural that standing, like walking, should cause a troublesome drag- ging on the ligaments or painful pressure of the displaced or pro- lapsed uterus on neighbouring organs; but in other cases, such as leucorrhoea, one cannot connect cause and effect. Whenever the uterus or the ovaries are affected, they necessarily become more sen- sitive, and they are sure to suffer simply from the weight of the abdominal viscera. It may be in this way that standing causes pain. In walking the weight of the viscera probably comes now on one and now on another part of the pelvis ; while in standing the suffering uterus bears the whole pressure continuously, and consequently many women prefer walking to standing. However, in the majority of chronic uterine diseases, walking and other physical exercises cause the most violent pain. It is needless to add that in cases where pain is felt when the patient is at rest, it becomes much more severe when she walks or otherwise exerts herself. Walking so generally causes pain that many women suffering from uterine disease lose the habit of walking. Others can walk in the house or on a smooth flat path, but suffer as soon as they try to walk on a rough road, or feel the vibration caused by a false step or even by going down stairs. This is especially so in cases of metritis and perimetritis, when the slightest shake is felt painfully and causes the patient instinctively to put her hand on the hypogastrium. It is easy to understand how much more certainly pain will be produced by other and more violent exercises, such as dancing, riding, driving, &c. I have seen patients suffer terribly after a little waltzing, and have known others obliged to give up riding because it excited pain. Travelling by railway, though better borne as a rule than driving, sometimes causes great discomfort, the continual vibration producing mental as well as physical excitement and uneasiness. With other patients uterine pain is provoked by movements of the arms, as in sewing or playing the piano ; these actions often caus- ing a painful reaction in the hypogastric region and throughout the body. Coitus produces pain in many women by a complex process. The physical movement, shock, orgasm, all unite in bringing about the result. We must ascertain whether pain is produced by intromission, depending on vaginitis, fissure, spasm, or contraction of the vulva ; or by the shock against the uterus causing a direct effect upon this organ and the surrounding tissues. Sometimes, though no pain is felt at the moment, great general fatigue, as well as throughout the pelvis, is experienced the following day. As a rule these invalids avoid sexual intercourse, either on account of the suffering it entails or because of real uterine inertia. But besides causing pain intercourse 110 GENERAL SURVEY OF UTERINE DISEASES may become very difficult and in some cases impossible. Barnes ^ considers this symptom of difficulty so important that he has given it the name of dyspareunia, a word by which household troubles were often signified by the Greeks. Dyspareunia may depend on (1) vagi- nismus, i.e spasm, either direct or reflex, of the constrictors of the vulva and vagina; (2) pain; (3) chronic nervous irritability due to a first coitus having been incomplete or awkwardly performed ; (4) pain caused by inflammation; (5) embarrassment; (6) tumours; or (7) malformations, imperfect development^ imperforate hymen, narrowness of vagina, &c., in short, whatever the cause may be the symptom is one that necessitates a direct examination. Tight dresses even when worn for a short time only have their influence in causing pain. Cruveilhier long ago pointed out the effects produced by tight lacing on the form and position of the abdo- minal viscera ; and we can easily understand how the compression of these organs and their pressure on the diseased uterus or ovaries may cause intolerable suffering. An abdominal belt on the contrary raises and supports the viscera. Indeed, stays are often voluntarily relin- quished before consulting a doctor. We must next ascertain whether pain can be elicited artificially. This is necessary with all patients in order to determine the seat and exact starting point of the pain ; but it is specially important with those who, from special idiosyncracy or from a hard and laborious life, are not sensitive to pain. The simplest plan is to ask the patient to make the movements likely to cause suffering. A woman who is seated in an easy chair may assure us in good faith that she has no pain whatever ; but ask her to rise and walk across the room, or lift a piece of furniture, and she will be conscious of suffering immediately. As a rule, it is by manual examination that we learn the seat and degree of pain. Abdominal pressure, digital examination by the vagina and rectum, separately or all combined, will generally elicit dull latent pain. Abdominal pressure may be made when the woman is either standing or lying, if standing she ought to lean forward, if lying the knees ought to be well drawn up, so as to relax the abdo- minal muscles ; a gentle but continued pressure must be made with the tips of the fingers over the hypogastric and iliac regions as well as in the groins. If pain is elicited by pressure, we ought to verify our diagnosis while the patient is standing, by placing the hand trans- versely on the hypogastrium above the pubis, lifting all the abdominal viscera towards the diaphragm and letting them fall abruptly ; repeat- ing this manoeuvre two or three times. If the patient feels relieved when the viscera are lifted up and experiences pain when they faU, we are able to determine the existence, seat, and often the cause of the pain, and can also estimate the utility of a hypogastric belt to support the abdomen. During vaginal and rectal examination the tip of the finger may press on the neck or body of the uterus, or on the ovary ; or, again, on a peri-uterine tumour, to determine whether it is solid, sanguineous, ^ Diseases of Women, 2nd edition. London, 1878, p. 65. PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 111 or purulent. If this pressure does not cause suffering, a slight shock, as in practising balottemeut to diagnose pregnancy, may elicit pain. At other times abdominal palpation must be associated with vaginal or rectal touch before we can determine the exact seat of suffering, which is sometimes in the ovary, sometimes in the uterus, and sometimes in a retro-uterine tumour. In any case it is very important to elicit pain. When felt it is impossible for the patient to conceal her disease or to ignore its existence. It is, however, necessary to point out an error into which we may fall. Some patients, especially young girls who are unaccustomed to the contact of a foreign body in the vagina, partly from sensitiveness, shrink with alarm and fear from the slightest touch, sometimes crying out as if in pain. If this occurs just as the finger touches the uterus the physician is all the more likely to be led astray ; he must remember that, apart from the sensitiveness of the patient, this apparent manifestation of pain may be owing to the shock or (so to speak) to the surprise of the organ ; if he continues the examination gently and patiently he will generally succeed iu discovering the real seat of pain. There are six seats of pain — three principal and three accessory. The three principal seats are — 1, the iliac regions ; 2, the loins ; and 3, the hypogastrium. 1. Iliac pain is the most common; it corresponds to the iliac fossa, spreading towards the hypogastric and lumbar regions, but especially towards the pelvic brim and cavity. This pain must not be confounded with true lumbar pain, nor with intercostal neuralgia, which patients so often complain of below the breast. The mistake is the more easily made, as both kinds of pain are generally felt in the left side. Iliac pain is described by patients as pain in the side ; as a rule this is a pathogno- monic symptom of uterine disease. Aran thinks it is generally due to inflammation of the ovary or appendages. Many cases may be ex- plained in this way, but not all, because ovaritis is not limited to the left side. I think it can be accounted for in another way; just as pain in the back may arise from tension of the utero-lumbar ligaments, so may left iliac pain be produced by tension of the broad ligament. This may occur without metritis, ovaritis, or perimetritis. The uterus, iu some morbid conditions, increases iu size and weight ; its normal in- clination to the right being still more exaggerated, it necessarily drags on the left side of the broad ligament ; this dragging is enough to cause pain, and may even produce perimetritis. 2. Lumbar pain i generally called ''^ backache," though less frequent than iliac pain, is yet very common, and often very troublesome. Some- times it is confined to the renal region, or it may spread to the sacrum, or even to the abdomen ; at other times it extends from the loins, where it reaches its maximum, down each side to the iliac regions and even to the hypogastrium and pubis, encircling the abdomen with a belt of pain and sometimes terminating in a violent uterine spasm. Its cause is as variable as its mode of manifestation. Sometimes it depends on the contraction of the utero-sacral ligaments, or possibly on their distension, from the descent or retroversion of the uterus ; some- 112 GENERAL SURVEY OF UTERINE DISEASES times on congestion distending the ovarian veins and pampiniform plexus j or, again, it may be due to the accumulation of leucorrhoeal mucus and to the contractions provoked in the uterus in order to expel it ; sometimes it is caused by cervicitis, whether simple, granular, or ulcerative. Lumbar pain generally indicates disease of the cervix, whilst iliac pain (especially if associated with dyspepsia) is more fre- quently connected with an affection of the body of the womb or of one of the uterine appendages. Sacral, like anal pain, is suggestive of retro-flexion, or of a retro-uterine tumour. 3. Hypogastric pain has its seat immediately above the pubis, and seems, more than any other, to have its starting-point in the body of the uterus and to be dependent on an inflammation of that organ. It appears when artificially elicited rather than spontaneously. Many patients, also, who do not complain of it at first, feel it as soon as pressure is applied to the abdomen. This symptom is never absent in uterine disease. Although this pain is seldom spontaneous, it is still very disagreeable to women ; it interferes with their walking, or, if they do walk, they feel the necessity of supporting the hypogastrium with a belt, or they keep their hands in front, ready to protect themselves from the slightest shock which might occur. This pain must not be confounded with the sensation of dragging at the umbilicus (associated with sacral pain), which is often a symptom of retroflexion. The three accessory seats of pain are — 1, the anus or perinseumj 2, the vagina or cervix ; 3, the cavity of the pelvis. 1. Anal or perineal pain is generally produced by pressure from a peri-uterine tumour, from the fundus of the retroflected uterus, or from the uterus itself, either hypertrophied or prolapsed. I have already referred to patients affected with hypertrophy of the cervix, who suffered pain at the anus and perinaeum, not only in walking and riding, but when sitting. %. Vaginal pain is less frequent. In cer- tain acute diseases the uterine pain extends to the vagina, but it is more often due to the development of peri-uterine disease, especially if such disease is of an acute or inflammatory nature. In this way hema- tocele, retro-uterine peritonitis, peri-uterine inflammation, or abscess, sometimes produce in the vagina heat, swelling, or sharp throbbing pain extending to the vulva, which may become excruciating. In chronic disease this pain is often not felt unless artificially elicited. 3. Pelvic pain is usually the symptom of peri-uterine disease, or of cystic or sohd tumours of the ovary or uterus. In acute peri-uterine diseases such pain may be violent and accompanied with throbbing and a sensation of distension ; in chronic diseases it is dull and heavy. Radiating pain is chiefly pelvic. Iliac pain extends to the groins, either along the round ligament or by the ilio-pubic branch of the lumbar plexus. In this case the radiation assumes a neuralgic cha- racter ; there is an iliac centre, an abdominal centre, and one in the labia majora. Lumbar pain radiates oftenest along the course of the sciatic nerve. This radiation, like neuralgic pain, is occasional and intermittent ; but it may be more trtquent, prolonged, and even con- PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 113 tinuous, if dependent on direct compression of one of the sciatic nerves by a uterine, ovarian, or pelvic tumour. The hypogastric pain, like the iliac, sometimes extends to the groin, but oftener to the upper part of the thigh, following the divisions of the obturator nerve, or extend- ing along the anterior aspect to the knee, and sometimes below it, fol- lowing the branches of the crural nerve. The other pains, whether sympathetic or reflex, are not simple radiations; they have already been referred to under the head of general disorders of the nervous system. Pain may be of a continuous or an intermittent type. Continuous pain varies in intensity according to the individual and to the disease. It is worthy of remark that the most painful diseases are not always the most serious, and that certain incurable diseases, such as cancer and epithelioma of the cervix, may be developed without producing symptoms fitted to arouse the anxiety of patients. Hence the phy- sician is almost always consulted too late to be able to do more than palliate suffering; whereas if called at the commencement he could have removed the diseased portion of the neck by the knife or cautery and so frequently might have saved life. Cancer itself, whether of the neck or of the body, does not cause suffering until ulceration begins ; on the other hand, acute inflammation, neuralgia and catarrh often produce most violent pain. The intensity of pain is not always pro- portioned to its acuteness. There are kinds of pain which are intense but dull, giving the sensation of a weight, a distension, a numbness in the various regions I have described, and especially in the pelvis and along the pelvic nerves. There are others of a burning or lancinating character, resembling neuralgia, but less persistent, aj)pearing and dis- appearing in proportion to the pressure exercised by the uterus on the ramifications of the crural, obturator, or sciatic nerves, this pressure depending on the posture adopted by the patient. Intermittence of pain depends on three principal causes : — Inter- mittence is often characteristic of neuralgic pain. The neuralgia which accompanies uterine disease may, like other neuralgia, cease after a certain time, or even acquire the character of periodicity. The sudden attacks and exacerbations which are often observed in chronic uterine diseases, especially in those of an inflammatory nature involv- ing the peritoneum and accompanied by suppuration, may also explain the occurrence of intermittence. Such crises are often dependent on disorders of menstruation, and each monthly period may be the signal for an exacerbation of the disease and of pain. Or intermittence may depend on the very nature of the affection, and on the uterine contractions which are developed in the course of the disease. These contractions are painful. They are easily distinguished by the expul- sive character they assume; ])atients complain of a sensation of some- thing pushing downward, as in labour pains ; young girls even can trace the coimeclion, when their attention has been called to the coin- cidence, between these pains and the expulsion of a certain quantity of mucus or clots of blood. They are caused by an accumulation of mucus or muco-pus in cases of catarrh and leucorrhoea; by an accu- 8 114 GENERAL SURVEY OP UTERINE DISEASES mulation of blood in haemorrhages ; or they may be due to stenosis of the OS, or to polypi or tumours in the uterine cavity, which may produce local irritability and spasm. Another indication is afforded by the character of the dis- charges from the vulva ; whether sanguineous, mucous or muco- purulent. 1. Uterine hemorrhage is by no means an invariable symptom of disease of the womb. In some cases there is little or no derangement of the menstrual function ; but this is the exception. The recurrence of the monthly period may be tardy, or too frequent, or there may be intermenstrual hajmorrhage; oftenest of all there is dysmenorrhoea with diminution in the quantity of blood. If the catamenia have never appeared, we must learn whether general and local symptoms recurring periodically may not have indicated the menstrual molimen ; or there may even have been hsemorrhage within the uterus without any external discharge, the blood being retained from imperforate hymen, obliteration or deviation of the cavity of the cervix, or an occlusion of the uterine orifice. It is important to distinguish the cases in which there is retention from those in which the haemorrhage has never taken place, and from those still rarer instances in which the uterus is wanting. I have seen an instance of the last kind, and also several cases where the uterus had no external outlet owing to the cicatricial obliteration of the vagina following upon gangrene after delivery. I have operated on several girls for imperforation of the cervix and have found menstruation subsequently take place regu- larly, and I have often seen menstruation entirely or partially obstructed by stenosis of the os externum or internum, or by ano- malies in the position of the orifice or in the direction of the cervical canal. Fortunately, amenorrhoea is much oftener due to some func- tional disturbance or to a morbid condition of the general health, such as chlorosis or ansemia, and it must not be forgotten that amenorrhoea may possibly depend on pregnancy even in a woman who has never menstruated. The next point is to ascertain whether the menstrual function is nor- mally performed. In a number of uterine diseases the catamenia are excessive, in others defective. It is important to ascertain whether the quantity of blood habitually lost has increased or diminished. Differences are relative rather than absolute; for one woman normally loses very little in comparison of another. The length of the period also varies, and in this respect we must take individual idiosyncracies into account. Some women may be in good health although the menses only last for a few hours, whilst in other cases they continue for twelve or fifteen days. The normal period of recurrence is also variable though in most cases the menses return every twenty-eight days ; in some women, however, the ordinary term is thirty, thirty-five, or even forty days, whilst in other cases it is reduced to twenty-five, twenty, or even fifteen days. We must carefully distinguish men- struation from simple haemorrhage having no connection with the catamenia. Although uterine haemorrhage may sometimes be accom- PRESUMPTIVE SIGNS INDICATING UTEEINE DISEASE 115 panied by general and local symptoms which make a differential diagnosis difficult, yet the menstrual flow is generally marked by distinctive signs not confined to the uterus but involving the whole generative system, and accompanied by an unusual sensibility in the woman as well as other symptoms, varying in different individuals, but habitually characteristic of each ; the whole being sufficient to prevent our confusing the physiological function with the pathological pheno- menon, in spite of their single common element, the loss of blood. The general and local symptoms of the menstrual molimen are so marked that they can easily be diagnosed even when there is no haemorrhage. Sometimes we see the catamenial molimen occurring in the intermenstrual period, accompanied by pain, local fatigue and reaction on the general system, which is all the more intense because not followed by a critical hsemorrhage that would give relief (see Chapter on Menstruation). It is no less important to have correct information as to the quality and colour of the blood discharged. Sometimes it is darker, sometimes paler, than normal. It may be so dark as to be almost black, with dense viscous consistence, or perhaps in a state of coagulation, being expelled probably at intervals rather than continuously. All this indicates that the blood is of venous rather than arterial origin, or that it is mixed with mucous secretions, or that it has been long retained in the uterine cavity owing to inertia or to constriction of the orifice. At other times the discharge is pale and thin, of serous or sero-sanguinolent nature, leaving on the linen a pale pink stain surrounded by a grey areola ; this is symptomatic of chlorosis, uterine catarrh, &c. The blood may be fluid or may be expelled partly in clots. The size of these clots and the presence or absence of pain at the moment of their expulsion may indicate increased size of the cavity of the womb with inertia of its walls, or on the other hand, contraction with spasm and partial occlusion of the orifices. In short, menstruation may undergo many important changes. "When these derangements are marked they are designated by the names of amenorrhoea, dysmenorrhoea, menorrhagia and me- trorrhagia; these may be not only important symptoms in diagnosing a case, but essential morbid conditions which will be described as such in due time. It must always be borne in mind that these different symptoms may not only indicate uterine disease, but possibly pregnancy, abortion, de- livery, &c. While no one doubts the significance of amenorrhoea and haemorrhage, dysmenorrhoea is treated as of less moment, in consequence of a common idea that many women suffer at their monthly periods who yet have nothing the matter with them ; but this is a mistake ; the more experience we gain the more we are convinced that dysmenorrhoea, especially when associated with dyspareunia and sterility, is invariably symptomatic of a mechanical obi^tacle to the excretion of the catamenia. We must learn all we can as to the history of these hajmorrhages, the frequency of their recurrence, whether they are spontaneous or elicited, if they occur in the morning or evening, whilst the patient is at rest or after exposure to fatigue, as in walkmg, driving, riding, and espe- 116 GENERAL SURVEY OF UTERINE DISEASES cially in coitus. A few drops of blood after congress, especially if associated with muco-purulent leucorrhoea, ought to make us suspect fungous granulations of the cervix, if not a more serious organic lesion, sometimes cancer. 2. Leucorrhoea, or the various discharges from vulva, vagina, or uterus, ought to engage our attention for two reasons — 1. Because many patients do not mention this symptom to their doctor, thinking that all women suffer in this way. 2. As leucorrhoea is always abnormal its existence convinces us that a pathological change of some kind has taken place in the generative system. We must find out if these dis- charges are spontaneous, or if they are caused by walking, coitus, &c. ; if they are insignificant or abundant, continuous or intermittent ; if they cause inconvenience and are accompanied by fatigue, pain in the stomach, dragging in the loins and in the middle of the back. The peculiar characteristics of these discharges give us indications, and often point out to us with certainty their source and even the nature of the disease which produces them. The normal secretions of the vulva, vagina and uterus are not con- tinuous but intermittent, only taking place simultaneously with the performance of their principal functions — coitus, menstruation, preg- nancy and delivery. They may also occur normally after any fatigue or excitement, whether local or general. When pathological, these discharges may retain their normal character, being produced simply by hypersecretion, or they may assume an abnormal nature, depending on some derangement of the secretion. Simjile liy per secretion. — The vulval mucus is transparent and viscid, with acid smell and reaction, presenting nucleated epithelium with fragments of pavement epithelium, the secretion being either continuous or intermittent, as the case may be. The vaginal mucus is a milky- white emulsion, not viscid, with acid reaction, continuous secretion, and a large preponderance of solid elements, giant cells of pavement epithelium predominating over the liquid elements. The uterine mucus is an albuminous liquid, very viscid and stringy, sometimes tenacious, closely resembling white of egg, often quite transparent, secreted intermittently, with alkaline reaction, containing cylindrical or ciliated epithelium viith mucous globules or nucleated epithelial cells ; the cervical secretion the most tenacious of all, and contain- ing more ciliated epithelium than the mucus of the fundus. As to age, we must remember that vulval leucorrhoea is specially common in children, vaginal leucorrhoea more frequent in young women, uterine leucorrhoea, especially when cervical, most common in middle-aged and old women. The first is sebaceous (except the liypersecretion of the vulval glands of Bartholini) ; the second, epi- thelial (common or pavement) ; the third, mucous or nucleated. Derangement of secretion. — The vulval discharge may become yellow, green, purulent, or, in mixing with hypersecretion of sebaceous matter, may form a magma, with strong, acid, cheesy smell, very irritating to the adjoining parts, which become excoriated. The vaginal secretion may become very thick, curdy, greasy (never viscid nor gluey), always PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 1 1 7 acid, or, on the contrary, very abundant, more fluid, mixed with pus, yellow or green or sero-purulent, like the pathological secretion pro- duced by a blister excreted continuously, very irritating, and causing excoriation of the vulva and upper part of the inner side of the thighs. It is an undoubted fact that the vagina suppurates much more frequently than the uterus, which is in accordance with Virchow's remark that mucous membrane with cylindrical epithelium is slow to suppurate. The uterine excretion may become white, grey, yellow, even green, or streaked with yellow and white, of yellowish-green colour, partly transparent, always alkaline, more fluid, sometimes quite serous, but often tenacious, excreted intermittently and with the knowledge of the patient who experiences uterine colics as soon as the contractions of the organ expel the liquid, which is sometimes accumulated in large quantity in the uterine cavity and then falls into the vagina or on the vulva in one mass, as the white of egg would do. When the cervix is aflFected the mucus may become so gluey and tenacious that it adheres to the organ for a long time, and is only detached from it in a half solid form, similar to the cervical plug of pregnancy. To these cha- racteristics, of which intelligent patients are well aware, we may add those furnished to us by stains on the linen, of which I shall speak when giving the diagnosis of leucorrhoea. MixUire with another liqiddy normal or pathological. — The dis- charges may become serous or sanguineous, which is almost always the indication of a serious derangement of the secretion, of superficial ulceration with exudation, or of the existence of an ulcer, granulations or fibroma, or of some organic lesion. They may become sero-purulent, purulent, ichorous, with fetid smell, the latter too often the indication of a cancerous afi'ection. I have never been mistaken as to that smell, to which sufficient attention is not paid. When the utero-vaginal secretion has accumulated owing to the presence of a pessary, and is heated, it has a foul smell certainly, but only that of acid fermentation or heated pus, which all surgeons notice on laying bare a wound when an abundant suppuration has been retained by the lint dressing ; the smell of suppurating cancer, on the contrary, is nauseous, stale rather than acid, somewhat similar to macerated animal matter, often noticed at a distance, or as soon as the dress of the patient is removed. At other times the discharges assume a character of liquid transparency, and are called watery discharges, hydrorrhoea, hydrometria (See this word). They may have difi'erent sources, as we shall see when we come to consider leucorrhoea. These watery excretions are sometimes of no moment; at other times they are symptomatic of serious dis- eases, such as an ovarian cyst, epithelioma, &c. The variety of patho- logical fluids is great. There are others to which I have not yet re- ferred, because there is much about them of which we are still ignorant. I mean those fluids produced by gaseous excretions or physometria (See this word). We must beware of the rather frequent accident of the introduction of air by the syringe into the vagina or uterus, or of the facihty with which the vagina opens and sucks in atmospheric air during pronation in some women after delivery, or of the less common 118 GENERAL SURVEY OF UTERINE DISEASES accident of a recto-vaginal fistula, which, though too small to admit the passage of the faeces, allows intestinal gases to pass ; but, apart from these accidents, gas may be developed in the vaginal cavity and even in the uterus so as to distend it. This symptom, called physo- metria, may be caused by putrid decomposition of fragments of fcetus or placenta, or by decomposition of uterine secretions when abundant and retained by some cause in the womb. Lastly, discharges may produce a sensation of pain, which though not common is very intense when present. I have already spoken of ex- coriations on the labia and thighs ; but in addition to this, there is often, especially in women who have passed the menopause, an intoler- able vulval pruritis. This pruritis is often coincident with a vaginal excretion, and may be due to want of cleanliness or to a disease of an iniiammatory, syphilitic, pruriginous, or herpetic nature. In such cases the vagina is altnost always painful, covered by an erythematous eruption, and sometimes excoriated. The pruritus, however, often exists alone as the effect of a peculiar nervous erethism depending directly or indirectly on the uterine disease, especially when not accompanied by any eruption, and when it does not yield to a solution of bicarbonate of soda or to local applications of tar or tannic acid. Certain Signs Furnished by Direct Examination By the time we have reached this stage we have often more than the presumption, we have almost the certainty, sometimes we have the complete certainty that the patient before us is affected by uterine disease. We can easily lead her to share this certainty and to see the necessity for a direct examination. Methodic interrogation has enabled us to diagnose uterine disease ; a direct examination will enable us to make a differential diagnosis. The means of investiga- tion at our disposal are, palpation, the touch, the speculum, the sound, 1. Abdominal Palpation — This is the simplest means of investi- gation at our command and therefore the one we ought to employ first. It is a kind of modified touch exercised by the whole hand, or part of it, through the abdominal walls. The form of the abdomen should be noticed, and the patient should be made to change her position so that we may ascertain if there is fluctuation. The other means of external examination are percussion, auscultation, the ex- ploratory puncture, mensuration, &c. Palpation. — Palpation should be practised in two ways; when the patient is standing and when lying. It matters little whether we begin with the one or the other. If the patient goes to the consult- ing room of her doctor, it is natural to begin with vertical j)alpation ; if on the contrary she is obliged to keep her bed and sends for the doctor he begins with horizontal palpation. In wiiatever order we take them, the combination of these two modes of palpation in two different positions, is more important than would appear at first . SIGNS FURNISHED BY DIRECT EXAMINATION 119 sight ; each position helps us to discover certain symptoms which we could not otherwise have made out. The })atient being in the erect posture, her back supported by a piece of furniture or by the left hand of the physician, the right hand is placed over the epigastric or umbilical region ; when exploring these regions with the palm of the hand their temperature should be observed. Gradually and methodically the hand is brought down, going from right to left, any change in the form and size of the abdomen being noted which may be dependent on a tumour con- nected with the uterus or ovaries, or on an increase in the size of the womb or its appendages, or to a fluid or semi-fluid effusion in the peritoneum or pelvis, or merely to distension from a tympanitic con- dition of the bowels, very common in uterine disease. Above all, the size and sensitiveness of the various parts of the hypogastrium and pelvic cavity should be ascertained ; and to do this, we must ask the patient to lean forward, so as to relax the abdominal muscles. In dejjressiiig the teguments with the tips of the fingers we often elicit sharp pain immediately above the pubis, or on the inner side of the left iliac fossa, at the transverse diameter of the brim. These pains, together with tumefaction of this region, leave little doubt as to the existence of an inflammatory disease of the uterus or ovary. Any increase in the temperature of the hypogastrium ought to be ascertained at the beginning of the examination as this is an additional sign in favour of the supposition of chronic inflamma- tion of the uterus, its appendages or surrounding tissues. We should also take advantage of the upright position of the patient to obtain another indication vi'hich is too often neglected, although valu- able to the physician both as regards diagnosis and treatment. Instead of pressing down the abdominal parietes towards the pelvis as at first, ■we raise the mass of viscera, so as to drive them upwards and backwards towards the diaphragm ; then we let them fall down abruptly. By repeating this little raanceuvre two or three times we ascertain whether the pressure exercised on the uterus by the weight of the viscera is a cause of pain, and consequently we can determine whether an abdominal belt, preserving the uterus from this painful pressure will be helpful to the patient. "When on the couch the patient should be on her back, the legs bent on the thighs, the thighs on the pelvis and sligbtly apart, the head raised by a pillow so as to relax the abdominal muscles. Whilst making the examination it is well to speak to the patient so as to distract her attention, for many women, from modesty or from sensitiveness, contract their muscles so firmly when touched, that it is impossible to proceed. When the patient is lying, we are able to depress the abdominal walls much more than when standing, and so can better ascertain the more deeply-seated changes ; not only those due to uterine tumours, fibromata, ovarian cysts and pelvic tumours, but those also which have their rise in disorders of other organs, such as the kidneys, the ureters, the bladder, the small intestine, the cfecum and the ascending colon. In this way it is possible to distinguish a mass of stercoraceous 120 GEXEEAL SURVEY OF UTEEINE DISEASES matter in the sigmoid flexure, which has sometimes caused so much pain as to have led to errors of diagnosis. In this investigation of abdominal and pelvic tumours by palpation it is not sufficient to ascertain the ditt'erences in size, form, sensibility, and position of the ditl'erent organs; we must also learn to distinguish differences in con- sistency aud in resistance to pressure presented by these viscera or by tumours. A single finger will sometimes appreciate these differences better than the whole hand. In this way may be ascertained the transmission of arterial pulsation, vascular or respiratory vibrations, intestinal gurgling, the depressibility and molecular mobility of the contents of some tumours susceptible of displacement, the stony, cartilaginous or fibrous hardness of others, the softness of a certain number, the resistance of abscesses or cysts, &c. I do not mean to say that palpation alone will enable us to diagnose small mobile tumours, or even to elicit pain in inflamed organs, which recede from pressure as the uterus does when not too large and not retained by adhesions. But associated with vaginal touch palpa- tion is one of the most certain and most valuable means of diagnosis. When practised on the hypogastric and lateral regions of the abdomen by pressing the pelvic organs down, it brings them nearer to the exploring flnger and sometimes indeed enables the examiner to hold them between the finger introduced into the vagina or rectum, and the hand which depresses the abdominal parietes. The fundus, the Fallopian tubes, the ovaries, mobile pelvic tumours, the posterior side of the uterus, would escape investigation if vaginal and rectal touch were not complemented by abdominal palpation and even exceptionally by another mode of examination to which I shall afterwards refer under the name of rectal palpation. One last remark : before abdominal palpation is practised the bowels should be evacuated by an enema or laxative, and the bladder naturally or by catheter, otherwise it will not give us the certain information that we require. The complementari/ means of external examination are : percussion, quest for fluctuation, change of posture, auscultation, observation as to the appearance and shape of the abdomen, an exploratory puncture, and mensuration. These are practised when the patient is lying. Fercussion of the different regions of the abdomen, and esjjecially in those parts where there is abnormal tumefaction, enables us to detect the jjresence of foreign bodies, whether gaseous, solid or liquid, and to determine the exact limits of a tumour of the uterus or ovary (left undecided by palpation), to discover their inequalities, and recognise other complications, &c.^ ' E.g. percussion enables us to perceive tympanitic resonance of the intestine at the hif^liest part of the abdomen near tlie umljilicus, or on the contrary at its most dependent parts the flanks, an essential distinction in diagnosing between ascites and an encysted tumour ; it limits the bounds of a solid or fluctuating tumour ; it enables us to ascertain the presence of dulncss in the most depen- dent parts (ascites), or above the pubis, uniformly in the centre, with iluctua- tion, (vesical tumour, retention of urine), or in the hypogastrium sloping downwards with irregular surface, &c. (pregnancy, hypertrophy of the uterus, SIGNS FURNISHED BY DIRECT EXAMINATION 121 Examining for fluctiiatioti is not less important in some cases ; it enables us to discover efl'usions which may be in the lower part of the peritoneal cavity and helps us to diagnose an ovarian cyst^ and to ascer- tain whether it is simple or multilocular, partly liquid and sohd, whether complicated with ascites^ &c. The association of percussion and even auscultation with this mode of examination leads us to dis- cover the characteristic hydatid thrill, and so distinguish an acephalo- cystic tumour of the pelvis or omentum from any other kind of tumour. In certain cases palpation must be associated with digital examination in order to discover fluctuation^ the finger of one hand resting on the most dependent part of the vaginal tumour^ while the other hand de- presses the hypogastrium firmly. Short taps on this region made by a finger of the same hand are transmitted by the liquid to the tip of the finger within the vagina. Changes of posture and shocks given to the abdomen are useful after percussion and palpation in giving additional information. In order to discover dulness, resonance, fluctuation and the various sounds which are recognised by auscultation we must examine the patient, not only when she is standing and lying, but also on the back on each side in pronation, and even on elbows and knees, as Bozeman does for the operation of vesico-vagiual fistula. Nothing is so useful as these changes of posture in displacing peritoneal efl'usions and solid tumours attached to the broad ligaments or to the mesentery, or in changing the relationships of organs or abnormal products. When these changes of posture are not sufficient to enlighten us as to the weight and consistency of organs and as to the presence of solids, liquids and gases in the abdomen, we may be able to throw light on the diagnosis by concussion, which communicates a balotte- ment, more or less considerable, to all the abdominal viscera. This balottement, as well as changes of posture, may help us greatly in diagnosing the case, not only because of the impressions transmitted directly to the physician, but because of the new sensations which it causes to the patient. Auscultation is especially usefsl when we have to distinguish between pregnancy and a uterine or ovarian tumour. When the uterus contains a living foetus we can generally hear the fcetal heart as well as the uterine souffle. The existence of the heart sounds in an abdominal tumour, more or less lateral and not dependent on the uterus, which is rela- tively defective in development, ought to lead us to diagnose extra- uterine pregnancy. This question should always be determined before forming a diagnosis of an abdominal tumour. In auscultating cases of ovarian tumours or of uterine fibromata compressing the aorta or the iliac arteries, a souffle can almost always be perceived on one side analo- fibroma, &c.), or on one side of the pelvis extending to a more or less elevated part of the iliac fossa (tumours of the broad ligaments or ovaries), or at the most elevated part of the abdomen, -with or without fluctuation and with tympanitic resonance in the flanks (cysts, cystosarcomata, solid tumours of the ovary). 122 GENERAL SURVEY OF UTERINE DISEASES gous to what is called the uterine souffle. This sound is often perceived on. the surface of the tumour and evidently arises from the great vessels which traverse it, whether it be due to an ovarian cyst or to the distension of the uterus by an enormous fibroma ; it depends probably on the compression which the volume of the tumour exercises on these vascular trunks at some point, and is an indication of their great size. Auscultation also enables us to dis- tino-uish intestinal gurgling, tympanitic resonance, peritoneal friction sounds, &c. The external appearance of the abdomen gives the physician an opportunity of receiving impressions which palpation alone would not have afforded. We not only note the changes in colour and appear- ance of the abdomen, the umbilical depression, the pigmentation of the linea alba, presumptive signs of a commencing pregnancy, the vibices due to the distension of the belly by a previous pregnancy, ascites, or a tumour, wrinkles, cicatrices, marks of chafing, &c., but it enables us also to detect the slightest change in the form of the abdomen. The patient ought alternately to be standing and lying, especially lying on the back. In this position we can easily distinguish the general swelling due to meteorism ; the peculiar tumefaction of the sigmoid flexure, colon or caecum, due to constipation ; the vesical tumour caused by retention of urine ; the uterine tumour of pregnancy ; the more Um'ited protuberance of a solid tumour of the womb, ovary, or broad ligaments ; the prominent tumour, raising the umbilicus and even the xiphoid cartilage, caused by the enormous distension of an ovarian cyst ; the iliac or hypogastric puffiness accompanying peri- metritis ; lastly, the increased size of the belly in the flanks and in the iliac regions due to ascites. The exploratory jmncture is of the same utility in diagnosing tumours of the genital organs as of other parts of the body. It determines the consistency and nature of the contents of the tumour by the issue of a drop of liquid or of a solid particle. It may be apphed not only to the abdomen and to the external organs of generation, but also to the vagina, to the posterior vagino-uterine cul-de-sac, to the uterus, or to tumours of its cavity. As the complement of palpation, tapinng is even more useful than an exploratory puncture. Evacuation of the tumour helps us in the same way that evacuation of the bowels and bladder does. I do not say that this is necessary in order to diagnose the existence of an ovarian tumour, but it is impossible to ascertain the peculiarities of its form and composition, the complications and adhesions, unless the evacuation of the cyst permits the examination of the empty sac and its appendages by means of palpation (associated with touch), the abdominal parietes being now as easily depressed as they were distended formerly. Mensuration frequently repeated is useful in determining the changes of size. We must measure the circumference of the abdomen carefully with a tape, and always from the same points, using the precaution of taking measurements from several points, in different SIGNS FURNISHED BY DIRECT EXAMINATION 123 directions (horizontally and vertically), before and after practising the exploratory puncture. 2. Digital touch. — All practitiotiers agree in giving to digital touch the first place as a means of examination ; it is all the more valuable as being the one which causes least distress to the patient, owing to our being able to employ it without uncovering her. I insist on the capital importance of digital examination for two reasons. The first is because it has been neglected since the discovery of the speculum. Now, I have seen so many women affected by serious uterine or peri-uterine disease which their physicians, nevertheless, had failed to discover, because they had only examined them with the speculum, that I cannot too strongly warn practitioners of the danger of abandoning touch for the spe- culum, which can do no more than correct and complete the informa- tion given by the touch. The second is my hope of persuading young practitioners to practise this mode of examination. Now, in order to be able to do so, or indeed to make any other examination profitably, it is not only dexterity that is required, we must also have an exact knowledge of the sensations due to a normal and an abnormal condition of the organs explored ; this knowledge is only acquired by habit, and I can assure all young practitioners who wish to perfect themselves in this mode of investigation, that they will be surprised to observe what constant progress they make. Digital touch, like abdominal palpation, is practised when the patient is standing or lying ; in England the usual position is on the left side. In most cases it is indispensable to examine the patient by touch when she is standing. It is often the only means of reaching the cervix in girls, as with them the uterus is generally very high up. It is the same with tall women who are stout, because the cellular adipose tissue, which lines the perineum, shortens the examining finger ; the vertical position is sometimes insufficient to enable us to reach the cervix, unless the patient makes an expulsive efi'ort which forces the uterus downwards. The vertical position facilitates exami- nation of the cervix of a pregnant woman, as well as that of a uterus containing a fibroid tumour ; in both of which cases the womb rises above the pelvis as Simpson has pointed out. This mode of exami- nation also helps us to practise balottement and to appreciate the weight of an inflamed or hypertrophied uterus which may be an important element of diagnosis. Lastly, this alone can give exact information as to elevation, descent, displacements or flexions of the womb ; for all these displacements are modified by the horizontal position. When making the vaginal examination in the erect posture the patient ought to have her back against a piece of furniture, the legs slightly apart, the body leaning forward so as to relax the abdominal muscles, the hands on the back of a chair. The physician on a low seat, or on his knees, introduces the right hand under the dress of his patient, having previously anointed the index finger, so as to preserve it from infection, as well as to facihtate its introduction. He follows the line of the right thigh and tries to reach the posterior commissure of the labia, endeavouring to avoid the anus behind and 124 GENEEAL SURVEY OF UTEEINE DISEASES the clitoris in front in order to save the patient the annoyance of having these sensitive organs touched. Contrary to the advice given by some authors the other fingers ought not to be bent on the palm of the hand, as doing so shortens the index finger nearly an inch. They ought on the contrary to be left in extension and as far as possible from the index, the thumb directed forwards to"wards the top of the vulva, on one side of the clitoris, resting on the labium, whilst the three other fingers, directed backwards, should rest on the perineum and anus, raising them if necessary, so as to shorten the vagina and bring the uterus nearer the index finger. We must learn to execute this little manoeuvre in spite of the resistance offered by the coccyx and adipose tissue of the perineum ; for in certain cases we could not otherwise reach the uterus, its appendages, or peri- uterine tumours situated high up in the pelvis. When the index reaches the posterior commissure of the labia it depresses the four- chette and insinuates itself easily into the vagina. The finger is made to feel its way all along the posterior wall of the vagina towards the cervix, taking note of the condition of the mucous membrane, its temperature, observing whether it is dry or moist, whether its surface is smooth or rough, &c. Having reached the cervix, it first examines the two lips and the os and then carefully examines the fundus of the Fig 111. -Vaginal touch associated with abdominal palpation. vagina. Then it makes its way back to the vulva, now exploring the anterior wall of the vagina in the same way as the posterior was pre- SIGNS FURNISHED BY DIRECT EXAMINATION 125 viously examined. Sometimes, in place of one finger we may have to introduce two or even four when we have to ascertain the presence, form and consistency of a tumour, its connections with the uterus, whether pediculated, &c. The vagina should next be explored whilst the patient lies on her back ; only by this means are we able to ascertain certain pathological conditions, the existence and limitation of ovarian or peri-uterine tumours, the distinction between these tumours and the uterus itself when deviated or flexed. Vaginal touch associated with palpation may give to our diagnosis a certainty which could not be acquired by any other means. It is the best of all modes of examination for enabhng us to judge as to the integrity of the uterus, the ovaries and the Eallopian tubes. Having asked the patient to flex the lower limbs and open them slightly, the physician, without uncovering her, proceeds to practise the touch with the same precautions as he employed in the vertical position. I think it is better for him to pass the hand under the thigh nearest him ; it is more convenient, there is less risk of touching the clitoris, it allows the finger to penetrate further, and above all forces the patient to keep her thighs well flexed, which facilitates the examination. After having acquired experience in this mode of examination, in using the other hand simultaneously for palpation and in depressing the various parts of the hypogastrium, there are very few lesions which can escape our investigation. In England it is usual for the patient to be placed on the left side when examined. It is also the custom in that country for women to be delivered in this position. The knees are drawn up, the head and shoulders directed obliquely across the couch, whilst the nates are brought near the edge of the bed. In this position the vulva is easily penetrated without uncovering the patient, but it is difficult to practise palpation, or to appreciate uterine displacement and the relative situa- tion of the various organs as exactly as in the dorsal position ; the only advantage of the lateral decubitus is that it sometimes reveals to us the mobility of a tumour or the existence of adhesions attaching the uterus and its appendages to the pelvis. Scanzoni and other writers have proposed that in the case of virgins we should content ourselves with the information furnished us by rectal touch, as if this mode of examination were not far more repugnant to the delicacy of girls than the vaginal touch itself. We can persuade a young girl as well as a married woman of the necessity of a vaginal examination, and it is easy to practise this without injuring the hymen — the physical sign of vir- ginity. The precautions to be taken are these : the patient should be requested to bring her thighs close together in place of separating them, as this puts the hymen in a state of tension unfavorable to the entrance of the finger into the vagina. The index finger (well greased) should then be placed on the fourchette, and rest there for a few seconds, till the si)asm caused by the contact of a foreign body has passed ; then let it glide gently forwards, depressing not only the fourchette, as in the case of a married woman, but also the inferior border of the vulva and the hymen attached to it. Bringing the thighs 126 GENEEAL SURVEY OF UTERINE DISEASES together makes this membrane depressible, just as bringing the fingers together makes their commissure depressible. It is only after having ascertained the depression of the hymen that the finger should be slowly insinuated into the vagina, when it will penetrate without pain or difficulty. I have often practised the vaginal touch under these cir- cumstances, and have never caused suff'ering or haemorrhage, nor torn the hymen, which is often more or less obliterated in these young girls owing to the leucorrhoea which so often accompanies uterine diseases in virgins. It is not so much the hymen as the sphincter of the vulva which it is difficult to pass, but it can always be managed by going slowly and gently. Finally, whatever may be the age of the patient, the condition of the genital organs, or the position in which we prac- tise the touch, we must endeavour to make the examination as short as possible, remembering that it is always disagreeable and often painful. On this account we must, above all, learn to practise the vaginal touch methodically ; we must know beforehand all that we ought to seek for and all that we can find by its assistance, observing every indica- tion given to us as we go along. Having already explained how it ought to be practised, I will now point out the valuable information which it gives to the physician as he proceeds from the vulva to the uterus, and from the uterus to the vulva. In the first place this ex- amination may disclose to us, or at least give us reason to suspect, some malformation. I refer the reader to the description given in another place of these abnormalities. Next, the condition of the labia and the orifice of the vagina should be observed, the contraction which this latter and the vagina itself may have undergone after the meno- pause being sometimes so great as even to make the entrance of the finger difficult. The presence of tumours, cysts of the labia, of the vulva, of Cowper's gland, of the posterior vaginal wall, tumours of the rectum perceptible through this wall, distension of the bowels due to the presence of fseces, which are depressible, and which nevertheless have sometimes been taken for real tumours, may be determined by this mode of examination. In withdrawing the finger we ascertain the state of the mucous membrane and the existence of any cysts, polypi, or vegetations which may be found on the anterior wall of the vagina. Vesical catarrh, cystitis, stone, gravel, may be recognised by the pain caused by pressure of the finger on the anterior wall ; inflamma- tion of the urethra, blenorrhagia, vascular or fibro-vascular tumours of the urethra and meatus are brought to light by compressing the inferior part of the anterior vaginal wall against the pubic arch. The finger, before reaching the cervix, may discover in the vagina a tumour originating in the uterus; this is often a polypus, a fibrous tumour, elongation of the vaginal portion of the cervix or of one of the lips, rarely retroversion of the uterus. It is important to discover the con- nection of this tumour with the cervix and fundus. At other times there may be an encysted tumour in one of the vaginal walls, or a solid tumour in the portion of the broad ligament which runs along the lateral part of the vagina, and which may be an inflammation of the lymphatics. Having reached the cervix we must first note the SIGNS FURNISHED BY DIRECT EXAMINATION 127 mobility or immobility of the uterus, distinguishing the mobility of the cervix due to flabbiness from that of the organ as a whole. When the uterus moves freely on its axis the finger is able not only to dis- place the cervix, but in so doing to perceive by the resistance offered the inclination of the fundus in the opposite direction. Mobility is an important sign of the integrity of the uterus and surrounding organs; it is destroyed by adhesions following peri-uterine inflammation ; it is diminished by diseases of the ovaries and Fallopian tubes, and even by uterine disease, or by the tumefaction, hypertrophy, and chronic in- flammation of the organ. Even when the uterus is mobile the finger may find the cervix changed in position, above, below, behind, -or in front of the normal position. When the cervix is placed forwards and high up, as if resting on the pubis, there is reason to suspect the ex- istence of a tumour forcing it in that direction. At other times the direction of the cervix is changed. It may be inclined forwards owing to retroversion, but this is rare. More frequently it is directed back- wards, the consequence either of an anteversion or of tumefaction of the anterior lip. In order to discover this deviation the finger must follow the posterior wall of the vagina till its tip can pass behind the cervix. In this case the anterior lip is first reached and can be examined. The posterior lip may have become inaccessible, and may- only be discovered after much seeking, and with difficulty be forced into the axis of the vagina so as to allow the finger to penetrate into the posterior cul-de-sac. At other times, though less often, the cervix is inclined to the right or left, according to the position of the fundus. This position can only be ascertained by a careful examination as to which side the os is directed ; unless this is done we should be apt to be deceived by the difi'erence of size between the two lips. The form of the cervix, its temperature, its hardness, softness, irregularity of surface, &c., ought to be carefully investigated by the touch. The neck may be conical in place of being round. This cone may hang freely in the vagina, may even be hypertrophied in a longitudinal direc- tion, occupying the centre of the canal, or may be compressed against one of its walls whilst preserving its mobility like the rest of the uterus. When compressed against one side constantly to the front and to the left the finger discovers on the opposite side, i. e. behind and to the right, an enormous vaginal cul-de-sac, the size being due to the penis habitually slipping over the conical cervix and lodging there during coitus. This state of things is sometimes made worse by the position of the os being on the side in place of on the summit of the cone, and is a cause of sterility, all the more important to diagnose because it can be remedied by partial amputation of the cervix. This abnormally exaggerated conical cervix must not be confounded with the slightly conical one often found in virgins, and which is quite normal. The cervix may, on the contrary, be flattened like a mush- room, the lips turned back, forming a circular border, which projects beyond the upper part of the neck. There may also be a difference of size between the two lips ; the posterior one is generally the longer, the anterior the thicker. The anterior lip often becomes hypertrophied 128 GENERAL SUEYET OF UTEEINE DISEASES and engorged; the posterior more painful, owing to granulations or ulceration. I have already described the varieties of form presented by the vaginal portion of the cervix in treating of congenital anomalies. The temperature of the cervix and also of the vagina may be higher than in a normal state. This is an almost certain sign of metritis or of peri-uterine inflammation. The consistency is variable also. Some- times the cervix is hard as in hypertrophy ; when there are follicular cysts or commencement of cancer the surface is irregular. At other times it is softj being easily indented by the finger. If this softening is accompanied by ascent of the organ and balottement it may be only a sign of pregnancy ; but if coincident with increased size, high tem- perature, disposition to hseraorrhage, &c., it may be a sign of congestion, inflammation, catarrh, or of fungous growths. The position, form, size, penetrability of the os, are all important elements in the diagnosis. The os may look in various directions, owing either to natural causes or to deviation of the organ, flexion of the cervix, or lastlyj^ to a difference in the size of its lips, e. g. one of them may be so much swollen or hypertrophied as partly to cover the other, which has preserved its natural size. The os externum is most frequently a transverse fissure ; sometimes it is a more or less circular orifice. In a woman who has had children the fissure is more marked, larger, and somewhat gaping; in the angles of the fissure are hard cicatricial marks, perceptible to the touch. Sometimes, even iu virgins, the orifice is large enough to admit the end of the finger. Unless there is pregnancy this indicates an abnormal dilatation due to catarrh, chronic inflammation, congestion, or the presence of a polypus, or other intra-uterine tumour, causing contractions in the body of the uterus, which tend to open the neck. The surface of the lips often present sensible irregularities. Sometimes we find bleeding granulations^ sometimes nodules, tubercles, irregularities, point to the development of little tumours. The lips may also be the seat of ulcers and fungous vegetations, or of real tumours, vascular, follicular^ or fibrous, more or less pediculated, as well as of cancer. Through the gaping neck the finger may enter the cervical and even the uterine cavity, and discover a clot of blood, a conception, an inter- stitial tumour, sessile or pediculated, polypi, fungous vegetations, cancers, &c. It is important to ascertain whether, if the touch pro- duces pain, in what way and at what points it is elicited. Sometimes pain is caused by a movement communicated to the uterus, by an attempt, successful or otherwise, to displace it ; it then indicates a morbid condition of the appendages, adhesions between the uterus and the peritoneum, the ovaries or Fallopian tubes. Sometimes it is caused by pressure of the finger on the neck or body of the uterus, and is then dependent on increased sensitiveness of this organ; it is felt most when recourse is had to binianual palj)ation. This sensitiveness may be confined to one limited point in tlie organ. It indicates general or partial metritis, or irritation symj)tomatic of commencing organic lesion. It occurs most frequently in the posterior lip, which seems more disposed to inflammation and ulceration than the anterior one. SIGNS FURNISHED BY DIKECT EXAMINATION 129 wliich, on the other hand, has a tendency to tumefaction and hyper- trophy. At the same time it is easy to recognise whether the size of the organ has increased, not only the size of the neck, but that of the body. Tumefaction sometimes attacks both parts of the womb at once ; at other times only the body is affected, the neck seeming to be normal, but above it can be felt, through the vaginal cul-de-sac, a rounded tumour, very similar to the form of the uterus in the beginning of pregnancy. The regularity of outline, the elastic and moderately firm consistency of the tumour, as well as its mobihty, should help us to distinguish it from a fibrous tumour, a flexion, an ovarian tumour, a hsematocele, or from a peri-uterine inflammation. The immobility of the uterus greatly facilitates this differential diagnosis. Whether the uterus be flexed or not, it loses its mobility if it contracts adhesions with neighbouring organs, either in front or behind ; but even though no adhesions are formed, if there be peri-uterine inflammation, inflam- matory tumefaction of the uterus or surrounding tissues, there will be a relative immobility owing to the severe pain which any movement produces. If the inflammation has produced an effusion into one of the peritoneal cul-de-sacs or in the broad ligaments, the uterus is not only rendered immobile, it is displaced. Sanguineous effusions pro- duce the same results ; retro-uterine hsematocele, for example, displaces the uterus, forces it forwards and upwards behind the pubis, whilst the tumour projects into the posterior vaginal cul-de-sac. In this case the M-omb is as immovable as if fixed in the centre of a mass of plaster which had hardened around it. In conclusion, the careful examination of the vagina all round the cervix furnishes us with the most valuable information. In a normal state the cul-de-sac is smooth and easily depressed by the finger in either direction, the uterus rising when this is done ; but it may un- dergo various changes. I have often found it as if glued to the pelvis, as the result of adhesions caused by peri-uterine inflammation ; at other times it is diminished in size by peri-uterine inflammation, a hsemato- cele, or by some other tumour situated behind, before, or on one side of the cervix. Sanguineous effusions and peri-uterine inflammatory tumefactions do not always project into the vagina, but they always pre- vent our being able to depress it indefinitely ; they offer a more or less determined resistance to pressure in lieu of the sensation of emi)ty space due to the displacement of mobile organs. At other times they form a more or less prominent border all round the cervix, or more especially on one side (corresponding to one of the broad hgaments), or in the posterior cul-de-sac (corresponding to Douglas's space). The touch may also disclose to us in this cul-de-sac behind, and either to right or left of the uterus, the presence of very sensitive globular tumours, due to ovaritis or abscess of the Fallopian tube ; whilst behind, and more especially at the base of the broad ligaments, we may also find inflamed and indurated glands which are very painful. By the touch we also recognise tumours formed by the uterus itself when flexed. We must learn not to confound these various tumours. Peri-uterine tumours can be distinguished from ovaritis by rectal touch, and 130 GENERAL SURVEY OF UTERINE DISEASES flexions from other tumours by the sound ; it is also most important to be able to appreciate not only the size of these tumours, but also the sensibility of the peri-uterine tissues. Let us always remember that when the peritoneum, the peri-uterine cellular tissue and the appendages are in a normal state, the examining finger should find the surface everywhere smooth and depressible. Having completed the thorough investigation just described, we ought to observe whether the finger has brought away any blood or mucus (milky-white, glairy, or purulent) , pus, ichor, cancerous matter, &c. Note should be taken of any haemorrhage which may accompany or follow the examination in the case of bleeding fungosities, cancer, epithelioma, &c. Rectal touch cannot supply the place of vaginal touch ; it is as repugnant to the modesty of women and it gives us less information. It is often necessary but ought only to be employed when requisite to complete a doubtful diagnosis. If we asked our patient's permission, we should expose ourselves to an almost certain refusal ; therefore it is better to practise it immediately after the vaginal touch, just as if it were usual and the natural complement of the other examination. Hence it follows that the patient should be in the same position as when examined per vaginaniy the only precaution necessary being to have advised the patient to take an enema a few hours previous to the examination. After having passed the sphincters, the finger having penetrated about two inches, comes upon a resisting and rounded tumour in front, which is the neck of the uterus pressing more or less on the anterior wall of the rectum in proportion to its size, its position, and its deviation towards the sacrum. Above the protuber- ance of the cervix the index discovers the body of the womb, and passes over its posterior surface but rarely over the fundus, unless it be inclined towards the concavity of the sacrum owing to a retrover- sion or retroflexion. On depressing the abdomen with the other hand and forcing the uterus downwards, i.e. combining palpation with rectal touch, we can better explore the posterior surface, the fundus, the outlines of the womb and the various tumours which may be found behind or on its sides. This mode of examination helps us not only to recognise flexions, deviations, tumours of the posterior wall of the uterus, such as fibroma, phlegmons, the results of pelvi-perito- nitis, inflammatory or cystic tumours of the ovaries and Fallopian tubes, extra-uterine pregnancies, &c., but it also allows us (especially when associated with abdominal palpation) to judge as to the size, the consistency, the mobility, the sensibility of these difi'erent tumours, and to obtain a precision in diagnosis which vaginal touch failed to afford. We must take care to raise the perineum as much as possible, for its thickness in stout women makes rectal as well as vaginal touch more difficult. Rectal touch is the only means we have of ascertaining the absence of the uterus. In this case it must be combined not only with palpation and vaginal touch but also with catheterism of the bladder. In short, rectal touch, alone or asso- ciated with vaginal touch, is necessary in order that we may judge of SIGNS FURNISHED BY DIRECT EXAMINATION 131 the condition of the recto-vaginal septum^ its tumours, abscesses, per- forations, fistulse, &c. Recamier used to insist on the necessity of introducing two fingers of one hand, the index and middle finger, one in the rectum the other in the vagina ; or the thumb in the vagina the index in the rectum ; or the index of one hand in the vagina and that of the other in the rectum. This is the only way to diagnose small retro-uterine tumours. Touch is not even always sufficient ; we must sometimes inspect the mucous membrane of the posterior vaginal wall, forcing it through the vulva by a kind of artificial recto- cele, or we may have to examine the anterior wall of the rectum, pressing it down through the anus by fingers introduced into the vagina. This little manoeuvre has often been of great use in helping to diagnose lesions of the recto-vaginal septum and in facilitating necessary operations. Uectal palpation. — I cannot give this any other name to distinguish it from the touch properly so-called, and to express the nature of this far too rough method of examination, which has been too often resorted to, on the authority of Simon, of Heidelberg, who was the first to practise it.^ It is certainly possible to introduce, not only Fig. 112. — Rectal combined with abdominal palpation (after Simun). one or two fingers, but the whole hand into the rectum especially of women when under the influence of chloroform, after having forcibly but gradually dilated the sphincter. The patient being placed on her back, the lower limbs and the head are flexed on the abdomen, which * Ueher die Enveiterung des Anvs und Rectmn, &c., Arcliiv.fiir KJinische Chirurgie herausgegchen von Langenbeck, Billroth und Gurlt, Band xv, Heft 1, p. 99, 1872 ; Gazette hcbdomadaire, 3 Janvier, 187?. 132 GENERAL SURVEY OF UTERINE DISEASES is thus shortened as much as possible whilst the surgeon introduces first two fingers, then two more, then the thumb, then the whole hand well greased through the anus with the same precautions as are used in introducing it into a narrow vagina or into the uterus for the purpose of turning or for the removal of the placenta, making small incisions when requisite round this orifice. In spite of the great dis- tension of the anal orifice, mere intra-rectal exploration does not relax the sphincter; cases requiring incision are followed by faecal incontinence for ten or twelve days. When the hand has penetrated into the rectum as far as the promontory of the sacrum, it is possible to reach the sigmoid flexure with three or even four fingers, and owing to the mobility of the rectum we can palpate (through its walls) the whole of the abdominal region as far as the kidneys and umbilicus, and so gain much information. In two cases of ovarian cyst Simon was able to determine the breadth and length of the pedicle, the absence of adhesions, and the existence in the fundus of the uterus of two fibromata of the size of a cherry-stone. Unless the patient is very stout, we can in this way examine the ovaries even when they are healthy and in a normal position. It appears from the researches of Simon that the greatest circumference of the rectum is at 6 or 7 centimetres above the anus, and may reach at this point 25 to 30 centimetres. In the upper part of the middle third it is only from 20 to 25 centimetres, and diminishes rapidly beyond that, being only from 16 to 18 centimetres in the middle part of the upper third of the rectum. The narrowest point corresponds to the beginning of the sigmoid flexure. Weir, in summing up these measurements, con- cludes that a hand measuring less than 26 centimetres in circumfer- ence can without danger penetrate from 17 to 19 centimetres but not farther. It is superfluous to remark that in this exploration, which is only allowable in very serious cases, a small hand is very useful, and that the greatest gentleness should be observed in the manoeuvre, especially if there is reason to suspect contraction of the intestine. Several deaths have already occurred as the result of this method. Heslop, of Birmingham ('Lancet,^ May 11th, 1S72), relates two cases of death due to rupture of the intestine near or at the seat of a contraction. Three other cases of death are reported by Eobert Weir ('Medical Eecord,'' New York, May 20th, 1875, p. 201) occurring in the practice of Sands, Sabine and Weir, all three due to laceration of the intestine. When an operation necessitates penetration far into the rectum we may have recourse to rapid dilatation of the anus and intestine; often rupture of the sphincter is sufficient ; if not we can resort to lateral incisions, or, better still, to a posterior one, with or without ablation of the coccyx. The introduction of instruments is greatly facilitated by posterior linear rectotomy as practised by Yerneuil, without haemor- rhage, by means of the thermo-cautery, and in this way operations are made possible which would not otherwise be practicable; but these operations are rarely required for diagnostic purposes. Lastly, when ocular inspection is associated with touch, various kinds of specula SIGNS FURNISHED BY DIRECT EXAMINATION 133 (the two best being the univalvular and Fergusson's) may be intro- duced, and furnish us with new and valuable elements of diagnosis, not only for rectal diseases but for those of the uterus and its appendages. Vesical touch. — I must not omit noticing this new mode of examina- tion, recommended by Noeggerath/ which may be exceptionally used ; it is the association of vesical with rectal or vaginal touch. The urethra being dilated the index finger is introduced whilst another finger is in the rectum or vagina, the uterus in the meantime being drawn down by a fine tenaculum hook. 3. The Speculum. — The speculum is a mirror reflecting light on the neck of the uterus and the distant parts of the vagina, whilst the vulva and rest of the vaginal walls are dilated by it.^ The one for habitual use should be one easily handled and, above all, easily cleaned. In these respects there is none superior to the cylindrical speculum, slightly conical, of Eecamier (1814), or of Dupuytren (1816) ; but this spe- culum is by no means sufficient for every case ; indeed, as apphcable to the largest number of cases, the duck bill is preferable. In enumerating the various instruments of this kind which are manufactured I will mention those which I use most frequently, as well as those to which I have recourse only in exceptional cases. The tubular metal speculum is, as I have said, most necessary to the gynecologist. He should have several sizes and all as long as possible. More than once I have failed to reach the cervix owing to the shortness of my speculum. It is well to have five sizes on account of the variable dimensions of the vulva and cervix in different women. It is not enough that a speculum enters the vulva ; it must also fit the neck of the womb. If the large size is most convenient for examination it is not so for the application of leeches to the cervix, because if this organ is not exactly encircled by the speculum the leeches may fasten on the vagina in place of on the cervix. Fig. 113. — Cylindrical speculum fitted with a plug. The gynecologist should also have several sizes of Fergusson's glass tubular instrument, silvered and coated with vulcanite ; it is more easily introduced into a narrow vagina, and is also more convenient for ' American Obstetrical Journal, May, 1875. * Verhnes, Monograpliie sur le dioptre ou specxdimi. These de Paris, 1848. 134 GENERAL SURVEY OF UTERINE DISEASES reaching a retroverted cervix. Unfortunately it is very fragile. The manufacturer ought to try to make it stronger by adding to the thick- ness of the glass. ^ Charriere's trivalvular speculum owes its great success to want of Fig. 114. — Fergusson's speculum. skill in the ordinary practitioner. However, the smallest size may be useful in examining a virgin. This instrument has another advantage ; Fig. 115. — Charriere's trivalvular speculum, fitted with a plug. by removing one of the valves it can be turned into a duck-bill, which allows the vaginal wall to be examined. These valvular expanding specula have, moreover, a further advantage, owing to their conical shape when shut they can be easily introduced into a narrow contracted vulva or where there are fissures, while they dilate the vagina when open. They were invented by Jobert (1833) and Ricord (1834), and have undergone various modifications, one of the most important (due to Ricord) being that of having the hinge on a level with the vulval orifice, so that when the blades diverge the circumference of the instrument is not increased at this point — an arrangement which pre- vents laceration of the vulval orifice. This bivalve speculum is useful in examining a large cervix, but it does not sufiiciently protect the vagina when applications have to be made to the cervix, and it also has the inconvenience of allowing folds of a large vagina to get between the valves. ^ As for the opaque glass speculum of Mayer, of Berlin, it neither possesses the advantages of Fergusson's nor of the simple boxwood instrument. It is certainly necessary to have a speculum which can protect the vagina from heat when the actual cautery is used, and which is not affected by acids and caustics ; hut I greatly prefer the simple boxwood speculum on account of its cheapness and strength, or those of Jjeitcr, of Vienna, in vulcanite, which are both strong and light. SIGNS FURNISHED BY DIRECT EXAMINATION 135 Charriere has made a new bivalve speculum for Cusco and Veiss, of Paris, and for Tyler Smithy of London ; whilst preserving a constant Fig. 116. — Segalas's quadrivalve speculum. 1, a, shut with its plug ; 2, b, open. Fig. 117. — Eicord's bi- Fig. 118. — Charriere's quadrivalve speculum, valve speculum. c, d, its plug. 136 GENEEAL SURVEY OP UTERINE DISEASES diameter at its vulval extremity, it allows the practitioner to separate the two blades widely at their uterine extremity, so as to expose the cervix to view without allowing the mucous membrane of the vagina to be caught between the valves. Tyler Smith's is of the usual size. Cusco's is shorter, so as to avoid pushing the cervix back when it is Fig. 119. — Cusco's bivalve speculum. low down, and to allow of its being examined nearer. Its only incon- venience is that it sometimes dilates the lips of the cervix, so as to cause ectropion, which may lead the practitioner into error as to the position of the OS externum. The univalvular speculum is indispensable for the examination and treatment of diseases of the vagina, and especially for vesico-vaginal fistula for which it was invented. Lallemand used a simple speculum of this kind for such cases. For a long time I have used similar instruments that I made myself of zinc or that I had made in wood, when I have had occasion to perform operations in the remote parts of the vagina. Hergott, of Strasburg,^ was accustomed to use a cylindrical metal speculum, a great part of which he removed so as to leave only a spoon fastened to a handle, having the desired size and Fig. 120. — One of Jobert's lateral blades. curve. Jobert ^ used long ago a very ingenious contrivance for dilat- ' Perfectionnements recents apportes a V operation de la fistule veaico- vaginale. Strasbourg, 1863. '■' Traits de chirvrgic plastique. Paris, 1849. SIGNS FUEXISilED BY DIRECT EXAMINATION 137 ing tlie vagina in the treatment of fistula; he had four blades of different shapes, one of which he applied to the anterior wall, another to the posterior, and the two remaining ones laterally. I have several times found them of great use. But all these instruments are inferior Fig. 121. -Duck-bill specula, for the operation for vesico-raginal fistula by the American method. to the duck-bill specula invented by the Americans to be used in operating for vesico-vagiual fistula. In Marion Sims^s instrument ^ the same handle carries two blades of difi'erent sizes. Bozeman^ has exaggerated the breadth and curvature of these blades; there may, however, be cases where the large dimensions of his instrument may be useful. Neugebauer was in the habit of simply using two long Fig. 122. — Neugebauer's speculum modified by Barnes. metal blades regularly curved, one being inserted along the anterior, the other along the posterior wall, so that the two formed a bivalve speculum ; the uterine extremities of the blades may be more or less ' Silver Sutures in Surgery. The Anniversary Discourse before the New Yorh Academy of Medicine. New York, 1858. ^ FoUin, E.vamen de quelques nouveaux procedes operatoires pour la gueri- son des fistules vesico-vaginales, Revue critique {Arch. gen. de med., 5* serie, t. XV, pp. 457, 584). Paris, 1860. 138 GENERAL SURVEY OF UTERINE DISEASES separated, while the vulval extremities serve as handles. Barnes has made various alterations in the curve and size of the valves ; in giving to each of the four extremities a different curve we have specula with different valves, and by associating two together we have four addi- tional specula. What I find most convenient is to have four of Sims's valves of different sizes, and two handles ; as each of these valves fits on to one Fig. 123. — Speculum made for mj own use with four valves and two handles. of the handles, we can when necessary use two valves at the same time, one to draw down the posterior vaginal wall, the other to raise the anterior wall. I have had such a speculum made for myself and use it every day : the smallest blade is a very narrow one for virgins, the largest a very broad one useful for operations ; by making use of two handles and two blades simultaneously my univalvular spe- culum is transformed into a bivalve of variable dimensions. I have similar valves made in wood, others in vulcanite, useful when acid applications are made, or when the actual cautery is employed. In fact this instrument can when necessary replace all other specula, whilst none can replace it. Therefore it is the most fitted for daily use when we do not wish to be cumbered by too many instruments. SIGNS FURNISHED BY DIRECT EXAMINATION 139 It is very easily introduced ; all that is required is to push the well- oiled blade along the side of the index finger of the other hand, the tip of which touches the cervix. The position of the uterus depends on whether the decubitus of the patient be dorsal, ventral, or lateral, Fig. 124. — Two univalve specula used as a bivalve. the position chosen being important not only for diagnosis (which is greatly facilitated by the examination of the two cul-de-sacs, impossible with any other speculum) but also for treatment. If the patient is in the pelvi-dorsal position we find the cervix opposite and quite near us ; if she is on the left side, she is in a less strained position, and the cervix is very mobile, a condition favorable to the exploration of the vagina and to the performance of operations on it ; if she is in the ventral position, the uterus is far ofi", dragged down by the weight of the viscera, which are propelled towards the umbilicus by the entrance of air into the vagina when the speculum is introduced ; but though the cervix is far off, its position is at the same time very convenient when applications have to be made. I should like to take this opportunity of warning young practitioners against making use of any mechanical contrivances for fixing the speculum either to the pelvis of the patient 140 GENERAL SURVEY OF UTERINE DISEASES or to the operating table ; the patient is thereby exposed to serious injury when she instinctively but involuntarily shrinks back from the operating instrument. Surely the hand of an assistant is preferable in every respect. The introduction of the cylindrical and bivalve speculum is less easy than that of the simple univalve; the difficulties are, to avoid giving pain when the instrument passes the vulval sphincter, and to find the cervix. Pain will be avoided if care is taken to depress the fourchette before passing the speculum, which should be well oiled. An inex- perienced practitioner, when using a cylindrical or valvular instrument, will find it advantageous to make use of a wooden plug with rounded extremity projecting beyond the speculum, which will glide gently between the labia into the vagina, and can be removed as soon as the instrument is in place. The bivalve must be introduced transversely and not perpendicularly, for the anterior and posterior vaginal walls touch, as shown in Fig. 46, p. 50. It is not sufficient to be acquainted with the normal direction of the vagina and position of the cervix ; before applying the speculum we must always ascertain the exact Fig. 125. — Ventral position. Posterior vaginal wall rai.'^ed bj univalve speculum. situation in each case by vaginal touch. The speculum as well as the touch can be used in the case of virgins without injury to the hymen, care being taken that the legs are completely flexed on the abdomen and kept close together, so as to relax the hymen and make it de- pressible. Of course only instruments of the smallest size must be used. The speculum should be oiled and slightly warmed before its intro- duction, otherwise the sudden contact of the cold metal with the sensitive genital organs might cause contraction of the vulva and spasm SIGNS FURNISHED BY DIRECT EXAillNATION 141 of the vagina, sometimes even sharp pain. The patient being in an upright position by the edge of a bed, sofa, or table, we ask her to lie back, when we raise the feet, flexing the legs gently on the abdomen, begging her (if no assistant is present) to keep them in this position by passing her hands under the knees. The ischiatic tuberosities ought to project as much as possible over the edge of the couch on which the patient is lying. I have learned by experience that women prefer this position (in which it is not necessary to uncover the patient), as being more modest than the one generally used in Trance, in which the patient has to open her knees and place her feet on two chairs before her, at a considerable distance from each other; besides, the patient being occupied in holding her knees, has her attention some- what distracted from the examination. It is, moreover, the only suit- able position for applying a speculum to a virgin ; the legs being close together the hymen and fourchette are relaxed and so laceration is prevented. Let me advise all my readers to follow my example in preferring a simple couch, ottoman or table, to all those ingenious mechanical arm-chairs, which only frighten patients. The physician, separating the labia and nymphse with two fingers of his left hand, examines the colour of these organs, the state of the hymen and carunculse and of the meatus, ascertaining whether there is any pus or leucorrhoeal discharge. He depresses the fourchette with the index finger of the right hand, to judge as to the rigidity of the tissues. Then taking the speculum between the thumb and three first fingers of the same hand, he places the narrow end flat on the four- chette, lowering the hand so that the uterine extremity of the instru- ment looks upwards. He then depresses the fourchette, vulval sphincter, or hymen (if there is one) , gradually bringing the axis of the speculum into the axis of the vulva, and by a see-saw motion, executed slowly and carefully, he inclines it more and more towards the sacrum, as in practising the touch. He must beware of letting the upper border of the speculum come against the meatus, as this might cause pain and bleeding. The vulva once passed, he slides the instrument towards the cervix, following the direction pointed out by the previous examination. This organ is usually situated behind, the os looking towards the concavity of the sacrum ; the easiest way of reaching it, therefore, is to follow the posterior vaginal wall. Daylight is always preferable to any other; 1 have, however, often been able to examine and even operate by artificial light. Collin's reflecting lamp is the best ; but a good moderator or even a candle is sufficient, if an assistant with his hand, or, better still, with a silver spoon, reflects the light into the speculum. As the speculum slowly penetrates the vagina the surface of the latter ought to be carefully inspected. We may find not only redness, granulations or erosions, but ulcers, vegetations or polypi, as well as mucus, blood, pus, &c., excreted by the uterus. If the cervix when reached is not in the axis of the speculum, it must be brought into view with the tenaculum hook or sound, and wiped with a pledget of cotton wool. If the mucus is too adherent to be got rid of by this method it should be re- 142 GENERAL SURVEY OF UTERINE DISEASES moved by injecting tepid water, and if this is insufficient we must use an emulsion of yolk of egg, as Pajot^ advises. We shall then be able to determine the position, size, colour and external appearance of the cervix. In short, the speculum confirms some of the information already furnished by touch, whilst it adds some new facts. If the os is directed back- wards (anteversion) the speculum only dis- closes the anterior lip ; and in such a case, to bring the os into the axis of the specu- lum we must not only have the patient's legs well flexed on the abdomen, but we must ask her or an assistant to depress the abdomen whilst we use the sound. In this way the fundus is lowered whilst the cervix is raised. If the os looks forwards (retro- version) we must direct the speculum behind the pubis, and with the sound try to draw the uterine orifice backwards. I have some- times found it useful to place the patient on elbows and knees or on her side, in order to cauterise the cervix, which I could not otherwise have reached. We can judge as to the volume of the cervix by the difficulty of including it in a cylindrical speculum, or by being obliged to have recourse to a bivalve. The inequalities, the consistency, the relative size of the two lips are visible, or can easily be ascertained by exercising pressure on the organ as a whole or on each of its lips. The principal facts revealed by the spe- culum are : the nature, abundance, and origin of morbid secretions, the form of the orifice, the colour of the cervix, its ulcera- tion or enlargement, whether due to hypertrophy or the existence of vegetations. If the cervix is dry it is well to squeeze it with the speculum, pressing the uterus at the same time through the abdominal walls, to see if by this means we can express a drop or even a flow of clear, milky, or purulent mucus. It is important to ascertain the form of the orifice; it may be a round hole or a transverse fissure, all but closed or widely open ; it may be con- tinued by secondary fissures, sometimes bordered by cicatricial tissue in multipara? ; or there may be ectropion of both lips, exposing to view the cervical cavity ; there may even be inversion, or, if one may so say, eversion of the mucous membrane of the cervix. The colour is important ; it may be pale pink, dark red, or even violet. The violet colour of the vulva, vagina and cervix is not exclusively a sign of preg- nancy. It exists to some extent for a few days before and after men- ' Annales de Gynecologic, t. v, p. 464. Paris, 1877. Fig. 126. — Collin's lamp, with reflector and re- fracting' lens. SIGNS FURNISHED BY DIRECT EXAMINATION 143 struation. This change of colour is so marked and is coincident with such equally important changes in the size, weight and consistency of the organs, that I make it a rule not to examine a woman for the first time before the eighth day after menstruation, i. e. if I wish to make an exact diagnosis of the condition of the uterus. Eruptions, erosions, ulcers of various kinds, are best seen at this time, and cannot be diagnosed with precision by any other means. The same may be said with regard to slight granulations and those that are confluent, as well as fungous growths and small follicular cysts. What has been said in respect of other modes of examination is especially true of the speculum ; it is not only a means of diagnosis but of treatment. It alone allows of various applications being made to the cervix or to the uterine cavity. But we must bear in mind that this instrument ought not to be unneces- sarily used, as it may irritate the urethra, vagina and cervix, and like all applications it fatigues the organ when used too often. 4. T/ie Uterine Sound. — The sound is our chief resource in making an examination of the uterine cavity. In the last century Levret ^ used one made of whalebone for measuring the womb. In 1828, Lair ~ introduced Larrey^s probe into the cervical cavity curving the extremity like a catheter, and in order to facilitate its entrance into the body of the womb he withdrew the speculum one third and de- pressed the handle of the probe as much as possible. It is, however, only recently that the sound has come into general use as a means of diagnosis and treat- ment, thanks to Simpson, Huguier, Valleix and Kiwisch. The circumstances under which this in- strument was invented indicate its chief uses. Val- leix, engrossed with uterine displacements, wanted like Kiwisch and Simpson to find an intra-uterine sound that would straighten the flexed uterus ; whilst Huguier, having discovered hypertrophic elongation of the cervix, invented the same instrument (calling it a hysterometer) to enable him to measure the cavity. To these uses we may add that of determin- ing deviations in the cervico-uterine canal, and above all, the increased capacity of the uterine cavity interstitial fibroma, polypi, &c. When the os is situated in a cervix which is conical and deviated from its normal position, the only means of ensuring the entrance of the sound is to ' Sur un allongement considerable qui snrvient quelquefois au col cle la matrice; Journal de medecine et de pharmacie de Boux, Octobre, 1773, t. xl, p. 352. Quoted by Stoltz, Gazette hebdomadaire, 1860. " Nouvelle methode de traitement des ulcerations de la matrice, Pavis, 1828. Fig. 127. — Intra- uterine sound with stem slid- ing into the handle and mov- able index. associated with very small, and 144 GENERAL SURVEY OF UTERINE DISEASES introduce it through the speculum. But after an entrance is secured it penetrates more easily without the speculum than with it. The reason of this is, that the axis of the uterus is not that of the vagina ; that there is also often a slight anteflexion between the neck and body of the womb ; besides, there may be abnormal flexions or tumours causing curves and angles in the uterine cavity. The uterine extremity must follow these various curves, consequently the handle must be inclined in a contrary direction. Therefore, after the sound has entered the os the speculum ought to be withdrawn and the handle of the sound depressed towards the rectum, so as to allow the bulb to enter the body of the uterus. When it is desirable to introduce the sound without the speculum, the patient ought to be on her back or on the left side. After examining by touch, the tip of the fmger is placed close to the os, and the sound is introduced by the other hand (its concave side being always directed forwards) ; guided by the index finger the os is easily reached and entered. The finger ought then to be placed behind the cervix, raising it slightly, whilst the sound is pushed gently forwards 25 or 30 millimetres. The operation so far is very easily performed, unless the orifice is circular and very narrow, as is often the case in virgins and nulliparse; usually no pain is felt, unless the patient is sutt'ering from metritis or neuralgia. If difficulty is experienced in passing the arbor vita, it will be overcome by moving the sound very gently from side to side ; but it often is not easy to pass the os internum without causing a little bleeding. The narrowness of the orifice, its natural occlusion owing to the median columns of the cervix fitting tightly into each other, the spasmodic contraction of the sphincter, the flexion of the body on the neck, all conduce to make it difficult to pass the OS internum. Indeed, sometimes it is impossible to do so ; occa- sionally, however, it is passed very easily and without causing any pain. Force must never be employed in order to enter the uterine cavity, by pressing very gently in the probable direction of the orifice, raising the neck or body with the finger, according to the mutual relationship of these two parts as indicated by vaginal touch, depressing the handle for an anteflexion, raising it for a retroflexion, or inclining it to the side in the case of a lateral flexion, we at last experience the sensation of resistance overcome, whilst the patient at the same moment expe- riences more or less acute pain. The instrument penetrates to a distance of 60 to 80 millimetres, and can be moved easily, especially in a lateral direction. When it impinges against the fundus it sometimes causes a peculiar sensation of discomfort and sutt'ering, which " goes to the heart,^' as patients say. I have seen some women suffer very acute pain, accompanied by hysterical spasms and nervousness, which lasted for some hours. As the sound follows the direction of the canal the uterus is replaced in proportion as the instrument penetrates, so that flexions disappear, being sometimes transformed into versions, whilst at other times the whole organ is brought back to its normal position. It is then that the mobility of the sound in the uterine cavity can be observed, and that it can be made to describe circles more or less extensive; and, at the same time, before its withdrawal care SIGNS FURNISHED BY DIRECT EXAMIXATION 145 Fig. 128. — Use of the sound in retroflexion. should be taken to move the index slide to a level with the cervix in order to measure the exact length of the organ. In the case of a uterine fibroma, anteflexion, &c., the introduction of a sound is very difficult and painful. In place of the ordinary instrument it is better to use Sims's small flexible silver or copper one. If we cannot reach the fundus with this instru- ment we must use a very small gutta-percha bougie, because in such a case it is of great consequence to measure the exact length of the uterus. We must not persist in forcing the sound onwards when we experience great resistance ; it is better to make a second or third attempt, or to delay it till another day. As a rule it is more prudent to use this instrument in the middle of the intermenstrual period, when the congestion which precedes and follows menstruation is not present ; however, if we cannot succeed then, we may take advantage of the menstrual period or the day following (when the orifices are dilated) to penetrate into the cavity and to dilate the os internum ; but in doing so we must use extra precaution. The use of the sound may be contra-indicated ; for instance, by pregnancy. To avoid all risks the Fig. 129.— a a, arc of a circle described in the uterine cavity by the bulb of a sound moving round a fixed point B h, at the OS externum. lU 146 GENERAL SURVEY OF UTERINE DISEASES practitioner should never use the sound without receiving an assurance that the patient has had no coitus since her last monthly period, and having satisfied himself that the usual presumptive signs of pregnancy are absent. The use of this instrument is also contra-indicated at the menstrual period, especially when menstruation is abundant and painful and associated with considerable congestion, as well as in an inflamma- tory condition of the uterus, in suppuration of the mucous membrane, in acute catarrh, in ovaritis, in acute pelvic peritonitis, in an organic disorder such as cancer or softening of the tissues of the body of the uterus, or in the few weeks following delivery. Care must also be taken not to use force in pressing the bulb of the sound against the uterine walls for fear of lacerating or perforating them. Such accidents have occurred, and although they have seldom been followed by serious con- sequences we must remember there is a great difference among women as to sensitiveness. Several cases of death^ have been recorded as the result of the imprudent use of this instrument. Unless the uterus is per- fectly mobile it ought never to be lifted up by the sound, nor should abdominal palpation be combined with the use of this instrument, for in pushing it against the fingers which depress the hypogastrium we run the risk of perforating the uterus. "Whilst admitting that the sound requires to be used with great care, I think all gynaecologists will agree with me in considering it indis- pensable in the diagnosis of a certain number of uterine diseases. If we remember that normally the uterus is slightly anteilexed, that the relative lengths of neck and body are anatomically determined, that in a state of health, especially in the nullipara, a cavity of the body cannot be said to exist, the two walls, being in close juxtaposition, only allowing sHght lateral movements to any instrument that may be introduced, and, lastly, that the smooth mucous membrane protected by epithelium is not liable to be torn by a blunt instrument nor to bleed unless there is congestion, we may conclude that examination by the sound will be of great use in giving us necessary information on the following points : — 1. The dimensions and entire length of the uterus, and consequently its volume. 2. The relative dimensions of the cavity of the body and neck, the latter being sometimes short, whilst the former is long and inflamed ; at other times the neck only is long, being more than three quarters of the whole length, presenting thus a true hypertrophic elongation. 3. The differences of size in other directions, the dilatation of the uterine cavity being easily per- ceived by gently moving the sound. 4. Irregularities of the surface, alterations in the form of the cavity, fibromata, polypi, vegetations, fungous growths, and the haemorrhage which accompanies them. 5. The absolute and relative position of the uterus and of its two segments with regard to each other, deviations, flexions, and the dift'erential diagnosis between these displacements and polypi, fibromata, whether interstitial or pediculated, utero-peritoneal adhesions, extra-uterine tumours, peri-uterine abscess, haematoceles, ovarian cysts, &c. 6. Stenosis, deviations, and spasmodic contractions of the uterine orifices. ' L. E. Dnpny, Progrks medical, pp. 109, 171, 195. Paris, 1873. SIGNS FUENISHED BY DIRECT EXAMINATION 147 7. Lastly, the accumulatiou of fluids in the uterine cavity, which can be diagnosed by means of the hollow sound, which at the same time affords a means of ascertaining the comparative dilatation of this cavity. II. Complementary means of exploring the Uterine Cavity. — The greater part of these are means of treatment as well as of diagnosis. I will, however, describe them here, because though Fig. 130. Fig. 131. Fig. 132. Fig. 133. Fig. 130. — Jobert de Lamballe's intra-utenne speculum. Fig. 131. — Mathieu's small speculum or uterine dilator. Fig. 132. — Bivalve uterine dilator (Lemenant-Deschenais). Fig. 133. — Trivalve uteiine dilator (Busch, modified by Huguier). 148 GENERAL SURVEY OF UTERINE DISEASES there is only one way of using them when they are employed as a means of diagnosis, their use varies, on the contrary, according to the exigencies of the case when they are employed as a means of treatment. The hitra-uterine specidum is, I think, the least useful of all instru- ments. There are various kinds, one of them (that of Desormeaux) being really a speculum, i. e. a mirror enabling us to see different parts of the intra-uterine mucous membrane; the others serve also as dila- tors. I may mention those of Atthill,^ Jobtrt, Mathieu and Blatin, the bivalve of Lemenant-Deschenais, the trivalve of Busch modified by Huguier, &c. Peaslee^ has also invented a somewhat similar instru- ment. It is a silver tube, 7 to 8 millimetres in breadth, 5 to 6 cen- timetres in length, with a conical end, through which are three openings, which not only afford a view of the fundus^ but also allow of the introduction of the very finest instruments, of vegetable or metallic threads, &c. The dilator is more useful. I may mention Aussandon's instru- ment, made of prepared wood or ivory, which, when placed in the uterus, swells to double its size. Dilatation, however, is effected 3C ^aammmSiSO^^ :^[OtSJ^=^^ Fig. 134. — Aiissandon's uterine dilator. f^ more surely and safely by means of ordinary bougies or by Simpson''s metallic stems (of tin, silver, or aluminium) of gradually in- creasing size, terminating in a bulb, which supports the cervix. But the best of all means of dilatation are tents of prepared sponge or laminaria, which expand so slowly and gradually that the dilatation of the uterine cavity and orifices is attended by no danger, and very often by no suffering. 1. Sj)ovge tents should be prepared in the fol- lowing way : — Take a piece of sponge of conical shape, soak it in a strong solution of gum, fix it on a central stem, and compress it as forcibly as possible by binding it round with string ; dry it thoroughly, remove the string, file off any roughnesses, and cover it with lard or wax to facilitate its introduction, which is effected by means of a stem inserted in the centre of the sponge, or simply 1 Dublin Journal of Medical Sciences, January, 1873, p. 73. ' Intra-uterine Medication : its Uses, Limitations and Methods, by M. D. Peaslee. Netv York Medical Journal, July, 1870, p. 481. Fig. 135. — Simpson's large intra-uterine pessary. SIGNS FURNISHED BY DIRECT EXAMINATION 149 by the uterine forceps. These tents should be made of different sizes^ varying in diameter from 2 to 10 millimetres and in length Fig. 136. — Sponge tent with introducer. from 2 to 7 centimetres. Before introducing one I cover it with belladonna ointment (Ext. Bellad. gr. xv, lard gr. Ix). After its insertion I pour two spoonfuls of glycerine into the vagina^ and then place a plug of cotton wool to keep the tent in its place. The glycerine, whilst determining a very abundant serous secretion, dis- infects this leucorrhoeal discharge entirely. The tent is left for twenty-four hours, when the patient can remove it herself by means of a thread attached to it, and which is long enough to hang out- side the vulva. The dilatation generally takes place without suffering ; sometimes, however, the patient has pains like those of menstrua- tion. If the sponge is left for more than twenty-four hours, it is generally expelled spontaneously into the vagina, probably from pressure of the mucus secreted above, aided by uterine contractions. However, if it is pushed high up into the cervical cavity, so that the OS externum closes over it, extraction may be necessary, especially if the thread breaks, as sometimes happens. The sponge itself may tear, a part being retained for months adhering to the mucous membrane. After having withdrawn the sponge the patient ought to take an emollient bath for an hour, injecting water from the bath into the vagina all the time. A second sponge may be introduced immediately afterwards, but it is more prudent to allow the patient to rest for one or two days. The vaginal injections ought to be made very slowly, for I have sometimes seen the occurrence of uterine colics, evidently caused by the fluid penetrating into the uterus. By taking these precautions, occasionally making an examination by speculum, and suspending the dilatation as soon as any signs of irrita- tion appear, we may in a few weeks — sometimes in a few days — dilate the cavity sufficiently to be able to explore its surface thoroughly with the finger, and even with instruments. During this time the patient ought to remain in bed and take an emollient bath every day. When the OS externum is too narrow to allow of the entrance of a tent, incision of the orifice must be practised, but even after this incision has been made it is often necessary to use tents to dilate the cervix and OS externum. If we have any reason to suspect cancer we cannot exercise too much care in dilating and examining the uterus, lest the substance should be torn and the wall perforated, as in a case I have seen. 2. Laminaria digitata is soft, flexible, and loses much of its 160 GENERAL SURVEY OF UTERINE DISEASES diameter when dried. Its structure being cellular, it dilates greatly under the influence of moisture, reaching a volume of five or six times its original size. The mucous secretions are generally sufBcient to effect this, but simple injections may be used if necessary. The young stems are the best, the size varying according to the case. The rind should be retained, and one end should be pointed, whilst the other has a thread attached to it. The tents before being used should be well washed and then damped and dried successively several times. Laminaria tents act as efficiently and quickly as prepared sponge Fig. 137. — Laminaria tent polished and perforated. and are better in some respects ; they are more easily introduced when the OS is very small, and they cannot break. They can be used indefi- nitely if care be taken to wash them in a solution of permanganate of potash, they are more quickly and easily prepared, they are abundant and cost almost nothing; but in spite of these advantages they cannot as a rule replace sponge tents beneficially. Sometimes the constricted OS is very unyielding, and prevents the laminaria from dilating to its full size at this point, as it does higher up, so that the tent is firmly retained, and cannot be withdrawn without incision of the orifice. Although incision of the os externum is not attended with danger, it is different with the internal orifice, incision of which is dangerous, and any attempt to withdraw the laminaria without incision is more dangerous still. 1 have seen a case where attempts at extraction produced pro- lapsus of the uterus, with evident laceration of the peritoneum, which brought on acute inflammation and almost caused death. Nothing of the kind is to be feared with sponge tents, therefore it is clear that they should have the preference. Artificial prolapsus of the vterus is another means of diagnosis that ought not to be omitted. This can be effected without danger, and even without pain, by seizing the cervix or one of its lips with the uterine forceps or a fine tenaculum hook, and exercising moderate but continuous traction till the os is on a level with the vulva. If the cervix has been naturally dilated by a tumour or artificially by a sponge tent, the finger may then be introduced into the cervix, and even into the body of the uterus, in order to examine it thoroughly. The same means ought often to be employed for treatment, to facilitate the ablation of polypi as well as for several other operations practised on the uterus. CHAPTEE II. TEEATMENT OF UTEEINE DISEASES IN GENEEAL — INDICATIONS TO BE FULFILLED IN THE TEEATMENT OF TJTEEINE DISEASES — METHODS OF TEEATMENT AND VAEIOUS MEDICATIONS IN UTEEINE DISEASES — MEANS OF FULFILLING- INDICATIONS IN THE TEEATMENT OF UTEEINE DISEASES. To institute a rational treatment, it is necessary first of all to lay down the indications and contra-indications ; afterwards to seek the best means of fulfilling these indications. I have con- siderable difficulty with regard to the indications, because of their infinite variety in diseases of the womb. If it is difficult to describe them correctly, it is more difficult still to lay down exact treat- ment. In practice it is of the first importance to remember that it is our patients whom we have to treat and not abstract diseases. However exact our descriptions and precepts may be, they can only represent types undergoing modifications which it is impossible to foresee ; therefore, in applying general rules to any individual case, a large margin must be left to the judgment of the attending physician. In spite of these difficulties we can place some finger posts which will help to keep us in the right road. In considering the question from this point of view I shall lay down some general principles to serve as a basis for a system of therapeutics as applied to uterine diseases in general, from which can be deduced the special treatment most suitable to each particular case. 1. The first indication is the necessity for treatment. It may seem superfluous to make this remark, but it is not really so. There are so many acute and even chronic diseases cured by nature that it is neces- sary to point out how different uterine diseases are in this respect. In their case the expectant method is deplorable, although very useful in many other circumstances. Experience teaches us that diseases of the womb have no tendency to spontaneous cure. Nothing can be hoped, even from the changes and evolutions which the uterus under- goes at different periods of life in passing from childhood to puberty, from puberty to the period of sexual activity, and from that to old age. Neither menstruation nor the menopause has any tendency to cure uterine diseases. Menstruation, on the contrary, brings a s^reat many. The menopause certainly has a tendency to lessen some dis- eases by the cessation of periodical ovulation with its accompanyino fluxion and haemorrhage ; but habitual fluxions do not always cease ; on the contrary, they sometimes seem to assume a character of greater intensity from having lost their regulator. It is the same with passive congestions which no longer have their periods for disappearing in 152 TREATMENT OF UTERINE DISEASES IN GENERAL the normal alternations of uterine plethora and depletion. Besides, various constitutional affections are apt to show themselves at the climacteric period, so that if one danger is removed anotlier is brought on. As for the changes occurring in the sexual period, they are hurtful in place ot being favorable to uterine diseases, often helping to perpetuate, hardly ever to cure them. Beware of hoping that marriage will cure a uterine disease. At the most it can only regulate or increase defective menstruation, and will certainly aggravate any real morbid condition ; for one disease that pregnancy has ameliorated or cured (supposing the retrograde evolution of the womb to have been well directed) it has aggravated a thousand. It is of consequence to have clear ideas on this point, that the physician may be able to con- vince his patients of its importance, so as to make them willing to continue treatment as long as is necessary. We must, however, remember that every functional disturbance or displacement of an organ is not a disease. This term should be reserved for those changes in the generative system which are accompanied by functional disturb- ance, abnormal phenomena, or pathological processes in this system or in the general economy incompatible with the free exercise of special or general organic functions, or with the continuance of life. Such are the limits beyond which we ought not to venture in pursuing a vigorous treatment, which cases recently reported (especially with regard to displacements) show not to be exempt from danger. •2. Under certain circumstances we must content ourselves with a palliative cure and not continue treatment when a perfect cure is im- possible, as unfortunately is too often the case. For example, how can we hope for the radical cure of interstitial and multiple tumours, pediculated subperitoneal tumours, of ovarian cysts when sufficiently tolerated by the organ not to necessitate extirpation, in short, of all material changes which are the starting point of functional troubles which art is powerless to remedy, or at least wliich it cannot attempt without exposing the patient to greater dangers than those of the disease itself ; therefore we are often obliged to limit ourselves to a palliative cure, simply regulating the functions of the sexual organs and of the general economy. By venturhig further and employing more energetic means we expose ourselves to terrible reactions and even to an exacerbation of the disease itself; or if we succeed in sup- pressing it we may determine serious disturbance of the whole economy or the appearance of a dangerous disease such as phthisis, which till then was lalent, in another organ. It is all the more important that we should restrict ourselves to palliative measures in certain cases, as the perfect integrity of the uterus and its appendages is not abso- lutely indis])ensable to the exercise of sexual and general functions. Experience teaches us that women may be affected by organic dis- orders of this system without being greatly inconvenienced by them. These disorders are often not only compatible with the free exercise of the general functions, but even with the accomplishment of the special functions of the sexual economy. Fibrous tumours and ovarian cysts do not always prevent conception nor induce abortion. INDICATIONS FOR TREATMENT 153 Very often we must limit our aim to the disappearance of functional disorders, pain, haemorrhage, leucorrhrea, and other morbid phenomena with the restoration of the general health. In morbid conditions characterised bj functional trouble, such as disorders of menstruation, or by pathological processes unaccompanied by neoplasm, functional restoration usually coincides with the radical cure of the disease, the treatment having attained both ends at the same time. In displace- ments and deviations, as well as in diseases characterised by the existence of neoplasm or organic alterations, it is possible to regulate function without restoring integrity of the structure or the position of the organs; and treatment need not be prolonged after the first of these results, a palliative cure, has been obtained. 3. When we consider how seldom it happens that the uterus is for a long period the seat of morbid processes without its organic tissue becoming more or less seriously affected and how little tendency uterine diseases have to spontaneous cure, we must see the importance of another indication : viz. the necessity of always associating general with local treatment. In general affections of the organ and in purely diathetic diseases, especially when the localisation is multiple, or when the accompanying material change is insignificant, it will be readily understood that not only are general means of treatment the most important, but that usually they are of themselves sufficient to produce a definite cure ; in the same way local treatment may suffice for traumatic lesions, changes of position, or the development of neoplastic tumours, whether homeomorphous or not, and even when produced by the localisation of a diathetic affection. But although local suffering may be relieved and the general health improved by one-sided treatment, it is very seldom that a permanent cure can be effected without combin- ing general and local means of treatment. The one or other may require most attention according to the case; but they cannot be separated, nor can the one be sacrificed to the other. Aran^ has made the same remark, and it is strikingly illustrated in the difference between our private and hospital practice. In private practice patients often refuse local treatment, either because of the pain which they fear as a consequence of energetic measures or from repugnance to sub- mitting to the frequent applications and various little operations which may be necessary. On the other hand, they are most willing to carry out any general treatment either internal or external, even baths and hydropathy when advised. Under the influence of such a regimen I have often seen the appetite restored, digestion regulated, nutrition increased, flesh gained, strength recovered. But the uterine pain never disappears, a real cure is never effected ; in short, the temporary improvement does not last more than a few months, when the patients fall back into their former state of ill-health and all has to begin over again. Hospital patients, on the other hand, are obliged to undergo local treatment, all necessary operations are performed, dressings made, &c. But it is seldom that general treatment is carried out with 1 Op cit., p. 162. 154 TREATMENT OF UTERINE DISEASES IN GENERAL necessary regularity. Some patients consider all drugs poison, and often manage to throw their medicine away, whilst baths, mineral waters, food and ventilation are often also defective owing to the limited resources of the hospital. In these cases I have noticed that the local sj'mptoms — pain, tumefaction, granulations, ulcers, leucorrhoea — may disappear temporarily, but if the general health does not improve proportionately with the local disorders the latter soon re-appear. 4. An appropriate treatment should he applied to every disease. — It may seem superfluous to point out this indication, but whilst it certainly would be so in reference to any other class of diseases, it is not so with regard to uterine pathology ; this is only explicable by the relative ignorance of our predecessors as to the variety of diseases of the womb. We must remember that in uterine pathology, as in the pathology of any other organ, there are species and varieties differing so much from each other as to require differences of treatment. The most characteristic feature of the progress of uterine pathology in our day is the tendency to distinguish the different diseases of the uterus as we distinguish different diseases of the lungs or heart, by their symptoms, their organic lesions and their nature. The most practical application of this nosological distinction is, without doubt, the general indication to vary the treatment according to the case, and to distinguish the special indications arising from the differential diagnosis of the various diseases. I meet so many medical men who have kept up the habit of treating all uterine diseases in exactly the same way (the treatment varying, not with the patient but with the doctor) that I must take this opportunity of warning young practi- tioners against all uniform and stereotyped therapeutics. Lisfranc did not escape this error. His opinion as to the frequency of engorge- ment, which he looked on as the basis of all uterine pathology, necessarily led him to prescribe for the majority of these diseases a common treatment, which we find reproduced almost word for word in his consultations. The chief points of this treatment were as follows : — Kest on the sofa, baths twice a week, conium internally, bleeding from the arm once a month ; lastly, the gradual reduction of food to the minimum quantity required to sustain life, with the idea that organic resolution is promoted by abstinence — cura /amis} Nonat has also adopted this mode of treatment, though not so ex- clusively. Others have made almost all uterine pathology to consist in replacing the womb, whilst others insist far too much on antiphlo- gistics. Some wear out the uterus by continual applications ; others limit themselves to the use of general means. One practitioner in- variably gives hot baths, a second cold baths ; some prescribe hip- baths, others general baths. Now, we cannot guard ourselves too carefully against any exclusive treatment of uterine diseases in general, or of any special means in particular. Disease varies in form and nature in the uterus as in other organs ; treatment ought to vary likewise. ' Bulletin de VAcadeinie de Mcdecine. INDICATIONS FOR TREATMENT 155 5. It is very important to consider the nature of the disease. — Uterine diseases are very seldom of a reactionary nature ; on the contrary, they may be classified as affective diseases, i. e. dependent on a general state. It is not that the general condition from which they derive their nature has always been the determining cause of their development ; but it impresses its character on the disease whether primarily or not. They may arise in two ways, either following the development of a general affection or being produced by a disease originally local. The diathetic affection exists; it has already given proof of its existence, though it has not yet attacked the uterus. However, it is not long before it fixes itself there, because this organ is more disposed than any other to be affected, owing to its position, its inclination, its monthly congestion, the increased vitahty developed in it by pregnancy and the traumatism determined by an abortion or by delivery. The diathetic affection manifests itself spontaneously ; at most it only awaits a favorable opportunity for taking possession. At other times the uterus is predisposed to disease. Menstrual troubles, sexual excess, over-fatigue, a miscarriage or difficult labour cause congestion, engorgement, hypertrophy. Disease is established. That would be of no consequence if the woman were healthy and strong; all would then disappear with a few simple precautions. If, however, a diathetic tendency be present the tendency becomes a localised affection, it fixes on the uterus, impressing its special character on the already existing disease. What occurs to a man suffering from blenorrhagia or engorgement of the prostate happens to the woman affected by uterine disease. These illnesses when recent and uncomplicated are easily cured in vigorous individuals. But given the existence of a special diathesis, these maladies open the door to the inroads of an affection till now latent, and cure is difficult. 6. That we may perceive, therefore, the leading indication, it is necessary first of all to determine the diathetic affection which is the essential cause of the malady. Any constitutional disease may become localised in the uterus; it is certainly so with cancer, rheumatism, gout, herpetism, scrofula, syphilis, &c. I do not think that any practitioner can doubt the correctness of ray statement with regard to the majority of the affections just named. I myself for a long time retained doubts as to gout; but lately I have seen a case which seems to me sufficiently conclusive to force conviction. Case. — A lady, aged forty-five, is mother of two grown up cliildren in good health ; her father is gouty, her motlier comes of a gouty family, and her brother is asthmatical. She has at various times suffered from pain and swelling of the joints, especially of the small articulations, sevei"al of which are deformed. The urine is often charged with brick-red deposit. She suifers to a small extent from hajmorrhoids, but her digestive functions are in good condition. She has repeatedly had serious attacks of pulmonary congestion, hjemoptysis, &c. For some titne back the lungs have been healthy, but the uterus is affected with chronic congestion, occurring apparently without cause ; twelve days after the catamenia there is an exacerbation caiising acute pain and rendering walking impossible. This state is accompanied liy serious general 156 TEEATMEXT OF UTERINE DISEASES IN GENEEAL disorder ; in a few days there is an improvement allowing the patient some days' rest before the return of the monthly period. This is ushered in with great pain, a condition which never existed previously ; after two or three days the pain ceases and the haemorrhage is more abundant than before the uterine disease. I have sometimes known this patient for five or six months to have hardly any sufEering or congestion, and then begin to suffer anew. These pains and the morbid conditions developed successively in the limbs, chest, and uterus, keep her extremely thin, and produce a great tendency to perspiration and a general weakness in spite of an excellent appetite and good digestion. I do not know whether I have given a sufficiently exact description of this case to convince my readers that this succession of morbid conditions, so serious and at the same time so variable, can only be explained as attacks of visceral gout. I do not think any one can doubt as to the influence of catarrhal, chlorotic^ herpetic and scrofulous affections on uterine diseases. 7. Infiammat'ion also plays a great part in the production of uterine diseases. Sometimes it constitutes the basis or even the essence of the disease; at other times it plays only a secondary role to the diathetic affection. In the first case the uterine disease may be called re- actionary; in the second, as in the case just cited, affective. Thus, as the result of traumatism or of causes which may be called traumatic, such as sexual excesses, fatigue during menstruation, abortion, difficult labours, operations performed on the genital organs, acute inflamma- tions are often developed which are, to speak correctly, reactionary, such as metritis, ovaritis, peritonitis ; these inflammations become chronic if they are too aggravated to undergo natural resolution, or too slight to terminate in suppuration or gangrene, and the disease retains the inflammatory nature with certain modifications. At other times the disease has begun with inflammatory symptoms but is evidently kept up by a diathesis retaining nothing of an in- flammatory character but the form or a state of special complication. Nevertheless, at a given moment, under the influence of unforeseen accidental causes or even of normal processes, such as menstruation, this condition may produce an increase in the inflammatory element which will now occupy the first place among the existing morbid phenomena, owing to the danger it involves. But whether inflamma- tion form the basis of the uterine disease or be only an element of secondary importance subordinate to the diathesis, or an accidental coincidence more or less serious, it always presents important indica- tions. In the one case the leading indication is to subdue it, in the other this is of secondary importance — secondary, that is to say, to that of the diathesis ; but in all cases it deserves the most serious consideration. 8. Another important source of indications is SSit asthenic nature of the majority of uterine diseases, no matter what part inflammation plays in them. If we consider the condition of the vital forces, i. e. the resistance which the economy is capable of making in this struggle, we can assuredly say that generally there is not a sufficient power of resistance. Occasionally it may exist in acute uterine disease and in inflammatory attacks, which give a new character and nature to the disease. But generally the reverse holds good. As a result of the chronic state of the malady, of the sympathetic disorders of digestion INDICATIONS FOR TREATMENT 157 aud innervation^ and of the consequent impoverishment of blood, there is a state of general debility which not only takes from patients the tone which gives energy and activity to the whole system, but also deprives them of what the ancients called motor force. Besides the atony with which the muscular system and the whole of the organism is affected, w^e may say that the majority of uterine diseases are characterised by asthenia. Therefore, after having subdued inflamma- tion or congestion by blood-letting or otherwise when necessary, we must hasten to overcome the diathesis which has a share in the disease, and above all to raise the strength by enriching the blood, soothing the nervous system, facilitating digestion, stimulating nutrition, and by giving an impetus to the repairing processes in all the organs. 9. The chronicUy of uterine diseases is also an indication of con- siderable importance. A small number of uterine diseases have an acute course. Such are those diseases which may be called trau- matic, as well as those having a sthenic character and tending to inflammation, and those consequently which participate in the nature of reactionary affections, such as cases of metritis, ovaritis, hcemato- celes at their commencement, peritonitis, inflammatory attacks of pelvic peritonitis or peri-uterine inflammation, active hsemorrhage, &c. But the majority, on the contrary, are chronic in character ; there is some- thing slow in their manifestation and a natural tendency to last indefi- nitely. This chronic character depends on two causes : primarily, on the influence of the diathesis, or at least on the asthenic nature of the malady. All diathetic affections are difficult to cure. They are deeply rooted in the whole economy ; the whole mass of the tissues needs to be gradually modified, a requirement which necessitates a long and uninterrupted treatment. Even when a uterine disease cannot be attributed to a diathesis, its asthenic nature calls equally for reconstitu- tion of the blood and restoration of the whole system. Secondarily, it depends on special causes peculiar to the uterus, which keep up the disease by bringing obstacles in the way of its cure. The womb is not only placed below all the abdominal viscera, which by their weight tend to keep up the congestion as well as to cause pain mechanically ; not only is it subject to the troublesome and repeated excitement of conjugal relationship, but every month it is the seat of a normal san- guineous discharge, which to a great extent undoes the good derived from previous treatment, giving at the same time new life to the disease. Those patients are fortunate who escape with only a monthly periodical flow, many having a recurrence every fortnight. These periodical discharges, besides tending to perpetuate the disease by the accompanying congestion, hsemorrhage, pain and other pathological conditions, are troublesome from their necessitating, in the majority of cases, an interruption to treatment, which delays cure. Therefore we must expect to lose every month part of the good we have already gained, and must content ourselves with a very slow and gradual improvement. As the chronicity of the disease cannot be altered, an appropriate treatment should be adopted, which can be prolonged indefinitely. 158 TREATMENT OF TTEEINE DISEASES IN GENERAL If a suitable treatment, local as well as general, is applied, patients soon obtain marked relief. Leeches, a purgative, baths and douches, with tonics, when rightly employed, seem to rid them of all their pains and discomforts. They think themselves cured. But the physician must not deceive himself; the relief is only temporary. The organs have not sufficient tcaie to preserve them from a relapse ; the diathesis still exists ; the uterine discharge will soon recur, forcing us to dis- continue treatment, and taking possession of the organ will throw it back into its original condition. Therefore, I repeat, as the disease is chronic the treatment must be so also. lU. More is needed: we must prevent relapses. Treatment must be continued for a considerable time after an apparent cure, even after a real cure. The causes of the chronicity of uterine diseases are, at the same time, causes of relapse, and if we would destroy their power we must give tone and strength to the whole economy, and especially to the diseased organs, in order to preserve them from relapses. 11. Tke elementary nature and form of the uterine disease is another source of indications which must not be neglected in treat- ment. The various elements which contribute by their union to give the disease its form, physiognomy, and special appearance, may com- bine in different ways or be associated with such or such a disease as primary or secondary element. In this way fluxion, congestion, hae- morrhage, leucorrhoea, ulceration, pain, engorgement, hypertrophy, displacement, may be alternately principal or accessory elements of the disease, and become the source of primary or secondary indications. Many of these elements are not mere alterations of tissue or modifica- tions of local life, but morbid processes of the whole economy, having the uterus for their starting point or goal, and passing for simple affections. These affections may remain simple or become compli- cated by several other pathological elements. This remark applies especially to the most common of these elements— ^?^^iow. Whether it be an original element of the disease or a later complication, fluxion is the morbid process against which we have to struggle with most persistency in the treatment of uterine disease. We have to contend not only with imminent or established pathological fluxion, but even with the periodical physiological fluxion, at least in its derangements, and to prevent the consequence of its baneful influence on the malady. I cannot too strongly recommend the excellent treatise of Barthez on this subject (' Traitement Methodique des Fluxions'). The distinc- tion made between the fluxion that is imminent and the one that is estabhshedis very practical. The precept to use revulsives to prevent the first from becoming fixed and to employ derivatives to arrest the second is excellent. Congestion or vascular fulness of the organ is often only an estab- lished fluxion. It may then be called active congestion, and indicates the necessity for revulsives or derivatives. When it is passive it is none the less an important and frequent source of indication, which is best fulfilled by depletion. INDICATIONS FOR TREATMENT 159 Engorgement, or the presence of interstitial plasma, which is some- thing between cedema, congestion and hypertrophy, naturally indicates the use of resolvents. Hypertrophy, or increase of the uterine tissue by excess of assimila- tion or defect of decomposition, indicates reabsorption. When this hypertrophy is localised on some point of the organ and some portion of one of the tissues, and has given birth to granulations, fungous growths, polypi, fibromata, &c., it may become the source of special indication, that of the local destruction of abnormal tissue by ablation or otherwise. The discharges themselves are sources of therapeutic indication, only these are often of minor importance, subordinate to others arising from the morbid condition, whether diathetic or otherwise, on which these discharges depend. For example, fluxion, congestion, organic alterations, in reference to haemorrhage ; catarrh, chlorosis, herpes, scrofula, with respect to leucorrhoea, furnish indications to be fulfilled primarily, being of greater importance than those even of the haemor- rhage or leucorrhoea. Ulceration and the consequent more or less serious loss of substance, whether granular or fungous, becomes in its turn a source of indication. Subordinate as it is to the treatment of the diathesis on which the ulcer often depends, the indication to bring about cicatrisation is not the less urgent. Pain is one of the most important sources of indication ; it may exist in the uterus or around it, or sympathetically in distant parts. It may be transitory or persistent; it assumes different forms — hyper- sesthesia, neurosis, or neuralgia — and may be idiopathic, symptomatic, or sympathetic. It must be subdued whenever it appears, for pain increases the fluxion and all the elements of the malady, and is suffi- cient to bring them back if we have been fortunate enough to get rid of them. We must attack it at every period of the disease, and even after its cure, for it sometimes persists after the organ has returned to a satisfactory state of health. Lastly, the position of the uterus, the condition of its suspensory ligaments, the changes in its normal relationships, all become sources ' of indications. Only we must find out whether the morbid symptoms really depend on the displacement or are independent of it. When the disease is confined to a deviation or displacement, even then the indication may be complex — 1. To prevent the abdominal viscera, by means of rest, attitude and supporting belts, from increasing the dis- placement of the organ and causing pain. 2. To render the displace- ment bearable by palliative treatment or by the use of mechanical support. 3. Lastly, to obtain a radical cure by attacking directly the causes of the displacement or deviation. 12. Special indications arise from neiglihourlng disorders accom- panying uterine disease. The condition of the urine ought to be examined. In acute as well as in chronic diseases we often find this excretion abnormal. Lithiasis, concentration, deposits of various kinds, are all sources of indication, as well as tenesmus, inflammation, catarrh, frequent or difficult micturition, mechanical compression of 160 TREATMENT OF UTEEIXE DISEASES IN GENERAL the bladder or urethra by uterine tumours, &c. Then we have dis- orders connected with the rectum, diarrhoea, tenesmus, haemorrhoids, glairy, mucous or bloody discharges, and, above all, constipation, the most common and hurtful of all complications, keeping up as it does pelvic congestion. 13. "What can be said of the sympathetic reaction of uterine diseases on the nervous system and digestive economy but that the consequent functional disorders are sources of indication? Let me, however, remark that the majority of the indications arising from these dis- orders are already fulfilled by the means employed in combating asthenia, raising the tone of the whole economy, soothing pain, regu- lating the nervous system, improving the condition of the blood, increasing nutrition, renewing the whole constitution. 14. What can be said too of the very serious complications which sometimes increase the severity of uterine diseases and prevent a con- tinuance of the treatment, but that these complications are new- sources of indications ? From the point of view of preservation of life or of general health they may take precedence of those arising from the disease of the womb, they may even oblige the physician to respect the uterine disease, as a sort of natural revulsive guaranteeing the general health against the rapid and disastrous evolution of the coexisting disease. This may be the case where pulmonary tubercu- losis is coincident with leucorrhcea or uterine ulceration. It is often imprudent to insist on the cure of uterine diseases in phthisical patients. If it is wise, as Bennet^ says, to modify uterine symptoms when they become oppressive, we must respect the kind of equilibrium established between the uterine affection and pulmonary phthisis when the symptoms are bearable ; all the more so as in these cases the use of energetic means is not always without danger. We must remember in this case, as in that also of haemorrhoids, rectal fistula, gouty deposits in the small articulations, &c., that there are diseases which it is dangerous to cure y^ and that the aphorism of Hippocrates^ is eauallv true with reference to diseases as to treatment : — "Auo ttovwv afxa yivonivwv /utj koto tov avTov tottov, o atpocpoTtpoq afxavpoi TOV tTipOV. METHODS OF TREATilENT AND VARIOUS MEDICATIONS IN UTERINE DISEASES. Having enumerated the indications, the question arises, what method should be employed in the treatment of uterine diseases, and what medications will suitably fulfil the indications for this treatment ? The medication is the direct answer to the indication : it is an impression produced on the organs by a means or the association of several means, and intended to modify the economy in one sense or * Bulletin general de therapeutique, t. Ixix, p. 49. Paris, 1865. ' Raymond de Marseille, Traite des maladies qu'il est dnngereux de guerir. Paris, 1816. •* Section 2, aphorism, 46. METHODS or TREATMENT AND MEDICATIONS 161 another. The method is the order to be followed in the use of the medications, and of the means by which they are carried out : it is simply a help which we give nature when she tends towards cure ; or a way indicated to her, an impulse given to her from different points all directed to one end; or a rule imposed on her without apparent reason, but which experience has proved to be wise. Methods of treatment according to Barthez ^ may be divided into natural, analytical, and empirical. It is needless to say that we can seldom in the treatment of uterine maladies limit ourselves to natural methods, because these diseases rarely have any tendency to sponta- neous cure. On the contrary, we must often have recourse to analy- tical methods ; for these diseases are usually the product of one or more elements of one or more essential affections, and of several simpler diseases existing as complications. They are almost always complex ; at least they are complicated with all the morbid conditions consequent on the special structure and functions of the womb. Therefore we must simultaneously treat the diathetic affection, which often gives to the disease its character, and the morbid processes which give to it its form or which determine its exacerbations, its relapses and its chronic nature, or sometimes the simple disorders of men- struation which keep it up or increase it. In this way inflammation, engorgement, hypertrophy, granulations, ulcers, necessitate the use of certain means, at the same time that the diathesis is treated by an appropriate medication. Haemorrhage, congestion, simple fluxion are treated as they arise according to their relative importance ; e.g. if fluxion is defective, the use of attractives is indicated ; if excessive, then depletion or derivatives are indicated. Lastly, we must some- times have recourse to empirical methods ; for the disease, even when capable of being analysed, may resist the ordinary means of treatment, showiug no tendency to be cured, or it may be kept up by a specific affection the cure of which can only be effected by a specific medicine which experience has proved to be efficacious. This happens in many chronic diseases, especially when neuroses or local indolent engorge- ment predominate ; in such a case an acute attack may bring about a change which may become the starting-point of a favorable impetus towards cure. Medications. — The methods of treatment suitable to uterine diseases having been determined, we must carry out the treatment in the order indicated by the use of the general and local means at our dis- posal. Here also we find a medium between the method and treat- ment. Every means of treatment produces several results, some- times the one, sometimes the other, successively or simultaneously; on the other hand, the association of several means may be necessary to produce a single impression on the economy, just as the concur- rence of several processes is necessary to accomplish a single function. The means therefore cannot be applied directly without an inter- mediary in answer to the indication. ^ Preface du Traiie des maladies goiiHcuses, 1819 ; V., Nonveaitx Elements de la science de I'homme, &c., 3*, ed., t. ii, p. 282. Paris, 1858. 11 162 TREATMENT OF UTEEINE DISEASES IN GENERAL The association of various general and local means constitutes a medicatio7i : and it is by the help of medications that we respond to the indications. The true answer to the indication is not the medicine but the medication or medications. One or several medica- tions answer to one or several indications. Sometimes a single medi- cation suffices for one indication, but it may include several medicines or kinds of medicines. Sometimes two or more medications must be associated to respond successively or simultaneously to two or more indications. The distinction is so essential between medicines, i. e. the means and methodsof treatment, and medications, i.e. the manner of responding to an indication by the effect which such remedies pro- duce, that it is as impossible to group these medicines by medications as by indications. The combination of several means is necessary for one medication, and, on the other hand, the same means may serve in several medications or may carry out several indications at the same time. Bleeding, for example, is a depletive, derivative, revulsive, debilitant ; purgatives are not only evacuants, they are derivatives, revulsives, resolvents ; hydropathy is at the same time sedative, tonic and revul- sive ; vaginal irrigation may be refrigerant, sedative, astringent, &c. The same medication makes use of various means according to the case ; thus, resolvent medication utilises evacuants, revulsives, altera- tives, hydropathy, starvation, &c. ; the choice depends on the patients, on the disease, on the constitution, on the remedies at our disposal. We must therefore postpone reviewing the means to be employed in the treatment of uterine diseases, contenting ourselves with grouping them according to their natural affinities. As for the medications, they are arranged naturally like the indications to which they are intended to respond. When I set out in quest of the indications I simply followed the order we adopt in practice to discover them and to determine the disease, and by enumerating successively their different sources I showed how they arise. But the indications, when once found, ought to arrange themselves in our mind according to their various degrees of importance, according as they are common or special, local or general, major or minor, primary or accessory. The medications respond so directly to them with regard to the cura- tive effects which we hope to obtain from them, that we cannot but arrange them in this essentially therapeutical order. There is the same difference between the order in which the indications present themselves and that in which the medications appear, as between the way of making a diagnosis and that of instituting a treatment. There- fore I distinguish between common and special medications. Common medicalions are those which respond to common indica- tions, i. e. indications which may arise in every uterine disease. I have already said that the various processes which go to make up men- struation are almost invariably sources of indication in uterine patho- logy. By their simple presence, by their absence, excess, derangement, by the pains accompanying them, they may of themselves constitute morbid states, and in the majority of cases be added to the disease as cause, effect, or complication ; or they may hinder the treatment or METHODS OF TREATMENT AND MEDICATIONS 163 retard the cure indefinitely. "We must be able to increase or diminish the flow, dissipate the congestion, relieve the vascular system, or deviate the blood which flows towards the organ by directing it to- wards a distant organ. To each of these indications there is a corres- ponding medication, attractive, depletive or evacuant, derivative, revulsive. Sometimes we wish to attract the sanguineous flow to- wards the uterus by the help of rubefacients, vesicants, leeches to the labia, groin, anus, or cervix, by hot, aromatic, or mustard foot-baths or sitz-baths, by stimulating purgatives, enemata, or suppositories, by hydropathy, electricity, &c. At other times we empty the uterine vascular system by leeches to the cervix, scarification, cupping, pur- gatives, &c. Sometimes in cases of fluxion and congestion we deviate, i. e. derive the blood, by applying leeches or blisters to the groins, hypogastrium, or loins, or we may cup. Sometimes we turn away or divert this current and the movement which produces it by blood- letting from the arm, cupping the breasts, administering a purgative, or even an emetic, or by directing the fluxion to the surface of the whole body by means of vapour baths and other hydropathic operations, &c. I will explain afterwards that it is not enough to be able to use these medications ; we must learn how to apply them opportunely. Special medicationa correspond to indications which do not occur in every case, but which vary according to the nature of the affection, the pathological form assumed, and the organic alteration produced by it. Some are local. Tor example, medication consisting of appli- ances which are reducing and supporting, for the treatment of dis- placements, deviations, &c. ; atrophic or hypertrophic in cases of uterine hypertrophy or atrophy ; substitutive and modificatory in cases of superficial alterations of vitality and fluxion, of granula- tions or ulcers; destructive by the knife, caustics or fire, in cases of more profound organic^alterations, or considerable tumefaction, or formation of new elements and of homeomorphous or heteromor- phous tumours. Other medications are general, or both general and local : antiphlogistic, directed against inflammation, no matter where the seat or what the extent may be ; resolvent, with which the atrophic medication is often associated, against engorgement or other causes of permanent increase of volume ; anti-diathetic, whether simply altera- tive or specific, against general affections, the localisation of which keeps up tlie morbid state ; sedative and narcotic, against pain, whether it be an essential element or a complication ; antispasmodic, against spasm and nervous erethism ; tonic, against weakness, want of tone, and strength ; restorative, against digestive troubles, disorders of nutrition, impoverishment of blood, chlorosis, &c. Opporfime?iess of treatment. — This is another great principle in general therapeutics, which is specially applicable to uterine diseases. A brief explanation of it will form the natural connecting liuk between the enumeration which I have just made of the principal medications used in uterine therapeutics and that which I am about to give of the means by which we realise these medications. In the cure of uterine diseases, next to precision of diagnosis, opportuneness of treatment 164 TREATMENT OF UTEEINE DISEASES IN GENEEAL is the best guarantee of success. The treatment, medication and means must all be employed at the right moment. Treatment may be useless in a few cases, indispensable in almost all, but hurtful at one t'me, beneficial at another. It is the same with medication and the means employed. Very often the same end may be reached by several medications, the same medication by several medicines and means ; in short, there are different ways of treating a patient. There is opportuneness with regard to the disease, the medication and the means, but especially with regard to the patient ; for the various parts of the economy are not in a good condition, the constitution is often enfeebled, the blood impoverished, the nervous system affected, all the functions languid. I cannot too carefully impress on my readers the necessity of exam- ining all the organs attentively. It is not enough to examine a patient for purposes of diagnosis ; we must also examine with reference to treatment. By carefully investigating the various functions, systems and organs, we sometimes find disorder where we least expected it. But that is not all. In treating disease it is necessary to make an impres- sion on certain organs by means of medicines. Only there are different ways of producing this impression, different means of arriving at the same end. True art consists in being able to choose the best, the one most appropriate not only to the disease, but to the patient. That is why we must interrogate every function, examine every organ to learn if we can and should act on the stomach, the intestines, the kidneys, the skin, &c. How often after having made a careful examination do we find another disease counter-indicating treatment ! How often do we find the condition of certain organs such that treatment would do more harm than the disease ! Supposing, however, that the patient bears the treatment, and that it is applied at the right time, it is not enough unless the medication and the means are used opportunely. It is of more importance to be able to seize the opportune moment in treating uterine than other diseases. The recurrence of menstruation introduces such important changes into the condition of the organ, that we must not only suspend the usual treatment during the whole of the monthly period, but we must utilise this time by employiag new means, which are only efficacious when used at the right moment. I have seen many patients who had undergone treatment which they assured me had aggravated their disease, and yet the very same means were most successful when used by me at an opportune time. Let us take an example. One of the means which gives the most marked and rapid relief in the treatment of uterine disease is the appli- cation of leeches to the cervix. Struck by my success, all my pupils have adopted this practice ; but sometimes I have been called on to rectify their error, and to repair the troublesome consequences of treatment clearly enough indicated, but inopportunely or insufficiently carried out. This practice, though less frequently adopted than it deserves to be, is yet common enough to have allowed me to see a certain number of patients from different parts of Europe who had undergone this little operation in their own country. With several I METHODS OF TREATMENT AND MEDICATIONS 165 have been obliged to have recourse again to the same means, and sometimes have had considerable difficulty in overcoming the opposi- tion of my patients, who remembered that a previous ap|)lication had increased their pain and all other symptoms, and had even developed new troubles. It is very easy to explain these differences, and I have laid down rules calculated, I hope, to prevent accidents resulting from an inopportune application of leeches, whilst retaining so valuable an agent in uterine therapeutics. Leeches may be applied to the cervix during any part of the intermenstrual period, with the exception of the last week, provided they draw a sufficient quantity of blood. If not, they must be applied again and again if necessary, because after an insufficient flow of blood we always see an aggravation of symptoms, especially of pain. The reason is this : — The suction of the leeches has determined a flow of blood towards the organ which has not been evacuated. The vascular system is more gorged than before, hence the marked aggravation of all the symptoms and of the disease itself. The only remedy is to make a fresh application of leeches, and if re- quisite another, till an abundant hasmorrhage has caused depletion of the blood-vessels. Leeching the cervix during the week preceding menstruation may be indicated by the absence or insufficiency of the liuxionary movement accompanying the recurrence of the monthly period. In this case it acts as an attractive inducing fluxion towards the uterus. As this indication, however, generally occurs in young girls, and as it can be responded to almost as well by leeching the groins or the labia, this latter operation should be preferred. If, how- ever, we have to do with another disease, metritis for example, or uterine congestion, for which the application of leeches to the cervix is clearly indicated (as a depletive, not as an attractive), we must beware of making the application during the days which precede men- struatioUj especially if we have to do with a hsemorrhagic congestion. The flow of blood towards the uterus commences a few days before the periodical discharge takes place. The organ, under the influence of this continuous fluxion, becomes gradually congested, and this con- gestion produces disease if the natural haemorrhage, which is the crisis and the third act of this morbid drama, does not arrive in time or is insufficient. If, then, the organ is suffering from simple congestion or an inflammatory condition or is the seat of hsemorrhages which, in place of relieving, add to the morbid condition, it is evident that the application of leeches will only increase pre-menstrual congestion and consequently all the accidents produced by the pathological congestion or inflammation. The natural congestion preparatory to menstruation is of itself a troublesome occurrence, and we know that in the majority of uterine diseases the return of the monthly period is coincident with the return and aggravation of all the principal accidents. What then will happen if this natural congestion is increased by the application of leeches, which will add to the usual afflux of blood preceding men- struation ? Even if the flow of blood were to be abundant it would not prevent the pre-menstrual congestion from being increased and all the symptoms from being aggravated^ because it would come too soon 166 TREATMENT OF UTERINE DISEASES IN GENERAL to be the crisis, and would not prevent menstruation from taking place at the usual time, within a few days of the application of leeches; nor could it prevent the manifestation of all the usual symptoms, intensified in consequence of the attraction which has been followed by insufficient or useless depletion. These theoretical explanations are only the deduction of facts learned by observation, for I have seen serious accidents produced by inopportune leeching. Therefore, as a general rule, the cervix ought not to be leeched in the week preceding menstruation. In the week following menstruation, on the contrary, the conditions are quite different. The organ remains congested, especially if the critical haemorrhage has been insufficient; but the fluxion which has preceded the haemorrhage and determined the natural congestion has been extinct for some days. Any depletion at that time will be beneficial to the uterus. The suction of the leeches will not reawaken the fluxionary movement which has just ceased, and which will only be reproduced normally in a month. We can, therefore, without fear apply leeches to the cervix at this time. If the flow of blood is in- sufficient it will not be followed on that account by any accident : the organ will be soothed, though incompletely. If, on the contrary, it is abundant and capable of causing disgorgement of the vessels of the uterine system, the amelioration will be as complete as rapid, and the effect produced will sometimes exceed all our expectations. To obtain this result we must not fear to apply leeches again the following day if the first application has been insufficient, and to follow it up by purgatives, which are often found to be the necessary complement to this method of depletion. Practice is rewarded by a success exceeding the anticipations of theory. Therefore, as a general rule, the cervix should be leeched the day following menstruation, or at latest during the week following it. What I have said as to the opportune application of leeches could be said with regard to other means — douches, silz-baths, irrigations, purgatives, ergot, &c. But no example seemed to me so striking as that of leeches, and I have so often seen the difference in the efiVcts produced by their application at diff'erent periods, that I cannot have a doubt as to the importance of the time chosen to make use of this and other means. MEANS OF FULFILLING INDICATIONS IN THE TREATMENT OF UTEKINE DISEASES It is not enough to state the general way of preparing and admin- istering these means, the modus fac'iendi ; we must also determine the manner and the time of employing each one of them under given circumstances in order to realise the medication indicated. It is the only way of successfully applying to other cases the means which have answered in any given case. To know why these means have suc- ceeded, is to know what medication they have realised and to what METHODS OF TREATMENT AND MEDICATIONS 1G7 indication this medication has responded. The means of fulfilling the indications are general and local. I. General Means The general means are hygienic or medicinal. 1. The hygienic means are : posture, rest or exercise, regimen, &c. Rest is often indispensable. The posture that ought to be adopted by the patient is generally neglected unless the physician makes it his business to give precise instructions with regard to this important though small detail, and sees that they are attended to. In serious cases, always in acute and often in chronic diseases, the patient ought to remain in bed. She should lie horizontally, the pelvis on a level with the shoulders or higher, the head resting on a pillow, the legs and thighs flexed and supported by pillows under the thighs ; in short the muscles relaxed by semiflexion. The bed ought to be hard so that the pelvis does not sink in it j if the mattress is not of hair it is well to put a hair pillow under the pelvis. Spring mattresses combine resist- ance with elasticity. Feather beds must be forbidden absolutely. This prescription is indispensable, not only in acute diseases when the patient feels the necessity of rest and semi-flexion, but in all cases of haemorrhage whether occurring at the menstrual period or not, and in several chronic maladies, especially where there is a risk of haemor- rhage, as in polypi, fibromata, &c. ; or in inflammatory cases, as in ovaritis, metritis, &c., absolute rest in the position of semi-flexion and on the back, are often the most important elements of success. In certain cases, e.g. retroflexion, the contrary position, i.e. pronation, must be prescribed. When the disease is chronic, it is not generally necessary to confine the patient to bed. She may be on the sofa during the day if she takes care (when necessary) to keep in the position I have just indi- cated. In spite of the great importance which I attach to rest, I do not agree with Lisfranc and his school, in thinking it ought to be invariably prescribed in chronic diseases. Absolute rest for any length of time, especially in bed, is weakening and leads to loss of appetite and impoverishment of blood which play so important a part in the existence of uterine disease. We must therefore recommend exercise in these cases ; but the exercise must be moderate, in proportion to the strength of the patient, and of a kind not likely to excite pain. Therefore we must sometimes content ourselves with carriage exercise on a smooth flat road, making the horses if necessary walk, the patient lying in the. carriage and being protected from shaking by air-cushions. When the patient can take active exercise without suffering it is much better; in such cases she should be advised to walk, taking the pre- caution to choose a smooth road and stopping as soon as she feels any pain. She should gradually increase the length of her walks, but it is better to take several short ones than one that is too long, and she ought to lie down immediately afterwards. A hypogastric belt is often of great use by supporting the weight of the abdominal viscera 168 TEEATMENT OF UTERINE DISEASES IN GENERAL and so preventing pain when walking or standing. Sitting is some- times very injurious, as it has a tendency to cause pelvic congestion. When patients are obliged to sit, they ought to choose a hard seat or an air or water cushion, which should be flat. Those which are excavated in the centre are injurious to women suffering from uterine diseases or from haemorrhoids. They spare the patient the pain caused by direct pressure on the haemorrhoids or on the uterus ; but they congest the anus and lower part of the rectum, by the circular pressure exercised on the seat. The physician ought to prescribe the physiological rest of the organ in addition to the mechanical rest. This rest is indispensable not only in acute cases but in the great majority of other diseases. Engorge- ments, deviations, prolapsus, do not always counter-indicate sexual intercourse. But whenever there is pain or fluxion, inflammation, haemorrhage, or a great tendency to the recurrence of any one of these morbid elements, coitus must be absolutely forbidden, and the patient advised not to share her husband's room. This rule cannot be too strictly enforced ; unfortunately, it is too often infringed as relapses testify. It is often difficult to get our instructions carried out by the poorer classes ; indeed, they are not always attended to by the rich. In such cases it is well to advise patients of the former class to go to a hospital, and those of the latter to go to a hydropathic establish- ment or to mineral waters when expedient, with the double object in view of undergoing treatment and of being separated from their husbands. When there is only engorgement, congestion, or general symptoms without local inflammation and a long time is required to complete the cure, intercourse ought to be allowed at distant intervals, for there are patients of a passionate nature for whom it is necessary. Only I advise them, as I advise men aff"ected by diseases of the pros- tate, to accomplish the act quickly. Unsatisfied erotic desires which keep up a fluxion, a nervous excitement, a persistent orgasm, are infinitely more injurious than coitus when quickly performed. It is therefore better in some cases to submit to the inconveniences of con- jugal relationship than to enforce abstinence; but it must be on con- dition that the patient is spared the fatigue of a prolonged state of erethism. Coitus may have to be forbidden for another reason : in order to avoid the possibility of pregnancy, which occasionally though rarely occurs before a cure has been obtained. If the physician considers that pregnancy will have an unfavorable influence on his patient he has no other course to take. The regimen in acute uterine diseases is the same as in all acute diseases. In chronic uterine diseases, atony, impoverishment of blood, debility of constitution, indicate the necessity of tonics and restora- tives. The best tonic is a good regimen ; the best restorative generous diet. We must therefore prescribe roast meat, green veget- ables, ripe fruit, wine, &c. Tarinaceous food must be forbidden, but green vcg(-tables and fruit allowed to prevent constipation. When the state of the digestive functions will not allow the use of beef and METHODS OF TREATMENT AND MEDICATIONS 169 mutton, we must content ourselves with white meat, chocolate and milk. I often prescribe partial milk diet to patients whose digestive mucous membrane is in an irritable state : in such cases the milk should be drunk warm and taken from the same cow or {. METHODS OF TREATMENT AND MEDICATIONS 211 over the crayon several times ; as a protector of the ulcerated surfaces by the coagulation of mucus and the precipitation of chloride of silver acting almost in the same way as collodion ; in repressing exuberant granulations when the crayon is applied. Lastly, in modifying as well as destroying tissue when the powder or crayon is left in the uterine cavity, a method to which I will afterwards refer when treating of intra-uterine cauterisation. The actual cautery. — It is specially suitable as an application to the cervix, for this organ is almost insensible to the action of fire — at least to the pain which this action produces on other tissues. There is no better mode of applying fire to diseased surfaces than by means of red-hot iron. Although this means has been employed for long, it has probably never been used with method and discrimination till our own time. Larrey^ gave all the necessary operative details, but it was Jobert's* works that popularised this operation in gynecological practice. As I believe that additional information on this subject would be welcomed, I will relate what a long practice has taught me. Several kinds of cautery are necessary, according to the use for which they are intended. I use two kinds especially ; the first are very fine, with a reservoir for heat for ignipuncture ; the others spear- FiG. 190. — Cauteries for ignipuncture^ shaped, straight or curved, for ignilysis or section by fire. I have also conical cauteries of every size down to that of a grain of corn, others Fig. 191. — Cauteries for scarifications, sections and excisions by fire. d, straight ; E, curved. cylindrical, nummular, &c. ; I even had a cup-shaped one made for ' Clinique chirurgicale, t. ii, pp. 114, 829. Paris, 1830 — 1836. ^ Plaies d' amies a feu, Memoire sur la cauterisation. Paris, 1833. 212 TREATMENT OF UTERINE DISEASES IN GENERAL destroying an irreducible inverted uterus, and I used it afterwards for cauterising a cervix enormously engorged or hypertrophied. I have found nothing better for heating the cauteries than the eolipile spirit lamp which solderers generally use. I think this lamp and these cauteries are to be preferred for this purpose even to the thermo- cautery, although I admit the superior advantages of the latter in other circumstances. The operation of cauterisation is performed in the following man- ner: after introducing a speculum of wood or of glass, the uterus is seized firmly and the speculum pressed against it so that it cannot escape, the operator being on his guard against any movements that the patient may make; the cervix is then well wiped with cotton wool ; if it is bleeding the cotton ought not to be withdrawn till an assistant has brought the cautery, which must be at white heat. Whilst the left hand holds the speculum the riglit applies the cautery to the uterus, and, according to the object in view, the uterus is barely touched, or the iron may pass lightly over different points of its sur- iPw. I'.i2. — Eolipyle bpirit lamp for heating cauteries. face, or may be left in contact with some point for a few instants, and when necessary be replaced by a second cautery ; or, lastly, it may even be introduced into the cervical cavity, care being taken to pro- tect the healthy i)art by one of Eecamier's large curettes. In most cases, however, the operation is much simpler, being limited to one or more punctures varying in depth from 5 to 15 millimetres, in one or other of the lips uf the cervix. At other times excision of the diseased part may be ])erformed by making use of a univalve in place of a cylindrical wooden speculum, and fixing the cervix by means of fine tenaculum hook forceps. METHODS OF TREATMENT AND MEDirATfONS 21:] Immediatelj the cautery is withdrawn cold water should be poured into the speculum several times ; this instrument may then be with- drawn, when the patient is placed in bed in the dorsal decubitus with legs and thighs flexed. Cooling applications may be made to the hypogastrium, vulva, and upper part of the thighs, of vinegar and water, the ice-bag, &c. Serious accidents may happen after cauterisation. They rarely occur unless the patient is suffering from metritis, ovaritis or perimetritis. However, the freedom from pain during the operation, the superficial action of certain slight cauterisations and the absence of trou- blesome consequences after imprudences committed by some patients subsequent to this operation, have inspired some practitioners with too blind a confidence in the innocuous nature of this means, and a blameable temerity in its use. I have seen patients who had actually been cauterised by a doctor in his con- sulting room ! I have also seen the de- plorable consequences of such impru- dence. Although the cervix is not sensitive to pain, there is none the less a reaction after the traumatism that has been undergone. An inflammation of elimination is necessarily developed round the scar; this inflammation if neglected may pass the limits within which it ought to be confined, and ori- ginate very serious pathological pheno- mena. Therefore, in order to avoid all accidents every possible precaution should be taken, not only by avoiding cauterisation even with nitrate of silver during the week preceding the cata- menia, but also by insisting on the patient remaining in bed for several days, the hypogastrium being covered with cooling or emollient applications. She should take an emollient bath every day, remaining in it for an hour at least, and making vaginal injections all the time; or if this cannot be done, vaginal irrigations should be made several times a day with some disinfectant. Thanks to these precautions, I have Fig. 193. — Isniipnnotiive of the cervix, wliich is kept fixed by the diverging tenaculum hook forceps. 214 TREATMENT OF UTERINE DISEASES IN GENERAL never seen any accident follow the numerous cauterisations I have performed, but on the contrary they have always produced good results. When the cervix is very much engorged or when considerable folli- cular hypertrophy exists, I follow the excellent advice given by Huguier, making a number of scarifications before cauterising. The cervix may be cauterised even during pregnancy if the precau- tions are taken which I have just detailed. I need hardly say that the redhot iron is not to be applied to the cervix of a pregnant woman who is merely suffering from simple granulations, not exceed- ing the limits often assumed by this morbid condition during preg- nancy, and giving no cause to fear a miscarriage. When, however, the cervix is seriously affected recourse may be had to cauterisation without misgiving; the operation being practicable from the end of the first month to the end of the sixth. There need be no anxiety as to causing abortion ; on the contrary, one of the advantages of this little operation in such a case is, that it increases the chances against the occurrence of this accident.^ Facts have proved to me not only the immunity of the actual cautery,^ but also that its application in Fig 194. — Apparatus for cauterising with gas. the case of pregnant women is followed in due time by a safe and normal delivery. ^ ' Mauny has published five cases of persistent vomiting during pregnancy, cured by cauterisation of the cervix with nitrate of silver or with acids. Paris, 1869. ' Annales cliniques de Montpellier, 25 aout, 1853. 3 Ibid., 10 avril, 1854. METHODS OF TREATMENT AND MEDICATIONS 215 I have also cauterised the cervical cavity when its mucous mem- brane was the seat of follicular or granular hypertrophy. Great care, however, must be taken to cauterise only the fungous and exuberant parts, protecting the rest from the action of the heat. Otherwise we should run the risk of causing scars, which might obliterate or at least narrow the orifices, as unfortunately too often happens. Nelaton has recommended using the flame of a gas-jet in place of the red-hot iron. The advantages of this cautery are, that it does not frighten the patient, who need not even be aware of the kind of operation about to be performed; it allows the cauterisation to be defined as exactly as if done with a pencil, and above all it permits of a more energetic action, as the gas flame can be kept in contact with the diseased part as long as necessary. It is therefore superior to the red-hot iron in many ways. In other respects, however, it is inferior. It only acts on surfaces, it cannot be used for cauterising the cervical cavity, for removing an excrescence, for scarifications, nor for deep i^'iG. 19n. FfG. 196. Fig. 196. — Galvano-tlienno-canstic battery. Ftg. 197. — G, platinum bistoury; l, oautery in f(irm of a knitV; r. (rantery ; o, cylindrical cantery. 216 TEEATMENT OP UTERINE DISEASES IN GENERAL ignipunctures^ which in my opinion are the most useful application that can be made of the actual cautery to the uterus. The galvanic cauiery is applied by means of a galvano-caustic handle or knife, and has been popularised by Middeldorpf. Electro- lysis has been recommended by Ciniseili and adopted by some sur- geons, who consider it very valuable ; they believe that in performing a section by means of the negative pole around which the alkaline elements arrange themselves, the scar will be soft, and the subsequent cicatrix non-retractile (which remains to be proved; in my opinion cicatricial tissue is always cicatricial tissue, i.e. retractile). The diffi- culty of keeping galvanic and electrical apparatus in order will always prevent their coming into general use. Paquelin's thermo-cautery has not the same drawbacks. At my request Collin has succeeded in making spear-shaped cauteries, some curved others conical, but as yet he has not been able to make any sufficiently pointed to serve for ignipuncture of the cervix. This apparatus though much simpler than electrical machines requires con- siderably more attention than the eolipyle lamp. Therefore this lamp and the ordinary cauteries seem to me preferable to all other instru- ments for cauterising the uterus. Fig. 197. — Paquelin's thermo-cautery. To understand the harmlessness of the actual cautery when applied to the uterus with the precautions indicated, we must remember that the fibro-plastic nature of the tissue, the tendency to hyi)ertrophy, the remarkable facility with which the mucous membrane of the uterus is renewed, this instability of a tissue which I have described as beino- con4aiitly in process of organisation, must greatly facilitate the pro- cess of repair in an organ like the uterus, when destruction has only METHODS OF TREATMENT AND MEDICATIONS 217 extended to a small part of its mucous membrane, and especially when this destruction has been limited to pathological excrescences. Not only is cauterisation of the uterus not invariably followed by the for- mation of a cicatrix, but the cauterised cervix which previously was hard becomes soft. There must, therefore, have been a work of absorption going on, perhaps the production of new elements ; but not, strictly speaking, the formation of cicatricial tissue. There is frequently even partial renovation of the mucous membrane. The oritice is the only part we must always treat carefully. Only a short time since I had a new proof of the wonderful facilitv with which repair of the uterine tissue takes place. It was a chronic case of complete inversion of the womb ; reduction was impossible, and it seemed to me that the only indication was the ablation or de- struction of the organ by the actual cautery. The ordinary cauteries seeming to me insufficient, I had one made expressly of a large piece of iron, forming therefore a much larger reservoir of heat than our largest cauteries, and slightly excavated on the surface so as to mould itself to the convexity of the uterus. I applied it at white heat to the mucous membrane, leaving it long enough to lead me to hope I had effected destruction ; but with the exception of a very limited spot, the whole of the mucous membrane resisted, or rather was renewed so effectively, that after making fourteen cauterisations (which were much more painful than those of the cervix) I had to renounce further attempts. In proportion as the scar was detached healthy granulations appeared underneath, and after a few weeks I found the surface covered, not with hard and retractile cicatricial tissue, but with a soft membrane resembling the mucous membrane of the uterus in appearance. It is certain that the red hot iron does not produce so deep a scar as one would think, nor as that caused by chloride of zinc. The rapid drying of the surface prevents the action of the fire from extending, so that the tissues underneath are modified rather than destroyed. I only know one contra-indication to the use of the cautery, whether actual or by caustics, and that is the existence of inflammation, and especially of peri-uterine inflammation. I cannot repeat the caution too frequently that it is very imprudent to cauterise, especially inter- nally, in cases of parenchymatous metritis, and even of inflammation of the mucous membrane, a disease all the more dangerous because it may simulate a simple catarrh or be coincident with it, and pass unper- ceived in a superficial examination. In order to arrive at a correct diagnosis we must have recourse to inspection, touch and the uterine sound ; for cauterisation performed in such circumstances has led to serious suppuration in the uterus and its appendages ending in death. At present I am attending a patient suffering from serious uterine and peri-uterine inflammation, developed after an inopportune cau- terisation, made, however, by a Trench surgeon who justly enjoys a great reputation. I am convinced, from knowledge of the special antecedents of this patient, that the inflammation existed before cau- 218 TREATMENT OF UTEEIXE DISEASES IN GENERAL terisation, that it passed unnoticed because the patient was only exa- mined with the speculum unaided by touch and palpation, and that it was deplorably aggravated by the operation. The scar generally falls between the tenth and fifteenth day. Cicatrisation should be hastened, and therefore, besides continuing the general treat- ment of baths, irrigations, and (when indicated) astringent and detersive injections, medicated applications should be made to the cervix at variable intervals. I may mention the following as particularly useful : laudanum, when all that is necessary is to promote the natural tendency of the wound towards cicatrisation; the solution of nitrate of silver, when it is desirable to stimulate the healthy granulations ; basic peroxychloride of iron,^ when the wound has a tendency to bleed, and when vascular fungous growths seem ready to reappear on the surface; the concentrated aqueous solution of tannin, or even the crayons of tannin invented by Becquerel, for a lesion not extending beyond the cervical cavity, when the catarrhal condition and aqueous infiltration seem to have caused the development of granulations (I have a case of slight catarrhal granulations where the application of these crayons sufficed to effect a cure); iodoform and the tincture of iodine, when the engorgement of the cervix and the size of the granulations seem to indicate a scrofulous diathesis; the tincture of iodine and the perchloride of iron, when the mucous secretion is very abundant, or when the wound is pale or diphtheritic, and requires to be stimulated or mo- dified, or when it threatens to bleed, &c. 3. The cauterisation of the uterine caviti/ is performed in a different way. Everything here contra-inciicates the use of energetic caustics; liquid or solid caustics cannot be blindly applied to diseased ))arts without risk of caujiing great injury ; the red-hot iron must not on any account be used, it would burn the orifices and the cervical walls before reaching the part requiring cauteri- sation ; and yet we cannot doubt the existence of fungosities and granulations on the mucous mem- brane of the body, less frequently, but still as decidedly, as on that of the neck ; nor can we deny that the means which succeed best in the treatment of these diseases would be applicable to the mucous membrane of the body as well as ^ MontpelJier nn'dical. 185S. 1* Fig. 1!*8. Two ifi-aduated ute- rine sounds of dif- ferent calibre. METHODS OF TREATMENT AND MEDICATIONS 219 to that of the neck. Leucorrhoea itself^ a morbid condition of the glands of this mucous membrane, seems to require the intervention of active applications. Might we not hope that astringents, cathartics, caustics would effectually help the action of general treatment as well as in analogous diseases of the vagina and cervix ? This conviction has suggested the idea of applying liquid modifications and even caustics by means of injections. The mtra-uterine injections practised by Melier, Vidal (of Cassis),^ Scanzoni and Aran, and met with disapproval by Hourmann, Nonat, &c., must be ranged among the most energetic means of modifying the tissues, but also the most dangerous that can be employed, if not practised according to the rules about to be laid down. We must begin by cleaning the uterine cavity from the mucus which covers it, either by injections of pure water, or by painting it Fig. 199. — Canula on which a fine india-rubber sound may be screwed, and which is fixed at the other end to the small injection syringe. Fig. 200. — Small graduated syringe for making uterine injections. 1, syringe in its metal case, the canula enclosed in the stem of the piston ; 2, syringe ready for use, which may be fitted to the metal sound or to a gum-elastic sound by means of the canula. with yolk of e^g to form an emulsion with the mucus and thus to expel it more easily. Then a caustic injection is made. The use of the uterine sound greatly facilitates the operation. Whether we use a fine india-rubber sound introduced by means of a wire in the interior, which is withdrawn immediately afterwards, or a hollow uterine sound made after the model of Simpson's, it is in any case useless to have one with a double canula, as the liquid should be able to flow back round about the sound, which ought to move freely in the orifice. As for the instrument of propulsion, whether the india-rubber bag of Hardy (of Dubhn) be used, or the graduated syringe which Collin has made at my request, the process is the same, and consists in first introducing the sound, then adjusting the syringe to its extremity and ' Essais sur le traitement metliodique des maladies uterines. Paris, 1840. 220 TREATMENT OP UTEEINE DISEASES IN GENERAL propelling the liquid very slowly, so as not to distend the cavity of the uterus, lest the sound by filling the orifice should prevent the free return of the liquid into the speculum. The speculum is always indis- pensable when a caustic liquid is used, to prevent the cauterisation of the vagina by the liquid as it issues from the uterus. Xotliing could be simpler or more efficacious than these injections if the susceptibility of the mucous membrane, the narrowness of the cervico- uterine canal, and the permeability of the Fallopian tubes were not the source of dangers, all the greater that they are sometimes not foreseen, and that the greatest skill and prudence have not always suc- ceeded in preventing them.^ As for myself, I have often made these injections without any bad result; but although I have never had occasion to deplore the death of a patient, I have sometimes seen the instantaneous occurrence of such formidable accidents after injections, that I have resolved never to make another caustic injection, or even one of simple water, unless assured of a free passage through the cervico- uferine orijice, allowing of the easy reflux of the liquid into the vagina as soon as it has filled the uterine cavity. In this case there is nothing to fear. We may, therefore, without misgiving follow this rule : to make an ivjedion into the uterus wheyi the orifice is sufficientli/ wide to alloic the excess of liquid to flow hack through the cervix ; in all other cases to abstain from this mode of treatment." This operation, moreover, must only be performed in the middle of the intermenstrual period. The liquids used are : simple water, solutions of tannin, alum, sul- phate of zinc, nitrate of silver, acid nitrate of mercury, tincture of iodine, perchloride of iron, and even of chloride of zinc. I must, however, repeat that every liquid caustic may become dangerous : (1) because it touches all parts of the mucous membrane, and so may cause too extensive a destruction, or excite an irritation in the mucous membrane, followed by inflammation dangerous in itself, and which may spread to the mucous membrane of the Fallopian tubes and to the peritoneum ; {'l) because the uterine cavity is so small that all the liquid may not flow back by the orifice, and, even when it can return freely, part of it may penetrate the orifice of the Fallopian tube and cause fatal inflammation. Therefore I restrict intra-uterine injections, in those rare cases which absolutely require them, to simple water used as a lotion, or to a very small quantity of catheretic rather than caustic liquid : — tincture of iodine, perchloride of iron, nitrate of silver, beginning with a very weak solution and increasing very gra- dually ; and I never make them when there is any cause to fear that, owing to a flexion, a deviation of the cervico-uterine canal, a constric- tion of the orifice, or any other obstacle, the liquid injected cannot return easily from the uterine cavity into the vagina. This is no doubt ' Naeggerath has related a case of death resulting from caustic injections into the utenis {New York Journal of Medicine and Gazette ined de Paris, 18(;)1, p. 190). ^ Gantillon, du Catarrhe uterin. These de Paris, 1868. Guyot, dee Injec- tions intra-vterines. These de Paris, 1868. MKTHODS OF TEEATMENT AND MEDICATIONS 221 equivalent to a half condemnation. In fact, I hardly ever perform this httle operation since I recognised its attendant dangers, and espe- cially since I ascertained the entire freedom from injurious results of the introduction into the cavity of the uterus of a small quantity of solid or pulverised nitrate of silver. There are, however, cases of obsti- nate hsemorrhage and abundant leucorrhoea, where injections of tannin; iodine, &c., have been of great use. Intra-uterine cauterisation ought only to be practised with nitrate of silver. Any other caustic seems to me dangerous, except in cases of serious alteration with suspicious vegetation of the whole mucous surface, when nitric or chromic acid, in solutions of varying strength, or even chloride of zinc may be indicated. Nitrate of silver may be applied to the uterine cavity in various ways. It may be introduced by a brush dipped in a concen- trated solution of the caustic, or the wet brush may be rolled in powdered nitrate of silver, or a sponge tent may be covered with wax and rolled in the powder, according to Gillespie^s plan {L^on medical, 20 aoiit, 1871). We may even with the brush, which presents none of the dangers of injections, apply other caustics, such as the aqueous solution of tincture of iodine, perchloride of iron, and even chloride of zinc, as I have done several times. The mode I adopt is as follows : I com- mence by introducing the sound into the cavity so as to learn the direction to be given to the instrument, taking care always not to cause hsemorrhage. Immediately after withdrawing it I insert a fine camePs- hair brush, mounted on a long handle and soaked in a strong solution of nitrate of silver, or rolled in the powder, and repeat the application a second and even a third time if the os internum remains sufficiently open to allow of it. Whilst this is being done I fix the cervix by means of the converging tenaculum hook forceps. In most cases this application repeated once a month three or four times is quite sufficient to produce the desired effect ; but in some rare cases, where a more powerful action is Fig. 201. — Cauterisation of the uterine cavity by means of a brusli. 222 TREATMENT OF UTERINE DISEASES IN GENERAL necessary, it has been suggested that the crayon should be introduced and applied to the mucous membrane lining the cavity in the same ■way as to ulcers of the cervix, or to the proud flesh of an external wound. Till lately, however, practitioners feared the danger that might be incurred by a fragment of the caustic being broken off and remaining in the womb. Having assured myself not only of the harmlessness, but even of the good results consequent on this accident, and having considered the advantages which might accrue from leav- ing a fragment of nitrate in the cavity of the womb provided its use was indicated, and that precautions were taken to avoid troublesome consequences, I have not hesitated to try this means of cure for obsti- nate leucorrhoea and fungous growths. Experience has answered my expectations in the most satisfactory way, and at present the introduc- FiG. 202.— Uterine caus- tic-bolder, a, sound ; b, stylet. Fig. 203. — Extremity of different utenne caustic- holders. 1, large sound with two large orifices for ointment ; 2, 3, smaller sounds for passing solid or pulverulent caustics into the uterus. tion of nitrate of silver into the uterus is not only one of the little operations which I perform as frequently as cauterisation of the cervix or of the cervical cavity, but it is a recognised application in gyneco- logical therapeutics. I perform it in the following way : I choose a crayon of varying length, according to the size of fragment I intend to leave in the uterus ; generally a very small crayon is sufficient. I METHODS OF TREATMENT AND MEDICATIONS 223 round and point the extremity, rolling it between the fingers in a piece of coarse wet linen, so as to facilitate its introduction ; then I fix it in an ordinary platinum caustic-holder with a long handle, or seize it with the uterine forceps, or place it in the end of Braun's sound. After having introduced the sound in order to learn the direction of the cervico-uterine canal, but very gently so as to avoid causing spas- modic contractions of the orifice, I apply the crayon to the uterine cavity; then, in place of trying to withdraw it intact, I try to push it in by partly opening the forceps, or to break it by inclining the caustic-holder abruptly, or I thrust it in by means of the gutta-percha sound invented by Braun of Vienna^ for this purpose; immediately afterwards I introduce into the vagina a large tampon, soaked in salt water, so as to neutralise the nitrate of silver which, as it dissolves, issues from the uterine cavity, and to protect the vagina and cervix. I keep this plug in place by a larger dry one, and then withdraw the speculum. In addition to these the same precautions are taken to prevent the development of inflammation as are used after the actual cautery. I may say that I do not know a more heroic means of treatment than leaving a fragment of crayon in the uterine cavity in those cases of large fungous granulations for which Eecamier invented his curette, and above all in cases of chronic and obstinate leucorrhoea, which cause despair to patients and physicians alike. It seldom happens that this little operation is required a second time. I have never seen serious accidents follow this mode of treatment. The cauterisation of the vagina is prevented by the introduction of the plug soaked in salt water; inflammation of the uterus or of its mucous membrane by baths, vaginal irrigations and absolute rest; and pain, spasm or nervous erethism, which are the most common accidents, by an antispasmodic draught or an opiate enema, I have only once seen excruciating pain alleviated neither by baths, antispasmodics, nor narcotics. It was owing to expulsive efforts and uterine contractions produced by a considerable swelling of the cervix which caused a temporary occlusion of its orifice. This morbid condi- tion, which prevented the expulsion of the mucus abundantly secreted under the irritating influence of the nitrate of silver, being the sole cause of these pains, a cause purely mechanical, I incised the cervix a few hours after the operation to facilitate the expulsion of the mucus, as well as of the nitrate of silver itself. The symptoms ceased imme- diately, and the good efl'ects of the cauterisation were produced all the same. In all my other cases, the pain, which has occurred more frequently than after cauterisation of the cervix, and which has some- times been severe, has always yielded to general and local antispas- modics, and to baths associated with continuous vaginal irrigation. Besides, if the nitrate is only left in the uterine cavity when the ' Since then a year never passes without a new instrument being invented for precipitating a fragment of nitrate of silver into the uterus, which is the best refutation of the objections made to my method, i.e. before having tried it experimentally. 224 TEEATMENT OF UTEKINE DISEASES IN GENERAL orifices are gaping, the mucus, which is abundantly secreted imme- diately after the operation, is easily expelled under the influence of uterine contractions, and it rarely happens that these contractions are painful. Sometimes the orifices are so patent that the crayon is expelled with the mucus. As it is not always necessary to introduce a large fragment, 1 often use ordinary open sounds furnished with a piston for propelling a small bit of nitrate, or simply the powder or an ointment. The contra-indications to this little operation are very clear. The first and most absolute is the existence of an inflammatory state of the uterine system. This rule alone would prevent many accidents. Another important contra-indication is never to leave the crayon in the uterine cavity when the secretions would have any difficulty in escaping. Consequently I never do so in cases of flexion, deviation of the uterine canal, or constriction of the orifices. I must now explain what takes place through the agency of this mode of cauterisation, and also account for its innocuity. The chief cause of its harmlessness is that the mucous membrane of the womb does not experience the direct and immediate action of the caustic. In fact the nitrate of silver cannot be brought into immediate contact with the mucous membrane, nor can it produce an energetic cauterisation on any part of it. The presence of the crayon causes hypersecretion of mucus, which protects the membrane, the crayon being enveloped with the mucus which coagulates around it from the first; afterwards it is only through this envelope that an exchange can be effected between the caustic and the secretions of the uterine cavity. We know this from seeing the crayon as it escapes seven or eight days afterwards, or rather its form, for it is strangely altered, decomposed, softened and foliated. It is evident that it has been greatly modified by its sojourn in the uterine cavity ; it is evident also that it has not dissolved as it would have done in a glass of water. A series of successive exchanges have been made between the elements of which it is composed and those of the mucus secreted by the membrane lining the uterus. The impression, therefore, made on the organ by the caustic must have been very gradual. This action differs, without doubt, from cauterisation properly so called; we can understand also that, if some parts are more affected than others, it must be the superficial ones, the granulations, the exuberant fungosities, the hypertrophied follicles. In short, we can understand that this modification of the uterine cavity is prefer- able to that produced by injections which penetrate further, reaching all the recesses of the mucous membrane, even of the Fallopian tubes, and presenting dangers the existence of which is proved both by experience and theory. 4. Eecamiei's uterine curette is a metallic stem in steel, twelve inches iu length, of the thickness of an ordinary goose quill, cylindrical iu the middle, presenting at each of its extremities a curve, which allows of its being more easily adapted to the axis and direction of the uterus. Its curves are disposed inversely with regard to each other. Their concave sides are excavated in deep grooves of unequal length, the METHODS OP TREATMENT AND MEDICATIONS 225 edges of which, although blunt, are very fine, like those of a rasp, and capable of removing exuberances of the mucous membrane by friction. After introducing the instrument into the uterine cavity Fig. 204. Fig. 205. Fig. 206. Fig. 204 — Recamier's uterine curette. Fig. 205. — Sims's curette, effecting abrasion by the external border. I have had one made which abrades with the internal border. Fig. 206. — Button-hook curette, differing from the other two in not beino' closed, so that it can be used for the removal of a polypoid excrescence. The stems of these instruments not being tempered, they can be inclined to suit the direction of the cervico-uterine canal. Eecamier used to impart to it light movements of circumduction as well as in a vertical direction, so as to explore successively every part of the mucous membrane. If he found that some points were especially exuberant, he scraped the mucous membrane with one edge of the groove, and when both of the walls seemed sufficiently smooth he withdrew the instrument, taking care to turn the groove upwards, so as to bring away the fungosities just abraded. I have often in this manner extracted fungosities, which were the only cause 15 226 TEEATMENT OF UTERINE DISEASES IN GENEEAL of metrorrhagia which ceased after abrasion by the curette. Eecamier sometimes repeated the operation several times at intervals of a few days. Each scraping was followed by cauterisation with nitrate of silver and bathing of the uterine cavity. This operation has been severely criticised by some and too much praised by others. To say thatMarjolin^ Eobert, Trousseau, Nelaton, Maissonneuve, Nonat, &c., have practised it several times with success is a sufficient justification of the use of the curette. When there are no fuugosities it cannot do very great harm to pass the curette lightly over the raucous membrane, and when there are it alone can remove them quickly and surely. It is, therefore, undoubtedly of great value. I specially recommend its use for the abrasion of a little polypus or fungosity clearly diagnosed by means of the sound. In such a case it may be necessary to have recourse to Sims's curette, which is broad, or to mine, which I have left open on one side in the form of a button hook. It cannot be denied that in cases of softening of the uterine tissue the curette may have produced perforations which, though cured in some cases, have in others had a fatal result. The danger of this accident, which is very rare and always easy to avoid, ought always to be present to the mind of the surgeon, who will use every precaution and even abstain from abra- sion in all cases where flexion of the uterus or softening of its tissue would facilitate the penetra- tion of the curette through the uterine walls. 5. Simpson^s intra-uterine dry cupping instrument is a hollow sound perforated with holes at the terminal extremity, whilst the other end is screwed on to a little aspirating pump, by means of which a vacuum can be made. The diameter of the sound is suffi- cient to fill the cervico-uterine orifice when the rounded extremity is in the cavity of the womb. In proportion as a vacuum is made in the body of the pump a kind of aspiration is exercised on the uterine mucous membrane which comes in contact with the little openings of the sound. After repeat- ing this application several days running, at the time when the catamenia ought to appear, there is a flow of blood towards the mucous membrane, and at last there may be a little oozing of blood from it. Simpson used to have recourse to this little opera- tion for amenorrhoea, but it has not been adopted by the profession. It is a complement of the intro- duction of the galvanic stem and of the dilatation of the orifice by stem pessaries of gradually increasing diameter. B. Special operations, — The operations which remain to be men- tioned are so entirely special that the description of them cannot well be separated from the history of the diseases for which they are indi- Fig. 207. Intra - uterine sound for dry- cupping the ute- rus (Simpson). METHODS OF TREATMENT AND MEDICATIONS 227 Fig. 208. — Simpson's simple hysterotome. Fig. 209.— Mjlthieu's double hysterotome. 1, open ; 2, shut. Fig. 210. — Division of the os ex- ternum with the blunt-pointed concealed bistoury and diver- gent tenaculum hook forceps. cated. Some of them^ though offering no apparent difficulty, and though devoid of all real gravity, are not on that account unaccompanied by dangers, occurring either from ignorance of the exact anatomical knowledge required, or from induced haemorrhage, or even from serious 228 TEEATMEXT OF UTEEINE DISEASES IX GENERAL accidents consequent upon them, such as the putrefaction of pus, the entrance of air into a purulent or sanguineous centre, the decomposi- tion of liquids contained therein and the purulent or ])utrid absorp- tion which may be one of these consequences. Otliers take their place among the most serious operations of surgical art, and neces- sitate special kno\iJedge as well as an experienced hand and a mind familiar with all the accidents and all the resources of general surgery. 6. Amongst the first class we may include division of the cervical orifices ; perforation of the hymen, vagina or uterus, in cases of atresia of these organs ; puncture of peri-uterine, uterine, or ovarian tumours, whether by the vagina or the abdomen ; injections of various kinds into centres, the contents of which have previously been evacuated. The division of the cervical orifices indicated in cases of constric- tion, of mechanical and even of membranous dysmenorrhoea, sterihty, or even of intra-uterine tumour (to facilitate means of access), is performed by means of simple instruments such as scissors, bistouries, sharp- or probe-pointed, with a director, kc, as on any other part of the body, with this difference that these instruments must be long enough to reach the uterus. Sometimes it is more convenient to use special instruments or hysterotomes, the concealed blades of which are made to spring out from their sheath when required. They may be either single or double-bladed like lithotomy knives, which they resemble in this respect. The simple hysterotome invented by Simpson is one of the most useful. Those which are double-bladed are preferable in some circumstances, owing to the rapidity with which they allow of the operation being performed. Or short-bladed straight scissors may be used, Kiichenmeister has invented a pair, the external blade of which is furnished with a point which fixes it firmly in the uterine tissue ; others have blades with teeth like a saw to prevent hsemorrhage. As for myself, I prefer fixing the cervix by means of diverging tenaculum hook forceps introduced into its cavity and stretching the os so as to facilitate its incision to the required depth by a simple bistoury with a fine concealed blade, like that of Blandin. Sometimes simple division is not enough, it being impossible to preserve a sufficiently large opening without really perforaiiug autoplasty of the orifice. There is a great difference between division of the os externum and the os internum as regards the gravity of the operation. In performing the last great care must be taken not to pass beyond the uterine tissue. My reason for preferring the simple tenotomy knife or Simpson's hysterotome to the double- bladed one is that I generally make a superficial incision, dilating afterwards with sponge tents. It should always be remembered that this operation must never be performed at the menstrual period, or even within a week of the time. I shall simply refer, as a means of treatment, to dilatation of the cervix by bougies, stem pessaries, sponge tents, or other dilating bodies, about which I have already spoken in detail as means of diagnosis. METHODS OF TREATMENT AND MEDICATIONS 229 Punctures are generally made wit^. trocars of various forms, straight or bent, and of different sizes, from the exploratory trocar intended for capillary punctures in supposed abscesses of the Fallopian tube or peri-uterine abscesses to the large one with which an ovarian cyst is punctured, especially in ovariotomy, in order to hasten and facilitate the escape of the thick fluid often contained in it. These different kinds of trocars, as well as the apparatus annexed to them either for increasing the orifice in cases of hematocele or retro-uterine abscess or for retaining the walls of the cyst and preventing effusion of the fluid into the peritoneum during ovariotomy, will be described with each of these diseases and the operations which they necessitate. Deep injections, generally more injurious than useful unless simply detersive, are made into the various peri-uterine centres or into ovarian cysts, as into every other enclosed cavity, by means of a syringe fitted on to the canula of a trocar. I have sometimes been able with great advantage to substitute for these injections real lotions made with a double canula sound to which a small hydroclyse has been fixed. 7. The second class of these special operations comprises autoplastic and the more or less serious operations necessitated by the partial or total absence of the vulvo-uterine canal, the excision or amputation of the cervix, the ablation of polypi by ligature or bistoury, the reduction of displacements, the taxis for the reduction of uterine inversion, the extirpation of pediculated or interstitial fibromata, and, lastly, amputa- tion of the ovary and of the uterus — an operation revived in our times with great success.. The operations necessitated by extensive vaginal imperforations or obliterations are very serious, their success being very variable and depending on the conditions under which they are performed. Their great difficulty arises from the necessity of performing autoplasty of a canal without having a sufficient extent of mucous membrane. Hence the danger of encroaching on neighbouring organs (bladder or rectum) whilst making a way by incision, dilatation, tearing, &c., in the narrow space which separates them. Hence also the imperfection of the results obtained, owing to the impossibility of lining the new canal with true mucous membrane, at least to the extent required, whilst almost all the benefit of the operation is lost owing to the formation of retractile cicatricial tissue. Amputation of the cervix, indicated in cases of conicity, elongated hypertrophy, or incurable organic alteration of this segment of the uterus, is performed by means of long curved bistouries or scissors while the organ is pulled down ; in cases of hypertrophy of the supra- vaginal portion a long and troublesome dissection is required, necessi- tating great precautions against hsemorrhage. Consequently it is better, as a rule^ to perform the operation with the therino-cautery. The same remarks are applicable to the removal of polypi. To the methods already mentioned we may add avulsion and torsion for small vascular tumours, and the ligature, esi)ecially the elastic ligature, used as in former times to effect strangulation and slow detachment hy 230 TREATMENT OF UTEEINE DISEASES IN GENERAL sloughing. Later on we shall consider the respective indications for these different methods. The reduction of chronic uterine inversion and the extirpation of the tumour are operations of the most serious description, but fortu- nately are very seldom necessary. The extirpation of fibromata, although easy when the tumours are small, presents great difficulties in the contrary case, and has led to the invention of a most ingenious method of operation, consisting in the division of the tumour in situ, and the extraction of it in fragments. These extractions necessitate long forceps furnished with claws and instruments of prehension of various kinds, in the fadrication of which great perfection has been attained during the last few years. The increase in size of fibrous myomata may be an indication for the partial or total extirpation of the uterus by abdominal section. Lastly comes ovariotomy, the most serious of all these operations, so serious that it has not yet been generally adopted. The minute details necessary and the various rules laid down by the enterprising minds who have most frequently performed this conquest of modern surgery must be reserved till we come to the description of ovarian cysts and serious alterations of the uterus. Gynecological Apparatus My pupils have very frequently asked me to furnish a list of the in- struments most necessary for examining women affected with uterine diseases, for making the applications and performing the various operations which these diseases may necessitate. Now the instruments which serve in diagnosing diseases of women have the exceptional advantage pointed out by Barnes, viz. that of serving for treatment as well as for diagnosis. I divide gynecological instruments into three categories; 1. Those which the gynecologist ought always to have with him, i.e. those that are necessary for examination, for applica- tions, and even for unforeseen and extemporaneous performance of small operations. 2. Those which are often employed, but the use for which is neither unforeseen nor indispensable. 3. Lastly, those intended for performing more important operations, whether on the genital organs or on other parts of the body. The first class alone constitutes the gynecologist's apparatus. The second forms what I may call the special arsenal of the gynecologist. The third is what the gynecologist borrows from general surgery. 1. — The Gynecologist's Apparatus 1. Two sizes of Sims's speculum as modified by Courty, i. e. two blades with handles made to screw off and on. They have this great advantage, that they suffice for any ordinary diagnosis or application, whilst any other may possibly be useless owing to the narrowness of the vagina, the abnormal direction of the cervix, the presence of a tumour, &c. GYNiliOOLOGlCAL INSTRTTMENTS 231 2. One or two pairs of Courly's dressing forceps (one pair straight, one curved) with short blades and blunt points, equally suitable for making applications, seizing the pedicle of a tumour, holding a needle, a piece of sponge, &c. 8. A female catheter, and by preference a sigmoid catheter. 4. A uterine sound made to slide into its handle. 5. Two silver sounds perforated at the point, the other end being made to fit into a syringe. 6. Two fine india-rubber sounds of small calibre, also made to fit on to the syringe by means of a conical canula with a screw. 7. Blandin's long-bladed concealed bistoury. 8. Three pairs of long scissors with short pointed blades ; one pair straight, another curved, the third elbowed. 9. Convergent and sliding tenaculum hook forceps. 10. Divergent tenaculum hook forceps with catch. 11. Two fine cameFs hair brushes on long handles. 12. Two long canulas with movable piston, one an intra-uterine solid caustic holder, the other an ointment holder like those of Braun and Barnes. 13. Two of Eecamier's curettes, one narrow, one broad. 14. A small syringe for intra-uterine injections fitting on to the sounds. 15. A larger syringe for washing the cavity of the uterus before and after cauterisation. To this list of instruments I will add a short one of medicaments which the gynecologist will find it useful to have beside him ; — cold cream, glycerine, laudanum, tincture of iodine, perchloride of iron, a nitrate of silver point in a glass tube, powdered nitrate of silver in a glass stoppered bottle, chloride of zinc in crystals in a similar bottle, canquoin plaster, Eriar Comers red arsenical powder. I need not say that I have only mentioned the most necessary, passing over a very large number of most useful drugs, such as chlorate of potash, alum, tannin, &c. 2. — The Gynecologist's Special Arsenal 1. Collin's reflecting lamp with refracting glass. 2. The two large blades of my speculum. 3. Two of the same in wood, to be used when the potential or actual cautery is applied. 4. Cusco's folding bivalve speculum. 5. Three sizes of Ferguson's glass speculum. 6. Eolipyle spirit lamp with stand for cauteries. 7. Four cauteries for ignipuncture, the points and bulbs of varying sizes. 8. Three spear-shaped cauteries, one straight, the others more or less curved ; and one very )iarrow in the form of a knifp 9. Six prepared sponge tents of diff'erent sizes. 10. Four Courty's galvanic stem pessaries, diff^erent sizes. 11. Sims'^ bistoury with reversible blade. 232 TREATMENT OF UTERINE DISEASES IN GENERAL. 12. Three of Startin's hollow needles, one straight, one curved in the axis, and a third (Courty's) curved perpendicularly to the axis like that of Deschamps, all furnished with Mathieu's threader. 13. Long but fine forceps with short claws and catch, straight and elbowed. 14. Two long fine tenaculum hooks with handles, one single the other double, 15. A long blunt hook. 16. Two curettes, cutting the one on the convex (Sims^s), the other on the concave side (Courty^s). 17. A curette in the form of a button-hook (Coarty). 18. A long and fine serre-noeud for extemporaneous ligature^ and one very small for vascular tumours of the urethra. 19. Grooch's cauula as modified by Courty. 20. Naudinat^s large size }iydrocly8e, with straight tubes varying in length and thickness. 21. A supply of iron wire, silver wire, waxed thread, fine whipcord, india-rubber thread, fine india-rubber tubing, cotton w^ool, &c. 3. — Instruments common to the Gynecologist and the General Surgeon. 1. A set of bistouries with long handles and short blades, pointed or blunt, straight, curved on the flat, or elbowed at the level of the blade. 2. MacClintock's corkscrew or vice for ^emo^dng polypi ; Aveling's polyptribe ; Simpson's polypotome. 3. Very strong single or double tenaculum hooks open or concealed. 4. Chassaignac's radiating, convergent, or divergent tenaculum hooks, Courty's semi-tenaculum hooks of the same make. 5. Strong polypus forceps, straight or curved, with lock. 6. Museux's strong tenaculum hook forceps, some very concave, for seizing strong tumours (Robert's pattern), others sliding (Green- halgh's), others concealed, and springing out when required (Collin, Mathieu, &.C.). 7. Box of instruments for vesico- vaginal and recto- vaginal fistulse. 8. Ovariotomy box. 9. Straight and curved ecraseur, furnished with Emmet's adjuster or Aubry's metallic thread for holding the chain. 10. Paquelin's thermo- cautery, with Courty's ignipunctor and curved knife. 11. Galvano-cauterj, with wire and electric battery. CHAPTER III GENERAL CHARACTERISTICS OP UTERINE DISEASES — THEIR EREQTJENCY PREDISPOSING CAUSES — GENERAL AND LOCAL SYMPTOMS — COM- PLICATIONS — PROGNOSIS — CLASSIFICATION. Hitherto I have only considered the characteristics of uterine dis- eases with regard to diagnosis and therapeutic indications. Now I shall endeavour, by considering them in groups, as they sometimes occur naturally, to give, not perhaps a more exact, but a more com- plete view of them, showing their special characteristics, and consider- ing the degree and elements of their curability ; in short, pointing out the various forms they may assume, the natural divisions into which they may be classified, and the relative frequency and importance occupied by each of them. 1. The first characteristic of uterine diseases is their frequency. I have already refuted the opinion of those who assert that they were less frequent formerly than now. I have shown how it was that they escaped the notice of the ancients. Is it necessary to explain why we, with our means of exploration, encounter them so often? Could it be otherwise with an organ which everything seems to have conspired to make the point towards which all morbid phenomena naturally tend and the starting-point of almost all constitutional disorders. Its position exposes the uterus to constant pressure from the weight of the abdominal viscera, whilst the accomplishment of its functions necessitates not only a hypersemia like that produced in other organs but considerable and repeated sanguineous fluxions, serious nervous disturbance, complete change of tissue and more or less serious trau- matism, in a word, the natural phenomena of menstruation, coitus, pregnancy, delivery; in short, the uterus reacts constantly on all the organism, and all the organism reacts on it : propter solum uterum, mulier id est ciuod est. Now that we know the physiological import- ance of the ovaries and how closely they are connected with the uterus we can apply the same adage to them, admitting an equal frequency in the occurrence of ovarian disease. This frequency is so great that it often allows of our presuming the existence of uterine disease, which at the time may be only latent. When the cause of more or less serious general symptoms cannot be discovered, attention should be drawn to the genital economy and inves- tigations should accordingly be made in that direction. By inquiring into the circumstances which have a more or less considerable share in the production of uterine diseases, we shall at the same time account for their frequency and recognise the character assumed by them in their development. 234 UTERINE DISEASES 2. Many predisposing causes are known but very few determining causes. Uterine diseases are generally awakened by the slow and gradual changes produced in the vitality and structure of the organ under the latent and continuous influence of a diathesis; but we cannot always determine the causes which have originated them. After all, these are of no importance as far as treatment is concerned j whether they are due to a traumatism, to the effects of delivery or abortion, or to a reaction from some injurious impression, these are often only the accidental causes which may have put the match to the fire, but they have neither prepared it nor kept it up. Therefore, for all practical purposes, it is sufficient to consider the predisposing causes of these diseases, local as well as general. The predisjiosing local causes, which depend on anatomical and physiological conditions peculiar to the uterus, explain not only the frequency of the diseases of this organ, but the relatively greater frequency of some of them, the favorite seat of others, &c. Thus the dependent situation of the uterus accounts for the frequency with which it is congested and engorged, as well as for the difficulty experienced in effecting a cure. The multiplicity of its means of sus- pension and the change which they undergo in the accomplishment of functions (pregnancy, delivery, &c.) are the natural causes of various displacements of the uterus and often of its engorgement. Its con- nections with the bladder, the rectum and the pelvis with the cellular tissue which fills it and the peritoneal folds lining it, explain the influence which may be exercised by these neighbouring organs on the uterus, and vice versa. The various phases of development dispose the uterus to disease in one part more than another. The precocious development of the cervix renders the cervical cavity liable to catarrh even before puberty. The later preponderance of the body explains the frequency of disease of this organ in the adult. Arrested development may suffice to cause a decided flexion, especially anteflexion, which is only the per- sistency of the fcetal condition. Even it.s structure involves a tendency in the organ to certain morbid conditions. The predominance of fibro-muscular tissue disposes the uterus to general or partial hypertrophy, to fibromata, polypi, &c. The richness ot the vascular element and the activity of its circulation dispose it to acute or chronic inflammation, complete or partial, primitive or con- secutive. The absence or rarity of cellular tissue explains the rarity of suppuration, apart from interstitial phlegmons, in the non-puerperal state. The ovary, containing more cellular tissue and an almost infinite number of little vesicles, destined to become Graafian vesicles, is on that account infinitely more liable than the uterus to be affected with suppuration, and to contain purulent, phlegmonous, or cystic cavities. The presence of a mucous membrane, rich in vessels and in glands, disposes the uterus to discharges and catarrhal affections. The mucous membrane of the cervix, and especially that of the os externum, like all other natural orifices, as Tyler Smith, Bernutz and others have pointed oul, may be the special seat of various eruptions, herpetic, GENERAL CHARACTERISTICS 235 syphilitic^ ulcerous, &c. The serous peritoneal fold which covers the greater part of the external surface of the womb exposes this organ to serous inflammations and their consequences, gives to peri-uterine in- flammation the special characteristics which often distinguish it, and is the frequent cause of the formation of adhesions and fibro-cellular bands between the different parts of the uterine system, between the ovaries and the Fallopian tubes, and between the Fallopian tubes and the uterus, &c., which suspend temporarily or definitively the accom- phshment of their functions, dispose to phlegmons, or keep up the irritation which favours the persistence of inflammatory centres. The continuity of the mucous membrane of the uterus and Fallopian tubes with the peritoneal serous membrane at the ostium Mtemmm tends to propagate the inflammation of this mucous membrane to the peritoneum, and consequently to increase the evil considerably. This propagation may take place, whether the inflammation be spontaneous or provoked, and this consideration ought to put us on our guard against the consequences which may result from caustic uterine injections, even where they do not penetrate into the peritoneal cavity. The vascular activity of the uterine system, with the periodic fluxions which take place in it, expose the whole or various portions of this system to sudden and violent sanguineous fluxions, to consequent congestions, to hpemorrhages internal, external, interstitial or apo- plectic; to hypertrophies, total, partial or histogenetic ; to ovarian products, especially to the most frequent of all, multilocular cysts. The periodic repetition of these fluxionary movements at the men- strual period and their return during pregnancy, as well as during uterine diseases, dispose the organ to fluxions, congestions, and to the pains resulting from this plethora of the vascular system, and lastly, to the persistence of these morbid states if critical evacuations do not take place. It is at the climacteric especially that this state of uterine hypersemia is developed as the result of persistent congestion unrelieved by any critical evacuations, and this condition not only constitutes a disease in itself, but may produce many kinds of diseases, especially of a diathetic nature. Sexual relations have an undoubted influence on the development and perpetuation of uterine diseases. This influence, however, has been exaggerated; it is not responsible for all the diseases attributed to it. West, for example, seems to attribute to coition imperfectly performed an exaggerated influence on the development of certain uterine maladies. It is nevertheless certain that marital intercourse not only may produce disease but keep it up. As to the part which it may have in the production of disease, it is evident that excesses may determine permanent congestion, and may even develop complete or partial metritis, followed later by leucorrhcea, granulations, &c. There is also no doubt that although coition may sometimes be practised at the menstrual period with impunity, such imprudence has often caused congestions, more or less serious inflammations and, what 236 UTEEINE DISEASES is much more dangerous, sudden suppression of the sanguineous dis- charge with internal haemorrhage of a formidable nature, such as retro- uterine or peri-uterine hematocele. Generally, however, sexual intercourse acts less frequently in pro- ducing than in perpetuating uterine disease. In special circumstances a diathesis may become localised in the uterus from the first sexual ex- citement. As a rule, however, it is not during the first years of marriage that the greatest number of uterine diseases are developed, but only after disorders of menstruation, pregnancy, abortion and labour. In such cases coitus is neither the original nor secondary cause of the disease; but it keeps it up, prolongs and aggravates it ; T have occasion to observe this every clay with regard to uterine congestion. It even causes relapses after a cure has been eff"ected, therefore under certain circumstances we cannot be too particular in forbidding it. Pregnancy and labour are beyond all doubt the most frequent causes of the development of uterine disease. They act in two ways : as predis- posing causes by the important modifications imparted to the organic structure, and as exciting causes by the traumatism which they produce. Aran classes two-thirds of all utero-ovarian disease as the results of pregnancy, labour and abortion, one-fourth as occurring in women who have had children, and one-tenth only among virgins and nuUi- parse. Pregnancy congests the uterus, imparting to it a violet hue ; it increases the capacity of its vascular, and especially of its venous system. It hypertrophies its tissue; in short, it determines the in- crease, the fall and the renewal of its mucous membrane, so that when the organ is freed from the product of conception it is in the most favorable circumstances for becoming, or rather for remaining, diseased, for this state of hypertrophy, however shortly prolonged after the ex- pulsion of the foetus, is a real disease. Labour acts as a real traumatism, owing to the mechanical lesions which it produces — the contusion and lacerations of the cervix, the bleeding wound resulting from the detach- ment of the placenta, the local and general reaction which follow, the uterine and peri-uterine inflammation which may be developed, the coincident traumatic fever with the suppuration and gangrene which are sometimes the results of this inflammation and which we may say are only developed in this single case of uterine disease. The results of labour have no less influence on the development of diseases of the womb. Tlie least complicated morbid condition which may result is the persistence of uterine hypertrophy characteristic of pregnancy, owing to defective retrograde evolution of this viscus. It is diflicult to determine the true causes of this defective involution, but it is pro- bable that they do not difl'er from those which produce other diseases resulting from labour, such as rising too soon, physical fatigue, resuming marital intercourse prematurely, &c. After abortion the uterus is even more disposed to become diseased than after delivery at the full period ; not to acute inflammations, suppuration, gangrene, &c., but to congestion, engorgement and hypertrophy, especially to the hypertrophy referred to as due to defec- tive involution. It seems that when the uterus has not passed through GENERAL CHARACTERISTICS 237 the various phases of progressive evolution which ought to be com- pleted between conception and parturition, the phenomena of natural involution is more difficult than after delivery at full term, and that it is more apt to be arrested. The elements of muscular tissue as well as those of the mucous membrane, when suddenly arrested half M^ay when in full activity of development, have no tendency to pass through the modifications of atrophy, fatty degeneration and retro- gression which characterise involution ; in place of returning rapidly and completely to the normal dimensions of the unimpregnated uterus, they preserve the volume and structure appropriate to gestation, which predispose them to all kinds of morbid alterations. If, then, pregnancy, labour and abortion have so much influence on the development of uterine diseases, what must the result be of cases of pregnancy rapidly succeeding one another, which leave the uterus no time to return to its normal condition and hinder the natural work of absorption of the gestative hypertrophy, and which, by keeping the organ in a state of congestion, expose it to the invasion of diatheses ? And yet I must admit that I have known several women in whom the rapid succession of pregnancies (eight or ten in twelve or fifteen years) has not produced the development of any uterine disease, which is one of the most striking proofs of the large share which general affections have in the constitution of diseases of the generative system. In others I have observed a local fatigue produced by the persistence of the tumefaction of this organ, and general consumption due to the impoverishment of blood caused by this continual return of gestation. I have therefore concluded that the development of uterine disease in these women was due rather to the localisation of a diathesis than to the number of pregnancies, which seemed merely to have played the part of exciting cause. The neglect of lactation is not without its influence in impeding the process of involution, and consequently in the development of uterine diseases. The considerable and continuous fluxion which lactation keeps up in the breasts probably diverts the fluxionary move- ments from the uterus, and therefore helps to dissipate congestion and engorgement. Lactation is also useful by preventing menstruation, with the fluxion and congestion accompanying it, from coming to add their influence to that of defective involution. It also prevents the premature return of pregnancy and therefore hinders the production of the morbid tendency just pointed out as the consequence of a rapid succession of pregnancies. Investigations made on this subject by Scanzoni show that out of 196 children born at full time of 5-i women suffering from uterine affections only 57 had been suckled by their mothers, whilst Aran^ tells us that out of 100 women aft'ected with diseases of the womb 70 of them had never suckled. Sterility may preserve women from many uterine diseases, but it does not guarantee them from others, especially from those which are dependent on the development and localisation of diathetic affections. Its influence is all the more liable to pass unobserved that when we ' Op. cit., p. 93. 238 UTERINE DISEASES encounter it accompanied with uterine disease it is not the sterility which has caused the disease^ but the disease which has caused the sterility. \Yith regard to this matter we cannot be too careful to trace the cause of uterine diseases to their first beginning and to the general and local conditions which may keep them up, for in removing them we may be able to cure the disease as well as the sterility. Sterility and celibacy can only be classed together with regard to absence of gestation. They differ entirely in other respects. In sterility the uterus has undergone the excitement of coitus, whilst the absence of this cause in celibacy seems to diminish the chances of the development of uterine diseases. Whether that be so or not, I will sum up my opinion on this point by saying that, with the exception of certain menstrual disturbances and the general disorders dependent on defective function, celibacy does not seem to me to predispose to diseases of the uterus ; but it does not prevent them, I have seen old maiden ladies die of cancer of the womb. As for sterility, it has seemed to me oftener to be the effect than the cause of disease. In short, in considering the whole of the utero-ovarian system, we see that the diseases of one part of this system may become the causes of disease in the other part, sometimes predisposing, sometimes exciting causes. The community of functions involves a community of morbid susceptibilities. The same links often unite these various organs with regard to pathology as well as physiology. Numerous examples testify to the reciprocal action which diseases of the ovaries and Fal- lopian tubes exercise on the uterus, and vice versa. The covering of all these organs by the same serous membrane is an additional element in favour of this reciprocity of action. Inflammation is propagated by the peritoneum from the uterus to the Fallopian tube and to the ovary, more frequently still in the contrary direction. The adhesions, the membranous bands which form pathological connections between these different organs, are not without their influence ; whether in imposing abnormal conditions in the performance of menstruation, or in favour- ing the escape of the ovum into the peritoneum in place of directing it into the Fallopian tube, they prepare the way for real morbid conditions. We know very little with regard to the influence which diseases of the bladder and rectum have on the development of uterine diseases. It is the same respecting the influence exercised by diseases of the mammary glands. Our knowledge is still less advanced with regard to the possible influence suggested by Aran of diseases of the stomach and liver, heart and lungs, in the production of these morbid conditions. As for the predisposing general causes, the circumstances which have more or less direct part in uterine pathogeny, are : age, tempera- ment, constitution, and especially diathetic affections and confirmed diseases. The age at which the greatest number of diseases of the womb has been observed is certainly that of sexual activity — the age when the generative functions are performed with most activity, when coitus is GENERAL CHARAOTERISTICS 239 most frequent, pregnancies most numerous. In 300 cases of metritis Nonat^ observed 155 between twenty and thirty years. Aran/ in 100 cases of uterine diseases, had 62 in women between twenty-one and thirty years. That does not mean that uterine disease may not be developed at other ages from childhood to old age. It is, however, exceptional, and even the exception may be remarked by its preference for certain kinds of these diseases and for certain organs of the genital economy. Thus we often see vaginal leucorrhcea in children. I have seen a child before puberty who had the uterine cavity and the external half of the Fallopian tubes filled with a cheesy substance formed of condensed epithelial cells, showing the existence of serious disease. I have seen an ovarian cyst in a little girl of eleven who had never men- struated. Uterine cancer is not rare in the last period of the life of woman, at least after the menopause. In short, every age has, so to say, its special predispositions. When we meet with disease of the womb in a child it affects the cervix, which at this age is much more developed than the body. After puberty and before coitus it is the body which is most frequently affected. After pregnancy both segments of the organ may be equally affected. Virginity does not exempt the young girl from uterine diseases. Bennet, Aran and others have made the same observation. They are liable specially to fluxion, congestion, leucorrhcea, uterine catarrh, and even to metritis, but less so than married women, especially women who have had children. The starting-point of these diseases is gene- rally some disorder of menstruation, the predisposing cause being a catarrhal or rheumatic affection, or a scrofulous or herpetic diathesis. Diseases of the body, especially of its mucous membrane, uterine catarrh, and leucorrhcea, are more common than diseases of the cervix amongst virgins. Diseases of the cervix, especially ulcerations and granulations, although sometimes met with in young girls, are much more frequent in married women, and especially in multiparse, in whom the cervix has been exposed to the contusions incidental to excessive intercourse, to the softening of pregnancy, and the lacerations of labour. After the menopause, uterine diseases, besides being rare, may exist for a long time without causing much pain or producing sympathetic disorders ; in fact they may remain latent for an indefinite time. We know nothing, at least nothing positive, as to the influence which mode of life, habit, residence in town or country, may exercise on the development of these affections. Whilst admitting that different modes of life exercise various kinds of influence, I cannot say that one leads more frequently to disease than another. Women of weak constitution and lymphatic temperament are certainly more exposed than others. They are especially exposed to the protraction of the disease owing to their defective reaction and to the predisposi- tion which they have to general debility, and to cachexia which in them more than in other women are the rapid consequences of the impression produced by the morbid condition on the organism. Heredity may ' Op. cit., p. 59. ^ Op. cit., p. 99. 240 UTEEINE DISEASES have some influence, especially in such diseases as cancer, I have seen a few examples of this kind. I have also observed the same kind of granulations and leucorrhoea in mother and daughter. It must, however, be admitted that direct hereditary influence is not frequent, nor is it clearly proved to exist. It is not so^ however, with the various diatheses and all general affections, which undoubtedly play a considerable part in the existence of diseases of the womb. Some authors, such as Pidoux, whose ideas seem to have inspired Tillot's^ thesis, exaggerate this influence by invariably attributing to diathetic affections the chief place in the etiology of uterine diseases. It is evident that the uterus, owing to its position, structure and functions, is not only exposed to the localisa- tion of the various diatheses, but has of itself a tendency to originate cbronic disease. We cannot, therefore, admit that in the majority of cases uterine lesions are only secondary symptoms occurring under the influence of a general state, nor that the lesion is in the uterus and the disease in the organism. The lesion is evidently the cause of all the suff'erings of the women. Whether, led by experience, we admit the multiplicity and diversity of these lesions, or whether with Lisfranc we give the predominance to engorgement, or with Yelpeau to de- viations and granulations, with Dubois to catarrhal phlegmasia, or with Bennet to metritis, we cannot possibly allow that the serious change which this lesion produces in the vitality of the uterus is not the dis- ease properly so called, and consequently the cause of all the symptoms, general and local ; nor can we admit with Pidoux" that from a physio- logical point of view the uterus and its annexes are only the centre of the general changes which characterise women from the time of puberty, and not the cause of them. Uterine lesions, whether acute or chronic, whether connected with a diathesis or not — whether they be functional, organic, or due to displacement — are really diseases characterised by their own symp- toms requiring direct treatment. Whilst willing to admit that the diatheses have a considerable share in producing them — a much greater share than the local conditions just enumerated — I cannot agree with those who think their influence exclusive. There is no chronic uterine disease that is entirely free from the influence of some diathesis. We cannot even make an absolute excep- tion of deviations and displacements, as Bund pointed out in a paper read before the Academy of Medicine in 1849. Thus, supposing that fluxion, congestion, chronic inflammation, hypertrophy may exist independently of a diathetic affection, it is not the less certain that these morbid conditions are in some degree under its influence. As for engorgements, leucorrhoea, granulations, ulcers, cancers, &c., they are almost always dependent on a diathesis or a general condition not less real. The knowledge of this diathesis, by enabling the physician to make ' De la lesion, et de la maladie dans les affections chroniques du systeme utSrin. These de Paiis, .32, 1860. * Lettre sur la fievre puerperale, 1854. GENERAL CHABACTEIIISTIOS 241 a general diagnosis, often facilitates the local one. If we have pre- viously discovered or if we recognise the actual existence of a marked diathetic condition, we may suspect it of being the cause of the evil. On the other hand we must beware of the tendency, which was too common with the ancients, of attributing the lesion to a constitu- tional taint of herpes, syphilis, scrofula or tubercle, and of com- mitting Lisfranc^s error of mistaking for tubercle some quite different cervical lesion. Three orders of facts prove, in my opinion, that the diatheses have a more or less important share in the existence of uterine diseases, and that we ought to take them into account. Firstly, the coexistence or simultaneous manifestations of these diathetic conditions in the uterus and in other organs. Thus, we not unfrequently see uterine leucorrhcea associated with vesical or intes- tinal catarrh, sometimes even with bronchial catarrh ; eruptions or ulcerations on the cervix with herpes on the vulva, anus and other parts of the body, especially on the other natural orifices ; a more or less painful but mobile congestion or engorgement of the uterus with rheu- matism or erratic pains in the limbs, even visceral pains having pre- viously manifested themselves in the same patient in other circum- stances; an engorgement, granulations, ulcers on the cervix, with scrofulous symptoms, glandular swellings, ulcers, impetigo, &c., on other parts of the body. These coincidences are even more frequent in syphilis. They may also be seen in tuberculosis, cancer, &c. Secondly, the alternation between the manifestation and especially the exacerbation of the uterine disease and the localisation of a dia- thesis on another point. This phenomenon is observed especially in affections the seat of which is variable and mobile, like gout, rheuma- tism, catarrh and herpes. Just as in a man I have seen the dartrous diathesis localised successively on the glans, urethra, prostate, bladder, ureter and kidney, so in a woman I have seen the vulva, vagina, cervix, uterus, Fallopian tube, or ovary attacked simultaneously, suc- cessively, or alternately, by the same disease. We know that several cases have been reported lately of ovaritis following on blenorrhagia, vaginitis or metritis, just as orchitis may foUow urethral blenorrhagia in man. I have seen some remarkable cases of rheumatism associated with pain and swelling ; of neuralgia depending probably on the same cause, and attacking alternately the uterus, ovary, or some other viscus, such as the bladder, the stomach, or the articulations, the nerves, fibrous tissue, aponeuroses, or lymphatic ganglia. Thirdly, the proof given by treatment, a sure test of the nature of disease. How many diseases there are, apparently simply inflammatory, which have been lessened by the application of leeches, rest, baths and all the other means of antiphlogistic treatment, but which have only been cured by mineral waters, hydropathy and specific treatment appropriate to the character of the evil ! The diatheses which have the greatest share in the etiology of chronic diseases of the uterus may be either hereditary or acquired. There is no utility in distinguishing them nor i)\ separating thein from 16 242 UTERINE DISEASES other general states of the organism which may have a similar influence on uterine diseases. We may, therefore, class in this category all spontaneous blood disorders, of which the most frequent type is chlorosis, which plays so important a part in female pathology. Chlorosis may exist already in a woman attacked with a uterine disease. It may even be the cause of this disease. When, however, the latter is developed the chlorosis generally becomes more marked. In some cases it is consecutive to the lesion which was primarily pro- duced by a diathesis. Deglobulisation of the blood, whether it be anterior, concomitant or consecutive to the disease, whether it be cause, effect or simple coincidence, does not the less frequently accom- pany the majority of uterine diseases.^ 3. The nature of uterine diseases, — Most frequently the diatheses have not been the exciting cause of the disease ; but after the malady is established they keep it up and really give it its character. The malady would not continue to exist without them ; and it would be impossible to cure it without curing them, or at least without greatly modifying them. After the diatheses an important part must be allowed in the pro- duction and chronicity — that is to say, in the nature and character of uterine diseases, to the vitality of the uterus, or rather to its mode of vitality, to the elementary physiological acts which are necessary to the accomplishment of its functions, to the facility with which it under- goes great changes and remarkable alterations in its structure and in its tissues. Undoubtedly the majority of our organs have in the accomplishment of their functions a continuity of action which would seem to make them more liable even than the uterus to the develop- ment of chronic diseases. But they do not undergo such great changes as this viscus does in regard to the innervation, circulation and change of tissue of the organ. It is just because of the extent of the oscillations, the return of these periodical acts, the temporary and exceptional activity of nutrition, that the uterus is more liable to become diseased than any other organ. Among the elementary physiological acts which are connected most frequently with the production and aggravation of uterine diseases, we must place in the first rank those which contribute to the accomplish- ment of menstruation, i. e. fluxion, congestion and the critical evacua- tion of blood. These acts occur in almost every uterine disease as cause or complication. The physician can rarely utilise them. He has to frustrate their influence, moderate their manifestation, combat their effects. These three acts, as we shall afterwards see, govern each other mutually : the energy of the fluxion increases the intensity of the congestion, and consequently the amount of the evacuation. When the balance between these three essential elements of the menstrual function is disturbed disease breaks out. ' Wc may include ainoiis blood disorders those produced by general miasma- tic poisoning. Paulin iXipuj', Essai clmiquc stir quclqucs troubles d'origine paludecnne dans Ics fonctions gcnitales de la fcmme. These de Montpellier, 1879. GENEItAL OHARAOTEBISTIGS 243 Fluxion is not only a powerful cause in the production of uterine diseases, it not only prepares the way for congestion, determines ha3niorrhagc, favours lluxion, aids hypertrophy, keeps up engorgement, furnishes to inflammation its natural element, but it hinders treatment, prolongs the disease by the periodicity of its return, increases it often by its intensity, and, in short, plays the principal part in the relapses which too frequently follow on apparent cure. Aran tells us that congestion ought to be considered under two aspects in uterine patho- logy : sometimes it is connected with an actually existing disease of the uterine system, of which it is a complication, aggravating or pre- cipitating its progress, retarding or hindering its cure ; sometimes it exists alone ; sometimes it facilitates the development of new affections. It constitutes, strictly speaking, an element in uterine disease, and becomes a source of therapeutical indications. The capital indication in fact itself includes two other indications : — 1, to diminish the con- gestive condition at the menstrual period ; 2, to subdue the congestive condition which persists after any period till the appearance of the next. The sanguineous discharge may be either defective or excessive. If excessive it constitutes a disease (menorrhagia) ; if defective it pre- vents the natural crisis from taking place, and leaves the uterus con- gested, as a result of which we may have all the ills which I have just pointed out in speaking of congestion. The physiological acts which take place in the uterus at every menstrual period are produced with much greater intensity at every pregnancy. Only here the fluxion and congestion of the organ are continuous, with the exception of some augmentation at the periods corresponding to the menstrual epochs. The sanguineous discharge, haemorrhage, depletion of the congested organ only occur after delivery. In fact, great changes are effected in the tissue of the womb, and are added as new causes of disease. I do not speak only of the changes of tissue which are produced by gestation, but also of those which are effected by the return of the organ to the state of vacuity. To the physiological hypertrophy of pregnancy succeeds the physiological atrophy of retrograde evolution. To this we must add the renovation of the mucous membrane, so characteristic of uterine life, that it is produced not only after gestation but sometimes after menstruation alone. The structure of the uterus is in accordance with its special func- tions. Its tissue is characterised by the presence of fibro-plastic elements, hence its continual tendency to hypertrophy. This tissue is in constant process of organisation, becoming hypertrophied by preg- nancy, atrophied after delivery, in order to bring the organ back to its normal dimensions ; in place of the stability characteristic of the other tissues, it has a continual instability, an incessant tendency to increase and decrease. This tendency is indicated by the presence, especially in the mucous membrane, of the organising element (the fibro-plastic element), and is coincident with analogous physiological tendencies, the habit of fluxionary movement, alternating congestion and deple- tion, &c. 244. UTERINE DISEASES Now, jluxlonary, plastic and hi/pertrophic tendencies cliaracterise the majority of uterine diseases as they characterise the functions of the organ. Fluxion, plastic exuberance, hypertrophy, may be exhibited in all the elements at once or only in some of them ; hence the fre- quency of engorcfements, congestions, fluxes, tumours or homologous productions of all kinds. Localised on the mucous membrane, very limited in extent, spreading to the most superficial part of the papillte of the dermis, to its vessels, and to the epidermis covering it, this hypertrophy gives birth to the granulations so frequently found in the cervix. This same hypertrophy, spreading to the healthy granula- tions of an ulcer, at the moment when the work of cicatrisation brings into play a more or less energetic increase of plastic action, produces granular fungosities more frequently there than anywhere else. When concentrated in the organs of secretion, it develops tumours, cysts, and follicular polypi. Localised on the tissue proper, on its elements generally, it gives rise to hypertrophy properly so called ; this hyper- trophy may extend to the whole uterus, or be limited to the body or to the neck, or even to one segment of the neck or body, to one of the walls of the latter, or to one of the lips of the former. When limited to certain elements it produces vascular tumours, fibromata, or polypi. Hypertrophy, besides being more common in the uterus than in any other organ, has the tendency to spread exclusively to one or other of the tissues composing the womb, and to a limited region of that organ. In this way the uterus remains increased in size owing to defective in- volution after delivery ; it continues to increase if deviated or flexed, and prolapsus is sufficient to double its volume. On the other hand, its mucous membrane in certain menstrual disorders undergoes an accidental hypertrophy and exfoliation, the cervix becomes the seat of general or polypoid excrescences, the follicles form glandular polypi or cysts, the tissue proper produces fibrous tumours, &c. Thus, by its structure, by its functions and the elementary acts which preside over their performance, the uterus differs from all other organs, in being in constant process of organisation, always liable to change of volume and structure. Iiistahility is its special charac- teristic. In its tissue the equilibrium established between the nutri- tive movements of composition and decomposition, assimilation and disassirailation is not stable as in the other tissues ; it is an unstable or momentary equilibrium. At the first impulse, it is disturbed and falls to the one side or to the other. This tendency to adapt itself to the part which it has to play in menstruation, conception, pregnancy and delivery it retains in all circumstances which place it in somewhat analogous conditions. Whether its cavity be filled by mucus, blood, or other fluid, or by a solid body like a polypus; whether a tumour such as a fibroma is developed in the inter.-itices of its tissue, or a foreign body, external or internal, is introduced within its orifices, iluxion is determined, the uterus becomes congested, hy- pertrophies and contracts in order to expel the tumour or foreign body, then returns to its normal condition, loses its hypertrophic elements. GENERAL ( 11 ARACTEEISTIOS • 245 repairs its mucous membrane ; in short, it passes from the state of vacuity to a condition similar to that of gestation, once more returning to that of vacuity. These curious, we may say unique ])roperties of the uterine tissue seem to me to place in our hands the key to a mass of physiological, pathological, therapeutical phenomena, which can be utilised for the knowledge and treatment of uterine diseases. These properties evi- dently play a great part in the production of the latter ; and it is also important to consider them again with regard to the form and course which they give to these diseases, and consequently the charac- teristic symptoms which they often communicate, such as hyper- trophy, painful contractions, uterine colics, dilatation of the cervix, &c. &c. 4. The kfiowledge of these properties {and especially the instability) of the uterine tissxie is important in relation to the cure, which they may either hinder or facilitate according to the manner in which they are utilised by the physician in his treatment of the disease. Hence the indication for action. Lornet induced hypertrophy as Simpson did by means of metallic stem pessaries ; sometimes he pro- voked dilatation of the cervix by the introduction of foreign bodies, which develop uterine contractions and so facilitate the expulsion of a polypus, the enucleation of a fibroid ; sometimes he compressed the in- troverted uterus by means of an air pessary, as Tyler Smith did, to provoke simultaneously a dilatation in the neck and a contraction in the body, both alike promoting reduction. Hence also the indication for action in the opposite direction, using means to overcome morbid hypertrophy, by placing the organ under the same conditions as when it spontaneously undergoes retrograde evolution after delivery. Hence the innocuity of intra-uterine cauterisation with the crayon when there is abundant leucorrhoea or considerable granular fungosities ; for the mucous membrane is not affected, or it is easily repaired at the points which may appear to have been too much acted on by the caustic. Hence the innocuity of the actual cautery applied to the cervix or to its tissue ; for its mucous membrane, even if severely affected, which is not often the case, has a manifest tendency towards regeneration. Hence also the resolution induced by these cauterisations in chronic congestion, engorgement and hypertrophy, by promoting absorption and by giving an impetus to nutrition in that direction. I shall not dwell longer on the tendency to hypertrophy, the plastic exuberance, the faculty of regeneration, which characterise the uterus anatomically, physiologically and pathologically. I shall have occasion to recur to it throughout this work when speaking of membranous dysmenorrhoea, granulations, fungosities, vegetations, follicular hyper- trophy, follicular tumours and polypi, uterine heemorrhoidal tumours, partial hypertrophies of the mucous membrane, hypertrophies of the tissue of the body, and of the cervix, fibroma, subperitoneal fibroma, sarcomatous polypi, &c. I must, however, remark that this tendency to vegetation is not limited to the uterine tissue. There is the same tendency in the Eal- 246 UTERINE DISEASES lopian tubes and in the ovaries, especially under a cystic form in har- mony with their structure. The same tendency is to be found in the vagina and vulva, with regard to which I shall point out some facts not generally known, showing that the vagina shares the hypertrophic tendencies of the uterus. Tor the present 1 shall only remark that the hypertrophic tendency shown in the highest degree in the mucous membrane, and in the muscular tissue of the uterus and in ovarian cystic formations, may be propagated successively to all the other parts of the generative economy, or separately to the various tissues which enter into their composition, either by simple extension, by participa- tion in a great increase of physiological activity, or by community of morbid influences. I think I have given a sufficiently detailed description of the general and local circumstances presiding over the development of uterine diseases to characterise these diseases sufficiently from this point of view. Several of the characteristics which remain to be described are simply deduced from these circumstances ; for undoubtedly till we reach them we cannot penetrate to the true nature of the diseases in question. 5. Uterine diseases invariably have a double morbid nature, general and local. I cannot share the opinion of Aran/ who thinks that the differences between the various morbid states are gradually effaced, and that after a certain time, in place of the original disease, we have to contend with a number of local and general symptoms, requiring, according to circumstances, the most varied treatment. Uterine dis- eases always preserve their twofold character ; as diseases of the womb, they often differ from all other organic disease ; as diathetic diseases they have more or less in common with other general affections. They have also a double set of symptoms : local symptoms, dependent on the sensibility and vitality special to the uterus ; and general sym- ptoms, dependent on the diathetic affection or on the sympathetic reaction excited in the organism by the local lesion. Uterine diseases may assume different forms according to the manner in which these symptoms present themselves. In this respect, groups of symptoms, whilst offering infinite varieties in the mode of associa- tion, nevertheless present themselves under two principal forms, which ought always to be present to the mind of the physician that he may be on his guard against errors of diagnosis : in one, local, in the other, general phenomena predominate. The form most easily diagnosed is evidently that in which there is a predominance of local symptoms. These are symptoms always linked together in a somewhat similar way. Pirst, hypogastric pains in- creased by exercise, fatigue, constipation and the approach of the menses, and localised often in the left iliac region. Lumbar, inguinal and femoral pain occur afterwards. Leucorrhoca and menstrual dis- orders sometimes appear very early, at the commencement of the disease with the hypogastric pains, or they may gradually follow these ' Op. cit., p. in;». GENERAL CHARACTERISTICS 217 first local symptoms. It is evident that uterine disease arising in this way cannot fail to strike the patient and to be diagnosed by the physician, especially if these local symptoms become more and more marked, if the hypogastric pains assume the character of colics, if the persistence or exacerbation of pain in the left iliac region draw the attention to the appendages, and especially if vesical tenesmus and con- stipation are added to the uterine symptoms properly so called. Very often, however, uterine diseases, in place of betraying their presence in a way likely to attract attention, remain undiscovered for a longer or shorter time owing to the obscurity, or it may be the complete absence of all local symptoms. In such a case the cry of the suifering organ does not come from the uterus, but from the whole organism. It is the result of the influence invariably exercised by the womb on the whole economy and the sympathetic reaction stirred up by the apparently insignificant disorders of this organ. Every time that a change takes place in the womb, that its functions are modified by puberty, menstruation, conception, pregnancy, the menopause, or that its vitality is impaired or its structure affected by some malady, the harmony of the whole system is disturbed. More than any other organ it is liable to disease, and more than any other organ it reacts on the whole economy. The second form, with, pi'edotfiinafice of general sijmptotm may be so marked as completely to efface all local phenomena. We can easily understand how the sole existence of general symptoms modifies the symptomatic expression of a local malady, deceiving the patient as to the seat of disease and leading the physician astray in his investiga- tions unless he is on his guard. I have already said that these sym- ptoms in order of frequency are : dyspepsia in every form and degree, with its inevitable result defective nutrition, emaciation, decline, de- globulisation of the blood, discoloration of the skin and mucous mem- brane, palpitations of the heart, feeling of suffocation, cough and nervous symptoms of various kinds. In most cases local symptoms are not entirely wanting, but they are insignificant and intermittent and tolerated by the patient from habit, or from energy of character, or her attention may not be attracted to them owing to their vague character. They must therefore be discovered by the physician. It is surprising what characteristic symptoms pass unnoticed by patients unless we are particular in our inquiries. This is the case with leu- corrhcea; many women think it is almost a normal phenomenon, especially if they have been chlorotic in their youth and the white dis- charge has replaced the sanguineous one, or if the leucorrhoca precedes i or follows the menstrual hfemorrhage and is not abundant. Now, it Lw<^ cannot be too distinctly stated that normally there is no white nor j transparent discharge, and that when such exists, whatever may be ' the general or local cause, it ought necessarily to suggest the idea of a genital malady, and that functional disturbance of the digestive organs is not sufficient to cause it; in fact it is not the dyspepsia which pro- duces the leucorrhoea, but the leucorrha3a which causes the dyspepsia. When the malady presents itself under this form, with predominance 248 UTERINE DISEASES of general symptoms, it rarely happens that certain characters of these A^ery symptoms do not lead the physician into the right track ; such are the coexistence of nervous phenomena in the lower limbs, nervous cough, facie,<< uter'ma and hysterical symptoms, especially a feeling of faintness felt by the patient when standing. It is remarkable, as I have already said, that between these two forms there is another in whicli local and general symptoms are con- cealed by a morbid increase of flesh, which gives the patient a fictitious look of health, although there is very real and sometimes very acute general suffering and local pain. I have seen several cases of this kind where the commencement of the malady was mistaken for pregnancy. 6 . The complexity of symptoms more or less vagne seems to characterise certain morbid conditions of the womb. Uterine maladies differ in character not only by the predominance of general or local symptoms, but also by the presence or absence of a certain symptom characteristic of a certain morbid condition. Sometimes the morbid state is easily determined ; it is accompanied by a certain acuteness ; its characters are well defined, its symptoms have one meaning. Sometimes after a certain period, the acute feature having entirely disappeared, the primitive form gives place to a congestive condition accompanied by several concomitant disturbances, each of which is insufficient to characterise a malady, but which taken together are serious enough, and yet there is no symptom predominant enough to indicate to the physician the dominating element of tliis morbid condition, the one with which treatment should commence. It. is this condition to which Pidoux has given the name of Dysmetria. I know that these complex and half-eff'aced morbid conditions are not described in uterine pathology, but they exist in practice. In such cases we must attack the various elements of the disease successively, at the risk of being accused of merely treating symptoms ; we often end by simplifying the malady and discovering the true starting point of the chief troubles. I admit that complexity is not special to uterine diseases more than to those of other organs, but it must be taken into account in making the diagnosis. Amongst all these associated morbid elements we must distinguish those which, although blended in one disease in the same organ, yet merit the name of complex diseases, from others which, by remaining always distinct, even when they spread to portions of the same economy, ought to be designated under the name of complications. 7. Theco7nplicationsof uterine diseases are variable. They are not only the sympathetic phenomena and the general symptoms occasionally developed ; they consist also in the disorders of various organs making part of the uterine system aiid in the organic disorders of other systems. The various organs coi?iposing the uterine system are seldom affected singly, or at least they do not remain long without being attacked by some malady which complicates the primitive one. When the ovaries are inflamed or transformed into cysts it is seldom that there is not GENEKAL CHARACTERISTICS 2J9 fluxion, congestion, engorgement of the uterus. When the uterus is diseased it is perhaps rarer still for the peritoneum, Fallopian tubes and ovaries not to be affected bj the same disease, or at least by the inflammation or congestion accompanying it. Mayer, of Berlin, in a paper entitled 'Quelques mots sur la sterilitc,'^ affirms that, out of 263 cases of women affected with sterility, and having some uterine ailment, 35 had fluxions or versions with the following com])lications : 13 had endometritis, 8 chronic ovaritis, 7 ovarian tumours, 4 hyper- trophy of the uterus, 2 uterine polypi, 1 a fibroid tumour. Sometimes there are complications which aggravate the evil and increase the difficulties of the case. Organs unconnected with the uterine system, may also be more or less affected. Thus, in 100 uterine diseases, Aran- has counted the follow- ing as complications : 18 cases of inflammation of the appendages, 31 of catarrh, 25 of pulmonary phthisis, 9 of cardiac disease. I think, however, that these complications are not so frequent as these statistics (which probably are hospital statistics) would lead us to suppose. In short, complication like complexity is a certain fact in uterine dis- eases which must be taken into account. The various elements of this morbid association must be attacked simultaneously or successively. Sometimes the complication has not been discovered till the uterus improves. Then the disease of the ovary or peritoneum which had passed unnoticed is distinctly recognised in such a case. This disease claims our attention and supplies the major indications. Such sur- prises can only be avoided by the physician making a very careful and minute examination. 8. Uterine diseases are essentially chronic. The course which characterises the majority of uterine diseases can be easily deduced from the long details into which I entered when treating of their etiology. With the exception of traumatic and puerperal diseases there is perhaps no uterine malady that is not very slowly developed. A great number even of the diseases of the uterus and appendages which attack women after delivery would not make their appearance if the organ or organism were not predisposed. Therefore, even when we see diseases such as these accompanied by a group of acute symptoms, we may say that all uterine diseases are primarily chronic. They owe this character of chronicity to the share which the dia- theses have in their constitution and to the anatomical and physiolo- gical conditions of the uterus on which I have insisted so much. In some circumstances, however, acute symptoms occur at the commence- ment of a uterine disease, at other times later. But these acute symptoms are merely associated with the invasion of the malady or may be exacerbations of it. The disease continues to pursue a chronic course. Its chronicity is kept up by the majority of the causes which induce acute phenomena. The periodical recurrence of fluxion and congestion hinder cure and keep up the evil. If they exceed their ^ Yircliovos Archiv, Sept., 1856. ^ Op. cit., p. 155. 250 UTERINE DISEASES ordinary proportions or if they are accompanied by some unusual cir- cumstance this is sufficient to revive inflammation or give to other morbid elements renewed nourishment which rekindles the acute symptoms. We may say that the periodical return of subacute symptoms is characteristic, as well as chronicity, of uterine diseases. 9. The (lifficultif of cure is not less characteristic of these diseases. Undoubtedly some are incurable. It is also certain that cure may easily be effected when the disease is simple and acute or at least recent ; even then it necessitates a longer treatment than if situated elsewhere. Whilst, however, the majority of uterine diseases are curable, we must admit that they are less so than the majority of dis- eases of other organs. I have already said that spontaneous cures do not occur. I may add that under the influence of the most rational treatment a cure is only effected very slowly. What retards it is the slowness and chronicity of the disease, the part played by the diathesis, the recurrence of menstruation which keeps up the disease, the unfavorable oscillations which this periodical fluxion establishes between the curative and the morbid tendencies, and the fixed exacer- bations and relapses due to menstruation or to other causes. The menopause may lead to a return of health, but even this result unfortunately does not always happen. Fluxions, though irregular, are not less common when kept up by an old lesion, and as they are not always accompanied by evacuation, they have all the more tendency to keep up congestion during a certain time, that is till the patient has really entered on old age. Therefore, even when under the influence of an appropriate treat- ment the malady has begun to yield, amelioration often remains sta- tionary, and much perseverance and energy are required before the end is reached. A cure cannot be said to have been effected unless it has stood the test of time and the recurrence of several menstrual periods. Subjective symptoms, such as lumbar pain and disorders of innerva- tion, may persist for a long time even after the disappearance of objec- tive symptoms. Treatment must be directed against them uninter- ruptedly, for they too may cause relapses owing to the debilitated state in which they keep the organism. Let me add that it is necessary to be on one^s guard against the appearance of cure of uterine diseases, in the course of which another malady occurs. When an acute disease is developed concurrently with the malady of the womb, the uterine symptoms disappear in some measure in virtue of the law, duohns lahorihus siviul ohortis non in eodem loco, vehementior ohscurat allernm ; but they return after the cure of the acute disease which had temporarily suspended them. Where a chronic disease occurs the two maladies exist and progress simultaneously, for the uterine disease has weakened the constitution, and this impoverishment only gives a greater hold to the other morbid act. Only a sort of equilibrium is established, in virtue of which sometimes the one sometimes the other has the advantage; in such cases, if the pathological condition endanger life, we must respect the uterine symptoms for fear that an exacerbation of this morbid condi- GENERAL CHARACTEEISTIOS 251 tion should hasten a fatal termination. All practitioners agree as to the necessity of expectant treatment in such cases. Two other reasons contribute towards diminishing the chances of cure in the case of uterine diseases which present a marked character- istic of chronicity ; the first is that patients have become so habituated to their sufferings, and have learned to tolerate them so well, that they are unwilling to submit to the exigencies of a treatment the strict observance of which is often the only guarantee of success ; for example, in certain diseases it is difficult to prevent marital intercourse, in others to prevent the fatigue entailed by social life. The second is the defective nature of the diagnosis and treatment ; the defective nature of the diagnosis arises from a want of necessary precision, from omit- ting something in an examination, from failing to interpret correctly the symptoms observed, or from the difficulty in unravelling the various phenomena in complex cases ; defective treatment is the result of a defective diagnosis, of the irregularity with which patients carry out their treatment, and in some cases, e.g. deviations, it is the result of the insufficiency of our therapeutical means. If we consider the various circumstances I have just enumerated we can easily understand how little chance there is of spontaneous cure in uterine diseases, and how necessary is an intelligent medical inter- ference, which must be both active and persevering if a cure is to be effected. 10. Before finishing this summary description of uterine diseases, I must refer to their diversity, and point out that mode of classifica- tion which seems to present them in the most natural order. After all that I have said hitherto with regard to the crude sys- tematisations that have been made in uterine pathology, and as to reducing all morbid conditions of the womb to one disease, the reader must have seen that I have throughout this work tried to give proofs of the existence of many morbid conditions differing as to cause, nature, seat, symptoms, indications and treatment. I admit that the difference is not always well marked, that the same causes sometimes produce different effects, that these morbid conditions are associated in place of being isolated and distinct j that, however, does not prevent the existence of a natural diversity. The recognition of this diversity is the best basis of diagnosis and therapeutic indications. Only we must remember the meaning of the words uterine disease, and the limits which exist between health and disease in the generative organs. Is every abnormal phenomenon, every material change a disease ? Is there any essential and primary affection connecting these lesions?^ Every abnormal phenomenon, every material disorder not involving disturbance of the uterine or other functions is an exceptional fact, but does not deserve the name of disease. If the uterine functions are disturbed, however, and if this disorder leads to others, there is disease. As to the diversity of uterine diseases, here as elsewhere we must apply * Boudet, JReclierches sur la nature ei les causes des affections uterines. Theses de Paris, 1857. 252 UTI-MUNE DISEASES the natural method in order to distinguish the various morbid condi- tions which have a common seat. Now, it is evident that there are physiological disorders of the uterus which may react on the whole organism ; and that there are affections of the whole economy which may be localised in the uterus. There are changes of organic tissue; there are displacements or changes with regard to the relationship of this and neighbouring organs. Lastly, there are diseases depending on one or other, or on both. The nature of diseases ought to form the basis of the principal divisions. The variety of form and seat, the diversity of the parts or elements of the organ affected by the disorder, is the basis of the secondary divisions. Now in placing ourselves at this double point of view, we at once recognise the existence of uterine diseases that are fundamentally different. Sometimes they are functional disorders, menstrual troubles more or less serious, derangements in the expres- sion and sequence of the physiological phenomena characterising the vitality and destination of the organ. Sometimes they are simply dis- placements, changes of position or direction, resulting from an altera- tion in the statical conditions of the organ, and causing a simple modification in its topographical anatomy and in its relations to the neighbouring organs. At other times the alterations are not limited to simple anatomical or physiological disorders ; they affect the organ in its vitality, in its nutrition, often even in its structure and in the com- ponent elements of its tissue. Sometimes the development of a modi- fication of local vitality or the localisation in the uterus of a general affection communicate to its functions a characteristic disturbance or determine'in the organ the manifestation of very characteristic patho- logical acts, and finally the realisation of a fixed morbid condition. Sometimes a real diathesis invades the organ at once, or profits by a simple pathological act to fix itself there, communicating to the morbid condition the anatomical and pathological characters which distinguish it, and lead to its recognition on any other organ. Lastly, persistent alterations of tissue or the formation of new tissue, M'hether homeomorphous or heteromorphous, produce in the organ functional disturbances and often pathological processes, constituting the chief phenomenal expression of the disease. It is plain, therefore, that uterine diseases can be distinguished by the same terms that are used in general and special pathology, viz. as anatomical lesions, vital ajfections, organic disorders. 11. T/ie diversity, however, is accompanied hy complexity, through the association of diseases. Regarded from the same point of view, uterine maladies will be seen to preserve their simplicity less than those of any other organ, liesides the characteristic complexity, we may remark the tendency in these diseases to be linked to each other ; so that after a certain time it is more or less difficult to discover which is the original malady, and to determine whether the principal indication for treatment Hes in the primary or in the subsequent lesions. Some- times in fact displacements cause menstrual disorders and pathological effects, more or less complex; sometimes menstrual disorders (conges- GENERAL OllAKAOTEKTSTH'S 253 tion and increased weight of the organ) ))roduce displacements. At other times diathetic disorders^ organic lesions, neoplastic tumours determine functional disturbance. On the other hand, functional dis- turbance after a certain time is followed by diathetic disorders and the development of tumours. Displacements tend to produce simple patho- logical processes, as well as the manifestation of the most complex morbid conditions and the development of organic lesions. The worst is, that when these diseases are associated it is difficult to determine which of them causes the most serious symptoms, and^ therefore, which ought to be first attacked. For example, it is not often that simple devia- tions cause real pain, but it frequently happens that they are accom- panied by metritis, pelvic peritonitis, &c., and that consequently they occasion serious accidents. We must always try to discover the link which connects ])athological processes, and to determine which of the morbid acts takes precedence of the others at a given moment. 12. In order to classify tJie various diseases according to their natural order of succession, we must try to put those foremost which occur most frequently alone, and which are seen more frequently and uncomplicated for a longer time than others, passing afterwards to those which are composite and to those whose composition becomes more and more complex, and at last reaching the most composite of all, in each of which we may say that the whole of uterine patholoo-y may be concentrated. I. Classified according to this principle, functional disturbances take the first rank, i. e. diseases in which functional disturbances play the chief part and form the principal element of indication. Whether idiopathic or symptomatic, menstrual disorders are real diseases, for they seriously disturb the health. Menstruation may be considered as a delivery in miniature. Now menstruation and delivery are two functions unlike any others ; in fact they resemble pathological rather than physiological acts : hence their tendency to produce disease. All functional disturbances are connected with menstruation. The cata- menia may be defective, excessive or abnormal, giving rise to amenor- rhea, including retention and deviation of the menses ; dysmenorrhea including uterine neuralgia; and hstlj , tnenorrhagia dCiA metrorrhagia, in which the sanguineous discharge is not only a critical evacuation but a real hsemorrhage (internal haemorrhage is described with pelvic tumours). Not only are disorders of menstruation the most frequent diseases, but they so often complicate uterine maladies and have so large a share in their chronicity or in their exacerbations, that we must always take them into account and discover when they are the cause of these diseases, that we may obtain the clue to an important part of general treatment. For these reasons we ought to commence uterine pathology with the diagnosis and treatment of the disorders of men- struation. II. Next to functional disorders, I have placed changes of ■position the chief characteristic of which is an alteration in the situation direction and form of the uterus. I know that these morbid con- 254 UTERINE DISEASES ditions are seldom as simple as has been supposed, their principal symptoms being as often dependent on their complications as on themselves ; sometimes they may be the result of preceding morbid conditions, such as congestion, engorgement, and hypertrophy ; whilst in their turn they may produce leucorrhcea, granulations, ulcers. But whatever may be the accompanying complications, whatever may be the displacement, there are cases in which a change in the conditions of the equilibrium of the uterus plays the principal part and may be disengaged from all concomitant phenomena. These changes are of four kinds : 1. Displacetnents, including elevation, descent, and hernia ; 2. Deviations, designated under the names of inclinations, or versions; 3. Flexions, or changes in the relative position of the two portions of the uterus ; 4. Lastly, Inversions, or changes in the relative position of the external and internal surfaces of the organ. III. In proceeding from the simple to the composite, we encounter in the third place morlicl states wi'tliout neoplasm. I give this name to affections generated by a simple morbid act, local or general, dia- thetic or not diathetic, but neither accompanied by persistent changes of tissue nor by the formation of new elements. These maladies are often designated by the name of vital affections. The first of all these morbid conditions, those which help to produce or complicate the others, are, in the order of their production ; fitixion, characterised by a temporary movement more or less vigorous, single or repeated ; con- gestion, characterised by the persistence of local hyperajmia ; engorge- ment, resulting from the repetition or persistence of the preceding states and from effusion of the serous elements of the blood into the affected tissues. Then follows inflammation, which borrows its prin- cipal elements from the preceding morbid conditions, and is character- ised by its tendency to suppuration or hyperplasia, and which occupies a large share in the pathology of the uterus as of that of all other, organs. I have classed with inflammation of the uterus that of its appendages, the surrounding peritoneum and cellular tissue ; i.e. the morbid states known under the names of metritis, endometritis, para- metritis, and perimetritis. I have not even separated ovaritis, inflam- mation of the Pallopian tubes and peri-uterine inflammation from metritis, because these morbid conditions are often associated and influence each other mutually; because when the one exists the development of the other is to be feared ; and lastly, because they occasion the same indications and necessitate almost the same treat- ment. The morbid conditions which follow, whilst often connected with inflammation as cause, effect, or complication, are generally dependent on a diathesis. They are : letccorrhma, hypertrophy, granU' lations, and fungous growths, ulceration and ulcers. The importance of hypertrophy, though for long misunderstood can hardly be over- estimated. IV. In the fourth rank I have placed organic alterations, i.e. the morbid conditions characterised by a persistent alteration of tissue and differing from each other according as they are produced without the formation of new elements, or with development of anatomical ele- GENERAL CHAEAOTERISTICS 255 ments having no analogy with the special elements of the uterine tissue. The first, corresponding to homomorphous productions, include f6ro?fiata, interstitial fibrous bodies or sub-peritoneal tumours, whether pediculated or not, andpolj/pi, mucous or epithelial, follicular, fibrous or vascular; with which, as far as diagnosis and treatment are concerned, tnoles are naturally connected. The second^ corresponding to heteromorphous productions, are tubercle and cancer with all their varieties of form and of locality ? V. Lastly, I have arranged in a fifth category the organic altera- tions of the apj^endages and the abdominal or pelvic tumours resulting from their formation. This category, from which ovaritis and peri- metritis have previously been separated, includes only two important morbid conditions : 1. Peri-uterine hematocele, which is as much con- nected with diseases of the appendages as with peri-uterine maladies, since it derives its origin so frequently from haemorrhages of the ovary and Fallopian tubes. 2. Ovarian tumours, among which multilocular cysts take the first place from their importance and the recent progress made in their treatment, and timiours of the Fallojna^i tuies, connected as they are with the interesting history of the migration of the ovum and of extra-uterine pregnancy. Sterility, its diagnosis and treatment, form the natural termination to this last chapter and to the knowledge of all the diseases previously studied. I have thought it useless to reproduce the statistics of uterine dis- eases given by some gynecologists; for they do not even give an approximate idea of the relative frequence of these various diseases. If it is a question of hospital practice, either a special class of cases is seen, e.g. venereal affections, or only the most serious cases or cases requiring operation : for, as a rule, patients will not go to an hospital while they can move about. Hospital practice, however, never can be a fair sample of the innumerable variety of uterine diseases to be found in any country. A general practitioner having the entire practice of a district in his hands would perhaps be able to furnish more correct statistics. But probably even he would only see the most serious cases ; the majority of the less serious would forego treatment under such cir- cumstances, while others would address themselves to specialists in a neighbouring town. It is almost impossible for any statistics of private practice to give even an approximate idea of the relative fre- quency of different uterine diseases. This difficulty is quite indepen- dent of the diseases themselves ; as for myself, I could not give such statistics. Formerly I had a great many cases of metritis, leucorrhcea, polypi, &c. ; now I hardly have one, the reason being that women affected with these diseases are more or less successfully treated by young practitioners. Now, on the contrary, I have great numbers of incurable diseases, cancers, enormous fibromata, and ovarian cysts ; patients coming to me from great distances because the treatment of other doctors has been unsuccessful. Such cases not only occupy much more space in my statistics than they formerly did, but much more than they ought to do from their relative frequency. It is the same with several other diseases, fortunately not incurable like those 256 UTERINE DISEASES just named, but more difficult to cure than a number of others, such as flexions, perimetritis, peri-uterine adenitis, phlegmons of the broad ligament, hematoceles, kc, as well as others such as mechanical dys- menorrhoea and the various diseases which result in sterility. These cases, which were almost entirely absent from my first statistics, occupy an important place in my later ones, since my successful treatment of a large number of cases became known to the pubhc, and has been a fact recognised by the profession. PART II UTEEINE DISEASES IN DETAIL CHAPTER I FUNCTIONAL DISOEDEES. — MENSTEUATION — AMENOEEHCEA — EETENTION OP THE MENSES — DEVIATION OF THE MENSES AND SUPPLEMENTAEY MENSTEUATION — pySMENOEEHOEA — UTEEINE NEUEALGIA — UTEEINE HiEMOEEHAGB, Strictly speaking, there is only one function with the disorders of which we are concerned, viz, menstruation; and this function can only j be deranged in three ways : it may be defective, excessive^ or dis- j ordered. Menstruation is a flow of blood from the uterine cavity, occurring in an intermittent manner, generally at regular intervals, except during pregnancy and lactation, from the age of puberty, i.e. from 1^ to 15, to that of the climacteric from 45 to 50. Its regular recur- rence shows an aptitude for reproduction besides indicating the most favorable periods for conception. The mean duration of the intercalary or intermenstrual period being about a month, these haemorrhages have been designated the monthly periods or menses, or the catamenia ; their regular recurrence at fixed times has led to the term monthly periods ; the dominant fact of the discharge to that of the catamenia ; and the idea of the evacua- tion being favorable to the general health to that ol pur g alio menstrua. Menstruation is the function. The words monthly period, menses, catamenia, &c., designate the external phenomenon which characterises it. Disorders of 'me7istruatio7i Menstruation deserves the attention of the physician as a means towards the interpretation of uterine diseases; it is a term of com- parison. If menstruation has rightly been called a pregnancy in miniature, we may say that it offers an epitome of several uterine dis- eases taken as a whole or in some of their elements. Menstruation also deserves attention because it may become a cause of diseases of the womb ; it has a considerable share in uterine etiology as well as in uterine pathology ; for, although itself a physiological act, it places the organ which is the seat of it in conditions different from the equili- brium which is one of the characteristics of health in all the other organs. Menstruation ought also to excite our interest because, by 17 yvr- ' 258 UTEEINE DISEASES IN DETA.1L its disorders, it always discloses the existence of a uterine disease. Often we have no other means of arriving at a diagnosis. In women suffering from uterine disease, the menses either produce pain, cause its reappearance, or increase it ; they last a longer or shorter time than in the normal condition, and often are so irregular that patients cannot fix the time of their recurrence. Menstruation is also worthy of our serious consideration on account of the aggravation of the local condition which it does not fail to produce in uterine dis- eases, as well as of the interruptions to treatment which it necessitates. Lastly, menstruation itself may be disordered; in its evolution and recurrence it is subject to more or less serious derange- ments which constitute those uterine diseases which will first occupy our attention. In order correctly to appreciate the disorders of menstruation we must follow this function throughout its whole course from beginning to end. It may fail in establishing itself, or great difficulties may present themselves in its establishment, or it may disappear for some time. When established and regulated, circumstances may occur to suspend its course, or if it continue to recur regularly, it may be accom- panied by more or less serious accidents at every period. The mens- trual discharge may also be deranged with regard to the quantity and quality of the fluid excreted.^ The ordinary division of the disorders of menstruation which, as I have said, may be excessive, defective or deviated, is very practical. The catamenia may not appear at the period of life when we naturally expect them, or they may be sup- pressed after a variable time ; or the discharge may take place with difficulty ; or it may be excessive in quantity, or it may recur too frequently. Hence three great classes of menstrual disorders, respond- ing to which are often three kinds of capital indications. 1. Amenorrhea including: retained moulruat'wn and deviated men- struation. 2. BysrnenorrhoRa, to which we may add membranous dysmenorrhcea and uterine neuralgia. 3. Uterine hfcmorrhages, including menorrhagia and metrorrhagia. These menstrual disorders arc sometimes symptomatic, sometimes idiopathic. It is of great importance to distinguish the one class from the other, and this is what I shall endeavour to do in the description I am about to give of them. It is easy to prove that the disorders of menstruation, considered as a whole, are of great practical importance. West^ rightly remarks that the changes q{ puherty in the girl, like those of dentition in the child, are not effected suddenly, but are prolonged over a period of some months, during which time diseases frequently occur. The tables of mortality show that this period is more fatal to girls than the preceding one, if we compare the numbers of deaths in the two sexes. Quetelet and Smits^ have shown that, whilst in infancy * Mcnatruatio aholetur, imminuitur, intenditur, depravatur. (Astnic.) ^ Diseases of Women, 4tli edition. London, 1879, p. 2(). ' Sur la rejyrodtdction ct la mortalitu de Vhomme. Brussels, 1832. MENSTRUATION 259 mortality is equal in the two sexes or greater amongst boys, it is, on the contrary, greater amongst girls, in the proportion of 1'28 to 1 from the fourteenth to tlie eighteenth year, and that it descends in the four following years to I'OS for girls against 1 for boys. The anxiety of parents at the approach of this period is therefore natural. Moreover, it is not without reason that this anxiety increases in proportion to the delay experienced in the first appearance of the menses. Whitehead has proved that the danger of accidents is greater when the menses are delayed than when they are precocious, and the researches made by West confirm this opinion. The following in- teresting statistics are given us by Whitehead •} First Menstruation. No. of Cases. Unfavorable Cases. Proportion. From 10 to 14 years . . . „ 15 „ 16 „ ... „ 17 „ 18 „ ... „ 19 and upwards . . 1141 1178 892 239 224 324 247 97 19-63 18-75 27-69 40-58 Total 3450 892 22-30 Whilst delay in the appearance of the catamenia seems to increase the chances of accidents which follow the establishment of this func- tion, \i& precocity seems to indicate in the uterus an activity favorable to the development of certain diseases, particularly of organic diseases, or rather of cancer.^ Kussmaul,^ having come across a case of cancer of the ovary in a child of two years with the development of a girl of twelve or fifteen, asked himself if there was any connection between precocious puberty and ovarian disease. After numerous researches he arrived at negative results for serous or dermoid cysts, but positive for sarcomatous or cancerous neoplasms. Out of six cases of this kind which he collected in three there was a history of precocious puberty. EUeaume* made similar researches with regard to the influence of precocious menstruation on the development of uterine cancer, and found that out of twenty-eight cases of this disease menstruation had occurred in nineteen before the age of fourteen years. Amenorrhcea. Amenonho&a (absence of menstruation), if we consider the etymology of this word, includes the tardy appearance of the menses, their premature cessation, and amenorrhcea properly so called.^ > Treatise on Abortion and Sterility, p. 48. London, 1847. 2 I have often noticed that women afEected with organic lesions of the uterus and ovaries had menstruated prematurely and abundantly. ' Wiirzhurger medicinische Zeitschrift, t. iii, 1862 ; Archives generales de tnedecine, fevrier, 1863, t. i, p. 224. * L' Association medicate, 15 fevrier, 1863, p. 55. ^ According to Etmiiller (Castelli Lexicon), the disappearance of the menses 260 UTERINE DISEASES IN DETAIL The delay in the appearance of the menses may depend merely on the defective estabhshment of this function. Sometimes ovulation takes place although there is no uterine haemorrhage. At other times there is delay in the sexual development or a suspension of the repro- ductive functions, either spontaneous or occasional^ by some malady. Lastly, there may be absence of the uterus or imperforation of this organ, causing retention of the menses; therefore I cannot too strongly advise the physician to assure himself of the normal con- formation of the genital organs, in certain critical circumstances in which a girl who has never menstruated may be placed ; for instance, on the eve of marriage. I knew a young woman in this position : the family physician was consulted, and in place of dissuading the parents from marriage he was imprudent enough to advise it, under the pretext that conjugal relationship would not fail to provoke the catamenial flow. Unfortunately, I discovered some years later com- plete absence of the body of the uterus, so that I could give no hope of children to the unfortunate parents who consulted me. I found, however, that the ovaries were present in this young woman ; so, too, were the menstrual molimen and sexual desire. I have had occasioii to see other cases of the same kind.^ The premature cessation of menstruation may also coincide with the cessation of ovulation or, which is rarer, may precede it. It seldom occurs without some exciting cause, either general or local. When genuine, it is neither accompanied by disorders nor by congestive phenomena in the utero-ovarian economy. Amenorrhcea, strictly speaking, is the absence of menstruation after one or more monthly periods. Whether it disappear after some time under the influence of the efforts of nature or of an appropriate treat- ment, or whether it persist to an age when it becomes definitive, being transformed into the menopause, it may constitute an anomaly rather than a morbid condition. Amenorrhcea is normal during pregnancy and lactation. In every other condition it is either an accidental ab- normal condition, or the symptom of a morbid condition, or a real disease. Diagnosis. — Symjjtomalic amenorrhcea depends on various patho- logical conditions of the uterus or of the body generally. As regards the uterus, these are : malformation, either congenital, such as I have described, or acquired, as I shall have occasion to refer to in speaking of retention of the menses ; inflatamation, acute or chronic, but espe- cially acute inflammation of the uterus or of its appendages ; rarely organic lesions of the womb ; oftener those of the ovaries. If depen- dent on the general organism, the menses may be suppressed by acute diseases, although this seldom happens when they occur at the com- mencement of a disease ; they are, however, almost always suppressed {suppressio mensium) should be distinguished from their delayed appearance {emansio mensium). ^ Courty, Demande en millite de mariage fondee sur le d^faut de caracterea sexuels feminins ; consultation medico-Ugale et considerants du jugcment. Montpcllier medical, t. xxviii, p. 473. Montpellier, 1872. Annates de Gyne- cologie, t. ii, pp. 325, 410. Paris, 1874. AMENORRHCEA 2G1 towards the decline of the disease or during convalescence.^ In chronic diseases the menses diminish, become irregular, and finally are sup- pressed, as the weakness increases and hectic fever makes its appear- ance and the prognosis becomes more grave ; it is what happens every day in tuberculous and cancerous affections, in organic diseases of the heart and in Bright's disease, in cirrhosis of the liver when dropsy commences, in some nervous affections, in ana3mia, in chlorosis, in polyuria, diabetes and obstinate diarrhoea.^ In symptomatic amenor- rboja the cause may disappear whilst the amenorrhoea persists. IdiopafMc amenorrhoea is that in which more or less prolonged sus- pension and cessation of menstruation depend on a cause exerting a direct influence on this function.^ Any general disturbance may produce it by arresting the functions of the ovary or uterus, by pre- venting fluxion from taking place, by arresting congestion and hsemor- rhage, by turning aside the synergetic movements which establish the molimeii and cause the discharge of blood. It is probable that ovula- tion cannot continue to be effected unless uterine haemorrhage is pro- duced. The impression of cold in any form and on any part of the body — for instance, a cold sitz-bath or foot-bath, a change of linen, a fall or blow, the disturbance caused by a fit of indigestion, by blood- letting, an emetic, pain, or fright — are the most common causes of this derangement. Uterine torpor, congenital or acquired, and pre- mature atrophy of the womb encourage this action. Anxiety, grief, change of habits and residence, as happens for instance with girls who are sent to school, a sedentary life like that 'wi convents, and im- prisonment following an active and free life, often produce a more or less serious and prolonged disturbance in menstruation. The facility with which this function is affected by slight causes is also common to most of the other acts of reproduction ; the impressionability of the generative system seems to be greater than that of the other organic systems, so great that Raciborski has seen occasion to attribute amenor- rhoea to the simple fear of pregnancy after illicit intercourse, or to the great desire of having children after prolonged sterility, and this he has designated amenorrhoea from psychical causes. Whether, however, the impression is produced on some part of the body (sudden chill, intestinal parasites) or on the brain (vivid moral impressions), it is by a kind of reflex action on the uterus that amenorrhoea is produced, which has led some writers to call it sympathetic amenorrhcea, ^ Herard, Be I'infiuence des maladies aigues fibriles sur les regies, Raci- borski, Traite de la menstruation. ^ Becquerel, op. cit., t. ii, p. 406. 3 It is evident that either the ovaiy or uteinis may be afEected, hence the division of amenorrhoea, according to Raciborski, into ovarian or radical and uterine. The first may be organic or functional. _ Functional ovarian amenor- rhoea, caused by a kind of torpor of the ovary, is true amenorrhoea ; it may consist either in delays or in complete amenorrhoea. To be still more exact, we must distinguish, from this point of view, three kinds of amenorrhoja : 1, from absence of ovulation ; 2, from absence! of tderine congestion ; 3, from absence of sanguineous exhalation. 262 UTERINE DISEASES IN DETAIL Differential diapiosis. — It is important to distinguish idiopathic from symptomatic amenorrlirea, from retention of menses, and from the accidents of various kinds which may result therefrom. Idiopathic amenorrhea is sometimes well tolerated ; but generally it produces more or less serious local or general phenomena. Some- times the local symptoms predominate, especially those of congestion ; fluxion is effected but has not its natural termination; absence of evacuation is not compensated by the natural reaction which tends to dissipate the fluxion after each period, and the congestion continues to increase, sometimes even rising to the degree of a permanent morbid condition. Sometimes fluxion does not take place, but this absence causes a disturbance in the general circulation and in all the other functions. General phenomena are manifested : in a few women it would seem that the habitual absence of sanguineous evacuation produces a plethora (resulting in congestions of the spleen, liver, lungs, or head, causing in the last case headache, drowsiness, congestive amaurosis,^ &c.) ; in others on the contrary, and in the majority the blood becomes impoverished, innervation is disturbed, and symptoms of chloroansemia are developed. It is important to distinguish chlorosis produced by amenorrhcea from that of which, on the contrary, amen- orrhoea is symptomatic. Sympioynatic amenorrhcea is always preceded by the disease of which it is only the symptom,^ till such time as it can continue of itself, by virtue of the morbid habit which the repeated suspension of menstrua- tion has impressed on the economy. Amenorrhcea symptomatic of defective development may have a number of features in common with idiopathic amenorrhcea causing them to be confounded together. Whether there is absence of the uterus or ovaries, or a rudimentary condition of these organs [uterus fetalis or infaniilii) they have the common feature of amenorrhcea. When the ovaries are wanting there is only this one negative symptom. In the contrary case, we gene- rally observe all the prodromata of menstruation, lumbar or hypo- gastric pain, a sense of pelvic fulness with pain radiating down the thighs. After lasting for some days this ceases, but is reproduced sooner or later the following month with a certain regularity. In other cases the disturbance is less marked : there is sometimes palpita- tion of the heart and violent headache necessitating bloodletting. Occasionally phenomena of hsemorrhagiparous congestion are devel- oped on various parts of the body, which might lead us to think that the economy was in need of depletion, and tried to effect a vicarious evacuation. The duration of these troubles and hsemorrhagic molimen is very variable. Sometimes they last for a few years only, not unfrequently, however, they are prolonged for twenty. Then a ' Such is the case related by Samelsohn of complete amaurosis the result of a sudden suppression of the menses, which gi-adually disappeared when men- struation was again established seven weeks later (Berlin. Klin. Wochenschr., 18 Jan., 1875). * We must be on our guard against the tendency that women have of attri- buting all their diseases to amenorrhcEa in place of regarding it as the effect of various pathological affections from which they may be suffering. AmenorRhcea 2G3 gradual amelioration takes place similar to what occurs after tlie menopause in women who have suffered from obstinate dysmcuorrhoja. Menstrual retention may be diagnosed by the hypogastric tumour of the uterus, distended by the accumulation of blood. The symptoms experienced by patients are generally in proportion to the quantity of fluid. Not only are symptoms of molimen manifested every month, but there are signs of repletion of the genital organs often accom- panied by fruitless expulsive efforts. These phenomena, differing as they do from those produced in the majority of cases of amenorrhoca, are attended by painful periodical exacerbations, an intolerable and almost continuous nervous erethism, and often still more serious symp- toms. In vshort, before deciding that there is amenorrhoea, we must ascertain that the genital organs are in normal condition. This examination ought not to be neglected even in women who have had sexual intercourse or children, for the obstacle to the discharge of blood is often internal or may have been produced after labour. The examination should not be confined to the vulva and vagina, but should extend to the uterus and its appendages. Lastly, the possi- bility of pregnancy must not be lost sight of. Treatment. — The indications may be various. In the first place amenorrhoea may be compatible with the free exercise of all the func- tions and with perfect health, in which case there is evidently no occasion for treatment. It is the same when it is irremediable and symptomatic of an incurable disease in an advanced stage. Treatment ought to be confined to hygienic measures when the amenorrhoea is only a delay in the first appearance of menstruation, or the result of convalescence from acute disease rather than amenorrhoea strictly speaking, and should be directed exclusively to the affection which has suspended ovulation in cases of symptoraatic amenorrhoea ; consequently, we must treat nervous asthenia, haemorrhages, im- poverishment of blood, ansemia, chlorosis, or even plethora (when it seems to have a share in producing the disease), without directing our attention to the genital system, and only endeavour to excite the ova- ries or uterus directly by more or less powerful stimulants after having cured the maladies of which the amenorrhoea is only a symptom. In idiopathic amenorrhea the indications vary according to whether the general or local condition predominates. Almost all cases may be included in one or other of these categories ; the periodical fluxion may either continue to take place in the uterus, congesting the organ without terminating in a discharge of blood, cases of this category being characterised by the predominance of local symptoms ; or the fluxion may not even take place, being directed instantaneously after suppression to another organ, or it may take this false direction at a later period, or not at all ; cases of this category are characterised by the predominance of general phenomena. The one class or the other, according to the case, becomes the principal source of indication. The local phenomena which predominate are chiefly congestive. When general symptoms predominate they are more varied. I'or the 264 UTERINE DISEASES IN DETAIL habitual suppression of uterine fluxion and evacuation may either de- termine plethora or cldoro-ancemia with their various aspects and numerous consequences, or fluxionary movements, so varied in their progress, tendency, aim and termination. Hence two kinds of indi- cations, the one being dependent on the defective normal fluxion which has to be recalled, the other on the intensity and nature of the general disorders which have to be cured ; the one class may predominate, or they may do so alternately at difi'erent periods of treatment in the same patient. Indications furnished b^ local troubles or by phenomena of uterine congestion. — It is not enough to characterise the form of these phe- nomena ; in order to treat them efficiently, we must also determine their essential cause or nature. It is important to be able to refer the local troubles to congestion; but this persistent congestion is only the form of the malady; the basis of the morbid state which keeps up this condition is a disorder aff'ecting the vitahty of the uterus. In tracing its origin to this source, we discover that the disorder may affect the vital functions of the organ, its sensibility, contractility, secreting power, &c., or the properties of its tissues, their permeabihty, elasticity, resistance, &c. It is not, however, always possible to push analysis so far as to determine with certainty which of the two is the source of indication. There may be primarily or secondarily a simultaneous appearance of these various disorders of vitality, which we regard as the essential cause of hindrance in the evolution of menstruation. We see infinite gradations of this in practice, but in this description we can only touch upon the principal varieties. Congestion may be imperfect, or may not be sustained by a sufficient efl'ort, not reaching the highest expression of the physiological act capable of determining evacuation. In this case we must strengthen the fluxion and regulate it, stimulating it by various applications which affect the vascular system of the uterus. Gentle purgatives, e.g. castor oil, or small doses of aloes, or laxative enemata containing manna, molasses, honey, or a mercurial decoction, or one of lettuce and white beetroot, to which may be added a few spoonfuls of oil, glycerine, or a little soap, produce an intestinal flux, which is favor- able to the establishment of menstruation. On the other hand, mild attractives, such as dry cupping, sinapisms on the upper and inner parts of the thighs as well as on the hypogastrium, or a hyv leeches applied to the external surface of tlie labia, arc excellent means of inducing an external discharge of the blood which congests the uterus. Uterine congestion may be sufiicient,the means of expulsion only being defective. Sometimes irritability of the organ is the principal obstacle. In order to calm this we must have recourse to emollients in various forms : general baths, sitz-baths, liot poultices on the abdomen, fumi- gations, enemata, &c. Sometimes the blood is retained by erethism or by spasm of the uterus. In this case preparations of aconite, henbane, belladonna, or poppy-heads may 'produce the desired result; they may AMENORRHEA 2G5 be administered internallyj or externally in the form of enemata, baths, fomentations, or embrocations. Sometimes inertia of the uterus or suspension of its muscular contractility, are essential conditions of the imperfection of the act. Emmenagogues are then the best uterine evacuants, especially ergot ; electricity, and douches on the cervix may also be tried with the same object. In a third class of cases congestion is more than sufficient, exceeding the limits of the physiological menstrual state, and by its excess hin- dering the natural discharge from taking place. The uterus is turgid, its volume greatly increased, its vessels are gorged, its fibres distended, its elasticity and contractility diminished. In this case the indication is to empty the vascular system, either by direct depletion or by revul- sion, with the object of subduing the excessive fluxionary movement which is the primary cause of this congestive tumefaction. The best of all revulsives is bloodletting from the arm ; it ought not to be copious, especially if it has to be repeated ; not more than from three to six ounces of blood should be taken, unless the intensity of the congestion and the attendant symptoms require a more copious evacuation. This is sometimes followed by an immediate appearance of the menses ; or it allows the other means used to produce their effect ; or it may only produce an effect on the following periods, at each of which it ought to be repeated. We shall have occasion to see that the indication for bloodletting occurs in other circumstances, especially in the treatment of amenorrhoea symptomatic of uterine congestion, metritis, peri-uterine inflammations, &c. Indications furnislied hy general trouhles, i.e. hy the absence of iiterine fluxion and its reaction on the tohole economy. — The aim of some is to attract or recall fluxion to the uterus, that of others to cure the general disorders or various affections the starting point of which was the absence or suppression of menstruation. I. To attract sanguineous fluxion to the uterus or recall it when it has ceased, is an indication which we cannot always fulfil, nor ought we to try to do so in idiopathic amenorrhoea before having fulfilled the second of the two indications just mentioned. Por the general dis- turbances imported by the amenorrhcea into the principal functions of women, especially when they have reached such a height as to have become themselves morbid affections, may ultimately have to be regarded as the essential cause of the suppression of menstruation. Idiopathic amenorrhoea touches so closely upon symptomatic amenor- rhoea at this point, that the former may be transformed into the latter ; so that after having been idiopathic and having produced dis- eases of the uterus or of the general economy, amenorrhoea may in its turn become symptomatic of these same diseases. Just as pain is the daughter as well as the mother of inflammation, amenorrhoea is mother and daughter successively of uterine congestion or metritis, of plethora, ansemia, chlorosis, frc. This mutual influence is exerted in various degrees, and the nature of its action in this intervention is as variable. But whatever its mode of action may have been, the amenorrhoea may, in its turn, become so dependent on certain morbid 266 UTERINE DISEASES IN DETAIL conditions, that the primary, sometimes the only indication, is to treat these diseases, the cure of which will bring about at the same time, without the apphcation of any direct means, the cure of the amenor- rhcea. We must therefore take this subordination into account, and, in these complex cases, know how to fix upon the dominant indica- tion, because it is the primary, sometimes the only indication to be fulfilled. It would be impossible here to analyse all cases of this kind, or to determine when one of these indications should be fulfilled to the exclusion of the other, when one before, or after the other, or when the two simultaneously. Forced to separate what ought often to be united, and to describe in a certain order of succession what ought often to be practised in an inverse order, we must point out that in describing the treatment of idiopathic amenorrhoea, we have given not the first rank, but the first place to a description of the indications connected with defect of the uterine fluxion, and the second to a description of those connected with the concomitant general disorders. To determine the appearance or return of the uterine fluxion is an indication that can be fulfilled by means analogous to those employed to attract fluxion to any part of the economy. It is manifestly easier to attract to the uterus and to establish in this organ a fluxionary movement which is natural to it, than to attract an artificial fluxionary movement to any other part of the body, the latter being essentially a morbid act, whilst the former is a physiological one. This fluxionary movement being intermittent and periodic, the means used to produce it ought to be in harmony with this characteristic, e.g. : when we have not succeeded in re-establishing menstruation during the first days which follow a sudden suppression of the period, we must limit our efforts to the treatment of the symptoms produced, and await the probable return of the following period to try new means. All the functions of the uterus having a share in the maintenance of its physiological state will have an equal influence in the cure of amenorrhoea. Menstruation being composed of several successive acts, we shall certainly have more chance of restoring the first of these acts to its normal type if we try to restore the others consecutively, and to bring into play the faculties and properties of the organ by means of which they are carried out. For instance, evacuation and congestion will encourage the physiological return of fluxion. The realisation of the former processes will exercise a kind of attraction on the latter : whilst on the contrary the more the fluxion falls short of its final result, the less tendency it will have to be reproduced. These principles ought to guide the practitioner as to the nature of the means he should use, and the order in which he should employ them. Of all these means the most physiological is marriage ; we are there- fore justified in advising it, when amenorrhoea does not seem to be dependent on any malformation or defective sexual development, nor to have determined the appearance of any serious disturbance in the uterine system or in the general condition of the patient. Before AMENOEEHCEA 267 giving such adviccj however, we must ascertain that a uterus is present and that there is no obstacle to the discharge of the menses. If this is the case, or if araenorrha3a has occurred after repeated men- struation, we must resort to those general and local means which have a tendency to encourage uterine fluxion and hsemorrhage. All medi- caments which attract the blood to the lower part of the body, to the pelvis, rectum and uterus are used to fulfil this indication in the treatment of amenorrhcea. Women themselves know the utiHty of foot-baths, sitz-baths, sinapisms, fumigations, leeching and purgatives in determining the appearance of the catamenia or recalling them when suppressed. They often employ them without consulting a physician in cases of sudden suppression of the menses under the influence of moral emotion, a chill, arrested perspiration, &c. Yerj hot sitz-baths repeated several times a day, especially when mustard is added (the efi'ect of which is more durable than that of heat) ; fumiga- tions taken by sitting on a high vessel at the bottom of which boiling water has been poured over a handful of aromatic herbs ; vapour douches round the pelvis ; prolonged tepid foot-baths with the addi- tion of half a pound of mustard ; sinapisms applied to the lower part of the body, especially to the inner side of the thighs and to the hypo- gastrium ; dry cupping applied to the same parts ; the application of leeches to the groins, anus, external surface of the labia or even to the cervix (care being taken in the latter case to apply not more than two on each side, and to repeat this application two or three days running); drastic purgatives, such as jalap, gamboge or aloes; enemata of aloes containing from 3ss to 5iiss of aloes suspended in the yolk of an egg and ^iij of water (Schonlein) ; sometimes cold douches to the pelvis and legs ; such are the means usually employed. They often suffice when repeated for several months consecutively. When neces- sary a stimulus may be applied directly to the vagina and cervix hy irritating vaginal injections. Ashwell advises 10 to 60 minims of liquid ammonia mixed with Jiss of milk repeated several times a day ; beginning with ten drops and adding five every day till a slight leucor- rhoea is produced. There are various ways of enconraging persistence of the congestion which these fluxionary movements determine in the uterus ; for instance by applying very hot emollient cataplasms for a long time to the abdomen, or by enveloping the pelvis and abdomen with hot fiarmels impregnated with aromatic vapours, and covered with oil-silk or gutta percha, so as to maintain a constant moist heat. For chlorotic patients Pajot recommends that the lower limbs should be bandaged, a powerful and rational means when blood-letting is contra- indicated, and when the digestive organs do not tolerate medicines. Other medicaments seem to possess the property not only of con- gesting but also of evacuating the uterus by causing contraction of its muscular wall. Their real or supposed action on the uterus has gained for them the name of emmenagogues. I do not refer to the tincture of iodine and some other medicines which have been tried and too highly vaunted by certain physicians ; probably they answer 208 UTEEINE DISEASES IN DETAIL special indications and modify the general healtli rather than exercise any direct local action. But amongst emmenagogues proper if the action of ergot is incontestable, what are we to think of rue, savin, absinthe, saffron, &c., which enjoy a popular reputation ? Ergot evidently causes uterine contractions and facilitates the menstrual dis- charge. It is generally associated with the others in various popular recipes of doubtful efficacy. The following pills combined with the other means just enumerated often prove useful : — Rue, Savin, Ergot, aa gr. f, Aloes gr. ^ to gr. |. — Make one pill and take 3 pills the first day, 6 the second, 9 the third, three times a day. As a rule these pills should be preceded by foot-baths, sitz-baths and fumiga- tions, and leeches should be applied to the labia the three days on which the pills are taken. These pills often cause colics and a little diarrhoea. Joret^ and Marotte~ give apiol (the active principle of apimn petroselinuni) for amenorrhoea and dysmenorrhoea in 4-grain doses twice a day at the time of the monthly period. Marotte says that this remedy is sometimes very efficacious, especially in cases of simple amenorrhoea, when apparently the only indication is to act on the uterine circulation, on its vaso-motor system, and so to induce an escape of blood from the vessels. It is the same in dysmenorrhoea not dependent on any mechanical obstacle or organic condition of the uterus. If amenorrhoea and dysmenorrhoea are partly dependent on a general local condition, apiol can only be of use when the complex condition has been brought back to that of simple amenorrhoea or dysmenorrhoea. The use of electricity is quite rational, and has given incontestable proofs of its efficacy. One of the poles should be ap- plied to the loins, the other to the groins, hypogastrium, and perineum. The cervix may be seized with an excitor having two branches isolated, so as to protect the vagina, except at the extremities which embrace the cervix ; or one of the poles may be applied to the cervix, the other to the hypogastrium ; or one of the poles to the uterine cavity, the other to the cervix, hypogastrium, or rectum. It is easy to understand how this repeated excitation may stimulate the fluxionary movement and cause contraction of the uterus. The cold douche applied to the cervix has an analogous action, and may also be useful -^ metritis, however, is to be dreaded. Simpson used other very ingenious means, based on the knowledge of the physiological laws of the uterus, and producing the effect of exciting contractions in that organ. For simple dilatation of the os externum, as in the case of mechanical dysmenorrhoea, Simpson used stems, or rather pessaries {S>ee Tigs. 185 and 186), the stems of which varied in diameter, like the bougies with which the urethral canal is dilated. But besides these pessaries, the mechanical action of which, although limited to the orifices, causes uterine contractions by the contractile reaction of the body from titillation of the cervix, Simpson sometimes introduced into the uterus longer stem pessaries made of two metals, > bulletin general de therapeutique, fev., 1860. 2 Id., octobrc, 1863. 3 Pauas. These de Engueliard. Paris, 1868. AMBNOBRHCEA 2G9 an instrument which we have already described as the galvanic stem pessary. At other times he applied what he called a dry cupping-glass {See Eig. 207) to the uterine cavity, i. e. a hollow sound pierced with holes at its terminal extremity, the other end being screwed on to a small aspirator. As a vacuum is made in the instrument, a kind of aspiration is effected on the mucous membrane of the uterus, which is thereby sucked against the minute apertures of the sound through which eventually the blood filters after repeated applications liave been made several days consecutively, or at several monthly periods. II. — General disorders due to amenorrhea are very numerous and very varied. They may be ranged under two principal divisions, according as they depend on ansemia or plethora. There may be a general plethora, or too great a quantity of blood in proportion to the size of the vessels which contain it ; the indication then is clear ; we must empty the vascular system by repeated blood-letting, general and local, by purgatives, by regimen, by diminishing the quantity of food, by exercise, &c. The state of plethora may, so to speak, be localised on one point or one organ, which has become con- gested owing to the repeated fluxions of which it has been the seat since the commencement of the amenorrhcea. This congestion is permanent or temporary ; it may be intermittent, recalling the menstrual periodicity, as I shall explain in speaking of deviated or supplementary menstruation. It may even extend to haemorrhage. Hence different indications varying with the seat of congestion, its character, intensity, duration, its intermittence, its sequences, such as hsemorrhage, &c. If the head, chest, or other important organ is the seat of the evil, the latter must be treated with greater energy without reference to the uterine fluxion which can be recalled after- wards. In short, we must carefully watch the affected organ in the interval or in the absence of the menses, and try to destroy the morbid predisposition which makes it the locus m'moris resisienlue (E. Fritz). Usually, however, the general disorders of health assume an opposite character from that of plethora, that namely of ancamia or chlorosis. These two maladies are often confirmed and greatly increased by amenorrhcea. The nervous disorders which follow suspension of menstruation, even when they do not assume the character of true neurosis, greatly contribute, in concert with digestive troubles and dyspepsia, to derange nutrition, and consequently to throw patients into an anaemic condition or to develop a tendency to chlorosis. This disease is apt to produce derangements in the health very difficult to remedy. Lastly, under these combined influences we may see diathetic affections developed in patients having a predisposition to them, but in whom the outbreak is occasioned by the general debility of the constitution. Such are the various sources of indications arising most frequently from general disorders of the health accompanying amenorrhcea. The indications are the same when these diseases have preceded and pro- duced amenorrhcea in place of following it. In both cases we must first 270 UTERINE DISEASES IN DETAIL of all direct our attention to the affection in question, and when it is cured the araenorrhoea will disappear spontaneously. In addition to the means to be used in the treatment of a nervous condition, to those which are efficacious in cases of dyspepsia, and to the medicaments peculiarly suitable to the diathetic affection that may have been developed, we must employ tonics of all kinds. Hygiene must be the basis of our treatment ; a country life, exer- cise, gymnastics, hydropathy, warm clothing, nourishing and easily- digested food, tonics, and iron in one of the forms already indicated, will generally be successful. The use of natural effervescing and chaly- beate waters, taken on the spot, and so involving change of scene and climate, is often of great service. The waters of Lamalou, Andabre, Sylvanes, Boulou, Vals, (Ardeche), Eoyat, Vichy, may be prescribed in such cases with great hope of success. Retention of the Menses. This condition is characterised by the apparent absence of the catamenia, which, owing to some cause or other, are retained in the vagina or uterus. It is not, therefore, strictly speaking, a disease ; at the same time it is so marked a symptom and connected so closely with certain anatomical lesions, that it is convenient to describe these various lesions under this common name. Amongst the maladies which may be the causes of this accident the most important are : 1. Congenital imperf oration of the vulvo-uterine canal, including the non-separation of the external genital organs, imperforation of the hymen, absence or obliteration of the vagina, imperforation of the cervix. 2. The accidental obliteration of the uterus or vagina owing to cicatrix or to gangrene. In neither of these two cases can the normal menstrual discharge take place by the efforts of nature. Excretion by abnormal paths ((?.y. genito- rectal or tubo-vaginal) can only be effected with great danger. Retention of the metises as a morbid condition, therefore, is limited to symptoms pathognomonic of atresia of the genital canals, i. e. to cases in which some obstacle, congenital or acquired, prevents the dis- charge of the catamenia. Characteristic troubles follow, and the indica- tion evidently is to allow the escape of the fluid accumulated in the cavity above the obstacle. Puech^ has collected and scientifically explained all cases of this kind in a monograph printed in 1863, in the Transactions of the Academy of Science and Letters of Montpellier, from which I shall make numerous quotations. The atresia (literally absence of orifice) or anatomical localisation of the obstacle varies in its seat and origin. I, With regard to the seat of the atresia, three kinds may be dis- tinguished depending on whether it is in the vulva, vagina, or uterus. ' De I'atrcsie des voies genitales de lafemme, in-4°, p. 165. Paris, 1864. RETENTION OF THE MENSES 271 1. Vulval atresia. — The labia majora as well as the minora may contract adhesions. These are almost always cicatricial ; they never cause retention of the menses, but they may interfere with the expul- sion of the urine or lead us to suspect the existence of stone^ and they necessitate an operation, insignificant as a rule. With the exception of cicatricial adhesions they yield to simple traction. Imperforation of the hymen is the most common form of vulval atresia.^ Puech has quoted 151 cases. Atresia of the hymen, which is most frequently congenital, may be complicated by an obstacle in the vagina, as Buysch, Schultz, Walther and Burns have observed, or by an obstacle in the cervix, as seen by Butler and Picard. 2. Vaginal atresia may be congenital or acquired. Congenital vaginal atresia is said to be simple when the obstacle is limited to the vagina, complicated when it involves both vagina and cervix, com- plex when, the vagina being double, one of the canals is obstructed. The first kind is the most common. It may be subdivided according to the extent of the obstacle into three varieties. In the first are in- cluded membranous im])erforations ; in the second, cases in which the obstacle extends from 10 to 40 millimetres; whilst the third includes those exceeding the last limit. The second kind is distinguished from the preceding one by imperforation of the cervix ; it presents two varieties, according as the two obstacles are or are not separated by a cavity. The third kind is characterised by duplicity of the vagina and imperforation of one of the canals. This kind, the rarest of all, has been observed by Leroy,^ Deces^ and Eokitansky."^ Pifty-three cases are recorded of acquired vaginal atresia. They may be complicated by multiple adhesions or by a vesico-vaginal fistula, as seen by Meerck and Puech. 3. Although uterine atresia is rarest of all, fifty-four cases have been collected by Puech. It may be congenital or acquired. In the first case, there is imperforation of the cervix; in the second, obliteration. Imperforations are said to be simple when there is only one cervix ; complex when, the uterus being double, one of the canals is occluded. There are on record thirty-four cases of the first kind and only two of the second. The seat of obliteration is generally the lower part of the cervix, and to this there is but one exception out of twenty-one cases, and that is recorded by Mattei, who observed obliteration of the os internum. II. With regard to the origin of atresia, cases may be divided i)ito congenital and acquired. Congenital atresia is an imperforation, acquired atresia an obliteration. 1. Imperforation, which occurs most frequently, is owing to arrested development. Taking the three zones (vulva, vagina, uterus) into ' We find a case of this kind in the Ephemendes d'Allemagne, Dec. 2, 3rd year, Obs. 151, quoted by Quesnay in his Memoirc sur les vices des himieurs {Memoires de I' Acad. roy. de Chirurgie, t. i). See a case of atresia of the hymen, Fig. 97, p. 90. '^ Journal des connaissances medicales, 1831. ^ Bulletin de la Societe anatomique, 1854. * Zdtschfift der Gesellschaft der Aerzte, 1860. 272 UTERINE DISEASES IN DETAIL which the genital economy may be divided with regard to develop- ment, we find the central zone the seat of the abnormality in 197 out of 230 cases ; the central zone and the internal zone affected simul- taneously in 7 cases; and in 31 the internal one alone affected. These malformations when cured are not inherited ; at least we have no examples of this kind. Fig. 211. — Congenital atresia of the vagina, from a preparation in St. George's Museum (from Barnes) : v, dilated utei-us ; v, vagina dilated above the seat of imperf oration, through which a sound (b) has been passed. 2. Obliterations are due to various causes, the most frequent being long and difficult labours, and especially laceration, suppuration, and gangrene ; eleven cases are recorded of their occurrence in the cervix and thirty-eight in the vagina. Tour times they occurred after the use of caustics, which in one case only had been resorted to for a criminal purpose, in the others they had been employed as therapeutic means. The cases recorded by Williams and Rigby, in which caustics had been used to cure cervical ulcers, ought to be a caution to sur- geons. I myself have had to remedy 14 cases of constriction and 9 of complete obliteration either of the os internum or of the upper part of the vagina behind which the cervix was imprisoned, owing to the inopportune or exaggerated application of caustics to the upper part of the vagina or to the cervix. At other times this accident is caused by acute or chronic inflammation of the cervix or vagina ; sometimes it is of spontaneous or unknown origin, sometimes it is RETENTION OF THE MENSES 273 produced by excessive coitus, by irritating mani])ulations, by a tumour or dexion of the uterus. Syphilis, diphtheria, scarlatina, measles and smallpox are also occasional causes. Lastly, cholera (three cases) and typhoid fever (four cases), by producing mortification of the mucous membrane of the vagina or cervix, have brought about the same result. In short, the morbid adhesions which cause obliteration of the genital canals depend on the formation of cicatricial tissue which unites the two ulcerated surfaces. Happily for the patients these adhesions Fig. 212. — Acquired atresia (obliteration) of the cervix, from a preparation given by Barnes to the London Hospital. A woman of forty-three, married and sterile. Obliterating adhesions, caused by endometritis in a' and h' ; c, lower part of the cervix ; 6, middle part dilated ; a, cavity of the body dilated as well as the Fallopian tubes. produce contraction and mechanical dysmenorrhcea oftener than obliteration. Diagnosis. — Atresia of the genital canals, whatever may be its seat (whether vulva, vagina or uterus), may be simple, complicated or complex. The retention of the secretion, which is total and forms a unilocular or bilocular tumour in the two first cases, is only partial in the third, giving rise to the singular phenomenon of the free discharge of the menses, together with all the symptoms of mechanical dysmenorrhcea and of menstrual retention, including the tumour caused by the 18 274 UTEHINE DISEASES IN DETAIL retentum, with this difference, that in place of being median this tumour is lateral or unilateral. Subjective signs. — The dominant symptom of atresia therefore is retention of the menses accompanied by phenomena of various kinds ; some local; either uterine (including hsemorrhage) or in neighbouring organs ; others general, symptomatic or sympathetic. In congenital atresia the commencement is often unnoticed ; it is mistaken for diffi- culties attending the advent of menstruation, the symptoms subside in the interval of the fluxionary movements, and the uterus gradually distends. Acquired atresia, also, may be well tolerated at first ; even from the beginning, however, the symptoms are more serious than in the former. In both cases they take the following course : at the time of the monthly periods the patients experience a sense of discomfort and weight in the pelvis. The back feels as if it were broken, and afterwards becomes the seat of pains which originate in the loins and extend to the hypogastrium and anus. These colics, after having lasted from three to six days, cease of themselves. At the next period the same phenomena take place ; only they gradually increase in intensity, the renal or lumbar pains become more frequent and more acute, their morbid character increases, and sooner or later expulsive pains are developed similar to uterine contractions at labour. At the same time other hypogastric symptoms show themselves ; the formation of a tumour of gradually increasing size, due to the dilatation of the uterine cavity from the accumulation of blood, is the inevitable con- sequence of retention of the menses and leads to various complications. These are generally in proportion to the quantity of fluid contained in the womb. If the uterine tumour presses on the sacro-lumbar nerves it causes a tingling and numbness in the legs. If it compresses the rectum it produces constipation or tenesmus ; whilst if it pushes against the bladder it sets up not only vesical tenesmus and dysuria, but also retention or incontinence of urine. For some months these are the only disturbances observed. The stomach and nervous system, however, are soon affected sympatheti- cally. There is loss of appetite, nausea and even vomiting. The reaction on the nervous system is quite as serious, a state of erethism is produced by the intolerable pains which continue almost without intermission, as well as a feeling of suffocation and attacks of dyspnoea. Sometimes even delirium occurs, with more or less violent fits of convulsion ; there is often loss of self control verging on insanity ; a propensity to suicide may even manifest itself. The interval of relief between each monthly period gradually becomes shorter. The crises follow almost uninterruptedly, the general health suffers seriously, life being a long series of continued sufferings to the patient mingled with periodical exacerbations. Objective signs. — The symptoms revealed by examination of the parts vary according to the seat and existence of the obstacle. I. In imperforation of the hymen the touch and sight discover, at the entrance of the vulva, a tumour sometimes deep red sometimes violet, varying in size between a chestnut and a large apple. When RETENTION OP THE MENSES 275 the hymen is very much distended the nymphse may be effaced. This tumour, which is generally insensible, becomes distended and painful at the monthly period. Efforts of any kind, cough or pressure on the hypogastrium, by making it more prominent, allow fluctuation to be perceived. The conical form of the tumour, its projection between the labia, its spontaneous reduction, have led to its being mistaken for prolapsus uteri. Dubois de le Boe, Mauriceau^ Amand, have related cases of this mistake. In other cases it has been said to resemble the bag of waters, and this singular error of diagnosis was once made. II. In atresia of the vagina, when the imperforation is membranous, the results arrived at by touch are identical with those just enumerated. When the obstacle is more extensive rectal touch must also be employed. To measure the length of this obstacle the thumb is intro- duced into the lower part of the vagina till the occlusion is reached, whilst the index finger of the same hand is passed into the rectum till the lower border of the tumour is reached. The space between the finger and thumb gives an idea of the extent of the obstacle ; if the thumb is not sufficient the index of the other hand is substituted for it, or a metallic sound : the results of this mode of exploration, though less exact, are valuable. Lastly, to estimate the thickness of the tissues separating the bladder from the rectum, a sound is introduced into the bladder, and is moved about whilst the index finger placed in the rectum follows its course ; we can judge of the space which separates the sound from the finger, and consequently of the thickness of the tumour, by the facility and clearness with which the contact of the instrument is per- ceived. It is curious that, in some cases of obliteration of the vulva and vagina or of partial or total absence of the latter, communications have sometimes existed under the form of a fistula between the uterus and the rectum or the bladder or urethra, these canals serving for coitus to the extent of permitting conception to take place. Oldham, Routh,! Uterhart^ and Spencer Wells ^ have met with cases where the urethra, being either originally large or dilated by use, has served for coitus, and sometimes even for menstruation. III. In atresia of the cervix, vaginal touch reveals the cervix shortened and deformed, projecting very slightly into the vagina and presenting no orifice whatever. The speculum confirms these data and allows the colour of the parts to be seen. The most signi- ficant characteristic, however, is that produced by distension of the uterus, by the tumour so formed, and its projection at the hypo- gastrium. Hypogastric tumour. — The hypogastric tumour, more or less volu- minous according to the frequency of menstruation and the quantity of blood exuded, is formed by the distended uterus. Bounded below by the obstacle, on each side by the bones of the pelvis, it can only be developed upwards. Consequently, although at first contained in the pelvis, it soon extends beyond it, and rising into the abdominal » Obstetrical Trans. 1870. 2 Berlin. Klin. Wochenschrift, 1869. ^ Med. Times and Gazette, 1870. 276 UTERINE DISEASES IN DETAIL cavity increases in size till it reaches the dimensions of a pregnancy at full term, sometimes, though rarely, exceeding even that.^ The tumour progresses by degrees, increasing and rising at the menstrual periods, diminishing and falling in the intervals, but each time remaining larger than it was before. Its form is generally globular, at other times it is ovoid and subdivided by strangulation, like a pilgrim's gourd, when the atresia, being at the base of the vagina, has suc- cessively determined distension of the vagina, cervix, and uterus, the situation of the sphincters of the vaginal orifice and isthmus being indicated by the resistance they ofter to dilatation, preventing the Fig. 213. — Globular hypogastric tumour, with lateral appendages, produced by dilatation and hypertrophy of the womb M and of the Fallopian tubes T T, owing to retention of the menses from complete absence of the vagina V. Retention of the menses for seven years, puncture by the rectum, followed by purulent peritonitis causing death on the eighth day (after Fiirst, of Leipsic). tumour from acquiring at these points the dimensions which it attains in the vagina and in the cervical and uterine cavities. Its position is generally median, but it may be more or less inclined and even lateral. As a rule this tumour is single, but in some cases it is double and even triple. These two or three tumours depend either on division of the uterus (Leroy, Deces, Eokitansky, Nelaton) or on dilata- tion of the Fallopian tubes by menstrual blood. In the latter case, which is important in reference to the prognosis, the principal tumour is bounded on one or both sides by an ovoid, cylindrical or vermiform swelling, soft and rolling under the finger. This tumour is resistant or doughy to the touch, communicating a sensation of fluctuation ; but the counter-stroke produced by the ' Tumours formed by the retention and accumulation of fluids in the imper- forate uterus or vagina may acquire so great a size in the fojtus as to form an obstacle to pai-turition. (Di- Gervis and Dr Gomer Davies, quoted by Alph. Hergott, Des maladies fcetales qui jieuvent faire obstacle d I'accoiichement, p. 225. These de concours. Paris, 1878.) RETENTION OF THE MENSES 277 displaced fluid is not distinct as in ascites or in a cystic tumour. The fluctuation is all the more obscure because the uterine walls are not only distended but hypertrophied by the repetition of expulsive contractions caused by the retention of the blood (I'igs. 213 and 314). Fig. 214. — Hypogastric tumour in the form of a pilgrim's gourd, caused by retention of the menses owing to imperforation of the vulva ; preparation in the Eadcliffe Museum at Oxford ; case described by Tuckwell, ^ natural size ; v, distended vagina ; oil, os uteri and cavity of uterus above it equally distended ; atresia of the vulva (after Barnes). Lateral hcematometra. — The most difiicult cases to diagnose are those of com.plex atresia, i. e. occlusion of one of the vagina or titeri forming part of a duplex sexual system ; because whilst the patient has all the symptoms of dysmenorrhoea, she nevertheless has her periods, and this fact removes from the mind of the physician all idea of retention of the menses. However, after having been apprised of the repeated occurrence of this anatomo-pathological anomaly, and having had the opportunity of seeing a drawing of it as given here, it would be inexcusable to ignore the possibility of its ex- 278 UTERINE DISEASES IN DETAIL istence. These imperforations of oue of the halves of a double genital canal have been met with 11 times iu the uterine canal and 23 times in the vagina. Out of 28 cases they have been observed 20 Fig. 215. — Max Jacquet, Ueber Haeniatometra bei Uterus duplex {Zeitschrift fiir Gehurtshillfe und Frauenkranhheiten, Bd. i, S. 134. Stuttgart, 1875). Double uterus in a girl of fourteen who bad menstruated for some months, and who succumbed to peritonitis caused by retention of the menses in the right uterus which was greatly distended, and in which a thin spot c seemed to correspond to the atresia of the cervix of the same size. The left utenis, which is open, shows the arbor vitce ; A B, the longitudinal folds of the vagina, greater behind A than before B ; vestiges of the parti- tion between the primitive vaginae. times on the right and 8 times on the left. They were all cases of uterus hicorms, except two tliat were bilocular or divided. The most striking symptoms are : manifestation of the pains of menstrual re- tention coinciding with discharge of the catamenia, and the presence of a tumour occupying one side of the hypogastrium and a large part of the pelvic cavity, hindering walking, and causing dysuria or retention of the urine, sometimes fluctuating, easily defined as to its superior limits, sometimes reaching the vulva below and pushing the vaginal portion of the cervix of the other side upwards, or remaining in the pelvis on one side only, pushing the cervix of the other uterus to one side, or forming, on a level with the urethra (the seat of the atresia) a spherical tumour which projects into one of the vaginal euls-de-sac, and presses laterally against the open cornu, which it pushes upwards and to one side till it appears to be almost surrounded by it (Fig. 218). Any pressure on the hypogastric tumour is trans- mitted to the vaginal portion and vice-versa} ' Puech, Annalcs de Gynecologic, April, June, July, August, 1875. RETENTION OF THE MENSES 279 These symptoms and catheterism of the open cornu ought to prevent any error in diagnosis. Nevertheless, unilateral hcematometra has been taken for congestive dysmenorrhcea, peri-uterine hematocele, and even an ovarian cyst.^ Sometimes it is water instead of blood which fills the imperforate cavity, sometimes it is pus, sometimes the tumour is uterine, but oftener vagino-uterine."' These are the most usual symptoms, but sometimes there are others in addition. In the way of complications we may mention : 1, dis- charges by the genital canals; 2, deviation of the menses; 3, hysteria; 4, chlorosis ; 5, vagino- and utero-vesical fistulse. The modes of termination constitute an element in the diagnosis. They are varied and depend on the disturbances which the presence of an obstacle causes in menstruation. 1. Deviation of the menses may be more than a symptom; it may also be a mode of termination of the retention. I have had a patient in whom this deviation persisted throughout life. 2. The obstacle may give way, either by bursting (8 cases) or by gangrene (4 cases). As a rule, the former mode occurs where the obstacle is thin, and it takes place after violent colics. I have once seen it. 3. The organs containing the menstrual blood are dilated, their walls become thin and in the end give way. When the uterus is the seat of this rupture, death may be the imme- diate consequence ; three cases of the kind have been observed. When it is the vagina or the lower part of the cervix, it is possible for the menstrual blood to be discharged by the bladder ; such cases have been observed by Treteau, Boyer and Desormeaux. 4. Dilatation of the Fallopian tubes by the menstrual blood takes place sooner or later. It is caused by the accumulation of blood and the uterine contractions forcing the orifices of the Fallopian tubes, which then remain open, owing to their loss of contractility. It is in such cases that the sound, when the obstacle has been removed, has been known to enter the uterus and penetrate into the Fallopian tube. The tumour thus formed in the Fallopian tube, especially if in the external half, may attain con- siderable proportions. The blood thus accumulated may be expelled, either by flowing backwards through the ostia uterina (£ cases) or by exuding through the fimbriated extremity into the peritoneum (14 cases). Discharge by the uterine orifices necessitates previous eva- cuation of the uterus ; it has only been observed by Barnotte and Amussat. Discharge by the fimbriated extremity is generally fatal. Amussat and Bernutz alone have seen patients recover, thanks to the ^ Carl Staude, " Haematometra und HaematoTiolpos hei zweigetheiltem Utero- vaginal Canale. Verivechselung mit Tumor Ovarii. Versuchder Ovariotomie, Heilung." The patient died accidentally six months afterwards, when the uterine tumour, caused by retention of the menses, was discovered. ZeitschHft fiir Geburtsh. xind Frauenlcranlc, Bd. i, S. 338. Stuttgai-t, 1875. - W. A. Freund, Haematometra und Haematoholpos lateralis hei Atresia eines riidimentaren ScheidenJianals eines Uterus duplex, in Bcitriige zur GeburtsJc. und GynaeJcologic, Bd. i, S. 26. Berlin, 1872. Id., id., Beitrdge zur Fathologie des doppvlten Genitalkanals, in Zeitschrift fiir Gtburtsk. mul Gynaekologie, Bd. i, S. 231. Stuttgart, 1877. — Breisky, Pyometre et pyokolpe lateral, suite d'atresie d'une moitie de vagin rudimentaire sur un uterus septus. Archivf. Gynaekologie, Bd. ii, S. 24. Berlin, 1871. 280 UTEEINE DISEASES IN DETAIL encysting of the blood and to its expulsion through the rectum. As for the other cases recorded, death occurred so rapidly as to leave no time for the development of peritonitis. Such are the cases of imperforate hymen, related by Brodie, Moore and Paget ; by Boyer, Ueces, de Haen, Locatelli, Maisonneuve (2 cases), Munck, of vaginal atresia ; by Hemman and de Pauly of atresia of the cervix. I have seen a woman succumb rapidly to peritonitis caused by atresia of the cervix. In lateral hsematometra the natural terminations are similar to the preceding: spontaneous rupture of the obstacle, perforation of the septum between the two lallopian tubes (Fig. 216), passage of the Fig. 216. — Breisky, Pyometra and Pyokolpos due to atresia of one half of a rudimentary vagina in a uterus septus. Archivfilr GynaeJcologie, Bd. ii, S. 48. Berlin, 1871. wZ, right vagina ; ?(rf, right uterus filled with pus ; vg,\eit vagina ; ug, left uterus ; o, orifice through which the pus retained in the right uterus was discharged externally through the left uterus and vagina. blood from the horn into the Fallopian tube, and from this into the peritoneal cavity, peritonitis caused by repeated crises, or finally, passage of the fluid into the normal uterus and vagina, and subsequent cure. In all these cases consumption may supervene and cause death ; for dyspepsia, vomiting, continued pain and constant lessening of the interval between the crises, wear out the best constitution and lead to marasmus. Occasionally the menopause, by putting a stop to the discharge, or rather to the sanguineous fluxion, at the same time puts an end to all accidents. To sum up, a cure can only take place when the obstacle gives way. Tolerance is established when the menses are deviated, when amenor- rhoea superA^enes, or when the menopause is established. Apart from these exceptions, there is always danger of death, and as nothing aft'ords any indication as to which of these terminations will occur, the wisest course is to avoid all by opportune intervention. Dijferential diagnosis. — Without having any pathognomonic signs, strictly speaking, retention of the menses nevertheless causes a number of characteristic symptoms, such as absence of all discharge, the coin- cidence in time between the commencement of the symptoms and the RETENTION OF THE MENSES 281 expected advent of menstruation, the expulsive nature of the pains, their duration from three to eight days, and their recurrence after about a month's interval, their localisation in the loins, hypogastrium and perineum, and lastly, the appearance of a tumour either at the vulva or above the pubis, or in both places simultaneously. When all these symptoms have been observed it is easy to diagnose atresia ; but it is different when some are wanting or when they are not well marked. In such cases a number of unjustifiable mistakes are sometimes made : menstrual retention from atresia confounded with prolapsus uteri, sciatica, ascites, cystocele, uterine polypus, amenorrhoea, or even with pregnancy. Sometimes hsematocele, pelvi- peritonitis and purulent tumours of the pelvis, ovarian cysts, hydatid cysts, fibroma, cancer and hydrometra may be mistaken for retention, and vice versa. Amenorrhcea is not attended by periodical exacerba- tions, nor, above all, by a hypogastric tumour. In pregnancy the knowledge of the antecedents, the mode of development of the tumour, the state of the areola of the breasts, especially if the patient has never had children, the results of auscultation (negative in retention, positive in pregnancy) with the physical signs revealed by digital examination, are sufficient to establish the distinction. There is one feature common to hydrometra and hsematometra, viz. occlusion of the cervix; but special and distinctive symptoms also always exist : hydrometra is consecutive to amenorrhoea, and has generally a slow commencement ; Fig. 217. — Freiind of Breslau, two cases of lateral hsematometra and ha?uiato- kolpos from atresia ot" a rudimentary vaginal canal of double uterus. Beitrdge zur Gebiirtshiilfeuml Gynaehologie, Bd. ii, Heft i, S. 2(3. Berlin, 1872. Vertical section : td, right Fallopian tube ; Ird, right round liga- ment; ovd, right vaginal orifice; av, vaginal atresia; ff/, left Fallopian tube ; Irg, left round ligament ; ovg left vaginal os ; li, hymen. 282 UTERINE DISEASES IN DETAIL accidental hsematometra begins suddenly, and is preceded by a disease affecting the cervix. The course of development of the tumour is not identical — in the first it takes place without pain, and almost con- tinuously ; in the second it is painful, and is produced in monthly stages. Lastly, in the one there may be sanguineous discharge, in the other there is none. As to the differential diagnosis of various kinds of atresia, a careful examination enables us to discover the special characteristics which I have already pointed out in describing their history. It will be ^9 Fig. 218. — Id. horizontal section : av, vaginal atresia ; vo, left vagina open. remembered that lateral tumors (haematometra, hydrometra or pyo- metra), in cases of double genital system usually project into the normal vagina or uterus (Eig. 218), so as to be partly covered by them on one side, and to jut out beyond them on the other, especially in the upper part corresj)onding to the cornu and to the Fallopian tube on the side of the seat of obliteration (Fig. 218). Treatment. — Out of the great number of cases recorded there are eight only in which the breaking up of the tumour has occurred spon- taneously. The age of the patients thus cured varies from 18 to 23. The time is that of a paroxysm : the necessary prelude, a series of violent colics. The seat of the obstacle was five times at the vulva,^ twice at the vagina,^ once at the cervix.^ In four cases only was this natural perforation produced by gangrene of the obstacle under the influence of continuous pressure of the accumulated blood and of uterine contractions. In that recorded by Allaire d'Hcricy^ the symptoms had lasted for seventeen months ; the tumour was the size ' Wier, De prestigiis dcemonum, lib. ii, cap. xxxviii. — Schenck, Ohserva- tioncs viedicoB rariores. Lugduni, 1643, lib. iv, p. 532. — Bartholin, Cenhtr. v., Obs. xliii. — Eschenbach, Obs. mcd. cliir., p. 8. — Lafitte, Revue thcrapeutique du Midi, t. X, p. 44. — Scanzoni, op. cit., p. 476 : " A girl of nineteen suffered for two years from severe dysmenorrhoia due to imperforate hymen, when during an attack of pain tliis membrane suddenly iui)tured allowing tlie escape of about a kilogramme of fcL^tid and decomposed l)lood. Immcdiatel.y after tliis accident we were called and ascertained that the rui)ture had taken place ; the hymen hung down from tlie vagina in several irregular shreds." ^ Dclisle, Journal general de medecine, t. Ixvi, ]). 91. It may be admitted that the seat of the second obstacle was at the cervix. — Kiwiscli, in Scanzoni, op. cit., p. 487. -The orifice in this case was irregular and funnel-sliaped. ^ P\iech, op. cit., ol)s. xiv, p. 56. * Gazette medicate de Paris, 1832, p. 513. RETENTION OF THE MENSES 283 of a small heii^s egg, and the hymen presented two blackish points, the one at the centre, the other at the side ; the latter opened first and gave issue to the contents. In that of Demaux^ obliteration of the vagina had been preceded by a difiicult labour, and sounds had to be used to dilate the opening which had formed in the centre as the result of sphacelus. In the two last^ gangrene completed the opera- tion which the surgeon had not the courage to finish. We cannot, therefore, count on the efforts of nature to bring about a happj termi- nation to a disease the course of which is beset with dangers. We must not, however, conclude that operation is always indicated. We have to consider the real dangers incurred by operation, the still greater perils which may result from the progress of the disease, as well as the abolition of the reproductive functions which always occurs. These three elements of the question are evidently the three principal sources of indication, or contra-indication, to the active intervention of art. The elements furnished by the intensity of the disease, its seat and its nature, must also be taken into account. The more the organs have been distended by the menstrual blood and the more they have lost their power of contraction, the greater likelihood there is of metro-peritonitis and purulent infection finding a favorable field for development. Whatever the size of the tumour may be, if it is bordered by one or two small lateral tumours formed by the distension of the Pallopian tubes, we have reason to fear a fatal result; the operation, perilous as it may be, in this case is the only means of preventing death. With reference to the seat of atresia, imperforation of the hymen and membranous occlusion of the vagina and cervix may be classed together as the least dangerous forms ; after them and in order of increasing gravity come partial absence of the vagina, complete absence of this organ, and lastly absence of the vagina with imperforation of the cervix. From another point of view operation as a rule is much more dangerous in acquired than in congenital atresia. Whenever an operation is indicated it should be performed as soon as possible, as delay only aggravates the danger owing to the increas- ing dilatation of the uterus at every monthly period. Operation is only absolutely contra-indicated when the uterus is atrophied and there seems no likelihood that the menses will be established; before operating therefore we must ascertain that the uterus exists, and that the morbid symptoms are owing to distension of this organ and not to any other cause. Operation is also contra-indicated when the existence of vesical or rectal fistulce allows the escape of the menses by the urethra or anus. In such cases intervention should only be resorted to when the operation is easy and the fistula small and susceptible of cure ; here also, how- ever, there is not strictly speaking retention, and therefore the opera- tion is not urgent. The age of the patient may also be an absolute 1 Gazette des hopitaux, 1850, p. 567. ^ Barth, Gazette mcdicale de Strasbo^lrg, 18i4, p. 221 : Spontaneous cure after four unsuccessful operations. — Blandin, Gazette mcdicale de Paris, 1846, p. 57. Operation causing vesical fistula ; spontaneous cure. 284 UTERINE DISEASES IN DETAIL contra-indication ; wliat may be attempted in the case of a young woman of twenty ought not to be thought of in the case of a woman of fifty. Nevertheless though, as a rule, it is wise to abstain when the menopause is established, or when the patient has reached forty and the menstrual periods have diminished in intensity, yet we ought to operate after this age when blood-letting and opium prove ineffectual and the tumour continues to progress ; for women of fifty and upwards have succumbed in such cases to spontaneous rupture of the uterus.^ With the exception of such cases operation is indicated, and the sooner it is had recourse to the better. Although Boyer,'-^ Dupuytren,^ Capuron^ and Cazeaux ^ have condemned it, it seems to me indicated within the limits just stated. The distension of the Fallopian tubes by the menstrual blood, although evidently a source of danger, is not a contra-indication : on the one hand the prospect of imminent death, on the other the success obtained by Amussat, Debrou and Barnotte, authorise active intervention. We should, however, warn the parents of the risk involved. The only real contra-indication is the extent of the obstacle, or rather the extent of the destructions, the length and narrow- ness of the vulvo-uterine cicatrix in cases of accidental obliteration, in short the insurmountable operative difficulties. If the atresia has been discovered in childhood the most suitable time for operating is at puberty, just before the appearance of the menses. After menstruation is established the indication is to operate as soon as possible. Whatever the age of the patient may be, this operation, like all others on the uterus, should only be performed in the intercalary period, seven or eight days after menstruation ; at this time the con- gestion is entirely dissipated, and the conditions are therefore the best possible for avoiding inflammation. The treatment, essentially surgical, of retention of the menses in- cludes two important indications: — (1) To give free passage to the blood retained above the obstacle ; (2) to maintain the patency of the opening made. We may make an outlet for the discharge of the blood in two ways, indirectly or directly. The indirect method, which consists in attacking the tumour through the abdomen, the bladder or the rectum, is only admissible in cases of complete absence of the vagina, where it is im- possible to reach the uterus through the recto-vesical space. The best of these three indirect ways is evidently the rectum. I confess, how- ever, that it seems to me more applicable to cases of atresia of the hymen or lower part of the vagina than to those of the uterus, and in this case it is easier to open the tumour directly through the vulva. Although this operation, which was performed for the first time un- successfully by Dubois,^ has been repeated in our days by Oldham, ' Duparqne, Traite des ruptures de la matrice. 1839, p. 13, 14. " Trait(i des malad. cJururg., t. x, p. 417, 4e edit. Paris, 1831. ^ Quoted by Pif?ne, Traite dcs chirurg., of Clidlius, t. ii, p. 62. ■' Bulletin de I'Acad. de med., 13th Sept., 1839. ' Gazette des hnpitaux. 18(51, p. 31. * See Boyer, Traite des malad. chirur., t. x, p. 447. — Boivin et Duges, op. RETENTION OF THE MENSES 285 Baker-Brown, and Hastings-Hamilton, who penetrate from the rectum into the tumour by means of a curved trocar, I cannot refrain from remarking that the operator risks piercing the peritoneum twice, and that, in order to prevent the consequences of the blood remaining in the uterus or vagina, its effusion into the peritoneum is encouraged, whilst, even in case of success, all that is gained is a utero- or vagino- rectal fistula ; with which, if it occurs spontaneously, we must be contented, but which is not desirable when gained at the risk of life. The direct method consists in attacking the tumour through the vulva and in establishing a lasting communication between the one and the other. This method alone satisfies all indications, for, by pre- venting accidents, it brings the parts back to their natural condition. Cauterisation has been tried, but without success, by Felix Plater^ and Gaspard Bauhin.^ Caustics in fact have inconveniences which are not compensated by any advantage; it is difficult to use them, and impossible to limit their action, and the orifice is made at the cost of a more or less considerable loss of substance and of the inevitable formation of cicatricial tissue. On the contrary, incision and tearing, either alone or aided by dilatation, are the most suitable means for opening up a vulvo-uterine passage, incisions or puncture suflicing for thin membranous occlusions, incision, dissection and dilatation being necessary for obliterations of considerable depth. As the modes of procedure vary according to the resistance of the obstacles, I will describe the manner of performing each operation successively. The bladder having been emptied by means of a catheter, and the rectum by an enema, the patient should lie on her back on the edge of the bed, opposite a window, in the position required for examination by speculum, the pelvis raised, the thighs and legs flexed and apart. An anesthetic should be given, unless especially contra-indicated; and, in most of these operations, the bladder should be raised by means of a sound introduced into its cavity and the rectum should be drawn down by the index finger. I. Imperforate hymen. — The plan which seems to me the best is the following, proposed by Puech.^ Having made the hymen bulge out, the centre is seized with forceps, whilst the right hand, with curved scissors or bistoury, removes a circular piece of membrane. The genital organs are then explored with the index finger, a gutta-percha bougie of medium size being afterwards substituted for the finger to close the opening. By this means the blood is prevented from gushing out and the uterine and vaginal cavities are enabled to recover their normal condition, whilst the air, having greater difficulty in penetrating into the uterine cavity, exerts a less injurious inffueuce on it. As a rule, this operation is not followed by any serious consequences ; but we cit., t. i, p. 272. Congenital absence of the vagina. Puncture by the rectum. Peritonitis ending in death. ^ Observationum , lib. iii. Basilese, 1614, lib. i, p. 241. 2 Theatrum anatomiciim. Paris, 1621, lib. i, cap. xxxix. p. 133. 3 Op. cit., p. 98. 286 UTEEINE DISEASES IN DETAIL must not forget that metro-peritonitis may occur and cause death, as has happened twice out of 135 operations.^ II. Atresia of the vagina. — In cases of membranous im perforations, a trocar or straight bistoury is plunged into the obstacle, and incisions are made in various directions till the finger passes easily. In more extensive atresia there are various modes of procedure, but only two deserve description. 1. The plan followed by Amussat^ in 1832 consists in more or less violent pressure exercised by the finger or a soft body, with the object of pressing the vulval mucous membrane into the groove corresponding to the entrance of the absent vagina. After a time this yields, and after several attempts, repeated at longer or shorter intervals, the tumour is reached, when the last barrier may be removed by the trocar. This plan is more seductive than perfect. It can neither be employed in accidental atresia, nor in cases where the rectal and vesical walls are separated by a tissue of much resistance. It is very slow. Amussat required six sittings and ten days to reach the uterus ; Parey^ four sittings and thirteen days, besides which, after the second sitting, the sensibility was so great as to make the latter attempts very painful. The patient operated upon by Bernutz ^ was discouraged after five attempts, in spite of her great desire to be cured. 3. Dupuytren^s plan ^ consists in the use of the bistoury, combined with separation of the cellular tissue. It is effected in a single sitting. The following is the description of it as modified by Puech,^ By means of a male catheter the bladder is kept raised. The index of the left hand is then passed as far into the intestine as possible to guide the bistoury and to protect the rectum. A transverse incision is then made in the centre of the obstacle, or in the vulval fossa if the vagina is entirely absent; when the cellular tissue is loose, the operator may, with the finger, catheter,'^ or handle of the bistoury, separate the vesical and rectal walls till the tumour is reached ; when it is thick or very re- sistant it must be carefully dissected, separating the tissues with the handle or the finger rather than cutting them, and when necessary cutting with a probe-pointed bistoury. The operator must proceed slowly and circumspectly, stopping occasionally to examine with the finger to ascertain how far he is from organs that must be avoided. 1 shall merely mention electricity, as it has been said to possess the property of causing extensile in place of retractile cicatricial tissue; this however has not been proved. When the newly-formed canal ' Quesnay in his paper Swi' les vices dcs huvieurs, printed in the Memoircs de I'Academie de chirurgie (1743, pp. 58, 59), characterises the blood which issues from the va<^ina after operations for atresia of the hymen as being black, thick, often inodorous, but sometimes fcetid (De la Motte, Kpliemcrides d'Al- lemugne, Benivenius, Merch'ren, Aquapendcnte). 2 Gazette Mcdicale de Paris, 1835, p. 785. ^ Gazette des hojntaux, 1861, p. 69. " Op. cit., t. i, p. 307. " Saljaiier, Theses de Paris, 1848, no. 08, p. 40. •■' O]). cit., p. 106. " Fletcher, Medico-surgical Notes and Illustrations. London, 1831, p. 143. — Archiv. gen. de tried., 1835, t. vii, p. 54it. RETENTION OF THE MENSES 287 admits the index finger easily, and when a clearer perception of fluctua- tion apprises the surgeon of the proximity of the collection of blood, he may plunge the trocar into it, and the issue of a brown syrupy fluid will prove to him that he has succeeded. A small quantity of the fluid is allowed to escape by the canula. This little orifice will only be enlarged after some time to ensure the final result. A few days afterwards a gutta-percha catheter is to be introduced into the uterine cavity, and injections of tepid water with a few drops of carbolic acid are to be made through it. A small syringe should be used, and the injections should be made with great precaution. The dressing finished, the parts are sponged and wiped and the patient placed in bed, care being taken to protect the bedding from being soiled by the black blood and mucous discharge which will be excreted for some days. This method is applicable to all cases ; only the use of the finger or soft instruments may be limited according to circumstances, some- times not being required at all. If it is logical to distinguish cases of this kind (the most serious, and those which cause most acci- dents), it is unnecessary, with Verneuil,i to adopt a different plan for them. Accidents attending the operation. — Roonhuysen,^ Benevoli,^ Liston,* the surgeon quoted by Dieffrnbach" and Barth^ were obliged to leave the operation unfinished ; Roonhuysen and the surgeon quoted by Dieff'enbach because they had involved the rectum and the others from want of courage. On one occasion I was unable to terminate an operation of this kind. The blending of the bladder and rectum was so complete at a certain depth that it would have been imprudent to have continued, for it was impossible to attempt to separate the one from the other. The menstrual retention was caused by a cicatricial occlusion of the whole vagina consecutive to gangrenous suppuration after a confinement. The patient was stout, extremely sensitive with regard to the consequences of her infirmity, and threatened by the accidents which often accompany retention. Prom that time the symptoms were gradually mitigated, and although the menstrual molimen and ovarian activity were more or less felt every month, there was no accumulation of blood in the uterus, no deviation of the menses, nor any other pathological phenomenon, thanks to the palliative treatment prescribed and to the progressive tolerance of the organism. The bladder has been injured three times : in one case a cure was effected ; in another a vesico-vaginal fistula was formed which Blandin could not cure ; and another time (de Haen), apart from the fistula, ' Bapport a la Societe de chirurgie sur V operation de M. Patry {Gazette des hapitaux. 1861, p. 69). 2 Observ. vied, rariores Gerardi Blasii. Amstelodami, 1677, p, 30. ^ Related by Chambon and by Colombat. ■* Gaz. des Mpitaux, 1839, p. 183. ^ Related by Verneuil, Gaz. des. hop., 1861, p. 31. ^ Gazette mecZ. de Strasbourg, 1844, p. 222. 288 UTERINE DISEASES IN DETAIL death occurred by the effusion of menstrual blood into the peritoneum through the Fallopian tubes. Haemorrhage is rarely serious ; but it may become troublesome. This has led Camerarius, Voisin and Guerin to make several short operations. In this case it is necessary in order not to lose the benefit of the first incisions, to insert a foreign body, or even a dilator, in the canal that has been hollowed out. The consecutive accidents which may occur are varied : metritis, inflammation of the Fallopian tubes, peritonitis, and even putrid in- fection. Out of 66 operations there were 6 cases of death due to the three last diseases. I am convinced that, in accidental obliterations due to puerperal gangrene of the vagina, the tendency of inflammations to assume the gangrenous character may be the cause of fatal symptoms, just as it produced the first accident and the deformity which necessitated the operation. I lost a patient in this way. After great difficulties, and even a little tearing of the peritoneal cul-de sac in front of the rectum, I reached the uterus, and things progressed so well for some days that we had hopes of success, when, concurrently with a slight attack of peritonitis easily subdued by treatment, gangrene of the walls of the new canal showed itself, which yielded to no tonic, nor to any injection detersive, antiseptic, stimulating, nor catheretic, and which finally caused death on the fifteenth day. Relapse has been observed four times. It is due to the insufficiency of the operation, to inflammation of the parts, or to neglect of dressing. Contraction of the canal due to the same causes has been observed nine times. To sum up, the results are as follows : — Out of 28 operations for congenital atresia 2 were not terminated, and 2 had to be repeated owing to relapses. There were 6 deaths, 4 of which were owing to the reflux of uterine blood ; leaving these out of the calculation, there were 2 deaths in 24 cases. Out of 33 cases of accidental atresia, 8 operations were not terminated or had to be repeated ; there were 6 deaths, one of which was owing to a reflux of uterine blood, and another to intercurrent pleurisy ; putting these aside there re- main 4 deaths in 31 cases, a greater mortality than in congenital atresia. 3. The author's method. I usually prefer rapid operation with the bistoury for accidental atresia ; but for congenital atresia I greatly prefer the slow operation by means of small incisions combined with the use of sponge tents of gradually increasing size, and the pro- longed issue of blood drop by drop.^ ' I have lately had occasion to congratulate myself on the success of this method in a young lady suffering from vaginal atresia. Sponge tents intro- duced into small incisions made every week of increasing depth allowed of my reaching tlie cervix which, owing to gradual cicatrisation of the wound after every operation, was at last drawn down to a level with the lower part of the vagina, tlie only part originally existing. Treatment lasted six months. It was followed some months afterwards by pregnancy which terminated in natural delivery. I performed the same operation successfully on a girl last RETENTION OP THE MENSES 289 III. Absence of vagina and imperforate cervix. — In this kind of atresia, the difficulty is to free the cervix; to effect this the circum- ference of this organ should be detached from the surrounding parts with the finger or a soft instrument, after a vagina has been made. In order to prevent the recurrence of the uterine atresia, which Debrou and Patry have observed, Puech^ recommends two operations. In the first, the vagina is to be formed ; in the second, two months afterwards, the uterus is attacked. This, of course, is only possible when the symptoms are not alarming, IV. Atresia of the cervix. — Different instruments may be used for attacking this obstacle : the straight or curved trocar, Pleurant^s trocar. Friar Comers pointed sound, the pharyngotome, Thomas's lithotome, Flamand's hysterotome, the ordinary straight and probe- pointed bistouries. The first time I had occasion to perform this operation, about thirty years ago, I had a grooved sound made about 30 centimetres long, and fitted on to a wooden handle which was roughened on the side corresponding to the groove. I had also two bistouries made of the same length, one sharp-pointed, the other probe-pointed, both sharp only to the extent of % centimetres at the extremity. The cervix having been seized and fixed with the help of the speculum, I punctured it with the pointed bistoury at the spot where a depres- sion was to be seen, and pushed the instrument in the direction of the axis of the cervix to the depth of 15 millimetres ; I then intro- duced the grooved sound, and succeeded in making it penetrate into the uterine cavity, where I felt that it moved freely enough to make sure that it must have penetrated. I next introduced the probe- pointed bistoury into the groove of the sound, and having directed it alternately to both sides, before and behind, I made an incision of some millimetres in length and of about 3 centimetres in depth, around the artificial orifice first made. Except a slight discharge of red blood caused by the incisions, only a few drops of black, thick, viscid blood escaped ; but I was not in the least surprised, for the body of the uterus was not dilated, and the patient suffered from a deviation of the menses, constituting a supplementary menstruation. No accident occurred ; every day I introduced a gutta-percha sound of increasing size, and the patient was soon able to leave. I have since heard that her cure has proved permanent. Since that time a pointed sound has been invented, as well as various concealed hystero- tomes with two blades, analogous to small lithotomes which I have already described as applicable to this operation, as well as to simple incision of the cervix in cases of constriction of the os. I have used them for three operations of the same kind ; one in a virgin, for imperforation ; two others for obliterations occurring after labour, summer. After having reached the uterus with difficulty from the vulva through an imperforate vagina, I made a puncture by which all the blood issued from the uterus in fifteen days without any accident, thanks to frequent injections of hot water and carbolic acid. It was only later that I dilated the orifice, 1 Op. cit., p. 118. 19 290 UTERINE DISEASES IN DETAIL As to congenital constriction and contraction taking place after con- finements, they occur very frequently, as we shall see when consider- ing mechanical dysmenorrhoca. In such cases, however, simple incision is often insufficient, and recourse must be had to one of the operations for autoplasty of the orifice, which I shall describe when we come to the surgical treatment of dysmenorrhoea. Usually the operation ought to be performed in the following way : the cervix is brought into view and fixed by a Tergusson's speculum ; then with a narrow-pointed bistoury a puncture is made at the spot where a de- pression indicates the primitive or probable position of the meatus. We have reason to believe that the uterine cavity is reached when there is a sensation of resistance overcome, and at the same time there oozes out a drop of brown, syrupy fluid. I do not enlarge the orifice by small incisions made in every direction, nor do I allow the accumu- lated fluid to escape till much later. I introduce every day a gutta- percha sound into the uterine cavity, through which I inject small quantities of hot water and carbolic acid. If puncture and incisions are insufficient recourse must be had to autoplasty. The immediate accidents are nil, and the consecutive accidents are identical with those I have described under vaginal atresia ; peritonitis and purulent infection have caused death three times. Relapse is frequent : seven patients have been cured only after a second opera- tion, and in two a third operation was rendered necessary. It is on that account that autoplasty is often indispensable. To sum up, 52 operations have been performed on 41 women, and among these there were 3 deaths and 38 permanent cures; 25 cures of congenital atresia and 2 deaths, 13 cures and 1 death in cases of accidental atresia. Dressing. — It is not enough to operate and make an outlet for the menstrual retention ; accidents must be preveuted, and above all the artificial orifice or newly-made canal must be kept open. In order to prevent accidents the discharge of the fluid must be regulated. Left to itself it is sometimes too rapid, giving rise to syncope and other accidents, due to the absence or exaggeration of uterine contraction; sometimes it is too slow, in which case the action of the air may cause putrefaction of the retained fluid. To prevent this antiseptic injections should be made twice a day for a fortnight. If decomposition of the blood, entrance of air, or suppu- ration give rise to a putrid discharge the uterine cavity should be gently washed out with disinfectants. In order to preserve the artificial canal or orifice, Puech^ recommends the introduction of india-rubber bougies, the upper third of which should be covered with linen to prevent slipping. In a case of cervical atresia the bougie or sponge tent should be fixed with pledgets of lint, and the whole kept in place with a T bandage. The bougie and dressing should be changed every day or two till the discharge has ceased and the injections are unnecessary, fn order to fit the vagina for fulfilling its functions> the canal ought to be dilated by applying sponge tents of gradually ' Op. oit., p. 12G. RETENTION OF TTfE MENSES 291 increasing size, after convalescence has been established. These appli- cations should be suspended during the monthly period ; but when it is over the canal should be examined by speculum, so as to destroy any adhesions that may have been formed. We can only be sure of the result when the walls of this canal are covered by a rose-coloured membrane analogous to the rest of the mucous membrane. As a rule, dilatation need not be continued longer than three or four months. In a successful case the ulterior consequences are most favorable. By acting on the local state, making an outlet for the retained fluid, and removing the cause of the crises, the operation exercises a most beneficial influence on the general economy. The patient soon recovers her strength, menstruation is established and recurs regularly without producing either disturbance or pain. Sterility disappears with the cause which occasioned it, women sometimes becoming pregnant soon after the operation ; and Puech has proved by numerous examples, that parturition may occur without laceration. Can we count on the restitution of a tnie vagina ? It is to be feared that the result will be but unsatisfactory when there is little or no vestige of vaginal mucous membrane between the uterus and vulva. WiUaume de Metz^ and Amussat obtained a fistula rather than a vagina. Even this result is useful because it allows menstruation to take place and puts a stop to the accidents of retention. But it cannot be hoped that the woman will thereby be fitted for marital intercourse, and still less for childbearing. Although very extra- ordinary cases of this kind have been recorded, we must not forget that serious accidents are to be feared at parturition, as in Debrou^s^ curious case, that the child may be expelled through the perineum, that the recto-vaginal septum may be torn, or that the uterine pains may diminish or cease altogether, &c. These dangers are especially to be feared after operations for accidental atresia, when cicatricial tissue replaces the destroyed vagina. It is said that electricity prevents the formation of this retractile tissue, but hitherto this fact has not been placed beyond doubt. If portions of the vagina are left, i.e. of mucous membrane which can be reunited, permitting the re- establishment of a distensible canal between the uterus and vulva, we may hope that in spite of cicatricial tissue and partial contractions following suppuration after the operation, there may be a sufficiency of dilatable material to enable it to fulfil its functions though in an imperfect manner. There are many cases, however, which, though calling for operation, in order ' "Revue medicale frangaise et ctrangere, 1826, t. iii, p. 168. ' Fibrous coarctation of the whole vagina ; imperforation of the cervix. The symptoms began at seventeen. At nineteen distension of the uterus and right Fallopian tube. First operation : establishment of the vaginal canal and of the uterine orifice. Relapse after two months. Second operation followed by complete success. Pregnancy, labour at natural term, eclampsia. Application of forceps ; child stillborn. Fatal peritonitis {Gazette medicale de Paris, ISSlj p. .32). 292 UTERINE DISEASES IN DETAIL to prevent the fatal results of retention, yet demand that we should warn the patient of the risk she would run by attempting a renewal of marital intercourse. Lastly, in cases where it is not possible to undertake an operation, we must content ourselves with palliative treatment. This exclu- sively medical treatment ought indeed to be prescribed in every case, in order to prevent the accidents of retention till such time as the operation can be performed. It consists in fulfilling two indications which present themselves in the treatment of some other menstrual disorders, especially in uterine fluxion, deviation of the menses, in nervous dysmenorrhoea, in painful and violent uterine contractions, and in imminent peritonitis. These indications are : to revulse, or turn aside the fluxionary movement by bloodletting, purgatives and other revulsives employed methodically, in order to prevent distension of the uterus by a fresh flow of blood every month ; to allay pain and irritability, and to diminish uterine contractions by opiates and nar- cotics, in the form of opiate enemata, chloroform, &c. Secondary indications may arise in different cases, according to the special symptoms which may present themselves. Deviation of the Menses and Supplementauy Menstruation. The various terms, deviation of the menses, supplementarij hamor- rhages, metises per aliena loca,2iervias insolitus enLmpentes, menorrhagia erronea, me?istruatio vicaria, ectojne or hcterotopie menstruelle, all signify a discharge of blood occurring at periodical times, from other organs than the uterus.^ This abnormal phenomenon sometimes replaces the catamenia, at other times it occurs simultaneously with this discharge which, however, is then greatly diminished. The two varieties ought to be distinguished by difi'erent names : the term cleviatio?i of the mensesi s used when, in the absence of the catamenia, a more or less abundant hemorrhage occurs almost every month from some other part of the body ; supplementary menstruation may be used in the same circumstances, but rather when an insignifi- cant discharge occurs simultaneously from the uterus. Ameuorrhcca is the only disease which can produce this morbid condition. Menstrual retention very seldom does so, only four times in 258 cases.' The reason is, that, in amenorrhcEa, it is not the defective evacuation, but the cessation of the fluxionary movement towards the uterus and its change of direction which can deviate the menses and produce haemorrhage in some other part of the body after an unwonted fluxion and congestion. There may not even alwa}'s be haemorrhage; there may only be more or less sudden or durable fluxion towards an organ, congestion of its tissue, a slight sanguineous 1 A. de Haller, Elemeyita physiologioe, t. vii. Lausanne, 1778, lib. xiviii, sect, iii, § 14. Qua: ruensiuin locum tenent. The great pliy.siologist point* out in a few lines all parts of the body by which the blood may be discharged when hindered from issuing by the uterus. ^ Puech, Acad, dea ac, seance du 9 ddc, 1861. DEVIATION OF THE MENSES 293 interstitial effusion or ecchymosis/ or the production of another discharge.^ This phenomenon attracted special attention in former ages, when there was a tendency to believe in the marvellous. If in those times people were disposed to be too credulous, in our days there is too great a reaction in the opposite direction. Diagnosis. — There is not, strictly speaking, any part of the body from which supplementary menstrual haemorrhage cannot take place. The tegumentary surfaces, the mucous membranes and the skin, seem to be the points towards which the menses most frequently deviate. The following are the various regions in which this phenomenon has been observed, according to 200 cases collected by Puech from various authors : Scalp ...... 6 Auditory canal .... 6 Eyes, eyelids, lachrymal carunculie . 10 Nasal epistaxis .... 18 Cheeks ..... 3 Dental alveoli .... 10 Salivary glands, or buccal mucous memhrane 4 Haemoptysis ..... 24 Haematemesis .... 32 Breasts ..... 25 Ti-unk, axilla), back, thoracic pariotos 10 Umbilicns ..... 5 Hsematuria ..... 8 Intestine, hajmorrhoids . ' . 10 Hands and fingers .... 7 Lower limbs ...... 13 Various seats, wounds, ulcers, exutories 8 The above table shows that, whilst these haemorrhages may be pro- duced anywhere, they show a predeliction for certain localities. For instance, the mucous membrane of the stomach, the breasts, the mucous membrane of the bronchi and of the nose. They may even take place from the roots of the nails. At other times they are dis- charged from varicose veins, from recent or old wounds, or from ulcers which resist cicatrisation in spite of all topical applications. I have seen them take place from the vagina and internal surface of the vulva. At other times they are produced from various parts of the body, either simultaneously or separately and alternatively. Pinel has related a case of this kind, and Gendrin another, to which I shall ' Torthe (Louis) relates a case he saw at the Hopital Saint-Antoine of pur- pura hcBmorrhagica replacing menstrual hajmorrhage. He has collected nine cases from different authors showing that subcutaneous sanguineous extravasa- tions, ecchymoses, and petechia) resembling purpura, sometimes with sometimes without external hajmon-hage, constitute a well-marked form of menstrual deviation {D'une forme rare de deviation menstruelle. Theses de Paris, 1877, No. 496). - Senator {Berlin Klin. Wochcnsch., 16 Dec, 1872, No. 57) mentions four cases of women in whom menstruation was irregular, and who suffered periodi- cally every month from an attack of jaundice, which ceased on the reappearance of the catamenia. Fasbender {Id., Ibid., April 20 and June 1, 1875) mentions two other cases ; the menses were not suppressed, but only diminished. 291 UTERINE DISEASES IN DETAIL afterwards refer. Jacqueraier and Lissner have observed fluctuating sanguineous tuLQOurs developed periodically at the surface of the thighs. I have myself observed a case of this kind.^ This supple- mentary menstrual hsemorrhage occurs always from the mucous mem- brane and the skin, more frequently from the former, because it is more vascular, and because the epithelium offers less resistance than the skin. Although the hsemorrhage is produced periodically, the blood is not always evacuated at every menstruation ; it may accumu- late in a hollow organ, to be discharged at a later period. I knew a maiden lady in whom for a long time supplementary hsemorrhage took place into the stomach; but the blood often remained for several months before being ejected. At every monthly period there occurred very characteristic critical phenomena with serious disorders of the digestion. After some months these disorders acquired greater inten- sity, and it was necessary to have recourse to bleeding to put a stop to the spasm and to provoke vomiting. In the matter vomited there were various layers, evidently superimposed, from the purest blood, to older, denser clots, some decomposed and in a state analogous to putrefac- tion. It was impossible to doubt that these various layers were the result of former successive hsemorrhages produced at epochs corres- ponding to the monthly periods. The predisposing causes, general or local, are very obscure. The circumstances under which these hsemorrhages occur vary in each woman, and yet when we examine authenticated cases they have certain symptoms in common. As a rule the women so affected have an extremely sensitive nervous system ; others are hysterical. The age at which these phenomena occur varies : they are generally noticed soon after puberty, or at the approach of the menopause. Tueffard^ relates a very uncommon case, in which the hsemorrhage appeared for the first time at fifty-six, six years after the menopause; it occurred regularly every month by the breasts, the discharge of blood lasting eight days, accompanied by the general phenomena of menstruation, and lasting lor a year up to the time when the case was published. As a rule the uterus is healthy ; sometimes, however, it is more or less deranged. Puech has met with menstrual deviation eleven times in women in whom the; genital canals were closed congenitally or accidentally ; and forty-two times in ^vomen having a foetal uterus or congenital absence of this organ,-'^ a new proof of the importance of the ovary in producing menstruation. The hsemorrhage generally occurs after sudden suppression of the catamenia, produced by a violent moral emotion or by some strong physical impression, such as would be produced, for example, by ^ Puech, Mcmoire sur les Atrdsies des votes gcnitales de lafemme. - Union medicale, 30 Nov., 1872. ' Brown has lately published a case of supplementary epistaxis in a girl, in whom the vagina was reduced to a cul-de-sac and the uterus to two horns {American Journal of Med. Science, p. 575, 1872). I have also found com- plete absence of the uterus and upper half of the vagina in a girl who had supplementary epistaxis without ever having menstruated ; a painfiil swelling of one ovary was felt every mouth through the rectum, a little to the right. DEVIATION OF THE MENSES 295 sudden immersion in cold water. At other times the menses are only retarded or difficult, when after an insignificant accidental cause, or even without apparent cause, there occurs at the time when the cata- menia ought to appear a sanguineous fluxion towards the region or organ naturally or accidentally predisposed to these hieinorrhages. Various explanations have been given of deviation of the menses. Some have thought, with Bordeu, Vigarous, &c., that this phenomenon is produced by an effort of the womb in virtue of the active influence which this organ exercises on other parts of the body. Others have considered it as independent of the action of the uterus, believing it to be the result of the action of the vis medicatrix provoking this pheno- menon in order to replace that which is wanting, and to which the economy is already accustomed. Others again have invoked the theory of metastasis to explain the fact; whilst some deny all connection between menstruation and these haemorrhages, which they believe to be simply congestive. Scanzoni^ has revived an explanation of this phenomenon which we can only partially accept. These haemorrhages, he says, having their seat in organs independent of those of generation, are always occasioned by a predisposition resulting from an anomaly of structure of these organs — an anomaly consisting principally in an unusual thinness and great fragility of the vessels. Under the in- fluence of the general vascular excitement manifested in the majority of women at the monthly period, the blood makes a passage for itself externally by the parts in which the abnormal weakness of the vessels off'ers least resistance.^ The haemorrhage which results acts on the genital organs in the way of revulsive bloodletting. If it is abundant enough to put a complete stop to uterine congestion there will be no discharge from the womb ; if, on the contrary, it is scanty the supple- mentary ha3morrhage may be accompanied by a slight oozing of blood from the genital organs. The connection of these haemorrhages with menstruation cannot be denied; but we cannot be satisfied with the explanation of a so-called metastasis of blood to another organ, in the way the ancients under- stood it, and which the figurative expression of deviated menstruation would imply if taken literally. Is it not merely a phenome- non of reflex action, in consequence of which the fl^xionary movement, finding an obstacle in the uterus, terminates in another organ and produces an abnormal haemorrhage ? The predisposition of the organ, its relatively inferior power of resistance to morbid attacks, would determine the question of locality.'' The influence exercised, by supplementary menstruation on uterine menstruation varies according to the date of the amenorrhcea, andaccord- » Op. cit., p. 319. 2 There is something true, as regards the seat of deviated menstruation, in tlie choice of the phice offering k>ast resistance ; only we must not he content with the admission that these ha^norrhagiparous organs are places offering least vascular resistance, they must rather be regarded as tissues or organs oft'ering least resistance to any morbid influence in general. ' Lorey adopts this patliogeny {Des vomisscmcnts de sang suppUmentaire, &c. Theses de Paris, 1875).' 296 UTERINE DISEASES IN DETAIL ing to the existence or absence of fluxion towards the uterus. If the amenorrhcea is recent and is produced by a sudden suppression, Scanzoni's explanation is undoubtedly correct ; I have lately seen a girl who has had hemoptysis under such circumstances ; in such a case the catamenia may return the following month; the fluxion towards the lungs is not of sufficiently long standing to have taken root there, nor has the uterine fluxion been so completely mobilised as to be irremediably deviated. If, however, the amenorrhcea has lasted long, the conditions are reversed; the uterus is not only not congested, the fluxion is not even directed towards it ; the abundance or scantiness of the supplementary hsemorrhage will have very little influence on the absence or presence of uterine haemorrhage. On the other hand, of however old a date the amenorrhcea may be, if there is periodical fluxion towards the uterus and congestion of that organ, and especially if the functional disorder depends on defective evacua- tion, or derangement in the physiological manifestation of the third element of this function, the menstrual hsemorrhage may reappear in spite of the supplementary hsemorrhage. It seems as if other excretions may be supplementary to menstrual hsemorrhage, e.g. hypersecretion of saliva, sweat, urine, intestinal mucus, diarrhoea, pus from ulcers, bile causing jaundice, &c. This appears less incredible to us than to Nonat^ when we remember that diarrhoea often precedes menstruation, whilst leucorrhcea replaces it in chlorotic patients suffering from amenorrhcea. Apart from these theories, we must find out whether there is the same connection between ovulation or spontaneous dehiscence and the supplementary hsemorrhage known as deviated menstruation that there is between periodical dehiscence and the concomitant uterine hsemor- rhage, especially if the hsemorrhage, whatever may be its seat, occurs simultaneously with ovulation. Light has been thrown on this question by the interesting researches of Puech.- A very interesting autopsy showed that the formation of the corjmra lutea, and especi- ally the recent rupture of a Graafian vesicle may coincide with each supplementary hsemorrhage. It has also been proved that pregnancy may occur in patients affected with deviation of the menses. The medical journal of MontpeUier^ relates the case of a woman who had deviation of the menses, the discharge taking place through a fistula at the right side of the chest : pregnancy occurred putting a stop to this discharge, and after delivery menstruation took place normally. Pauli * knew a girl of seventeen in whom menstruation was replaced for eighteen months by bleeding of the nose. After her confinement menstruation reappeared regularly. A woman of thirty, of delicate constitution, married for five years without having children, menstruated regularly to the age of twenty- » Op. cit., p. 587. * Academic des sciences. Seance du 13, avril, 18(5.3. ^ Joxirn. de mod. de Monipellier, 2* serie, t. v, p. 212. ■» Gazette modicaXc, 1839, p. 036. DEVIATION OF THE MENSES 297 six. At that time menstruation ceased, and the woman believed her- self to be pregnant. A few weeks afterwards a tumour was formed in the left hypochondriac region, which suppurated, burst, and was converted into a large ulcer fifteen centimetres square, from which a certain quantity of blood was discharged regularly every three or four weeks. The internal administration of emmenagogues, and the appli- cation of leeches were continued for some years without success. The woman at last became pregnant; the discharge of blood from the ulcer ceased, the wound cicatrised, and all passed off well. Two months after delivery normal menstruation recommenced and has continued regularly for five years.^ In other cases which we have to relate pregnancy occurred in iden- tical conditions, but was not followed by similar good results. Preg- nancy and lactation, it is true, suspended the deviation, but only tem- porarily, the supplementary hsemorrhage reappearing after delivery or after lactation. — Catherine Vincent, who menstruated at nine years, had her monthly periods regularly during eight days of every month. She was hysterical, and when annoyed the catamenia were accompanied by the oozing of a sero-sanguineous discharge from the left breast and axilla. She became pregnant and was delivered at the seventh month. When menstruation was re-established the deviation also reappeared, and besides taking place from the parts above-mentioned, it occurred also from the skin of the left loin, from the back, the epigastrium, the left thigh, &c.^ — A woman of weak constitution had after her first confine- ment a suppression for five months, then the catamenia were scanty for five or six months. At that time she had a considerable vomiting of blood, which was repeated at her monthly periods. Under these conditions she became pregnant; after delivery epistaxis occurred periodically, then hematemesis.^ — A woman who had never menstruated except by hematemesis became pregnant; she had a good confinement, and suckled her child for some months. On being obliged to give up nursing the hematemesis returned. Afterwards she became dropsical, and died at the end of six months.* — A woman of thirty-one had a sudden suppression owing to a great fright she had experienced at her monthly period. The following month the catamenia hardly appeared, but there was expectoration of blood, which stopped spontaneously at the end of four days. From that time a more or less abundant dis- charge of blood occurred every month by the lungs. During her pregnancies menstruation and hemoptysis both ceased. After delivery, and even during lactation, the hemoptysis returned. Her health, how- ever, was in no way affected.'^ — Brierre de Boismont tells of a woman who had deviation of the menses during her whole Hfe in spite of a good confinement. — Molinetti knew a woman of great beauty who, till the age of fifty, had vomiting of blood every month in place of mcu- ' Gazette viklicale, 1843, p. 532. — Obs. of Dr. Sohwabe of Weimar. - Bulletin de la Societe royale de mklecinc. — Obs. of Dr. Bonfils. ^ Gendrin, Traite 'pliiloso'phiqiie de mcdccine pratique, t. ii, p. Go. * Journal de mklecinc, 1757, t. vii, p. 384.— Obs. by Ilcnry. Surgeon at Auxerre. » Hoffmann, t. ii, p. 207. 298 UTERINE DISEASES IN DETAIL struation. This did not prevent her from having several children.^ — A woman of twenty-four, who had never menstruated, was subject from the age of fifteen to monthly epistaxis. She became pregnant, when the epistaxis disappeared, to return, however, with its previous regu- larity six weeks after her confinement.^ We see, therefore^ that, except in cases of atresia or serious disorder of the uterus, deviation of the menses does not imply sterility ; unless there be serious derangement of the economy ovulation continues to take place, and rupture of the Graafian vesicle coincides with the 2^eriod of the deviation. Pregnancy is therefore possible and has been observed : it suspends the deviation, which, however, reappears after delivery or lactation. Deviation of the menses depends on the san- guineous fluxion being turned from the uterus by some cause to another organ predisposed, anatomically, physiologically or pathologi- cally to become the^ar^ recipiens of this fluxion. The recurrence and the periodicity of the phenomenon depend on the same causes of vital habit which kept up the periodicity of the uterine fluxion in its normal type. Treatment. — Although compatible with health, and sometimes lasting from puberty to the menopause, deviation of the menses is nevertheless a pathological process; it is even a serious condition, as it has fre- quently caused death. It is more than a functional disorder, it is an essentially morbid state. It is useless to say that it is a beneficent effort of the vis medicatrix ; it is not the less true that the haemorrhage takes place by organs whose structure is not physiologically suited for its production, and that it is provoked and kept up by a special morbid condition. It is true that the economy becomes habituated to such a state, and tolerance may be established, nevertheless the health is not perfect till the supplementary hEcmorrhage is replaced by normal men- struation. The prognosis varies according to several circumstances connected with the production of the hajmorrhages, their seat, kc. It is only serious when women who are already debilitated become more so by the prolongation and abundance of this loss. Death, as I have said, may result, and one of the most curious exam])les of this termi- nation is that published by Yricker de Horb,^ in which a third attack of supplementary nasal epistaxis was followed by death. It is unneces- sary to say that when hemorrhage occurs in important organs the danger is increased. Lastly, considered in themselves, and independently of the organs in which they are localised, supplementary hemorrhages are always a troublesome accident. Except in cases of atresia, when they really prove beneficial by obviating uterine distension, they produce great inconvenience to the patient ; they always indicate debility ; they are extremely difficult to cure ; they recur with extreme facility, and as * Related l)y Bergcr, Phytsioloyie, chap, xx, p. 252. ^ Otto Obersaeur, Virchoto'8 Archiv, 1872, vol. xlv, part 3, ^ Medecin. Correspondenz-Blatt, 1844, p. 510. — Dunlap {Ncxo Yorli Jonrn. of Medicuic, May, 185r>), lia'iiionhaf^o from the gums ; after cupping with the scarificator hemorrhage ensued and carried oft" the patient. DEVIATION OK TilR MENSES 299 they may chancre their scat or threaten an important organ, they ought to have the serious consideration of the physician. Cases are on record which have lasted during the whole of menstrual life, in spite of the most suitable treatment. De Mynck and Kluyskens ^ have related a case in which sup])lemcntary haemorrhage from the breast, established at forty, terminated at fifty-eight in a cancer. Treatment should be directed: 1st, to the amenorrhcBa, by means previously described; 2nd, to the supplementary haemorrhage, the abundance and seat of which may indicate various means in addition to haemostatics, according to the speciality of the case. Nothing seems simpler than these indications, and yet the result is very uncertain. The treatment of amenorrhoea in these cases consists principally in strengthening the constitution and in drawing to the uterus the hsemorrhagic molimen produced in other organs. In order to fulfil the first indication, besides having recourse to therapeutical means, great attention should be paid to hygiene. In addition to a generous diet, exercise ought to be prescribed; if the patient is too weak to walk she ought to drive. Tonics should be given, and the best of these are quinine and iron. To fulfil the second indication, to determine a fluxionary movement towards the uterus sufficiently strong to turn aside the abnormal fluxion, we may employ irritating topical applications, mustard, sitz baths, dry cupping, or with the scarificator, leeches to the inner and upper parts of the thighs, or one or two leeches to the cervix, or better still dry cupping which does not cause loss of blood, or, if necessary, intra-uterine dry cupping as advised by Simpson. The time chosen for beginning this treatment should be one or two days before the monthly period, and it should be continued the whole time it lasts, till the phenomena of abnormal fluxion have completely disappeared. The treatment of mjiplementary hmnonhages is less important, except when these discharges endanger life by their intensity. In such cases we must have recourse to the most powerful haemostatics, and to the various means employed in the general treatment of haemorrhages. We must, however, beware of trying to subdue these abnormal haemorrhages energetically before having re-estabhshed normal menstruation : we should run the risk of producing them on another and more important organ. Eorestus" and Chautfe^ relate cases of mental derangement and fatal cerebral apoplexy occurring as the result of such inopportune treatment. ^ Gazette mecl. de Paris, 1844, p. 595. ^ De cerebri viorbo, obs. 24. ^ Des accidents et des maladies qui swrviennent a la cessation de la mens- truntion. Theses de Paris, an x. 300 UTEEINE DISEASES IN DETAIL Dysmenoerhcea Dysmenorrhoea, according to its etymology, is difficult menstruation. This disease includes sluggishness and difficulty attending the cata- menial discharge ; irregular menstruation ; pains, often very violent, usually preceding the sanguineous flow, sometimes accompanying it ; menstrual evacuation in certain cases nil, in others insufficient, some- times putting a stop to the pain on its first appearance, but some- times occurring without any cessation of the pain, and occasionally acquiring an intensity which amounts to metrorrhagia. Diagnosis. — Aran ^ has given a very exact description of dys- menorrhoea and of the distinctive features of this pathological condition. "The menses may be delayed in many women without affording cause for anxiety. Nothing but disorder of the general health or abnormal phenomena manifested in the genital economy need direct the attention to what otherwise is merely an anomaly of menstruation. In women suff'ering from chlorosis or from any serious disease of a debilitating nature, the menses are delayed more and more, till at last they cease altogether or only recur at long and irregular intervals ; unless an effort is made by the organism to re-establish them, the physician ought to confine his attention to the chlorosis and to the debilitating pathological condition ; delay in the appearance of the menses is only a cry of alarm, a signal of distress from the economy. They may, however, be delayed amid symptoms which betray an energetic effort for their re-establishment. Very often these symptoms do not differ much from those which coincide with the sudden or prolonged su])pression of the catamenia ; but, limited to the genital economy, or at least affecting it principally, they have witli reason received the name of dysmenorrhea. The symptoms of dysmenorrhoca, without being completely similar in all cases, yet have a common basis, viz. sluggishness, the difficulty with which the dis- charge is established each time, its irregularity ; the presence of pain in the uterine system, and often in other of the organic systems for some hours or days before its appearance, pain which increases till the catamenia appear." It is easy to understand that dysmenorrhcea is principally met with in girls, or in women who have never been pregnant. It is not enough to recognise its existence in the preceding symptoms ; it is important further to distinguish between symptomatic and idiopathic dysmenorrhoea. In one sense all dysmenorrhcea is symptomatic of a morbid condition ; but when this condition is not produced by any persistent organic derangement, and may disappear under the influence of a modification of the functions of innervation or of the vascular system, the dysmenorrhcea is called idiopathic; when, on the contrary, it is caused by contraction of the orifices or by a disorder of the mucous membrane requiring the intervention of the surgeon, it is called symptomatic. ' Op. cit., p. 300. DYSMENORRHCEA 301 Dysmenorrhoea may be symptomatic of simple neuralgia, especially of lumbo-sacral neuralgia. It may also be symptomatic of an organic lesion depending on a nutritive alteration of local life, a fibrous tumour, polypus, hypertrophy, or the localisation of a diathetic affec- tion such as cancer ; but these lesions are complicated with menor- rhagia and metrorrhagia more frequently than with dysmenorrhoea. It may also be symptomatic of the formation of a clot in the uterine cavity ; but this formation infers other lesions, such as coarctation of the cervical orifice or dilatation of the body of the womb. It is fre- quently symptomatic of uterine congestion, of acute or chronic uterine inflammation, of inflammation of the appendages, &c. Oftener still, it is symptomatic of anteflexion or retroflexion, and especially of torsion and contraction of the cervico -uterine canal, with partial retention of the menses, and of the monthly exfoliation followed by the periodical expulsion of the mucous membrane with the menstrual blood ; hence the name of mechanical dysmenorrhoea and of membranous dysmenor- rhoea to distinguish them from symptomatic dysmenorrhoea. Idiopathic dysmenorrhoea is not connected with any cause foreign to menstruation itself. It is a functional irregularity affecting one or more of the three elements (fluxion, congestion, evacuation) of the catamenial act, and produced by a deterioration in the health and oftener in the local life of the organ, the nature of which may vary, allowing of the existence of differences in the essential cause of dys- menorrhoea, and consequently in the indications for treatment. With regard to this nature, all physicians recognise a nervous, spasmodic, hysteriform dysmenorrhoea, and a sanguineous, vascular, congestive form. The first depends on a state of pain, spasm, or neuralgia, which has led to its being called catamenial hysteralgia ; the second depends principally on hypersemia of the organ. The first consists specially in a derangement of the mode in which the fluxion takes place towards the organ, or of the mode in which the uterus is accessory to the evacuation of the fluid, under the influence of a derangement of in- nervation ; the second, in an excess of congestion or an alteration in the manner in w^hich it is produced, either that it is limited to the uterus or that it is extended to the Pallopian tubes and to the ovaries under the influence of a derangement of the circulation, and is vitiated in its mode of termination, even to the extent of producing haemor- rhagic centres in the Fallopian tube or in the ovary, and even hsematocele. 1. Idiopathic Bysmenorrhma Differential diagnosis. — Nervous dysmenorrhea is characterised by general and local disorders of innervation. Pain, spasm, neuralgia, developed in the uterus, in the uterine system, in the neighbouring organs, or even in the whole economy during menstruation, may equally play the part of essential cause of the disease, either separately, suc- cessively or simultaneously. These morbid conditions may be them- selves under the dependence of various general or diathetic affections. However that may be, one of these elements, pain, spasm or neu- 302 UTERINE DISEASES IN DETAIL ralgia may characterise this kind of dysmenorrhcea iu au especial way. As a rule the symptoms (discomfort^ dyspepsia^ cephalalgia, more or less violent lumbar and hypogastric pain) cease as soon as the menses appear, especially when the discharge is abundant ; if, however, it only comes by drops (stillicidmm uteri of Aetius, uterine strangury, as con- trasted with vesical strangury) they may persist for a longer or shorter time, and be the indication of a contraction of the cervix or of the os internum in which the nervous state seems specially to be localised ; they may continue till the expulsion of a clot, which follows the incom- plete sanguinolent or sero-sanguinolent discharge permitted by the im- perfect permeability of the orifice, or which is accompanied by real menorrhagia, and announces the imminent cessation of the trouble and soon of menstruation itself. These symptoms may attain an extreme degree of intensity ; I have seen girls shed tears, scream with pain, writhe in bed, roll on the ground. The violence of the pains may even react on the whole economy, causing nausea, vomiting, hysterical or epileptiform symptoms, &c. Congestive dysmenorrhma is characterised by the symptoms of con- gestion itself ; discomfort, sense of pelvic fulness and weight, frequent micturition, heat and smarting in passing water, tenesmus, diarrhoea, swelling of the breasts. The symptoms may increase during the first few hours following the commencement of evacuation. The pain may increase so as to assume the character of the expulsive pains of labour, shooting down the groins and thighs, increasing at intervals and being accompanied by swelling of the hypogastrium, which cannot tolerate the touch of the hand or the contact of the clothes. At this period the pains may attain the violence and assume the form of those of nervous dysmenorrhcea, both in their local manifestation and in their reaction on the whole economy. Usually all these phenomena, the pain especially, disappear in proportion as the flow increases, unless the dysmenorrhcea has caused congestion of the uterus. At other times patients suffi^r from dull pelvic pain, not only all the time of the men- strual flow but also for some days after it has stopped. It is the congestive form that is related to what Simpson^ called ovarian dysmenorrTiata^ which depends on the excess of congestion which causes the pain affecting the ovary rather than the uterus. The tension and sensitiveness of the ovaries are especially evident when these organs are displaced, either into the recto-vaginal cul-de-sac of the peritoneum, or into a hernial sac.^ It is often met with in ansemic women as the result of defective equilibrium, of unequal distribution of blood. It is also frequently observed in prostitutes, in whom it is produced by venereal excesses, and it is sometimes met with in old maids and in young widows as a consequence of unsatisfied sexual instinct. ' Simpson, op. cit., p. 411. ' In a case related by Oldham (PJiilosophical Transactions), in which the ovaiy descended by the in^inal canal into the labium, this organ swelled some days before the appearance of the menses, and the patient suffered greatly. DYSMENOREHCEA 303 Treatment. — The indications differ according to the nature of the dysmenorrhoca. In nervous dysmenorrlma the two elements of pain and spasm are the two principal sources of indications. The element of neuralgia and the neuralgic form assumed by the pain may give rise to a third order of indications, to the special indications of neuralgia ; these may exist apart from the menstrual period, they may vary according to the locali- sation of the neuralgia and the essential cause of the affection which keeps it up ; frequently, however, the same medication is employed with equally good results in cases of neuralgia, properly so called, and of pain. Pain is subdued by narcotics, and, if necessary, by anesthetics, such as the various preparations of opium, morphia, laudanum, henbane, belladonna, Indian hemp/ ether, chloroform, &c. To prevent dysmenorrhoea, general baths for an hour or more should be [prescribed, made with a decoction of bran or gelatine, and re- peated daily for some days before the menses are expected ; or sitz- baths "with vaginal injections of a decoction of poppy-heads, or henbane and belladonna leaves ; sedative embrocations of camphorated chamomile oil, laudanum, morphia, &c., should be applied to the hypogastrium, the groins, and the inner surface of the thighs, and care should be taken to keep the bowels open by means of emollient or laxative enemata. The moment that the catamenia appear, if there is dysmenorrhoeic pain, opium or morphia should be given ; perhaps the best method is to give a small enema of decoction of marshmallow or poppy-heads with from 10 to 20 drops of laudanum, which may be repeated. Bromide of potassium in doses of from 8 grains to 5j in the day, given before, during, and after menstruation sometimes produces beneficial effects. Hot linen, antispasmodic infusions, baths of bran or lime-tree flowers (^x in a bath) taken during menstruation may produce a sedative effect. Lastly, if the pain instead of yielding becomes excessive, inhalations of ether or chloroform may be tried, as advised by Bennet and Aran. Spasm is more effectually subdued by the administration of anti- spasmodics given alone or associated with the sedatives just men- tioned. Orange-flower water, ether, valerian, castoreum, musk, camphor, assafoetida, ammonia, hydropathy, have often put a stop to the most violent attacks of dysmenorrhcea. After having used baths and narcotics as preventive measures in the various forms above named, spasm may often be relieved by 25 to 30 drops of the following anti- spasmodic mixture : Sulphuric Ether, Tinct. Valerian., Tinct. Castor., Tinct. Op., aa 5J, with a tablespoonful of distilled orange-flower water in half a glass of eau svcree, to be taken in spoonfuls every five minutes ; a second dose may be given in an hour if required. I * ^. Lnpulin, gv. .3 ; Ext. Cannabis Ind., gr. \. M. ft. pilula. Sig. Take two pills in the morning and three in the evening as soon as the first symptoms appear (Debout, Aran). 304 UTERINE DISEASES IN DETAIL have little confidence in musk and camphor, but if the above-named antispasmodics do not succeed, assafoetida may do good (1^ gr. in a pill given every hour, or 30 gr. suspended in yolk of egg in 3^ oz. of decoction of poppy-heads as an enema); or 15 gr. of sesquicar- bonate of ammonia, or a few drops of ammonia in a glass of water. Lastly, cold compresses on the hypogastrium, and other hydropathic applications often do great good when administered with caution. When spasm especially affects the cervix, and it has been ascer- tained, by the pain which the sound causes, and by the difficulty of passing it through the internal os, that this orifice is probably con- tracted, we may try the efi'ect of applying belladonna to the cervix, or we may inject a few drops of a solution of neutral sulphate of atropine (1 in 100) into the tissue; or douche this organ with carbolic acid or chloroform spray ; or subdue the spasm by using the sound every day or every other day shortly before the monthly period, or even by introducing a gutta-percha sound or one of Simpson's solid pessaries of ivory or metal, and leaving it for a few hours. This, however, ought not to be employed unless we are sure of the absence of any inflammatory element, and only after having tested the susceptibility of the uterus by touch. In congestive dysmenorrhea there are two different sources of indi- cation : an excess or defect of strength, hypersthenia, or asthenia, which, although opposite in character, may equally cause hypersemia. Hypersthenia, by increasing the intensity, energy, and persistency of fluxion, gives to congestion an importance which exceeds all physiological bounds, and brings about all the conditions of acute uterine congestion . The treatment of this morbid condition does not differ from that of congestion. Asthenia, implying defective fluxion or inertia of the uterus in excreting the menses, indicates the use of various stimulants of the uterine system, the value of which has already been discussed in the treatment of ameuorrhoea : attractions, emmenagogues, cold douches, electricity, &c., or even the momentary or prolonged introduction of the sound or of solid stem pessaries into the uterine cavity. In the interval between the monthly periods baths of bran or starch should be recommended, and especially exercise, living in the country, travelling, &c. West^ and Simpson," believing that dysmenorrhcea is caused by a rheumatic or gouty diathesis, recommend the use of tincture of colchicum associated with small doses of laudanum and antimonial wine. The colchicum is to be continued during the whole intercalary period, or the iodide of potassium may be substi- tuted for it. Yichy water, the baths of Carlsbad or Wiesbaden, and other means indicated by the nature of the afi'ection complete the treatment. Lastly, the indications vary according to whether we are consulted during the crisis or in the intervals. In the first case, as Simpson'* ' Op. cit , p. 87. "■ Op. cit., p. 242. 3 Op. cit., p. 234. DYSMENOERH(EA 305 wisely remarks, the treatment is simply palliative, our aim being to mitigate the paroxysm ; in the second, it is curative, radical or pre- ventive, the indication being to destroy the obstacle to the free evacuation of blood, or to prevent the return of the symptoms by various means, according as the dysmenorrhcea is nervous or conges- tive; not only by therapeutical means, but by hygiene, hydropathy, exercise on horseback and on foot, in short, by every means that can subdue the nervous irritability, or dimmish the tendency to con- gestion by re-establishing equilibrium in the general circulation. 3. Mechanical dysmenorrlicea This malady, which Simpson ^ describes under the name of obstruc- tive dysmenorrhcea, and which some German authors designate as stenosis of the cervix, is nothing more than the series of symptoms developed by the energetic and painful contractions of the uterus in its endeavour to expel the product of menstruation through too narrow an orifice. It is in miniature the morbid state produced by complete retention. Diagnosis. — The seat of contraction may be at the external os, throughout the cervico- uterine canal, or at the internal os; but usually it is at the external os. Mackintosh^ called attention to this subject in 1823, and in 1826 proposed dilatation by bougies. The cause, which is always organic, is a congenital malformation, or a cicatrix following upon inflammation and ulceration of the cervix, laceration, or inopportune or unskilful cauterisations. When the deformity is congenital it is designated by the name of narrow os; when accidental it is called contracted os. The malady is characterised not only by the violence of the expulsive pain, uterine tenesmus and muscular contrac- tions of the womb, but by the difficulty of evacuation, the blood escaping only in small quantities at intervals, sometimes under the form of narrow elongated clots mixed with fibrinous concretions. The tumefaction of the uterus by the blood, which has a difficulty in escaping, causes excessive congestion and irritation in the organ, which, according to Rigby,^ is sometimes transmitted to the ovary, producing pains in the groin and even causing menorrhagia. The examination of the uterus by speculum, and the introduction of a very fine sound, enables us to ascertain the reality of the impediment. When the contraction is at the internal os it is sometimes necessary to dilate the external orifice and cervical cavity previously with sponge tents in order to make sure of the fact. It seldom happens that the internal os is narrow when the external one is so, unless the narrow- ness of the former is more marked than that of the latter ; for the im- pediment caused by the latter to the escape of the blood produces an accumulation of this fluid in the uterine cavity situated above, and so necessarily leads to the dilatation of the internal orifice. The narrow- ness of the os is the most common obstacle to menstrual excretion. It I Op. cit., p. 245. ^ Practice of Physic, 4th edit., t. ii, pp. 436, 481. London, 1836. ^ Med. Times, 25th October, 1851. 20 806 UTEEINE DISEASES IN DETAIL is always indicated by the circular form of this orifice (a point instead of a line), so much so, that circular form and narrowness of the orifice are almost synonymous, whilst narrowness of the os and dysmenorrhoea are almost invariably associated. If menstruation is scanty this narrowness may not have any troublesome consequences, and may even, to a certain point, pass unnoticed. This is what often occurs at the commencement of sexual life. If, however, the fluxionary move- ment and the quantity of menstrual blood are increased by the develop- ment of puberty or by marriage, the blood has difficulty in escaping, and clots are formed, which increase the difficulty. Expulsive pains are developed ; sometimes uterine cramps are associated with these pains. Dysmenorrhoea is accompanied by retention, and assumes the form of spasmodic nervous dysmenorrhoea. By dint of contracting in order to expel the retained blood, by constant dilatation from this menstrual retention, the uterus is in a continual state of hypergemia, and remains congested. The dysmenorrhoea takes the character of congestive dysmenorrhoea. This character is added or even substituted for those of retention or spasm. The congestion cannot long remain in the parenchyma with pain, contractions, &c., without producing inflammation in the tissue proper. On its side contact with the retained blood irritates the mucous membrane, and soon metritis (parenchy- matous, congestive, sometimes hfemorrhagic) and endometritis (leucor- rhoeic, granular, &c.) are added to or substituted for the simple mechanical dysmenorrhoea which was present at the outset. Fig. 219. Fig. 220. Fig. 221. Fig. 219. — Narrow round os on a cervix of normal conformation already con- orested. Fig. 220. — Nan-ow os, round and excentric, on a cervix of normal conformation more strongly congested. Fig. 221. — Narrow os, round and excentric, on a cervix of normal conformation, still more congested than the others and inflamed. Such is the course which the malady takes in married women. Thenceforwards symptoms of inflammation are added to those of mechanical dysmenorrhoea caused by narrowness of the os. These symptoms become aggravated, and are multiplied and complicated day by day. Sterility, which is equally a consequence of narrow os, is associated with the other symptoms, and helps to complete the diagnosis. DYSMENOERHCEA 307 In virgins this mechanical dysmenorrhoea may cause the gradual diminution of the menstrual haemorrhage till it ceases almost entirely^ sometimes completely, when atrophy may be produced ; but this is rare. Fig. 222. Fig. 223. Fig. 224. Fig. 222. — Congenitally narrow os on projecting cervix (after Sims). Fig. 223. — Narrow os on a congested projecting cervix. Fig. 224. — Narrow os on an inflamed and congested projecting cervix. In married women, on the contrary, the phenomena previously described occur invariably ; whether the cervix is normal, slightly conical, or very conical and long, it gradually increases in volume, as seen in the accompanying figures. Besides increasing in size it becomes Fig. 225. Fig. 226. Fig. 227. Fig. 225. — Narrow os on a long and conical cervix. Fig. 226. — Narrow os on a long, conical and congested cervix. Fig. 227. — Narrow os on a long, conical, congested and inflamed cervix. dark red in colour, very sensitive and painful to the touch; the orifice becomes slightly enlarged, sometimes assuming a cup form, but still remains insufficient for excretion. Therefore, in order to put a stop to these troubles it must be enlarged. The preceding figures show the changes which mechanical dysmenorrhcea produces in the cervix, whilst the figures which follow, taken from plaster casts, show the changes produced in the form of the uterine cavities. When the narrowness of the os is sufficient to cause retention of the menses or of mucus, the capacity of the uterine cavity may be increased, and even 308 UTERINE DISEASES IN DETAIL the orifices of the Fallopian tubes may become sufficiently dilated to allow of tbe entrance of the sound. Fig. 228. Fig. 229. FjG 228. — Cast of the cavities of a normal uteras in a virgin of seventeen. Fig. 229. — Cast of the uterine cavities in a nullipara of twenty-five or thirty ; marked constriction and elongation of the isthmus ; enlargement of the cervical cavity ; constriction of the external orifice. Fig. 230. Fig. 231. Fig. 230. — Cast of the uterine cavities in a nullipara of foi-ty-two ; marked constriction of the os externum. Its form is the same as that of the virgin uterus, but the horns are larger, the isthmus is dilated, and owing to the constriction d, the upper segment of the body and the cervical cavity are more developed. Fig. 231. — Cast of the uterine cavities in a multipara of thirty-five; constric- tion and torsion of the isthmus ; permanent lateral deviation of the body on the cervix ; c, well-marked enlargement of the body. DYSMENOREHCEA 809 Torsion of the isthmus (Fig. 231) which, like other flexions, may either be primitive or occur after childbirth, is also a cause of mechan- ical dysmenorrhoia, to which I shall have occasion to refer when speaking of flexions. Treatment. — It is important to treat mechanical dysmenorrhcea because the pains that it produces are intense and have no tendency to disappear naturally, because sterility is the invariable consequence, and the secondary effects disorder the health seriously. The treatment is mechanical, like the cause of the disease, and at the same time that it cures the dysmenorrhcea it also removes the inflammation and con- gestion which result, as well as the leucorrhoea and other disorders of the mucous membrane which owe their existence to the same cause, and very often it is followed by pregnancy. It is analogous to that em- ployed in constrictions of other organs, consisting in dilatation (rapid or gradual), incision, or autoplasty of a new orifice. I. Dilatation. — Rapid dilatation by means of intra- uterine forceps or speculum, the branches of which are introduced closed into the cervix and then opened quickly, has the disadvantage of causing lacerations. It is only admissible in cases of constriction caused by muscular contraction of the sphincter, with more than a sufficiency of mucous membrane externally as well as internally, that is, in spite of Ellinger^s ^ assertion, in the minority of cases. Gradual dilatation is preferable. Of course, before using a dilator we must be sure that the dysmenorrhcea, and the constriction which causes it, are not con- nected with some other morbid condition. Among complications which contra- indicate the use of dilatation I may mention inflamma- tion especially. If there be any uterine, peri-uterine, or ovarian phlegmasia it should be subdued by leeching and the use of anti- phlogistics ; for in such cases there would be as great a danger in dilating as in cauterising the cervix. Mackintosh ^ used flexible bougies or metallic rods of gradually increasing volume ; Higby a dilator with steel blades, which were opened and left for some time in the cervix; Eaynaud, of Montauban,^ conical wax bougies, by means of which he obtained pregnancy in two very interesting cases of dysmenorrhcea and sterility ; Simpson metallic stems of gradually increasing size, supported by an oval bulb, which rests on the poste- rior wall of the vagina and keeps the instrument in place without causing fatigue. These stems are left a longer or shorter time, according to the irritability of the uterus and the sensitiveness of the patient. As a rule, she ought to remain in bed ; if she is sensitive the instrument is only left for one or two hours. It is applied again the next day or the following one ; the stem is changed for a larger one as soon as the canal is sufficiently dilated to allow of its entrance. If the patient tolerates the dilatation well, the first stem may be left 1 Archivfiir Gynaehol., Bd. v, Heft. 2. Berlin. ^ Out of twenty-seven women lie cured twenty-four, and eleven of the twenty -four had children. ^ Jobert de Lamballe's " Report to the Academy of Medicine on Raynaud's Paper," Bulletin de V Academic, 25 June, 1850. 310 UTEEINE DISEASES IN DETAIL Fig. 232. Simpson's intra- uterine stem. longer, and when it is withdrawn it may be replaced by a second, and that by a third, and so on. Simpson regularly em- ployed this means of dilatation. Bennet^ prefers bougies of wax or gutta percha to metallic sounds. He says that, when used cautiously, good results can be obtained without suffering, and in cases of slight constriction no further treatment is required. Wax bougies may be used every second day till the canal is sufficiently dilated ; each bougie should be kept in place for some hours. When using Simpson's metallic sounds Bennet gives them a slight curve, with the concavity on the anterior surface, that they may be better adapted to the form of the cervico- uterine canal. Sims has wisely substituted the use of aluminum for other metals in the manufacture of these dilators. Aluminum is light, not easily de- composed, and more readily borne than any other metal. Nevertheless, instead of making use of bougies or catheters it is better to have recourse to dilating bodies, and to the most inoffensive of all, viz. prepared sponge. The naturally dilating bodies are especially useful when we cannot at once succeed in passing the internal orifice, either on account of its excessive narrowness, or on account of deviation, inflexion or torsion of the cervico-uterine canal. If they do not effect the complete dila- tation of this canal including the internal orifice, they at least prepare the way for the penetration of instruments through this orifice. The treatment may be completed afterwards by incision or by the introduc- tion of bougies or metallic stems into the cavity of the womb. The dilating body most commonly employed is prepared sponge, which should be applied according to the rules previously laid down (p. 149). Each sponge-tent should penetrate a little further than the preceding one, and as this application should be discontinued during menstrua- tion, one or two months are often required to produce complete dila- tation. Laminaria may be substituted for sponge- tents in dilating the external orifice, but it should never be used for the os internum, the swelling of the laminaria above the constriction rendering extraction of the stem impossible without lacerations, which may endanger the life of the patient. Prepared sponge alone ought to be employed in dilating the cervico-uterine orifice, and as 1 do not see any advantage that laminaria has over sponge, I use the latter exclusively for the dilatation of the vaginal orifice, as well as for the os internum. Unfortunately dilatation is often insufficient, especially for the os externum. II. Incision. — When dilatation appears insufficient, incision of the cervix should be resorted to. This little operation, to which the imposing name of uterotomy or hysterotomy has been given, is not un- accompanied by accidents when performed inopportunely or too deeply. ' Op. cit., p. 338. DYSMENORRHCEA 311 The incision may be single or multiple, superficial or deep; it may be limited to one, or extended to both orifices of the cervix. Some gynecologists proscribe division of the os internum in ail circumstances.^ As for myself, I have often remarked that obstruction of the internal orifice is caused by a curve or flexion of the uterus, a tumour on a level with the orifice, or simple hypertrophy of the upper part of the anterior cervical wall ; but some constrictions are produced by congenital mal- formation, others by retraction of the circular or oblique fibres of this orifice, and others again by true contraction of the sort of sphincter which surrounds this orifice, the existence of which seems to me as clearly proved by my anatomical investigations as by the physiological phenomena I have observed. I acknowledge that incision of this orifice is much more dangerous than that of the external one ; fortunately it is less frequently necessary. Nevertheless I think that dilatation by sponge-tents, and even by superficial incision, may be performed without danger, provided that suitable precautions be taken to arrest haemorrhage if it threaten to be serious, and especially by avoiding operation at the menstrual period. It is only accidentally and quite exceptionally that division of the external orifice can lead to any accidents. It is so often indicated that we must give up all hope of curing a large number of uterine maladies caused by a narrow vaginal orifice if its enlargement is to be proscribed. Different metJiods of incision. — The utility of hysterotomy being admitted, all that remains is to procure the best instruments and dis- cover the best way of performing the operation. I began by using the simplest instruments : a pair of long-handled scissors ; a director with a long stem fitted on to a handle; a bistoury with a short blade like that of a tenotome, pointed or probe-pointed according to cir- cumstances, with a long stem mounted on a handle which could be introduced into the uterus along the groove of the director. I will describe the way in which I now perform the operation with the same instruments, with the addition of a pair of diverging tena- culum hook forceps ; before doing so, however, I shall mention the instruments invented for the same purpose by other gynecologists, and which in some cases may be preferable by simplifying the operation and rendering it more rapid. The first of these instruments, Simp- son's^ hysterotome (Fig. 208, p. 227), is a kind of concealed bistoury, resembling in its mechanism the lithotome of Friar Come, and which requires no description. Simpson, after incision, always applied the tincture of perchloride of iron or the glycerole of it to the cervix by means of a brush, and he plugged if necessary. The second, the double hysterotome, several varieties of which have been invented in France and England (Fig. 209, p. 227), allows of the incision of both sides of the cervix simultaneously. If Greenhalgh's instrument were less complicated and less costly there is no doubt it would be prefer- 1 Discussion at the Obstetrical Society of London, June 7, 1805. Lancet, July 15tli, 1865, and Obstetrical Transactions, 1866. 2 Op. cit., p. 254 312 UTERINE DISEASES IN DETAIL able to others, for by an ingenious contrivance the blades, in springing out, cut the tissues of the cervix from within outwards to an extent which increases in proportion as they advance from the cervico-uterine orifice to the utero-vaginal one ; besides, the divergence of the two blunt blades, on a level with the vaginal orifice, separates the walls of the vagina from the sharp blades, and stretches the tissue of the cervix so as to facilitate incision. The analogous but simpler mstruraent made by Mathieu, although far from presenting the regularity and perfection of Greeiihalgh^s, is often useful. Many operators prefer scissors of various kinds to these concealed bistouries. Kiichen- meister has invented a pair of scissors, the external blade of which is armed with a point which penetrates the tissue of the cervix and fixes the instrument at the desired height. Others have used scissors with toothed blades, to make the section a kind of tearing, so as to prevent hsemorrhage. I have abandoned scissors as well as simple and double metrotomes, and have adopted a method by which the extent of the incision can be better controlled. Incision in some cases, however, being insufficient, recourse must be had to autoplasty. I shall, therefore, before de- scribing these operations (incision and autoplasty) explain in which cases the one operation ought to be preferred to the other. Indications for incision and autoplasty afforded hy the condition of the vaginal orrjice. — In cases of congenital narrowness there is gene- rally a want of depth iu the contraction of the os externum (Fig. 233). This may depend on two causes: — 1. On the contraction of the sphincter (the mucous membrane is puckered, as is often the case with the orifice of the prepuce). This contraction will certainly yield to slow dilatation by sponge tents or to rapid dilatation with simple forceps, the blades being quickly opened after their intro- duction. 2. On the scantiness of the mucous membrane itself (in these cases it is not puckered). Slow dilatation may be tried; but incision is generally necessary : it succeeds because the two folds of mucous membrane (the vaginal and cervical) are close together and easily adhere to one another (this may be aided by the application of fine sutures). Lastly, the widening of the opening caused by the two lateral incisions persists almost completely, because the tissue of the uterine wall is thin and the cervical cavity which it limits is very large (Fig. 223). In cases of accidental constriction, and in some even of congenital narrowness, the constriction is of some depth. In place of an orifice [p) there is a real canal (o i) (Fig. 234), varying in length and breadth. If the external mucous membrane of the vaginal portion of the cervix is sufficiently extensive, the same cannot be said of the limited internal mucous membrane, separated from the other by a more or less considerable thickness of tissue proper, and unable to come into contact with it, both on account of its insufficiency (there is want of material) and in consequence of the interposition of a foreign tissue in the regular conformation of the uterine orifice. If this canal be divided by a simple incision we enter an insignificantly small cervical DYSMENOEE,HCEA 313 cavity. The internal mucous membrane can never be brought into contact, and still less made to adhere to the external one, and the Fig. 233. — Congenital pin-point os ex- ternum. The orifice o has no depth. The uterine cavities which are behind are dilated by the accumulation of retained blood. Fig. 234. — Congenital pin-point os, having the depth of a true canal o i ; the fibro-muscular tis- sue of the utenis helps to make the orifice. The uterine cavities are also greatly dilated. divided tissues will unite again, either directly by immediate reunion, or by cicatrisation and the gradual retraction of each commissure, from the angles of the bilateral incision to the primitive orifice. In such a case we must ensure the persistence of the commissures by an auto- plastic operation. 1. Division of the orifice by bilateral incision. — The method I have adopted for a number of years is the following: — In order to fix the uterus and at the same time to give to the tissues the tension requisite for clean and exact incisions, I introduce into the orifice my long diverging tenaculum hook forceps (see Fig. 235), one hook of which penetrates into the centre of the anterior lip, the other into the posterior. By opening them as wide as possible I fix the cervix and draw it a little towards the vulva whilst stretching each side right and left, so as to be able to perform the section slowly, regularly, and to the extent which seems to me necessary.^ Two fine stitches may be applied afterwards, or a metallic suture to each side. As a rule this is not necessary. If I think congestion of the organ renders a little bleeding advisable I let a sufficient quantity of blood tiow after the ' Olshausen {Sammlung Klinischer Vortraege von Volkmann, No. 67, Leip- zig, 1874) has often recourse to what he calls bleeding dilatation ; but in per- forming it, like me, he prefers using a simple probe-pointed bistoury. 314 UTERINE DISEASES IN DETAIL Fig. 235. — Division of the os externum by bilateral inci- sion. Fig. 236. — Instrument for perforating the cervix and passing a vegetable or metallic thread through it ; this is often indispen- sable on account of the resistance and hardness of the uterine tissue : s, sound penetmting into the cervix ; a, needle pushed by a piston, v, through one side of the cervix and retained by the double hook e. operation and then plug to prevent ha3morrhage. The patient removes the plugging by degrees, beginning the second or third day, taking baths or at least injections, which greatly facilitates the extraction of DYSMENOREHCEA 315 the cotton wool. Great patience and care are required to prevent the occurrence of haemorrhage or inflammation. Rest in bed should be enjoined for a few days, and sometimes the additional precautions of cataplasms, laxatives, enemata of laudanum, emollient vaginal injec- tions, &c., should be resorted to. If necessary, the enlargement of the orifice may be completed by the application of sponge tents, but not before the following month. 2. Bilateral divisiofi by means of elastic ligature. — In order to ensure the permanence of this dilatation I have tried to perforate each side of the vaginal portion of the cervix at a certain distance from the orifice by means of a special instrument (Pig. 236) made for passing iron or silver wire, which I draw tightly after the following monthly period, tightening it gradually till the tissue has been completely divided. Latterly I have substituted elastic ligature for metallic Fia. 237. — Cervix, through which an elastic ligature has heen passed right and left fi'om the natural to the artificial orifice. wire, performing in fact an operation similar to that for anal fistula. Making on both sides of the natural orifice, at a distance of 1 or 2 centimetres, a new orifice, I pass through this opening an elastic thread, which comes out at the os. I stretch it tightly, and after having tied it firmly with a wax thread leave it. The bilateral section is effected slowly, and I have often the satisfaction of seeing the large opening that has been made remain permanent. Fig. 238. — Autoplasty by the formation of artificial commissures. Dissection of two lateral pieces of triangular mucous membrane cc' o', hb' o" ; circu- lar oi'ifice 0. 316 UTERINE DISEASES IN DETAIL HI. Autoplusty} — In cases where tissue is wanting, an artificial uterine orifice must be made. Fig. 239.— Jc7., deep lateral incision extending from the narrow circular orifice to the centre of the base of the triangular flaps cd o', bb' o". 1. Autoplasty hy the formation of artificial commissures. — If the orifice is narrow but the cervix not conical, I dissect lateral triangular or quadrangular flaps; when these are turned back (Pig. 238) I Fig. 240.— Id. Fig. 241.— Jc?. stretch the orifice well with my diverging tenaculum hook forceps, and divide it right and left (Fig. 239), and between these two lips which are held apart, I insinuate into each bleeding commissure thus made the bleeding surface of each lateral flap, keeping it in position by means of one or two simple or button sutures on each side (Figs. 240, 241). The threads are removed sooner or later as in vesico- vaginal fistulae. The results of these autoplastics are most interesting (Fig. 242). I have seen some several years after operation in which the enlargement of the orifice with solid commissures had remained intact. In the patients who had undergone this operation dysmenorrhoea was cured, and in several pregnancy had occurred. 2. Autoplusty Ly excision of ivedge-shaped pieces of fibrous tissue and turning down the Jlaps oj' vaginal or e,rlernal mucous membrane on ' Societede chirurgie, 1872. — MontpeWer medical, t. xxx, pp. 515, 522, an. 1873. DYSMENOREHCEA 317 in the cervical or internal mucous membrane. — When the cervix is conical, and when, consequently, there is an excess of fibrous tissue as Fig. 242. — Id., appearance of the orifice and its commissures after the removal of the sutures. Later on, the points of the dissected pieces ai-e drawn into the commissures by the retraction of the cicatrix, and the orifice becomes more regular (figure drawn from nature). well as an alteration in the shape of the organ, autoplasty is facilitated by the excision of two prismatic portions of this tissue before and behind, and by the suture to the cervical mucous membrane of quad- rangular flaps of the vaginal mucous membrane, both before and behind. (See Eigs. 243 — 246, and their explanations.) jn Fig. 243. Fig. 2U. Fig. 243. — Quadrangular flaps of external mucous membrane of the cervix, meant to be turned down towards the internal mucous membrane after excision of a prismatic portion of the tissue proper. Fig. 244. — Plan of operation : v v, vagina ; m m, quadrangular vaginal flaps, designated by the same letters as in Fig. 243; c, cervical cavity; a a, dotted lines showing the limits of the excision of a prismatic portion of the tissue proper ; m' m' , points of the cervical mucous membrane which are to be united to points m m of the vaginal mucotis membrane. 3. Autoplasty hj excision of conical pieces of the vafjinal portion of the cervix. — The method by dissecting quadrangular flaps which I 318 UTERINE DISEASES IN DETAIL have just described has been imitated by Simon, of Heidelberg, and described by Max Marckwald^ under the new name of autoplasty by Fig. 245. — Four metallic sutures ap- Fig. 246. — Plan of the result of the plied so as to keep the anterior operation : v v, vagina ; c, cervical and posterior dissected pieces of cavity ; vim, points of union of external mucous membrane in con- the dissected pieces of external tact with the lining cervical mem- membrane with the intenial. brane. conical flaps. The former has performed it sixteen times, the latter four. This method of autoplasty is especially suitable to hyper- trophied elongation of the cervix; the operation fulfils the double Fio. 247. — Max Marckwald's method Fig. 248. — Id., juxtaposition of the of autoplasty by excision of conical mucous membranes. The sutures pieces. Dissection of the mucous drawn together, membrane. Excision of the pieces. Insei-tion of the sutures. indication of diminishing the volume of the cervix and making as large an orifice as possible, there being no fear of subsequent contraction, such as occurs after simple division of the cervix or after excision of the whole thickness of the cervix including the mucous membranes. This last method, however, being much more complicated than mine, ' Archivfur Gh/naecologie, Bd. viii, S. 48, Berlin, 1875. DYSMENORRHCEA 319 ought to be reserved for cases in which it is indispensable to excise a large portion of the cervix. 3. Membranous Dysmenorrhea. One of the most curious maladies^ and somewhat similar to con- gestive dysmenorrhcEa, is that described by Oldham in 1 846 under the name ol pseudo-membranotis dysmenorrhcea, which Simpson studied at the same time under that of pathological exfoliation of the uterine mucous membrane, and which would be more correctly designated membranous dysmenorrhcea?- Although this disease is far from common, the singularity of this sort of mould of the uterine mucous membrane and its connection with the decidua have attracted the atten- tion of many writers. Besides being one of the most interesting forms of dysmenorrhcea, it is one of which the very existence has been the subject of lively debate. Whilst some, with Beruutz/ considered its existence as established beyond question, Hobin^ and others* denied it, founding their arguments on the simflarity of its morbid products with those expelled a month or six weeks after conception. This can- not be gainsaid; I myself have often recognised products of abortion in them. The arguments in favour of membranous dysmenorrhcea are drawn on the one hand from the fact that the phenomenon may be repeated regularly every month till cure takes place, notwithstanding the dis- continuance of marital intercourse, and on the other, that it has been observed in virgins. I. Many cases have been published of persistent membranous dys- menorrhcea in married women, about which there can be no doubt. The first case of this kind which is carefully recorded is Morgagni's.^ It is a case of membranous dysmenorrhcea in a multipara which gradually disappeared at the approach of the menopause. The entire exfoliated mucous membrane was eorpelled in the form of a bag. The hollow polypiform tumour due to dysmenorrhcea, described by * Oldham, London Med. Gazette, 1846, vol. ii, p. 970. — Simpson, Monthly Journal of Med. Science, Sept., 1846, p. 161. 2 Bernutz, op. cit., p. 128. ' Gazette medicale de Paris, 1857, p. 761. ■' Raciborski, quoted by Aran, p. 308. Since then, however, Raciborski has admitted the fact of the pathological exfoliation of the uterine mucous mem- brane (See Traite de la menstruation, p. 559. Paris, 1868). ^ Morgagni, De sedibus et causis morborum. Letter xlviii. "Of false pregnancy, abortion, and unhappy delivery," § 12. In 1814, Moreau also, in his inaugural thesis, describes the existence of this disease. He says, " Evrat has frequently observed that sterile women, some days after intercourse, passed portions of membrane analogous to the decidua, but the expulsion of these membranous fragments did not generally take pLace till the montlily period, and was invariably accompanied by tension, weight, and sometimes by dull hypogastric pain ; may we not reasonably infer," he adds, "that the excitement produced by coitus is sometimes sufficient to determine the formation of the decidua without fecundation having taken place." Although our ideas on the nature of the decidua are quite different from those of Moreau, it is not tlie less true that these exfoliated and expelled nmcous membranes are, after all, a species of decidua. 320 UTERINE DISEASES IN DETAIL Boivin and Duges/ may be connected with this same disease, as also the exfoliated products recognised as belonging to the uterine mucous membrane by Coste, Lebert, Follin, Dutard and Laboulbene, whose works have been judiciously revised by Semelaigne.^ One of the cases published by Tyler Smith/ another published by Hegar,** a third ob- served by Tilt,-^ and others to which I shall afterwards refer are examples which seem indisputable. Troque,^ who has recently published an in- teresting monograph on membranous dysmenorrhoea, relates thirteen doubtful and fourteen authentic cases, without counting those of Lehnert and Eggel which I shall presently quote, that of Bourgarel^ and those which have come under my own observation during the last few years. There is no doubt that the product expelled at every men- struation was not always examined with all the detail of which a micro- scopic examination admits ; the monthly repetition of the phenomenon, however, was established, and the existence of membranous dysmenor- rhcea cannot be doubted when patients observe the most absolute abstinence from sexual intercourse as mine have done.^ In this way I have lately observed two new cases of undoubted monthly uterine exfoliation. The first relates to a patient who began to menstruate regularly and abundantly at sixteen ; at twenty-one she had a natural labour followed by chronic metritis cured in a few months, at least to all appearance ; at thirty tardy and insufficient menses, with phenomena of abortion. Since then membranous dysraenorrhoea, and the same whether sexual intercourse was discontinued or not. The expulsion became more painful after four years. Cauterisation of the uterine cavity with nitrate of silver ; result almost nil. The other case is that of a young woman presenting traces of rachitis and some scrofulous symptoms; married for two years; nullipara. Membranous dysmenorrhoea occurring at every menstruation and several times taken for abortion. Leeches applied to the vaginal portion of the cervix, division of the os. Retro-uterine inflammation, probably diathetic ; formation and spontaneous opening of an abscess." Deatli from consumption. I have noticed that a large proportion of the patients affected with membranous dysmenorrhoea have, like the above named, a bad con- stitution, are weak, lymphatic, scrofulous, or disposed to tubercle. The malady, although local, seems to depend upon a general condition which makes the probability of cure very uncertain. On the other hand, we sometimes find a tendency to the same disease in several ' Maladies de I'uterus, t. ii, p. 419. "^ De la Dysmenorrhee membraneuse et de la membrane dysmenorrheale, These de Paris, No. 232, annee 1851. 3 The Lancet, 18 June, 1855, p. 608. * Monatsschrift filr Geburtsk, 1863, Bd. xxii, S. 176. * Arch, of Med., 1861, vol. iii, p, 96. — On uteiinc and ovarian inflamma- tion (exfoliative internal metritis), p. 267. London, 1862. * iltude critique sur la dysmenorrhee metnbraneuse. Paris, 1869. '' Union onedicale de la Provence, 1864. * Courty, Nouvelles observations de dysmenorrhee membraneuse, in Mont- pellicr medical, t. xxiii, p. 215, 1869. DYSMENOEEHCEA 321 women of the same family, a fact to be taken into account with regard to etiology. Brouardel has communicated to Siredey (Nouv. diet, de med. et de chirurc/ie pratiques, art. " Dysmenorrhce"j Duplan's case of a girl who had five sisters, all of whom suffered from membranous dysmenorrhoea ever since their first menstruation. One of Siredey's patients has a sister who, like herself, has suffered from membranous dysmenorrhoea. II. The montlily eccfoUation of the mucous membrane has not been observed as frequently in virgins as in married women, for the simple reason that membranous dysmenorrhoea, like all other uterine diseases, is rarer in the former than in the latter, and that the physician is taken less into the confidence of the former with regard to what occurs in the course of a menstrual malady, were it for no other reason than the ignorance and want of observation of the patient. No one, however, engaged in scientific research, or who makes minute inquiries into all doubtful cases of menstrual disorders occurring in a large gynae- cological practice, can fail to meet with authentic cases of the malady in question in virgins, and consequently to acquire a new scientific proof of its existence independently of conception and abortion. In this way I have collected four cases of membranous dysmenorrhcea in virgins, which are not without interest. The first was observed by Dubois of Neufchatel,^ and is a case of expulsion of membrane from the uterus at the monthly period in a girl of eighteen. The second case is that of a girl of sixteen expelling dysmenorrhoeic membrane.''^ The third case is one of membranous dysmenorrhoea existing throughout the virginity of the patient as well as after marriage. The case is related by Eggel,^ who read it before the Gyngecological Society of Berlin, when several members admitted the existence of this disease in virgins. Lastly, I have myself seen a case of membranous dysmenor- rhoea in a virgin, the cause of which was obscure, and which was only ameliorated by partial treatment. The latter series of cases proves that the exfoliation of the uterine mucous membrane may take place independently of any abortion. The membrane which is expelled periodically presents, it will be seen, the special characters of the uterine mucous membrane. It often has the triangular form of the cavity of the body of the uterus (Fig. 249). Sometimes it is divided into two triangular portions ; sometimes it is expelled in small fragments (Fig. 250). When it is passed entire it ' Dubois of Neufchatel, Gazette med. de Paris, 1847, p. 729 and 909. ^ Monatssclirift fur Geburtshunde, 1868, Bd. xxxi, S. 5. ^ ^g>^e\, 3Ionatssc]irift fur Geburtshunde, 1869, Bd. xxxiii, S. 11. — Solowief AlexAndveiDeciditanienstrualis, Archiv. fur Gynaekologie, Bd. ii, S. 66. Berlin, 1871) describes the case of a girl of twenty-one whose hymen was intact and who had frequently passed fragments of exfoliated mucous membrane after dysmenorrhcea. Einkel relates another case of expulsion of the uterine mucous membrane in a virgin in whom the hymen was intact, and two others in women who had abstained from sexual intercourse for two or three months {Archiv fiir patlwl. Anat. und Physiol., Bd. Ixiii, 1875). Beigel admits also tliat it is not rare to meet with it in virgins {Arcluv fiir Gynaelcoloyie, Band ix, Heft 1). 21 322 UTERINE DISEASES IN DETAIL generally presents several orifices ; the lower one, irregular, with the border more or less torn, corresponds with the os internum ; the two Fig. 249. — Uterine mucous membrane expelled en- tire, opened, showing the smooth internal cavity perforated with glandular orifices, and the external surface covered with vil- losities, the extremities of blind tubular glands. Preparation in St. Thomas's Museum, na- tural size (after Barnes). Fig. 250. — Portion of the uterine mucous membrane expelled in dysmenorrhoea (after Oldham). It is the first figure ever given of the exfoliated mucous membrane. There are two others in Tilt's work {On Uterine and Ovarian Inflammation, p. 266 etseq. London, 1862), and another in Henning's MemoiriMonatsschriftfiirGeburtsJc., 1864). The monthly expulsion of the mucous membrane generally takes place in this way, in fragments. others, which are very small and situated at the two upper angles of the expelled product, correspond with the ostia uierina. The colour is usually deep red ; the external surface is villous, sometimes infil- trated with small clots of blood, whilst the internal surface is perforated with holes corresponding with the glandular orifices, and is smooth to the touch. Vannoni has observed that when the sac is inverted during its expulsion from the uterus the villous surface may be found within. As a rule the external surface is very slightly villous ; the villosities may, however, acquire a considerable size, as Henning, of Leipsig, has seen.^ In this case, described under the name of villous dysmenor- rhoea, it is difficult to admit that the villosities belong to a chorion, and that the expelled membrane is a product of abortion, as the phe- nomenon was repeated six times, and each time at an interval of exactly a month. Although this case is very different from the preceding ones, it seems to be an additional example of exfoliative dysmenorrhrea. Examined by the microscope, the product presented the structure of the uterine mucous membrane, only differing from the decidua by the slighter development of its capillary vessels, by the small amount of > Monatssckriftfilr GeburtsJc., 1864, Bd. xxiv, S. 1.30. DYSMENORRHCEA 323 its special cells and of its epitheliunij which is of the prismatic instead of the pavement variety, like that of the decidua at the second month. This product contained a great quantity of debris of utricular or blind glands. The causes of this pathological exfoliation are very obscure. Oldham explains nothing in attributing it to ovarian influence ; this influence has neither been proved nor defined. Tilt,^ in a communication to the London Medical Society, connects it with an inflammatory condition ; in a later pubHcation, however, he justly remarks that the latter is not only the cause but the consequence of the passage of the sac or of this kind of delivery which occurs monthly. Scanzoui says he has only seen one case in which there was not an appreciable alteration of the womb ; in all others, the uterine walls were the seat of a chronic engorgement, or there were flexions, fibroids or polypi. As for myself, I do not know of a single case in which the disease was not preceded by more or less disturbance of the economy or of the uterus, shown by painful and irregular menstruation. It seems to me to be the result of a san- guineous congestion, a kind of apoplexy of the mucous membrane ;- in support of this opinion we may refer to the small clots found infiltrated in the expelled product, adding that, like apoplexy, it may be produced ' The Lancet, 1853. — Several authors, commencing with Andral (Anat. pathol., t. ii, p. 681. Paris, 1829), and including Huchardand Labadie-Lagrave, attribute the exfoliation o£ the uterine mucous membrane to inflammation or irritation. They call it tnenstrual metritis {Archiv. gen. de med., 1870) ; Kaschewarowa {TJeber die Endometritis decidualis chronica, in Monatssch. filr GeburtsTi., Bd. xxxii, Heft 5). In some cases the inflammatory nature of the disease cannot be denied, as in Labadie-Lagrave's cases {vaginitis, endometritis, membranous dysmenorrhcea for nineteen years, antiphlogistic treatment and cure) and in Huchard's {membranous dysmenorrhcea connected icith menstrual metritis for thirty -tivo years, contrast between the amelioration of the sijm- ptoms in the intercalary period and their aggravation at each monthly period, improvement from the use of emollients. Huchard and Labadie-Lagrave, Contributions a I'etude de la dysmenorrhee membraneuse {Arch. gen. de med. de Paris, 1870-72). We do not, however, consider that this form of dys- menorrhcea is necessarily the consequence of inflammation, nor that it should be designated exfoliative endometritis as Beigel suggests {Arch, filr GynaeJcol., Bd. ix, Heft 1. Berlin, 1876). Gaillard Thomas is also of our opinion (op. cit., p. 595). — Besides, we know that membranes analogous to those referred to are found in the nterus at other times than the monthly period, and there is no reason why inflammation should have more share in the formation of the one than of the other {Chronit Slawjanshy, Endometritis decidualis hemorrhagica bei Cholerahratiken, in Archiv filr Gynaecol., ^d.. iv, S. 285. Berlin, 1872). — Other authors, e. g. Mandl {Zur Pathologie und Therapie der Dysmenorrhcea membranacea, Wiener medical Presse, 1869, No. 1 to 16. Monatssch. filr GeburtsTi., Bd. xxxiv. Heft 5. Berlin, 1869), regard it as special {morbus s^ii generis), whilst following Robin and Haussmann some consider it early abortion {avortement ovulaire) ; but if so, it should be possible to recognise it by its form, structure, &c. - For which reason Hegar and Eigenbrodt have given it the name of apo- plectic dysmenorrhcea. Besides, the thrombic accumulations, the real sub- mucous apoplectic centres prove the existence of sanguineous effusions, which associated with uterine contractions would be the chief secondary causes of the exfoliation of the uterine mucous membrane. The membrane is separated from the subjacent surface by a fibrinous layer containing free round cells (Beigel) or by real apoplectic centres, the results of sub-epithelial or sub- mucous sanguineous extravasations (Huchard and Labadie-Lagrave). 324 UTERINE DISEASES IN DETAIL in the absence of any organic alteration of the womb ; the mucous membrane must also have a special tendency to exfoliation. As to dysmenorrhoea, strictly so called, although it usually accompanies ex- foliation, it may be wanting without the malady losing its distinctive character, which is the expulsion of the mucous membrane. Exfolia- tion and expulsion of the mucous membrane are the anatomo-patho- logical elements of the disease in question. Mayer,^ of Berlin, relates the case of a married lady, twenty-seven years of age, who was sterile, and who suffered from the monthly exfoliation of a thick and consistent membrane without dysmenorrhoea. The dysmenorrhoeic pain depends solely on the relation between the size of the expelled membrane and the orifice through which it has to pass. A httle reflection on the special nature of uterine diseases will con- vince us that there is nothing so very extraordinary in membranous dysmenorrhcea. The same properties characterise the organs and tissues in the evolution of their pathological processes as in the accomplish- ment of their physiological processes. Many pathological phenomena are only an impairment or an exaggeration of physiological ones. With various degrees of reaction to pathogenic causes, the tissues respond to the action of these causes in the same way that they respond to the causes which normally elicit the display of their activity. Now the uterine mucous membrane becomes hypertrophied and is exfoliated by the physiological act of parturition, and by the pathological act of abortion (intermediate between the exfohation of parturition and that of dysmenorrhoea). Is it surprising that, under the influence of a uterine disease which places the tissues in a condition analogous to that of the beginning of pregnancy and abortion, this mucous membrane should be exfoliated in the same way, although it does not contain any product of conception ? In this case an abnormal process takes place analogous to what occurs normally under the in- fluence of conception. This process commences at the ripening of every ovum in the ovary, at the dehiscence of every Graafian vesicle, at every menstrual period. The mucous membrane swells and commences to hypertrophy, as if in preparation for a possible conception. It is this jjcriodical hypertrophy of the mucous membrane which has been described by Aveling under the name of nidafwn, and in place of hyper- trophy Aveling,2 Williams,^ and others admit a monthly development, a new formation after every menstruation. This new uterine mucous membrane formed during each intercalary period, is supposed to be entirely detached and expelled every month, owing to fatty degeneration and disintegration with subjacent haemorrhage, and to disappear with the menstrual discharge in fragments which escape observation. There- fore Aveling calls it the nidal decidua to distinguish it from the decidua of gestation. Membranous dysmenorrhoea is, according to this theory, only an exaggeration of this phenomenon. • Beitrage zur GeburtsJcund. und Gynaekol., Bd. iv, Ileft 1, S. 33. Berlin, 1875. - London Obstetrical Joufnal, July, 1874. 3 Id., February .and March, 1875. DYSMENORRHOSA 325 The formation of a new mucous membrane every month is not proved, and I think the exfoliation of this membrane is only an exceptional fact. The only thing really proved is the enormous hypertrophy of the uterine mucous membrane at every menstrual period. An excess of this hyper- trophy is sufficient to constitute an obstacle to the discharge of the menstrual blood and a local cause of the detachment of the mucous membrane by subjacent sanguineous effusion. It is not even necessary to suggest this hypothesis. In fact when fecundation does not take place, the uterine mucous membrane resumes its normal condition, and all congestion and erection ceases in the utero-ovarian system. If, however, this regressive atrophy (the analogue in miniature of the retrograde evolution following delivery) is absent owing to a local malady or a general condition reacting on the uterus, there will be a great risk of exfoliation of the mucous membrane taking place. Now, I have observed that the majority of women affected with membranous dysmeuorrhoea are thin, delicate, chlorotic, rachitic or scrofulous. All writers have made the same remark ; and some physicians consider this malady merely as the localisation of a variable diathetic affection, the nature of which is not yet clear, but the existence of which is probable, since it is sometimes seen in several women of the same family (p. 321). If some refuse to see in membranous dys- meuorrhoea the localisation of a general affection, they cannot deny that the reaction of the disease is sometimes propagated to more or less distant organs ; for instance, a propagation of this kind may produce real exfoliative enteritis ;^ it is perhaps a propagation of the same kind which causes buccal ichthyosis, and which has led Gautier, of Geneva,^ to suppose that the disease in question is only uterine ichthyosis, detached in patches. To sum up, there is a connection between membranous dysmeuorrhoea and morbid conditions of other organs till now imperfectly determined, but which deserves attention. Dlaffnosis. — The symptoms of this affection are those of congestive dysmeuorrhoea, frequently aggravated by complications. When un- complicated, the disorders only exist at the monthly period. Scanzoni^ observed in one of his patients an acute pain in the renal and umbilical regions, occurring eight or even fifteen days before the menses appeared ; this, however, is exceptional, usually pain ajjpears only the evening before menstruation. It seems to cease all at once with the appearance of the discharge, but recommences shortly afterwards with renewed intensity. It is at first congestive or in- flammatory, with a feeling of fulness in the pelvis, heat, tension at the hypogastrium, in the loins, and in all the pelvic cavity. It afterwards becomes expulsive and intermittent, assuming the character of labour pains, of real uterine contractions which may be transformed into 1 Huchard and Labadie-Lagrave {Archiv. gen. cle mcclecine, 1870). ^ Congres international des sciences nicclicales, 5^ session, p. 460. Geneva, 1878. ^ Op. cit., p. 335. 326 UTERINE DISEASES IN DETAIL cramp, which requires to be calmed in order to regulate contraction and facilitate the expulsion of the caducous membrane. At last, after repeated alternations of exacerbation and comparative relief, lasting fro;n four to six hours, a more or less extensive membrane is expelled either at once or at different times in fragments, and from this moment there is a diminution of the violence of the pains. After expulsion there is a pale red discharge soon replaced by one altogether mucous in character. At the next monthly period the same scene may be repeated with more or less violence ; only the membrane may be less extensive, and may no longer represent the mould of the uterine cavity exactly. This indicates an improvement which may either be due to treatment or to natural causes, giving us reason to hope that cure is not far off. It is not uncommon for exfoliation and expulsion of the uterine mucous membrane to coincide with other serious pathological states. These concomitant phenomena are : general deterioration of health, anfemia, chlorosis, scrofula, tuberculosis, leucorrhcea, chronic endo- metritis, repeated formation of false membranes, of coagulation of mucus, of epithelial desquamation of other organs, such as the tubuli uriniferi in catarrhal nephritis, the trunks of the bronchi and the trachea, the larynx, the pharynx as the seat of pultaceous angina, &c. Glairy enteritis (not including dysentery, diphtheria and thrush) and exfoliative enteritis (Heyfelder, Siredey, Huchard, &c.) have been observed simultaneously with exfoliative metritis, as have also analogous alterations of the mucous membrane of the bladder (Luschka, Fir- cAow's Archiv ; Deneffe, Bulletin de la Soc. anat. de Paris, 1 862 ; Spencer Wells, Obstetric. Transact, vol. iv) and of the vaginal mucous membrane (Tyler Smith, Farre, Vannoni, Tilt, Delore). Differential diagnosis. — Membranous dysmenorrhoea must be dis- tinguished from abortion. There are differences, as Raciborski^ says, which enable us to distinguish them ; the dysmenorrhceic expulsive pains precede the monthly hsemorrhage, whilst haemorrhage precedes the pains of abortion ; in the former the cervix is closed, in the latter it is open ; the dysinenorrhoeic membrane is generally in frag- ments, that of abortion more or less entire; if entire, the former is rather triangular (moulded on the uterine cavity), the latter ovoid ;2 the former is often an incomplete decidua, in which a great number of elements, glandular and vascular especially, are wanting, the latter, like every gravid decidua, is thicker, richer in vascular arborisations, and even showing a trace of the spot where the ovum^ was lodged ; the former is only expelled at the menstrual period which is not delayed,^ the latter at other times, independently of menstru- ' Traite de la menstruation, p. 559. Paris, 1868. ^ See the form of this decidua of aboi-tion, compared with that of the djs- menom-hceic membrane (fig. 2'19) in a drawing added to \nj paper entitled, Mecanisme habitnel de V avortement dans les premiers mois de la grossesse, &c., Montijellier nu'tdical, t. v, pp. 215, 428, &c., 1800. ^ Gillet de Grandniont, De la tnuqueiise uterine et de son evolution pendant la menstruation ct la grossesse. Inaugural tliesis. Paris, 18(54. * Tliis expulsion occurring always at the menstrual period may be repeated DYSMENORRHCEA 327 ation, usually after some delay, that is to say, its expulsion is pre- ceded by a gestatory araenorrhoea (however short) ; the former has a cylindrical, the latter a pavement epithelium ; the former is often accompanied by symptoms of metritis and inflammatory exudations, the latter by neither. It is important to notice these differences in forming a prognosis and to confirm them by enjoining strict discon- tinuance of marital intercourse; for if it is a question of mem- branous dysmenorrhoea an unfavorable prognosis as to a future preg- nancy will be given ; if it is a question of abortion the prognosis will be relatively favorable to another pregnancy, at least propor- tionately to the gravity of the causes which have produced the abortion. The expulsion of the exfoliated mucous membrane has often been confounded with that of other products of the womb. Apart from clots of blood, we know that a certain number of products, appa- rently membranous, may come from the uterus. But an attentive, minute histological examination, aided by the microscope, will not fail to detect profound differences under apparent analogies. The apparently similar membranous products which may be expelled from the uterus may be classed under three heads : 1, coagulations of mucus presenting the characters of inflammatory exudations, moulded on the uterine cavity, and preserving sufficient consistency to be expelled under the form of entire pseudo- membranes, being sometimes formed of several homogeneous layers or plastic concretions which increase their thickness and tenacity, and may give rise to an exudative dysmenorrhoea j^ the desquamation there effected is sometimes only the first stage of the malady followed by exfoliation which will take place later on; %, false membranes strictly so-called, analogous to those which are formed on other mucous membranes from slight epidermic exfoliations lined with coagulations of mucus, analogous to those of thrush and to more serious exfoliations lined with fibrinous products, separating from the dermis of the mucous membrane only by ulceration or laceration, which are of the same nature as croupous membranes and equally serious, hence the name of diphtheritic metritis. We may there- fore give the name oti pseudo-membranous or diphtheritic dysmenorrhea^ to this disease ; 3, lastly, the uterine mucoiis membj'ane itself, which is separated from the underlying tissue as at delivery or at miscarriage or at a simple abortion, and which is expelled sometimes entire in the form of a sac, with external or internal villosities according as it conseciitivelj for eight years (Case of Veit, Christot), ten years (Huchard), fifteen years (Mandl), in fact indefinitely. ' No one doubts the reality and nature of these exudations and of these coagulations of mticus. - This name has been adopted by Huchard and Labadie-Lagrave {Contribu- tion a I'etude de la dysmenorrhee vionbraneuse, Paris, 1873, and Arch, de med., loc. cit.). Boggs {Notes et reflexions chirurgicales sur les phlegmasies de la 'inatrice. Theses de Paris, 18G6) ; Her\deux {Traits clinique et pratique des maladies pioerperales, t. i, p. 2iO. Paris, 1870) ; Krieger {Die menstruation, eine gynaekologische Stiidie, S. 196. Berlin, 1869) ; Scanzoni (op. cit.. p. 335) • Churchill (op. cit., p. 218). 328 UTEEINE DISEASES IN DETAIL passes directly or iuverted, sometimes in more or less considerable fragments, sometimes in small shreds, but always with its characteristic elements, its glands, epithelium, kc. It is for the disease characterised by the exfoliation and expulsion of the uterine mucous membrane itself that we must reserve the name of membranous or exfoliative d^smenorrhcea} Lastly, besides products of the womb, there are also membranous debris from the vagina (epithelial vaginitis of Tyler Smith and Farre, Arc/lives of Med. 1856-59, vol. i, p. 71), sometimes even real moulds of the vagina, expelled by patients, as described by A. Farre {Beale's Archives) and Barnes (op. cit., p. 217), which must not be confounded with membranes produced by dysmenorrhoeic uterine exfoliation, and which differ in every respect. Besides the difference in the macroscopic and microscopic characters of the expelled pro- FiG. 251. — Exfoliated vaginal mucous membrane, forming a mould of the vagina, in St. Thomas's Museum (Barnes). ducts, it is sufficient to add, to complete the diagnosis, that the vaginal products are always expelled without dysmenorrlmic pains. Treatment. — Although this disease does not involve risk of life, it is serious, not only because of the monthly suffering, but also on account of the reproductive functions. It is all the more important to treat it, as Beigel justly remarks, because it is a cause of sterility and abortion. I have collected several cases in which abortion was ' Savielti {Contribution a I'etude dc la caduque menstruelle. Turin, 1869) ; So\o\v\ei (Deciduamenstrualis, Archiv f. GynaeJc, Bd. ii, S. 08, 1870) ; Hegar and Mayer (Beitrdge zur Pathologie des Eies, Virchow's Archiv, Bd. ii, S. 1(31, 1871). DYSMENORRHCBA 329 undoubtedly connected with this morbid state, and a number of others, in which this disease was so evidently a cause of sterility that in several conception followed the cure of the malady. The patient whose history is related by Ilenning is a striking example of this : after having expelled these membranous products six times during the first six months of her marriage, she was cured so completely that three months afterwards she became pregnant and had a good delivery. I may here quote two other equally authentic cases of cure of membranous dysmenorrhosa. I could mention several others, but do not wish to put before the reader any cases as to which there could be the slightest doubt. The first case is an example of membranous dysmenorrhoea in a virgin with aggravation of symptoms after marriage. — Sterility. — Amelioration. — Widowhood, cure. — Second marriage. — Two preg- nancies followed by delivery at term. It is probable that the con- solidation of the cure by widowhood was the indirect cause of the cessation of sterility at the commencement of the second marriage. The second case is an example of membranous dysmenorrhoea occur- ring after marriage and an abortion. — Slight retroflexion, leucorrhcca, monorrhagia. — Long duration of the disease. — Cure after a long con- tinued general treatment, tonic and anti-diathetic, and slight cauterisa- tions followed by tonic applications to the uterine mucous membrane. It is evident that in these two cases the disease was of an inflammatory nature. That does not imply that an analogous treatment would not succeed even when symptoms of metritis were less accentuated. We must, however, remember that, membranous dysmenorrhoea being frequently connected with a serious disturbance of the constitution, we must try to modify the constitution by general treatment, more fre- quently tonic, alterative and anti-diathetic than anti-phlogistic. The local treatment is less difficult to institute. The treatment varies, not only according to the patients and their constitution, but also according to the stage at which the physician is consulted and the complications which may co-exist. Referring the reader for these latter to the chapters devoted to them, I will confine myself now to mentioning what should be done in the simplest cases, those in which the inflammatory element is the only complication to be feared. Whatever the case may be, the primary indication at the time of suffering is to alleviate and diminish the pain ; preparations of opium given internally should be associated with belladonna or chloroform liniments applied to the abdomen. In the intercalary period, however, it will be well to ap])ly some leeches to the cervix and to cauterise the uterine cavity with nitrate of silver. Although these means have often succeeded, especially in the hands of Tilt, they have also failed ; Scanzoni has cauterised for whole months without obtaining the slightest alleviation. These failures chiefly depend on tlic nature of the complications : when they cannot be combated successfully the dysmenorrhoea resists all therapeutic efforts. 330 UTERINE DISEASES IN DETAIL To prevent the formation of membranes, especially in exudative or pseudo-membranous and even in diphtheritic djsmenorrhoea, we may resort to the injection of a saturated solution of chlorate of potash or to crayons of chlorate of potash introduced every tM'o days into the uterine cavity ; they are sometimes completely dissolved, at other times reduced to small fragments in twelve hours. Injections of a strongly alkaline solution of bicarbonate of soda may act favorably on the mucous membrane. Solowief^ has proposed electricity for the same purpose. When the dysmenorrhoeic symptoms seem to be produced by want of proportion between the uterine orifice and the membrane which has to be expelled we may follow the example of Tyler Smith,^ who relieved a patient by introducing a metal stem into the cervix in order to dilate mechanically. This question requires more investigation. It seems to me, that in the majority of cases, the local indications are hmited as follows : — 1, by dilatation or incision to render the uterine orifice easy to pass ; sufficient attention is not paid to this matter : prepared sponge is in such cases an excellent means of dilatation and of render- ing the tissues supple; 2, to modify the internal surface of the organ by catheretics or slight caustics, such as fine injections of saturated solution of chlorate of potash (the action of which on the mucous membranes is so efficacious), or of nitrate of silver, tannin, perchloride of iron, iodine, or of very weak solutions of arsenic or mercury, or even chloride of zinc greatly diluted. It is only by modifying the tissue of the mucous membrane and its vitality more or less ener- getically that we can hope to arrest this continued tendency to exfoliation. The treatment which I have found most successful consists in dilating the cervix with sponge-tents, the dilating and resolvent action of which is assisted by the use of belladonna ointment, the application of mercurial ointment to the hypogastrium, by small rectal injections of iodide of potassium, by emollient and alkaline baths, and by a tonic and antiphlogistic general treatment, in which hydropathy should not be forgotten; the surface of the uterine mucous membrane should be modified simultaneously by the direct application of chlorate of potas- sium, nitrate of silver, tannin, iodine, perchloride of iron, ointment of red precipitate of mercury, &c., according to the predominance of the local indication. During the whole time of treatment the general health should be particularly attended to, tonics, alteratives, a good regimen, exercise, hydropathy, mineral waters being prescribed as may be specially indicated ; in this way we must try favorably to modify the constitution, which in its turn will exercise a beneficial influence on the uterus. Uterine Neuralgia Uterine neuralgia or hi/steralgia is like the neuralgia of all other organs, a serious disorder of sensibility, characterised by acute pain, ' Archivf. Gynaecolog., Bd. viii, S. 3. Berlin, 1875. ' The Lancet, 16 June, 1875. UTERINE NEURALGIA 331 independent of any other morbid state such as congestion, iuflamma- tiou, &c., which, however, may co-exist with it. Whilst beheving that neuralgia is usually the localisation of diathetic affections, such as catarrh, rheumatism, arthritis, gout, herpetism, &c., I admit that it may be developed temporarily in an organ as a simple morbid act, resulting from the existence of a local or general pathological condition. Hysteraigia is what the ancients called a disease without matter, a transition point between simple local uterine diseases without neoplasm, and those maladies depending on a general affection, characterised by an organic alteration. Diagnosis. —'NonaV- distinguishes jjrimitive hysteraigia, occurring suddenly, in which the nervous pain commences in the uterus and is propagated into various regions of the body, from secondary hys- teraigia manifested subsequently to a neuralgia developed on some other point of the organism. He also distinguishes idiopathic from sym])tomatlc hysteraigia. The latter, which may depend on metritis, pen- uterine phlegmon, &c., does not seem to me to be as important as the former ; for it is accompanied by symptoms foreign to the neuralgia itself, and yields to the treatment of the dominating malady. As for idiopathic neuralgia, although it is a disease without matter, it is not only nervous and essential, but also diathetic like sciatica and all other neuralgias. Uterine neuralgia usually coexists with lumbo-abdominal, lumbo- sacral or intercostal neuralgia. Valleix ^ considers uterine neuralgia as nothing more than the mode in which these morbid states are manifested, i.e. as a lumbo-abdominal neuralgia, of which the most painful spot is situated in the uterus. The majority of practitioners look upon uterine neuralgia as primitive, and the pain produced in the various nerves of the lumbar plexus as only sympathetic or sympto- matic irradiations. Struck by the coincidence of uterine neuralgia with cervico-brachial, facial, supra-orbital and especially with inter- costal neuralgia, Bassereau ^ admits that the painful condition of the uterus reacts through the branches of the great sympathetic on the intercostal nerves determining neuralgia. There may assuredly be irradiation, or reflex action, or coexistence of two neuralgias under the influence of a common morbid affection. It is probably this malady which Gooch ^ designated by the name of irritable uterus. Although several writers have attributed his description to metritis or to the painful contractions which any kind of disorder may excite in the organ, I think that the name of perma- nent dysmenorrhcea, which he also gave it, leaves no doubt as to the nature of the pain and its continuity during the intercalary periods as ' Op. cit., p. 393. ^ Traite des nevralgies et Bullet, gen. de thcr., Jan., 1847. — Guide dii mede- cin praticien, t. v, p. 195. Paris, 1801. 3 Essai sur la nevralgie intercostale considcree covime sijmptomatiuue de quelques affections viscerales. Theses de Paris, 1840. ■* On the more important diseases peculiar to ivomen, p. 332. London, 1831. — See also Genest, Gazette me'dicale, 1830, pp. 323, 385 ; Scott, Gazette medic 1834, p. 809 ; Balling, Neue Zcit.f. Geburtsk., Bd. i, S. 21, 2nd case. 332 UTERINE DISEASES IN DETAIL well as daring menstruation. It is this character of spontaneous and continued pain, hardly interrupted for an hour, often seated in the lower part of the uterus, quite different from uterine colics or expul- sive pain, sometimes causing intolerable suffering at the slightest movement or touch, radiating into the lumbar plexus, which allows of our diagnosing hysteralgia and distinguishing it from other painful states of the womb. This is all the more striking, as usually it is only the isthmus and the mucous membrane of the body of the uterus that are sensitive. The sensibility of other parts is very dull ; the cervix apparently having none. The pain varies in nature from the sensation of itching, irritation, intolerable heat to that of intense shooting pain in the uterus and in the course of the nerves just referred to. It is often confined to one side of the pelvis. It may be aggravated by heat as well as by move- ment. It prevents sleep or interrupts it suddenly by a fit of pain. It is greatly increased by the cervix being touched, and I have seen it accompanied by contraction of the vulvo-vaginal sphincter. It is generally worse a few days before the menses, without, however, interfering with the regularity of menstruation, it does not necessarily hinder the free exit of blood, and consequently, while liable to be confounded with nervous dysmenorrhcea on account of the develop- ment of pain and the dysmenorrhoeic symptoms which may complicate it, it may be distinguished by the freedom with which the catamenial discharge takes place, and by the absence of the expulsive pains cha- racteristic of uterine colic. The deferential diagnosis is certainly difficult when there are com- plications. Tor example, nervous, congestive or even mechanical dysmenorrhcea, congestion, inflammation, hypertrophy of the uterus, peri-uterine inflammations, prolapse of the uterus and vagina, with the very painful draggings thereby caused, organic lesions such as cancer, hysteria and the local phenomena accompanying it, are all morbid states which may be mistaken for neuralgia owing to the pain which they cause. Therefore great care should be taken to discover if any of these lesions exist ; for hysteralgia is so rare that, however violent and persistent the pain may be, we should always presume that it is symptomatic of some one of these morbid states rather than of hyster- algia. Graily Hewitt regards it as being only a symptom of retro- flexion ; in a supposed case of uterine neuralgia related by Allison,^ the autopsy disclosed a serious peri-uterine inflammatory lesion. Even the effects of uterine neuralgia help to conceal its true nature ; leucorrhoca in fact may accompany it as a symptom, just as salivation and tears accompany neuralgia of the trifacial, and whilst in the majority of cases we are liable to be misled in attributing to a sup- posed hysteralgia the pains produced by another disease, so on the other hand we may overlook hysteralgia when it really exists, attribut- ing the suffering to leucorrhwa which is only one of its symptoms. • Painful affection of the cervix, excision, cure ; death the following year. Tho post-mortem examination showed adhesions unitin'j tlie uterus to tlie lihiddcr and rectum {Gazette med. de Paris, 1843, p. 301). UTERINE NEURALGIA 333 The characteristics of neuralgia, however, are sufficiently well marked by the pains just described which are accompanied by great sensibility of the neighbouring tissues, sharp attacks of pain with slight inter- mittence, shooting pains, Szc. The seat of liysteralgia may also require to be diagnosed ; it is sometimes in the body but more fre- quently in the cervix, according to Malgaigne ;^ it may even be con- fined to the right or left. Treainient. — Hysteralgia, although not a fatal illness, is very serious, owing to its duration and the extreme difficulty of curing it. Of three patients Scanzoni^ only saw one cured, and evt-n this cure was effected spontaneously as the result of marriage, the disease having resisted all treatment. The two other patients were treated in vain by several physicians. We must therefore attack the evil early and by general and local means powerful enough to give some hope of a good result. The treatment must necessarily vary with the nature of the neuralgia. Judging from my own practice, I think half of all the cases of neuralgia are connected with rheumatism or an analogous diathesis. Therefore we ought to prescribe a treatment appropriate to this malady, sulphur or alkaline mineral waters, vapour baths and hydropathy which is the best sedative as well as an excellent means of treating rheumatism in young women. In addition, we must prescribe the general or local treatment suitable for the special nervous form charac- terising the neuralgia, which is neither simple pain nor spasm. The most efficient internal remedies are narcotics and antispasmodics, associated with tonics and even with iron according to the indication. Sulphate of quinine with digitalis or aconite has produced very good results in many cases, especially when the neuralgia, as is often the case, assumes an intermittent or periodic type. When necessary, the attacks may be alleviated by inhalations of chloroform, and local sedatives should be applied to the hypogastrium, uterus and rectum. The transcurrent cauterisation recommended by Nonat may also be tried on the lower part of the abdomen^ or better still hypodermic injections of morphia may be given. Suppositories or small injec- tions containing laudanum or belladonna may be introduced into the rectum till narcotism is produced ; or vaginal irrigations may be made with decoctions of hemlock, poppy heads, or belladonna in sitz- baths of the same composition. Carbonic acid or chloroform spray may be applied to the cervix. Aran advises the local application of ice, or better still of laudanum. Malgaigne who, with the majority of Prench writers, thinks hysteralgia much more common than it is, recommends division of one or both lips of the cervix. The best of all local applications is the hypodermic injection of morphia or atropine. It has been suggested that these injections should be made into the uterine tissue itself, but the latter is so vascular that it bleeds at once on being punctured, and so the injec- tion is apt to be lost ; besides, patients affected with uterine neuralgia 1 Sxw la nhralcjie du col de I'uterus, &c. Revue medico-chirurgicale, avril, 1848. - Scanzoui, op. cit., p. 339. 334 UTERINE DISEASES IN DETAIL suffer terribly when the cervix is touched. Therefore it is better to make these punctures in the hypogastrium at some painful point corre- sponding to the ramifications of the lumbo-abdominal branches.^ The puncture is made into a fold of the skin, and as soon as the injection is made the finger should be applied to the skin as the canula is with- drawn so as to prevent the return of the fluid ; the puncture is then covered by a drop of collodion, when a local and general narcotism is rapidly obtained. The injection should be repeated sufficiently often to prevent the return of pain, and the points of puncture should be varied according to necessity. In addition to these injections chloral may be given to procure sleep, and bromide of potassium for the hysterical symptoms. It is very seldom that these three principal means, aided by some of the accessory measures mentioned, such as belladonna, henbane, supposito- ries, fomentations, &c., do not temporarily alleviate the suffering, whilst we must trust to mineral waters, alteratives, specifics, &c., for attacking the source of the evil, i. e. the diathetic affection (rheumatism, herpes, &c.) which is generally the hidden cause of uterine neuralgia. I have obtained such satisfactory results from these means that I am convinced that, when associated with hydropathy, they constitute the most efficacious, if not the only efficacious treatment of hysteralgia. Utehine Hemorrhage Uterine haemorrhage may occur under three different circumstances : — 1, in the unimpregnated uterus ; 2, during pregnancy;^ 3, after delivery or abortion. These latter forms depend generally on special causes which have to be studied in connection with pregnancy and delivery — that is to say, with the conditions which produce them. I shall, therefore, confine myself to the first kind. Uterine haemorrhage occurrmg in the unimpregnated state is called Menorrhagia when it is apparently only an exaggeration of the monthly period, and metrorrhagia when it is independent of the menses. It may assume various forms : the quantity of blood discharged in the same time may be greater than usual (a phenomenon which often depends on a disorder of the mucous membrane) ; or the periods may last longer, the result being the same, though due to a different cause (generally to the persistence of congestion); or they may recur more frequently, thus giving a different character to the malady (connecting it with more frequent ovulation). Lastly, there may be an intermenstrual discharge of blood independent of menstruation, and constituting a symptom of an organic disorder or morbid state similar to that which ' De I'ejjlcacite des injections narcotiques sous-cutanees dans le traitement des nevralgies. Montpellier medical, Conrty, October and November, 1859. ^ Coiirty, Memoire sur le 7necanisme habituel de I'avortement dans les pre- miers mois de la grossesse, &c., Montpellier medical, IHfJO. Barnes, Lectures on Obstetrical Operations, 2nd edition. London, 1871, p. 387. UTERINE HiEMORRHArrE 335 obtains in other organs under the name of haemorrhage, and which alone therefore has a right to the name of metrorrhagia. Uterine haemorrhage is also an important symptom, and occurs so frequently that it deserves the serious attention of the physician. It may be idiopathic or symptomatic. i. The possibility of idiojjathic metrorrhagia has been wrongly denied. It is not uncommon for the menses to be occasionally more abundant than usual without the existence of any abnormal condition. In some women they may be less abundant one month, and increased in quantity the following month ; or having been retarded or suppressed they may return abundantly, as if to compensate for the temporary suspension. Frequent cases of this kind occur at the menopause. They often alternate or coincide with congestions or hsemorrhoids, and like these may disappear. No anatomical alteration is to be seen in the uterus beyond a temporary distension of the capillaries. There are some cases on record of metrorrhagia terminating in death which could not be explained by the existence of any lesion. Case 1. — West^ has related a case of death from metrorrhagia in which ho other lesion could be found than a small clot in the cavity of the womb, with- out any alteration in the mucous membrane. In another case the autopsy is not given. Case 2. — Obre" has seen the same occur in a virgin of fourteen years, in whom the first menstrual discharge could not be arrested. Everything was normal except the uterine mucous membrane, which wa^s softened and ecchy- mosed and detached from the muscular layer in several places. Case 3. — Whitehead-'' has seen a similar case; only here menstruation had been regularly established for four years. When the girl was seventeen she fell on the ice in the street, and sustained a severe shock. Ten days after the menses appeared, and were followed by profuse hsemorrhage, which lasted five or six days, from the effects of which she only recovered in ten or twelve days. The catamenia returned the following month, and lasted for sixteen days. The next menstrual period they returned, but a few days afterwards they were replaced by a metrorrhagia, which it was impossible to control, and which ter- minated fatally in thirteen days. At the autopsy no organic lesion was discovered. The iiterus was nulliparous, rather larger than usual ; its walls, although less firm than usiial, were of normal thickness. It contained a clot of blood, which filled the cavity ; the appendages were normal. Menorrhagia is more frequently idiopathic than metrorrhagia : e. g. premature and tardy menstruation, uterine epistaxis, haemorrhages from excessive ovarian pain, from prolonged uterine erection, from inertia and disturbance of vaso-motor innervation. 2. Symptomatic metrorrhagia occurs very often, more so than dysmenorrhcEa or symptomatic amenorrhoea. It happens more frequently in the intercalary period than during menstruation; it often continues almost uninterruptedly from one period to another with exacerbations corresponding sometimes with the menses, sometimes not. Metrorrhagia may be symptomatic of local diseases or of general affections not localised on the uterus. Amongst local diseases may be reckoned hemorrhagiparous congestion, defective involution, rarely * West, op. cit., p. 65. " British Medical Jo^irnal, 1857 ; Gazette med. de Paris, 1856, p. 596. ^ London Medical Gazette, 1846 ; Archives de medecine, 1846, t. xii, p. 48.3. 336 UTERINE DISEASES IN DETAIL metritis, sometimes softening of the uterine tissue or alterations in the mucous membrane (granulations, fungosities, exfoliations, ulcerations),^ very often polypi, hydatidiform or fleshy moles, fibroma, cancer; less frequently hematoceles, peri-uterine inflammation, ovaritis, organic lesions, cystic or otherwise, of the ovary^ especially in their first stages, deviations, flexions, &c. As for ovarian neuralgia, the influence which it is said to have in producing hfemorrhage has been greatly exagge- rated. Amongst general affections we may mention : the acute exan- themata, smallpox, measles, scarlatina, typhoid fever (in the course of ■which uterine epistaxis may occur)," and above all the hsemorrhagic diathesis,^ the influence of which is felt upon the uterus as well as upon all other organs; sometimes plethora, but more frequently impoverish- ment of blood from Bright's disease,'* chloro- anaemia, scorbutus, &c. : lastly, blood stasis in tlie system of the vena cava inferior from incom- petence of the mitral valve, mitral constriction, hypertrophy of the heart, development of abdominal tumours or other chronic maladies. In fact it is much more common than idiopathic bsemorrhage. It is characterised by frequent recurrence and persistency. Diagnosis. — It is a differential diagnosis that is required. It is not difficult to assure ourselves that the blood comes from the uterine cavity, but it is not so easy to decide whether we have to do with menorrhagia or metrorrhagia; whether the hsemorrhage is symptomatic or idiopathic, active or passive, &c. The knowledge of the causes and analysis of the symptoms facilitate this diagnosis. Amongst the pre- disposing causes age should be taken into consideration. Middle age is the period when haemorrhages, like all other uterine diseases, are most common. Metrorrhagia is also very common at the menopause, constituting one of its most remarkable phenomena. Brierre de Boismont" has observed fifty-seven cases out of 111 women arrived at the climacteric. It is difficult to believe that metrorrhagia can be idio- pathic after the menopause. We know very little as to the influence of constitution, temperament, general health, &c. The influence of hygienic agents seems to be undoubted. According to Saucerotte," women who inhabit the highest points of the Yosges are subject to haemorrhages. The influence of hot climates or change of climate, and the abuse of hot baths, as in the East, is certain. What are we to think of that of alcohol, of the abuse of hot-water bottles, and of so many other real or imaginary causes to which great importance has been attached ? Probably a more real predisposing cause is to be found in the structure of the uterus itself, its mucous membrane, its muscular ' Occasionally more serious alterations produce metrorrhagia ; e.g. the case related by Grailly Hewitt of fatal hajmorrhage after delivery, due to a trau- matic aneurism of the uterine artery {Obstet. Transact., v. ix, p. 2 i(3. London, 1807). ^ Upon uterine epistaxis, so called by (Jiiblcr. V. supra, p. 410. ^ Gendrin, Traite de med. philos., t. ii. ■* West, op. cit., p. 51. * Op. cit., p. 228. " Melanges de chirurgie, p. 25. UTERINE HiEMOBRHAGE 337 tissue, its vascular system, the activity of its circulation, the inertia of its muscular tissue, &c. Among detennining causes simple physical acts (a blow, a fall, the application of leeches to the cervix) may give rise to metrorrhagia, which may assume the character of active haemorrhage if it is the result of the violence of the reaction rather than of the traumatism itself; but sexual excitement, violence of menstrual molimen, excessive inter- course, especially in the case of prostitutes,* as t\ell as influences of the same kind on neighbouring organs, e. g. repeated drastic pur- gatives, are all causes which rather increase the activity of the haemor- rhage than originate it. Although moral impressions more frequently suspend menstruation, they may exceptionally produce an excessive flow of the menses, or even metrorrhagia. The sympto7ris of metrorrhagia are those of hseraorrhages in general : progressive debility, pallor, chilliness, especially of the extremities, small pulse, tingling in the ears, giddiness, &c. Those of essential or idiopathic metrorrhagia are variable. Sometimes the discharge of blood and even uterine fluxion are intermittent, the blood flows to the uterus in jerks, the loss seems to cease or at least diminish in con- siderable proportions, but it soon returns with violence ; at other times the discharge of blood is continuous, without pain or colics, but with increasing loss of strength. Sometimes the discharge is pure blood, red or black, but liquid ; at other times, after an apparent in- terruption or after the excretion of a certain quantity of sanguinolent serum, more or less voluminous clots are passed accompanied by uterine colics indicating alternations of distension and contraction of the organ. Those of symptomaiic metrorrhagia are symptoms peculiar to each of the morbid states of which the haemorrhage may be symptomatic. We must beware of confounding metrorrhagia or menorrhagia with the consequences of an abortion at the commencement of a pregnancy. Women are apt to mislead the physician by attributing the unforeseen and abundant recurrence of menstruation to a delay of the monthly period. Generally this delay is due to pregnancy and the recurrence is an abortion, as shown by the nature of the pains, which are real uterine colics, and by the expulsion of an embryo, a villous placenta, or a decidua, on which a circular groove may be seen, indicating the point where the ovum was lodged. The likelihood of this should always, therefore, be present to our mind, and a careful examination should be made. Active and passive haemorrhage should also be dis- tinguished ; for symptomatic metrorrhagia itself may be either active or passive, the result of a simple stasis of blood, or of an energetic uterine reaction. Active or sthenic metrorrhagia, by general or local fluxion, or by vascular expansion, is accompanied by all the signs which characterise fluxionary movements, and by all the symptoms of local congestion and excitement or of general reaction which are peculiar to this patho- ^ Parent-Duchatelet, de la Prostitution dans la viUe de Paris, t. i, p. 232, 3= edit., 1857. 22 338 UTERINE DISEASES IN DETAIL logical act : pain, tension, sense of weight in the uterus, pain and dragging in the loins and groins, pruritus at the vulva, painful tume- faction of the breasts ; shooting neuralgic pains in the kidneys and legs ; hardness, swelling, extreme sensibility of the hypogastrium ; tumefaction, heat, sensitiveness, dark red colour of the vulva, vagina and cervix ; a general excitement, a strong and rather quick pulse, followed by weariness, cramp, giddiness, feverishness, and sometimes by various nervous or hysterical symptoms; in short, an exaggeration of the ordinary symptoms of uterine fluxion as they occur at the com- mencement of menstruation. Passive metrorrhagia is asthenic. It is favoured by general conditions not only of debility, atony and asthenia, but still more by those characterised by adynamia, such as scorbutus and other serious constitutional disorders. It is never preceded by premonitory symptoms, nor accompanied by the local phenomena which characterise the hsemorrhagic molimeu. There are no signs of local plethora in the genital organs; of the heat, tension and arterial pulsation which characterise fluxionary movements. The pulse is quick, but small and compressible, and there is a general chilliness and want of reaction. The haemorrhage, which generally occurs suddenly and with a certain moderation, continues uninterruptedly, sometimes without clots when the blood is serous. The clots and colics are to be met with in both kinds of haemorrhage, but with shades of diflerence which suffice to distinguish them ; for instance, the expulsive pains are less acute and less frequent in passive haemorrhage, whilst active haemorrhage is characterised by extreme sensibiHty or hysteralgia and by repeated uterine colics. Treatment. — The first question is : Should the haemorrhage in metror- rhagia, or even in menorrhagia be arrested ? In the immense majority of cases this may be answered in the affirmative. The haemorrhage becomes injurious whenever it passes the limits of menstrual evacua- tion ; for it is insufficient to effect depletion of the organ, it continues or recurs indefinitely, one haemorrhage is followed by another, the morbid habit is established, the constitution deteriorates, the blood is impoverished, the patient becomes anaemic, and these conditions, in place of being favorable to the cessation of the haemorrhage, only facilitate it and induce its return, so that from being active it becomes passive. Therefore every means should be taken to prevent and arrest metrorrhagia. The means to be employed vary acccording to the nature of the haemorrhage. The indications are principally drawn from the active or passive character of the metrorrhagia. In the former case we have to contend with the fluxionary movement, the fluxion and even congestion of the organ. In the latter, with exhalation and exudation, as well as with the general debility of the constitution and impoverishment of the blood. The indications vary also according as the haemorrhage is symptomatic or idiopathic. In the former case, arresting the flow of blood is only a palliative treatment which, though useful, is insuffi- cient as it does not attack the malady which causes the haemorrhage ; UTERINE HAEMORRHAGE 339 in the latter case, it is from the haemorrhage itself and its nature that the indications are taken. I cannot now enumerate the means of treatment of the various maladies which determine symptomatic hsemorrhage. They will be described in connection with each disease. I cannot even review all the means of treatment of the various ])athological elements which participate in the production of idiopathic haemorrhages, for these various elements require to be treated independently of the flow of blood which they may produce, but which they do not necessarily cause. I shall therefore only consider them from the point of view of the share which they take in the production of haemorrhage. Metrorrhagia, strictly so-called, being separated from the maladies which produce it, and from the elements which co-operate in its mani- festation, it only remains for us to state the indications special to it ; these are: — 1, to prevent the fluxionary movement from taking place; 2, to divert it when it has taken place ; 3, to subdue the congestion and erethism; 4, to employ haemostatics; 5, to destroy haemorrhagi- parous organic alterations of the mucous membrane ; 6, to prevent haemorrhage by mechanical obstacles ; 7, to treat the impoverishment of the blood and its want of plasticity. 1. To prevent the occiirrenee of the fiuxionary movement. — This can be attained by the use of three means : rest, local refrigeration, general heat. There should be absolute rest, the patient lying on her back with the thighs and legs flexed, and supported by pillows, and the head or at least the shoulders low. She should be kept in this position, not rising even to pass water. Local refrigeration is obtained by means of compresses soaked in cold water of the temperature of the room in winter, in spring water or ice in summer; these compresses should be applied to the abdomen and upper part of the thighs and renewed as they become warm. It is often better in order not to wet the patient, to substitute for the compresses a bladder or gutta-percha bag filled with pieces of ice which can be renewed as they melt, or fragments of ice may be intro- duced into the vagina every quarter of an hour. General heat should be maintained by blankets, or eider-down quilts, and hot- water bottles to the feet and arms. If necessary sinapisms may be applied to the wrists, arms and even upper part of the chest, the knees, calves and insteps. Ventilation should also be attended to. In all haemorrhages great care should be taken to renew the air of the room frequently. By these means, not only is a bracing eff'ect produced on the whole body, but a kind of general revulsion is eft'ected on the whole system which has a tendency to divert the fluxionary movement from the uterus ; hematosis is facilitated, and by the rapid renewal of air in the lungs an activity is given to the general circulation favorable to peri- pheric circulation and tending to subdue the disposition of fluxionary movements to select one point in preference to all others. 2. To divert the fluxion by revulsives. — The most powerful revulsive is bloodletting. It should be from the arm rather than the foot, for the blood should be diverted from the lower to the upper part of the 340 UTERINE DISEASES IN DETAIL body, and not merely deviated from the pelvis to the feet. Blood- letting is not always limited to a revulsive bleeding. If the patient is strong, plethoric, and experiencing a movement of general expansion or fluxion, copious depletion should be resorted to. If she has not too much blood, or if there is a tendency to debility, if the bleeding has to be repeated every month as a preventive measure against a menorrhagia which threatens to become habitual, it will suffice to take from 1^ to 4^ ounces from the vein according to Lisfranc's method. When the fluxion, in place of being imminent or recent, is fixed on the organ, derivative applications of leeches or cupping to the hypo- gastrium, to the iliac regions and loins, will mobilise the congestion and advantageously precede the use of revulsives proper. A powerful revulsive action may be effected in ansemic women without loss of blood by dry cupping of the loins, back, thorax, arms or breasts according to the precept of Hippocrates. i In such cases there is no need to fear the use of large cupping glasses acting on the whole of a limb according to Junod^s method. The application of ligatures to the root of the four limbs, according to Galen's precept, so as to congest them by retaining in them the venous blood, is a very good substitute for large cupping glasses, which are not always at hand. All that is required are four handkerchiefs folded like scarfs and tied tightly round each limb, and tightened at will by means of small sticks passed through the knot of the handkerchief. I have never had recourse to this means in uterine haemorrhages, but it has been of such great use in very serious cases of haemoptysis, that I have the greatest confidence in it. Lastly, sinapisms on the arms are also excellent revulsives which should not be neglected. If the fluxion is persistent or of long standing, and if it has a ten- dency to be renewed periodically or to become chronic, more continuous revulsives ought to be employed : — blisters, even exutories, or, if the patient is young, hydropathy in the intervals between the attacks. Lastly, ipecacuanha and antimony as used by Stoll and Pinke in metrorrhagia when sympathetic of bilious affections, and emetics gene- rally, may be useful as revulsives as well as means of perturbation. Ipecacuanha in small doses frequently repeated has proved very effica- cious, probably by the movement of expansion which it determines towards the periphery. 3. To subdue the congestion which follows the fluxion or the erethism which accompanies it. — I have seen patients in whom hsemorrhage was arrested by the application of leeches to the cervix, after the failure of the majority of means usually employed. In these cases the haemorrhage seemed to be kept up by a painful and persistent congestion of the uterus. The indication is clear; it must not be misunderstood, for no other means than direct depletion of the organ will avail. When general or local nervous and vascular erethism is associated with congestion, sedatives, antispasmodics and narcotics may be indicated. Aran recommends veratrine in large doses, Dickinson digitalis, Behier opium by the mouth or laudanum in rectal ' Translation by Littre, Aphorism 50, Section v, t. iv, p. 551. UTEltlNE HiEMORRHAGE 341 injections. Tlie progress of the hsemorrhage must however be watched, care being taken that time is not lost in the use of remedies which produce no effect. It is difficult to know whether the warm bath acts as a sedative or as a general revulsive in the treatment of metrorrhagia ; but there is no doubt that in some cases it is sufficient to arrest the haemorrhage. Unfortunately we have not yet been able to determine when this treatment is indicated. Heat applied to the loins often does great good, and can never do harm. To sum up what we know with regard to this subject, we must be content to say that the application of heat to the lumbar region according to Chap- man's plan (the application of an india-rubber bag filled with water as hot as the patient can bear), in order to stimulate the vaso-motor action of the sympathetic ganglia, has succeeded with de Mussy,^ Cusco and myself. So, too, has the application of heat to the uterus and vagina. A vaginal injection of water as hot as can be borne (as a rule, 45° centigrade) is often the best way of preventing or stopping uterine haemorrhage. Like Etnmet I have tried these injections repeatedly and found them to have an excellent haemostatic effect {Annates de Gynecologie de Paris, mai, 1880). Experience has proved the use of digitalis as an additional sedative of the vascular system ; by lessening the frequency of the pulse, it diminishes the impulse by which the blood is incessantly accumulated in the con- gested organ. 4. The use of hemostatics, strictly so called, astringents, styptics, and coagulants. — These means are especially indicated in the treat- ment of passive metrorrhagia when there is exudation as well as im- poverishment of blood and general debility ; they are also very often indicated in the palliative treatment of symptomatic metrorrhagia. The local application of cold to the hypogastrium by a bladder filled with ice, cold compresses, enemata, sitz-baths, vaginal plugging with ice, should be made continuously. The most convenient plan is for the patient herself to introduce ice frequently into the vagina, the water discharged being received by a sponge placed under the four- chette in a piece of waterproof. Acids and astringents should be taken internally. Those most employed are : vinegar and water, or a few drops of dilute sulphuric acid in a glass of lemonade, a spoonful of which may be taken every quarter of an hour. This simple means is often very successful. Tincture of cinnamon, as advised by Van Swieten, the Germans, Eecamier, Gosselin and Aran (from 1| to 5 drachms in four ounces of water, of which one tablespoonful every hour), alum, acetate of lead, catechu, tannic acid, and especially rhatany, are recommended, as in all haemorrhages. The extract of rhatany, given in an enema (15 gr. to one quart), or in mixture (B. Ext. E,hat. 3J, Syr. Aurant. 5j> Aq. ^iv. Sig. ^ss every two hours), is one of the most efficacious and the least dangerous of astringents. 2 I have often tried perchloride of iron, but do not trust * Annales de Gynecologie de Paris, July, 1875. ' I often give the following prescription : — Infuse 4| gr. of digitalis leaves in 4 oz. of water. Add 1 oz. of syrup of comfrey, 5 drachms of syrup of 342 UTERINE DISEASES IN DETAIL to it. If indicated by impoverishment of blood, anaemia, or a scor- butic condition, it should be prescribed in the dose of from 15 minims to 5j in a glass of water, of which one tablespoonful should be taken every two hours, followed by cold milk to remove the disagreeable sensation left in the throat. In chronic metrorrhagia with chloro- ansemia I give from 5 to 15 drops morning and evening in water followed by a glass of milk. It may also be applied directly to the uterine mucous membrane. Weber, of St. Petersburg, injects a solution into the uterine cavity. I have done the same, commencing with small quantities, and trying to avoid the formation of clots, the expulsion of which would be painful and might cause additional haemorrhage. I prefer the use of the tincture of iodine. Uterine specifics, i. e. drugs which have the property of exciting uterine con- traction as well as of favouring hemastasis, are employed along with the preceding in the treatment of metrorrhagia, e. g. savin and ergot, the latter especially. I generally prescribe 4 grains every six hours, or if necessary every three hours, in a little coffee or brandy or sugar and water. Wlien the action has to be kept up for some time I use ergo tine instead.^ The application of electricity to the uterus, by inducing contractions of the tissue, is a valuable adjuvant of ergot, especially when the latter is not tolerated ; the interrupted current should be used. 5. To destroy the organic alterations hy which the discharge of Hood is produced, and to modify the state of the mucous memljrane in which these alterations are developed. — Kecamier's curette renders great services in such cases. I have had a broader one made, and also two others of a different pattern {see p. 225), and with these instruments can remove fungosities however large they may be, and even small polypiform excrescences. There are haemorrhages that can be arrested in no other M'ay. It is sometimes necessary to dilate the uterine orifice by sponge tents before introducing the curette. After such operations, local hemastatics or caustics ought almost always to be applied to the uterine mucous membrane and cavity by means of in- jections.^ I often use a camel' s-hair brush saturated with tincture of iodine or perchloride of iron, or rolled in the powder of nitrate of silver, in place of injections ; sometimes I inject a piece of solid caustic by means of a canula with piston [see p. 222). The medica- ments most commonly used as injections to modify the mucous mem- ether, and 5 drachms of tincture of cinnamon, 1 drachm of extract of rhatany, 15 gr. of Bon jean's ergotine, and Is gr. of extract of opium. Shake the bottle and take one dessert spoonful every six, or if necessary every four hours. ' The hypodermic injection of ergotine is very convenient ; the usual formula is 15 gr. of ergotine (Bon jean) dissolved in 100 minims of pure glycerine and 5ij of distilled water. Two Pravaz syringes are filled and injected : \ gr. to 1^ gr. of ergotine will arrest hjemorrhage in a few minutes. Doubtless the hiemorrhage often occurs again ; the hemastasis is only temporary, but even that is a great gain. 2 Real, Thhses de Paris, 1852; Dupierris, Gazette des hopitaux, 1869; Guyot, Theses de Paris, 1868. CHANGES OF POSITION 843 membrane are : alum^ tannin, perchloride of iron, tincture of iodine, or a concentrated solution of nitrate of silver. 6. To prevent the discharge of blood by a mechanical obstacle is the last and often the first means to which the continuance or violence of the haemorrhage obliges us to resort ; a heroic means the use of which must not be neglected whilst there is yet time. This means is plug- ging. It must be preceded by an iced injection of solution of alum, and by the application to the uterus of a pledget of lint saturated with tincture of perchloride of iron or charged with a hemastatic powder; the vagina is then filled with cotton wool, the last tampon being kept in place by a T bandage. There is nothing further to do than to watch lest the haemorrhage which has been arrested in the vagina should take place internally, distending the uterus and passing along the Fallopian tubes. Should this occur, which rarely happens, the plugging must be renewed, and the other means previously described must be once more employed with increased energy. In cases of haemorrhage kept up by uterine inertia, in thin women in whom the abdominal parietes are easily depressed, I should be in- clined to try compression of the aorta before plugging. I do not understand the objections which have been made to this method. I have seen two women saved by it after delivery : the aorta was com- pressed by the midwife or myself for three hours, during which time, by emptying the uterus of clots, by irritating the cervix, by grasping the fundus and administering ergot I succeeded in getting the womb to contract, and was rewarded by the formation above the pubis of the hard reassuring uterine globe. 7. To treat the debility and impoverishment of blood which dispose to hemorrhage by the defective plasticity of this fluid and by the facility given to the production offluxionary movements or passive con- gestions by defective equilibrium. Whatever the nature of the haemor- rhage may be, care must be taken to prevent its return by using means to prevent fluxion, to increase the plasticity of the blood, to give tone to the vessels, to strengthen the constitution by a good regimen, tonics, bark, iron, &c. We must prevent relapses as in all uterine diseases, remembering that we can only be sure that a cure has been effected after the recurrence of several normal and regular monthly periods. CHAPTER II CHAJTGES OF POSITION — DISPLACEMENTS — DEVIATIONS — FLEXIONS — INVEBSION With the exception of cases of hernia, prolapsus^ retroflexion, complete retroversion and inversion, simple changes of position very seldom determine the development of serious morbid symptoms. They deserve attention, however, owing to the complications which precede, accompany or follow them, and which are sometimes the chief cause of the pains felt. These maladies are not only mechanical lesions. 344 UTERINE DISEASES IN DETAIL they may be designated : diseases in which an alteration of the mechanical conditions of the uterus plays the principal part, causing a disturbance in the relationship of this organ with neighbouring organs. This disturbance may occur in three ways according as it may affect : 1, the means of suspension (utero-sacral ligaments) which form a suspensory ring for the organ, ensuring its fixity of position in the pelvis at a certain height ; 2, the supports direct or indirect (broad and round ligaments, vaginal attachments, pelvic connective tissue), which keep the longitudinal axis of the uterus in the normal median inclination, whilst allowing divergences which its natural in- difference for a fixed position renders compatible with health ; 3, the consistency of the uterine tissue, the relative dimensions of the walls and borders, the reciprocal relations of the two segments (body and neck) which determine the preservation of the normal form of the organ, and the natural relations of the various parts with each other. According to these three modes of origin the primitive alteration leads to a secondary one: 1, in the position of the organ; 2, in its abso- lute direction and its relations with neighbouring organs ; 3, in the relative direction or the reciprocal relations of its two segments. In the first case this secondary alteration takes the name of displacement, . in the second that of deviation, in the third that oi flexion. 1. Displacements of tlie uterus are, therefore, changes in the position of this organ. The womb, not being properly retained in place by its suspensory ring, or yielding to the pressure or traction exercised by a neighbouring organ, abandons its proper place. It escapes partially or entirely from the pelvic cavity by a subcutaneous opening, and forms a hernia under the skin (hi/sterocele) , or it remains in this cavity, but at a different spot from its natural position, giving rise to displacements properly so called, horizontal or vertical, the most important of which is descent {prolapsus). Hernise of the ovary and Fallopian tubes are analogous displacements, and will be described at the same time as those of the uterus. 2. Deviations are changes of direction of the uterus as a whole, or displacements of the vertical axis of the organ, independent of those of its suspensory ring, the latter either preserving its normal position or not. They vary in degree, from the slightest inclination to the most complete version. 3. Flexions are alterations in the form of the organ owing to a change of direction of one portion with regard to the other. The organ as a whole may or may not preserve its normal position and direction. It follows that flexions may either exist alone or coincide M'ith displacements and deviations. They sometimes coincide with another change of direction, which it is interesting to take into account, viz. deviation of the transverse axis. This axis turns slightly sometimes to one side sometimes to the other, so that the anterior surface of the uterus, instead of looking straight forwards, looks forwards and to the right or forwards and to the left. This deviation is of little consequence when both segments of the womb are equally affected, but if the deviation affects them unequally there is torsion, CHANGES OF POSITION 346 which may cause other symptoms, and be the source of special indica- tions. 4. Lastly, inversion is another mode in which the statical conditions of the uterus may be altered. Cruveilhier compared it to prolapsus, in common with which it has the anatomical characteristic of invagina- tion, whilst, in common with flexions, it has a change in the mutual position of the various parts of the uterus with regard to each other. It is characterised also by a change in the reciprocal relations of its two surfaces, the internal surface gradually becoming external and convex, whilst the external becomes internal and concave. It follows that the organ is in a sense turned inside out, like the finger of a glove. With the exception of inversion, which is essentially a morbid con- dition, and prolapsus, which involves destruction of the suspensory attachments of the womb, all the different changes of position (dis- placement, deviation, torsion, flexion) may occur in foetal life which, representing a certain period in the development of the genital organs, or rather a stage in the progressive changes in their position in the pelvis, can only be explained by the influence exercised on them by the normal or abnormal evolution of the neighbouring organs. Ereund,^ in a recent work on the development and changes in position of the rectum, bladder and genital canal from the sixth week of foetal life up till birth, shows that the changes in position brought about by organic evolution simultaneously in the rectum and bladder, cause inverse changes in the uterus; that the distension of the rectum by the meconium and that of the bladder by the urine exercise an important influence upon the elevation of this organ. Lastly, that the descent of the intestinal convolutions into the pelvis, the daily evacua- tions of rectum and bladder, and the increased size of the pelvic cavity, notify a period of restitution or return, during which the uterus is liberated from the temporary changes in position which the development of the pelvic organs had imposed upon it. These changes, however, may become permanent ; normal at one period, they sometimes persist as anomalies. The pelvic organs themselves may be developed abnormally, new alterations in the natural position of the uterus may be produced, and may persist and constitute so many pathological elements new in the history of the changes in position of the uterus. These changes are met with in about one third of the patients affected with uterine disease, either constituting a disease in themselves or complicating some other malady or organic disorder. They occur, I think, less frequently in the south of Prance than in the north, especially prolapsus. As to relative frequency, anteflexions and anteversions^ are much the most numerous; then come retroflexions and retroversions ; then prolapsus, and lastly, lateroversions and lateroflexions, double incurvations, torsions, dis- placements of the organ as a whole, either forwards, backwards or ^ Max Bernhard Freund, Die LageentwicJcelung der Beclcenorgane unsbeson- dere des weiblichen Genitalcanals und Hire Ahwege. Breslau, 1864. 2 See pp. 17, 23. 346 UTERINE DISEASES IN DETAIL laterally. Inversions are rarest of all, with the exception of hernia of the uterus and ovaries. Displacements The importance of disj)lacements of the uterus, from a practical point of view, depends on whether they are simple or complicated. Ascent, descent and horizontal displacements, such as lateral position or lateral migration and even antero-posterior migration may generally be ranked as simple displacements. Whilst, on the contrary, cases of hernia and prolapsus must be considered as complicated dis- placements. 1. Hernia of the Ovaries and Fallopian Tales This is sometimes produced by an alteration affecting the organs themselves, sometimes by displacements of the uterus or changes in it. I. Hernia of the ovary is not the only displacement of this organ. Congestion or inflammation may increase the size and weight of the ovary and cause its displacement into the pelvis, especially descent either lateralhj or behind the uterus?- This displacement is easily dis- covered by rectal and even by vaginal touch, as well as by the increased size and sensibility of the ovary. Its pathological sensibility is de- veloped to such an extent, that the least pressure produces intense pain. — On the other hand, when the ovaries are merely dragged by a deviated or flexed uterus, it is seldom that this displacement is not at last complicated by congestion of these organs. Lastly, when the displacement coincides with ovarian inflammation the phlegmasia often extends to the peritoneum, especially if the ovary, Fallopian tube and uterus are affected simultaneously. Peritonitis generally leaves vicious adhesions between the ovaries and neighbouring organs. These adhesions, by rendering displacements of the ovaries permanent, form, according to Madame Boivin, one of the most frequent and least known causes of abortion. They attach the ovary sometimes to the Fallopian tube or to the uterus (which causes sterility), sometimes to the csecura, to the colon, to the sigmoid flexure, to the rectum or to the walls of the pelvis.- Hernise of the ovary are displacements outside the pelvis, which occur less frequently than the preceding, but yet oftener than is generally believed. The first detailed case was published in the seventeenth century by Bessiere, a surgeon in Paris. Deneux^ wrote an interesting paper on this subject in the beginning of this century. Velpeau"* described this disease under the name of ovarioncie. Several ' Braun has described some of these displacements under the name of ovario-vaginal hernia {Monatsschrift fiir Geburtsk., Bd. xiv, S. 472). * Barnes gives a very practical resume of the princi^ml causes of displace- ments of the ovary, op. cit., p. 297. ' Recherches stir la hernie de Vovaire. Paris, I81.S. * Dictionn. en 30 vol., t. xxii, p. 558. Paris, 1840. DISPLACEMENTS 347 new cases have been recently published.^ I have myself seen five cases of ovarian hernia : a right inguinal hernia, reducible, in a child of ten (probably congenital) ; a right crural hernia, irreducible, in a virgin of forty, which sometimes swelled and became painful at the monthly period, and was at one time attacked by inflammation, when it developed symptoms of stricture, which yielded to antiphlogistics and purgatives j a right crural hernia in a woman of forty-two, who assured me that the tumour, which had existed for fifteen years, became painful and larger at every monthly period j she succumbed to symptoms of stricture and peritonitis, the slow progress of which (about fifteen days) would have allowed of her being saved, had she not obstinately refused any kind of operation; a left crural hernia in a nullipara of fifty, who had ceased menstruating for four years, and who remembered having sometimes experienced pains in the tumour during menstruation ; she had worn an elastic bandage for twenty- five years to contain the hernia, the nature of which had probably been misunderstood ; a left inguinal liernia, probably congenital, in a virgin of twenty-six, forming in the groin a tumour very sensitive to the touch, very painful and larger at every monthly period, and which coincided with a marked obliquity of the uterus, the cervix of which looked backwards and to the right ; the puffiness of the tumour led to the t^upposition that the Eallopian tube shared in the displacement; a bandage tried for some months had to be abandoned, on account of the pain that it caused. Inguinal ovarian hernia is more frequent than crural in newly-born children, and indeed at every age, contrary to what we might expect, the reverse generally being the case with intestinal hernise in women. — According to Deneux crural is to inguinal in the proportion of one to nine, according to Murat two to nine. — The ischiaiic or dorsal has been described by Papen,^ who discovered in a hernia the presence simultaneously of the intestine and right ovary; Camper, in 1759^ found one, in the sac of which the left ovary alone was contained. — Umbilical ovarioncia may occur in cases of pregnancy or of any uterine disorders sufficient to cause displacement of the ovaries towards the umbilicus. Ovarian hernia may be simple or double. In the latter case it may occur on both sides at once, through the corresponding openings, as in Pottos case,^ where both ovaries were removed ; or through different openings, such as the umbilical and ischiatic, as in Camper's case. According to the statistics of Puech, completed since the pub- lication of his paper,^ there are on record 82 cases of inguinal hernia, 12 of crural, 2 of ischiatic, 3 of abdominal (the results of abscess or of Caesarian operation), and 1 through the foramen ovale (Kiwisch) ; but of the 82 inguinal 50 are undoubtedly congenital, 16 doubtful, 16 really accidental. Congenital hernia has been found twenty-six ' Loumaigne, De la hernie de Vovaire. Paris, 1869. ^ Haller, Disputationes chirur., 1750. 3 Pott's Works, vol. iii, p. 329. London, 1783. ■• Des ovaires, de leurs anomalies. Paris, 1873. 348 UTERINE DISEASES IN DETAIL times unilateral, twenty- four times bilateral or double.— They are often complicated by malformations of the genital organs, e. g. accom- panied four times with uterus unicornis or hicornis, fourteen times wdth hermaphrodism, sixteen times with apparent or real absence of the uterus. From an analysis of the cases just mentioned we may conclude that ovarian hernia belong to two quite distinct classes : 1, congenital hernise, always inguinal, often double, and when single generally left, caused by an abnormal descent of the ovaries analogous to the normal descent of the testicles, constituting anomalies rather than diseases, and coinciding usually with anomalies of the genital organs, such as embryonic uterus, uterus unicornis, hermaphrodism, &c. ; 2, hernise properly so called, accidental and morbid, right or left indifferently, inguinal or crural, oftener crural, frequently following an intestinal hernia, in which case the ovary may occupy the sac either alone or simultaneously with the intestine, epiploon, &c,, occurring in well- formed adult women.' If congenital hernia is inguinal it is because the persistence of Nuck's canal favours its production. Lassus" gives an example. If accidental hernia, on the contrary, seems to be more often crural, it is because, like intestinal hernia, it takes place through the abdo- minal opening which is the widest in women. Ovarian hernia when congenital and observed in early life generally contains only the ovary ; it may be the same in the adult ; but in old hernise the ovary has sometimes dragged down with it the Fallopian tubes, the uterus, the vagina, and the intestine. When a hernia of long standing is complex, it seems to be because the ovary has carried with it the Fallopian tube and even the uterus ; for by the fact of its displacement the ovary drags the womb to the side of the herniary tumour ; the uterus then executes two distinct movements, a swinging one, by which its fundus is inclined forwards, and another of rotation, which directs its posterior surface towards the side of the displace- ment ; one of its angles is then turned towards the ring through which the ovary has passed ; the intestine presses and increases the uterine deviation, tending to complicate the ovarian hernia with that of the Fallopian tube and even with the uterus. Ovarloncia is very seldom complicated with enterocele. Lastly, ovarian hernia may be reducible or irreducible. Its irreducibility may depend on increased size, adhesions or strangulation. II. Hernia of the Fallopian tube may be produced, according to Nelaton,^ by ovarian hernia. The oviduct very rarely escapes through one of the abdominal orifices by itself. Such a case, however, has been described by Scholler : a little girl, who died three weeks after ' Pucch, who has collected the greatest number of cases of ovarian hernia, thinks that a radical distinction should be made between these two kinds ; he therefore proposes that congenital ovarian hernia should be called inguinal ectopia. ' Med. oper., t. i, p. 211. Paris, an iii. ^ Pathotog. externe, t. iv, p. 440. Paris, 1857. DISPLACEMENTS 349 birth, had a tumour in the right inguinal region, which reached as far as the labium, and contained the Fallopian tube, red and swollen, but without adhesions. The round ligament of the same side was shorter than the other. The uterus was slightly displaced, its axis not being parallel with that of the body. Biagnosis. — This is draw'n from the following data : at the groin, in the direction of the principal axis, or in the labium, or even below the crural arch, there is a small ovoid tumour, circumscribed, painful, dull on percussion, reduced with difficulty and rarely spontaneously, always without gurgling although slightly indented, of a dense homo- geneous consistency, not easily detached from the soft parts ; if we pull it, so as to increase the displacement, we perceive behind it a flattened fibrous cord passing through the ring. The pain is increased by pressure, by dorsal decubitus or by lateral decubitus on the oppo- site side from the hernia (Seller), by the movements of the legs, by stooping and rising again, so much so as to cause limping (Guersant) and to make all work impossible (Imbert, Percival-Pott, &c.) ; it is also aggravated by pressure on the hypogastrium, by pushing the fundus of the uterus from the seat of the hernia, or drawing the cervix near it with the finger (Lassus) ; it is propagated into the pelvis and loins by a very painful sensation of dragging; it extends from the seat of the hernia to the uterus and if, with tlie end of the finger introduced into the vagina or rectum a considerable movement is convened to the womb from the side opposite to that of tlie tumour, this movement is transmitted to the contents of the hernia (Lassus). This movement should be made suddenly, and is aided by pressure on the hypogastrium from the other hand, or better still by means of the uterine sound,^ which acts simultaneously on the whole of the uterus and at the same time reveals the inclination of the fundus of the organ towards the hernia ; it is well for an assistant to place his fingers on the tumour in order to judge of the amount of movement communi- cated ; similar movements cannot be transmitted to an enterocele (Loumaigne^s case).^ Pain which is absent in some patients and in a state of rest or in the intercalary period, is developed on the contrary by exertion, the advent of menstruation, coitus, &c. -^ it increases also with the size of the organ at puberty, at every menstrual period, during ges^tation and by taxis; it may increase to such an extent as to be symptomatic of strangulation. Although these symptoms would seem sufficient for distinguishing between an ovarioncia and an intestinal or epiploic hernia, an abscess of the groin, a lymphatic tumour, &c., many mistakes have been made. Inflammation, atrophy, cystic, cancerous or tubercular degeneration of the ovaries, are sometimes met with simultaneously and increase the difficulties of diagnosis. We must also remember that, even 1 Huguier, Traite de I'hystSrometrie, p. 202. Paris, 1865. ' When digital touch cannot be practised, owing to absence o£ the uterus or in the case of children, examination must be made througli the bhidder and by ' rectal touch. ^ In ovarian hernia, coitxis becomes sometimes so painful that marital inter- course is impossible. Beigel gives instances of this (op. cit., t. i, p. 136). 350 UTERINE DISEASES IN DETAIL when inguinal hernia is double, it is no obstacle to menstruation, "and that while it may cause sterility (when the ovary is not accompanied by the Fallopian tube in the common hernial sac), it does not abso- lutely prevent uterine pregnancy, and that it frequently predisposes to extra-uterine pregnancy.^ Treatment. — This consists in reducing the ovarian tumour and in keeping it reduced. It is easily done when the hernia is recent and when the ovary is not adherent to the sac. As a rule, however, after a short time the tumour ceases to be reducible. In such cases it must be protected from blows and from friction by a suitable bandage, e.g. a truss with a concave cushion. When symptoms of strangulation are developed the patient should be kept in a position of semi-flexion, and leeches, poultices and emol- lient or narcotic fomentations should be applied over the tumour. If the strangulation persists an operation is indicated,^ i. e. the ring which produces it must be incised ; for it is enough to cause death. I have seen a woman afi'ected with crural hernia of the right ovary suc- cumb to peritonitis as a consequence of strangulation of the hernia. The ovary can seldom be reduced after incision ; it will be found too adherent to the internal surface of the sac. The adhesions must first be destroyed and reduction made afterwards, or else we must imitate Lassus, and after having incised the ring apply emollient applications to the ovary, dress it simply, and when the inflammation has passed exercise moderate and methodic pressure. If the ovary is degenerated, cancerous or transformed into a mul- tilocular cyst, it should be removed. In some cases, as in that of Pott, the operation has not been followed by any accident. In Pott's^ case there was double inguinal ovarian hernia in a woman of twenty - three ; the removal of both ovaries was followed by cure, but men- struation ceased. Meadows^ published a very interesting case of inguinal hernia of the right ovary, which was successfully removed. In other cases extirpation is not necessary, the hernia being found reducible after incision of the ring. Loper^ obtained a cure in this way. The case was one of inguinal hernia of the right ovary occur- ring after delivery in the sac of an old enter ocele. Kelotomy neces- sitated the destruction of some adhesions and also incision in order to allow of the reduction of the ovary. The operation was followed by cure. By adding these three cases to those already recorded we find that out of sixteen cases of reduction or extirpation of ruptured ovaries there have been nine definite cures and seven deaths, five of which followed extirpation. Although these statistics are not en- ' Balin, Art de guerir les hernies, p. 150. Paris, 1768. — Widerstein, Gazette hehdomadaire de medecine, 1853, p. 79. — Rektorzik, Monatssch. fur Geburtsk., Bd. xvi, S. 475, 1860. ^ Owen. British Med. Journal, 13 Dec, 1873. — Wibaich, Theses de Paris, 1874, n". 469. ^ Pott's Works, vol. iii, p. 329. London, 17 83. —MacChur, American Journal of Obatetrics, vol. vi, p. 613. * Trans, of the Obstet. Sac. London, 1861, p. 438. * Monatssch. fiir Gehurtslc, 1866, S. 453. DISPLACEMENTS 351 couraging we cannot avoid the necessity of operation when life is in danger, but ii should only be resorted to in such cases. We may therefore lay down the following rules : 1, to incise and reduce, in children and young women, congenital and recent hernise which have neither been inflamed nor as yet present any extensive adhesions ; 2, to protect, in women who are mothers, by means of a truss with a concave pad, hernise which are not very painful, but which have become irreducible owing to adhesions; 3, only extirpate the ovaries when the hernia is irreducible, adherent, painful, and has de- veloped symptoms of strangulation and inflammation which have resisted antiphlogistic treatment and endanger life. 3. Hernia of the Uterus {Hysteroceley- It is not uncommon to see the uterus, when distended by preg- nancy, protrude between the recti muscles (separated by several pre- ceding pregnancies), and hang down like a kind of wallet, even as low as the thighs when the excessively distended linea alba is incapable of supporting it ; it is rare, however, to see this organ undergo the displacement for which the name of hernia is reserved. A certain number of authentic facts, however, prove that the uterus may be dragged a certain distance from its normal position and, with other ab foUowed by fatal results. - Blandi'n, quoted by Le Gendre, op. cit., p. 70. ' Barnes, op. cit., p. (532. ■• Huguier, AUongements hypertrophiques du col. 366 UTEEINE DISEASES IN DETAIL faeces which the patients are obh'ged to force back with the tumour in order that they may escape by the anus. Objective symptoms. — Direct examination by touch and sight suffice to make diagnosis easy. The first symptom is the presence of a tumour at or outside the vulva. This tumour, which is pear shaped, directed downwards and surrounded by folds of vaginal mucous mem- brane, keeps the labia apart ; the surface is red or pink, dry, smooth, sometimes excoriated ; the top, conical or slightly swollen, presents a transverse fissure, the os uteri, from which there is an exudation of mucus ; the base seems sometimes pediculated by constriction of the vulval ring ; in front of it may be seen the meatus ; and behind it the perinseum forced back, projecting and diminished in its antero-pos- terior diameter ; the anus itself may project, giving passage to a hernia of its mucous membrane. This soft depressible tumour, mobile in every direction, and easily pushed back, gives a sensation of great resistance. It can be reduced completely, and is reproduced with great facility. In this double movement the reduction and invagination of the mucous membrane can be easily ascertained. \Yhen inversion of the vagina is not com- plete, a circular groove may be felt more or less marked above the tumour; this is the portion of the vaginal mucous membrane which has not been inverted, under which the characteristic hardness of the uterus may be perceived. Eectal touch allows the diagnosis to be completed by determining the position occupied by the uterine fundus Fio. 255. — Complete procidentia vieri of twenty years' standing, in a woman of seventy years. DISPLACEMENTS 367 below the pelvic cavity ; whilst catheterism discloses the cystocele, and by associating it with rectal touch the information given by the latter as to the descent of the fundus uteri and its absence from the cavity is confirmed. The form of the tumour, resembling at first that of the neck, afterwards becomes conical, surrounded by folds at its base, and finally gets more and more globular and smooth in proportion as its size increases. Its volume may become very considerable, when in addition to prolapsus of the uterus there is also prolapsus of the vagina, bladder, rectum and small intestine, the latter known by its gurgling and filling the posterior peritoneal cul-de-sac ; an extreme case which is very rare, but which is possible, for I have seen a case of the kind : it may reach the size of the head of a fcetus and even of an adult. Defecation and micturition are considerably impeded, especially if the tumour is irreducible. The colour of the vaginal mucous membrane with which the tumour is covered is also gradually altered by the congestion which makes it darker by exposure to the air, and by friction which imparts to it a greyish tint, and by irritation and inflammation which produce Fig. 256. — Complete procidentia uteri with cystocele and rectocele, hyper- trophy and ulceration of the cervix and eversion of the cervical mucous membrane (after Sims). ulceration in the neighbourhood of the urethra and the most depend- ent portion of the tumour. Continued contact with the external air renders this membrane dry and discoloured, imparting to it the charac- teristics of skin^ without, however, preventing it from regaining its pro- ^ Tliis is so true, that in an old negress affected for fift}" years with complete procidentia this membrane became as black as the skin, and was even covered with down. 368 UTERINE DISEASES IN DETAIL perties of mucous membrane should the tumour be retained for a time in the pelvic cavity ; but if the tumour increases in size and remains ex- ternal, its mucous membrane and the adjacent tissues become congested, thickened, hypertrophied, whilst those parts exposed to friction pre- sent irregular ulcers in patches, from which a little pus is excreted and which sometimes become affected with gangrene. The uterine orifice, as well as the isthmus and cavity of the body, which are ob- literated in aged women, are, on the contrary, sometimes dilated in young women ; I have already spoken of this peculiar dilatation and aversion which may extend to five centimetres in diameter,^ and conse- quently be sufficient to admit the penis, examples of which eminent writers have given us. Palpation and percussion of the tumour may give the sensation of fluctuation in front. Pressure on the same point makes the urine escape from the meatus. Compression of the whole of the tumour, which is not painful in chronic prolapsus, diminishes the volume and communicates a sensation of internal resistance pro- duced by a cylindrical organ larger above than below, terminating on a level with the upper and strangulated part of the tumour, and possessing all the characteristics of the uterus. It is not always easy to reach above the body ; but the neck is more easily perceived through the inverted vagina, because of its being harder, longer, more cylin- drical than in a normal condition, especially in the numerous cases in which the displacement of the cervix depends on the elongation of the neck more than on the descent of the uterus. The presence of the intestines in the posterior peritoneal cul-de-sac is recognised by the peculiar gurgling sound heard when reduction is being made. Catheterisation shows the direction of the urethra towards the lowest part of the tumour, the existence and extent of the diverticulum of the bladder, and consequently the lowest limits of the cystocele, and lastly, the upper limit of the uterus in the centre of the tumour. By rectal touch we discover the rectocele, the position, deviations or curves of the uterus, and the elongation of the suspensory ligaments. Lastly, the use of the uterine sound allows us to determine in a still more precise manner the upper border of the uterus, the length of its vertical diameter, and consequently the absence or development of the longitudinal hypertrophy of the neck, and lastly, the various altera- tions in the direction of this organ. I do not understand the danger that Le Gendre apprehends from its use.^ Differential diagnosis. — The characteristics just enumerated hardly allow of our failing to recognise an infirmity so marked as uterine pro- lapsus ; it is not, however, so easy to distinguish simple from compli- cated cases, nor to determine the nature of the complications. Tumours arising from the cervix or even from the cavity of the body often project at the vulva, or outside, gradually dragging the uterus with them especially when they are large, and causing vaginal invagination to some extent, which is another cause of error. These fibrous, mucous, follicular polypi are difficult to distinguish from prolapsus by ' Huguier, Allomj. hypertrophique. » Op. cit., p. G8. DISPLACEMENTS 360 their external aspect, on account of the alterations affecting the vaginal mucous membrane when the prolapsus is of long standing. It might be thought that the existence of the os uteri allowing the sound to penetrate into the uterine cavity would be a sufficiently dis- tinctive mark ; it is not so, however, for the orifice may be obliterated or hidden, e.g. pushed forward by uterine retroversion (co-incident with prolapsus), which places the fundus of the uterus in the posterior peritoneal cul-de-sac, and its cervix in front against the pubis. In such cases catheterisation and rectal touch will help to show the absence of the uterus from the cavity, and to determine the ex- istence of retroversion in the tumour. As for vulval or extra-vulval tumours, in the formation of which the uterus does not participate, such as cystocele, rectocele, cysts of the labia and vagina, catheterisa- tion, rectal and vaginal touch sufiice to determine which organ is dis- placed and whether the uterus occupies its normal position. There is, however, one malady which it is especially important to distinguish from prolapsus titeri, viz. uterine inversion. It must be remembered that uterine inversion does not necessarily involve propulsion of a tumour outside the vaginal cavity, and that when this is produced it is because prolapsus is added to inversion owing to the elongation or rupture of the utero-sacral ligaments. Now, inversion is almost Fig. 257. — Complete procidentia uteri. Fig. 258. — Complete inversion of the utenis complicated bj vaginal in- vagination or uterine prolapsus. always produced suddenly, from traction exercised on the adherent placenta, or from violent efi'orts accompanying the expulsion of the foetus, from a fibrous tumour or a polypus. The surface of the tumour has the spotted aspect of the congested uterine mucous mem- brane in place of the wrinkles of the vaginal mucous membrane ; it often causes dangerous haemorrhages ; it is globular, broader below than at the vulva, where there is a strangulated pedicle ; on a level with this pedicle the vaginal culs-de-sac and uterine lips may be seen, 24 370 UTERINE DISEASES IN DETAIL the outline of which may be followed by the finger, whether the inver- sion has affected them and the neighbouring part of the vagina, or whether they have kept their normal position, surrounding the portion of the inverted neck with a kind of ring. This tumour shows no trace of an os uteri. Lastly, neither rectal nor vaginal touch, nor yet catheterisation, discloses the presence of the body of the uterus, supposing it has remained large enough and soft enough to be pene- trable. Pregnancy is said to be a complication not unfrequently met with, especially when prolapsus is incomplete and the largest part of the organ is still contained in the cavity. The presumptive signs of pregnancy, especially the rapid development of the uterine tumour in a woman whose youth and health exclude the idea of any disease, and later on the signs of certainty, can leave no doubt as to the existence of this complication. It is evident that prolapsus even in the first degree is an obstacle to the regular progress of gestation. If the uterus cannot be reduced grave symptoms may arise, followed frequently by abortion or miscarriage. The dead foetus has been seen to remain for some time in the prolapsed uterus before being expelled ; in a few cases, to which I have already referred, pregnancy has termi- nated normally, delivery having been effected solely by the contrac- tion of the organ. Catheterisation reveals the existence of vesical calculi. Lastly, the hypertrophic elongation of the neck is beyond doubt the most frequent complication. Huguier regarded the majority of cases of prolapsus as simple inversion of the vagina gradually pushed towards the vulva, on a level with, or outside this orifice, by the pro- gressive elongation of the hypertrophied neck of the uterus. I can, however, affirm that there are cases of simple longitudinal hypertrophy as well as of simple prolapsus and even procidentia without hyper- trophy, besides a great number of cases of prolapsus complicated with more or less marked hypertrophy. It is easy to see that constant congestion of the prolapsed uterus at last causes hypertrophy, especially of the supra-vaginal portion of the cervix. This elongation of the neck was first observed by Morgagni •} afterwards described by Levret,- was called by '^wch.o'w prolapsus of the uterus toWioxit procidentia of the fundus,^ and was exhaustively studied by Huguier under the name of hypertrophic elongations.^ We may add that prolapsus must also be distinguished from hermaphroditism; in the 17th century a woman was taken for a hermaphrodite till Saviard ^ announced that he had treated her for j^^'olajjsus uteri, which he had reduced. Valentin saw a similar case :^ a woman was taken for a hermaphrodite and accused of impotence; an examination showed the mistake, the uterus was reduced and capacity for conjugal intercourse admitted. Treatment. — Uterine prolapsus hinders women from moving about ' De Sedibus, &c., Epist., 45, art. 11. * Journal de mod. et de chir. de Boux, vol. xl, p. 352. ^ Verhandlungen der Gesellschaft fiir Gehurtsh. Berlin, Bd. ii, S. 205. * Memoires de V Academic, 1859. * Nouveau recueil d' observations chirurgicales. * Franque, op. oit., p. 27. DISPLACEMENTS 371 freely, the least effort, especially that of lifting weights, bringing on lumbar and pelvic pain, which is all the more annoying from often being incurable. When I say incurable, I mean in an absolute manner; for there is no reason to despair of ameliorating the evil, or at least of palliating it. It is, however, alike impossible for art and nature to bring about a complete and lasting cure, especially when the prolapsus is chronic and has passed into the state of complete proci- dentia. Acute prolapsus is more easily cured : the ligaments which are relaxed are elastic like the tissue of the organ itself; we may therefore hope to see the supports of the womb recover a certain degree of their retractihty, sufficiently so to retain the organ in a position somewhat similar to its normal one if we lose no time in applying suitable treatment. The patient should observe the abdominal rather than the dorsal decubitus in order to help the uterus to ascend, and to shorten the distance between the neck and the promontory; when walking the uterus should if necessary be supported by a Hodge or some other kind of pessary, the bladder should be kept empty, and astringent appHcations (powdered tannin in a small pledget of cotton wool) should be made to the cervix. On the other hand, prolapsus when left to nature has a tendency to increase : the intestines fill the vacuum left by the uterus in the pelvis, preventing this organ from resuming its own place and continuing to push it down by the pressure which they exercise on it, whilst the prolapsus of the vagina is daily increased by the efforts of defecation. The presence of the uterus provokes expulsive efforts which increase the evil. I know that the possibility of spontaneous cure has been admitted by some. Scanzoni^ thinks that peritonitis, which is sometimes developed after traumatism or delivery in a woman affected with prolapsus, may, by determining adhesions between the fundus of the uterus and some other portion of the visceral or parietal peritoneum, become the means of retaining the uterus in the pelvic cavity. In the same way cicatricial coarctations following suppurative vaginitis, by supporting the uterus from below and preventing its falling towards the vulva so as to invert the vagina, may bring about natural cures. These modes of cure, however, are very rare and not suitable for imitation by art. We must therefore content ourselves with a palliative cure which renders the infirmity supportable and prevents the displacement from being produced to its full extent, without hoping to modify the malady itself, the relaxation, rupture of the attachments, &c., which are the cause of the displace- ment. The measure of curability is furnished by the relation between the indications to which this lesion may give rise, and the imperfect means which we are able to employ in order to fulfil them. The sources of therapeutic indications here as everywhere lie in the pathological elements the association of which constitutes prolapsus. The treatment necessarily varies with the case. In prolapsus two distinct pathological states must be admitted : simple prolapsus of a normal uterus, and descent of the vagina from a hypertrophied uterus. 1 Op. cit., p. 130. 372 UTEEINE DISEASES IN DETAIL Sometimes weakening of the suspensory ligaments is the primary cause of the prolapsus; sometimes it is the weight of the womb increased by defective involution, congestion or hypertrophy. These two states are often combined, the one which has occurred first soon producing the other. 1. Let us first take simple descent of the uterus, without hyper- trophy. The cause of the displacement is not io the womb : it exists in the abdomen above or below the uterus ; above, tumours, dropsy, pressure, efi'orts, elongation or rupture of the suspensory ligaments, may push the womb downwards or let it fall; below, hypertrophy, tumours, prolapsus and relaxation of the vagina, laceration of the perinaeum, may draw it in the same direction or withdraw from it all support. The indications are two : one easy, reduction ; one difiicult, retention. Reduction may take place simply, if there is no other obstacle than vaginal prolapsus, by taxis similar to what is employed in the reduction of hernise. It may necessitate the destruction of obstacles opposed to its accomplishment, e.g. puncture in ascites and in ovarian cysts, the apphcation of belts to support the abdomen, the ablation of vaginal tumours, kc. In order to maintain reduction the suspensory ligaments must be acted on, the distended ligaments shortened, the torn ligaments reunited, contractility restored to the paralysed muscular fibres, the last-named being only possible in the beginning. The impossibility of acting efiicaciously by these means on the morbid elements to which they are addressed has led to the idea of maintaining reduction by giving tone to the vagina and sup- porting the perinaeal wall by bandages or pads; by supplying the de- fective resistance of the vulval ring and vagina by intravaginal supports, pessaries, hysterophores ; by contracting the vaginal or vulval ring by excision, either circular, longitudinal or in folds (followed by adhesive or inodular cicatrisation), by cauterisation, by constriction and gangrene, by ligature, suture, or by any other means causing loss of substance. Lastly, by closing the vaginal orifice in- completely by infibulation, or completely by suture. 2. In cases oi prolapsi uteri with elongation the hypertrophy may affect either the body, neck or isthmus, and be produced by the development of tumours, polypi, fibromata, or by various alterations of the cervis, by a hypertrophic inflammation, or oftener by mere hyper- trophy. There are two indications : one or other may be fulfilled according to the case. The cause of the prolapsus may be removed by bringing the uterus back to its normal dimensions, i. e. by favouring absorption or by removing tumours developed on the surface or in the tissue itself by excision, crushing, cauterisation, ligature, &c., or the uterus may be reduced and maintained by efiicient support without remo\ing the cause of the descent. This palliative cure is often suffi- cient, the compression of the organ being tolerated by the habit which the pelvis has contracted of containing large bodies, especially if they are flexible. 3. In the association of these two principal varieties of prolapsus the one always plays the part of complication with regard to the other. DISPLACEMENTS 873 It is important to distinguish which of the two is the primary malady and which the secondary, even when the latter has acquired a major importance. The primitive element should be attacked first, and then the secondary, which has become permanent. These general indications being laid down, let us see how treatment should be practically carried out. I. Reduction. — This is easy, and often spontaneous. In most patients the horizontal decubitus on the abdomen is sufficient to cause the entrance of the tumour, as is proved by the facility with which conception takes place in such cases. In a few patients the favorable tendency of the horizontal position is increased by the natural action of the vaginal walls (and probably also of the ligaments), which, in contracting from below upwards, raise the uterus so as to replace it in the pelvis. Scanzoni has proved this by projecting cold water on a prolapsus the size of the fist, which then entered the pelvis sponta- neously. If reduction does not take place spontaneously owing to the increase of volume which constriction of the vulva determines in the recent or congested tumour, or if it is desirable to use some means of retention in cases where the uterus does not easily rise, artificial reduc- tion must be made by performing a kind of taxis on the tumour similar to that used in reducing herniae. 1. The patient lying on her back with the head and limbs flexed so as to prevent all abdominal pressure and the pelvis slightly raised, the tumour is grasped with both hands and compressed in such a manner that the various parts composing it rise successively into the cavity. The uterus may either be first pushed back, the reduction of the vaginal inversion taking place after- wards, or the vaginal wall near the vulva, as well as the rectocele and cjstocele (when these complications exist), may be first replaced and the womb afterwards. 2. If difficulty is experienced in effecting re- duction when the patient is in the dorsal decubitus, we take advantage of the fact that, as the essential causes of prolapsus are relaxation of the suspensory ligaments and retroversion, reduction will be facilitated by placing the uterus in anteversion, and by bringing the neck near to the sacro-lumbar ligaments. In fact, by placing the patient in ventral pronation on elbows and knees we are able to replace the uterus much more easily than in any other way, and to reduce the rectocele and cystocele at the same time. The weight of the abdominal viscera descending towards the umbihcus, the traction which they exercise on the womb, and the entrance of air into the vagina, are all favorable conditions for facilitating reduction. Whether it be the neck or vagina which has escaped first in the commencement of prolapsus, there is no doubt it is the vagina which escapes first in long-standing procidentia. If after having replaced the parts in their normal position the patient is asked to make an effort to expel them anew, the anterior vaginal wall will be seen to descend against the perinseum in the form of a cystocele. A slight efi'ort will push it beyond the vulva, and the neck will follow immediately, drag- ging with it the posterior wall of the vagina. In reducing procidentia we must therefore reverse this order : begin by replacing the posterior 374 UTERINE DISEASES IN DETAIL cul-de-sac, then the neck; the anterior wall of the vagina and the bladder M'ill follow naturally. The swelling which has occurred in the tumour owing to congestion, the development of inflammatory pheno- mena or constriction of the vulval ring, is not the only reason why reduction should be undertaken at once, A more important one still is pregnancy. Although in this latter case the irreducible uterus may be sufficiently supported by a suitable bandage to reach the term of gestation without accidents, and to expel a living fcetus from its cavity, yet it is prudent to attempt reduction before the size of the foetus prevents the passage of the womb through the vulva and outlet. Mauriceau^ once effected reduction at the fifth month. The prognosis is not more unfavorable when reduction is difficult. Provided that it be possible, there is all the more chance that it will be maintained owing to the resistance of the vulva and perinseum. If, however, it be possible, the nature of the obstacles which hinder or retard it must be determined, in order to apply an appropriate treat- ment. In a few cases reduction is impossible. For example, a number of small fibroid tumours filling the pelvic cavity may prevent it (Sims). The adhesions of intestinal circumvolutions to the internal wall of the sac may be another cause. If there is merely congestion or oedema, the horizontal position of the patient, elevation of the tumour, applica- tions of cold, astringents, styptics in various forms, suffice to facilitate reduction. If there is chronic inflammation, rest, the application of leeches to the cervix, emollient fomentations and the use of other antiphlogistic means, are usually successful in diminishing inflamma- tory tumefaction sufficiently to allow of reduction of the prolapsus. It is the same with the remarkable and frequent hypertrophic thicken- ing of the vaginal walls t rest, the horizontal position, applications of glycerine, resolvent fomentations, may effect modifications favorable to reduction. Lastly, the parts must be gradually accustomed to resume a position which has become^abnormal to them. It must not be thought thcPt ulcers and other alterations mentioned as being frequently developed on the vaginal mucous membrane in long-standing cases of prolapsus are contra-indications to reduction, and necessitate preliminary treatment as Scanzoni advises. As a rule, the mucous membrane is cured spontaneously when no longer exposed to the contact of air, of urine and to friction. Therefore it may be said that reduction is usually easy, whatever maybe the obstacles; all that is wanted is a great deal of patience. Unfortunately, however, it is difficult to maintain the tumour reduced. II. Jieteniion. — Some means of retention are only used as pallia- tives, others aim at producing a radical cure. The former are all the more satisfactory because, without pretending to effect a radical cure, they sometimes contribute powerfully to it by enabling the ligaments to recover their elasticity and the uterine su))ports their resistance ; whilst every day^s experience proves that, in addition to the danger which accompanies the latter, they are quite insufficient to realise the ' Observations sur la grossesse et V accouchement, Obs. 95, p. 78. Paris, 1728. DISPLACEMENTS 375 aim to which they pretend. Both, but especially the artificial means of retention, may be helped in their action by medical treatment. Sometimes this is the only treatment that can be used and we should always begin with it. A. General or medical treatment. — This should be directed against chronic congestion, engorgement and all causes of increased weight of the uterus, as well as against debility, laxity of the ligaments, defective tone of the soft parts which support the uterus, and of the whole organism. Resolvents associated with restoratives, tonics, hydropathy, &c., constitute the principal agents of this treatment. If the evil is due to a labour or miscarriage, to fatigue during a menstrual period followed by neglect at the following periods, then absolute rest, the horizontal position, laxatives, cold sitz-baths, astrin- gent injections, vaginal applications of tannin or alum, local depletion if necessary, will often suffice to diminish the volume of the congested or hypertrophied uterus and gradually to dispose it to resume its normal position. These means must be used for several months and be resorted to again and again. If the prolapsus depends on a sudden distension of the ligaments, and has been produced suddenly in a young woman, in fact, if it be recent and acute, the same means may suffice, especially if the genu-pectoral attitude is assumed. Electricity and the cold douche exercise on the suspensory ligaments a local action, the association of which with general hydropathy and tonics produces excellent effects. If electricity is tried one of the poles should be applied to the cervix and the other to the groins and sacral region at the point of attachment of the utero-lumbar ligaments. If hydropathy is prescribed, general hydropathy should always be combined with the douche or spray on the loins, sides and groins and the treatment should be continued for a long time. When nothing better can be had cold sitz-baths may be prescribed for one minute at a time and repeated five or six times in the day. Although there is no certainty of a cure being obtained from this kind of treatment, it will be well to give it a fair trial and for a long time if there is no contra- indication. I have seen it produce excellent results. I am in the habit of seeing a lady for whom I prescribed this treatment more than twenty years ago for a prolapsus which made walking impossible and produced terrible attacks of hysteria ; she continued the treatment for six months, and since that time she has had no serious hysterical symptoms, and she can walk as far and almost as easily as before she was ill. I ought to add that she could never bear a pessary. These are really the only means that can produce in the tissues a natural modification capable of overcoming the cause of the descent. They ought always to be used, and sometimes exclusively, especially in cases of slight prolapsus that are recent and due to a uterine malady which is still curable. B. Palliative mechanical treatment is indicated in cases of long- standing prolapsus, with rupture of the suspensory ligaments, lacera- tion of the perinseum, cystocele, rectocele, &c. The mechanical means 376 UTEEINE DISEASES i:«« DETAIL of retention are very numerous, but in this apparent wealth we have only an additional proof of real poverty. I do not mean to say that any one of these means does not answer some special indication. But the contact of these foreign bodies with the mucous membrane, the embarrassment which their size causes in the cavity, the irritation, the pathological secretions and the other alterations of tissue to which their presence gives rise, the trouble which their introduction causes to patients, owing to the difficulty which they have in introducing them, the shocks felt by the neighbouring organs, the painful pressure which they necessitate on other parts, all go to prove a state of imperfection in these means which makes them intolerable to many patients. There- fore, as a rule, they should frequently be withdrawn from the vagina, not only for the sake of cleanliness but to rest the organ, and, when a tendency towards cure shows itself, which may occur when there is only relaxation without laceration, instruments of gradually decreasing size should be used till they can be dispensed with altogether. The pessary, by maintaining the organ in its natural place, allows the tissues in virtue of their natural elasticity to resume their normal size and resistance, in fact gradually to effect a cure. Therefore it is a mistake to say : A prolapsus is a hernia, and a pessary is a bandage which retains it. A pessary by maintaining the reduction places the uterus in a condition to recover, if that be possible, a contractility temporarily suspended. The choice of the pessary ought to depend on whether the vulva and perinseura are intact and resistant or not. a. When the vulta and penncemn are intact, when the contractility of the fibrous and muscular tissue of the vagina has not disappeared, the smallest foreign body with a surface sufficiently soft not to irritate the mucous membrane, and large enough to fill the space which sepa- rates the cervix in its normal position from the perinseum suffices to sustain the uterus in its normal position. 1. The simplest and often the best of all these pessaries is a fine sponge {see Tig. 154, p. 193), or if that cannot be had, a tampon saturated in an astringent or styptic solution ■} the sponge should be carefully washed every day, and taken out for the night when the patient is in the horizontal position. Spherical pessaries are in their action somewhat like sponge ; they press equally on all sides, but by dilating the vagina in every direction have the disadvantage of changing its form and of compressing important organs, especially the bladder and rectum. By making spherical pessaries elastic, as Gariel has done [see Fig. 155, p. 193), they can more easily mould themselves to the vaginal cavity and multiply their points (Vappui without provoking pain. They have been covered by a layer of amadou to make contact with the vagina less trying, and when resistance of the perinseum is defective, they may be kept in the vagina by means of a perinseal pad kept in place by a T bandage. With the view of avoiding painful * In 185.3, Fordyce Barker wrote a paper on the treatment of procidentia by the use of tampons soaked in a solution of tannin, which is quoted by Sims. DISPLACEMENTS 377 pressure, bung-shaped pessaries have been invented which preserve the form of the vagina, and others like a sandglass, which, from the hol- lowing out of their central part, have no oihtr point d'apjmi than the cervix on one side and the perina3um on the other ; unfortunately the size of these instruments makes them intolerable. 2. The difficulty of maintaining these pessaries in the vagina even when the vulva offers a certain amount of resistance, and the import- ance of avoiding compression of the rectum and bladder have led to spherical pessaries being transformed into discs and ovals pierced in the centre to preserve the uterus from contact with them and to facili- tate the evacuation of mucus ; they have also been hollowed out in front and behind to avoid pressure on the rectum and bladder. Such has been the origin of the biscuit-shaped or figure-of-8 pessaries, which are introduced longitudinally and afterwards turned round in the vagina, so that their greatest diameter is transversal. Lastly, to avoid distension of the vagina as well as painful pressure on bladder and rectum in cases where the resistance of the perinseum is consider- able, cup-shaped pessaries with a short stem have been invented, like those of Hervez de Chegoin, Simpson, &c., which support the cervix in their cavity, whilst their other extremity rests on the perinseum. Besides, however, necessitating the resistant perinseum, these retentive means are insufficient for a displacement like prolapsus. 3. The disadvantages of distension of the whole vagina when pushed beyond certain limits have led German gynecologists to try to support the uterus by distending the upper part of the vagina. This is the origin of the new pessaries incorrectly called hysterophores ; these hysterophores, like pessaries, may be free or retained, may either have their two points d'appui on the vagina which they distend, or they may support the vagina by means of an external point d'appui. Kilian's elytromoclilion was the first one invented. To make the in- troduction of the instrument easier, its position more fixed and the divergence of its extremities more constant, Zwank (of Hamburg) invented his hysterophore, composed of two wings with stems and furnished with a hinge in the centre, which allows of closing the wings in introducing the instrument, and when once it is in place of sepa- rating them to distend the vagina, keeping them in position by a screw. Schilling made the use of the instrument inconvenient by trying to regulate the divergence of the wings by means of a vice ; but Eulen- bourg and Savage have improved it, the former by substituting an india-rubber ring, the latter, a tube of the same material for Zwank's screw (Figs. 170, 171, pp. 196, 197). 4. We cannot advise the use of any of these means excepting always a sponge, a tampon, and Gariel's pessary, which are useful in some cases, especially when associated with astringent applications ; they all have the disadvantage of irritating the vaginal and uterine mucous membranes, and of taking up too much space or exercising painful pressure which is not compensated by the advantages they offer. This cannot be said of Hodge's lever pessary, which has been still further improved during the last few years. This is the best 378 UTERINE DISEASES IX DETAIL pessary, both when the prolapsus is recent and the vagina has pre- served its contractihtj (which is apt to be lost by the use of the Fig. 259. — Hodge's aluminium pes- sary : a, anterior transverse branch, indented on a level with the urethra ; h, transverse pos- tero-superior rounded branch. Fig. 260. — Hodge's pessary in place ; its form is less sigmoid than in Fig. 2-59. Every time the inferior branch descends, at every inspiration, the upper one rises and raises the womb along with the posterior vaginal cul-de-sac. previously named instruments owing to their excessive distension of the vagina), and when the vagina has lost this contractility, when the perinseum is weakened, and when we must try, by keeping the uterus in its place, to restore the contractility and resistance of these organs as well as of the suspensory ligaments. In the first place instead of distending the vagina and of being fixed in it, the instru- ment is mobile, rising and falling at every inspiration. It has the sigmoid form, and its size may be determined approximately by a measurement made with the finger. The length ought to be such that when the postero-superior limb is at the farther end of the pos- terior vaginal cul-de-sac, without touching the uterus, the antero- inferior one is behind the symphysis, above the meatus. It is intro- duced by pushing the posterior limb first upwards then backwards, so that, guided by the finger, it reaches the posterior vaginal cul-de-sac, when the anterior liujb should be raised and brought behind the pubis. "When in place its action is as follows : during inspiration, when the intestines are pushed against the uterus and bladder and cause the anterior vaginal wall to descend, the antero-inferior limb of the pessary which rests on this wall, follows it in this movement and descends a little ; the postero-superior limb necessarily rises in an opposite direction, raising the roof of the vagina and with it the uterus, the cervix being raised and directed backwards whilst the fundus is inclined forwards (if care has been taken to reduce it pre- viously) ; now when the fundus is anteverted, it is impossible that it can fall. Tiie action of the pessary is helped by the posterior wall of the vagina and the perinaeum constituting a firm, thick, elastic tissue which, partly owing to its contractility, partly under the influence of DISPLACEMENTS 379 atmospheric pressure^ is maintained in immediate contact witli the anterior wall and prevents prolapsus. This pressure is exercised naturally on the upper limb of the pessary embraced by the vagina. The vulval sphincter by its contraction also assists in supporting the instrument. The patient ought to wear her pessary continuously; it is unnecessary to withdraw it at niglit, it does not prevent coitus, nor even conception and j)regnancy, which occur frequently^ although it is better to avoid marital intercourse while wearing it. Its light- ness and its cleanliness, which is easily maintained by warm vaginal injections made twice a day with a weak solution of carbolic acid, exempt its use from all inconvenience. It only requires to be removed occasionally, to prevent accidents and allow of local exami- nation. Therefore it is the first pessary that should be tried, especi- ally when the prolapsus is recent, and when it is not accompanied by any lesion of the vagina or perinseum. When it fails we may have recourse to other kinds of pessaries which we are about to describe ; but we must not expect more than a palliative cure from them, no more than from a truss. h. When the vulva is enlarged, the perinaum thin or destitute of elasticity, and even the fourchette lacerated, the defective resistance of the perinaeum must necessarily be supplied by a pad which replaces it, or by means which keep the uterus raised by supporting it either directly or indirectly. 1. A simple perinaal pad (Fig. 153, p. 192) furnished with straps fastened to a strong belt or pelvic corset may suffice to maintain the uterus in the pelvic cavity, thus converting the painful prolapsus into a descent that can be tolerated. The pad ought to be of wood, ivory, gutta percha or horsehair, and sufficiently thick ; the straps of strong leather and cylindrical, kept in place behind and before by buckles placed as near the centre as possible ; the belt, a piece of ticking lined with chamois leather with a padded metallic plate, resting above the pubis (Hull), or rather on the upper part of the sacrum (Ashburner), the firm and mild compression of which considerably relieves lumbar pain. I have seen these means succeed even in cases of hypertrophy of the cervix, the replacing of which could be effected without pain. By not distending the vagina it has the advantage of enabling it to recover its elasticity. 2. The inadequacy, however, of this means has suggested the idea of seeking externally for the points d'appui which are refused by the vulva and perinseum to cup- shaped pessaries, which seem the best fitted, especially when elastic, to support the uterus directlij, without distend- ing or pressing painfully on the parts situated in the neighbourhood or below it. This is the origin of all the cup-and-hall pessaries on which the cervix rests, including those of Bauhin,! Suret, Desormeaux and Amussat" {see Tig. 180, p. 199), as well as those of Bourjeaurd, 1 Bauhin, A'p'pendix ad partum ccesareum Bosseti, quoted by Sabatier, Memoires de VAcad. de chir., t. iii, p. 374. 2 Bourgery and Jacob, Medecine operatoire, t. ii, p. 319 and pi. 72. Paris, 1840. 380 UTERINE DISEASES IN DETAIL Gabriel, Coxeter, &c., all of which are pierced with an opening in the centre for the discharge of fluids {see Fig. 181, p. 199), and attached to a belt by flexible supports, like those of Bourjeaurd, or by rigid stems made mobile by the ductihty of the metal or by the play of certain articulations of the stem which bears the cup destined to sup- port the uterus, like those of Lazare witch ^ and other makers. 3. Lastly, the difficulty of supporting the uterus directly and the drawback of the cervix resting (especially when it is diseased) upon a hard body which irritates it, ulcerates it, or makes it bleed, has sug- gested the idea of using indirect points cVappui which, by raising the vagina, maintain the uterus also in its place. One of the simplest and most convenient instruments of this kind is Scanzoni's pessary on a movable pivot, the stem of which supports a polished sphere and has its point (Vappui below on a T bandage by means of a ball-and-socket joint {see Fig. 183, p. 199). The instru- ments called retained hysteruphores are also of this kind. These are bent stems taking their pjoint d'appui on the plate of a hypogastric belt, and terminating in a sphere, a ring or a plate sufficiently elastic and resistent to keep the anterior vaginal cul-de-sac raised without hurting it. Saviard^'s pessary and the hysterophores of Roser, Scanzoni, Charriere and Becquerel are of this kind {see Fig. 182, p. 199). c. Surgical treatment or radical cure. — This consists in modifica- tions efl'ected on the perinseum, vulva and vagina by various operations, with the object of exercising on the reduced uterus natural and per- manent retention. These operations aim at closing or contracting the passages which allow the escape of the prolapsed uterus. a. Closing the vulval ring completely may be tried in cases where the patient is aged, the uterus obliterated, &c. It may be efl'ected by one of the means about to be described as used simply to contract it, or by the operation of Vidal de Cassis for obliteration of the vagina in cases of vesico-vaginal fistula. The vulva may be incompletely closed by the union of the labia, i. e. by intibulation. This operation was success- fully performed by Schielfer in 1856 by means of a trocar and leaden thread. Klein- repeated it, passing two threads of lead and failed ; the uterus escaping near the commissure, was hurt and strangulated by the thread. In 1859 Aran^ performed it four times; one case relapsed, another was followed by strangulation; the result of the two others is unknown. b. Contraction of the passages which afford escape to the prolapsus may be effected : 1, on the vulva or on the vagina in the neighbourhood of the vulva ; 2, on the vulva and peringeum ; 3^ on the vagina only. 1. Contraction of the vulva {episioraphy) is obtained by the dissec- tion and suture of the three inferior quarters of the labia, an operation suggested by Mende and executed by Fricke, of Hamburg/ in 1833. • Coup d'cBil SU7- les changeinents de forme et de position de V uterus et sur leur traitetnent. Paris, 1862. " Deutsche Klinih, 1856. 3 Op. cit., p. 1047. * Annalen der chirurgischen Abtheilungen des allgemein. Krankenhauses in Hamburg, Bd. 2, S. 142. Gottingen, 18:33. DISPLACEMENTS 381 Adhesion is not always complete ; disunion of the fragments below has been observed^ and consequently the persistence of an opening against the fourchette. This accident is not exactly unfavorable, for it pre- vents the surfaces which have been brought together from being sepa- rated by haemorrhage or suppuration, as has happened in other cases ; besides, the perinseal opening, though narrow enough to prevent the escape of the uterus, is sufficient for the menstrual discharge, and has been dilated enough to allow of the passage of the foetus in labour, as in the case described by Platt.^ Unfortunately the success of this operation is far from being certain. If it has succeeded once with Loscher and once with Knorre, it has failed once with Velpeau and Paget and four times with Scanzoni, once with Eoux, and several times with Stoltz, the labia distending without rupturing till they allowed the tumour to escape anew. Therefore, although recommended 'by Dieffenbach, episioraphy was definitely condemned by Kilian. Perhaps it would have been successful if performed as Kuschler advised, deep suture associated with superficial suture, as in perineoraphy. — Con- traction of the vulval portion of the vagina, inferior elytroraphy , per- formed by Malgaigne in 1837, did not succeed. Simon also failed in performing elytro- episioraphy, i. e. juxtaposition and suture after dissection of the vulva and lower portion of the vagina. 2. Contraction of the vulva and perinseum, episio-perineoraphy , consists in the greatest extent of juxtaposition by extending the incisions from the vulva to the perinseum, and in the increase of the depth and resistance of the cicatrix which contracts the vulva behind. The resto- ration of the perinseum, far superior to partial obliteration of the vulva, restores to the pelvic organs the support of which they had been deprived by an accident, and seems to constitute an essentially cura- tive measure. The operation consists in removing a portion of tissue in the shape of a horse-shoe and uniting the two sides by a double set of sutures, consisting of three deep and three superficial stitches. Cases of relapse seem to have been exceptional and to have de- pended on the extreme smallness of the uterus ; there was no death. Breslau does not excise the dissected fragments, but turns them inside out, placing them in juxtaposition, like a spur or beak, in front of the perinseum, a method which gives more height to the plane of reunion. Hilton" and Oldham^ have added section of the anal sphincter to facilitate the autoplasty and to extend the perinaeum. This operation, although inaugurated in France by Stoltz, of Strasburg, has been performed most frequently in Germany and England, and principally by Baker Brown,* who performs similar operations for cystocele, rectocele, and rupture of the perinseum. In 1861 this surgeon had operated on forty-one patients by this method : the result was thirty- eight cures, improvement in two cases, one relapse. Unfortunately ' Gazette Tnedicale, 1836, p. 16. - Guy's Hospital Reports, 2nd series, vol. viii, 1854. ^ Med. Times and Gazette, 1857. ■* On Surgical Diseases of Women, 2nd edit., p. 96. London, 1861. — See also Savage, Lancet, vol. i, p. 164, 1858. 382 UTERINE DISEASES IN DETAIL he does not say how long it is since his patients were operated on ; and as firmness of the pericceura and existence of the hymen do not prevent uterine prolapsus, we may be certain that restoration of the perinseum does not suffice to cure it. Kiickler, of Darmstadt, and Anger pursue a much surer method ; the latter proceeds by dissecting off the mucous membrane of the labia and the neighbouring part of the vagina, and both carry the dissection and suture close to the urethral orifice. Anger has ascertained that cure was persistent eighteen months after- wards ; this operation is therefore successful, but the escape of vaginal mucous is difficult and coitus impossible. 3. Stricture of the vagina has been produced by suppuration and by the formation of retractile cicatricial tisstie (Hamilton)^, in imi- tation of the traumatic cicatrices which obliterate or contract the vagina. This suppuration and consequent cicatrisation are brought about by the simple excision of a zone of vaginal mucous membrane all round the tumour, as proposed by Eomain Gerardin ;^ or by the excision of a piece of the vagina and uterus at the top of the tumour, as performed by Mayer^ an excision which may necessitate the applica- tion of the actual cautery to arrest the hsemorrhage; or by the excision of several fragments round the neck (Cruveilhier), in imitation of Dupuytren^s quadrangular excision of portions of tissue, to cure anal prolapsus. The formation of a cicatrix may also be procured by cauterisation with nitrate of silver (Cruveilhier), or acid nitrate of mercury (Laugier), the actual cautery (Velpeau), or sulphuric acid (Selnow) ; in all cases, however, cauterisation is either insufficient or dangerous. Therefore this means has never been tried for complete ob- literation of the vagina as proposed by Gerardin. The ligature applied to one or several portions of the raised vaginal mucous membrane, as to the pedicle of a polypus, as proposed by Blasius,^ or the wrinkled suture proposed by Bellini under the name of colpodesmoraphy , are equivalent to suture after excision. Lastly, pincement, simple or by caustics, intended to provoke gangrene in several folds of the vaginal mucous membrane, which are retained between the teeth of strong serre-fines, has been proposed and practised by Desgranges, of Lyons. This surgeon has published several successes due to the application of this method. Nelaton has also had successful cases. The means is ingenious, but the operation frequently requires to be repeated, and is not without danger. This is the drawback of almost all the opera- tions just described ; they are liable to cause serious dangers in trying to cure an infirmity which is usually unattended with any, and to substitute a deformity admissible in old women, but which in the young may be the cause of pains and fresh dangers, from the ^ Cooper's Dictionary of Surgery. ' Arcli. gen. de med., viii, 132. Paris, 1821. * Neue Operationsmcthode heitn Geharmuttcrvorfall mittels hreisforrmger Ligaturen. In a woman of twenty-four years Blasius applied four along the vagina, the first in the neighbourhood of the uterus, the second near the vulval orifice, the two others in the interval. It is npedless to say that the result cannot be counted upon. Freussische Vereinszeitung, 184)4, n. 41. Schmidt's JahrbUcher. Bd. 45, 8. 52. DISPLACEMENTS 383 obstacle which it puts in the way of the accomplishment of the functions of the^ vulvo-uterine canal, especially that of delivery. These operations I think are only indicated when extreme relaxation of the vulva and vagina, cystocele or rectocele, occur not only as con- secutive elements and secondary complications, but as principal elements and serious complications of prolapsus. If narrowing of the vagina is decidedly indicated, as alone able to prevent prolapsus, suture of this membranous canal on one or both of its walls is pre- ferable to all these operations. This suture is known by the name of elytroraphy or colporaphy . Elytroraphy or colporaphy is an operation which consists in dissect- ing off a band of mucous membrane from the anterior or posterior Vfiginal wall between two longitudinal incisions, and bringing together the edges of the wound with points of suture. Marshall Hall^ invented this operation. Heming, quoted by Boivin and Duges,^ performed it successfully in 1831, Ireland^ modified it by making the incisions on the side of the tumour to avoid wounding the bladder. A. Berard, who gave it its name, performed it several times unsuccessfully. Velpeau fixed the threads before finishing the incision and repeated the operation before and behind without more success. Scanzoni performed it thirteen times without success. Therefore, although Dieft'enbach has modified the proceeding by removing two bands in place of only one oval one as formerly, and by repeating the operation several times in a different spot, if the tumour is reproduced, the majority of surgeons regard this method of treatment as useless, besides being attended with danger. Colporaphy, however, has been revived after undergoing several modifications ensuring for it more success in the future than it has had in the past. a. Anterior elytroraphy . — Marion Sims^ in place of making the suture after having denuded a large oval surface of the anterior vaginal wall (as in his first attempts), has improved the operation by dissect- ing off the anterior wall a portion of mucous membrane in the form of a trowel (Fig. 261), so as to form a real fold, the upper ends of which {c d) are brought into contact and so directly support the neck of the uterus. In a case where the rest of the suture had failed, Emmet ^ ascertained that the union of the surfaces [c d, Eig. 261) and the con- sequent narrowing of the vagina in the anterior cul-de-sac sufficed to maintain the uterus in place. The performance of elytroraphy by this method is a delicate opera- tion. The patient lies on her back or on the left side. Denudation and suture being usually performed on the anterior vaginal wall, the posterior wall and the perinseum are depressed by a Sims' ' He removed a band of mucous membrane tbe length of the vagina and 12 mm. in breadth, and united the edges of the wound by sutures ; two years afterwards, in 1833, Vincent found the uterus and vagina in position. ^ Translation of Heming's paper, 1834, p. 53. ^ Gazette med., 1832. ■« Op. cit , p. 310. * A Radical Operation for Procidentia Uteri, New Yorh MedicalJournalf April, 1865. 384 UTEEINE DISEASES IN DETAIL speculum. I then fix in the anterior lip of the cervix the two terminal ends of a catheter, the convexity of which depresses the ante- rior vaginal wall towards the bladder ; the curve of the catheter is Fig. 261. — Elytroraphy as performed by Sims, a, h, c, d, bleeding surface in the form of a trowel ; /, central part of the anterior vaginal wall, which will be enclosed by bringing the sides of the wound a c,b d, together ; e, com- munication of the farther cavity/ with the anterior utero- vaginal groove insufficient to allow the passage of the cervix. It will be seen that the meatus is below, the patient being in the genu-pectoral position. buried under the lateral folds formed by the mucous membrane, and these folds indicate very exactly, where they meet in the median line, the spot where the mucous membrane ought to be dissected, so that these folds may be afterwards brought into contact. I then pass a solution of nitrate of silver over these folds and afterwards one of salt, which whitens them and allows me to mark out beforehand and very exactly the surface which has to be denuded ; in order to trace the transverse line of denudation (c d) the cervix is drawn downwards. In tracing the branches of the V care must be taken to make them neither too divergent nor too close together. I then reproduce the cystocele, which makes denudation easier ; a few points of suture may even be made before reducing anew. These sutures should be placed transversely, commencing from below, and the uterus should be pushed backwards with the sound till those nearest the cervix are passed. 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G." --3 i--a ■3 3 5 ""3 « H 1-5 ill! I'^-i.s s !.§ E JJ a a._5 3 " '-5 ^ ?; P > £ p^ i ■§ •^S 2 '^■^ S £ S g; e'3532sa5:S ■^ ^. " «-;g o g ? t »^ §•!:§ 2^ 2-3'2'i 3 ? S-5 2 = 1 ^S 3- S 5^^ 2 a 9-3 •> " 6C O o ^ — ■ ■" 2 a.* 3 9 . u 5_3 .•§ g.2 5 i M «" =■ g 2 a* = § & 2- I a >- a ■ ^ ss £=8 5 OS a a >.= o P "•■5 S a a 3'S '• u a-'-S 3-3 s^ « S -= 3 -S o S -i ■& ?, »^ 'cj . a.fc; a 5 o - CJ-^ a 2 (o *J- 3 3' £ :.- oaaaosSi-u ■■i S 1^ -=! a 2 "I--:: sis" I E-i'a g 0-3:3 tba 2-3 E £ C Ow .% I o o a JJ.S £ S 2 3 a °Zii 0.0 3 a 3=^ f igS2-=S§ 'a.-Sso.-'ao o a, o o) __i J -3 a"^ "s: 3 -'-' S a . ~ "3 .= .3 ■*; o,!-na^"|= illillsa" « ~ "t: a —• o o a a-3 ESS o " 5 c« . * OS o o -"i o a .S 55 o §3 -5 =-:j a (3 2.2 = j! -^ "^r 6E 3 J- a " ="3-= js X ■s»-u3 — "aae , J j= a « J - a -a _-t^ ■ t-Jal 2 ;S.S o ■< o K o H H 01* HO n p4 as during gestation. In- creased mobility of the organ owing to laxity of the ligaments. Always consecutive to delivery, or rather to nu- merous deliveries. A kind of hypertrophy physiologi- cal in its origin, patholo- gical in its permanence. It does not always prevent a fresh pregnancy, but it has still less tendency to cure after another delivery. Is hardly ever met with except in multipanc. Tonics, resolvents, revul- sives. Especially sea ba- thing, hydropathy,douche3 on the loins, groins and sides. Above all, excite uterine contractions by er- got, electricity, or the gal- vanic stem pesaury. i a a. s h §2 Rarely primary. Usually consecutive. Succeeds congestion or chronic metritis, or even arrested involution, or is developed spontaneouslv in consequence of the phy- siological tendencies of the uterine tissue. It may not only be total or partial ; but it may be general (affect the whole of the tissues), or be local- ised on one tissue, on the mucous membrane (fun- gosities, mucous polypi), ou the tissue proper (fibro- mata, fibrous polypi). Sec. Is never cured spon- taneously. Hare in nullipara.'. Resolvent medication. Solvents. Alteratives (iodine, mercury, alkalines, vapour baths, hydropathy, curafamis). Cutaneous and intestinal revulsives. o 1 3 "3 o Always secondary. Caused by another ma- lady which impedes circu- lation (perimetritis, peri- uterine tumours, venous obliterations of tlie broad ligaments). Often symp- tomatic of suppuration, of a deep uterine, peri-uterine or peritorieo-pclvic abscess, as cjedema of the limbs is symptomatic of sub-apo- neurotic abscess. Always passive. May be dissipated after the opening of the abscess which has caused it. Acute or chronic, ac- cording to whether it is caused by a phlegmon or a chronic malady. Often kept up, like the malady which causes it, by a dia- thesis. More frequent in multiparce, but may be met with in uulliparce. Treat the malady which is the cause. Afterwards apply the treatment for engorgement, or the gene- ral treatment of dropsy and adema. Blisters ou the vaginal portion of the neck, &c. nesa, resistance. Mobility preserved. No other neigh- bouring malady. No phe- nomena of reaction. Most frequently second- ary; produced by effusion of plasma under the influ- ence of repeated fluxions, chronic congestioii,or plas- tic processes (inflamma- tion),which have not reach- ed proliferation or the for- mation of neoplasms. Al- ways passive. Essentially chronic. Often kept up by a diathesis. Most frequent in multipara;. Turn aside the fluxiouary movements. Dissipate con- gestions. (Cutaneous and intesti- nal revulsives, hydropathy, no bloodletting). Stimulate absorption of engorgement in the organ and in the economy. (Cau- terisation of the cervix. Solvents internally, ou the skin, on the cervix, in tlie rectum. Alkaline baths, Vichy, &c.). Treat thediatheaes which keep up the engorgement. O S Ei ill ?^.2 25>£ .2S2 o o. a a 3 a a §1 Appearance sudden after traumatism, suppression of the menses, abortion, or delivery. At other times inflammation is developed slowly, and increases from day to day from want of care. Thus there is acnte metritis and chronic metri- tis. According to the seat, there is endometritis, me- tritis, parametritis and perimetritis. It may be total or partial (of the neck or of the body). Always active. Persists indefinite- ly if not treated. Experi- ences an exacerbation at every menstrual period. May be observed in all married women, but espe- cially in primiparie. It is usually the consequence of the puerperal state. Essentially antiphlogis- tic. Bloodletting, especially local. Absolute rest,emollients, diluents. Tepid, continuous, pro- longed irrigations; baths; very hot injections. Intestinal or cutaneous revulsives. Sedatives. Resolvents, mercurial ointment. Alkaline baths. Hydro- pathy as a preventive means witli regard to re- lapses rather than ciu'a- tive. 1 Often secondanj. Rarely active : result of the re- (iletion or persistence of fluxion. Sometimes ;) Op. cit., t. ii, p. 564. * Mcmoire pour servir a I'etvde des maladies des ovaires. Paris, 1844. OVARITIS AND SALPINGITIS 511 four principal stages : hypersemia, tumefaction and softening, suppu- ration, grey softening and putrilaginous or gangrenous decay. To these must be added induration, which Chcreau rightly describes as characteristic of chronic ovaritis, and -which is always accompanied, in this disease, by alterations of another kind. Before describing the anatomical characters of these alterations, the periods of the malady to which they are related, and, as far as possible, the symptoms leading us to suspect them, I copy Scanzoni's ^ excel- lent description of an inflamed ovary met with accidentally in a woman suffering from pneumonia. " The autopsy showed, in the pelvis, to the right of the uterus, a coagulated mass of fibrin of the size of the fist, easily separated from the adjacent organs, and which evidently resulted from an effusion. After its removal the ovary was seen pre- senting a longitudinal diameter of 2 j inches, whilst the transverse dia- meter was 1| inch, and the thickness of the organ about 1| inch. The ovary had an ovoid form, it was considerably enlarged, its surface was deep-blue and covered with numerous dilated veins, and towards the internal angle of the posterior surface the place of an ovarian vesicle which had burst a short time previously was recognised by its dark- red colour. The consistency of the organ was pasty, almost fluctuat- ing at some points. In cutting it a considerable mass of blood flowed and the section showed the same violet colour and some venous vessels greatly engorged. The vesicle in question on which the point of rupture was easily seen was the size of a pea; it contained in its centre a little black liquid blood, whilst the walls were covered by a thick layer of fibrin. Two neighbouring vesicles presented almost the same dimensions^ projecting slightly above the surface of the ovary ; on opening them a serous sanguineous fluid was discharged. Towards the other extremity of the organ, where the congestion was less strong, the red less intense, and the consistency [firmer, there was in the parenchyma an abscess of the size of a bean containing sanious pus mixed with blood. Beside this rather large abscess there were other smaller ones, the size of which varied from that of a millet seed to a pea, all situated deeply in the parenchyma and all containing sanious pus. The whole tissue was infiltrated with serosity, and the majority of the vesicles were visibly enlarged by an abundant accumulation of fluid. The pathological alterations observed in this ovary correspond exactly with the description of acute ovaritis given by some writers ; considerable increase in the size of the organ, marked hypersemia, traces of efi'usion into the vesicles, purulent centres in the parenchyma and fibrinous exudation on the peritoneal covering of the organ." Gallard- remarks that this description represents a type of ovaritis extending to the whole organ and to all its elements : in fact, the alterations are threefold ; they affect the vesicles, the parenchyma and the envelope. Is it always so ? May the inflammation be limited to one of these tissues in place of extending to all simultaneously ? It is difficult to believe that it runs its course in one of these tissues 1 Op. cit., p. 392. ^ Gazette des Mpitaux, July, August, October, 1869. 612 UTERINE DISEASES IN DETAIL without affecting the others. However, I have seen alterations of the organ so limited to one or other of these elements that it seems to me beyond doubt that this anatomo-pathological distinction can be made : in some cases the peritoneum covering the organ is alone inflamed ; adhesions unite it to the neighbouring organs, and bands retain the ovary in a vicious position, without any real cliange in the latter; the inflammation may also commence in a folUcle and remain for a long time confined to the membranes composing it ; the solid organic alterations so often met with in the ovary show us that the starting- point of the inflammatory phenomena is at other times limited to the parenchyma of this organ.^ I think, therefore, we must admit general ovaritis and partial ovaritis, commencing in one of the three elements of the organ, Usually the latter soon extends to the whole of the ovary, for acute general ovaritis is much the most frequent ; but the three forms usually co-exist, and treatment can hardly vary even if differential diagnosis were possible. A more practical division is that of five degrees of intensity in the inflammation at five periods of the malady : 1st congestion, 2nd red softening, 3rd induration, 4th suppuration, 5th grey or gangrenous softening. Besides these alterations, pathological anatomy shows that others exist, which cannot be connected with any of the five degrees enume- rated above, because several of them are met with in various periods of the malady, without belonging especially to any one of them. Such are displacements of the ovaries, their adhesions to neighbouring organs (Fallopian tubes, uterus, bladder, intestine, &c.), perforations of ovarian abscesses, the presence of pus in the lymphatics and in the ovarian veins, the varicose dilatation of veins, &c. A second remark is that the alterations due to inflammation are manifested in various degrees on different points of the ovary: adhesion here, suppuration there; induration at one point, softening in another : this depends not only on the course which the malady follows in the organ, but also on the difference of structure of the various elements of which the ovary is composed. One last remark : ovaritis alone or simple is excessively rare : the peritoneum is always affected hke the pleura in pneumonia ; the Tallopian tube participates almost always in the inflammation, the uterus IS often involved, primarily or consecutively, the broad ligament rarely escaping. Etiology. — Ovaritis is most frequently developed in the puerperal state, and as a consequence of menstrual disorders. With the puer- peral state are connected abortions, hard labour, obstetrical operations, want of care, fatigue, chills, &:c. With disturbance of the menstrual function are connected all the causes which increase catamenial fluxion and ovarian congestion, e.g. hot baths, eramenagogues, &c., and those which increase the ovarian congestion by suddenly suppressing the catamenia, e.g. coitus during menstruation, a sudden chill, especially of the feet or lower part of the body, emotion, violent grief, &c. ' Every day brings additional proof of the diversity in the seat of ovaritis. Bouveret, Annales de Gynecologic, t. iv, p. 427. — DaroJles, ibid., t. vi, p. 419. OVARITIS AND SALPINGITIS 513 Ovaritis is developed also by the propagation of a pre-existing inflammation in the uterus, or of a metritis produced by a traumatism, and even by an inopportune cauterisation. Cauterisation by causing the metritis to pass from the chronic to the acute stage leads to the propagation of the inllammation to the Fallopian tubes and to the ovary. A violent inflammation of the vagina, especially if virulent, contagious and disposed to be propagated to the uterus or to the Fal- lopian tubes, may reach the ovaries. Therefore ovaritis may be due to the extension of blennorrhagia to one of the ovaries, the inflammation either reaching by degrees the internal parts of the uterine economy including the ovary, or else by a kind of metastasis favoured by a natural sympathy and tlie vascular communications between these two organs, it is transported suddenly from the vagina to the ovary, as in man from the urethra to the testicle. Eicord has described this kind of ovaritis as comparable to blennorrhagic orchitis. Bourraud^ has related some interesting cases, and I have seen some also. Thus delivery and the puerperal state, menstrual disorders and uterine inflammation are the principal causes of ovaritis. Direct traumatic causes may also produce the development of ovaritis, but the ovary, owing to its internal position and mobility, usually escapes their action. The general causes deserve our attention. Maladies may attack the ovary like other organs : amongst acute maladies we may mention variola as a sequel to which Beraud^ has observed variolous ovaritis, which he compares to the variolous orchitis described by Velpeau and Gosselin ; amongst chronic diseases we may count scrofula {see later, on Tuberculisation of the Ovary), syphilis (Nekton has mentioned syphilitic ovaritis), gout and rheumatism (I have seen several cases of rheumatic ovaritis). According to some physicians, ovaritis is often double ; but Scanzoni^ says that it very often affects only one ovary, and I can affirm that, if both are aff'ected, one is always much more diseased than the other, perhaps the left ovary more frequently than the right,* but the ovaritis on one side does not only coexist with ovaritis on the other, it coexists still more frequently with inflammation of the Fallopian tube or cor- responding broad ligament. Ovaritis may be either acute or chronic ; it is sometimes difficult to distinguish the two forms, all the more so that chronic ovaritis easily returns to the acute stage. Puerperal ovaritis is the most intense and the most dangerous form of acute ovaritis ; it often terminates fatally in a few days. The most persistent chronic ovaritis often commences before marriage. Diagnosis. — The diagnosis of chronic non-puerperal ovaritis in the first stage is difficult, and yet it is very important. A girl, two or three days after her period has commenced, feels pain in the iliac fossa, with radiations, nausea and vomiting ; this pain becomes permanent ^ De I'ovarite blenorrhagiqtie, Theses. Paris, 1847. ^ Arcliiv. gener. de Medecine, 1859, 5® sene, t. xiii, p. 588. » Op. cit.,'p. 399. ^ Chereau, op. cit., p. 155. 33 514 UTEEINK DISEASES IN DETAIL although diminished in degree, being increased at the monthly period ; menstrual disorders occur ; the patient is nervous and irritable ; she becomes emaciated, a dark ring forms under the eyes, her face is sallow ; she probably has ovaritis. Marriage, often recommended with the idea that it Will regulate menstruation, increases the pain^ leucorrhcEa is set up and the young wife is sterile ; ovaritis is more and more probable. The importance of an early diagnosis is evident when we think of the many dangers to which the patient is exposed for want of it ; for ovaritis is a much more common disease than is supposed ; very often the ovaries are not examined, and very often the uterine complications are cured while the principal malady is ignored, ovarian inflammation being increased and suppuration produced by cauterising the cervix. Uncertainty of diagnosis would be less prejudicial in the latter case than in that of ovaritis at the commencement. The temporary fluxion, the luore or less permanent congestion of the ovary, may indeed be taken for the beginning of inflammation of this organ. It is all the more desirable to recognise and to distinguish them as the treatment is not identical, although necessitated in both cases by the fear that the persistence of fluxion or congestion may favour the development of inflammation. If, however, the diagnosis of the first stage is ditficult, especially of chronic ovaritis in a girl, it is quite different with confirmed ovaritis especially of the acute form. The obscurity of the diagnosis depends on two almost opposite causes: either on the latent form or on the extreme intensity of the symptoms, in fact on a want of equilibrium which hinders observation. Peritonitis especially, according to whether it is developed or not, may either produce this intensity of symptoms or leave them in obscurity. Acute and chronic ovaritis are very diff'erent with regard to the intensity of the symptoms and the order of their manifestations. Puerperal ovaritis is only the subacute form, generally accompanied by puerperal peritonitis. Acute ovaritis — subjective signs. — Acute ovaritis may from its com- mencement be true acute ovaro-peritonitis. Its reaction on the organism is immediate, causing rigor, fever, nausea, vomiting, pain more or less acute, spontaneous or provoked, often very acute as in peritonitis, continuous, but with exacerbations which may be accompanied by hysterical fits. Added to these there is frequent desire for micturi- tion, constipation, jjain on going to stool, the impossibility of stand- ing; the patient is almost bent double when trying to walk; it seems as if a bar of iron depressed the belly, from one iliac fossa to the other; whilst raising the leg on the affected side, and decubitus on the healthy side cause acute pain followed by dragging ; the lochial and menstrual discharges are either suppressed or diminished. In simple acute ovaritis the general reaction is less ; sometimes there is a little fever in the evening ; no vomiting, but distaste for food, dyspepsia, constipation, pain on going to stool and at micturition, with discomfort at some point of the abdomen. Chercau describes the OVAIUTIS AND SALIMNGJTIS 515 following as symptoms of ovaritis occurring after suppression of the menses : aching in all the limbs^ headache, thirst, and disorders of digestion. Standing, walking on an uneven road, a false step, extension of the leg on the same side as the ovaritis provoke pain, which is still more true of peri-uterine inflammation. The pain is so limited, that the patient may be able to place her finger on the start- ing point, which is situated in one of the iliac fossa? above the Fal- lopian ligament. From there it radiates towards the hypogastrium, the lumbo-sacral region, down the thigh to the calf, sometimes with numbness of the leg. The termination of acute ovaritis may be added to the other sub- jective signs as a help to diagnosis. Ovaro-peritonitis may rapidly reach suppuration, general peritonitis and death; or the phenomena may be alleviated, simple acute ovaritis alone remaining, with pre- dominance of local symptoms. Eeduced to this degree it may ter- minate by resolution, in spite of menstrual exacerbations, the only termination which can pass for a cure. It is only obtained in acute ovaritis at the period of congestion ; it is hardly possible when the malady has reached the stage of red softening. Recovery may take place in from three months to a year, with the exception of the per- sistence of abnormal sensibility and of some remains of ovarian trouble. Sometimes it reaches suppuration very quickly. The for- mation of pus is announced by increase of pain, erratic rigors, per- spiration in the evening, more acute pain on pressure, diffuse tume- faction in the pelvis, or a circumscribed tumour, rarely as large as the fist, allowing obscure fluctuation to be perceived when pressed between the finger introduced into the vagina and the hand placed on the hypogastrium. When pus is formed in the ovarian vesicles it may remain encysted for a long time ; when produced in the paren- chyma it makes more rapid progress. It may invade the whole ovary without going beyond it, retained by the fibrous covering, the resist- ance of which is increased by the false membranes deposited on its surface and forming a kind of lining. This resistance, increased by that of the adhesions which the ovary has contracted with the neigh- bouring parts of the serous membrane, fortunately as a rule prevents the abscess from opening into the peritoneum. Termination by suppuration is relatively very rare, it being only on account of the extreme frequency of ovaritis that it has been met with so often. ^ It is serious for the ovary, for the neighbouring organs, for the whole organism which may succumb to peritonitis or pysemia. It causes emaciation and discoloration of the face. Additional adhesions are established between the ovary and the neighbouring organs at each succeeding monthly period. Nevertheless the sac of the abscess becomes thinner and finally ruptures, the pus being effused all around. According to Chereau, Tilt and others the abscess generally opens into the rectum. I have collected six such cases. Dupuytren, Andral, • I think there has been an error of diagnosis in several cases ; it is easy to confound abscess of the ovary with inllammation of the broad ligament or iliac fossa ; abscess of the ovary often remains encysted. 516 UTERINE DISEASES IN DETAIL Montault, Nauche, Boivin, Churchill, Peudefer, Bennet and others have described cases of the kind. Of all spontaneous openings it is the most desirable. However more than one patient has succumbed to this accident, either immediately or after some time from the effects of exhaustion caused by the purulent secretion. Bennet^ mentions the case of a girl of fourteen, who after having menstruated once or twice was seized with haemorrhage followed by anaemia ; later on by emacia- tion, pain in the left iliac region, development of the corresponding ovary, discharge of pus and death with hydrencephalic symptoms. — Opening into the rectum causes tenesmus and a kind of dysentery from the contact of the pus with the intestine. When the abscess is not acute and cannot close immediately after being emptied, there is either an incessant excretion of pus or an alternation of occlusion with opening of the purulent centre, giving rise to the incessant recurrence of pain, fever, and all the accidents caused by each new distension of the abscess with pus and each new laceration of the imperfectly cicatrised wound. Opening of the abscess into the vagina is rather less frequent. Husson, Dance, Cruveilhier have mentioned cases. I have seen three. This result appears favorable to cure ; only it is sometimes difficult to discover the opening : we must remember this when desirous of en- larging the natural opening, or of making injections into the cavity of the abscess. — Exceptionally ovarian abscesses may open into the bladder, but this involves an abnormal position of the inflamed ovary. Andral and Murat have related two cases and Gallard a third, in which nothing was wanting but confirmation by necropsy. — The pus may pass into the oviduct and remain there, dilating it (Laumonier), or be discharged into the uterus and thence externally (Chambon de Monteaux, Chereau) ; or into the body of the uterus, and thence into the vagina (Boivin). — It may make a way for itself into the caecum (Dupuytren), into the colon (Montault), or following the round liga- ment or the crural vessels, be discharged by the inguinal canal or by the crural arch ; or after previous peritoneal adhesions it may escape through the abdominal parietes, at the iliac fossa (I have seen two such cases); Bennet (the Lancet, July, 1848) also mentions two cases. — The abscess may very exceptionally open into the peritoneum, causing fatal peritonitis. The pus has even been seen to make two ways for itself, e.g. by the bladder and the uterus (Boivin). After the abscess has opened, pus may be reproduced indefinitely, being discharged by the opening and causing hectic fever; the dis- charge is sometimes continuous, sometimes intermittent, and may issue from several points successively. It may, however, be cured even after capillary puncture, and the general health may be restored. Objective signs. — Pressure from above downwards, on the painful point of the abdomen, increases pain so much as to extort a cry from the patient. Sometimes the ovary may be felt by abdominal pal- pation : I have often discovered it, high up, when the patients felt it ' New York Journal, Sept., 184G. OVAlilTIS AND SALPINGITIS 517 themselves. It is perceived all the more plainly, because often retained on a level with the iliac fossa by adhesions. The vagina is hot, sometimes dry, sometimes moist; the uterus fre- quently deviated, but not so much so as in hematocele ; the cervix having variable disorders, being usually engorged or oedematous. The uterus has lost part of its mobility owing to adhesions between the ovary and the neighbouring organs ; in one direction especially it has become fixed; when we try to remove it from the diseased ovary great pain is elicited. In the vaginal cul-de-sac answering to the abnormal fixity of the uterus the finger sometimes encounters resistance, sometimes a small tumour; at this point resistance is experienced and excruciating pain sometimes produced by pressure. It is by rectal touch, however, in following the lateral borders of the uterus that we can best discover a tumour of the size of a nut or a small egg, very painful, the situation of which is variable, depending on the point at which the inflamed ovary is adherent; by associating abdominal palpation with touch a still more precise diagnosis can be made. Chronic ovaritis — subjective signs. — The pain which Scanzoni de- scribes as a disagreeable sensation is not always so acute as has been said; it is sometimes sharp, sometimes burning, extending up the loins during menstruation : patients say that it seems to them as if a hot coal were placed in the pelvis. It continues in a modified degree during the intercalary period; it causes permanent discomfort with darting exacerbations after exercise or fatigue. It is in the middle of or a little above the fold of the groin, not extending to the iliac fossa nor generally causing tension of the abdominal parietes. It radiates from this point, principally along the corresponding thigh to the knee, causing numbness or even coldness of the leg ; it is increased by walk- ing, standing, rising, effort of any kind, pressure from above down- wards, coitus and menstruation. In cases where the ovary adheres to the posterior surface of the lower border of the uterus, so that the penis touches it during coitus, such terrible pain is caused that inter- course becomes impossible. This pain is particularly sharp some days after menstruation, or for one or two days before it, and very often is not alleviated by the catamenial flow. The first symptoms of chronic ovaritis are menstrual disorders, menorrhagia or amenorrhoea, or menorrhagia and amenorrhoea may alternate with pain in the ovarian region during the period, a symptom often occurring in young girls. These disorders seldom consist in amenorrhcea, but rather in a diminu- tion, delay, or suppression of some months. In some chronic cases there is menorrhagia, heemorrhage even occurring in the intermen- strual period, which is always in advance ; but in that case there is also metritis, or at least leucorrhroa, itching, heat, with vulval and vaginal desquamation. The symptoms of neighbourhood are : frequent desire for micturition, scalding urine loaded with urates and phos- phates, constipation, hsemorrhoidal tumours, tenesmus, uterine colics, constriction of the vagina or vulva. These are often unimportant on account of the small size of the tumour. The general subjective signs 518 UTERINE DISEASES IN DETAIL are those of chronic metritis^ but more numerous and occurring more rapidly and perhaps still more marked, especially those of the nervous system. Disordered digestion causes nausea, sympathetic vomiting, principally at the commencement of the malady or at the time of the painful attacks ; it causes epigastric sensibility, loss of appetite, ema- ciation, depression, suffering, paleness, palpitation, breathlessness, arterial pulsation, fainting, in short chloro-ansemia, especially in patients suffering from leucorrhoea and menorrhagia. Disorders of the nervous system are not less serious. Diseases of the ovaries like those of the testicles, seem to affect the patient morally still more than do those of the uterus. Women so affected become morbidly sensitive; they experience an indefinable discomfort and suffer from erratic pains on the track of the intercostal, lumbar and sacral nerves, principally on the left side, with painful irradiations into the corresponding leg ; spasms of the pharynx, glottis and sphincters of the bladder, anus and vulva and various hysterical phenomena such as hypersesthesia and anesthesia, in fact all the cortege of hysteria except the convulsive fits, which are rare. The gravity of these symptoms is not surprising when we remember that of all the maladies of the uterine system, chronic ovaritis is one of those which furnishes the most dangerous cases. Ovaritis primarily chronic has an extremely slow course, but it is increased by menstruation and coitus. There is exacerbation at e^tiy monthly period, till at last fever breaks out, and pain increases so as to become intolerable. This passage to the acute state is serious, because it sometimes determines formidable accidents : the rupture of an ovarian abscess, circumscribed peritonitis becoming generalised on the slightest cause, increasing debility, pyaemia itself and finally death. Aran gives the case of a woman in whom the introduction of a pessary led to these fatal results. Whilst an inflammatory centre exists in the ovary or in one of the pelvic organs, an acute attack may occur at any moment. A more gradual but not less dangerous conse- quence of ovaritis is the development of a cyst. But even when it does not pass to the acute form causing perimetritis or general perito- nitis, chronic ovaritis, owing to its duration, has not the less serious consequences : the gradual debility of patients and the serious disturb- ance of their general health dis])ose them to contract other diseases, and expose them to the attacks of the various diatheses, especially the tuberculous. Supposing the patient escapes all these dangers, chronic ovaritis may terminate by induration and atrophy. This transformation of the organ is not strictly speaking a cure ; but it may cause the cessation of painful phenomena and the general disturbance of health. ToUow- ing red softening, it is characterised by a hyperplasia and a new formation of connective tissue; this tissue ends by stifling the other elements : the ovary either remains voluminous while becoming fibrous or cartilaginous, or it may atrophy and shrink, the ovarian vesicles and ovules disappearing. The small vesicles as well as the large are surrounded by peritoneal adhesions, the visible remains of the inflam- OVARITIS AND SALPINGITIS ol9 matioii which has caused the degeneration. Fatty degeneration may also produce atrophy. When both ovaries are "affected complete and irremediable sterility is the result, for the malady goes on increasing with time in jjlace of being cured. Objective nigns. — Palpation is insufficient, for, as in acute ovaritis, the ovary is hidden in the pelvis, lying close to the uterus or adhering to it. The small size of the tumour allows of its escaping observation in a superficial examination. Vaginal and rectal touch alone lead to diagnosis. The passage of the linger through the vulva sometimes provokes very acute pain, on account of the contraction of the sphincters. The vagina is very rarely hot and is often moist from mucus. The cervix looks healthy, half open, and somewhat oedema- tous. Usually the uterus is inclined to one side, its mobility being diminished ; it is impossible to push it from the painful to the opposite side without causing dragging, which increases the pain as well as the curve existing in the corresponding vaginal cul-de-sac, but without allowing the discovery of an indistinctly circumscribed tumour which can only be diagnosed by rectal touch. The inHamed ovary is more accessible to our investigations than the healthy one, on account of its size and weight which make it fall behind the uterus, retroverting the latter slightly. This displacement of the ovary into the posterior cul-de-sac may be considered as the rule though there are numerous exceptions. The diseased ovary, whilst descending lower than the healthy one, is prevented by the utero-ovarian liga- ment from being precipitated to the bottom of the posterior peritoneal cul-de-sac : it is situated behind and on one side of the uterus answer- ing to the vaginal insertions of the cervix where it may be retained by adhesions. Hence a dragging on the uterus, and a slight unsteadi- ness of this organ; if this slight retroversion is not produced, the ovary remains elevated. Hence the utility of rectal touch so strongly recommended by Lowenhardt, of Preslaw, in 1835, and since then by Lisfranc, Aran, and all gynaecologists ; hence also the importance of the association of rectal with vaginal touch recommended by Gallard.^ Unless adhesions keep the ovary in place, this organ escapes from the simultaneous pressure exercised by the two fingers that have seized it. We may add that, iu order that the fingers may reach and seize the retro-uterine tumour supposed to be the ovary, hypogastric pressure must be combined with this double touch in order to press the viscera into the pelvic cavity. By what signs can we know that this tumour is really the ovary ? It is an ovoid body, sometimes elongated, a little flattened from before backwards, adhering to the lateral or posterior part of the uterus, or separated from this organ by a more or less deep groove, sometimes mobile, sometimes not. In consistency it is hardly elastic, never indurated ; its surface, sometimes smooth and polished, sometimes indented and irregular, sometimes elastic, is usually rounded and resistant. The sensibility is extreme and is revealed by pressure, sometimes causing acute pain; for notwithstanding what has been said ' Gazette des hopitatu-, July, August. ISOD. 520 UTEEINE DISEASES IN DETAIL bj some writers^ the ovary is very sensitive normally, and when this sensibility is increased by inflammation, pressure becomes most painful. The greater size of the tumours of ovaritis prevent their being confounded with those of retro-uterine adenitis which occupies almost the same place and is also very painful. Lifferential diagnosis. — Ovaritis must be distinguished : 1, from other ovarian diseases; 2, from uterine and peri-uterine diseases. 1. The ovarian diseases which have to be distinguished from ovaritis are fluxion, congestion, oedema, apoplexy, engorgement, hypertrophy, &c. Morbid fluxion of the ovaries, like that of the uterus, occurs chiefly at puberty, at menstruation, on the occasion of venereal orgasm, &c. It exceeds the fluxion which is normal to those organs under such circumstances. It is manifested not only by pain, but also by stronger venereal excitement, discomfort in the iliac and lumbar regions, symptoms of neighbourhood, &c. Ovarian conges- tion may be met with in girls; it is sometimes produced by a con- genital tendency, or in consequence of the sudden suppression of the menses, or of the existence of dysmenorrhoea ; it persists or is repro- duced under the influence of a general state such as plethora, impoverished constitution, &c., or from a diathetic afl'ection such as rheumatism. It has many symptoms in common with uterine con- gestion (pain, heat, persistent discomfort in the iliac region and in the cavity), and as the latter differs from metritis, so ovarian congestion differs from ovaritis in the symptoms being less acute and continuous; the heat is less intense and the pain less excruciating, even when provoked by compressing the organ directly. Serous infiltration, a kind of oedema of the ovary, has been described by Morgagni^ as occurring in a woman who succumbed after delivery. According to Cruveilhier ^ it must not be confounded with ovarian inflammation ; but it seems to me difficult to distinguish it from the softening which characterises one of the stages of this inflammation and which may be accompanied by an interstitial san- guineous efl"usion followed by the coagulation of the fibrin and infil- tration of a yellowish serosity between the tissues of the organ. Hsemorrhage of the ovaries may be interstitial or vesicular, may take place slowly or suddenly (apoplexy), be contained within the envelope of the organ or be eft'used externally (hematocele), may accompany other lesions or result from a simple alteration of the vascular system (congestion, lacerations of the capillaries, &c.). It usually occurs suddenly during the menstrual period, after physical or moral emotion, on the occasion of venereal excesses, sometimes during pregnancy. The sudden appearance of symptoms of peritonitis added to those of internal haemorrhage distinguishes haemorrhages with effusion of blood into the peritoneum from interstitial haemorrhages and from simple ovaritis. Docs engorgement exist ? Is it a step towards induration, described as one of the terminations of inflammation and as characteristic of ' De sedlh-us, Ac. Epist. xlvi, §. 27. ' Anatomic patholugique, IS*-" liv., p. 13. OVAEITIS AND SALPINGITIS 521 chronic ovaritis ? It is difficult to judge the question, and still more so to diagnose such a morbid state. Hypertrophy may either affect all the various elements of the ovary or each separately. In describing organic lesions we shall see that it gives rise not only to unilocular and multilocular cysts, to cysto- fibromata, to cysto-sarcomata, but also to simple fibromata, and that the ovary, by hypertrophy of the fibrous tissue and atrophy of the Graafian vesicles, may be transformed into a more or less voluminous body, hard, compact, fibrous, fibro-cartilaginous and even stony at some points. These transformations may be consecutive to ovaritis. The slow development, the tumour,, the tolerance of the malady by the organism are the elements of a differential diagnosis between these degenerations and ovaritis strictly so called. Tubercle and cancer are not so well tolerated ; in addition to the symptoms of ovaritis there are the local symptoms produced by the increased size of the ovary or the extension of the malady to the neighbouring organs, and the general symptoms resulting from the progress of cachexy. Ovarian neuralgia is distinguished by the absence of all signs of inflammation except pain ; this pain itself has special characters : it is excruciating, it darts upwards to the loins and sometimes downwards to the vagina, urethra, and pubic symphysis ; it is not increased by pressure, frequently even appearing to be diminished by sustained pressure ; the ovary cannot be reached per vaginam, for it does not usually descend as in ovaritis, but seems on the contrary in some patients rather to have ascended ; the pain may be strong enough to de- termine nausea, vomiting or hysterical symptoms ; it comes by fits, not always coinciding with the monthly period ; it is often accompanied by neuralgia in other regions, especially by lumbo-abdominal neuralgia. Lastly, a suppurating cyst must not be confounded with an abscess resulting from ovaritis. The cyst is always much larger than the abscess; it has no tendency to open spontaneously; it is situated in the abdomen in place of being contained in the pelvis ; it has given signs of its presence and developed to some extent before suppurating ; the local and general symptoms of inflammation and of the formation of pus have therefore followed the development of the tumour in place of preceding it. Besides those cysts the internal membrane of which becomes inflamed and suppurates after puncture, there are some which are primarily purulent. I once removed an ovarian cyst which con- tained nothing but pus; it was formed after delivery; everything was going on well till the eleventh day, when the patient succumbed to serous diarrhoea. 2. Ovaritis must also be distinguished from uterine and peri-uterine inflammation. Not only may ovaritis be confounded with maladies of the neighbouring organs, but it is also almost necessarily accompanied by inflammation of the Fallopian tube and peritoneum. The frequency of ovaritis has been exaggerated by Boivin and Duges, Chereau and Lisfranc, whilst that of peri-uterine inflammation, abscesses of the broad ligaments and pelvic peritonitis has been exaggerated by more modern practitioners. Bor while it is easy to diagnose a retro-uterine phlegmon 522 UTERINE DISEASES IN DETAIL it is very difficult to distinguish a lateral one from ovaritis. It is cer- tain that iu a number of cases peri-uterine phlegmasias are constituted, as we shall afterwards show, by inflammation of the peri-uterine cel- lular tissue, of the pelvic peritoneum, ovary and Fallopian tube, or even of the uterus, without its being possible to establish exactly which tissue was first affected and which most acutely inflamed. Neuralgia, especially lumbo-abdominal neuralgia, presents circum- scribed points of pain which do not exist in simple ovaritis. Metritis is distinguished from ovaritis by the following characteristics : the pain is median, sharp, increased by pressure, especially by bimanual palpation, and also by movements transmitted to the organ, which is not the case in ovaritis, unless the body of the uterus is pressed against the inflamed ovary. Peritonitis is characterised by acute pain produced by the slightest contact and forbidding any thorough examination by pressure of the abdominal parietes or by vaginal touch. In place of simple nausea or vomiting of food there is bilious green vomiting, hiccough, &c. A peri-uterine phlegmon determines a considerable elevation of the tem- perature of the vagina, puffiness of the tissues, which are hard and resistant although cedematous and the formation of a tumour which is fixed and does not fly from the finger, adhering to the neighbouring tissues and making them adhere together. The uterus is no longer mobile, but fixed in the midst of inflamed tissues. The tumour pro- jects into the vagina, forming a protuberance all round the cervix or in one of the culs-de-sac which becomes efl'aced ; it presents arterial pulsation on its surface. Retro- or peri-uterine adenitis, whilst occu- pying almost the same place, is less extensive than ovaritis; I do not doubt, however, that it has sometimes been confounded with it. In addition to the difference of size, the simultaneous presence of analo- gous small tumours in the neighbourhood should allow of its being distinguished. I must now indicate the differential characters which enable us to distinguish chronic ovaritis or an ovarian abscess from a pelvic abscess or from a phlegmon of the iliac fossa. The form of the tumour and its relations facilitate this distinction. The form of the tumour is ovoid and circumscribed in place of being diffused ; its relations with the neighbouring parts are more clearly defined ; there exists a more or less marked interval between the tumour formed by the ovary and the pelvic organs or ilium. We must, however, remember that these characters disappear as soon as the ovaritis has determined around it, as frequently happens, more or less extensive pelvic peritonitis with suppuration, or at least exudation, adhesions, &c. Treatment. — It cannot be denied that acute ovaritis is one of the most dangerous of diseases, while chronic ovaritis is one of the most difficult to treat and to cure, and that during its whole course it ex- poses patients to continual danger from peritonitis. Therefore it must be treated in spite of its reputed character of being incurable ; for even if treatment is insufficient to restore the organ to its original integrity it may at least prevent serious terminations aiid ejiable the system OVARITIS AND SALPINGITIS 523 to tolerate the malady. Lastly, by the alterations which it determines in the ovary or the vicious adhesions which it establishes between this organ and the neighbouring parts, it becomes an almost incurable cause of sterility : an additional reason for treating it intelligently and energetically. In the treatment of ovaritis especially patients must be warned that months and years are required to effect a cure. As a rule perfect rest should be ])rescribed for the genital system, even in the treatment of chronic ovaritis ; but exceptions may be made in the case of some women as described at page 167. As for the desirability of marriage as advised by Gallard for girls suffering from commencing ovaritis, with the double view of preventing sterility (which the malady could not fail to produce at a later period) and of favouring resolution (by the repose from ovulation given to the organ during the nine months of pregnancy), I think it is important to make the distinction between inflammation of the ovary strictly so called, which is always aggravated by marital intercourse, and the simple congestion or fluxion of this organ which not only can tolerate coitus, but may be favorably influenced by pregnancy. The indications for treatment are reduced to the two following : to subdue the inflammation by antiphlogistic treatment proportioned to its intensity ; to promote resolution of the diseased ovary and of the plastic products formed in its parenchyma or around it, and if neces- sary to evacuate pus, while supporting the strength of patients, favouring nutrition and restoring the constitution. I. Antip/dogistic treatment ought to be proportioned to the intensity and to the complications of the acute form. In acute ovaritis compli- cated with peritonitis, in ovaro-peritonitis properly so called, it cannot be too energetic. In simple acute and in chronic ovaritis, the long continued use of the same means should be substituted for the energy used during a few days in complicated acute ovaritis. Bloodletting constitutes the first and the most energetic means. Bleeding is seldom indicated ; but leeches and scarifications may be applied largd manu, and repeated at longer or shorter intervals according to the case. In superacute ovaritis, 15 or 30 leeches may be applied to the iliac fossa or hypogastrium, or the scarificator may be used, so as to keep up a flow of blood for some hours. The perfect calm following this first application and the use of other means must be distrusted. When abdominal palpation causes pain, or if in the absence of this sign the temperature of the vagina continues high, and the tuuiour occupying the lateral portion of the pelvis outside the uterus is still sensitive to pressure, bloodletting should again be resorted to. If necessary, leeches and the scarificator may be applied three or four days successively, diminishing the number each day. In simple acute and in chronic ovaritis, the diminution of pain allows of the application of leeches not only to the abdomen but to the cervix, which is preferable, because depletion of the utero-ovarian vascular system being quicker a smaller number of leeches produces more effect, besides which ovaritis is frequently accompanied by hypersemia of the uterus or even by metritis. Alleviation is often immediate; but sometimes on the 52-4 UTEEINE DISEASES IN DETAIL contrary fresh applications must be made several days running or at short intervals. In chronic ovaritis it is well, as a rule, to leave an interval of a month at least between two consecutive applications, and they should always be made immediately after and not before men- struation. TVe must take advantage of the time when menstrual con- gestion has terminated, to empty the utero-ovarian vascular system. If the patient is plethoric and it is desirable to bleed before the monthly period, blood should be drawn from the arm as a means of revulsion to prevent the approaching catamenia from being as consi- derable as usual. The application of leeches in cases of subacute ovaritis should be immediately followed by the use of auxiliary means, such as rest, diluents, emollient and sedative cataplasms, an emeto-cathartic if there is gastric derangement, or a simple laxative or enema if there is intes- tinal irritation, and sedatives and resolvents in peritonitis, i. e. opium and mercurial frictions. There need be no fear of giving opium in large doses if the precaution is taken to administer it less frequently as soon as a sedative effect is produced, and to cease it entirely if the patient shows a tendency to remain drowsy. Here as in other cases, opium may when necessary be replaced by morphia either administered internally or by hypodermic injection, but opium when tolerated is preferable. It is of course needless to employ it in chronic ovaritis. Trictions should be made with mercurial and belladonna ointment. On such occasions it should be used like leeches lar^a munn^ i. e. one ounce of ointment should be spread on the abdomen every five or six hours, and covered by a large poultice of linseed meal hot and very moist, in which a few dro])s of laudanum may be sprinkled. A thick layer of cotton wool should be placed over this with oil silk above all. The following morning patients take a bath, and after having dried the abdomen well keep it covered all day with a flannel bandage unless there is an indication to have the belly constantly covered with ointment and cotton wool to keep up a moist heat favorable to resolution. Baths and irrigations are valuable auxiliaries which should be pre- scribed as soon as they can be used without fatigue to patients. We begin with prolonged warm general baths (emollient, gelatinous or alkaline) with vaginal irrigation every day or every other day; they should soon be replaced by hot irrigations. At a later period, though rarely in cases of chronic ovaritis without exacerbation, tepid and cold sitz-baths may be substituted with cold irrigations and enemata, which constitute a suitable means for subduing the continual tendency to renewed fluxion towards the ovary, and for facilitating resolution of the chronic phlegmasy by their tonic and slightly revulsive action on the skin. II. Resolvent medication ought to follow antiphlogistic treatment especially in chronic ovaritis ; it should be continued for a long time, for it requires months and even years to obtain a cure. We can measure the progress made towards health by the amelioration efl'ected in the performance of the menstrual function. OVARITIS AND SALPINGITIS 625 Resolvent medication consists in the internal use of alteratives, mer- curials, iodide of potassium, oxide of gold, &c.; and of the external use of the same medicaments, frictions of mercurial ointment, tincture of iodine, and even blisters, the utility of which is undoubted, although not equally successful in all patients, and less so in cases of ovaritis than in peri- uterine inflammation or pelvic phlegmon ; cauterisation is preferable, and igni-puiictures from being less painful and causing less cicatricial deformity are doubly preferable, because they can be resorted to again. In cases of ovaritis 1 have found the use of rectal injections of resolvent ointment of great use : this means is very superior to sup- positories, as it enables us to apply the medicament in sufficient quantity to the diseased organ and to vary the composition according to the condition and tolerance of the patient. We must also remember that the choice of these medicaments is not indifferent, that after in- flammation is once fixed in the ovary the organ often remains diseased, in spite of the most energetic and most rational antiphlogistic treat- ment, because this inflammation has sufficed to determine on the ovary the localisation of a diathetic condition to the cure of which even ovaritis is secondary. In chronic ovaritis I have frequently observed what I have also remarked in orchitis : that the rheumatic, herpetic, scrofulous or tuberculous diathesis may localise itself on the diseased ovary and keep up hypereemia, fluxion, prolonged pain, or produce still more serious alterations. Copland^ has described rheumatic ovaritis, giving two cases; Gallard^ has published another; and I have collected several. Henry Bennet^ describes a case of death due to a tuberculous deposit in the ovary ; in three cases of the same kind the pus made way for itself through the abdominal wall. It is evident that the means of treatment ought to vary according to the nature of the diathetic affec- tion, which takes a more or less considerable part in the prolongation of the ovaritis. Tor instance I have succeeded in curing chronic ovaritis of two years^ duration in a very scrofulous woman by iodide of potassium in large doses, followed by the administration of oxide of gold continued for a long time, associated with residence at the sea- side during the summer, the patient taking two baths a day and resting for eight days every month. I have cured three cases of chronic ova- ritis with sulphur water taken internally as well as in baths, combined with cold douches on the loins, in which alkaline baths, associated with the ordinary resolvents, had produced no effect. In one case, about which I was almost in despair as to the cause (there only being very slight external manifestations of the herpetic diathesis), I tried arsenical preparations followed by a season at Avene (Herault) and was successful. The addition of carbonate of soda or sea-salt to sitz-baths may be made when acute ovaritis passes into the chronic stage. General baths (alkaline or chlorinated, or both), natural waters such as those ' Gazette medicale de Paris, 1830, p. 362. "^ Gazette des hn^ntaux, October, 1869. •' The Lancet, July, 1818. 526 UTERINE DISEASES IN DETAIL of Plombieres, Vichy, Vals and Boulou, purgatives from time to time, irrigations with cold water, cold applications to the abdomen, cold sitz-baths and douches, in fact hydropathy : these are the resolvents usually indicated associated with the medicaments just referred to in the treatment of chronic ovaritis. III. The frequent complications which exist in the uterus, the co- existence of leucorrhoea, ulceration of the cervix and vulval pruritus, require treatment suitable for these various morbid states. There is one more indication to be fulfilled, viz. to facilitate digestion, relieve nervous symptoms, stimulate nutrition and improve the condition of the blood by exercise, generous diet, tonics, iron, and hydropathy. Lastly, if an abscess has formed projecting into the vagina or rectum, the rapid increase of which may cause the fear of its opening in an unfavorable direction, after having made an exploratory/ puncture, the pusshotddbe evacuated by the vagina and detersive or slightly irri- tant injections made into the centre. When the abscess points towards the abdominal wall it should be opened with Vienna paste according to the method employed in opening abscesses of the liver, so as to prevent the effusion of pus into the peritoneal cavity : the scar is in- cised and excised every day, in order to apply more Vienna paste to the wound and so get nearer the centre, after having determined adhesions in the neighbourhood. Faures^ describes a case of ovaritis followed by suppuration, in which the artificial opening of the abscess above the crural arch was followed by cure. I have lately seen a similar case, and another in which, after numerous applications of the cautery to the left hypo- gastric and iliac regions, the abscess opened spontaneously near the linea alba; the patient was cured. 2. Inflammation of the Fallopian Tube Salpingitis (inflammation of the Fallopian tube), hardly mentioned by West (1858) and Nonat, is described by Scanzoni, Aran and Becquerel. Inflammation is easily developed in the Fallopian tube, on account of the continuity of this canal with the peritoneum on the one hand, and with the uterine mucous membrane on the other ; but it rarely occurs unaccompanied by ovaritis or pelvi-peritonitis. Usually there is simultaneous inflammation of the Fallopian tube and ovary, this double inflammation being very similar to peri-uterine inflammation. When salpingitis exists alone it may pass unobserved : lesions charac- terising it are met with in women who have never complained, and yet, according to statistics, diseases of the oviducts alone are more frequent than those of the ovaries alone. Scanzoni ^ thinks that inflammation of the Fallopian tube, and especially inflammation of its raucous membrane, which he calls catarrh, almost always accompany an analogous affection of the mucous membrane of the uterus or vagina. Salpingitis is often double. It exists simultaneously or suc- ^ Gazette hebdomad., v, 517. "^ Op. cit., p. 365, et seq. OVAKITIS AND SALPINGITIS 527 cessively on both sides. It may be either acute or chronic. In acute inflammation the FaUopian tube becomes entirely or partially fixed and adherent to the neighbouring organs, is still more llexuous than normally, is distended by iluid and fumeficd ; the walls become thick, soft, dark red in colour, with or without vascular arborisation. The fringes of the fimbriated extremity which are reddish, infiltrated and sometimes adherent to the neighbouring organs, are usually bent down and applied to one of the organs to wiiich they adhere. The mucous membrane is red, swollen, moistened with a iluid composed chiefly of epithelial cells and sometimes of pus. When the fimbriated extremity is obliterated, especially if the ostium uterinum is so also, there is an Fig. 316. — Fallopian tubes thiclcened by inflammation and distended by a col- lection of fluid (after Hooper, The Mo7-bid Anatomy of the Hmnan Uterus and its Appendages, xvith Illustrations of its Organic Diseases, pi. in-4. London, 1832). accumulation- of fluid dij^tending the cavity of the Pallopian tube. It is exceptional to see these morbid products discharged into the peri- toneum,^ and when peritonitis is developed it is usually due, not to an effusion, but to the propagation of inflammation by continuity of tissue. In chronic inflammation the Fallopian tube is two or three times the size of the organ normally, in colour it is slaty grey, the walls are 4 or 5 millimetres in thickness, of firm consistency, almost obliterat- ing the cavity in which pus is not accumulated unless there are adhe- sions; the mucous membrane is greyish, thickened and resistant. ^ Puech has published a remarkable case of this kind {Gazette des hopitaux, 1860, pp. 517 and 522). 528 UTERINE DISEASES IN DETAIL Salpingitis may be complicated by inflammation of the uterine mucous membrane, by obliterations from adhesions formed with the neighbouring parts, or by the fringes of the fimbriated extremity adhering together, and by the accumulation in its cavity of a serous or sero-mucous fluid incorrectly called droj^sf/. The usual seat of this dropsy is the abdominal extremity of the tubes. Scanzoni says that they may be folded back at several points, divided into five, six, or even a larger number of sacs of various sizes, resulting from as many obliterations of the canal. He has seen one of these tumours equal in size the head of a child of ten years ; but they do not generally exceed the size of the fist. At other times external adhesions close the tube and there may be dropsy without inflammation ; sometimes the fluid is contained in a cyst of the tube or in multiple cysts which do not communicate with each other. A considerable number of cases are recorded in which the fluid contained in the tube appears to have made a way for itself through the uterus or vagina. Although this profluent dropsy of the tubes as Eokitansky calls it has been proved to exist, Kiwisch observes that the same symptoms may result from the perforation of an ovarian cyst or from hydrorrhoea of the uterus, and that it is surprising that a discharge from the abdominal extremity of the tubes into the peritoneal cavity has not been observed, since it is nearer the seat of the dropsy. In such cases, however, this extremity is often obliterated, and Scanzoni,' who mentions these objections, gives the details of an autopsy proving the possibility of such discharges by the uterine extremity of the tubes into the womb and vagina. These cases, however, are very rare. The causes of salpingitis are uncertain ; abortion, delivery, previous inflammation of the uterus seem to determine it. It may possibly result from ovaritis, pelvic peritonitis, or even be idiopathic, but more frequently it is propagated from acute endometritis. hiagnosis. — There is the same uncertainty with regard to the dia- gnosis. Acute ijiflammation may be confounded with ovaritis, metri- tis (especially when internal) pelvic or generalised peritonitis; chronic inflammation with chronic internal metritis which is often concomitant. Kiwisch gives as a sign of inflammation and dropsy of the tubes the presence of elongated, mammillated, elastic tumours in emaciated women on the lateral and upper portions of the uterus on both sides. I agree with Aran and Scanzoni that this sign is not sufficient ; for other pelvic organs, multiple adhesions, the ovaries, the inflamed and tumefied broad ligments may be taken for the tubes. In the case of salpingitis the kind of mammillated, undulating, irregular and painful cord formed by the congested tube, is perceived higher up than in the case of phlegmon of the broad ligament : it is attached to the ovary and uterus, and occupies less than phlegmon of the broad ligament the corresponding side of the pelvic cavity. It is not uncommon to observe it on both sides simultaneously or successively, the inflamma- tion extending from the uterus to the tube, to the ovary of one side, ' Op. cit., p. 367. OVARITIS AND SALPINGITIS 529 and soon afterwards, at a monthly period, when the patient is thought to be cured, it reaches the tube and then the ovary of the other side. I have diagnosed salpingitis from these signs, the autopsy proving that I was correct. In order to be certain, we must be able to recog- nise the ovary and distinguish it from the diseased tube, which is very difficult especially in the pathological state. In a doubtful case the probability is in favour of ovarian disease, as the latter is more com- mon than salpingitis. Aran describes a case of tubal abscess mis- taken by himself for abscess of the ovary. Digital touch associated with palpation indicates the form and seat of the inflammatory tubal tumour. A bougie might be introduced into the tube if the uterus had been previously dilated by a relentum. Scanzoni says that simple catarrh of the tubes (inflammation of the mucous membrane) is never, during life, accompanied by symptoms allowing of its being diagnosed, and frequently dropsical dilatations of the tubes have persisted for years, without presenting any morbid phenomenon of importance. My own observations have convinced me that this malady always proceeds in this way when there is no peritoneal inflammation; when there is, the symptoms are very marked, especially when perforation of a tubal abscess is the cause of the peritonitis. Accumulations of pus in the tube, real abscesses, which Scanzoni thinks are almost always con- nected with the puerperal state, expose to the same accidents as ovarian or pelvic abscesses. Observation has proved that they may open into the rectum (Scanzoni relates a case), vagina or peritoneum, and that in the latter case death is almost inevitable. Verjus ^ describes a case; fifteen days after an abortion death occurred in con- sequence of an abscess of the left tube the size of a chestnut having opened into the peritoneum. Peritonitis may result from salpingitis in three ways: 1, by the inflammation being propagated from the fimbriated extremity to the peritoneum ; 2, by discharge of the tubal pus through the gaping fimbriated extremity; 3, by perforation of the tube.^ In addition to the case previously mentioned (527 note) I have collected three other examples of perforation of tubal abscess into the peritoneum. Therefore chronic salpingitis, like chronic ovaritis, exposes women who suff'er from it to the constant danger of peritonitis which may break out on the slightest cause, the most insignificant surgical opera- tion on the uterus causing death in twenty-four or thirty-six hours ; for this reason the physician before performing any operation on the uterus ought to ascertain that there is no inflammation of the uterus, its appendages, or the pelvic peritoneum. The treatment of acute salpingitis is the same as that of perito- nitis, and that of chronic salpingitis the same as for endometritis and chronic ovaritis. ' Tlicses de Paris, 1844. ^ Forster, Wiener rned. Wochenschrift, 1859, Nos. 44 and 45. 34 530 UTERINE DISEASES IN DETAIL 3. Inflammation of the Fallopian Tube and of the Ovary The features most deserving of interest in these cases of salpingitis and ovaritis are the coexistence of the one with the other, or the simultaneous existence of oophoritis or salpingitis on both sides, or the successive development of inflammation in both organs alternately on either side. This propagation of uterine inflammation to the ovi- duct and thence to the ovary, sometimes on one side, sometimes on the other, is certainly one of the most singular and characteristic features of these kinds of maladies. It probably depends, on the one hand, on the organic sympathy connecting the various parts of the genital economy, and facilitating the development of these inflammations, so well observed by Gosselin apropos of perimetritis. On the other hand, it depends on the influence which a diathetic afi'ection exercises on the development of inflammation successively on the various points of the genital economy and even of other organs. It is characteristic of dia- thetic affections to prolong their duration till the cause of the malady has been extinguished by treatment, and to provoke manifold simulta- neous or successive localisations of the same affection on several organs or several tissues, till this affection has been exhausted or completely neutralised by general treatment. In syphilis, and even in venereal affections such as leucorrhoea, I have observed the propagation of the malady to the oviduct and to the ovary. In herpetism I have observed the same thing and have seen the most curious cases of successive or alternating localisations on the vagina, uterus, Fallopian tube, ovary and vice versa, on one side or the other, or on both. Rheumatic inflammations do not escape this law. But the most curious fact of all is that, in patients in whom I have been unable to discover any other symptom of a diathetic affection (owing to this organic sympathy connecting the various organs of the genital economy by an invisible link), I have seen inflammation just as it was thought to be extinguished revive in the most unexpected way, and be propagated suddenly to the Fallopian tube on one side and then to the ovary, always taking advantage of the monthly congestion as the best opportunity for these unexpected recurrences; then again, when we had reason to hope that its action was exhausted on the ovary, it revived in the uterus at another monthly period, producing metritis, differing more or less in its form from that which had been treated three or four months ago ; at the following periods this metritis was propagated from the uterus to the oviduct of the other side, then at a later period to the ovary of the same side, and only finally exhausted after all parts of the internal genital economy had been attacked by inflammation, sometimes frequently. I have seen several cases of this kind, some more or less incomplete with regard to the various parts of the affected ovaries or oviducts, others more or less comjilete, all parts of the ovaries and tubes having been affected successively, some even repeatedly, as if the remains of the inflammatory congestion furnished PERI-UTERINE INFLAMMATION 531 materials for the revival of the former inflammation, or for the develop- ment of a new inflammation. I remember a patient who came from Algiers to consult me for chronic metritis, from which she had suffered for several years, in whom this propagation occurred; the various parts of the internal genital economy being alternately and successively affected right and left without any apparent cause and lasting for eight months. In such a case it would have been most dangerous to have cauterised the cavity of the body. In such patients, I have profited by the displacement of the inflam- mation, to discover the symptoms which pain and tumefaction of tube or ovary determine. The diS'erence between the symptoms of salpingitis and those of ovaritis are easily recognised when we have the opportunity of observing them from month to month, sometimes incompletely de- veloped, sometimes at the summit of their intensity, now on one side, now on the other, now on both simultaneously, alone, or associated with those of pelvic peritonitiSjCellulitis, phlegmon of the broad hgaments, &c. Such cases help to dissipate the obscurity which in other circumstances may conceal the real signs on which we have based the diagnosis of salpin- gitis and ovaritis. It is only after having had the opportunity of observing them and submitting them to rigorous analysis that we have been able to arrange the elements of this diagnosis in descriptions repre'senting the various aspects which these maladies assume. The diagnosis and treatment of this disease is the same as for peri- uterine inflammation, which it produces easily, as I shall now have occasion to show. Peri-uterine Inflammation I willingly retain this expression adopted in the previous editions of this work to designate the malady described till lately by surgeons under the name oi pelvic abscess, which only describes one of its ter- minations, and by contemporary gynsecologists as pelvic cellulitis (Gendrin), peri-uterine phlegmon, peri-uterifie engorgement (Nonat), inflammation of the annexes, phlegmon of the broad ligaments (Henry Bennet), perimetritis (Scanzoni), pelvic peritonitis (Burnutz and Goupil), names which recal not only the ideas which these various practitioners had as to the seat of the malady,^ but also the inflamma- tions which may attack the various tissues and various regions round the uterus. Matthews Duncan- has proposed the name oi perimetritis for inflammation of the peritoneum surrounding the uterus andpa7'a- metritis for that of the cellular tissue in connection with the uterus. The expression peri- uterine inflammation is more correct because more vague, including all the others without prejudging anything as to the seat of the malady. Now, this seat may vary, the disease attacking one or other of the organs subject to it, or all at once. > In Germany it is described vinder the name o£ peri-oi^phoritis, or peri- salpingitis, according to whether the ovary or tube has been the stariing point. " A Practical Treatise on Perimetritis and Parametritis. Edinburgh, 1869. 532 UTERINE DISEASES IN DETAIL Seat and pathological anatomy. — I shall describe cellulitis, perito- nitis and adenitis. 1. Peri-uterine cellulitis and pelvic cellulitis. I do not think pelvic cellulitis can be denied. I shall not content myself with simply stating that I have seen it, and that Nonat thought that all peri-uterine inflammation might be included under the head of peri-uterine phlegmon, but I shall refer to the chief observations which have been made on it recently. Gosselin has described cases of peri-uterine phlegmon. Gallard ^ has devoted his inaugural thesis to the description of this malady. Aran has seen the two peritoneal folds of the broad ligament separated from each other by a thick layer of pus : three times partial engorgements of cellular tissue, diagnosed during life, have been verified after death in two newly-delivered women (infiltration of blood and pus), and in an old woman (fibro-plastic indurations) ; in another puerperal woman, with internal uterine gangrene, there were found plastic lymph and serosity in the recto- and vesico-vaginal septa and in all the pelvic cellular tissue. Peri-uterine cellulitis is accepted by English surgeons as well as by the German school. Graily Hewitt ^ summing up the ideas of his countrymen on this point says : inflammation, swelling, and the formation of pus in a large number of cases certainly originate in the connective tissue surrounding the uterus. This tissue becomes the seat of oedema or of infiltration of fluids. West,^ whose remarks on pelvic abscesses are very instructive, agrees with PirogofF that this state is correctly designated by the expression acute purulent oedema. Virchow '^ has lately published the results of the investigations he has made on this subject : the cellular tissue, according to him, becomes at first tumefied, thickened, hardened and oedematous, a fluid being discharged from it when it is incised. Although not so frequent as Nonat supposes, peri-uterine cellulitis has been long known. ^ Nume- rous cases have been recorded of phlegmons of the broad ligaments, especially in the ])uerperal state, developed and propagated to a greater or less extent in the surrounding cellular tissue, and even turning into an abscess without causing an attack of peritonitis. I have seen a phlegmon of the right broad ligament open into the rectum, another of the left ligament into the vagina, without having given rise to any symptom of peritonitis ; in three patients I have seen indurations and cicatricial bands, causing.a lateral and persistent displacement of the uterus, twice to the right, once to the left, with a slight obliquity in ^ De V inflammation du tissu cellulaire qui entotire la matrice, &c. Paris, 1855. ^ The Diagnosis and Treatment of Diseases of Women, p. 227. London, 1863. 3 Op. cit., p. 432. * Virchow's Archiv, 1862, Bd. xxiii, S. 415. * GiisoUe, Des Abchs de la fosse iliaque, in Archiv. gener. de medecine, 1839, and Paihologie interne, 8^ edit., 1862, t. i, p. 598. — Marchal de Calvi, Des Abchs phlegmoneux intra- jjelviens, these pour 1 'allegation. Paris, 1844. — Behier, Clinique medicale, 1864. — Briand, Thise de Paris, 1866. — Trousseau, Des Inflammations peri-hysteriques, Clinique medicale, t. ii, p. 747. Paris, 2 edit., 1865. — Frarier, Etudes siir le phlegmon des ligaments larges, These de Paris, 1866.— Guichard-Choisitj, These de Paris, 1862. PERI-UTEBINE INFLAMMATION 533 two cases, maladies of eight, ten and twelve years' standing in which the CO -existence of pelvic peritonitis could not be presumed at any period. The correctness of this diagnosis was confirmed more than once by autopsy. Frarier describes a case^ of suppurating plegmon of the right broad ligament after confinement which opened into the bladder: the autopsy proved that the peritoneum and the intestines did not participate in the inflammation. Behier has published a case^ of suppurative phlegmon of the left broad ligament, occurring two days after a first delivery, extending to the left iliac fossa, without alteration of the peritoneum covering it. I have seen an equally conclusive case. There are also examples of ante-uterine and retro- uterine cellulitis without any symptom of peritonitis, and even without any organic alteration of the serous membrane. Simon^ has published a case of extra-peritoneal, inter-utero-vesical abscess, occurring in the course of malignant variola amidst symptoms of purulent infection. Alph. Guerin* has met with a similar abscess resulting from direct trauma- tism, from the ablation of a polypus situated in the anterior wall of the cervix. Naudier {Annales de Gi/necologie, vi, 293) has described an abscess of the retro-uterine cellular tissue in a woman who had hypertrophic elongation of the neck ; the abscess, which was evacuated through the anterior wall of the rectum, extended behind the whole of the vagina, the whole posterior surface of the uterus and laterally to the interior border of the left ovary ; pelvic peritonitis had only slowly followed the formation and evacuation of this abscess ; the annexes of the uterus and the parts surrounding Douglas's space could not be considered as the starting-point of this retro- uterine cellulitis : the case proves these two points. I have seen an abscess formed between the cervix and the bladder projecting towards the vagina and opening into the bladder^ where it discharged pus for a long time, causing attacks of pain from time to time. I have also seen an abscess deve- loped rapidly behind the neck of a prolapsed uterus in a patient who had been imprudent enough to go out the day after leeches had been applied to the cervix ; it opened into the rectum on the fourteenth day, was discharged at once and was cured in three weeks. In neither of these cases were there any symptoms of peritonitis. It is therefore evident, not only that the cellular tissue of the broad ligaments may become inflamed, especially in the puerperal state, without the peritoneum participating in this phlegmasia; but also that inflammation of this tissue which usually extends laterally (internal iliac fossa, cervical arch, abdominal wall) may be propagated towards the centre, round the cervix ; and further, that the inflammation may even, in very rare cases, be developed primarily in the cellular tissue loosely connecting the cervix with the peritoneum. Phlegmon of the broad ligaments (including parametritis) may con- ' Gazette hebdomadaire, t. ix, p. 82. ' Clinique mcdicale, Obs. 33. ^ Bulletin de la Societe anatonvique, 1858. '' Bulletin de la Societe de chirurgie, 1866. 534 UTERINE DISEASES IN DETAIL sist in a simple gelatinous infiltration of these organs, cellulitis being arrested at the first stage; an induration remains the resolution of which occurs afterwards, gradually diminishing the size; most fre- quently the inflammation pursues its course, becoming acute, and an abscess is formed ; these phenomena rarely occur without pelvic perito- nitis being produced simultaneously. Phlebitis is a frequent compli- cation of phlegmon of the broad ligaments. Trousseau^ has insisted on this point : " Phlegmon of the broad ligament occurs in newly- delivered women after contusion or inflammation of the uterus and its annexes. After suppuration of the placental surface, phlebitis and lymphangitis occur. An incision made on the borders of the uterus at an autopsy reveals small abscesses in the venous tissue. The cellu- lar tissue round these veins is oedematous, and if patients do not succumb to purulent infection on account of adhesive phlebitis below the purulent collection, the intra-venous abscesses will most frequently be the origin of abscesses of the broad ligament. The same remark may be made of suppurative lymphangitis." According to the same writer phlebitis is the most common cause of phlegmon of the broad ligaments ; but it may also be the conse- quence of it. It may be said that it is primary in puerperal phleg- mons, consecutive in non-puerperal. When the autopsy shows circum- scribed phlebitis, obstructing clots, pus existing or not in the cellular tissue, phlebitis has been the cause of the phlegmon ; when it shows pus in the cellular tissue, traces of phlebitis, absence of clots, purulent infection, phlebitis has been the result of the phlegmon, the inflamma- tion having commenced in the cellular tissue of the organ. Pelvic cellulitis may be divided like pelvic peritonitis according to whether it extends over the whole pelvis, which it rarely exceeds, or whether it is confined to one region : sometimes round the uterus or along one of its surfaces, or round its cervix ; sometimes, on the contrary, as far as possible from the womb, in the iliac fossa ; some- times in the broad ligament, either in all its extent or at its base, or at the summit in its three folds or only in one. Both broad ligaments are seldom inflamed simultaneously. The inflammation is usually limited to one of these organs, i.e. to one of the sides of the genital economy. 2. Peri-uterine peritonitis and pelvic peritonitis. — Autopsies have proved that more or less extensive inflammation of the peritoneum not. only frequently complicates the inflammatory tumours of which I have just spoken, but also in great part constitutes inflammatory peri-uterine tumours ; this inflammation may be simply sero-adhesive or may become sero-purulent ; whatever the termination may be, it is com- plicated by numerous adhesions uniting together the various surfaces of the peritoneal covering of the pelvic organs, e.g. the annexes to each other or to the uterus, or to the neighbouring organs, contained also in the pelvis, the intestinal circumvolutions, the rectum, bladder, &c. : the more adhesions there are the larger the tumour appears. It Cliniqae medicale, 2' edit., t. iii, p. 747. Paris, 1865. PEEI-OTERINE INFLAMMATION 535 is to Bernutz ^ that we owe the elucidation of this important point in uterine pathology. He has proved by three autopsies that the inflammatory tumour which, during life, had presented characteristic signs of peri-uterine phlegmons, was not situated in the pelvic cellular tissue, but that it was constituted by peritoneal adhesions uniting the viscera of the pelvis together. Bernutz and Goupil " have not been content with proving the exist- ence of pelvic peritonitis, but have denied that of peri-uterine phleg- mons, having always seen partial peritoneal inflammations in peri- uterine inflammatory tumours. Moreover, they have also seen in this pelvic peritonitis, a phlegmasia of the peritoneum by propagation, having as starting-point an inflammation of the internal genital organs of woman, just as we see inflammation of the testicle in man produce that of the serous membrane covering it. Only, if there is an analogy in the morbid process which takes place, there is none in the consequences ; the transmission of the inflammation existing in the uterus to the neighbouring peritoneum provokes a plastic exudation which not only determines numerous sympathies by its extent, but also gives rise to the production of adhesions connecting the uterus with neighbouring organs and more or less compromising its func- tions. In this way tumours are developed perceptible to vaginal touch or hypogastric palpation, formed partly of fibrinous exudations, and partly of agglomerated viscera. Lastly, according to the same writers this inflammation of the pelvic peritoneum which is always symptomatic, arises more frequently from inflammation of the ovaries and tubes than of the uterus. But the chief symptoms of these peri- uterine aff'ections belong to pelvic peritonitis, whilst the uterine or tubo-ovarian aff'ection, although the most important, being the cause of the development of inflammation of the pelvic serous membrane, is only indicated by obscure symptoms, at least in the present state of our knowledge. Pelvic peritonitis, however, does not merely dominate symptomatology, so as to allow peri-uterine inflammation to be dis- tinguished from isolated inflammation of the ovary or tube, but it dominates therapeutics, being really the source of the chief indica- tions. It is what seems to me to constitute the most important practical consequence and therefore the chief interest of the valuable investigations of Bernutz and Goupil. Aran ^ went further than Bernutz and Goupil in reference to the subordinate place he gave to pelvic peritonitis beside ovaritis and sal- pingitis. He considers partial peritonitis only secondary. The true element of peri-uterine inflammation is alteration of the uterine appendages, ovary and tube, constituting an inflammatory centre, small in proportion to the tumour formed round this focus by the pelvic organs including the intestines adhering together. It is prob- ably always from the ovary or tube that the inflammation first arises, ' Arcliiv. gencr. de medecine, 1857. " CUiuqtie medicale sur les maladies des femmes, t. ii, premier memoire : De la pelvi-peritonite et de ses diverses varictes. Paris, 1862. . => Op. cit., p. 667. 536 UTERINE DISEASES IN DETAIL After acute pelvic periiomtis, especially when this is puerperal, in addition to the characteristic alterations of ordinary peritonitis we find in the pelvic cavity, below the intestinal circumvolutions which adhere loosely together and to the neighbouring organs, a globular tumour as large as a hen's t^2^, attached to the uterus, from which it may or may not be separated by a groove, sometimes confounded with this organ, which it is difficult to recognise. The displaced uterus is drawn towards and attached to the tumour or pushed back in a contrary direction, according to the seat of the tumour. This tumour is formed of thick false membranes hollowed out here and there into cavities, containing a citrine, purulent serosity or pus ; above them, the in- flamed peritoneum is seen and a serous infiltration of the sub-peri- toneal cellular tissue ; in the centre of the tumour we find the ovary and tube inflamed, as well as the broad ligament, the peritoneum of which is injected and the cellular tissue infiltrated with sanguinolent serosity and pus. The ovary and tube being prolapsed, the tumour often rests on the pelvic floor. The purulent collections contained in the cavities with tometitous walls which are formed by adhesions, have frequently been mistaken for infiltrations of the cellular tissue of the pelvis. Suppuration of the pelvic cellular tissue, however, is quite exceptional. When the annexes are inflamed on both sides the tumour Fig. 317. — Retro-uterine and tubal tumours* held back by false membranes to the ovaries, uterus and adjacent tissues, the result of peri-uterine inflam- mation (after Hooper). Compare this woodcut with Fig. 1, representing the general view of the same organs in their normal condition. is enormous and surrounds the uterus in a kind of ring. In the chronic state, the false membranes in place of being soft, whitish or yellowish, have become thick, resistant, grey or black, forming short bands extending from the annexes and from the uterus to the neigh- bouring organs, which they unite together enclosing sj)aces which are rKUr-UTElilNE INFLAMMATION 537 empty, or whicli contain citrine serosity or pus. The uterus more or less inclined, deviated or Hexed, tumefied, but seldom atrophied, is sometimes afl'ected with internal inflammation. The alterations of the annexes are fully developed : the tubes contain pus or a more or less considerable quantity of serosity which may give rise to the degenera- tion incorrectly called tubal dropsy ; the ovaries, which are seldom atrophied, usually form purulent sacs, the envelope of which resists laceration or rupture for a long time. The abscesses which, after pelvic peritonitis, open into the peritoneum, rectum, vagina, bladder or externally, are generally abscesses of the ovary or tube, less frequently peritoneal purulent collections encysted by the adhesions of false mem- branes. These latter are discharged usually at the commencement, the false membranes being then imperfectly organised, and as a rule are emptied into the peritoneal cavity by laceration or fissure. The former are evacuated by the rectum or vagina, from the eff'ect of ulce- ration, after previous adhesion of the two cavities, between which a communication is set up, that of the abscess on the one hand and of the rectum or vagina on the other. The opening becomes a fistula, esta- blishing a permanent communication between these cavities, and even allowing stercoraceous matter to pass from the rectum into the cavity of the abscess. In this way pelvic peritonitis or perimetritis may pass through the various stages of adhesive, sero-adhesive, sero-encysted, purulent peri-metritis, and even of hsemorrhagiparous pachy-peritonitis {see p. 545). Lastly, although it may be limited to one side, the side of the diseased ovary, the starting-point of the inflammation of the serous membrane, peritonitis is often propagated to the other side, and seldom is limited to the side first attacked ; usually it spreads round the uterus surrounding all the internal genital economy. 3. Feri- uterine Adenitis and Angioleucitis . — Peri-uterine cellu- litis and pelvic peritonitis, with all their varieties, are the only maladies included by gynaecologists under the common name of peri-uterine inflammation. For several years I have taught in my lectures that a third inflammatory malady exists, which ought to be included in the peri-uterine inflammations; it is adenitis and peri-uterine angioleucitis, which is often acute and the prognosis of which is very serious when it is puerperal ; more frequently it is chronic and is then less important in itself than from the ulceration of the uterine mucous membrane of which it is the certain sign. In fatal puerperal inflammation pus is not found in the veins. Although, however, inflammation of the veins is exceptional even in puerperal affections, that of the lymphatics is common, as was proved by the autopsies made by Championniere, Leopold and others. In puerperal metritis, inflammation may attack the lymphatics more vio- lently, so that after death the latter may be found filled with pus, not only below the mucous and serous membranes of the uterus and in the thickness of the organ, but also in some points corresponding especially with the posterior region of the uterus and near its cervix, where. 538 UTEEINE DISEASES IN DETAIL according to Championniere, may be found ganglia gorged with pus and clusters of lymphatic vessels distended with this fluid, which may be mistaken for suppurated ganglia, not only on the dead body, but even during life, causing errors of diagnosis. In other circumstances, and in the non-puerperal state, adenitis and angioleucitis may present themselves in the acute form in the same organs, the inflammation either being developed under the in- fluence of traumatic causes and especially of acute metritis or ovaritis, or it may have originated from acute peri-uterine inflammation, in the participation of which the ganglia and lymphatic vessels do not escape, and in which the adenitis and angioleucitis developed in such con- ditions survive for a longer or shorter time, varying in intensity and duration. In other circumstances again and more frequently, angioleucitis and adenitis especially occur in the chronic form and are all the more in- teresting to describe, as they appear to have almost escaped observation till now. After having made a careful vaginal examination, especially posteriorly and laterally, as well as at the base of the broad liga- ments, I have often found behind and to the sides of the uterus, usually to the right, sometimes at one point only, small rounded tumours, a little indented, smooth at certain points, irregular at others, the form, hardness, mobility and sensitiveness of which contrast strikingly with the characters of softness, insensibility, &c., of the surrounding tissues. These small tumours of various sizes are less voluminous even than the ovaries, even when the latter are not en- larged by inflammation, and are usually less painful than these organs, though sometimes, on the contrary, they are excessively so, less mobile also, and appear to be connected loosely with the uterus, the vaginal cul-de-sac, and especially with the innermost layer extending above them. I could not have interpreted the tumours just described otherwise than as remnants of inflammatory indurations or as adenitis and angioleucitis, i.e. tumours formed by clusters of vessels, or lymphatic ganglia tumefied and rendered painful by inflammation, even if an autopsy had not allowed me on one occasion to verify my suppositions in a woman of forty, who I knew had suffered for long from leucor- rhoea and ulcerous endometritis, and who was carried off by pleuro- pneumonia, in whom I found adenitis and its usual cause (chronic ulceration of the mucous membrane); autopsies also on newly delivered women who had succumbed to puerperal disease and in whom suppurative adenitis was found occupying the same regions, in like manner justified my opinion. In presence of such symptomatic and microscopic proof, hesitation is no longer possible. I observed this retro-uterine adenitis in patients who had for long suffered from some affection of the internal genital organs, vaginal and uterine leucorrhcea, or from long existing ulceration of the cervix which still existed on the mucous membrane of the cavities. These patients came to consult me because they had been treated for a long time by their own doctors, who now assured them that they were cured ; and PERI-UTEEINE INFLAMMATION 539 they were cured except in the uterine cavities : the sound, the passage of which was often painful, brought back pus or leucorrhoea, some- times a little blood, which made me suspect a suppurating ulcer situated on the mucous membrane of the cervix or body, another example of the services rendered by the sound. I have usually regarded this chronic adenitis as well as cervical and other forms of adenitis as symptomatic of inflammatory suppurative action on one of the mucous membranes where the afferent vessels of the tumefied ganglia had their absorbent network. From this point of view, the verification of retro- or latero-uterine adenitis is interesting even if only as a symptom of a chronic suppurative phlegmasia the seat of which is easily determined. It is also interesting in itself; for it con- stitutes a malady, the intensity, extent, and progressive tendency of which requires great attention. Apart from the symptoms, either direct or sympathetic of the uterine malady, and of the ulcer which has . caused it, peri-uterine adenitis has special symptoms characterising it : lumbar or lumbo- sacral pain, sometimes extending to the anus ; continuance of the pains previously experienced by the patient which are increased by marital intercourse even when most of the apparent uterine symptoms have disappeared ; pain elicited by digital touch, especially when pressure is exercised by the finger behind the uterus and laterally, and when an attempt is made to depress the retro- or dextro-uterine cul-de-sac. Cuurse. — Like all phlegmasias, peri-uterine inflammation may be acute or chronic. The term super-acute has been added to designate acuity of the highest degree, and that of suh-acute to mark a kind of transition between the acute and the chronic forms. I do not think it necessary to multiply divisions ; but I maintain the marked differ- ence, with regard to causes, symptoms and treatment between the acute and chronic forms. It has also been proposed to distinguish puerperal from non- puerperal peri-uterine inflammation. Marchal de Calvi ^ and H. Bennet ^ attach importance to this distinction. The latter says, that the puerperal state, which may be said to extend to the fourth, fifth, or even sixth week after delivery, is one of the most dangerous conditions. So long as it lasts all inflammatory affec- tions present a special gravity and especially those of the organs which, directly or indirectly, have participated in parturition. If inflammation occurs in the ovaries or broad ligaments immediately after delivery, it is frequently as a complication of metro-peritonitis and as merely an after symptom of this formidable affection. A number of writers on puerperal fever have noticed the frequency of suppuration of the ovaries and broad ligaments in cases of metro- peritonitis terminating in death. But even when the broad ligaments are inflamed several weeks after delivery, the general symptoms are more intense, the local tumefaction more considerable, and the inflam- ' Annales de la chirurgiefr. ct ctr., July and August, 18 i4. ^ Op. cit., p. 39. 540 UTERINE DISEASES IX DETAIL mation presents a greater tendency to extend to the adjacent tissues than in the non-puerperal form of the affection. It is also much more difficult to arrest its progress ; the inflammatory and suppurative action continues to extend long after the first collection is evacuated, and in a number of cases it gives rise to adhesions and abdominal per- forations. This serious form is quite exceptional in the non-puerperal state, whilst in the puerperal it is so common that till now it has been considered as the only one under which the affection is manifested. I share Bennet's opinion, but do not see why the two forms should be described separately. Peri-uterine inflammation may arise in the puerperal state as in any other ; it is certainly produced oftener in the former state ; it is then more serious and has a more rapid course, terminating often in suppuration. But its coincidence or its relations with the puerperal state do not change its character; it passes fre- quently from the puerperal or post puerperal to the chronic form, and there may be great uncertainty as to its real origin : lastly, it is dia- gnosed in the same way, and the indications offer differences of degree rather than of nature. Frequenci/. — Peri uterine inflammation is very common : indeed it forms about one third of uterine diseases. It is very difficult to make an exact calculation, because peri-uterine inflammation in place of occurring alone may comphcate the majority of uterine diseases. Aran thought that with inflammation of the uterus (parenchymatous and mucous) it forms two thirds of uterine diseases. It is certain that out of 100 women there will be 55 with peritoneal adhesions and showing traces more or less intense of pelvic peritonitis. Of this number there are far more married women than virgins and more multiparse than primiparse. Etiology. — Menstrual disorders and their causes physical and moral, long-contniued excitement of the genital organs, pregnancy, labour, extension of inflammation of the uterus or its annexes to the neigh- bouring parts. It will be seen that the causes are almost the same for metritis, perimetritis, ovaritis, &c. ; it is the predisposition which varies and determines the locahsation. But this etiology may acquire some interest from a little more precision. Now we know from ob- servation and statistics that peri-uterine inflammation is common espe- cially from 20 to 30, which is not surprising, seeing that ovarian and tubal inflammation are also common at this age and are usually the starting-points of pelvic peritonitis. Another interesting result is that about two thirds of these diseases are the consequences of labour, abortion, and consecutive inflammation : West thinks that labour, abortion and consecutive inflammation enter into the etiology of peri-t uterine inflammations at the ratio of 77 per cent. ; Gallardand Bernutz reduce this influence to 45 or 44 per cent., which gives an average of 60 per cent, between the two extremes, which is very nearly the pro- portion of the number of cases (55 per cent.) in which Aran found peritoneal adhesions and traces of pelvic peritonitis. This cause of peri- uterine inflammation may sometimes be ignored because symptoms are PERI-UTERINE INFLAMMATION 541 not always developed immediately after delivery, sometimes only appearing much later ; but in taking care to trace the morbid mani- festations to their source we discover the frequency and importance of this cause. It is probable that the operations necessitated by difficult labour and the imprudence often committed by newly-delivered women in resuming marital intercourse and their ordinary work too soon have a considerable share in the development of perimetritis. Often, how- ever, these are not the causes of the malady. Churchill^ has given a good description of the various ways iu which peri-uterine inflamma- tion may commence. I agree with Aran that very often there is either a latent morbid state or a morbid predisposition existing before de- livery, labour being only the determining cause. Menstrual disorders which may be placed in the second rank as causes, in the proportion of 20 per cent, according to Bernutz and Goupil, in that of 9 or 10 per cent, according to Aran, are frequently only symptoms of uterine inflammation already existing, of a previous latent morbid action, which has necessarily caused either dysmenor- rhoea or menorrhagia. The same remark is applicable to leucorrhcea and blenorrhagia which may also become causes of pelvic peritonitis, especially in women who have had diseases of the annexes, mechanical influences having their share also. Bernutz attributes a great deal to blenorrhagia after the third week and more as the monthly period approaches, in the propor- tion indeed of 29 per cent., whilst West and Aran reduce this propor- tion to 1 or 2 per cent., and I think certainly that it has been exaggerated by Bernutz. The neighbouring inflammations, those of the rectum or intestines, dysentery, metritis especially, the persistence of ovaritis and salpingitis cause the development of perimetritis and determine its chronicity. Mechanical influences (cauterisation, the use of the sound, pessaries, injections) have not apparently a greater share than 1 per cent, in the etiology of peri-uterine inflammation. Diagnosis — subjective signs. — The symptoms of peri-uterine inflam- mation greatly resemble those of ovaritis and salpingitis, but there is one dominating element which for the time effaces all the others : peri- tonitis or pelvic peritonitis. Actite peri-uterine inflammation breaks out suddenly, after abortion or delivery, by shivering, heat, perspiration, nausea, vomiting, or the appearance of fits of intermittent fever which might be mistaken for ague ; or it may be preceded for days, weeks or even months, by vague discomfort, symptomatic of inflammation of the appendages, such as loss of appetite, diarrhoea, constipation, vague and dull pains. Then comes the pain characteristic of perimetritis, sometimes limited to one point of an iliac fossa, generally more diffuse, occupying a portion of the belly, very acute if not spontaneous on pressure near the Fal- lopian ligament. In addition to pain there is great heat, swelling, tension of the lower half of the abdomen, the muscles of which contract as if to shelter the organs underneath, dorsal decubitus, alteration of ' Dublin Journal of Medicine, xxiv, 1844. 542 UTERINE DISEASES IN DETAIL the features, small concentrated pulse, bilious vomiting in some cases, just as in simple peritonitis. When these symptoms are alleviated there remains a feeling of fulness, discomfort, pain in the hypogas- trium, especially on one side, exacerbations of pain, slight fever, in- creased in the evening, anorexia, &c. The description of the symptoms of pelvic abscesses following delivery which may be regarded as typical is generally characteristic : rigors, more or less intense pain, quick pulse and acute fever mark the commencement of inflammation. But these initial symptoms may be absent, the patient becoming gradually ill without the appearance of acute symptoms of any kind. It is not uncommon to see a woman who was in good health at the time of her confinement experience symptoms of general indisposition three or four weeks afterwards, become gradually weaker and thinner, and complain of pain down the legs or in the pelvis, lose her appetite and power of digestion and occasionally have shivering fits ; after these symptoms have lasted for a week or two the pelvic symptoms become more marked, such as difficult and painful defsecation and micturition, pain and discomfort in the pelvis, &c. This pain is increased by the slightest movement, and yet the real cause being misunderstood, it is often attributed to weakness. The presence, however, of a pelvic tumour soon discovers to the physician the cause of all these symptoms. Chronic peri-uterine injlammation may either be the termination of acute inflammation or it may be chronic from the beginning, which leads to many errors of diagnosis. A subacute condition may exist, an intermediate form, presenting the same phenomena as the acute but less intense, and producing hectic fever in delicate patients. This form is not uncommon after delivery ; the patient rises, but she is weak and complains of pain, indigestion, &c. ; there is slight feverish- ness and the secretion of milk is irregular. In others who are stronger the inflammation only shows itself later, but it originates from labour. This uncertainty as to the origin of chronic perimetritis seems to me a reason for rejecting the distinction of the puerperal and non-puerperal varieties. When chronic inflammation is developed all at once, which is rare, the commencement is insidious. It only attracts attention when the tumour has become large, or when the pains become acute and when functional and digestive disorders occur, which happens especially during menstruation. In fact, chronic peri- uterine inflammation presents few marked local signs, especially if there is any intercurrent malady such as tuberculisation. General symptoms occupy the first place. These are : weariness, paleness, emaciation, sallow face, eyes without expression, dry sometimes hot skin, weak, small, compressed pulse, frequently oppression, palpitation, headache, neuralgia, hysteria, numbness of one side especially of the left, tingling of the extremities, increased or diminished sensibihty, painful points along the spine, dyspepsia, acidity, epigastric swelling, occasionally vomiting. On interrogating patients we generally find that there have been acute symptoms of some kind to begin with. Since then in spite of TERI-UTERINE INFLAMMATION 543 the comparative calm, a feeling of weight and discomfort has remained in the pelvis, with internal heat and pulsation increased by walking, fatigue or coitus. Menstruation is supj)ressed or less abundant (metrorrhagia being the exception) ; at the monthly periods the pains are more acute in the abdomen, there is tumefaction of the belly, nausea, vomiting, heat of the skin, shivering, increased leucorrhoea, vulval irritation and desquamation, loaded urine, painful defecation, excretion of mucus by the anus or diarrhoea. Order is re-established till a new crisis ; but there is still weariness, continuance of lumbar and hypogastric pain radiating in one or both limbs to the knee or even to the foot ; leucorrhoea ; constipation or diarrhoea ; vulval itch- ing. On resuming work or coitus, or at the monthly periods, there are exacerbations as in ovaritis, characterised by the redoublements inflammaioires of Gosselin, and causing a symptomatic manifestation analogous to that of the acute period, with the exception of the general symptoms, which are less marked. These exacerbations last from three to eight days ; they may be repeated every month or at intervals of three months, six months or a year. They aggravate the position of patients but rarely cause death. We must remember that the chronicity and inflammatory attacks depend not only on the impru- dence of patients and on insufficient care, but chiefly on the persistence of inflammation of the ovary and Fallopian tube. At every fresh attack peritonitis appears ; in the end, however, it organises a boun- dary of false membranes which it does not cross. This boundary is on the level of the brim, iliac fossae, or iliac crests (p. 553, fig. 323) : inflammation of the serous membrane never passes beyond the level of the umbilicus. Percussion reveals its exact limits : all the inflamed part gives a dull sound, while the portion which escapes peritonitis gives a tympanitic sound. Pain during the development of acute pelvic peritonitis or an exacerbation of the chronic form tends to become generalised whilst preserving a maximum of intensity in its original seat as in ordinary peritonitis. It is acute, darting, incessant and pulsating with exacer- bations every three or four hours, especially when there is internal metritis, leucorrhoea, &c., and with tension of the belly which cannot bear any pressure. It is also felt in the vagina and rectum preventing the introduction of the finger. In chronic peri-uterine inflammation this pain is often confounded with that of ovaritis, metritis and even with the leucorrhoea which co-exists with it. Like the disease it has various seats : generally occupying one side of the belly, especially the left, or a large part of the hypogastrium with a maximum of intensity at the point corresponding to the tumour; it radiates towards the kidneys, loins, pelvis, vulva, thighs and legs, especially on the affected side; it is fixed, deep, pulsating, aggravated by walking, fatigue, standing, or coitus ; sometimes it is acute and darting, at the same time becoming mobile, wandering, intermittent, in which case it is probably due to neuralgia; it is sometimes hardly apparent unless elicited artificially by touch, abdominal pressure, a fall, coughing, vomiting, constipation, efforts during micturition or defecation, walk- 644 UTERINE DISEASES IN DETAIL ing, the presence of a foreign body in the vagina^ the heat of the bed, uterine congestion, the menstrual period. Sometimes even lying down increases it, so that patients instinctively adopt the decubitus which is least painful to them ; this is generally the dorsal with slight inclina- tion to the opposite side from the tumour. The heat felt by patients in acute perimetritis is considerable ; it is at the bottom of the pelvis, becoming sometimes burning in the vagina. In chronic perimetritis it is hardly observed except at the time of an inflammatory paroxysm. The symptoms of neighbourhood are variable; there is constipation, discomfort and pain on going to stool with vesical tenesmus. Nonat says that in acute perimetritis menstruation is usually increased : this is not my experience, nor have I often remarked leucorrhoea as a result of inflammatory reaction on the uterine mucous membrane. What is more frequently observed is suppression of the lochise in the puerperal state and the extension of the inflammation to the uterine parenchyma. In chronic inflammation the anatomical and functional disorders of neighbourhood and the general symptoms take quite a different character : the neighbouring organs are displaced, their relationships altered j the uterus especially is pushed back, deviated or flexed ; there is compression of the bladder, rectum, pelvic vessels and nerves ; there is a permanent state of congestion round the phlegmon or pelvic peritonitis, especially in the uterus, which is hypersemiated, and the chronic congestion of which often accompanies peri-uterine inflamma- tion; hence pain, leucorrhcBa, menstrual disorders, the period being usually advanced and prolonged, though the quantity is rarely in- creased, but there is often gradual diminution or suppression; dis- ordered menstruation reacts on the perimetritis itself, causing increase of pain ; sometimes persistence of the peri-uterine inflammation pro- duces hypertrophy of the uterus, especially in multiparse. Marital intercourse is nearly always painful, and should be forbidden. It is less so when the inflammation is in the broad hgaments, and not immediately in contact with the uterus. Chronic peri-uterine inflam- mation is not an absolute obstacle to conception unless there are abnormal adhesions of the Fallopian tubes; but in the few cases in which pregnancy occurs there is undoubtedly a risk of miscarriage from mechanical and physiological causes, therefore treatment should be continued during pregnancy. Micturition is frequent and painful, accompanied by tenesmus and sometimes by retention. There is often constipation, at other tiQies diarrhoea by propagation of the inflamma- tion. At other times defecation is painful and difflcult, the rectum and anus being the seat of spasmodic contractions causing real nervous attacks ; the laces are discharged as if moulded in a tube no larger than a pen, and are covered with mucus, showing the existence of glairy enteritis ; there are hsemorrhoids and even anal fissures. The stomach is affected sympathetically as in metritis and leucorrhoea; there is usually loss of appetite, slow digestion, weight with epigastric swelling after meals, depraved taste, heat, epigastric dragging, gaseous eructations, nausea, vomiting, &c. Eespiration is often difficult, and PEEI-UTERINE INFLAMMATION 545 accompanied by a dry nervous cough. Fever appears with every paroxysm ; in many patients the pulse is moderately but continuously quick, or there may be a recurrence of this frequency in the evening after fatigue. In some women disorders of sensibility and motility are added to these general symptoms. Lastly^ chloro -anaemia and debility are usually the most marked general symptoms. The course of the malady may help in the diagnosis. Puerperal peri-uterine inflammation passes rapidly and frequently to suppuration. Non-puerperal perimetritis has a slower course. It may terminate in three ways : by resolution after gradual diminution of the symptoms in two or three weeks or at the normal recurrence of the second monthly period ; by transition to the chronic stage, in which case the tumour remains stationary and becomes indurated ; or by suppuration, which is the rarest case. The malady progresses very slowly except in a few cases, when it terminates by sudden generalisa- tion of the peritonitis. Even in the most fortunate cases patients suffer a long time from debility and nervous symptoms, pelvic weight, lumbar pain on standing, and pain in the accomplishment of the sexual functions. The abdomen is painful on pressure; traces of the tumour exist, either peri-uterine puffiness, or small tumours of the size of a pea, so well described by Gosselin, tumours which are not perhaps always vestiges of peri-uterine inflammation, but which may often pass for a remnant of this malady; so that resolution of the peri- uterine inflammation perhaps is never complete — at least it is very slow. Usually the malady passes to the chronic state with or without inflam- matory paroxysms. Death may occur in one of these paroxysms by generalisation of the peritonitis, putrid absorption, or even by purulent infection (Aran has seen it twice). At other times the neo-membranous peritonitis favoured by these inflammatory paroxysms may be vascularised and hypersemiated to the point of causing haemorrhages, which again are the sources of new maladies (hematoceles), and which have won the name of hsemorrhagi- parous pachy-peritonitis. At other times, after having passed through several paroxysms and escaped their dangers, patients find their health gradually improved. If, however, they are tuberculous they continue to suffer, now from the chest, now from pelvic peritonitis, till con- sumption at last ends in death. Objective signs. — At first it is difficult to perceive the pelvic tumour by abdominal palpation. But when the tumour increases and approaches the surface we discover in the centre of the hard abdomen a tumour, which may or may not be circumscribed, as large as the fist and more painful than the surrounding parts on pressure. In chronic peri-uterine inflammation the belly is always sensitive to pressure and sometimes distended; palpation reveals marked resistance or a real tumour, flattened or rounded, which may reach to the umbilicus, or farther. Digital touch is not possible in the commencement of acute peri- metritis, the vagino-uterine pain being too great to allow of it ; but ^s 35 646 UTERINE DISEASES IN DETAIL soon as the pain is somewhat less intense this examination is indispen- sable in order to prevent the consequences of the phlegmon. It is usually easy to discover a globular projection with smooth, regular, resisting surface, hot, painful, and projecting into the vagina, rectum or hypogastrium. There is marked vaginal heat, the vulvo- uterine canal being more or less moistened with mucus. The cervix varies in position, but appears fixed on a solid base; the fundus is immobile ; the utero-vaginal cul-de-sac offers at some points a certain resistatice, puffiness or a projection, sometimes in the form of a semi- FiG. 318. — Phlegmon of the broad ligament, partially surrounding the cervix (after Barnes). circle (Fig. 318). Immobility of the uterus and an imperfectly circum- scribed peri-uterine tumour, together with the general phenomena suffice to diagnose the malady. In chronic inflammation digital touch shows the uterus to be com- pletely immobile, either in its normal position or inclined, or in a kind of gangue from which the neck alone is free, or closely attached to a lateral or posterior tumour, or pushed back in an opposite direction from the tumour, from which the cervix is separated by a groove, sometimes with oedema of the neck and upper part of the vagina. Rectal touch enables us better to recognise a shapeless mass, or bands, or a more or less complete ring fixing the uterus. Lastly, the asso- ciation of palpation with digital touch allows the extent of the tumour to be appreciated, its thickness, its consistency, its elasticity announc- ing the formation of pus, &c. The association of vaginal and rectal touch has been successfully employed by Recamier to discover sup- puration, by determining fluctuation in the tumour. As for the ovary and Fallopian tube, they are too much in the centre of this tumour to be accessible to touch. Peri-uterine inflammation always leads to the formation of a tumour. This tumour is sometimes apparent above the pubis, through the abdominal walls ; its presence can be verified by manual examination, hypogastric ))alpation, association of vaginal with rectal touch. It may vary much in form and volume, from the size of an I'ERI-UTERINE INFLAMMATION 547 almond to that of an orange, and may be either circumscribed or diffuse. The surface is generally regular and smooth, without soft depressible projections like those produced by stercoraceous accumula- tions in the rectum ; in consistency it is solid, firm, sometimes hard, generally elastic, like that of the body of the uterus unless there is suppuration. This tumour is sometimes mobile relatively to the uterus, sometimes adherent to this organ, either by one end, or by one surface; it is not on that account necessarily immobile in the pelvis, it may be limited to the folds of the broad ligaments to which it adheres by one surface, whilst the other is free ; in fact it is usually fixed and immobile in the pelvis and round the uterus or at one part of this organ. Digital touch shows the parts occupied by the tumour. Nonat says ihdit phlegmon usually begins with one of the broad ligaments and from there spreads inwards towards the uterus or outwards towards the iliac fossae. This writer distinguishes besides this phlegmon of the broad ligaments, latero-uterine phlegmon (the most frequent after the preceding), then antero-uterine, retro-uterine, and lastly, that which makes a belt round the womb meriting the name of peri-uterine, and perhaps the peri-rectal. West's statistics give us an idea of the comparative frequency with which the different parts are affected : out of 52 cases the broad liga- ment was the seat 34 times, the utero-rectal cellular tissue 14 times, the utero-vesical cellular tissue 3 times. Pelvic peritonitis is also more common laterally than in the median portion, the ovary or fallopian tube being the usual starting point. As to frequency, peri-uterine inflammation evidently has a tendency to attack the postero-lateral part to the right or left indifferently, except in puerperal women when, Aran says, the proportion seems rather larger to the right. The statistics of Gallard and Aran confirm those of West in this respect. In 52 cases, West found 34 on one side, 21 to the left. „ 53 „ Gallard „ 32 . „ „ 11 „ 24 „ Aran „ 17 Next to the lateral, the posterior part or the utero-rectal cul-de-sac is the most frequent seat of peri-uterine inflammation. Peri-uterine adenitis is also more frequent behind and on one side, usually on the right. There is another sign perceptible by digital touch to which Nonat attributes great importance : usually, he says, a tolerably large arterial vessel, as large for instance as the radial, creeps round the base of the tumour giving pulsations perceptible to the touch. It is only to be found in old tumours ; it can be observed in the third month but more clearly in the eighth ; it is never absent from peri- uterine engorgements of a year's standing, but it may not be accessible to exploration. Its volume is proportioned to the age of the phlegmon, it aggravates the prognosis, the afflux of a larger quantity of blood making the malady more difficult to treat. These remarks of Nonat's 548 UTERINE DISEASES IN DETAIL are mentioned in Martin's ^ thesis. Arterial pulsations may be per- ceived in peri-uterine tumours; but I think this writer exaggerates their importance. Differential diagnosis. — Acute but especially chronic peri-uterine inflammaticus have been long ignored ; they have given rise to many errors of diagnosis ; we may even affirm that such errors continue to be made. We must therefore lay down the basis for a serious diag- nosis. Every unusual phenomenon produced in the abdominal region, especially when accompanied by disturbance of the general health, whether it occur after labour or not, ought to attract the attention of the physician leading him to fear peri-uterine inflammation (for this malady occurs 50 or 70 times out of 100 diseases of the utero-ovarian economy), and induce him to make a minute examination, especially after delivery or abortion, even when this has taken place two months ago (for the disease may have been misunderstood till then) ; or even if there was another malady (for perimetritis may coexist with it. 1. Sjoecial signs of the various peri-uteri^ie inffatnmaiions. — They establish a distinction between ^^erimeiritis, parametritis, phlegmon of the broad ligaments, pen-uterine adenitis. Although Thomas,- Bernutz,^ and other writers have tried to enumerate these signs, it is very difficult to find sufficient reasons for deciding whether we have to do with a case of perimetritis, para- metritis, or phlegmon of the broad ligaments, whether it be that they coexist, or that the distinctive signs are not sufficiently pathogno- monic. It is not often that a physician can be sure as to the seat of inflammation, except when he has been called in at the beginning and has seen the malady follow its course, terminating by resolution or suppuration, the abscess having opened at some point or another. There are also cases when we have to do simultaneously with peri- tonitis and pelvic cellulitis. As, however, these diseases may be absolutely independent of each other, each existing separately, I shall endeavour to give the diff'erential diagnosis of peritonitis and simple pelvic cellulitis, after having described the complicated morbid states which most frequently occur under these names, just as I have before endeavoured to bring into relief the characters of simple ovaritis amidst symptoms of complicated ovaritis which is also commoner. Feri-uterine cellulitis or pelvic c^/Zm/zV?'*, especially when situated on a level with the cervix, is so rare that its existence has been denied; it has, however, been seen after traumatisms and extension of inflam- mation of the broad ligaments : it is a median parametritis, whilst phlegmon of the broad ligament is a lateral parametritis ; it has no direct connection with puerperal fever. There is little or no shivering except at the time of suppuration; dull pain from the abscess, and feverish pulse. The tumour may be felt all round the cervix project- ' Phlegmong des ligaments larges et du tissu cellulaire peri-utSrin. Paris, 151. ' Diseases of Women, pp. .36f!. .375. Op. cit., t. ii, p. .397, et seq. PERI-UTERINE INFLAMMATION 549 ing either in front between the bladder and uterus raising the vagina, or behind between the retro-uterine peritoneum and the womb raising Fig. 319. — Pelvic cellulitis and pelvic abscess encysted to the right of the uterus, seen from the front, from a case observed at University College Hospital (after Graily Hewitt). Fig. 320. — Right pelvic cellulitis, same tumour seen in profile. the posterior vaginal cul-de-sac, or laterally whence it extends to the broad ligament, forming a hard surface on the side corresponding to the vagina ; more frequently it is from the broad ligament that the inflammation extends to the circumference of the cervix; it is slowly developed, not being perceived for some days ; it is very circumscribed hardly rising except when it attacks the broad ligament; it cannot be perceived above the brim ; it is hemispherical and annular, sometimes very hard in the centre, and oedematous externally ; the oedema may extend to the cervix on one side and to the vulva on the other ; later )50 UTERINE DISEASES IN DETAIL on it becomes puffy and fluctuation ai)pears; the tumour is immobile. The uterus is not completely immobile, only its mobility is limited in one direction or another according to the seat of the phlegmon; it is the same as to its direction, which may also be altered. The groove of separation between the uterus and the tumour may not exist or is inappreciable. The pain, which varies with the stage of the disease, is elicited by micturition or defecation according to the seat of the trouble ; dysuria is not uncommon ; pain is also caused by the pressure of the finger in the vagina. There are no signs of peritonitis ; fever is Fig. 321. — Pelvic ceUulitis or right pelvic phlegmon, which has spread from the broad ligament, on one side round the uterus, on the other side into the iliac fossa. Parnell's case, preserved in University College Hospital, front view (after Graily Hewitt). sometimes high ; there is no tendency to relapses ; duration is limited ; there is marked tendency to suppuration ; termination is by resolution, suppuration or induration, which in all cases diminishes the size of the tumour causing its disappearance, unless some centres of induration persist in its place. Sometimes, on the contrary, the phlegmasia extends towards the periphery of the pelvic cellular tissue, towards the pubic or obturator region, towards one of the iliac fossse, all round the rectum. But the favourite seat of cellulitis is the broad ligament, i. e. the point where the connective tissue is contained between the two folds of peritoneum enclosing in their upper wings the ovary, the ovi- duct and the round ligament. Phlegmon of the broad ligaments (utero-pelvic cellulitis) is frequent; it is a common malady in the puerperal state, and may be developed from the second to the twentieth day after labour : it may be seen in nulliparae and even in virgins, but is rare in the state of vacuity. Rigor is not constant, occurring only in about half the cases ; fre- quently it is only produced at the time of the formation of pus. There is dull pain in the abscess, darting at intervals, with a feverish, full pulse. The tumour is lateral and not median as in pelvic peritonitis, extending easily, generally perceived in the broad ligament, and above the margin of the pelvis ; from the first there is the sensation of a cord when abdominal palpation is practised (if when the uterus is PERI-UTERINE INFLAMMATION 651 seized with the thumb and middle finger, they are passed along the sides of the organ from above downwards, in place of the soft and supple annexes a cord is encountered, directed from the cornua of the uterus towards the anterior part of the iliac fossae; this cord is hard, tense, and always painful on pressure at the enlarged point); the tumour is sometimes hardly accessible to vaginal touch; always to be felt at the hypogastrium from the beginning, owing to the tendency of the inflammation to be propagated to the neighbouring areolar tissue, especially in the iliac fossa ; it is sometimes developed indis- tinctly and slowly, the reverse of pelvic peritonitis ; it is generally first perceived on the sides of the pelvis, probably because it commences Fig. 322. — Phlegmon of the left broad ligament pushing back the uterus to the right, with diffusion into the pelvis. Formation of an abscess. Open- ing by the inguinal canal (I'ound ligament), below the crural arch, by the obturator foramen on the left side of the vagina (Courty). where the cellular tissue is loose ; it is probably also for the same reason that it extends to the internal iliac fossa, the anterior abdominal wall, the crural canal and to the buttock, as well as to the side of the uterus ; tumefaction is perceived later on at the side of the womb on account of the condensation of the cellular tissue at this point, thus it generally progresses from the periphery to the centre and from above downwards ; it may commence or terminate by inflammation of the utero-ovarian veins and pampiniform plexus. Percussion gives a dull sound laterally, a clear sound in the middle of the hypogastrium. By vaginal touch the tumour is felt at the bottom of the lateral cul-cU'Sac on the sides of the vagina and cervix, under the form of an cedematous plaque, sometimes as hard as wood and regular, often without either indentations or irregularities, not sensitive and almost completely immobile; the internal part embraces the cervix with which it is continuous, or from which it is only separated by a narrow groove ; at the border of the cul-de-sac the induration may double on itself and be prolonged round the walls of the vagina, sometimes even the latter is to a great extent enveloped in this kind of lining ; the tumour then becomes soft, pasty and fluctuating. 552 UTERINE DISEASES IN DETAIL As in internal abscesses^ oedema appears in the superficial parts and neighbouring tissues : thus the cervix, vagina and corresponding labium are manifestly cedematous ; this fact, to which I have often called attention, has not been sufficiently noticed as an element of diff'erential diagnosis. The uterus is only fixed to a limited extent; in place of being completely immobile as in pelvic peritonitis, it preserves a portion of its mobility, its lateral movements only being very restricted; the organ is not displaced if the phlegmon is small; in the contrary case there may be three kinds of displacement, answering to differences of extent and seat in the phlegmon ; if the tumour occupies the whole broad ligament, the uterus is inclined to the other side; if it is less developed, it is the fundus or the cervix which is pushed back to the opposite side, according to whether it is the upper or lower part of the broad ligament which is the seat of the tumefaction ; after cure, owing to the retraction of the inodular tissue the uterine dis- placement is the reverse of what it was originally. The groove sepa- rating the uterus from the tumour is absent or hardly apparent. The dull, heavy, strong, continuous pain has nothing in common with that of peritonitis ; it is caused by micturition more than by defecation, is elicited by pressure on the lateral portion of the vagina and on the hypogastrium above the crural arch. Shortening of the thigh is very common, although not as constant as in sub-aponeurotic abscesses, and especially inflammations of the psoas and internal iliac fossa. There are no general signs of peritonitis ; no nausea, nor excessive vomiting nor tympanitis, nor alteration of the face, nor concentrated pulse. Febrile phenomena predominate over functional alterations of the digestive economy : the latter are more like the symptomatic digestive disorders of pregnancy or those of a malady of the fundus than of peritonitis. There is marked tendency to suppuration and to the formation of abscesses, but no tendency to monthly relapses. The duration of the malady is limited and varies according to whether it terminates by resolution, induration or suppuration. Pelvic peritonitis is very common whether puerperal or non-puerperal, acute or chronic. It may occur in the state of vacuity, as a sequence of menstrual disorders, ovaritis, traumatism or abortion. When puer- peral it is developed during the first ten days, generally sooner than phlegmonous inflammation. Shivering is never absent, especially at the outset. la the beginning pain is acute and at one point, recalling that of pleurisy; the pulse is frequent, hard and concentrated. The tumour is usually situated in the utero-rectal cul-de-sac ; but it may be perceived at several other points round the uterus, though it does not project much except in the posterior vaginal cul-de-sac, where the longest prolongation of the peritoneum is found. The effects of it are felt sooner than those of phlegmon, on account of the rapid develop- ment of peritonitis and adhesions ; at first it attacks the lowest parts extending from below upwards and from the centre to the periphery (unless the Fallopian tube or ovary have been the starting-point) ; it does not rise above the brim unless there have been successive attacks of inflammation or extension of the disease to the whole peritoneum ; PERI-UTEEINE INFLAMMATION 553 it depresses the posterior vaginal cul-de-sac to tlic point of descending below the cervix, but not- round the walls of the vagina; it is hemi- spherical, rounded, often indented and irregular ; projecting into the vagina in front, into the rectum behind ; it is resistant and hard, but not woody nor cedematous; it is immobile. The uterus is also im- FiG. 323. — General pelvic peritonitis, rising to below the umbilicus, seen in front, raising the uterus and annexes. Fig. 324. — General pelvic peritonitis and intra-peritoneal pelvic abscess, seen in profile, felt through the vagina and hypogastrium (after Graily Howitt). mobile in every direction, fixed by the tumour and always displaced ; the neck is deviated either to the side of the tumour or to the opposite one, according to whether it presses on the body or neck ; usually the M'hole organ is pushed upwards and forwards towards the pubis. The groove separating the uterus from the tumour is always appreciable. Pain is often very acute ; it is elicited by defecation, digital pressure 554 UTERINE DISEASES IN DETAIL in the vagina and by pressure over the hypogastrium : the tumour is never indolent. A vague, diffuse, resistant tumefaction is felt through the abdominal walls when the paiu is not extreme ; usually excessive abdominal sen- sitiveness is developed above the pelvis, towards the median line; shortening of the thigh never occurs. The general signs of peritonitis are manifested : excessive pain, frequently with paroxysms, prostration, the face drawn and anxious, nausea, green vomiting, distension of the belly, tympanitis, quick and concentrated pulse ; the digestive sym- ptoms predominate over the febrile phenomena. But slight tendency to suppuration, marked tendency to monthly relapses ; duration is Fig. 325.— Left lateral pelvic peritonitis, encysted, with pelvic peritoneal abscess surrounding the ovary, tube and uterus with adhesions. long, the malady being prolonged by frequent recurrences to the acute state. In short, acute perimetritis is more easily confounded with retro-uterine hematocele than with phlegmon of the broad ligaments. Peri-iiterine adenitis follows pelvic cellulitis, pelvic peritonitis, or more frequently still chronic endometritis with leucorrhoea and ulcera- tion ; it hardly forms a tumour ; it is perceived by the touch in the form of indentations, nodosities and induration in the connective tissue of the base of one of the broad ligaments and the posterior region of the uterus. It scarcely alters the mobility of the uterus. It is painful on pressure and when the uterus, is moved ; it lasts long ; cure is diffi- cult ; there are hardly any relapses or inflammatory paroxysms, but on the other hand there is no tendency to resolution. 2. Distinctive signs of peri-uterine inflammations and other maladies of the uterus, its annexes and of the pelvic caviti/. — Actite metritis is distinguished by less intensity of the general and local phenomena, by the different seat of pain, which occupies the whole belly, by its expulsive character, by leucorrhoea, more frequent vomiting, the absence of a tumour and especially by the mobility of the uterus, which is recognised as the only tumour occupying the centre of the hypogas- trium. — Simple ovaritis forms a smaller tumour than that of peri- metritis, smooth, mobile, very painful, raised behind the body and one PEKI-UTERINE INB'LAMMATION 555 of the borders of the uterus ; when complicated, it is the centre of true pelvic peritonitis. — Simple salpingitis forms an elongated tumour, either knotted or globular, perceptible by palpation associated with touch, on one side of the uterus, being continuous with one of the cornua; when complicated, it also is the centre of true pelvic peri- tonitis. — Cystitis is known by examination of the urine and is easily distinguished from perimetritis. The diagnosis of chronic perimetritis is the most difficult. Engorge- ment of the uterine walls is less hard than peri-uterine phlegmon, and can be slightly depressed. It is not limited to one side or to one part of the uterus ; there is no border round the neck, nor any groove indicat- ing the boundary between the womb and the peri-uterine engorgement. Pregnancy is distinguished by the uniform development of the body of the uterus, which is globular, without any groove, of normal con- sistency, increasing daily in size. Interstitial fibrous tumours are distinguished by the same characters, by the absence of any groove, by hardness, absence of sensibility, the less frequent existence of arterial pulsations, the mobility which the uterus preserves in spite of its increased size. Fibromata and sub-peritoneal myomata may occupy the cavity, making diagnosis difficult. We must remember that they are harder, round, often multiple, more or less mobile, indolent, &c. They sometimes become enormous. Deviations diXiAflexio7is, which have given rise to frequent errors, are distinguished by the fact that the body of the uterus can be found nowhere apart from the tumour. The uterus must be held simultaneously with the tumour, to be quite certain that the latter exists ; the sound facilitates the diagnosis. Amongst extra-uterine tumours, phlegmon of the intertial iliac fossa has a recognised seat and boundaries. In order to feel it the abdomen should be depressed behind the ilium, and not behind the crural arch ; no tumour is found in the cavity by vaginal touch ; the cuts de-sac are free and supple, the uterus quite mobile; the thigh is flexed, the nerves supplying it and the genital organs are the seat of neuralgia. If the peri- uterine cellular tissue is invaded no distinction can be made ; it is the same malady, differing only as to seat and extent. Tumours formed in the rectum by retention of stercoraceous matter have led to mistakes. They are sometimes soft and depressible, some- times hard and indented ; they can be recognised by rectal touch ; an enema given several days running removes all doubt. Sometimes the two maladies are observed simultaneously, for the coexistence of a peri-uterine phlegmon with constipation is not uncommon. Teri- uterine hematocele is perhaps the malady which can most easily be confounded with acute sero-adhesive pelvic peritonitis. There is more resemblance between these two diseases than between pelvic peritonitis and peri-uterine or laterouterine phlegmons. Nevertheless, hemato- cele does not commence under the same circumstances or in the same way ; the history of the case gives the clue to the differential diagnosis. It frequently follows sudden suppression of the menses. The forma- tion of the' tumour is very rapid, and is accompanied by the general symptoms of hsemorrhage, acute pains like those of peritonitis, and by 556 UTERINE DISEASES IN DETAIL fluctuation from the beginning, which is the reverse of what takes place in pelvic peritonitis. Pain and reaction soon make confusion possible. But the tumour gradually hardens owing to coagulation of the blood, in place of softening ; it is not so sensitive to pressure as the inflammatorv tumour of pelvic peritonitis ; its usual seat is behind the uterus, which is pushed forwards and upwards against the pubis. An exploratory puncture removes all doubts ; it is not, however, necessary. When hematocele is accompanied by pelvic peritonitis, as happens in the most painful and troublesome cases, it requires the same treat- ment as acute pelvic peritonitis. Peritonitis furnishes the dominant symptoms and affords the chief indication. Tubercidisation of the ovaries, broad ligaments and tubes is more difficult to distinguish, for it is but a chronic and diathetic peri- metritis. Cj/sts, especially ovarian cysts, whether serous or purulent, present evident fluctuation unless there is very great distension, thick- ening of their contents, or too great multiplicity. A characteristic globular, mobile form is felt by the vagina and hypogastrium. They are not painful on pressure, nor is there any arterial pulsation. Extra- uterine pregnancy forms a heterogeneous mass, composed of soft and hard parts, mobile, unequal, &c. Perimetritis may coincide with it, or with a serous or purulent cyst. As for sub-aponewotic abscesses, hydatid tumours, cancer, and even aneurisms which may be developed in the pelvic cavity, they give rise to pathognomonic symptoms which allow of their being easily distinguished from peri-uterine inflamma- tion. ^ Lastly, chronic peri-uterine inflammation must not be con- founded with maladies Hke pulmonary tubercle which are connected with diathetic general affections, and gradually produce consumption. The antecedent circumstances, the general symptoms, the fades uterina, dyspepsia, the symptoms of neighbourhood, viscid leucorrhoea, &c., lead to a direct examination, and consequently to the differentia- tion of two maladies which may indeed coexist in the same patient. The general symptoms may be analogous and increase the confusion, but the local symptoms and, above all, the presence of the retro-uterine or peri-uterine tumour, remove all doubts. Peri-uterine abscess. — The only termination of perimetritis of which I have not yet spoken because it presents special signs, is the termina- tion by suppuration and the formation of pelvic or peri-uterine abscess, called by Puzos " and Van Swieten, depots laiteiix. This termination is rare, according to West it occurs fifty-one times in 100 cases, but according to Aran, Gallard and Gosselin only from seven to ten times in 100. tJnder the influence of crowding, weak constitution, lymphatic temperament, a cachectic state, the puerperal condition, or in the absence of special treatment, acute peri-uterine inflammation terminates in supjiuration ; or under the influence of external irrita- tion, a blow, a fall, or some menstrual disorder, chronic peri-uterine inflammation passes into the acute stage and may become purulent. ' See Dictionnaire encyclopedique dee sciences medicates, art. Bassin {•pathologie) . * Traite d'accouchemenis, 1743. PEEI-UTERINE INFLAMMATION 557 The pus may be infiltrated or collected together according to whether suppuration is rapid or slow. 1. If suppuration of the peri- uterine cellular tissue is rapid, recent diffuse abscesses are formed, according to Nonat, the relations of which vary according to the seat and extent of the inflammation. There is a retro-uterine or recto- uterine abscess, which must be distinguished from intra-peritoneal purulent collections, an ante-uterine or vesico-uterine abscess which is rare, a lateral abscess which separates the folds of the broad liga- ment and bathes the Fallopian tube and ovary in pus. Usually the pus spreads round the uterus filling the pelvis, and may even reach the iliac fossee or rise to the umbilicus. There is no doubt it happens much oftener in peritoneal suppuration than in phlegmons. However, according to Nonat, fragments of cellular tissue, vessels, nerves, &c., are found in the centre. 2. When suppuration is slow, the pus is collected in a focus enveloped in a pyogenic membrane, forming one or more circumscribed encysted tumours in relation with the neigh- bouring organs, which may also possibly result from a serous cyst, or suppurating hematocele ; sometimes pus is formed in a latent manner, and is not suspected till evacuated. When there is much of it it may be supposed to come from the peritoneal cavity ; when there is little, it is more likely to be from an ovarian or tubal abscess. From one of these centres which was larger than the uterus at term 15 litres of pus were evacuated. It may be accumulated in a kind of cyst and remain there for a year, becoming very dense, in place of remaining serous, as when recent. These abscesses may open spontaneously into the peritoneum, which is rare and is a cause of rapid death, or they may open into the rectum or vagina, or even into the bladder, on the abdominal wall, or even by various orifices such as the inguinal canal, crural canal, the obturator foramen or the sciatic notch (Fig. 326). In one case which was verified by autopsy, Seux ^ saw the pus discharged through the posterior wall of the uterus. According to Graily Hewitt ^ the most frequent opening is into the intestine ; it is also rather frequent into the vagina and bladder. It is less common along the course of the vessels or nerves leaving the pelvis. With regard to this, a wide distinction must be made between a perimetric and a parametric abscess and one of the broad ligament. They have common points by which they may be discharged, notably the rectum; but there are points of selection by which some open rather than others, for example, the rectum and bladder, for the abscess of pelvic peritonitis ; the abdominal wall or the groin, for abscess of the broad ligament. The former has besides a greater tendency to become encysted and to be tolerated, the latter to ulcerate and discharge the pus. As the purulent matter is discharged at certain points determined by exact anatomical connections, the place of opening of the abscess is a last means of completing the difl'erential diagnosis. Supjnci-ative pelvic cellulitis having less tendency to open by the abdominal wall and into the intestine, or even into the bladder and uterus, may be 1 Bulletin de la Societe imperiale de medecine de Marseille, 1862, p. 87. ' Op. cit., p. 228. 558 UTERINE DISEASES IN DETAIL discharged by the vagina or even by the rectum, all round the anterior part of the brim, by the crural arch, the inguinal canal, the obturator Fig. 326. — Points in tlie pelvic cavity by which the pus of phlegmon of the broad ligament may be discharged, a c, above and below the cniral arch. s, the great sciatic notch ; o, the small sciatic notch ; t o, the obturator foramen ; 1, 2, 3, the sacral foramina. foramen, as well as by the sciatic notches ; I have seen some open simultaneously into the vagina (by the lateral wall), below the crural ^rnh. and in the centre of the buttock at the highest part of the sciatic Fig. 327. — v, vagina ; u, uterus ; l i, upper border of the broad ligament ; p, peritoneum in which sero-adhesive or sero-purulent peri-uterine inflam- mation is developed ; l s p, sub-peritoneal space of the broad ligament on each side, rising to the upper border L i, in which suppuration of the phlegmon of the broad ligament takes place ; s c, subcutaneous space where abscesses are formed, which only open round the anus and vulva. notch; at a point through which an india-rubber bougie might be passed PERI-UTERINE INFLAMMATION 559 to the centre of the pelvis where the point could be felt by vaginal touch through the vaginal wall. Suppurative pelvic peritonitis then may be discharged by the rectum, vagina, bladder, or even the uterus, and at various points of the abdominal wall as well as into the intestine, the sigmoid flexure, caecum, or small intestine. I have seen one opening simultaneously into the vagina, into the intestine, and through the abdominal wall at a point more or less distant from the crural arch. Abscesses which are subcutaneous and subaponeurotic, i.e. below the deep perinseal aponeurosis, open round the vulva and anus. The accompanying figure explains how it is that one abscess should open at one point and another abscess at another point. The suppuration which follows puerperal perimetritis has a rapid course, terminating fatally in a few days. In non-puerperal peri- metritis, pus may appear in a fortnight or even sooner. Nonat does not think it possible that pus can be absorbed ; however, I have seen cases of the kind, but the tumours were small. When, however, art does not intervene at an early stage, purulent collections usually make way for themselves to the teguments or to some hollow organ. Some days previously there is exacerbation of the symptoms, then suddenly after a fall, contusion or effort the tumour suddenly gives way bringing relief. Sometimes there is no particular sensation, at other times there is a sensation of internal laceration, and passage of pus into the vagina, which is a favorable termination. I have recently seen a case of this kind in a patient who would not allow vaginal puncture to be attempted, and in struggling the abscess broke into the vagina : cure soon followed, but it was impossible for me to find the vagino-uterine orifice by which the abscess was discharged. Evacuation may either be complete or not ; it then takes place several times. At the monthly period the pus becomes sanguinolent. When the opening is made into the rectum there may be tenesmus, dysentery, and the most serious accidents, as Aran once saw in a virgin. Except in cases where the pus is effused into the peritoneum, death seldom follows rupture of the abscess, though it may result from prolonged suppuration, from the formation of fistulous passages and from the marasmus into which patients finally fall. I have already said what happens when several openings place the abscess in com- munication with the bladder and rectum simultaneously, sometimes even with the abdominal wall as well. Consumption may occur in these cases, as well as in those where the evacuation of pus is incom- plete, where the abscess opens and closes several times, where there is stagnation of pus owing to the existence of only one opening for two or three abscesses.^ If, on the contrary, the opening is large, and the ' Nevertheless, there are cases in which the constitution of patients is able to resist the continued secretion of pus, perforation of the digestive canal, &c. ; I have just seen a case of the kind, where, in spite of the fear of peritoneal adhesions of the tubes hindering the adaptation of the fimbriated extremity to the ovary, and so causing sterility, suppuration had hardly ceased, the patient still being convalescent, when she became pregnant. 560 UTEillNE DISEASES IN DETAIL abscess well emptied, the symptoms disappear : hence the justification for surgical intervention, the right limits of which I shall try to define when describing treatment. Treatment. — Peri-uterine inflammation, apart from that which is developed in the worst conditions of the puerperal state, is serious, not from the rapidity of the termination, but from the long duration and natural incurability of the chronic form, the constant dangers incurred by the paroxysms, and the risk of consumption which is all the more serious, as Aran considers that two thirds of the women attacked by chronic perimetritis are predisposed to tubercle. Besides which, if the malady is allowed to become intense or be prolonged, sterility fol- lows, except very exceptionally, when the peritoneum is not involved in the inflammation, or when the annexes of one side have preserved their integrity; pregnancy is always difficult, as Madame Boivin^ has shown, but she attaches too little importance to remains of inflamma- tion and exaggerates the mechanical influence of adhesions. It is evident that the treatment of perimetritis ought always to be con- sidered as urgent, and this should be explained to patients as well as the length of time required. I shall not speak of prophylactic treatment, which consists in avoiding all fatigue after delivery, rising too soon, marital intercourse, cold injections, cold foot baths, and also the sudden suppression of the milk, but shall now pass on to treatment strictly speaking. The chief indications are the following : 1, to subdue inflammation ; 3, to promote resolution of the tumour; 3, to treat the diathetic affection under the influence of which chronic inflammation has a ten- dency to perpetuate itself; 4, to treat complications ; 5, when necessary to promote the evacuation of pus. 1. Antiphlogistic treatment is so plainly indicated, that all physicians' are agreed as to its occupying the first place in the treatment of the acute form, but opinion is divided with regard to it in the chronic form, especially as to bleeding. Experience has taught me the wisdom of limiting myself to local bloodletting, though I do not deny that bleeding may be indicated exceptionally in a strong woman of sanguine temperament. In acute perimetritis leeches or cupping glasses should be applied to the abdomen even in the puerperal state, and should be repeated at short intervals. The apparent amelioration effected by a first application associated with narcotics must not be trusted to ; fresh applications ' Recherches sur une des causes les phis frequentes et les moins connues d'avorteinent. Paris, 1828. ^ Behier recommends preventive treatment. Whenever the cord is felt, which, according to him, is the first sign of the development of phlegmons of the broad ligament, continuous refrigeration is applied to the abdomen. An india-nibber bag, two-thirds full of pieces of broken ice, is placed over the painful region, with a wet towel folded in eight under it, to prevent its being in immediate contact with the skin, the whole being kept in place by a large towel which allows the patient to move without any danger of disarranging the ice. Tlie application of cold should be continuous. The success obtained by this treatment has been described bv Briand in his thesis and by Joulin in his I'rnite d' accouchemcnts, p. 1171. PERI-UTEBINE INFLAMMATION 661 should be made three or four days running, gradually diminishing the number till pelvic pain is no longer elicited by pressure. Leeching is impossible when inflammation is very acute on account of the difficulty and pain caused by the introduction of the speculum; but it should be resorted to as soon as the local symptoms are somewhat alleviated, as well as in chronic perimetritis. Bloodletting produced by leeching is neither revulsive nor derivative ; it is really depletive. This deple- tion of the utero-ovarian sanguineous system is necessary to ensure the efficiency of the revulsive and resolvent treatment which is to follow. It has seemed to me insufficient in itself to produce a cure, especially in the chronic forms of these maladies. Further : bloodletting alone, whether local or general, especially in chronic peri- uterine inflammation, as in all other chronic phlegmasias, congestions and engorgements, is followed by a decided aggravation of symptoms, if not immediately, at least subsequently. I have so often had occasion to observe these troublesome results, that I have not the slightest doubt on the matter, and explain the phenomena by the increased instability produced in the organism by the debility of the patient. As a rule the weaker a patient is the greater tendency will there be to fluxionary movements followed by more or less intense congestion, especially in the organs which have become the seats of these fluxionary movements. The equilibrium once broken is lost by increased general debility. Restoration of tone and strength to the economy can alone re-establish it, and facilitate the gradual disappear- ance of local inflammatory phenomena. Therefore depletion of the utero-ovarian vascular system by leeching the cervix ought to be as complete and as rapid as possible, so that it may not be necessary to recur to it unless in cases of chronic inflammation with exacerbations, which can never be removed quickly nor at once. When necessary, therefore, I always make two or three consecutive applications after menstruation. When one application has produced a very abundant flow of blood necessitating plugging, cure follows very rapidly. This depletion of the utero-ovarian vascular system ought to be accom- panied not only by other antiphlogistic means, but by strong revulsives and resolvents as well as by tonics. Absolute rest should be enjoined in acute inflammation; patients instinctively feel the necessity for it, the semi-flexed position being the most favorable to relaxation of the muscles compressing the inflamed parts. Bernutz rightly insists on confinement to bed being prescribed as for men in cases of orchitis. In fact even in the chronic form patients should take as much rest as possible, both mental and physical, and should always keep their bed at the monthly period. Marital intercourse should be absolutely forbidden, for unless the suffering organ has perfect rest treatment is powerless to efi'ect a cure. I agree, however, with Bernutz that in the last stage of the malady there is no occasion to dread the occurrence of conception, which sometimes takes place easily at the end of the menstrual flow. Pregnancy indeed is one of the most effectual means of modifying the diseased organs and of completing the resolution imperfectly produced by the various medi- 36 562 UTEEINE DISEASES IN DETAIL cations employed, that is if proper care be taken during gestation and after labour. In order to allow patients to rise without interfering with the rela- tive rest required for the abdomen, Bernutz has invented a particular kind of corset, which is useful, not because it fixes the organs as he thinks, but because it supports them and especially prevents the effects of shocks during a period of the disease when the hypogastric belt and cushion (very superior as a means of supporting the abdominal viscera) could not be tolerated on account of the sensitive state of the abdominal region. According to Bernutz this corset plays the same part that the sling does for men affected with orchitis. The idea of supporting the abdomen is good : the best belt is that of Bourjeaurd with or without the air cushion according to the indication. Strict diet should be ob- served during the acute stage, and even in the transition stage great prudence should be exercised. In the chronic form, on the contrary, the diet should be very nourishing, though light and digestible, so that the patient may regain flesh and strength. Emollients should be applied in every form : linseed poultices to the abdomen, fomentations of decoction of marshmallow or poppy-heads, and when these are not tolerated, embrocations of camphorated oil ; enemata of the decoc- tion of marshmallow, linseed, poppy-heads, starch or oil ; prolonged tepid baths as soon as they can be borne, repeated daily in the acute stage, twice or thrice a week in the chronic form, vaginal injections being made all the time of the bath. Vaginal injections should also be made on the bidet with starch and water, and in some cases poultices in muslin bags should be introduced as far as possible into the vagina 5 they may be made of linseed, fucus crupus (Lelievre's instantaneous cataplasm), &c. : such are the dif- ferent ways of employing emollients concurrently with antiphlogistic treatment. In acute perimetritis, as in peritonitis, rest should be ensured to the intestines and pain alleviated by the use of narcotics, especially opium. One of the great uses of opium is to put a stop to the stimulation produced by pain which is a continual cause of fluxion (ubi stimulus ihifluxus), and thus two elements of the inflammation are subdued simultaneously. It is useful also in suppressing alvine evacuations and of giving absolute rest to the intestine, which is so necessary in alleviating the inflammatory phenomena: when required, laxative enemata should be administered previously, by means of a large rectal or oesophageal sound introduced far enough to pass beyond the tumour (which often projects into the rectum and compresses it), so that the fluid may penetrate into the colon. After an evacuation produced by this simple means rest is often obtained for the intestine. While, however, using narcotics to alleviate pain, the physician should beware of mistaking the insensibility produced for real improvement and con- sequently of omitting to prescribe a fresh application of leeches when required. When leeching followed by the use of other means just enumerated fails to relieve the inflammatory symptoms, or when the weakness of the patient does not allow of bloodletting, recourse may TERI-UTERINE INFLAMMATION 563 be had to mercurial and belladonna ointment : from Jv to ^vij of the ointment is spread on a large compress and laid on the abdomen ; this plaster is better than frictions, which aggravate the pain. A thick layer of cotton wool should be laid over it and waterproof over all in order to maintain a moist heat over the abdomen, which helps the absorption of the ointment. The external application of mercury may sometimes be associated with the internal use of calomel. Small doses of calomel may be given combined with jalap. But I do not think that the intestinal fluxion produced is favorable to the resolution of the inflammation nor that salivation is desirable ; for even supposing it efficacious it is attended by so many disadvantages that I have quite given it up. II. The second indication is to try to obtain resolution of the tumour and of the liquid and solid matter which has been deposited on the peritoneum. Having explained how useful intestinal rest is durino- the acute period, it is needless for me to say that purgatives should be proscribed during this period. After bloodletting Bernutz recommends that the whole abdomen should be covered with a camphorated blister. This means certainly may be of great use, but should only be applied in very serious cases. Usually blistering is indicated rather at a later period. When resolu- tion commences but progresses slowly a hypogastric blister is an excellent means. We may then follow the example of Piedagnel, Nonat, &c., and powder it with gr. ^ or gr. | of hydrochlorate of morphia to prevent its causing pain. The blister should not be applied at the time of the monthly period, and its effects should always be carefully watched. It is, however, in the transition stage of the disease to the chronic form and in the latter period that blisters are of most use ; they may be said indeed to be the best means of causing the dis- appearance of plastic products. Velpeau has been the means of their being largely used in such cases. They are applied after bloodletting or substituted for it when there are signs of the formation of pus. One may be applied every month, a few days after menstruation ; but if necessary it may be repeated two or three times a month, and should exceed the size of the tumour. They are applied to the hypogastrium, to one or other of the iliac fossse, to the loins, sometimes to the buttock. They should be removed in twenty-four hours and the serum evacuated, care being taken to leave the epidermis in place. A thick layer of cotton-wool should be applied and kept in place by a bandage for several days, as in the case of a burn. Aran boasts of the efficacy of blisters applied to the cervix in chronic perimetritis, but I confess that their use has always seemed to me more suitable in chronic leu- corrhoea than in peri-uterine inflammation. The cauteries, moxas and setons proposed by Huguier and Gosselin are not so useful as in the treatment of ovaritis. The blister acts on a larger surface, it stimulates more suddenly, and its repeated action is more favorable to the elimina- tion of the serum and pus than the continuous but slow and moderate action of these exutories. The action of resolvents and alteratives should be associated as soon 564 UTERINE DISEASES IN DETAIL as possible with the former means. Preparations of mercury, iodine, gold and arsenic should be administered internally, whilst externally frictions should be made daily with mercurial or iodine ointment, or the hypogastrium may be painted with tincture of iodine.^ In such cases, as in ovaritis, I have found small enemata of resolvent ointment of great use ; they are better than suppositories because they can be introduced farther, they melt more easily, are tolerated better and are more easily absorbed. The injection of mercurial ointment per rectum may be associated with painting the hypogastrium, cervix and vagina with iodine ; or the application of mercurial ointment on the hypogastrium may be associated with iodide of potassium per rectum and tincture of iodine per vaginam. The action of these medicaments is increased by tepid and prolonged alkaline or saline baths, by the use of iron, tonics, £fenerous diet and residence in the country, by the use of mineral waters (alkaline and chloride of sodium waters, such as those of Plombieres, Ems, Soden), and at a later period by cold sitz-baths, cold abdominal compresses, cold enemata — hydropathy in short — which may be con- tinued for several months till the menses have recurred regularly several times. When the malady is on the decline or when resolution is effected, mineral waters are suitable for the treatment of complica- tions and for restoring the strength ; sea-bathing, hydropathy, sulphur or iron waters, the waters of Luchon, Cauterets, St. Sauveur, Spa, Plombieres, Neris, are indicated. Hydropathic and hydromineral medi- cation is not merely palliative. It is the best adjuvant of resolvents. Purther, these waters have an essentially resolvent action of themselves, in addition to the tonic, restorative or sedative action which they exercise according to their nature or to the manner in which they are adminis- tered- Only this action varies with the patient and the period of the malady ; it varies according to the nature of the diathetic affection which complicates the peri-uterine inflammation ; it varies also with the mineral water and with its mode of administration. Hence another action beyond that of simple absorption of plastic products, which leads to these medicaments being classed among those which fulfil the third indication in the treatment of perimetritis. III. The third indication is to treat the diathetic affection under the influence of which chronic perimetritis has a tendency to be per- petuated, and at the same time restore the weakened and deteriorated organism. Pelvic peritonitis being according to Bernutz a malady symptomatic of very different affections, presents very various thera- peutical indications, not only according to its acute or chronic form, its sero-adhesive or purulent nature, but according to the indications furnished by the diathesis of which the inflammation of the serous membrane is a remote manifestation. Bernutz therefore recommends mercury when there is reason to believe that the diathesis is syphihtic, turpentine when there is blennorhagia, &c. * Joannowsky of Prague {Prager Vierteljahrschrifi, 1878) has proved tliat iodine is absorbed and is found in the iiriue. Out of 30 women treated by- painting the hypogastrium, cervix and vagina with iodine, 11 were cured, 1 i improved. PEBI-UTERINE INFLAMMATION 566 It is in chronic pelvic peritonitis that the principles of Beruutz may be applied. He recommends the alkaline waters of Vichy if dyspepsia predominates, hydropathy if the symptoms are nervous, sulphurous baths if scrofula has previously existed, arsenical baths if there is any cutaneous affection the result of scrofula, arthritis or rheumatism. The determination of the diathesis, to which the chronicity of the inflam- matory action is to be attributed, deserves the careful attention of the physician. Bernutz usually associates hemlock with this antidiathetic medication. He considers it the specific narcotic of the genital organs, and increases the dose till disorders of vision and hallucinations are produced. He is not, however, sure of its efficacy. As to iodide of potassium, I do not see that its administration is contra-indicated, as he says, by the necessity of feeding up patients. lY. The comphcations which coexist with perimetritis or which persist after its cure must also be treated. Yomiting is one of the first complications which may require treatment, for it is symptomatic of peritonitis. It appears at the most acute period of the disease and returns with every exacerbation. In order to stop it nothing should be taken but fragments of ice from time to time or a little iced cham- pagne, lemonade or soda water ; sedatives should be given externally and internally, opium, belladonna, chloroform, a blister powdered with hydrochlorate of morphia on the epigastrium, nux vomica or strychnia in small doses or subnitrate of bismuth. One of the best preparations is the following: Pulv. Radic. Calumb., Calc. Carb. prep, aa gr. 1^ to gr, 3 ; Pulv. Bellad, Eadic, gr, -\j to gr. i mixed and given in a spoonful of iced water, and repeated every four hours or oftener if necessary. The distension of the belly which often occurs with vomiting should be treated with poultices sprinkled with camphor- ated oil or with iced compresses. Constipation necessitates the administration of simple or laxative enemata introduced by a thick and long cannula ; mild laxatives may be given by the mouth in the chronic period, and in the absence of acute pain in the belly. When it does not yield to these means, cold ascending douches should be prescribed or pills containing from gr. I each of the extract and powder of bellad. and gr. -Jg of strychnia, a little sulphate of zinc, or even a little aloes with great prudence. If diarrhcea occurs, it should be treated with bismuth or opium, giving from gr. 3 to gr. 4^ in the day, care being taken to give it in small doses at a time. Small enemata may also be given containing a little laudanum or nitrate of silver in the proportion of gr. 3 to gr. 6 in Jiij of water. Pain and neuralgia are the most frequent complications during and after the malady. I have already explained how the pains of acute perimetritis should be subdued by large doses of opium which also ensure the rest so necessary to the viscera. Anodyne fomentations should be applied simultaneously with the same object. Beruutz recommends a bath every three or four days, and from 5 to 7 grains of powdered hemlock every day. When pain occurs suddenly in the loins or belly during chronic perimetritis, it is usually the sign of an 566 UTEEINE DISEASES IN DETAIL exacerbation : one of the best means of dissipating it is to leech the cervix and then apply a blister to the abdomen or rub with croton oil, care being taken to cover the part afterwards with adhesive plaster to prevent pain being produced by contact with the clothes. When pain continues and uterine or peri-uterine hypersesthesia also exist, Aran's application of laudanum may be tried, which consists in pouring a little into the vagina by means of a speculum and then applying a tampon. In place of simple pain, there is often neuralgia, even at the commencement of the disease in hysterical patients, but generally at the end. This neuralgia is best subdued by the apphcation of a small ammoniated blister to the painful part, which must be after- wards dressed every day with hydrochlorate of morphia, or by sub- cutaneous injections of this salt. Lastly, as the final treatment of the nervous symptoms which persist after pelvic peritonitis, recourse should be had to hydropathy and to residence in the country, as the best adjuvants of narcotics, faradisation, the continuous cur- rent, &c. There may be hsemorrhage in chronic perimetritis though this seldom occurs ; when it does, haemostatics should be administered, such as lemonade, mineral acids, rhatany, cold or acid applications to the hypogastrium, or on the contrary very hot injections; sometimes a blister on the iliac fossa stops the flow. Ergot should never be employed in such cases. As for the other complications, metritis, uterine catarrh, leucorrhosa, vulval pruritus, deviations, &c., they are ameliorated by the treatment of perimetritis, but should not be attacked directly till after the peri-uterine inflammation has been cured. ^ V. The opening of the purulent collection. In the case of acute pelvic peritonitis puncture may be made through the vagina. This often simplifies the malady and hastens cure as in cases of acute pleurisy with effusion; but as it is attended with some risk it is usually preferable to wait the formation of pus. Even when pus is formed, opinions are divided as to whether the abscess should be opened. Bourdon ~ is in favour of the artificial opening of pelvic as of all other abscesses ; he says " the presence of pus facilitates its formation ; the tumour may be very large and the pus may travel a long way producing irreparable mischief; the abscess finding no external outlet may be discharged into the peritoneum ; and if the opening occurs spontaneously or is made late, patients are condemned to sufferings which they might have been spared ; it may also open at an unfavorable point for the discharge of pus; and lastly, in many cases the patient being greatly enfeebled by a long malady is no longer in a favorable condition for recovery after the opening of the abscess, even in the absence of interminable fistulge and suppurations.'" iS'onat also insists on the necessity of opening abscesses ; the presence of pus may cause peritonitis, even phlebitis with general disorders and * Piotowsky {Du catarrhe iiterin dans la jyelvi-peritonite et de son traite- ment) places beyond doubt the dangei-s attending too hasty intervention. ' Tumeurs fluctuantes du petit hassin [Revue medicale, 1841). PEEI-UTERINE INFLAMMATION 667 perforations which may be fatal. Bernutz also recommends artificial opening as soon as symptoms of hectic fever have succeeded the acci- dents of acute pelvic peritonitis. Aran on the contrary thinks that pelvic abscesses should seldom be opened artificially : he says that the pus being imprisoned in a kind of cyst formed by false membranes does not spread ; an artificial opening does not prevent a natural opening occurring at an unfavorable point for the evacuation of pus ; hectic fever may follow the one as well as the other ; lastly, the pus may possibly be absorbed and the malady be cured without any opening either natural or artificial as occurred in cases described by Aran and Marchal de Calvi. It is therefore prudent he thinks to abandon the opening of pelvic abscesses to nature. I think, however, that these reasons are exaggerated. On the one hand, the origin of abscesses should be taken into account ; expectation is more indicated in those produced by pelvic peritonitis (which is usually encysted), artificial opening for those resulting from a phlegmon of the broad ligaments, as it has a tendency to spread. On the other hand, whatever be the origin, though pelvic abscesses may not always be in conditions to be opened early, as happens in other purulent collections, I think it is dangerous to wait too long. If the abscess reacts on the economy, if the presence of pus causes hectic fever, if the tumour raising the abdomen seems to adhere to it or to project towards the vagina or rectum, if the walls have become thin announcing imminent rupture, if the abscess has opened at an unfavorable point for the complete evacuation of the pus, if the urine or fsecal matter accumulates in the sac the abscess should be opened artificially. When the abscess is subtegumentary it should be opened through the abdominal wall. When it is very superficial and points to the surface of the abdomen, and when there is reason to hope that adhe- sions are established between the visceral and parietal peritoneum the bistoury may be used ; in doubtful cases the bistoury should only be used according to the method of Graves, who reaches the peritoneum ■without opening it, or according to that of Begin, who incises the parietal peritoneum without touching the tumour. As a rule, how- ever, the use of caustics is preferable, all the more so that by arousing the vitality of the tissues and producing a salutary derivation they may exceptionally bring about the absorption of pus. In employing them the rules laid down by Recamier for the opening of liquid tumours of the liver should be observed, or those of Martin^ for the opening of deposits of the annexes occurring after delivery, that is to say, succes- sive applications of caustic potash should be made at the same point from without inwards. Vienna paste is better still : the scar should be incised and excised daily and a fresh application of the caustic made so that adhesions may be established all round the opening after the abscess is reached. If the opening remains fistulous too long there is no danger in cautiously trying antiseptic and iodine injections. ' Memoires de med. et dc chir. prat., p. .312. Paris, 1835. 568 UTERINE DISEASES IN DETAIL Bertrand^ cured an abscess in this way, the pus from which was eva- cuated by the navel after puerperal metro-peritonitis lasting for six months. We know of cases of definite cure due to pregnancy, proba- bly owing to the compression and adhesion of the walls of the abscess. Why then not imitate nature, taking care to exercise methodic com- pression of the hypogastrium, after the pus has been evacuated, with Bourjeaurd's belt? I have seen methodic compression do so much good in cases of iliac abscess and of enormous abscesses in the hips that I have no doubt as to the efficacy of this means when applied to the cure of pelvic abscesses. Lister's antiseptic treatment should also be carefully carried out. When the abscess points towards the vagina or rectum it should be opened there. Opening by the vagina is easier and more favorable, and therefore should always be preferred when possible. According to Bernutz, a curved trocar can when necessary be introduced by one of the iliac fossae passing thence into the vagina. This method has been employed by Koeberle after ovariotomies giving rise to an accu- ■ raulation of pus in the vagino-rectal cul-de-sac, and by Pean,^ who has invented a curved trocar for perforating the posterior vaginal cul-de-sac from above downwards; it is introduced by a small incision in the abdominal wall above the crural arch near the border of the uterus. In such cases I have introduced a long curved trocar (such as is used in puncturing the bladder by the rectum in men) behind the uterus, by means of which I have perforated the retro-uterine cul-de-sac and passed a drainage tube into the wound. In such cases caustics cannot be used ; the bistoury is introduced with or without the speculum to the dependent part, or to the most projecting portion of the tumour. When Fergusson's speculum cannot be used Sims's should be tried, or the labia and vaginal walls may be kept apart by the fingers of assis- tants or by the instruments invented by Jobert for the operation of vesico-vaginal fistula. Eecamier used a pharyngotome or a silver bis- toury.^ Blandin's or any other concealed bistoury can be employed. However an ordinary straight bistoury will serve the purpose ; its blade should be covered with linen or diachylon plaster to within half an inch of the point and introduced flat on the index finger till the most projecting and resistant portion of the tumour is reached and pierced, moderate pressure being used till we feel that resistance has been overcome and that pus is being discharged. Large openings should not be made for fear of haemorrhage, for the flow of blood is often considerable even when a vertical direction has been given to the incision according to Eecamier's advice. The best instrument of all is the fine aspirator trocar ; it is introduced like the bistoury on the index finger of the left hand ; we make sure that it has entered the cavity of the abscess by withdrawing the stylet, and if the pus is not discharged easily the opening is enlarged. Usually there is not much ' Bulletin de la Societedemed.de Besangon, 1858. — Gazette med. de Paris, 18G0, p. 430. * Ovanotomie et splenotomie, p. 21. Paris, 1869. * H. Bourdon, Mem. cit., p. 71. LEUCORRHCEA AND UTERINE CATARRH 569 pus, and it is quite exceptional for the sac to fill again and again and to persist in the fistulous state. Hence the uselessness of a second punc- ture ; it would be better to discover the purulent collections of the ovary and Fallopian tube, which are situated frequently in the centre of the abscess, and evacuate their contents ; unfortunately it is very- difficult. After puncture it is unnecessary to leave the cannula of the trocar in the opening ; or even to introduce a gum-elastic sound as Laugier did after puncturing a peri-uterine hematocele, or a tent, because there is not always pus to be discharged, and all these foreign bodies touch the peritoneum and consequently may become very dangerous. After puncture perfect rest should be enjoined and emollient enemata and cataplasms prescribed. That improvement may be lastino- inflammation must be entirely extinguished : many cures are then ob- tained, as mentioned by Bourdon in his paper. A strict diet, how- ever, should not be enforced for long. On the contrary, tonics, bitters, quinine and iron should be given. Lastly, we hold ourselves in readiness for the approaching monthly period when there will be a recurrence of pelvic pain and inflammation. Op Leucourhcea in General and Uterine Catarrh in Particular Leucorrhoea is a pathological discharge produced by the increase and alteration of the normal secretions of the genital economy. This name, which literally means white discharge {Xsvkoq white, paTv to flow), is commonly used to denote all discharges except that of blood, depending on diseases of various nature, excreted by difierent organs, being less a special malady than a symptom common to several diseases. The progress of medicine with regard to this has been checked for long by a feeling of modesty on the part of women ; for a great number refrain from telling their physician of these discharges, whilst others inform him of the fact, but refuse to submit to an examination. Now there is as much difl'erence between the various kinds of white discharges as there is between various kinds of expecto- ration. We shall give the name of false lettcorr^cea to fluid discharges of various kinds issuing from the genital organs, reserving that of leucor- rhoea to those produced directly by these organs under the influence of a very characteristic pathological condition. I. False leucorrhcea. — This may be occasioned by the presence of foreign bodies or by the development of more or less serious organic lesions. A foreign body, such as a pessary, remaining in the vagina or in the uterus produces inflammation, hypersecretion and suppura- tion, retaining purulent fluids which in decomposing exhale a pene- trating odour of acid fermentation. Hydatidiform or fleshy moles, polypi, fibroid tumours, produce discharges resulting from the irrita- 570 UTEEINE DISEASES IN DETAIL tion produced by tlieir presence on the uterine mucous membrane and especially on its glands. Abscesses of the uterus or extensive sup- puration of the whole internal surface of the organ may determine the mtermittent or continuous discharge of quantities of pus, which are seen in such cases to issue from the uterine cavity itself. Ashwell has seen half a pint of pus discharged from this cavity, and Safl'ord- Lee once saw an abundant purulent discharge produced by the presence of a polypus (referred to by Graily Hewitt, p. 86). Matthews Duncan^ describes the case of an old woman who had ceased to menstruate, and who had a considerable discharge of pus from the uterine cavity ; I have seen a similar case ; and another in which an interstitial abscess opened on the anterior lip of the cervix. Uterine tuberculisation, which however is rare, may also determine an aqueous, dirty yellow or pale brown discharge. Cancer produces a serous or sero-sanguineous discharge like reddish water, sometimes acrid and irritating to the sub- jacent tissues, seldom inodorous, usually foetid. Lastly, the evacuation of an ovarian cyst by the Fallopian tube may cause a discharge which may be confounded with leucorrhoea. II. Leucorrlma p-ojjerly so called. — Leucorrhoea, like the white discharges just enumerated, is usually symptomatic ; indeed it is only by an abuse of language that leucorrhoea can be called idiopathic. Nevertheless I think it is well to keep the name and give the patho- logical description of leucorrhoea for several reasons. The first is the interest presented by leucorrhoea in uterine semeiology. The second is the importance of this symptom with regard to indications. In order to judge of the existence, intensity, seat and nature of leucorrhoea, we must first of all learn to recognise the leiicorrhceal products. The normal secretions of the vulva, vagina and uterus differ from each other just as do the membranes from which they are produced. Vulval mucus is viscous, slightly adherent to the fingers when touched, becoming thready when the latter are slightly separated. That of the vulvo-vaginal glands resembles greatly that of Cowper's glands in man. It gives an acid reaction. The mucus of the ves- tibular and peri-urethral follicles has always seemed to me more acid than that of the vulvo-vaginal glands. When mixed with the seba- ceous secretion it often forms a kind of magma with a cheesy smell or rather a smell of sour and fermented cheese. Sometimes, although in immediate contact, the two products do not mix. The vaginal fluid, to which the name of mucus should perhaps not be given, cannot apparently be produced in such abundance as the mucus of the vulva and uterus, at least not in the normal condition. It is a clear, transparent, serous fluid, having no viscosity, but seldom seen alone, for apparently it is only the vehicle of innumerable broad, lamelliform corpuscles which are detached continuously by exfoliation and in more or less considerable quantity from the surface of the mucous membrane, giving to the excretion the white, opaque, cheesy aspect which characterises it. The vaginal excretion therefore is in > Edin. Med. Journal, March, 1868. LEUCORRHCEA AND UTERINE CATARRH 571 factj as described by Donne/ a thick creamy fluids never {glutinous like that from the uterus, acid and containing cells of pavement epithelium four or five hundredths of a millimetre in diameter. This mucus is acid, whilst that from the uterus is alkaline ; both contain globules of pus in proportion as the mucus is diseased ; their colour is more or less modified according to the quantity of these anatomical elements. The uterine mucus is quite different from the vaginal fluid. It is more like vulval mucus, although distinguished from the latter by its physical characters and by its mode of excretion. We must, however, remember that the name uterine mucus includes two very different kinds of mucus : that of the cervix and that of the fundus. Both are limpid normally, and the secretion is so scanty when the organ is at Fig. 329. — Vaginal pavement epithelium covering the mucous membrane of the cervix. 240 diameters (Tyler Smith). rest that when examining with the speculum a woman whose uterus is normal not only is there no discharge to be seen, but not even a single drop can be forced to exude by pressing the cervix with the instru- ment. Both may appear at the uterine orifice in the form of a drop of thin transparent fluid spreading from the orifice to the lower lip of the cervix, increasing in quantity by pressure, but remaining adherent to the organ, from which there is usually some difficulty in detaching it entirely even by wiping with cotton-wool. In this mixed fluid there is usually more mucus from the cervix than from the fundus ; but the mixture may be so equal that it is difficult to distinguish them. Some- times their different characteristics are recognised at once by the absence of one or other secretion ; sometimes the cervix is obstructed by its own secretion ; sometimes it does not apparently secrete mucus, but after the sound has been used a fluid is seen to exude which really comes from the body, or the hollow sound brings with it a portion of this fluid, the special characters of which may then be distinguished. Both are transparent and limpid, and if, as some observers affirm, that of the cervix is yellowish and that of the body semi-transparent and greyish, it is owing I think to some slight disorder of the secretion. I ^ Cours de microscopie complementaire des etudes viedicales, p. 155 Paris 1844. 572 UTERINE DISEASES IN DETAIL have never observed such differences in the normal state. Both have a peculiar stale odour, which may be strong in different diseases and after delivery or puerperal fever, but which is never acid ; both, on ,U-§i!Jlfj^l ■<% Fig. 331. — Cylindrical epithe- lium with vihratile cilia from the cavity of the body of the utenis. 220 diame- ters (Tyler Smith). Fig. 330. — Normal mucous secretion from the cervix, extracted from its mucous follicles. The mucous corpuscles are ranged in longitudinal series owing to the viscosity of the fluid in which they are entangled. 220 diameters (Tyler Smith). the contrary, are always alkaline. As to their distinguishing charac- tt ristics, that of the cervix is gluey, tenacious, half solid rather than liquid ; hypersecretion of it is frequent ; mucous corpuscles, cells of nucleated epithelium, are more or less abundant in the transparent and granular fluid. During pregnancy it is produced in considerable quantity, and is then more glutinous, more tenacious still than in the state of vacuity, and it plugs the cervix (douc/ion gelalineux) . It does not hold any other anatomical element in suspension except the nucleated cells ; it is entirely homogeneous. That from the body is viscous, less tenacious than that from the cervix; it contains numerous epithelial globules, ovoid nuclei, coming from the flexuous follicles of the mucous membrane, prismatic epithelial cells or cylindrical and vibratile cells from the surface of this mucous membrane, sometimes granular bodies of inflammation. The relatively large number of these solid elements mixed with the secreted fluid sometimes alters its transparency, giving it the grey tint of which I have just spoken. This distinction is all the more important as uterine leucorrhoea is often limited to the cervical raucous membrane. To sum up, this mucous surface, which was long regarded as iden- tical in all its parts, secretes mucus, the ])hysical and chemical LEUCOERHCEA AND UTERINE CATARRH 573 characters of which are very different. If these differences have not been observed sooner, it is because the speculum has only been used during the last fifty years, because the utero-vaginal secretions were often altered or mixed in cases where the introduction of the speculum would have allowed them to be distinguished, because the attention of the physician was not directed to searching for differences between fluids coming from mucous membranes the anatomical structure of which was supposed to be similar, and lastly, because in other cases in which it was a question of diseases not accompanied by discharges, or in which the genital organs, the uterus especially, were in normal health, secretions were not observed. III. Idiopathic leticorrhcea is an ahiormal discharge from the mucous membranes of the genitals, more especially from the uterus ; it is mucous or muco-purulent, favoured by general atony and by a local predisposition, and finally determined by a slight irritation of the secreting membrane or by a functional imperfection, such as chlorosis. It constitutes a special morbid condition or an essential malady, the same as any other fluxion such as diarrhoea, bronchorrhoea, urethral blennorrhcea, sialorrhoea, profuse sweating, &c. Amongst other condi- tions of general atony which predispose to leucorrhoea, we may men- tion age, temperament, constitution, climate, food, &c. It is difficult, however, to appreciate the influence of these various causes. It is said that feeble constitutions and lymphatic temperaments are subject to leucorrhoea, which I think is true in spite of the contrary assertion made by some pathologists who have probably observed cases of simultaneous blennorrhagia, vaginitis and leucorrhoea in prostitutes, and who have made these the basis of their statistics. I think it is more commonly met with in young women than in old ; I have seen it in girls after the appearance of the catamenia. Cold and damp climates also predispose to it. It has been said that warm climates relax the vessels and prepare the way for fluxions and haemorrhages, but as a matter of fact it has been proved that damp countries, such as Belgium, Holland, and the marshy districts of England do so much more.-^ According to statistics made in Paris by Marc-Despine, and in Marseilles by Girard, two thirds of the women in Paris suffer from leucorrhoea, whilst only one fourth of the Marseilles women do.^ Residence in towns is generally considered as favorable to leucor- rhoea, and this opinion is confirmed by the researches made by Brierre de Boismont.^ Lastly, a poor diet is one of the most powerfully pre- disposing causes ; it is on this account that the use of coffee has been blamed, but wrongly so, for when pure it is very wholesome. To these causes of general debility we may add the more special ones which act in the same direction : prolonged lactation in weak nurses, cardiac disease, chronic pulmonary disease, emphysema, tendency to ' Graily Hewitt, op. cit., p. 89. ^ Marc Despine, Recherches anatomiques sur quelqiies points de I'histoire de la leuccyrrliee, in Archives generales de medecine, 2' series, t. x, p. 165. Paris, 1836. ^ De la menstruation consideree dans ses rapports physiologiques et patholo- giques, ch. xiii, Desfliieurs blanches, p. 259. Paris, 1842. 574 UTEEINE DISEASES IN DETAIL phthisis and phthisis itself, lastly the various diatheses of which leu- corrhoea is not always symptomatic but which prepare the organism for it by the debility into which they throw it. To this I think we may add a local predisposition, consisting in a special atony of the genital economy or of one of its organs, I have often observed that leucorrhceic women were pale, flabby, the vulvo-vaginal mucous mem- brane being very extensible, the follicular or glandular orifices open, that there were symptoms of passive hypersemia, prolapsus or flexion of the uterus, relaxation of its ligaments, frequent involuntary excre- tion of urine caused by laughter or some other effort, sometimes even nocturnal incontinence of urine. In women who have these predispo- sitions, leucorrhoea may be determined by two causes of different kinds which it is important to diagnose in order to seize the indications of treatment. Sometimes a slight local irritation suffices to produce the discharge which is afterwards kept up all the more easily because the patient is in a sense prepared for it. Venereal excitement, excessive coitus, menstruation, pregnancy, abortion, delivery are the most com- mon causes. These same causes acting energetically and continuously may produce inflammation of the vulva, vagina or uterus ; but usually their action is Umited to the production of leucorrhoea. The approach of puberty, the slight excitement which precedes and follows every monthly period, are often marked by the whites. Pregnancy, under the influence of the fluxion and congestion which it keeps up in the genital mucous membrane often develops vaginal leucorrhcea. The simple congestion which it may leave in the organs, the slow retro- grade evolution of the uterus, are often the starting-point of a leucor- rhoeic fluxion which may be prolonged indefinitely. Sometimes a functional imperfection of the uterus or the reaction on this organ of the functional disorder of another organ may be the origin of leucorrhcea. In chlorotic and amenorrhceic girls it seems that from some alteration of the blood such as general debility or atony of the san- guineous vessels of the uterus, the periodical fluxion of this organ is insufficient to produce haemorrhage ; it terminates in a simple mucous, sero-mucous, muco-sanguineous or muco-purulent fluxion. This dis- charge sometimes only appears at the monthly period, sometimes it is repeated in the interval. At other times it is continuous but usually increases at the time corresponding to the monthly period, decreasing afterwards. I have often seen all these varieties. This discharge some- times undoubtedly contains globules of pus, indicative of a slight irrita- tion of the surface of the mucous membrane or its follicles ; at other times it contains globules of blood which seem to signify a tendency to the accompUshment of the natural haemorrhage, or to the recurrence of the normal conditions of the function ; frequently it is sero-mucous as if serum exuded from the vessels was mixed with mucus hyper-secreted under the influence of the fluxion of which the follicles with all the rest of the uterine system are the termination. The reaction exercised on the uterus by the functional disorder of another organ may also cause uterine leucorrhoea. The suppression of a physiological or pathological function such as lactation, perspiration, expectoration. LEUCORRHCEA. AND UTERINE CATARRH 575 diarrhoea, hsemorrhoids, an exutory, &c., may originate it, or the sup- pression of menstruation itself. This kind of leucorrhcca has been designated by the terras metastatic or supplementary ; but in these cases it is still more difficult than in those of amenorrhrea to discover the true pathogeny of leucorrha3a and to decide whether it is really supplementary of the fluxion the suppression of which coincides with its appearance, or if it is, like these fluxes themselves, symptomatic of a common general condition which causes both. Lastly, leucorrhcca often exists in women who do not menstruate. Now, when the menses are absent leucorrhoea may be produced in two ways : like amenorrhoca it may either be symptomatic of a general state which dominates both, or it appears or is increased at the time cor- responding with that of the menses by the fluxion and congestion which characterise this period : menstruation commences ; its ter- mination by the ordinary crisis is impossible ; it terminates by a mucous discharge instead of a sanguineous one. When the first monthly period has been delayed, when the menses do not reappear after an acute malady, or when they begin to disappear in the course of chronic maladies, e. g. in phthisical patients, the appearance and return of menstruation are often announced for some months by a periodical leucorrhoeic discharge, which lasts like the menses for a few days, and which is the indication of a real uterine congestion insufficient to lacerate the vessels and produce hsemorrhage ; this menstrual leu- corrhcea, analogous to that which accompanies ovulation in some mam- malia, has been exceptionally secTi for several years in women who are apparently in good health, occasionally even in some who have become pregnant. IV. Sj/mptomatic leucorrhda. — Usually leucorrhoea is only a symptom. The diseases which produce it are of various kinds and occupy different seats. These diseases may be either acute or chronic, general or local, diathetic or non-diathetic. Amongst the diathetic causes we may mention herpetic, rheumatic or scrofulous affections ; amongst the local causes, sexual excitement; inflammation of the genital organs and especially of their mucous membranes, uterine catarrh, or blennorrhagia, which may affect the vulva, vagina and uterus, extending even to the ovary, and which is distinguished by its essentially contagious character. With regard to the seat, leucorrhoea may be limited to the vulva, more frequently to the vagina or to the uterus. It may invade simultaneously the mucous membranes of these three organs; it may even extend to the Fallopian tubes and to the ovaries and produce inflammation [see Ovaritis). It can be distinguished on micro- scopic examination by the characters that I have just assigned to the various leucorrhoeic products of the vulva, vagina or uterus. Some maladies have a greater tendency than others to determine the appearance of leucorrhoea simultaneously or successively on all the mucous membranes of the genital economy, in place of limiting it to one of them. Eor instance herpetic leucorrhcea has a tendency to invade alternately, or successively, various points of the utero-vulval 576 UTEEINE DISEASES IN DETAIL raucous membrane and even of the neighbouring organs. Sometimes the uterine leucorrhcea diminishes and the vaginal increases ; sometimes Ibe latter is ameliorated, and the vulva is affected; the labia, the in- ternal surface of the thighs and the anus are covered with eczematous or herpetic vesicles, with pustules of impetigo, or at least they are attacked by erythema ; and then when these organs begin to improve the vaginal or uterine mucous membrane is affected anew. I have seen similar cases in men ; herpetic diseases successively and alter- nately invading the scrotum, foreskin, glans, urethra, neck, of the bladder, bladder, urethra and kidney. The same remarks are appli- cable to virulent or co7itagious hlennorrhagic leucorrhoea, to catarrhal leucorrhcea, to rheumatic leucorrhosa and to scrofidoiis leucorrhoea. A. Vulval leucorrhaa. — This is common in children, especially in scrofulous or herpetic girls ; it coexists or alternates with crusts on the head, with impetigo, eczema, herpes. It is sometimes complicated with superficial ulceration, engorgement of the inguinal ganglia, inflamma- tion and suppuration of these organs. It is evidently due to excessive secretion, to a herpetic eruption, to superficial ulceration caused and kept up by scrofula, as suppurative maladies of other mucous mem- branes usually are at this age, especially maladies of the mucous membrane of the orifices, the mucous membrane of the lips, the Schneide- rian membrane, the conjunctiva, the external ear, &c. It extends rapidly to the vagina; I have seen it, however, go further; in making a post-mortem examination of a child of 12, I remember having seen the uterus and the external half of the Fallopian tubes filled and dis- tended with epithelial debris forming a mass of cheesy matter. B. Vaginal leucorrhoea. — This is rarely seen in children. It is very common in married women, beingcaused by venereal excitement, blennor- rhagia, vaginitis even, or by pregnancy. Usually there is neither swelling nor heat at the vulva, but it may occur, the fluid in issuing may irritate the mucous membrane of the labia and produce erythema, or at least an inconvenient and sometimes a painful pruritus is excited. The discharge of the fluid is almost continuous, especially in pregnant women. When the hymen exists or when the vulval ring has not been dilated by frequent marital intercourse, the leucorrhceic fluid may be accumulated for some time in the vagina before being discharged, and then its issue may appear intermittent. Frequently it is milky, justifying the name of whites. Sometimes it is very liquid, at other times rather consistent, on account of the epithelial elements which it holds in suspension, but it is never viscous, strictly speaking, nor c. Uterine leucorrhoea is very rare in children, but common in chlorotic girls and in married women before or after pregnancy; in many it is abundant before and after menstruation. It may be pro- voked by venereal excesses, but usually is caused and kept up by uterine disease, often by catarrh, sometimes even by inflammation or by a rheumatic, herpetic, hlennorrhagic or syphilitic affection locaHsed on the womb, or by the presence of a polypus, fibroid tumour, simple granulations, an ulcer, &c. Generally there is neither heat, nor pain LEUCOREHCEA AND UTERINE CATARRH 577 nor any other symptom of disease of the vulva, vagina or neighbouring parts. But there is frequently a feeling of weight in the pelvis, lumbar and hypogastric pains almost as commonly, with colics, especially in young girls, corresponding to the contractions by which the uterus expels the fluid; therefore the discharge is intermittent in place of being continuous. Even when the uterine orifice is large and the fluid runs out without a uterine contraction accompanied by pains, the mucus or the muco-pus is retained by its viscosity, and is only detached from the mucous membrane to which it adheres when the mass is large enough to be dragged away by its own weight. A flow of liquid then escapes from the uterus, and finally from the vagina, from time to time, of which the patient is conscious even when she has not felt any pain previously. Differential diagnosis of the various kinds of infantile leucorrhma. — The importance of this diagnosis from a medico-legal point of view induces me to devote a few lines to it.^ The leucorrhoea of children may, as I have already said, attack the uterus itself; but it is more common in the vagina, and especially in the vulva, when the urethra may be affected simultaneously. The chief symptoms which distinguish infantile leucorrhcea caused by an indecent assault (especially when blennorrhagic) from other forms ^. ^#->, Fig. 333. — Mucous corpuscles with some epithelial cells and oily granulations in mucous or cervi- cal leucorrhcea. 220 diameters. Fig. 332. — Pavement epithelium in every degree of development, in epithelial or vaginal leucor- rhcea. 220 diameters (Tyler Smith). of leucorrhcea are the following : traces of contusion, sweUing, ecchy- mosis, turgescence of the vessels of the vulva and vagina, the rapid and intense development of the malady, purulent discharge of a green- yellow hue, and abundant enough to cover the external parts and soil the linen in many places, thick enough to glue the vulval lips together ^ See Tardieu, Fdv.cle r.ur les attentats an.v mceurs, 4*= edit. Pai-is, 1862, p. 20 and following. 37 578 UTERINE DISEASES IN DETAIL when dry, simultaneous discharge from the vagina and urethra. This last sign is important, as being peculiar to virulent and contagious leucorrhoca; for according to Tardieu, the violence exercised on the genital organs of a child by the healthiest man may produce as acute and as violent an inflammation, as well as a discharge as abundant and thick as that caused by the approach of a man affected with blennor- rhagia or any other contagious disease. V. Uterine catarrh is the malady which most frequently produces uterine leucorrhoea. It is sometimes confounded with inflammation of the uterine mucous membrane, and described as internal metritis, mucous metritis, endometritis. It sometimes assumes the acute form, frequently the chronic; it may be complicated with inflammation, erosion, ulceration of the mucous membrane, as occurs in old bronchial or intestinal catarrhs. It must not, however, be confounded with these various morbid states, or regarded as being only symptomatic of them, for it has distinctive characters which allow a differential diagnosis to be established. What characterises it is the peculiarity of its manifes- tation, the causes which produce it, its mode of development, the analogy of the complications, the speciality of the treatment. The speciality of its manifestation is the discharge itself. How often the uterine mucous membrane is inflamed, red, painful, even suppurating like that of the vagina without producing any discharge ! How often, on the contrary, this discharge exists alone, abundant, seldom purulent, but often muco-purulent or merely mucous, the glandular hyper- secretion increased, fatiguing patients by its quantity and persistence, ending by producing swelling of the mucous membrane and pain in the organ by hypertrophy of the follicles, but not accompanied by really inflammatory symptoms except in the acute state caused by a sudden attack or after a long duration from the effect of organic alterations produced by prolonged functional alteration ! The external causes producing it are the same as those which usually determine locahsed catarrhal afl'ections on other mucous membranes : coryza, bronchial catarrh, intestinal catarrh, &c. I have often seen leucorrhoea follow a sudden chill of the genital organs and abdomen occurring in women while perspiring, either from sitting down on the cold grass or on a damp stone, or from taking inopportunely a cold sitz-bath follow^ed by no reaction, or from having the genitals exposed to a current of cold air. I have seen men contract vesical and prostatic catarrh from the same causes. The influence of these causes is still more marked when a number of women are affected as by an epidemic. TrousseU says that when the Pont des Arts was finished at Paris it became a fashion- able promenade. Ladies sat there after sunset as in the public gardens, and owing to the cool, damp air from the river were attacked with leucorrhoea. We find proofs of the epidemic character of uterine catarrh in Blatin's work, and in the article Leucorrhee in the Diction- naire des Sciences medicates, in which are recorded the facts observed by the Breslau physicians in 1703, by Morgagni in Italy in 1710, by ' Des ecoulements particuliera auxfevimes. Paris, 1842. LEUOORRHCEA. AND UTERINE CATARRH 679 Bassius of Magdebourg at Halle in 1730, by Eaulin' at Paris in 1765, by Leake in England, concurrently with catarrh and diarrhcea ; the observations made at Berlin in 1712 are also given, and those in Erance by Roux in 1769. Its mode of development presents this peculiarity, that it often depends on a feeble constitution, on a lymphatic temperament, a susceptibility of the mucous membranes, and an impressionability to the action of damp cold and to sudden varieties of temperature, or to the hygrometric state of the air, being determined by the action of the external causes just mentioned — that is, by circumstances which beget the catarrhal affection and which produce localisation on the nasal, bronchial, vesical, intestinal mucous membranes. Acute uterine catarrh may be complicated by a certain degree of inflammation. The mucous membrane affected by the morbid cause is first painful and the secretion is diminished. In proportion as reaction takes place hypersecretion commeuces, being more or less intense and more or less altered. Hypogastric pain is accompanied by heat, pelvic discomfort, pain during defecation and micturition, assuming occasion- ally the character of colics. Chronic uterine catarrh follows, or this form may be assumed from the commencement ; sometimes also it follows metritis, which develops in the uterine glands a tendency to hypersecretion which is favoured or prepared by a general tendency. Subjective signs. — Hypersecretion, this discharge being apparently more weakening than that from the vagina, and sometimes, when it is abundant, coinciding with an irritation which extends from the uterine mucous membrane to that of the vagina, vulva, the internal surface of the thighs, where it produces irritation, a kind of erythema, and even slight epithelial desquamation. Menstrual disorders, usually dysmenorrhoea, occasionally metrorrhagia ; in the latter case, it is seldom that there is not some alteration of the mucous membrane symptomatic of a concomitant morbid state such as ulceration, granu- lations, fungosities. Pains beginning at the sacrum and terminating in the groins and pubis, accompanied by colics preceding the expul- sion of the muco-pus accumulated in the uteriae cavity, and compli- cated with a feeling of discomfort, weight and pelvic fulness. Very often an impression on some other part of the body, such as the sudden sensation produced by laying the hand on marble, reacts on the uterus awakening a slumbering pain and determining hypersecretion with expulsion of mucus. Gastralgia is soon added to these pains, a sensation of weariness and dragging extending from the epigastrium to the dorsal region between the shoulders, resulting from derange- ment of the digestive functions, from the general debility which follows, from the chlorosis and chloro-ansemia which are its conse- quences. Dyspeptic symptoms are developed : heartburn, acidity, vomiting, abdominal distension are often followed by constipation or catarrh in the lower portion of the intestine, painful defecation, tenesmus, mucus passed with the fajces ; the urine becomes muddy, ' Traits desjiuewrs blanches avec la metliode de les guerir. Paris, 1766, 580 UTERINE DISEASES IN DETAIL loaded, muco-purulent, and micturition is painful. Emaciation, languor, sadness complete the picture. Objective signs. — Tension and resistance in the hypogastrium, sensi- bility of the cervix ; digital touch discovers a characteristic glairy or purulent mucus ; there is often flaccidity of the uterine walls, some- times increased size of the neck or body ; the latter becomes globular, especially when by occlusion of the orifices from the swelling of the mucous membrane or by their obliteration from the formation of bands or the adhesion of ulcerated surfaces, the products of secretion are accumulated and retained in the uterine cavity. The hollow uterine sound penetrates with some difficulty ; but when once it has done so, it is mobile in every direction, showing an increased capacity of the cavity of the womb ; sometimes mucus is discharged from its canal. Frequent exuberations are observed on the cervix, even on the border of the orifice and particularly on the inferior lip, a pheno- menon which may depend on maceration of the epithelium by the mucous secretion as Gosselin has remarked,^ but which may also exist as a complication, as in more serious alterations such as granulations, fungosities, and follicular cysts. I agree with Scan- zoni^ that persistent leucorrhcea, like uterine congestion which often accompanies it, may, by the irritation and hypersemia which it keeps up in the organ, favour the development of chronic me- tritis, ulcerations, granulations, uterine fungosities, follicular cysts, fibroid bodies, &c. Catarrhal leucorrhcea is rarer in the vagina than in the uterus ; but may manifest itself in the former organ, succeeding vaginitis ; it may, especially in the acute form, exist simultaneously in both. It is the same with rheumatic leucorrhcea which scarcely differs from catarrhal leucorrhcea : but usually rheu- matism affects the muscular tissue rather than the mucous membrane of the uterus. VI. IhjdrorrhcBa. Hydrometria. Physometria? — This is the occa- sion to say a few words on these rare morbid states, the existence of which has often been doubted. Kydrorrhoea is the abundant discharge of an aqueous fluid from the uterine os; hydrometria, the tumour formed by the retention of this fluid in the uterus ; physometria, the distension of the uterus by gases. Apart from amniotic dropsy, the results of abnormal pregnancy, 1 De la valeur symptomatique cles ulcerations du col uterin [Arcliiv. gener. de med., 4^ serie, t. ii, p. 129, 1815), 2 Op. cit., p. 175. 3 Lafosse, Theses de Strasbourg, 1816, No. .39. — Tessier of Lyons, Be I'Hy- dropisie et de la Tympanite uterines hors de I'ctat de gestation {Gaz. med. de Paris, p. 8, 1844). — Jobeii, De VHydropisie du col uterin {Journ. de Chir., t. i, p. 265. Paris, 1843). — P. Franck, Traite de med. prat., t. ii, p. 20. Paris, 1842. — Bonet, Sepulchretum, L. iii, sect, xxi, obs. 55. Consult also for Hydrometria : Dard, Gazette medicale de Paris, 1855, p. 44 ; Shanks, Id., 1855, p. 178 ; and a case in the Gazette hebdomadaire, 1855, p. 411 ; Malicheis, Gazette des Hnpitaux, 18G6, p. 323. For Physometria : Roy (Gazette medicale de Paris, 1833, p. 629) ; Batten (Id., 1834, p. 505) ; Pellet (Id., 1850, p. 114) ; and Cunstatt's Jahrcsbericht, 1849. p. 333. LEUCORRHCEA AND UTERINE CATARRH 681 moles, alterations in the dead body of a fcctus, its membranes, or the placenta, the intra-uterine opening of a tubal or ovarian cyst, and the other causes of false leucorrha3a already enumerated, hydrorrhoea and hydrometria can only occur from hypersecretion of the uterine mucous membrane.^ The fluid secreted may be altered in its quantity and quality, be discharged continuously or intermittently, be completely retained in the uterine cavity and even produce gases ; these are the only direct causes to which hydrorrhoea, hydrometria and physometria can be attributed. The serous, sero-sanguinolent, sanious, ichorous discharges produced by the serious organic alterations of the mucous membrane, are sometimes considerable, but they hardly exceed the limits of the symptomatic discharges included under the name of false leucorrhoea. Idiopathic hydrometria only originates from the secretion of the uterus. Hydrorrhcea therefore supposes an increase of the uterine secretion, accompanied usually by a diminution in the density of the secreted fluid. This diminution in density, which is common to dropsies of other organs, is caused by the precipitation of the solid elements or by an alteration in the secretion of the organ which is brought about by the distension and attenuation of the latter to the condition of a kind of fibro-serous capsule.^ Hydrometria supposes the imperforation of the neck, more frequently its obliteration or its obstruction by the presence of a polypus, by a well-marked flexion or an abnormal tume- faction of the columns of the isthmus which, fitting closely into each other, close the os internum, or even by an interstitial uterine tumour or an extra-uterine one such as an ovarian cyst,^ in short, by the same causes to which we have already attributed (p. 270) retention of the menses (hematometria). It is evident that these two conditions (abun- dant secretion and retention of the fluid secreted) are alone favorable to the formation of a fluid collection in the uterus and to the consecu- tive distension of the walls of this organ. It is also evident that it is after the menopause or prolonged amenorrhoea that hydrometria must be produced ; for in other conditions there would be retention of blood instead of mucus. 1 . Hydrometria thus defined is the uterine ascites or uterine dropsy of the ancients. — The diagnosis may present some difficulty, especially when the uterus is very thin and much distended ; the question is then of a differential diagnosis between hydrometria, hematometria, and preg- nancy (p. 281). In every case there is amenorrhoea or at least reten- tion of the menses. In most cases the size of the uterus does not exceed that of the same organ in the sixth month of gestation, and it only reaches these dimensions slowly. Exceptionally the fluid may pass into the Fallopian tubes, distend them gradually and find an issue into the peritoneal cavity, or it may distend the uterus to the point of causing rupture. ' The existence of idiopatliic hydrometria has heen proved by autopsies made by Cruveilliier {Anat. 'pat]iolo(j .,\. ii, p. 8i9) ami by Thompson {Bledlc.-chir. Transactions, xiii, part i, p. 170). '^ Scanzoni, op. cit., p. \W. 682 UTERINE DISEASES IN DETAIL Puncture of the uterus through the hypogastriura^ may be necessi- tated, or better still puncture of the cervix from the vagina/ dilatation of the cervico-uterine canal, suppression of the obstacle preventing the discharge of the accumulated fluid, all these methods being followed up with great care to keep the uterus open by means of a sound or tents, to make detersive and afterwards caustic injections, to exercise methodic compression on the hypogastrium, to provoke contractions of the muscular fibres of the uterus and the gradual return of this organ to its normal dimensions.^ Cases have*been described in which the fluid was discharged from the uterus by perforation due to ulceration : this evacuation may be very dangerous.* When the isthmus, in place of being obliterated, is only obstructed by a temporary tumefaction, this mechanical obstacle may temporarily hinder the exit of a single drop of mucus from the uterine cavity, as the swelling of the median or one of the lateral lobes of the prostate prevents the discharge of a single drop of urine from the bladder. If this obstacle yields to the variations which menstruation, various movements and muscular contractions produce in the position or in the form of the uterus, there may be alternative retention and evacua- tion of serous or viscous fluids, sometimes in great quantity. T have seen five cases of this disease.^ 2. Fhysometria, pneumatosis or uterine tympanitis when not merely the result of the introduction of air by the injection syringe, or when not dependent on the formation of gas produced by the decomposition of the foetus or placenta, a polypus, or a menstrual clot, may be due to the alteration of the sero-mucous fluid of hydrometria, but this is rare. It is evident that the gas always occupies the upper part of the uterus, in the region of the navel or hypogastrium^ according to whether the patient is standing or lying. Percussion and succussion usually enable us to perceive the peculiar sensation as well as to hear the sound characteristic of air mixed \vith fluid in the uterine cavity. Lastly, the discharge of this gas may take place simultaneously with the fluid in a noisy manner.^ The treatment is the same as that of hydrometria. Treatment. — Leucorrhoea, especially when acute, may, like every catarrh, be cured spontaneously. Treatment ought not, however, to be neglected on that account, for it has often a great tendency to pass into the chronic form, and chronic leucorrhoea is one of the ' Wirer has extracted in this way 32 lbs. of a thidt fluid from the utei-us of a woman of 53 years of a<^e, who recovered {Ann. litt. vied, etr., ii, 29U). ' Cruveilhier has mentioned a case in wliich this puncture was followed by death {Anat. path., i, 281). — See also Clements of Frankfort {Gazette viedicale de Strasbourg, lSi3, p. 371). 3 Fantonelli, Hydrometrie guerie par le seigle ergote {Gazette medicale de Paris, 1837, p. 234). * Luigi {Annali universali di medicina. Milano, March, 1861). ' Browne has described a case, quoted b}- Duges and Boivin (Op. cit., t i p. 259). * Gooch has seen a case of this kind {Diseases of Women, p. 241) ; and Scanzoni two (op. cit., p. 198). LEUCOERHCEA AND UTERINE CATARRH bti3 most obstinate diseases. It gradually produces disorders of the diges- tion, impoverishment of blood, emaciation and consumption mani- fested by languor, paleness of tlie face, alterations of the features and complexion, the whole being designated by the term fades uterina. The physician ought therefore to explain to the patient the necessity for prolonged treatment, not only on account of the difficulty of obtaining cure but of the frequent relapses. Vulval leucorrhoea in children requires more immediate attention still; it ought to be cured at once to prevent the little patients from acquiring the habit of touching the genital organs with their hands, which keeps up and increases the evil and sometimes leads to mastur- bation. On the other hand, leucorrhcea in phthisical patients should not be treated except in the way of paying great attention to cleanli- ness which alleviates the pain and irritation. It plays the part of an anal fistula or artificial exutory, and its suppression sometimes aggra- vates the pulmonary symptoms and havStens death. Most practitioners are agreed as to this. Lagueau was strongly of this opinion, and Lisfranc also {Clinique chirurgicale, t. ii, p. 300), who says, " I have observed a great number of women in whom leucorrhcea diminished or suspended the progress of pulmonary phthisis, sometimes even check- ing it ; hence the necessity for respecting leucorrhoea when there is a morbid visceral affection." A. Treatment of acute leucorrhcea ouglit almost always to be general as well as local. 1. General treatment is much more important than one would be inclined to think : it is almost impossible to cure leucorrhoea without resorting to it, and in some cases it alone is sufficient. It is so in chlorotic patients when the leucorrhoea is dependent on functional disorder. In such cases injections, local applications and cauterisation may be dispensed with. What is required are sedatives, antispasmo- dics, tonics, iron, mineral waters and hydropathy. General treatment is usually sufficient in acute catarrhal leucorrhoea. We should remove the causes, subdue the complications, especially inflammation when it exists, by rest and emollients if not by antiphlogistics, e. g. by general baths, sitz-baths, tepid and sedative irrigations, enemata ; avoiding chills, especially sudden changes of temperature, by wearing flannel and making dry frictions over the whole surface of the skin ; and keeping up the strength by tonic but unstimulating diet. These means, however, are not always enough : sometimes we should try to bring on a crisis as in the treatment of bronchial catarrh. The skin from its great extent and the influence which it may have had in the development of the catarrh from exposure to a chill, appears the most favorable organ for the establishment of this crisis. With this aim in view diaphoretics are employed to promote perspiration. When leucorrhoea persists and threatens to pass into the chronic form, this diaphoretic action is transformed into revulsion hy sweating, or irritating or serous revul- sion by the use of dry or stimulating frictions over the whole surface of the body, rubefacients, epispastics, blisters, or at least frictions with croton oil, so as to obtain a miliary eruption which is covered by an 584 UTERINE DISEASES IN DETAIL adhesive paper to spare the patient too great pain. If cutaneous revulsion is insufficient, intestinal revulsion may be added by repeated purgatives. The cure which is quickly obtained in this way should be kept up by overcoming the debility which predisposes to relapses and chronicity by administering iron, cold baths followed by frictions, residence in the country, &c. 2. Local treatment. — Lastly, passage to the chronic state should be prevented by the use of local astringents: tepid vaginal injections (tannin, coal tar, sulphate of zinc or copper, alum) ; inert or astringent powders like subnitrate of bismuth, alum alone or mixed with starch, applied to the vagina by insufflation or on a tampon ; and by painting the vagina with a weak solution of nitrate of silver or tincture of iodine. These means, however, though heroic in chronic leucorrhcea, should be cautiously employed in the acute form. B. Treatment of chronic leucorrlma. — 1. Prom the beginning it often affects this diathetic character, which shows the necessity of attacking it by general treatment. It does not necessarily follow that it has been originated by a diathesis : defective and disordered men- struation, pregnancy, abortion, delivery, physiological excitement, excesses, mechanical irritation, the sudden invasion of an acute catar- rhal affection have often been its starting-point ; but a diathesis, the latent existence of which had passed unobserved till then, finding in this morbid state an opportunity to become localised, is not long in replacing the occasional cause the action of which is soon exhausted ; it imprints its character on the leucorrhcea and soon becomes with the alteration of tissue which is dependent on the duration of the disorder, the principal if not the only cause of its persistence. Whatever point may have been invaded by a pathological action, however limited the space on which its evolution is effected, however slight the symptoms of its presence may be, a pre-existing affection almost always takes this opportunity of ceasing to be latent ; it manifests itself externally, and forms, if not the very nature of the morbid state, at least one of its most serious complications. Therefore even when not diathetic origin- ally, leucorrhcea soon becomes so. What takes place in women in the case of leucorrhcea is similar to what occurs in men in the case of chronic discharges from the urethra and prostate. Nothing is more easily or quickly cured in a healthy man of good constitution : nothing more difficult in a catarrhal, rheumatic, gouty, herpetic or scrofulous subject. I have seen so many examples in both sexes of the difficulty of effecting a cure in such circumstances, and of the necessity of resorting to antidiathetics and restoratives, of the insufficiency of local treatment employed alone, of the success of the same treatment when preceded by general treatment, that I have no hesitation in saying that this is the true secret of the treatment and cure of these maladies. The affections which exercise most influence on the duration of leucor- rhcea may be arranged as to their frequency almost in the following order : chlorosis, chloro-ana^mia, catarrh and rheumatism, herpetic, scrofulous or sypliilitic diathesis. Each of these is the source of a special indication, sometimes specific; in this way iron, alteratives. LEUCORRUCEA AND UTERINE CATARRH 585 iodine, mercury, arsenic, iodide of iron and cod-liver oil may be admi- nistered successfully in the treatment of leucorrhoea in cliildren, according to the nature of the afi'ection which keeps up this morbid condition. At the head of these means we must place restoratives, tonics, quinine, iron, residence in the country, change in the mode of of life, and especially climate. I have seen striking examples of the influence of the change to a dry and warm climate from a cold and damp one. The balsams, tar water, pills of turpentine, in leucorrhoea as in all other catarrhal diseases, act simultaneously on the base or affection and on the form or hypersecretion. I find tar water of great use and it is not repugnant to patients when mixed with seltzer water. Ergot has a more direct action on the uterus and has been employed with success. Marshall Hall,^ Bazzoni," recommend it in chronic leucorrhoea, one drachm boiled in eight ounces of water, half to be taken one day, the other half the next; they say that very rarely more is required. It may also be taken in powder every six hours in varying doses. It is evident that it may render great service in cases where the cavity of the uterus is the seat of the excretion, by stimulating the weakened contractility of the walls of the organ. Mineral waters are often recommended but are not always efficacious. Natural or artificial iron baths, so highly thought of by some physicians, are useful in cases of chlorotic leucorrhoea ; but if another diathesis is added to the chlorotic they may be more hurtful than useful. I have even seen some chlorotic patients to whom they have done no good, whilst alkaline waters, but especially sulphur and sea bathing, have been very beneficial. In doubtful cases therefore we should try different means in place of obstinately persevering with one which, however valuable, has its limits. Sulphur baths and sea bathing are efficacious in scrofulous children. Hydropathy, however, is much more generally useful. In chronic uterine catarrh cold water employed in various ways with the graduated and energetic reactions provoked by its methodic application produces wonderful results. It is the best revulsive and the best tonic and cannot be too much used in the treatment of this disease. When necessary, the douche may be pre- ceded by a vapour bath which determines revulsion on a large surface and by abundant sweating helps to restore the functions of the skin, substituting cutaneous perspiration for the morbid flux of leucorrhoea. Only we must beware of weakening patients, and take care to follow up this medication by tonic treatment. When vapour baths, dry frictions and hydropathy are contra-indi- cated, we may resort to the revulsion produced on the digestive tube by purgatives, or on the skin by epispastics. I cannot, however, recommend this kind of revulsion : patients affected with chronic leucorrhoea being generally weak and dyspeptic, the only result is increased debility and irritation. Cutaneous epispastics also sometimes ' London Medic, and Phys. Journal, vol. Ixi, p. 399, 1829. - Omodei, Annali di medicina, May, 1831. — Lazowski, Bemie therapeutique du Midi, t. V, p. 211, 1853. 586 UTERINE DISEASES IN DETAIL irritate greatly by the pain which they cause and the rest they neces- sitate, especially when applied to the abdomen. Therefore I seldom use purgatives and then only at the end of acute leucorrhoea to prevent its passage to the chronic form, or during the treatment of the latter as laxatives to keep the bowels regular, increase the appetite and stimulate digestion, rather than as a revulsive on an organ which ought to be spared. Schoenbein and Aran ^ have recommended enemata containing aloes suspended in a kind of mucilage of soap and water. The results are successful in proportion to the time they are retained. One may be taken every night or every two nights till there is irritation of the rectum or anus ; they should then be sus- pended for a few days and resumed if found useful. They are only suitable when all the congestive or inflammatory symptoms have dis- appeared : after all, they are very uncertain, and the same may be said of enemata of colocynth. The application of blisters to the cervix is very useful in cases of uterine leucorrhoea especially when it IS the body of the uterus that is affected, when there is no discharge from the vulva and vagina and when the cervix is almost healthy, merely engorged or at least when it is not the principal seat of the discharge. The blister is applied according to the rules pre- viously laid down. One blister is not enough, it is almost always necessary to apply a second, third, and sometimes even a fourth at intervals of a fort- night, taking care to prevent inflammation by rest, the use of baths and emollients, continuing general treatment as much as possible. It is needless to say that blisters should not be applied at the monthly period. I have found them very useful when circum- stances prevented the use of hydropathy and mineral waters. Simul- taneously, I recommend the abdomen to be wrapped in cotton wool with an india-rubber bandage over it so as to keep up constant moist heat. 2. We have now come to the local treatment of chronic leucor- rhcea. This should frequently be associated with general treat- ment; but with the exception of simple irrigations or emollient and detersive injections to promote cleanliness and alleviate pain, topical applications should generally be confined to the last stage, when the constitution is sufficiently modified to give us reason to hope that energetic local action may put a stop to the discharge. For vulval and vaginal leucorrJuea these local applications are : injections, powders and various applications. Their object is to modify directly the surface of the mucous membrane and the cavity of the follicles which are the seat of leucorrhoeal discharge, in fact the local morbid state, which seems to keep up the discharge as if by habit of hypersecretion. The injections or rather vaginal irrigations made on the bidet with ' Bulletin de thdrapeutique, t. liv, p. 193. Maladies de I'uterus, p. 464. The prescription is : Aloes gr. Ixxv ; Saponis gv. Ix.w ; Aq. fervent is ^iij ; to be injected at bedtime when cold, after having enaptied the intestine by a tepid enema. LEUCORRHCEA AND UTERINE CATARRH 587 the hydroclyse should usually be tonic, astringent and caustic. They are sometimes made with the mineral water itself during the bath, whether emollient, alkaline, iron or sulphur. After having injected pure water into the vagina for a few minutes, a solution of coal tar may be used, or a decoction of walnut-leaves, tannin, or oak bark, or a solution of alum (^j to a quart of water), sulphate of zinc (same strength), sulphate of copper (30 grains to a quart), or a very weak solu- tion of salicylate of soda. Instead of injections it has been proposed to apply astringents or slight caustics in the form of ointments or powders. The action of ouitmeuts is uncertain, and the presence of grease in the vagina is not favorable to the cure of leucorrhoea. It is different with powders -. they absorb the fluid or are gradually dis- solved, and so the tissues in contact with the solution are affected continuously. The subnitrate of bismuth is the best, and the way to apply it is to powder the diseased surfaces with it through the specu- lum. Sometimes bags filled with inert and astringent powders are introduced, or they may be placed on a tampon of cotton wool. The latter is one of the best ways, I prefer it to soaking the pledget in an astringent or caustic solution because it acts simultaneously as an absorbent and modificator : I confess, however, that I do not much hke leaving any foreign body in the vagina ; but I except tampons saturated in a glycerole of tannin (gr. 30 to 5ij of tannin to glycerine 5J). The solubility of tannin in glycerine, and the absorption of the glycerine by the vaginal mucous membrane render this apphcation, which was first suggested by Demarquay,^ very efficacious. After cleansing the vagina thoroughly introduce a large tampon wrung out of hot water and then saturated with the glycerole and repeat every two or three days. It is better still to pour one or two spoonfuls of this glycerole into the vagina through a Tergusson's speculum and afterwards introduce a tampon of dry cotton wool vrhich the patient can remove the next morning and then make a vaginal in- jection. It is still easier to modify the mucous membrane by painting with a brush. A solution of tincture of iodine (1 in 5, 10 or 20) may be used, or tannin or glycerole of tannin of the same strength, or peroxy chloride of iron or a solution of nitrate of silver ( 1 in 30, 20 or 15) applied every two days. The same medication is applicable to uterine leucorrhoea ; only it is more difficult to apply caustic to this mucous membrane and to make it penetrate into the follicles. The following method is the best : in the first place the mucus must be expelled from the uterine cavity. To do this I compress the cervix with the speculum, and sometimes the body simultaneously by abdominal palpation ; or I direct a small douche on the cervix ; or after having used the sound to ascertain the direction of the cervico-uterine canal, I introduce a fine brush or inject tepid water by means of a hollow sound, continuing to do so suffi- ciently long to let the cavity be thoroughly cleansed, i. e. if the orifice is large enough to allow the water to pass back into the vagina. If ^ De la Glycerine et de ses applications a la medecine et a la chirurgie. Paris, 1863. 588 UTERINE DISEASES IN DETAIL the OS is not large enough it must first of all be enlarged. The os and cervical canal should be sufficiently enlarged to expose the mucous membrane of the cervix. We are then sure of reaching the sources of the leucorrhceic secretion with the caustic. After these preliminary preparations I introduce a brush covered with caustic into the cavity of the organ turning it in various directions so as to reach the whole surface. When the leucorrhoea is situated in the cervical portion and is of sufficiently long standing to have produced hypertropiiy of the cervical glands more must be done : in such circumstances we cannot dilate the raucous membrane sufficiently nor cleanse it thoroughly, nor yet reach the follicles and excretory canals of the rugged surface (Fig. 334) with the caustic. I therefore have recourse to a small preliminary operation which I often employ in the treatment of fol- licular granulations of the tonsils, palate and pharynx : I make numerous scarifications m various directions over the whole of this rough surface, either with an ordinary scarificator, a narrow convex " or concave tenotome knife, or with a small lancet. I wait till the slight haemorrhage is arrested : I then wash the cervix with very hot water to stop the haemorrhage and to cleanse the surface of the cavity, after which I apply a caustic solution. If these caustic solutions are insufficient, or if the leucorrhcea is compli- cated by ulcerations, granulations or an engorgement of the neck, I substitute the solid caustic or even the actual cautery (a fine cautery like the bill of a bird or a knife), which T apply in various directions in the most tumefied portion of the cervical mucous mem- brane, taking care to protect the other portions by Recamier's large curette, to prevent vicious cicatrices which contract and obliterate the cervix when the cauterisation has affected the whole periphery of the cervical cavity (lamentable cases of which I have seen). Huguier^ was the first to recommend making scarifications before cauterising, in order to ensure the action of the caustic on the mucous membrane of the cervix : and I can certify that it is one of the best means of curing this membrane. The difficulty of painting the uterine cavity when the leucorrhcea is from the mucous membrane of the body hais led to the use of caustic injections. Fine vulcanite uterine sounds are used, or india-rubber sounds into which the small cannula of a syringe is fitted (Fig. 199, page 219). We must make sure of two things : 1, that the sound moves freely in the cervico-uterine orifice, and that the fluid when gently injected returns easily by the neck and falls into the vagina ; 2, that there is no trace, I do not say of metritis, but of inflammation of the annexes, perimetritis or pelvic peritonitis. I often prefer cauterising with the solid caustic, with a brush moistened and rolled in powdered nitrate of silver applied several times to the fundus. This cauterisation when well applied is very successful. No leucorrhcea, however abundant, purulent, or chronic withstands this treatment. To sum up : the os ' (iazciic des Hupitaux, 1819. LEUCORRHCEA AND UTERINE CATARRH 589 must be large or well dilated and quite free, there must be no flexion of the body on the cervix preventing the passage of the mucus from Fig. 334. — Transverse ramifications of tlie arhor vita in the cervical cavitj, to show the uneven surfaces of this cavity and the difficulty there is in reach- ing the diseased follicles in cases of leucorrhoja. the one into the other, nor must there be any inflammation either uterine or peri-uterine, or even strong congestion of the organ ; the menses should have ceased a week previously, so that the monthly congestion may have quite disappeared ; lastly, a general treatment should have been followed and simple intra-uterine injections made with applications of less energetic medicaments such as tincture of iodine, iodoform or tannin, to test the sensitiveness of the mucous membrane, or to see whether these milder topics are not sufficient. Usually I apply powdered nitrate of silver to the fundus. Unless 590 UTERINE DISEASES IN DETAIL the OS is unusually large I first dilate it with a sponge tent (Fig. 136, p. 149) ; then I wash it with very hot water and carbolic acid, or salicylate of soda; and then holding the cervix with tenaculum hook forceps I apply successively three or four brushes moistened in water and rolled in powdered nitrate of silver to the uterine fundus, so as to be sure that the whole surface of the mucous membrane has been reached (Fig. 201, p. 221). — Immediately afterwards the patient takes an emollient bath, making injections all the time, or she makes injec- tions on the bidet. She should be confined to bed for a fortnight, con- tinuing the baths and injections. When the leucorrhoea is of long standing and so abundant that this mode of cauterisation seems insuffi- cient, 1 use the crayon. After having used the sound to ascertain the direction of its cavities, I introduce the crayon by means of forceps, or a porte-crayon furnished with a piston (Figs. 202, 203), leaving it in the uterine cavity by opening the forceps, or pushing the piston and then withdrawing the instrument gently. It is needless to say that the fragment of nitrate of silver left is sometimes extremely small, and that its size should vary with the in- tensity of the malady and the more or less favorable conditions for applying it. A tampon saturated with salt water should be introduced into the vaginal cul-de-sac close to. the cervix, and care be taken to prevent the development of inflammation. Immediately alter the operation the pain is alleviated by general and local antispasmodics, enemata, baths and vaginal irrigations, which when necessary may be prolonged for several hours and continued till the next monthly period. I have never seen a case of leucorrhoea withstand this treatment combined with the other means already mentioned, and I have proved by experience that it is unattended with any danger for reasons already explained (p. 224) ; that menstruation has become normal, that conception has taken place and has been followed by normal pregnancy and delivery. Other gynecologists have acknowledged the usefulness of this mode of cauterisation and its innocuity when applied according to the rules I have laid down. Braun of Vienna has invented a small instrument consisting of a cannula of vulcanite furnished with a piston to precipi- tate the nitrate of silver into the cavity in the way 1 first suggested. I have also received letters from a great number of physicians telling me of the success they have obtained from the use of this means in the treatment of obstinate leucorrhoea.^ Hypebtrophy and Atrophy In the first place, common hypertrophy must be distinguished from special hypertrophy. 1. Common hypertrophy atfects all the elements at once, it is true ' Laroyenne of Lyons has also adopted this means ; he uses a crayon composed of equal parts of nitrate of silver and nitrate of potash, Blanchard {ThHes de Paris, 1873). HYPERTROPHY AND ATROPHY 591 uterine hypertrophy. It may be totals i.e. extending over the whole organ (body and neck) ; ox partial (hypertrophy of the body, hyper- trophy of the neck) ; or even be limited to one portion of the body or neck ; when the body is affected, it may be limited to the anterior or posterior segment or one of the cornua, and in the neck it may be confined to the supra- or sub-vaginal portion, or to the anterior or posterior segment, and even in each of these segments, the hyper- trophy may be limited to the vaginal or to the uterine portion of the one or other, to one of the cervical lips, or to one of the columns of the cervico-uterine isthmus. 2. Special hypertrophy or hypertrophy of the tissue affects only one or more of the histological elements of the organ. It may be general, i.e. extending over all the portions of the affected tissue {e.g. hyper- trophy of the tissue proper, hypertrophy of the mucous membrane, hypertrophy of the vascular economy, &c.) ; or local, i.e. limited as to seat as well as to tissue (giving rise to fibromata, follicular polypi, vascular tumours, fungosities, granulations). Nevertheless, although this division is the exact expression of the diversity of the anatomical alterations, I think it is sufficient in practice to distinguish total from partial hypertrophy, and for the latter specially to study hypertrophy of the neck. Partial hypertrophy is more common than total hyper- trophy, that of the cervix is more common than that of the whole uterus, that of the mucous membrane or of some special element of that membrane is more frequent still. Special or histological hyper- trophy is more frequent than common hypertrophy. When the elements of the mucous membrane are aflTected, excrescences are pro- duced known under the names of granulations, fungosities, follicular cysts, mucous polypi, vascular tumours ; when the elements of the tissue proper are affected, polypi, fibroids, &c., are produced. The former having common symptoms requiring analogous treatment will be described in another chapter. The latter, which are very much localised and also often very much developed, assume the character of true organic alterations, and in this way become the source of special indications and will be studied in another section. Here therefore I shall only describe common hypertrophy or hyper- trophy properly so called, that which affects all the elements of the organ and which attacks the whole uterus or one of its two principal segments. The first is total hypertrophy of the womb, the second partial hypertrophy of the cervix. I. — General Hypertrophy of the Womb 1. Hypertrophy proper. — In my lectures I have taught for a long time that general hypertrophy of the uterus should be admitted, and I have shown preparations in support of the opinion. I have distin- guished hypertrophy not only from inflammation, congestion and fluxion which are accompanied by pain, redness, infiltration^ vascular injection and general phenomena ; but also from engorgement which is less consistent, from osdema which is soft, and from the irregular and hard tumefactions of commencing cancer. In general hypertrophy 592 UTERINE DISEASES IN DETAIL the uterus preserves its normal aspect, but is more voluminous ; one would say a womb belonging to a woman of colossal dimensions. Simpson has given a perfect description of this state. Hypertrophy- is always an acquired condition resulting from morbid action, from an exaggeration of normal nutrition. It is a morbid increase in the size of the uterus and of the elements of its normal tissues. Real hyper- trophy is essential or idiopathic, that which Scanzoni designates by the name of primary, which is a disease in itself requiring special treat- ment, the basis of which is resolvent medication. Essential hyper- trophy is seldom primary, i. e. it is rarely developed unless a pre-exist- ing morbid state of the uterus has brought the organ into a condition in which hypertrophy may be developed. The two most favorable conditions for the development of hyper- trophy are congestion and defective involution. When congestion is repeated or prolonged it introduces into the material conditions of the organ the inevitable changes always produced by hyperseraia in the organs aft'ected by it, and in particular hypertrophy. It is in the nature of long continued by persemia to stimulate nutrition in the tissues which are the seat of it. Chronic inflammation may produce the same result ; but it is more apt to induce engorgement or induration : something more is required to bring about hypertrophy. As to defective invohition, it leaves the organ hypertrophied rather than produces hypertrophy : if absorption is interrupted while the normal work of nutrition continues in a uterus the retrograde evolution of which is suspended, the size of the uterus will not decrease, the thickness of its walls will be pre- served, the density of its tissue and the mass of its textular elements will persist, and it will continue in this condition, i. e. it will be hypertrophied. In the former mode of production the hypertrophy is active, in the second it is passive.^ It is very seldom that the whole uterus is equally hypertrophied, sometimes the mucous membrane, at other times the tissue proper is chiefly hypertrophied. Sometimes it is accompanied by enlargement of the cavity of the organ, like excentric cardiac hypertrophy; this is especially the case when a foreign body occupies this cavity. Some- times it coincides with a relative diminution of this cavity, as in con- centric hypertrophy of the heart; there is then often partial hyper- trophy of the tissue proper at one or more points, e. g. the formation of fibroids. I have recently seen a lady who presented a case of this kind, and in whom the uterine cavity measured from 6 to 7 inches in length. Diagnosis. — Individual differences of size and excessive congenital development must be taken into account. When the uterus is really hypertrophied the patient experiences a feeling of discomfort in the ' West describes one cause of uterine hypertrophy to which he attributes great importance, but which seems to me only dependent on congestion or on repeated fluxions produced by immoderate sexual excitement. The cause is not so much excessive coitus, as a voluntary imperfection in the accomplishment of this act, that is to say, copulations repeated too frequently but which are always incomplete and congest the uterus uselessly, and in which conception cannot take place. UYPEliTROPHY AND ATROPHY 593 pelvis and weight on the i)eiiria3ura, without either heat or pain; there is little or no leucorrhocaj sometimes metrorrhagia, at other times amcnorrhoca. Digital touch combined with palpation shows an in- crease in size and weight with prolapsus or deviation ; examination of the cervix by speculum confirms these facts ; the sound discloses an increase in the length and breadth of the uterine cavity and yet no indication of tumour either sessile or pfediculated. The principal symptoms are : on the one hand those which indicate an increase of size, and on the other hand negative characters. For the organ has increased in mass and volume, the number and dimension of its con- stitutive elements are increased, it may even have changed its form ; but its structure has not become modified, nor have its physiological or pathological properties fundamentally altered. Tillaux read a paper before the Societe de Chinirgie} describing a very interesting case of a nullipara who suffered for fifteen years from prolonged and acute menorrhagia to which she succumbed at the age of Vl , and which was due to essential varicose hypertrophy of the uterus associated with fibromata. The case is very interesting from the double point of view of the size that the organ had acquired and the vascular character of the hypertrophy, and affords me an opportunity of here describing the differential diagnosis of symptomatic and essential hypertrophy : 1. Symptomatic hypertrophy (especially from a fibroma) is produced by a double influence. As a foreign body the fibroid provokes con- tractions for its expulsion from the uterine cavity which are unsuc- cessfully repeated till the womb becomes hypertrophied. The fibroid by obstructing the orifice or incompletely determining its occlusion may cause considerable menstrual retention ; a portion of the con- tents may at first escape by overflow, but enough always remains to distend the organ or to provoke contractions ; clots are expelled, but every expulsive effort is an additional cause of hypertrophy : 2. Hypertrophy proper does not require for its development the presence of a foreign body in the uterus. It is not so uncommon as is believed ; cases of special hypertrophy, of fibromata especially, occur frequently in girls and nulliparae. Common and total hypertrophy, although not so general, is sometimes seen. It is known by the absence of any foreign body, or any cause which could have determined frequent contractions of the uterus. In Tillaux's case the hypertrophy was idiopathic : it was common and total, having affected all the ele- ments and the whole organ ; only it was localised more strongly on three points of the tissue proper, where it gave birth to three fibro- mata. One of the most interesting circumstances in Tillaux^s case was that of considerable periodical variations in the volume of the tumour : the enormous increase of the uterus before menstruation and the sensibly diminished size of the organ afterwards. The uterus was congested at every monthly period as if it were really pregnant, I have seen this very often though in a less degree. This great varia- tion in size probably depends on hypertrophy of the sinuses and their enormous dilatation. It might also probably serve as an element of 1 Meetin;^ of the IStli Noveuil.ev, 1868. 38 594 UTERINE DISEASES IN DETAIL differential diagnosis between the hypertrophy which affects simulta- neously all the organic systems of the uterus and the vascular economy exceptionally, and that of the tissue proper in particular. — Lastly, these periodical variations of size, due to the enormous congestion of the uterine vessels, ought to be distinguished from those which depend on incomplete menstrual retention. The essentially distinctive sign between these two morbid' states seems to me to be the absence of muscular contractions in the former, the frequent appearance of ex- pulsive efforts in the latter; the acute pains, the uterine colics expe- rienced by patients in the latter case, will be distinguished easily from the continuous dull pain caused by slow and persistent congestion of the uterus. As to the definite results of menstrual retention on uterine hyper- trophy, what occurs in complete retention must be distinguished from what takes place when retention is incomplete. In the former the uterus is sometimes considerably distended, and the thickness of its walls is not developed in proportion to the capacity of its cavity ; the continuous accumulation of blood which induces haematometria distends the organic tissue, which gradually loses its powers of con- traction at the same time that its walls become attenuated. In the latter, on the contrary, the uterus, especially the muscular tissue, is always hypertrophied. The coagulated blood, the expulsion of which is difficult though not impossible, acts on the uterus as a foreign body, a fibroma, a polypus, a mole ; it provokes incessant contractions, de- termining hypertrophy, particularly hypertrophy of the muscular tissue, and consequently considerable thickening of the uterine walls. Treatment. — Hypertrophy is best treated by resolvent medication, including local resolvents, strictly so called, as well as caustics poten- tial or actual ; and all general m,eans, cutaneous and intestinal revul- sives, alteratives (iodine, mercury, arsenic), vapour baths, hydropathy, and cura /amis. It must, however, be remembered that a malady like hypertrophy takes a long time to cure. The treatment is long and does not always succeed completely. Tortunately health may be restored without complete resolution of the hypertrophy. "When reso- lution cannot be obtained we must be satisfied with palliatives, e.g. a pessary or perinaeal pad kept in place by straps under the thighs and a belt with braces such as is used in cases of prolapsus. 2. Arrested Involution I have reserved a special description for a form of hypertrophy not uncommon according to Simpson -^ I mean hypertrophy due to the arrest of the retrograde evolution of the uterus after delivery. I have said that it is very important to recognise these two phenomena in interpreting uterine diseases. The retrograde evolution of the uterus, which has been well studied in Germany and especially in England, is effected by gradual absorption of the hypertrophied elements. This process comprises two others : a primary modification, the fatty infil- tration of the hyperplastic or hypertrophic muscular fibres, or rather - Op. cit., p. 585. HYPERTROPHY AND ATROPHY 595 the substitution of fat for the elements of muscular fibre, which brings back this fibre to an elementary form more favorable to its absorption and to its definite disappearance ; and a second act of decomposition, the successive absorption of the fibres which have undergone this fatty Fig. 335. Fig. 336. Fig. 337. Fig. 335. — Fibres of the pregnant uterus. Fig. 336. — Fatty infiltration of muscular fibres and gradual absorption of their elements during the period of involution, i.e. recurrence to the state of vacuity after gestation. Fig. 337. — Return of the muscular fibres to the size they present when the uterus is in a state of vacuity. infiltration, and the gradual return of the organ to its histological composition and to its normal dimensions. This process, which is regressive, resorbent and retractive, is designated in England by the term involutioti. Simpson applied the term subinvolution to defective and superinvoluUon to excessive involution. In the former case the uterus remains partly what it was during pregnancy or after delivery : now, in the unimpregnated condition this state is one of real hyper- trophy. In the latter case the uterus exceeds the limits of the normal diminution in size, becoming quite small and atrophied. The hyper- trophy proceeding from defective retrograde evolution is pathological in its permanence, but physiological in its origin. We know nothing of the causes strictly so-called which arrest regressive transformation, absorption and involution of the uterine walls. The occasional circumstances which are most favorable to the action of these essential causes are : metritis, fatigue experienced by the uterus in women who rise too soon after delivery, especially repeated pregnancies and abortions. Diagnosis. — This malady is not very uncommon. Simpson men- tions three cases, and I have seen several others that were very characteristic. It may be suspected then if, in the absence of signs of inflammation or congestion, the patient experiences after the birth of 596 UTERINE DISEASES IN DETAIL her last child menstrual disorders, a feeling of weight and fulness in the pelvis, in short most of the rational symptoms of uterine hyper- trophy. \\e ascertain by direct examination the absence of a distinct tumour while the volume of the uterus is increased in every direction equally, recalling the size of the uterus at the third month of gesta- tion, the sound showing the cavity to be 9 or 10 centimetres or more. Fig. 338. — Uterus of a woman who died immediately after delivery. This figure shows the volume which the organ may preserve when involution is arrested. It is anteflexed ; in other women it is sometimes retroflexed (fig. 291, p. 435). Defective involution always coincides with softening and may be com- plicated by flexion, prolapsus, permanent congestion and even chronic inflammation. There are two principal characteristics which will especially help us in making a diagnosis and in distinguishing the arrest of involution from other kinds of hypertrophy : the first is the uniform softness of the uterine tissue, combined with the wine-red colour and other character- istics of gestative congestion ; the second is the extreme laxity of the ligaments and consequent tendency to prolapsus, or at least the indif- ference of position or direction of the uterus. This distinction is important, since the treattnent of this kind of hypertrophy consists less in the use of resolvents strictly speaking than in the application of means capable of stimulating muscular contractions, and inducing involution ; I have frequently seen this lead to cure in cases in which the disease (for long misunderstood) had been treated as simple con- gestion or chronic hypertrophic metritis. Treatment. — Simpson recommends the use of local antiphlogistics in the acute form of arrested retrograde evolution, asserting that such treatment effects absorption ; but I think he confounds hypertrophy resulting from defective evolution with the cause itself which pro- HYPERTROPHY AND ATROPHY 597 duces it and which temporarily suspends the contraction of the organ; in fact he adds that all traces of inflammation disappear with the use of these means and that their disappearance is followed by rapid improvement. Therefore, he adds, even if all inflammation seems to be extin- guished, and when the results only remain, we often find, without knowing why, that local antiphlogistic treatment has the effect of determining absorption of the hypertrophied organ, and of finally restoring it to its normal condition. Consequently if the patient is not too weak we begin by the application of ten or twelve leeches to the vaginal portion of the cervix, or the perinseum, or round the anus. But in these cases and in the most chronic form the same eS'ects are obtained from the application of counter-irritants to the external surface of the abdomen or sacrum, such as antimonial ointment, croton oil, tincture of iodine; but cantharides is the best stimulator of absorption especially in the chronic form of the disease and when the bladder is not irritable. A series of small blisters may be applied to the lower portion of the abdomen every two or three days till the volume of the uterus is visibly diminished, Simpson used to make them the size of a five-shilling piece and apply one every few days. Whilst absorption is stimulated by the application of counter-irritants to the cutaneous surface, the same action may be promoted by the apphcation of mercurial ointment to the vagina, or iodide of lead, or bromide of potassium, in the form of pessaries. Local applications, however, are not sufficient ; resolvents should also be administered internally. Amongst these the most efficacious are the iodide and bromide of potassium. Simpson preferred the bromide : it has this advantage over the iodide that it can be administered for a much longer time without causing marasmus ; it is tonic and perhaps the best resolvent in the whole pharmacopojia ; it is also a sedative to the genital organs. In such cases from 3 to 7 grains may be given three times a day, indeed the dose may be raised to 90 grains a day. Sometimes patients suffering from this kind of hypertrophy are anaemic and feeble. When this is so recourse should be had to resolvents of iron, manganese and other tonic metals, either alone or associated with more specific remedies in order to improve the general health of patients by hygienic measures. Lastly, when the uterus does not respond to any indirect stimulus we may try Simpson's plan of introducing small sponge tents into the uterus or an intra-uterine pessary. We may provoke a tendency to hypertrophy in the uterus and then take advantage of the tendency of the organ to undergo molecular fatty substitution and retrograde evolution, as soon as the artificial stimulus is withdrawn, and by the use of the various resol- vents already mentioned, rest, counter irritants, and bromide deter- mine such absorption so actively, that the uterus is at last reduced to its normal dimensions. I have also found the use of ergot and elec- tricity beneficial, as well as iron baths, sea bathing, stimulating fric- tions, hydropathy, &c. Simpson says that in some obstinate cases he has been obliged to repeat this treatment by irritation and artificial 598 UTERINE DISEASES IN DETAIL hypertrophy of the organ from time to time before obtaining a com- plete cure. II. Partial Bijperirophy of the Cervix The hypertrophy which is limited to the cervix is characterised especially by the elongation of this portion of the organ. It has often been mistaken for prolapsus. It must not, however, be thought that this uterine displacement is always simulated by hypertrophic elonga- tion of the cervix. Huguier, who deserves the credit of showing the mistake which had for long been made with regard to supposed proci- dentia, has given examples of complete prolapsus uteri without elon- gation of the cervix, and has published woodcuts of them.^ On the other hand we cannot believe with Veit [Zeitschrift f. Geburtsk.,V)di.\, S. 144), that primary hypertrophic elongation is very rare and that this kind of hypertrophy is usually consecutive to prolapsus ; it is on the contrary the hypertrophy which simulates prolapsus ; hypertrophy subsequent to descent may occur, but it is very rare. Hypertrophy may atfect the whole of the cervix ; but usually it is limited to one or other of the two portions of this organ, sometimes to the vaginal or intra-vaginal portion situated below the insertion of the vagina, some- times to the supra- or utero-vaginal portion, situated above this inser- tion and ending in the isthmus separating the cervix from the body ; sometimes even it is insensibly extended to the latter. The former might be designated by the name of cervico-vaginal hypertrophy, the latter by that of cervico-uterine hypertrophy. At other times the hypertrophy is confined to one of the segments, anterior or posterior, or to one portion of this segment. These three maladies should be studied separately. These different kinds of hypertrophy should never be confounded with (Edematous elongation and prolapsus of the cervix during pregnancy, described by Gueniot,^ Scarlau,^ &c. 1. Subvaginal Hypertrophy of the Cervix The relative length of the two portions of the cervix (vaginal and supra- vaginal) de} ends in some women on the height of the vaginal insertion ; but in addition to this cause, which is foreign to the cervix, there is another which exceptionally increases the projection of the cervix, so as to give it considerable length. The proof of this is that in virgins we often see the cervix (usually conical) several centimetres long. Bennet^ has also seen the cervix in virgins nearly 9 centi- metres long, resting on the vulval orifice or even projecting below it, and asserts that the elongation may exist congenitally notwith- standing Huguier's opinion, and in spite of the great tendency of the uterus and cervix to become hypertrophied under the influence of inflammation or even of simple congestive irritation. He has seen ' Memoire siir les allongements hypertrophiques. See the plate taken from Dnpuytren's museum. Case xii, and fif^ure .3. ' Archives de vipdecine, April, 1872. ^ Beitrdge zur Gehurtsk. v. Gynnh., Bd. ii. Heft 1. Berlin, 1872. « Op. cit., p. in. HYPERTROPHY AND ATROPHY 599 several cases in unmarried women when no inflammatory action of any kind could be discovered. They consulted liiin for prolapsus, the appearance of the cervix at the vulva having frightened them and in- duced them or their parents to seek medical advice. The congenital elongations which I have met with have never seemed to me to reach 9 centimetres in length. West says also that hypertrophy of the vaginal portion of the cervix is met with not only in sterile married women, but in virgins, that it may be so serious as to be mistaken for prolapsus, the cervix appearing at the vulva, and that it forms an obstacle to marital intercourse causing sterility. More frequently hypertrophy of the cervix follows the swelling produced in the tissue of the organ by the persistence of the modifica- tions accompanying pregnancy, and is the result of defective involu- tion of the uterus after delivery. The hypertrophy may even be limited, in this case, to one of the cervical lips, usually to the anterior ;^ Fig. 339.— Conical hypertrophy of the sub-vaginal portion (Hugiiier). as a rule also elongation and hypertrophy of the cervix follow the swelling produced in the tissue of the organ by the persistence of con- gestion, inflammation and frequently ulceration of the mucous mem- brane, which is itself the cause of the long duration of these morbid states. Another cause requires to be added to the ulceration, congestion and 1 Evory Kennedy, in Dtiblin Medical Journal, 1838. — Simon of Rostock has also published a remarkable example, with three drawings {Monatsschrift fur Gebiirtsh. n. Frauenl-rankheiten, 1864, Bd. xxiii, S. 241). 600 UTERINE DISEASES IN DETAIL inflammation and to the swelling which accompanies them, in order to produce hypertrophy : the special tendency of the uterus to hyper- FiG. 340. — Pyriform hypertrophy of the sub-vaginal portion (Huguier). trophy requires to be stimulated ; for a congested and swollen cervix equal in size to that of a hypertrophied cervix may remain after several years soft and simply engorged. There is, however, so great a ten- dency towards hypertrophy in the uterus that the effusion of plastic lymph produced by inflammation in the deep tissues becomes organised ; the elements of the tissue proper, stimulated by the persistence of the fluxionary movement, increase in size and multiply ; in fact, real hyper- trophy supervenes, which may survive the extinction of inflamma- tory phenomena. It is very easy to distinguish congenital from morbid hypertrophic elongation of the vaginal portion of the cervix. Congenital hyper- irophy is rare, the elongated cervix is regularly cylindrical or conoid ; its consistency is relatively soft; in appearance it is normal, presenting no lesion, or only superficial alterations, unless it has really become diseased. Morbid hypertropJnj is common, the elongated cervix is irregular, not only conoid but globular, the lower portion sometimes spreading out when the latter is particularly affected by the hypertrophy ; it is congested, inflamed or even ulcerated, and consequently it is hard, painful, sometimes bleeding and requires energetic treatment. HYPERTEOPHY AND ATROPHY 601 With regard to cervical hypertrophy consecutive to inflammation as well as hypertrophy of the whole organ due to defective retrograde Fig. 341. Fig. 342. Fig. 341. — Hypertrophy of the siib-A'aginal portion affecting the two lips un- equally, with aversion of the lips and ectropion of the arbor vita (Huguier). Fig. 342. — Hypertrophy and procidentia of the vaginal portion affecting both lips, which converge towards the cervical cavity ; the anterior lip is more hypertrophied in its centre, the posterior in its whole extent and at its extreme points ; hypertrophic polypi coming from the central column of the anterior lip (Barnes, p. 638). evolution, we must take into account one important circumstance, viz. the time which has elapsed between a delivery or abortion and the development of inflammation; for the hypertrophic character of the malady is frequently due to this circumstance. The nearer the in- flammation is to the period of delivery or abortion the more con- siderable the consecutive hypertrophy will be, because the organ has been seized at the time when regressive absorption had not been able to produce any eff'ect on it. Whether hypertrophy of the cervix may or may not be dependent, like that of the whole organ, on arrested retrograde evolution consecutive to delivery, the limitation of this hypertrophy to the cervix is a favorable circumstance in the prognosis : it is always easier to dissipate cervical hypertrophy, whatever its origin be, than to bring back the hypertrophied fundus to its physiological stale and to its normal dimensions. Whether congenital or morbid, hypertrophy gives to the cervix varied and occasionally singular forms. Sometimes it is pointed and 602 UTERINE DISEASES IN DETAIL conical below (Fig. 339), the os being at the extremity of the cone or on one of its surfaces ; sometimes it is cylindrical, globular or enlarged at the base in the form of a club (Figs. 342, 345). Sometimes the two lips are equally hyper- trophied and the utero-vaginal OS is in the centre (Figs. 343, 345) J sometimes they are une- qually hypertrophied (Fig. 341), the OS being on one or otlier of the surfaces, and occasionally completely hidden by the more hypertrophied lip. Lastly, when the hypertrophy has chiefly af- fected the external layers of the organ the borders of the orifice incline towards the cervical ca- vity (Figs. 340, 342) ; when, on the contrary, the hypertrophy has most affected the internal layers eversion of the lips takes place (Figs. 341, 343) and a kind of eversion of the os, which spreads out like a flower, allow- ing the mucous membrane of the cervical cavity to be seen on the two lips, either equally or unequally, according to whether the hypertrophy has attacked these two portions of the organ equally or not.^ It is to these anomalies of form already known that we must add that prolongation of the cervical lips described by Virchow under the name of polypus of the lips of the os.^ I shall, however, have occasion to recur again to partial hypertrophy of the segments of the cervix, which deserves the serious attention of the physician on account of^its con- nection with sterility. Diagnosis — subjective sigus. — Patients often experience a painful sensation of dragging in the loins, the iliac regions, even the abdomen, a more painful sensation still of weight in the pelvis, produced by tension of the ligaments and pressure of the cervix on the rectum, periiiseum and vulva. When standing they feel as if the uterus were going to escape from the vulval opening; when lying down they feel the pressure of ' See the Atlas belonging to Boivin and Dugfes's work and Huguier's paper. ' Virchow' s Archiv, Bd. vii, S. 164 ; and Verhandl. der Geselhch. f. Ge. bvrtsk. Berlin, Bd ii, S. 205, 1847. Fig. 343. — Advanced hypertrophic elon- gation of the sub-vaginal portion, affecting both lips equally, which di- verge in escaping from the vulva (Barnes, p. 640). irYPEjrnioi'HY and atuoi'Iiy 603 the organ to the right or left and a dragging when the position is changed ; when sitting another sensation is felt, that of compression Fig. 344 — Conical congenital hypertrophy, more common than the preceding. Fig. 345. — Acquired hypertrophy, club-shaped, also more common than the preceding. of the tumour or of the organs situated above it by the chair on which they are seated. And if they sit down quickly in a chair they expe- rience a shock which is felt not only in the hypertrophied organ but in the abdominal viscera; therefore they instinctively sit down with great care. As for the objective signs an idea will readily be formed of the varie- ties of size and form of the organ by looking over the different wood- cuts representing the various kinds of cervical hypertrophy. Bennet ^ gives a characteristic sign distinguishing scirrhous indurations of the cervix from inequalities due to simple hypertrophic induration. When division of the cervix into knotty and irregular lobes results from laceration in a previous confinement and is simply inflammatory or hypertrophic, the fissures which separate the lobes radiate towards the centre of the os, which does not occur in the case of cancerous tumour. Treatment. — I have already laid down the principal indications for the treatment of general hypertrophy of the uterus. They are the same in hypertrophic elongation of the cervix ; effect depletion of the organ when necessary, especially when there are traces of inflammation or congestion; stimulate absorption by resolvents administered inter- nally and externally, by mercurial preparations, iodides, bromides, &c., and by more general means still, addressed more directly to the general I Op. cit.. p. 90. 604 UTERINE DISEASES IN DETAIL nutrition, such as strict diet and regime, sweating, hydropathy, cura famis. With these general means I combine energetic local treatment, with the object of giving a new direction to the vitality of the organ, and of bringing into action the faculty of absorption which has been in some degree stifled by hypertrophy. The use of these last means is doubly indicated because cervical hypertrophy is often due to local pathological conditions consecutive to morbid states which, although they may have been general, have yet only left a limited result on the diseased part. Sometimes I make more or less deep scarifications, introducing into them perchloride of iron, or I apply the actual cautery to them ; at other times I make ignipunctures at the most hypertrophied points of the organ. Paqueliu's thermo-cautery and my small cauteries are the most suitable instruments for this opera- tion (pp. 211, 216). Unfortunately medicinal means and the various modes of cauterisa- tion are insufficient for the treatment of serious hypertrophic elonga- tion. Recourse must be had to excision. Congenital conoid hyper- trophy does not always necessitate amputation of the cervix. Cases requiring incision must be distinguished from those requiring section. Sims (Fig. 846) has represented very exactly a normal tjpe of rounded and truncated cervix. Let us suppose the cervix extended in the direction of the dotted line a, we shall then get a very common form of conical cervix which is almost always associated with constriction of the OS, and almost as constantly with induration. Division of the os extending to the circular fibres will suffice to separate the lips, bring the cervix back to the form of a rounded cone, and cure dysmenor- rha?a and sterility ; but if the cervix extends in the direction of the dotted line b, simple division is not sufficient. A portion of the cervix Fio. 346. — Normal cervix : a, cervix slightly coni- cal ; h, cervix veiy coni- cal (Sims). Fig. 347.— Dotted line indicating the point for section of a coni- cal cervix (Sims). HYPERTROPHY AND ATROPHY 605 will require to be amputated, following the transverse direction of the dotted line in fig. 34-7. Acquired hypertrophy, especially club-shaped hypertrophy (I'igs, 342, 345) or hypertrophy with elongation simulating procidentia, is not only a cause of dysmenorrhoja and sterility, but it cannot be cured by either simple incision or by cauterisation applied in the way I have just described. When hypertrophic elongation of the cervix gives rise to serious symptoms, and has withstood the means described, when it is of long standing, and when it has reached from 5 to 7 centimetres in length, I agree with Huguier ^ that there is only one means of effectual cure, viz. amputation of the cervix \ of an inch from the vaginal insertion. Bennet,^ although not in favour of this ope- ration, acknowledges that it should be performed when elongation of the cervix resists all means of treatment, when it produces permanent dis- comfort, and is an obstacle to marital inter- course or a cause of sterility. West,^ after exaggerating the dangers from haemorrhage and peritonitis, judging from an unfortunate case performed by Paget with the ecraseur, admits that he knows of no other treatment for this malady except ablation of the hypertrophied portion. Scanzoni'^ goes further in his approval of the operation ; he says : "I have so often seen the inefficiency of all therapeutical means, local as well as general, that now I always perform am- putation of the cervix." I also have seen sterility yield to amputation of the hypertrophied cervix. This operation is doubly desirable when elonga- tion is complicated with a cyst, a fibrous tumour or epithelioma commencing at the lower ex- tremity of the cervix. Huguier says, "We should have all the less hesitation in performing it in that it is an operation at once quick, easy, almost painless and generally unattended with danger,^ and that it relieves patients so quickly and surely of their malady." I agree with this opinion all the more willingly that I know of no other means that can be substituted for ablation of the cervix, and that there are cases in which the malady not only proves uncomfortable but ' Op. cit., p. 23. "' Op. cit., pp. 11, 324. 3 Op. cit., p. 100. * Lehrhuch der Kranl-hcitcn dcr Weihlichen Sexnalorgane. Wien. S. 7(i. ^ This operation however, like simple cauterisation, is not without danger Fig. 31S. — Museux's forceps for seizing the hypertrophied cervix : A, with two hooks ; B, with three hooks. 006 UTERINE DISEASES IN DETAIL painful, reacting on the whole economy and necessitating prompt and decisive intervention. The patient should lie on her back so that plenty of light is thrown on the pelvis. Sometimes the cervix pro- jects at the vulva, in which case the labia and vaginal walls may be separated with dilators or the fingers of an assistant, to reach the point at which the amputation is to be performed. Sometimes it is hidden in the pelvic cavity : in which case it must be brought to view by means of a large bivalve speculum, or two dilators. In any case, it is best to follow Huguier's advice to amputate the cervix without using efforts to try to bring it to the vulva and without dragging on the uterine ligaments. The cervix is then seized with a strong tenaculum hook or with Museux's forceps. It is at first drawn upwards, and then with a long- handled curved bistoury a semicircular incision is made at its lower portion, half a centimetre below the vaginal insertion. It is then drawn downwards, and the upper half of it is divided in the same Fig. 349. — Amputation of the vaginal poi-tion of the hypei-tropbied cervix with Chassaignac's linear ecraseur. manner. The hardness of the tissue and the difficulty of managing the bistoury, sometimes make long curved scissors preferable. I have often used them if not to commence with, at least to finish the section, so as to give it the proper regularity. In fact I prefer using the thermo-cautery or a small cautery at red-heat, to avoid haemorrhage in Apart from opening the peritoneum, examples of which I shall give later on, I may just refer to the case published by Greenhalgh of ablation of the cervix by the ccrasetir, followed by peritonitis and death [Obstetrical Transactions, vol. V, pp. 75 and 102). We should therefore be sure that there is no inflam- mation of tlie annexes or pelvic peritoneum. HYPERTROPHY AND ATROPHY 607 forming the posterior and anterior flaps. Even when the haemor- rhage does not seem alarming at first we sliould pay attention to it, and not leave the patient till it has entirely ceased. Plugging the vagina is sufficient, but it should be done methodically : after having washed the cervix with cold vinegar and water or with iced water (provided that ice can be continuously applied for several days to the hypogastrium, rectum or vagina), small tampons of cotton- wool powdered with alum or saturated with tincture of perchloride of iron should be laid against the bleeding surface, then compressed and kept in place with a number of other tampons till the whole vaginal cavity is filled, when if necessary they can be retained by a T bandage. This dressing is removed the next day or the day following, care being taken to remove only the superficial tampons at first, leaving those that are in contact with the amputated portion for some time longer, and facilitating their removal by making injections to prevent any laceration which would inevitably cause a return of the haemorrhage. All these inconveniences, however, are avoided by the use of the actual cautery. When the base of the tumour is large and traversed by arteries the pulsations of which can be felt, when the patient is chlorotic and can- not be exposed without danger to haemorrhage, the ecraseur should be used. This instrument, however, has two disadvantages : the first is, that it makes the operation not only long but painful when chloroform is not used, on account of the symptoms of strangulation determined by the constriction of the chain ; the second is the difficulty of placing the ecraseur properly on the cervix alone without including a portion of the vaginal walls, and even without touching the bladder or without opening the peritoneum. Huguier mentions a case that occurred in Langenbeck's clinique, in which these two accidents both happened ; the patient died the third day ; a perforation of the bladder and peri- toneum was discovered.^ Therefore I have replaced the ecraseur by the elastic ligature, which has all the advantages of the extemporaneous ligature and is more conveniently applied. If it is desirable to operate more quickly the galvano-caustic wire may be applied, which was used so successfully by Lehmann [Nederl. Tidjschrift voor Geneeslc, 1877, No. 7) in a case of prolapsus with elongation, in which the total length of the uterus was 16 centimetres; but Paquelin^s thermo- cautery is better. We must take precautions against consecutive obliteration. I have collected six cases. In order to prevent it I commence by dissecting (with the cautery) two large flaps of mucous membrane, either antero-posterior or lateral, and apply the elastic ligature to the tissue proper at the base, where the flap is adherent, or I finish this section with Paquelin^s thermo-cautery. The flaps of mucous membrane are then united to the tissue by a metallic suture, and ^ This accident has occurred several times, after removal of the cervix by the linear ecraseur, either on account of hypertrophy or cancer. Besides Lan- genbeck's patient, in whom the peritoneum was injured, according to the report made by Mayer to the Obstetrical Society of Berlin, five cases at least of this serioiis accident are recorded. 608 UTERINE DISEASES IN DETAIL are sufficient afterwards to procure autoplastic restoration of the orifice. This is, I consider, at present the best method of performing partial section of the cervix. When there is no danger of haemorrhage and no special indication for the use of the ecraseur, the thermo-cautery or the elastic ligature, it is better to make a clean, transverse section of the cervix which allows of union by first intention. It is to Marion Sims that we owe this idea. In 1859 this surgeon, being about to perform section of a hypertrophied cervix, and not having an ecraseur by him, slit the organ on both sides with scissors as far as the insertion of the vagina, excised both halves,^ and covered the bleeding surface with the vaginal mucous membrane, as the stump of a leg is covered with the skin after circular amputation. The borders of the wound were united from before backwards with four metallic sutures, two on each side of the cervical canal. The wound healed by first intention ; the sutures were removed nine or ten days afterwards. There was no other opening than the oval orifice of the cervical canal in the centre of the line of union.- Since then Sims has adopted this method in his practice.^ I have also employed it with success; but I prefer autoplasty of the cervix by excision of two portions of the uterine tissue, after previous dissection Fig. 350. — Amputation of the cer- Fig. 351. — Twisted sutures, union by vix, four metallic threads passed first intention (Sims), though the lips of the wound. of two flaps either antero- posterior or lateral according to my method, or semicircular to allow of excision of a conical portion of the tissue, according to Max Markwald's method. ' Later on, he adopted a kind of small guillotine for excision of tlie cervix (op. cit., pp. 211, 224). ^ Spiegclberg has published a paper in Archiv fiir Gynaelcol., Bd. v, Heft 3. Berlin, 1873 {Ueber die Amputation des Scheidenthcils der Geharvmtter), containing unpublished cases on various modes of amputating the cervix in cases of carcinoma, ]iypertro])hy, elongation, etc. The author prefers the method of Sims for hypertrophic elongation (llayem, Revue des sciences modi- cales, iii, 205). HYPERTROPHY AND ATROPHY 609 After amputation of tlie cervix, whether simple or by the method of Sims, even when followed by immediate union, if there is consecutive contraction of the external orifice it is better to let things take their course than prevent union of the wound by premature and inopportune dilatations. Two or three months afterwards the orifice can be enlarged by incision and dilatation, as in cases of congenital narrowness in which autoplasty is practised. 2. Supra-vaginal Hijpertrophj of the Cervix Hypertrophic elongation of the supra-vaginal portion of the cervix (cervico-uterine elongation) was discovered by Huguier^ in 1849. Before the appearance of his work this elongation had been mistaken for procidentia, and although measurements had been taken both on the living and dead body by Saviard, Morgagi)i, Hoin, Levret, Dance, Cloquet and Cruveilhier, which proved excessive length of the supra- vaginal portion of the cervix and the presence in the pelvis of the supposed prolapsed uterus, no conclusions had been drawn from them as to the existence of cervico-uterine hypertrophy, its diagnosis or treatment. West2 refers in a few words to the existence of supra-vaginal hyper- trophy. He mentions the case quoted by Morgagni^ and the descrip- tion given of it by some German writers, especially by Virchow,* under the name oi prolapsus of the womb without descent of the fundus. He mentions a specimen of this kind of alteration which is in the Museum of St. Bartholomew's Hospital, series xxxii, 30. He justly remarks that the mechanical means of support and reduction, which are useful in true prolapsus, are useless here and only aggravate the sufferings of the patient. Diagnosis — subjective signs. — The principal are the following : abnormal heat and sensibility, pain, muco-purulent hypersecretion from the uterus. Menstruation usually longer and more abundant, prolonged after the age of the menopause, sometimes accompanied by metrorrhagia. Marital intercourse often difficult or impossible, and generally sterility. Micturition frequent, painful, difficult and even impossible^ unless the patient pushes the tumour backwards and up- wards with her hand ; for the bladder partly escapes from abdominal pressure, its walls are relaxed and weakened, and the urethra is strongly flexed at the point where it crosses the subpubic ligament and Wilson's muscle. Sometimes there is incontinence of urine, at other times re- tention. The clothes, the abdomen and the tumour are soiled by con- tact with the urine, which cannot be voided in a jet; hence itching, irritation, frequently even excoriation and ulceration of the vaginal mucous membrane, especially of that which covers the anterior surface 1 Memoir e sur les allongevients liypertrophiques du col cle I'utertis dans les affections designees sous le noni de descente, de precipitation de cet organe, et sur leur traitemeni par la resection on V amputation de la totalite du col, suivant la variete de la maladie. Paris, 18G0. ^ Op. cit., pp. 141-45. ^ Morgagni, De sedibus et Causis Morborum, folio. Venetiis, 1761, 2nd vol epist. 45, art. 11, p. 201. '* Verhandl. der Gesellschaft f. Geburtshiilfe in Berlin, vol. ii, p. 205, 1847. 39 610 UTERINE DISEASES IN DETAIL of the tumour. There is constipation and difficulty of defecation from the retention of fscal matters at the point where the tumour projects into the rectum, patients being sometimes obliged to lift the tumour upwards and forwards, to favour'the accomplishment of this act. When the Fig. 352. — Considerable hrpei-trophic elongation of the supra-vaginal portion especially, but also of the sub-vaginal portion. From a preparation in St. Bartholomew's Museum. The Fallopian tubes are also diseased. The vagina contains the globular portion of the elongated cervix (Barnes). perinaeum is lacerated there is at the same time incontinence of fsecal matter ; in such cases there is irritation and frequently ulceration of the posterior half of the tumour. Lastly, when the patient is obliged to walk or work, in addition to the general feeling of discomfort, there is a dread of the viscera escaping through the vulva, there being no longer any resistance from HYPERTROPHY AND ATROniV 611 the peririDcum, and she also experiences constant pain, dragging in the lumbo-sacral region, sometimes in the hypogastrium and groiiis, at other Fig. 353. — Hypertrophic elongation, principally o£ the supra-vaginal portion of the neck, simulating prolajDsus : /, fundus ; i, isthmus ; c, cervix (from nature, after Farre). times in the epigastrium. Every position, especially the vertical one, becomes difficult. Lastly, digestion and nutrition are disturbed. Objective signs. — In procidentia the sound penetrates to a depth of from 6 to 7 centimetres, in elongation from 9 to 15 centimetres and exceptionally to 20. The sound also allows us to ascertain the direc- tion of the cervico-uterine canal, the situation of the fundus, &c. Other means also allow a differential diagnosis to be established and completed by the discovery of other elements which may exist in the tumour. For instance, in hypertrophic elongation, rectal touch dis- covers the cervix and above that the body of the uterus ; in procidentia it reveals a vacuum in the middle, and laterally two painful cords, ex- tending from the angles of the womb and formed by the round liga- ments, the ovaries and the Fallopian tubes. A sound passed into the bladder and directed towards the rectum is arrested in the middle by the hypertrophied cervix ; on the contrary it may be felt by the finger placed in the rectum above and behind the uterus when the latter is merely prolapsed. Palpation of the tumour in cases of elongation discovers the presence in its centre and throughout its whole length of a hard and rather broad cylinder ; while in procidentia it reveals a vacuum in the centre of its base, and below this a firm elastic body, of the form and consistency of the uterus, and continuous with the sub- vaginal portion of the cervix, which is visible externally. Lastly, attempted reduction .of the tumour gives quite different results in both cases : in procidentia, the first part of reduction, that of making the body of the uterus pass througli the vulva, may be painful, difficult or 612 UTEEINE DISEASES IN DETAIL impossible, especially during the menstrual period ; the second part is easy, the parts seeming to go up of themselves, the patient is soothed and the uterus may be maintained by a pessary ; in hypertrophic Fig. 354. — Complete procidentia, from a preparation in St. George's luuseuni (Barnes), pa, anterior peritoneal fossa; pp, posterior peritoneal fossa; T, cjstocele ; E, rectum ; p, pubis ; v, uretlira ; A, anus ; o, ovary ; v, bladder ; M, womb. elongation reduction is easy at any time, either before or after men- struation, the entrance of the tumour is effected without any resist- ance from the vulval orifice, it takes place gradually, without pain till the cervix is on a level with the lower extremity of the vagina ; flat, oval, annular pessaries may then be borne with benefit ; but if we wish to raise this part higher, to its normal position, we usually feel resist- ance, the uterus becomes curved on itself, and more or less acute pain is produced, or the body of the uterus is raised out of the pelvic into the abdominal cavity, where it causes great discomfort and even un bearable pain by its pressure on the neighbouring parts and by the tension exercised on its own ligaments. These considerations are very useful in establishing a differential diagnosis. Treatment. — The impossibility of reducing the tumour and of main- taining it reduced in confirmed hypertrophic elongation explains how this malady, reputed to be incurable, becomes a real infirmity which onlv rest combined with the use of vulval bandages of various kinds BYPERTROPHT AND ATROPHY 618 makes bearable. The discomfort attendant on micturition of which I have spoken, the contact of the urine with the tumour, the friction of the latter against the clothes, and the ulceration which follows cause such constant discomfort that the intervention of art becomes neces- sary. Unfortunately the means at our disposal are very incomplete, and are only successful when the malady is slight. As for medical means, those which I have enumerated in speaking of general hypertrophy may be used ; the horizontal posture with the pelvis raised, iodide of potassium, ergot, cold enemata, frictions with resolvent ointment, &c. When the elongation is not very extensive (about 2 or 3 centi- metres), when the upper extremity of the vagina only is inverted and when the whole of the tumour does not protrude more than from 4 to 5 centimetres beyond the vulva when the patient strains in a standing position, the cervix and vagina can usually be kept reduced by one of the numerous varieties of pessaries (especially Hodge^s lever pessary). Unfortunately reduction cannot always be maintained for want of aj)oini d'appui owing to the considerable enlargement of the transverse diameter of the vaginal opening. Their diameter must therefore be proportioned to that of the vaginal opening. I know a woman aged sixty affected with hypertrophic elongation measuring nearly 12 centimetres, mistaken till lately for a simple prolapsus ; she was accustomed to reduce it by means of a large ball of linen which served as a pessary, and although suffering discomfort she is able to do a great deal of hard work in a maternity hospital. When the pro- lapsed parts can be raised above the vulval opening and when patients cannot tolerate any kind of pessary, we must be content with main- taining the tumour in this position by means of an oval plate sup- ported by elastic bands, or mounted on a steel spring fixed to a belt. Unfortunately the presence and pressure of this plate can hardly be borne by women who have hard work to do ; sometimes too the uterus escapes at one side of the instrument, and the contact of the latter irritates the organs and provokes secretions so that patients are obliged to lay it aside. When these means are found insufficient, an operation should be tried. ^ This operation, which consists in removing a part or the whole of the cervix with the upper extremity of the vagina, by scoop- ing it out from without inwards, after having previously detached the bladder from the part which is to be removed, has been suggested by Huguier under the name of conoid amputation of the cervix. It has been successfully performed by this surgeon and by others ; I have performed it several times with equal success ; and although not exempt from danger, it seems to me that it ought to be accej)ted as the only means of curing an infirmity which though not endangering life yet produces very great discomfort. We must not, however, * I agree with Marion Sims who, while approving of Hugtiier's operation, says, that as a rule conoid amputation should only be made when there is hypertrophic elongation of the infra-vaginal portion of the cervix as well as procidentia and supra-vaginal hypertrophy. 614 UTERINE DISEASES IN DETAIL forget that the most serious accidents may be developed, for they occur on the occasion of much less serious operations. Metritis or peritonitis may cause the death of patients. Peter/ the translator of the last edition of Bennet's Treatise on Uteritie Inflammation, mentions an unfortunate case of the kind which he saw. The surgeon must judge of each case individually, taking into account all the indications and contra-indications. The object of the operation is not merely to amputate the sub- vaginal portion of the cervix, but also to remove that extending between the insertions of the vagina and the body of the organ, which is the principal seat of hypertrophy. It should be performed a few days after the menstrual period, the patient having since then made very hot injections and kept the horizontal posture. The first part of the operation consists in section of the posterior walls of the vagina and cervix. The danger incurred is that of lesion of the peritoneum. To avoid it the surgeou introduces the index finger of the left hand into the rectum, pressing against the anterior wall of the intestine ; this finger indicates to the eye the limit of the recto-vaginal fold of the peritoneum, and serves as a guide during the whole operation. The portion of the vagina which is inserted on the cervix is incised above this finger, whilst an assistant pushes the whole tumour upwards and forwards by means of a pair of Museux's forceps fixed in the posterior lip of the cervix. This incision is carried at first towards the cervical cavity to avoid the peritoneum, then into the uterine tissue obliquely, from below upwards, and from without inwards till the cervical cavity is reached. The second part of the operation consists in section of the anterior walls of the vagina and cervix. The chief danger incurred is injury to the bladder. To avoid it, a sound is introduced into this organ and directed downwards into the lower portion of the vesical cul de- sac vihich. invariably forms the anterior part of the tumour; this part is raised and rendered prominent, and the assistant to whom the sound is entrusted is told to make it perceptible to both finger and eye. The anterior lip of the cervix is seized with Museux's forceps and drawn down by an assistant ; the surgeon then makes a horizon- tal and semi-lunar incision, convex above, at about one centimetre from the projection formed by the sound, which embraces the anterior portion of the cervix, its extremities joining those of the first incision. The anterior surface of the cervix below the bladder must only be reached by small incisions; when the operation has arrived at this point the sound is taken away ; the bladder is separated by a careful dissection from the anterior portion of the cervix to an extent of from 2 to 4 centimetres in the centre, and from 40 to 50 milUmetres on the sides, for fear of injuring the ureters; after which the anterior wall is divided from the cervix obliquely from below upwards and from before backwards, till the cervical cavity has been reached, as has been done for the posterior wall. The portion taken from the uterus ought to be cone-shaped, the base corresponding with the cervix, and the vagino-uterine wound funnel-shaped, the most con- ^ Op. cit., p. 463. HYPERTROPHY AND ATROPHY 615 tracted portion corresponding to the uterine cavity. In order to pre- vent ha3morrhage, especially after the operation, the arteries should be ligatured as they are opened. The uterine tissue is so dense and friable that it is very difficult for the ligatures to keep a hold of them. Iluguier has invented an ingenious method of ensuring constriction : the use of hooked pins. In place of seizing the uterus with forceps or with an ordinary tenaculum hook, he uses a good strong pin in the form of a fish-hook to the head of which a long thread is attached. A ligature is made on the parts fixed by the pin, the point of which is cut at 1 millimetre from the knot, so as to prevent it from pricking and hurting the neighbouring parts. The whole is left in place and falls from the third to the fifth day. In applying the ligatures in this way as the arteries are opened time is gained, the loss of a quantity of blood is avoided, and the patient spared a subsequent hasmorrhage. When haemorrhage continues in spite of the use of the ecraseur and in spite of the application of tenaculum ligatures, the vagina must be plugged as after amputation of the subvaginal portion of the cervix. I have left this description unaltered because there are cases in which it is necessary to have recourse to the bistoury in order to avoid the formation of cicatricial tissue and preserve the flexibility and supple- ness of the uterus, but I should add that latterly when performing this operation, especially in old women, I have used very small cauteries or Paquelin's thermo-cautery in place of the bistoury. I have also pre- scribed very hot injections previously as a preventive hasmostatic means, and I think the gravity of the operation is greatly diminished by their use. After section of the cervix has been performed, I push the rest of the uterus and vagina back into the pelvis, and make no other application than simple detersive vaginal injections. Cicatrisation is usually completed towards the twentieth day. The upper extremity of the vagina is then retracted and punctured ; it presents a reddish cicatrix nearly 2 centimetres long, at the base of which is felt a small mammillated eminence the size of a finger-tip, pierced in the centre by a small transverse opening : it is the lower part of the uterus. The womb at the end of two or three months is less voluminous and shorter than after the operation : it diminishes from 1 to 1 1 centimetres. This diminution is to be attributed to the resolution and suppuration which have followed the solution of continuity, as well as to the retraction of the cicatrix. The procidentia is then radically cured, except in cases in which there is a very wide pelvis and vulval open- ing, a more or less lacerated perinseurn, and considerable weakening of all the soft parts which form the floor of the pelvis, and when the body of the uterus is completely prolapsed from the pelvis and in retroflexion, so that the fundus of the organ is lower than the cervix. These various circumstances contra-indicate operation, or at least give no hope for complete success. Lastly, when the malady is preceded by a voluminous rectocele or cystocele, or by both, it may be necessary, after removal of the cervix, to operate for the hernise of the rectum and bladder separately. The best way of operating consists in destroying on each side a circular 616 UTERINE DISEASES IN DETAIL portion of the vaginal wall which covers them^ in order to determine strong cicatricial retraction. It is important in dissecting the vaginal wall to avoid injuring the bladder and rectum. Huguier has con- trived for this end an ingenious method, which he applies one or two months after conoid section of the cervix, i. e. when the first wound is cicatrised, the patient out of bed, and the result of the operation can be judged of. For cystocele, after having previously dilated the urethra with prepared sponge, he introduces the little finger by this canal, and if possible, the index finger of the left hand into the bladder. He seizes the tubercle and the anterior wall of the vagina with a small pair of Museux^s forceps, making an assistant draw them downwards and forwards, so as to stretch them and separate them, if possible, from the corresponding wall of the bladder. Then he passes, at the base of the fold formed by the part of the vaginal wall which he wishes to remove, a long pin, or several pins crossed, for example four, form- ing two crosses, taking care that the pins traverse the cellular tissue lying between the vagina and bladder without touching the walls of this organ, of which he is warned by the finger introduced into the vesical cavity. He throws a loop of thread behind each cross formed by the pins, forms a pedicle of the whole with a triple thread and applies the ecraseur. The same operation may be performed simulta- neously on the posterior wall of the vagina covering the rectum, care being taken to introduce the index finger into the intestine to serve as a guide, and to preserve the wall of the organ, remembering that the upper portion of the rectocele is not only in proximity to the anterior wall of the rectum, but also with the vagino-rectal cul-de-sac of the peritoneum. 3. Hypertrophij of the Cervix limited to one Segment or to one Lip} I have already said (p. 602) that the two lips of the cervix may be ^ I cannot better sum up my opinion on partial hypertrophy o£ the cervix than by quoting the conclusions o£ the paper on this subject presented to the Academy of Medicine, 22 May, 1877. 1. Partial hypertrophy of the cervix is an increase of volume limited to one point of this organ. 2. It must not be confounded with tumours properly so-called of this organ. 3. It exists in the peripheric parts or in the parts which form the walls of the cervical cavity. 4. This partial hypertrophy of the walls of the cervical cavity is the least known and the most important to recognise. 5. It exists most frequently in the median line. It is often congenital, depending on arrested absorption of the partition which separates primitively the two uteri, and of which the columns of the arbor vita are the vestiges. 6. The irritation caused by excessive coitus and inflammation of the cervix after abortion or delivery, also cause or increase it. 7. It is often situated on a level with tlie vaginal orifice, lies frequently on a level witli the isthmus, more rarely in the central portion. 8. The subjective signs are sometimes those of metritis or dysmenon'hoea (for deep-seated hypertrophy), alwaj's sterility. Usually there is the contrast of persistent sterility with the al)sence of dysmenorrhanc symptoms. 9. The most marked objective sign is the semi-lunar form of the os ; in liypertrophy of the upper part of the cervix there is difficulty in passing the HYPERTROPHY AND ATROPHY 617 unequally hypertrophicd so as to jjlace the orifice on the one or the other surface, and even to hide it behind the most hypertrophied Hp. I have given examples of sterility due to this cause, in which aptitude for conception has been restored by the cure of the hypertrophy {see chapter on Sterility). Here I wish to g-ive a brief but more coinj)lete explanation of the various kinds of partial hypertrophy which may afi'ect one of the segments of the cervix. In this kind of partial hypertrophy it is not one of the transverse segments of the cervix which is affected, but one of its two longitudinal segments, the anterior or the posterior. The anterior has seemed to me more frequently affected than the posterior. I have reason to believe it is the same M'ith the body, and that partial hypertrophy may exclusively affect either the anterior or posterior segment, and, if I may judge by my own observations, it is more commonly the posterior. These partial hypertrophies of the body, however, besides being more difficult to verify than those of the cervix, do not produce such marked symptoms, and are not so easily curable. Hypertrophy of one of the segments of the cervix is often observed at the lower part of this organ, i. e. on one of the cervical lips ; but it may exist also at its upper ex- tremity, as well as at its median part, and even in its whole extent. Sometimes we can only gain an exact idea of the existence and seat of this partial hypertrophy after dilating the cervix with sponge tents. We then see clearly that the obstacle to the free penetration of the sound is a partial hy])ertrophy of one lip (in this case the anterior one) a little above the orifice, and therefore we cauterise at the seat of the hypertrophy or the cervix itself, penetrating, however, deeply into the hypertrophicd lip. Hypertrophy of one lip not only is more frequently observed than other forms of hypertrophy, but it is more frequent ; for whilst some- times congenital, as the others generally are, it is much more commonly than these the consequence of chronic congestion or inflammation. Now the causes of these morbid states are much more numerous for the cervico-vaginal than for the cervico-uterine portion of the neck, more numerous also for the anterior lip (which is more commonly hypertrophicd) than for the posterior. The hypertrophicd lip may assume various forms : sometimes it is very voluminous, especially ex- ternally, entirely hiding the opposite one by projecting beyond it; sometimes, on the contrary, it is more developed internally, and then it distends the opposite lip and becomes covered by it;^ sometimes it sound ; dilatation by sponge tents and subsequent use of the sound allow of its being distinguished from anteflexion. 10. Treatment consists in general and local resolvents (baths, injections, medicated pessaries, hydropathy). 11. The special means are dilatation by sponge tents, scarifications or caus- tics for hypertrophy situated at the cervico-uterine isthmus, ignipuncture for hypertrophy situated at the vaginal orifice. 12. The cure of partial hypertrophy of the cervix leads to the cure of the sterility. ^ Figs. 355, 356, give an exact idea of this arrangement. The cervix, as seen through the speculum (Fig. 355), shows a marked increase in the size of the anterior lip. The orifice assumes the form of a crescent, convex posteriorly, 618 UTERINE DISEASES IN DETAIL is broad and thin, exceeding the other lip, over which it falls like an apron ; at other times it is narrow and long and_, projecting beyond the opposite lip, assumes the form of a beak or snout. ^ Even when the Fig. 355. Fig. 356. uterus is conical, and when the os is reduced to a pin-point, not un- frequently this pin-point instead of being at the summit of the cone is on its posterior surface, constituting true hypertrophy of the anterior lip ; sometimes the hypertrophy seems connected with flexion of the cervix, and in this case the lip corresponding to the convexity without being thicker is much longer than the other (anteflexion being most common, it is the posterior lip which is usually the seat of this elonga- tion, of this hypertrophic extension). These various kinds of hypertrophy are met with in women who have never conceived, and are either congenital (in which case they chiefly affect the conical form) or acquired in consequence of venereal excesses or local disease neglected for a long time. They are observed more frequently in multiparae; then they are always acquired, and are due to chronic inflammation which has hypertrophied the organic tissue or the mucous membrane. They are a common cause of sterility, though not generally recognised as such, for though presenting an obstacle to the penetration of the semen, they permit the easy discharge of the menses, and consequently do not attract the attention of patients. I have seen in several sterile women a partial hypertrophy, the remains of the union of the two uteri, more common before than behind, and exaggerated by the natural anteflexion of the organ. This tubercle, which may be called the uterine uvula, is similar as regards position and symptomatological consequences to hypertrophy of the median lobe of the prostate. It does not always prevent the escape of the menses, sure sign of hypertrophy of the anterior lip. The sound only penetrates into the uterus by following the curve formed by the cervical cavity, as is indicated in the section of the uteinis, shown in Fig. 356. The posterior lip covers the anterior lip partly. Sims also refers to this semi-lunar form of the orifice (op. cit., p. 223). ' Beigel has made similar observations {Berlin. Klin. Wocheiisch., 1867, Nos. 47, 48). HYPERTEOPHT AND ATROPHY 619 but even when it offers no obstacle to any discharge from the interior it opposes an impassable barrier to the entrance of any fluid from without. Hypertrophy of the median portion of the cervix is less frequent than that of its extremities. In this the cervix follows the law of every hollow organ, the orifices of which are the seat of hypertrophy or of the development of tumours and of degeneration more frequently than the walls. But it exists all the same, especially in the columns of the arhor vita, sometimes on both simultaneously, but more commonly on one only, the other being depressed by the progressive development of the former. Usually it is consecutive to hypertrophy of the internal orifice or of the lips of the vaginal orifice, and gradually disappears towards the median portion of the cervix. It may, however, be inde- pendent of it, existing alone. Diagnosis. — This is easily made when we are aware of the possi- bility of the existence of such a disease. I am sure that I often ignored it in the beginning of my gynsecological practice. Besides the subjective signs, sterility, dysmenorrhoea and the other symptoms of hypertrophy, sight, touch, and the sound especially leave no doubt on the subject. Sight and touch only discover the excessive size of one of the lips, or the alteration in the form of the orifice. The in- ternal seat of the hypertrophy of the tumefied lip is disclosed by the sound, which alone permits of the verification of partial hypertrophy of the median portion and of the os internum. Treatment. — I shall add nothing to what I have already said as to resolvent treatment, general and local, solvents, tampons of glycerine, and glycerole of iodide of potassium, which may be applied here as in other kinds of hypertrophy. There are, however, two points upon which I ought to insist, because they may lead to cure without neces- sitating recourse to operation : I refer to puncture with the actual cautery, and the application of dilating bodies. It is especially in hypertrophy limited to one of the cervical lips that I have been able to observe the marked resolvent action of the actual cautery ; but it is principally in this case that the tissue must be pierced with pointed cauteries at red or white heat according to the size of the tumefaction, taking care to spare the circumference of the orifice ; although the cautery may be introduced into the cervical cavity, this is not usually indispensable {see Eig. 194, p. 213, representing ignipuncture of the hypertrophied anterior lip) . As for laminaria or sponge tents, they produce the most remarkable effects ; it is sometimes necessary to slit the cervix or to incise the portion of the prominent lip slightly in its thickness, then to dilate the cervix with tents of increasing size, and lastly to profit by the dila- tation to incise, excise, or abrade the exuberant tissues. But dilata- tion alone suffices to produce great modification of the hypertrophy ; it softens the tissue, determining hypersecretion, a discharge which may be increased by the addition of a tampon of glycerine, facilitates resolution, and by the excentric compression which it exercises on the tissue, it stimulates the resolvent action. Resolvents may then be 620 UTERINE DISEASES IN DETAIL applied directly to the tumefied parts to complete the mechanical and vital action of dilatation. Recourse must sometimes be had, notwithstanding, to extreme measures, which are not dangerous if applied intelligently ; these are excision^ incision, or abrasion of the hypertrophied part. In per- forming incision and excision the flaps of mucous membrane should be preserved so as to allow the full size of the orifice to be retained. In amputation of the cervix there is still more reason for preserving fragments of mucous membrane when the os is involved. It is different when the malady is in the cervical cavity, or even at the os internum. When the hypertrophy is situated in the cervical cavity or at the cervico-uterine orifice we should commence by dilating the isthmus before thinking of section. Yery often repeated dilatation is sufficient to procure a satisfactory result. When insufficient, section, abrasion, or even amputation may be tried, according to the size of the tubercle or valvular barrier. Having dilated the uterine canal, I introduce one of Recamier's large curettes, which serves me for a guide, and prevents the uterus from bending. Then with a short probe-pointed bistoury or curved tenotome, guarded by the curette till the obstacle is reached, I make a median incision, or two converging incisions, which must not be deep ; or I try to excise the tubercle, dividing it from left to right. To facilitate this amputation, or rather this abrasion, when the hypertrophied portion is soft, I have used one of Eecamier's curettes, broad and sharp at the end, or better still one with a trian- gular fenestrated and sharp extremity, like that of Marion Sims, with which the excrescence, or its fragments if it has been previously di- vided, can be removed by trapping each successively in the fenestrum and withdrawing the instrument ; or I sometimes use a kind of little hooked knife, the stem of which is flexible enough for it to be inclined in various directions. When the hypertrophy is situated in the median part of the cervical segment it may be first treated with sponge or laminaria tents, scari- fications, ignipunctures, or the same methods of abrasion and section may be employed as in cases of partial hypertrophy of the isthmus. III. Atrophy of the Uterus Atrophy of the uterus constitutes a morbid state in which this organ, after having been normally developed, loses, from various causes, its normal dimensions and shape, and is reduced to a smaller size. Scanzoni,^ from whom I borrow this definition, divides atrophy into excentric and concentric. Excentric atrophy, a thinning of the walls with dilatation of the cavity, is usually symptomatic, either of hydro- metria produced by the accumulation of mucus and the obliteration of the cervico uterine orifice in the period of decrepitude, or of a rapid and considerable effusion of blood, with atresia, in young women, or of the formation and persistence of a fatty state after puerperal diseases. ' Op. cit., p. 71. HYPERTROPHY AND ATROPHY G21 Concentric atrophy, thinning of the walls with contraction of the cavity, may be general or partial. When general, it is often accom- panied by softening and small apoplectic centres. When partial, it may affect the cervico-uterine isthmus and produce flexions of the fundus on the cervix, or contractions and obliterations of the os internum. Sometimes it depends on a purely local cause, compression exercised on the womb by tumours situated outside this organ, by sub-peri- toneal fibroids, peritoneal exudations, organised plastic deposits round the uterus, solid ovarian tumours, or by large tumours arising from the pelvic walls. At other times it is due to simple senile altera- tions, or alterations of nutrition produced in the uterus by chronic maladies: to this last category belong cases of uterine atrophy brought on by a state of paralysis, a result which appears possible from some curious cases observed by Scanzoni in young paraplegic women, in whom the fact was demonstrated by autopsy. Jacquet {Beitrdge z. Geburtsk., Bd. ii, S. 2) mentions two cases of atrophy of the uterus : in one ovarian molimen persisted, in the other it was wanting. Ac- cording to Chiari ^ atrophy may be observed in chlorotic patients and may be dependent on menstrual disorders. I have seen a case of uterine atrophy due to amenorrhoea dependent on general as well as local causes ; and I have met with another which occurred after eight abor- tions. There is, however, a special kind of atrophy, due to an excess of the retrograde evolution which the uterus undergoes after delivery, to which Simpson has referred under the name of atrophy from exces- sive involution or super involution. It is the inverse of hypertrophy from subinvolution. It occurs when the progress of absorption is effected, after delivery, to an excessive degree, the organ being reduced to a size smaller than that of the uterus in the state of vacuity. It is comparatively rare, but occurs occasionally. Simpson ^ saw several cases in his practice, one of which was confirmed by autopsy.^ Diagnosis — subjective signs. — Suppressed or imperfect menstrua- tion, which is not established normally after lactation. The breasts shrivel, the subcutaneous adipose tissue covering them is absorbed, the skin becomes wrinkled, the patient although young having all the appearance of premature old age. The whole economy participates in the change that has taken place in the uterus, just as in women at the climacteric when the functional activity of this organ terminates. Sterility results as a matter of course. The health is afiected, the patient suffering from anaemia, dyspepsia, frequent headaches, and general debility of body and mind. Objective signs. — Vaginal touch reveals an unusually small cervix, projecting so slightly beyond the vaginal cul-de-sac that it is hardly ^ Klinih der Geburtsk. in Gyndcol. Erlangen, 1852, S. 271. 2 Op. cit., p. 597. 3 Mickschik {Wiener Zeitschr., 1856, Bd. xii. Heft 3) has published the autopsy on a woman 24 years of age, who died five months after two deliveries. The ovaries and the uterus were atrophied. The latter was 30 mm. in leng-th, 40 in width. The walls were ^ inch thick. Microscopic examination showed fatty degeneration of the uterus and ovaries. 622 UTERINE DISEASES IN DETAIL perceptible ; the womb is small^ light and mobile ; it is difficult to seize it by abdominal palpation notwithstanding the thin and relaxed abdominal wall. The os is small, only admitting the entrance of an extremely fine sound, in the introduction of which great care must be taken not to use any force, for the walls are hardly any thicker than a sheet of paper. Klob ^ mentions a case of the kind, Simpson saw a similar case, where a sound carelessly introduced pierced the uterine walls and penetrated the peritoneal cavity. This accident has happened more than once ; fortunately it is not followed by such serious conse- quences as might be supposed. When the sound is used with all necessary precaution, it only penetrates to a depth of 3 to 4 centi- metres, which proves that the organ is abnormally small. Treatment. — Is there any means of bringing the uterus back to its normal condition and of restoring the patient to her former health ? When the uterus is completely atrophied, this is hardly possible, but when only slightly affected there is some chance of cure. In atrophy . of the uterus due either to congenital imperfection of development at puberty, or to excessive retrograde evolution during the puerperal state, the best treatment consists in the use of the galvanic stem. In order to understand the way in which this treatment acts, we must remember this general law : in uterine therapeutics as well as in uterine physiology and pathology, all continuous and increasing irrita- tion, all dilatation of the walls of the uterine cavity by a foreign body, promotes the development and hypertrophy of the organ. When the uterus is atrophied, a short and acute irritation like that produced by the introduction of a sponge tent for one or two days is not enough, a more continuous irritation is required, like that produced by the pro- longed use of a series of small galvanic stems of gradually increasing length and thickness. Simpson ' often saw menstruation restored temporarily or even permanently by the use of this means. Among other cases he mentions a very remarkable one, in which the galvanic pessary was left several months or even years in the uterus and in the end effected the restoration of regular menstruation, the return of the organ to normal dimensions and the disappearance of all the serious accidents which had for long disordered the general health. Marriage may be the means of curing atrophy. Therefore Vannoni ^ has recommended coitus in atrophy of the cervix as useful in hasten- ing the development of this organ. Intra-uterine injections may be beneficial, as well as stem pessaries, laminaria tents, or other foreign bodies. Electricity is especially likely to be successful : it would act probably on the uterus as it does on atrophied muscles. ' Pathologische Anatomie der weiblichen sexual Organe. Wieu, 1864, p. 206. ' Op. cit., p. 637. ^ Journal des connaissances med.-chir., 1850, p. 19. GRANULATIONS AND FUNGOSITIES 623 Granulations and Fungosities Uterine granulations are small fibro-vascular excrescences, usually multiple and confluent, variable in number and size, seen most com- monly about the cervical orifice, although they may be developed over the whole external and internal surface of this organ and even in the uterine cavity, either from a simple disturbance of its local life, or under the influence of a general morbid condition whether diathetic or not. Fimgosiiies are only granulations in a further stage of development, softer, more vascular, bleeding more, situated on the cervix or at different depths in the uterine cavity. ChomeP says : " Granulations constitute a malady proper of the cervix uteri." He adds, however, that a tendency to similar granulation is sometimes observed in the mucous membrane of the pharynx, and more frequently in men than in women. Etiology. — Predisposing causes. — Local predisposing causes. — The vitality of the uterus with its remarkably plastic tendency, its struc- ture in harmony with this tendency, showing an instability of organisa- tion, or rather a continual tendency to hypertrophy and atrophy, the character of its functions, favouring by the frequency, periodicity and nature of its fluxions this tendency to plasticity, are evidently three circumstances which predispose the uterus, and particularly its mucous membrane, to hypertrophy, and more especially to granular hyper- trophy. The fibro-plastic tissue, which is chiefly found in the dermis of the mucous membrane, is by its nature more predisposed to hyper- trophy than any other ; for it constitutes in itself a state of transition between the blastema and the fibrous tissue, and manifests anatomically, in the most evident way, the incessant tendency of the uterus to organisation or hypertrophy. It is to this structure that the internal membrane of the uterus owes the power of undergoing an enormous tumefaction from the moment of conception, of forming the decidua and of finding the elements of its regeneration ready to hand at the given moment. It is impossible not to attribute to these anatomical conditions a great influence over the hypertrophic tendency which characterises all uterine maladies, particularly those of its mucous membrane; and further, it is difficult not to attribute to the existence of Vae fibro- plastic tissue the part which it takes in the formation of the papillae of the dermis, and to its interposition between the mucous follicles the special tendency to granular hypertrophy. Thus it is that uterine fungosities, i. e. more or less fungous granulations of the cervical cavity are frequent ; and that granulations of the cervix especially, as the part most exposed to external agents and to all the morbid acci- dents capable of producing them are more frequent still ; there is no diathesis under the influence of which they cannot be developed or 1 Diction, de med., en 30 vol., art. Utebtjs, Meteite gbanulee. Paris, 1846. 624 UTERINE DISEASES IN DETAIL perpetuated : judginp^ from my own experience, out of nearly 3000 cases of uterine maladies I have had 450 cases of granular cervix. General predisposing causes. — Diathetic affections of all kinds have a large share in the production and chronicity of uterine maladies. Almost all writers on uterine diseases in the last few years have attri- buted these granulations to inflammation of the cervix. Since Bennet^ published his admirable book on this disease, metritis has taken too large a place in the domain of uterine maladies. For Aran, Becquerel, Nonat, granulations as well as redness, erosions, ulcers, leucorrhcea, &c., are but symptoms of metritis. I am not, however, alone in trying to prove that inflammation is not everything in uterine diseases in general, and in the production of uterine granulations in particular. Timbart,^ although he admits, contrary to my opinion, that granula- tions do not of themselves form special and distinct maladies, demon- strates in the conclusion of his work that these lesions may occur as symptoms or complications in the majority of uterine affections : those affections with which he specially connects them are uterine catarrh and scrofulous engorgement of the cervix. Eontan, Durand-Fardel and Gueneau de Mussy, being struck with the coexistence of pharyn- geal and uterine granulations with skin diseases, think that they may often be dependent on herpetism. Tillot,^ like Pidoux, connects them as well as all other uterine diseases with the existence of some diathesis. Among the diathetic states which, in fixing themselves on the cervix, may produce uterine granulations, syphilis and catarrh seem to play the chief part. — In the lock wards of the General Hospital of Montpellier I have had occasion to see a number of women affected with uterine granulations coexisting with various syphilitic symptoms, and although it is difficult to decide in all cases whether there is simple coincidence or community of origin and nature between these granula- tions and the various manifestations of the syphilitic affection, I am inclined to believe (especially after the cures which have followed the specific treatment employed) that the syphilitic diathesis had a share in the development of the granulations. It is seldom, however, that anti-syphilitic treatment is sufficient of itself to overcome this malady ; this is doubtless owing to the hypertrophic tendency of the uterine tissue under the influence of which it is produced and has a tendency to become perpetuated. — Catarrh which attacks the uterus so frequently, not only in multi|)ar8e but in newly married women, and even in girls, is not only manifested by a mucous discharge, but by the fluxion which it keeps up towards the mucous membrane, bring- ing its hypertrophic tendencies into play and producing granulations. Timbart justly remarks that cervical erosions and granulations dia- gnosed constantly as lesions of blennorrhagia and uterine catarrh 1 A Practical Treatise on Inflammation of the Uterus, its Cervix and Ap- pendages. ^ Des ('rosions et des granulations du col de Vuterus, de leur valeur nosolo- gique. Theses de Paris, 1849. ' De la lesion et de la maladie dans les affections chroniques du systhne uienn. Theses de Paris, 1860. GRANULATIONS AND FUNGOSITIES 626 ought to be included as special characters in the history of these dis- eases : simple erosion for the acute and non-malignant form, and granulations for the chronic and serious form. I could myself men- tion cases of catarrhal granulations, and have no doubt that granula- tions of this kind are at least as frequent as others. — The diathesis which exercises most influence on the development of granulations according to Chomel, Robert, Huguier, Scanzoni, Gueneau de Mussy, Durand- Fardel, Fontan, &c., is the herpetic, the external manifestations of which these writers have often seen coincide with the existence of granulations. I have also met with several cases in which these two maladies coexisted (herpetism and granulations), especially in women affected with pityriasis, eczema, herpes, ciliary blepharitis, simulta- neously with uterine granulations, and who had no symptoms of any other affection, such as catarrh, scrofula, inflammation, &c., or who could not attribute the development of this disease to any local cause, such as excessive intercourse, pregnancy, &c. Tillot, in reviewing the various diatheses which play the chief part in the etiology of chronic uterine affections (granulations amongst the rest), enumerates them in the following order of frequency : the strumous, syphilitic, herpetic, cancerous, &c. In the production of these granulations I do not think that the scrofulous should have a more prominent place assigned to it than the other diatheses just named. — The part taken by rheumatism and more rarely by gout, although less marked, is not the less certain, and I think the prac- titioner cannot afford to ignore it. Determining causes. — Any cause which produces a certain degree of irritation in the organ, which stimulates its vital activity, and excites its plastic or hypertrophic tendency, may occasion the formation of these granulations. In this way dysmenorrlioea and other menstmal disorders suffice to develop them, and may be the only causes to which they can be attributed in girls. Marital intercourse in newly married women is undoubtedly a determining cause. Owing to the novelty of the act, and in some measure to the traumatism to which the cervix is exposed, or it may be to the frequency of coitus and the attendant excitement, the cervix undergoes, as a consequence of this anatomical and physiological shock, a modification in its vitahty which brings into play its tendency to hypertrophy, probably at the most sensitive parts, or at the orifices, whence it results that the urethral meatus is usually the starting-point of the granular formation. In such cases especially these granulations seem to me to coincide with inflammation of the follicles and uterine discharges. Excitement of the sexual organs by venereal excesses, especially the frequent contact of the penis with the cervix, may have a share in the development of granulations, but not more, it appears to me, than it has in the development of other uterine diseases. Pregnancy , by bringing into play the hypertrophic tendency, should be the most common of all determining causes. Pregnancy of itself modifies the life of women so greatly, producing so many pains and morbid symptoms due to the development of the uterus and abdomen, that the majority of women, 40 626 UTEEINE DISEASES IN DETAIL even when they suffer much, do not think of consulting a physician, and still less of undergoing an examination; therefore it is difficult to establish any conclusions with regard to this matter. It may, however, safely be affirmed that it is rare to examine a pregnant woman without finding a granular cervix. Delivery, and especially the after effects of labour, bringing in their train engorgement, con- gestion and even inflammation or hypertrophy, may be regarded next to pregnancy as the most powerful determining causes. Lastly, uterine inflammation, when left to itself, or if some condition of its develop- ment have fixed it on the cervix, may play the double part of occa- sional and essential cause. Course. — Usually these granulations first appear at the os, on one of the lips or else all round the orifice. This is seen especially in women who have not conceived, in whom the cervix is more or less conical, with a narrow circular orifice. They afterwards spread either externally or into the cavity, so that when examined they already form a red mammillated patch from 1 to 2 centimetres in diameter, the centre of which corresponds very nearly with the os, the borders being very irregular on both lips, owing to the unequal development of the granulations on the neighbouring points of the uterine tissue. At the same time that the granulations spread over the surface, whether ex- ternally or in the depth of the cervical cavity, they also extend in all their dimensions — that is to say, that having increased in number they increase in size, acquiring sometimes a considerable volume, and taking the name of fungosities. This course is essentially chronic, offering no natural retrograde tendency — that is to say, no tendency to spon- taneous cure. The intervention of art is all the more necessary that the course of these granulations is not always limited to the symptoms I have just sketched. Although they sometimes exist without com- plications, they more generally cause concomitant symptoms, functional alterations or pathological processes, either concentrated in their own sphere or further removed from it. Thus follicles, the orifices of which are usually at the bottom of the grooves which separate the granulations, become irritated and secrete an abundant, opaline, whitish mucus. Sometimes they become inflamed as well as the granulations themselves ; they secrete pus, ulceration may attack the granulated surface, and the purulent secretion of this surface is then added to the muco-purulent secretion of the follicles. This secretion may be the only apparent trace of organic lesion when the granulations or fungosities are situated in the interior of the cervix, and when the conditions are not such as to allow of the gaping of this organ. The development of granulations, which are an obstacle to free communi- cation between the uterine and vaginal cavities, prevents conception and may become a more or less painful obstacle to the expulsion of uterine raucosities, menstrual blood, &c., even when it does not cause the still more serious symptoms of uterine fluxion, tumefaction of the womb, or obstinate menorrhagia or metrorrhagia. This, however, hardly occurs except in the case of fungosities developed in the cavity of the body of the uterus, and known as uterine fungosities. Since GRANULATIONS AND FDNGOSITIES 627 Eecamier's^ investigations these latter alterations have been the object of special study." Although infinitely less frequent than granulations^ they seem to form an analogous malady, and several times the gradual extension from the one to the other has been observed. Granulations, in certain cases, cannot long continue without causing engorgement, and more frequently partial or total hypertrophy of the cervix, and what is more serious, inflammation of this organ and even of the whole uterus. They are, therefore, a constant source of danger for the women who are affected by them, especially in cases of preg- nancy. Most writers agree in considering granulations and fungosities, as well as ulcerations, as possible causes of abortion in pregnant women. Varieties. — The seat is at the os uteri, especially in virgins and in nulliparee : usually on the cervical lips in pregnant women and in multiparse; very often extending farther on one lip than on the other (the anterior has seemed to me more frequently affected than the posterior), but seldom on one only; often limited to the external surface of the cervix (especially in pregnant women) ; often also ex- tending to a more or less considerable height into the interior of the cavity (when they occur after delivery); sometimes even reaching to the cervico-uterine isthmus, in fact they may be situated exclusively in the neck whilst there is no external trace ; this is especially the case when they are catarrhal in nature. The number of the granulations is usually considerable. Some idea can be formed as to the variation in number from their differences of disposition and volume. The disposition may differ much according to whether the granula- tions are discrete or confluent. They are very seldom discrete : the only examples perhaps being the hypertrophic inflammatory pimples round the follicular orifices, which, as I have said, may be seen on the cervix. On the contrary, they are almost always confluent, spreading more or less on the surface of the cervix, or rising more and more from the point where they have taken birth so as somewhat to resemble a strawberry or raspberry. Lastly, granulations are seldom seen dis- seminated singly or in little groups outside the principal granulated surface. This surface is rounded or elliptical, sometimes irregular, with jagged edges. It seldom extends over the whole cervix, although it may greatly exceed the average extent of from 1 to 2 centimetres, especially in cases of hypertrophy. In colour and relief it contrasts strikingly with the pale colour and smooth aspect of the rest of the cervix when the latter is neither congested nor inflamed. The size of the granulations is usually very small, about that of a millet seed, seldom equalling that of a small lentil. The agglomera- tion and confluence of these little pimples often give to a number of them the appearance of one large one. However, there is no doubt that the granulations which are formed on ulcers, those which become fungous, those which are of scrofulous nature and those which are ' Union medicale, 1850. ' Eouyer, Des fongosites uterines. These de Paris, 1858. *8ij 628 UTEEIXE DISEASES IN DETAIL found on an engorged or oedematous cervix, sometimes present very considerable dimensions. The colour of the granulations is always more or less red. This red- ness varies little in successive examinations in the same woman. It may, however, increase or diminish in intensity, according to whether menstruation is near or not. Usually this redness is very marked, but sometimes it is pale pink, at other times it is more or less purple ; in this respect inflammatory granulations, for example, may differ much from granulations of a scrofulous nature. The colour of the granula- tions although contrasting strongly with that of the cervix in the normal condition, is not so different as Chomel has asserted. For in- stance, during pregnancy they assume the wine-red aspect which is characteristic of the cervix at tliat time, and which spreads, as we know, to the surface of the vagina and to the nymphse. It is remark- able that after death they lose much of their colour and even of their volume, especially those which are fungous. The structure of these granulations may vary like the other charac- teristics of which I have just spoken. It is such as to impart a soft consistency generally to the granulations; therefore in practising digital touch they may be torn with the nail or be made to bleed by wiping the surface with cotton-wool. Sometimes, owing to the pre- dominance of fibrous or fibro-plastic elements, they acquire a hardness which enables them to resist these attempts and prevents their being removed by scraping. At other times from the predominance of the vascular elements, they become fungous on the contrary, bleeding easily, the slightest contact, coitus especially, in such cases causing slight haemorrhage, or at least the flow of a few drops of blood. Between these two extremes there may be a number of degrees and even varie- ties of structure, according to whether the fibrous element, the epithe- lium, the amorphous matter, the lymph, &c., have more or less share in their composition. As to the diferences in nature, herpetic granulations are generally external, bright red and only slightly projecting ; scrofulous granula- tions more frequently than others occupy only one lip, they are more voluminous and paler; catarrhal granulations are often more developed internally than externally, and are always covered by a more or less opaline consistent mucous discharge. Fungous granulations frequently developed on a pre-existing ulcer often occupy the cervical cavity also; they are voluminous, red and bleeding. Granulations are not con- tagious unless syphilitic. Liagnosis. — They often exist without giving rise to any characteris- tic symptom, or to any local phenomena; therefore we must take sympathetic disorders into account ; however slight they may be they should never be neglected ; leucorrhoea especially ought to be taken into serious consideration as well as lumbar pain. Subjective signs. — Uterine granulations sometimes cause disordered menstruation. When fungous they may determine menorrhagia, the ex- pulsion of clots, &c. ; when they are hard, hysteralgia uterine colics, and excited doubtless by the difficulty which the uterine contractions have GRANULATIONS AND FUNGOSITIES 629 in overcoming the spasm or mechanical obstacle caused by induration of the cervix. The pains are sometimes absent or are the same as in all uterine maladies ; they seem to be seated in the vagina or deve- loped on the cervix, especially during coitus. The remote pains are in the renal region or in the thighs, seldom in the hypogastrium or in the iliac regions, as in metritis, peri-uterine inflammations, engorge- ments, deviations, &c. When there are no pains, or when they are concealed, for example by pregnancy, the trouble may be ignored, manifested only by general discomfort, want of appetite, paleness, emaciation and all the consequences of the sympathetic disturbance of the digestive and nervous functions. There is one general symptom which is not pathognomonic but which is frequently the consequence of granulations, viz. sterility. It is owing to the mechanical and physiological difficulties in the way of fecundation formed by the granulations fitting into each other, the viscosity and adhesiveness of the mucus which covers the surface and forms a gelatinous stopper and by the irritability and spasm pro- duced in the cervico-uterine sphincter. Objective signs, — A red, granular surface, commencing at the os uteri and radiating over a more or less considerable extent of the cervix, formed of small granulations usually confluent, seldom discrete, rarely attacking the whole cervix, but forming a kind of patch or mammillated elevation somewhat hke a raspberry, surrounded on all sides by a healthy annular surface of the cervix. A more or less abundant glairy, muco-purulent or purulent discharge almost always covers it, and must be removed before the granular surface can be seen. This discharge which is seldom pus, but which may be opaque, semi-transparent or opaline, is often clear like white of egg. In the latter case it is seldom that it is not sufficiently abundant to be dis- charged from the vulva moistening the inner surface of the thighs, and leading the patient to think she must have some uterine disease. The finger with difficulty determines the circumference of the granula- tions, but can easily discover the elevations round the cervix or in its orifice; the sensation felt by the tip of the finger, and which has been compared to that produced by shagreen leather, is more like that communicated by Utrecht velvet (Chomel) ; the finger almost inevit- ably brings away a few drops of blood from the nail slightly scraping the diseased surface : it is easy by sight and touch to distinguish granulations of the cervical cavity from simple leucorrhcea. Differential diagnosis. — Granulations must be distinguished from vegetations, ulcers, erosions and the various eruptions which may have their seat on the mucous membrane of the cervix, such as pemphigus, eczema and especially herpes. Vegetatioyis are only vascular epithelial excrescences. When the epithelial development is not accompanied by a rich vascular develop- ment there results a hard production of a dull leathery white, some- thing like a flattened wart, developed on one of the lips or on one of the sides of the cervix rather than at the orifice. In the rare cases when great vascularity is added to epithelial exuberance, vegetations of 630 UTERINE DISEASES IN DETAIL the cervix have the familiar appearance of vegetations of the vulva and prepuce, and consequently are distinguished by their projection, their subdivisions, by real granulations and even by uterine fungosities. As for the other vegetating excrescences which do not depend on syphilis, like the majority of the vegetations of which we have spoken, and which under the names of fungosities, cauliflower excrescences, &c., are only manifestations of the more or less rapid increase of uterine cancer, it is still more difficult to confound them with granulations of the cervix. Folypi are pediculated tumours of a more or less considerable size, resulting usually from the hypertrophy of one of the anatomical ele- ments of the uterus, and developing gradually without any diathesis or morbid state other than hypertrophy pure and simple. It is the same with i\\Q follicular cysts described by Huguier. Various vesicular and pustular eruptions, such as herpes, eczema, pemphigus, &c., may appear on the cervix leaving a red surface, which bleeds easily, and which is sometimes confounded with granulations strictly so called and classed with these latter by some writers, and more or less distinguished from them by other authors under the name of erosions, exuberations, &c. It is always easy to verify the charac- teristic course of these maladies, the gradual development of vesicles, pustules, follicular eruptions, however small and confluent they may be, the flat bleeding surface which results, the distinct borders of the erosion, the absence of more or less thick mucous secretion, the epi- dermic denudation ; lastly, the absence of exuberances due to the de- velopment of the anatomical elements, the existence of which is verified in the granulations. Ulcers may attack a more or less extensive portion of the cervix, in some circumstances presenting at first sight so much apparent analogy with uterine granulations, that several writers have not distinguished granulations strictly so called from granular ulcers. Now, at the com- mencement of their development, ulcers may present the appearance of some of the eruptions first named, but with the progress of the patho- logical process which produces and keeps them up they soon assume a characteristic form, an inspection of which is usually suflicient to distinguish them. — There is, however, a period when ulcers may assume characters which make them resemble granulations : it is when they become really granular, either from being covered by true cicatricial granulations, which will soon produce a real cicatrix, or because they become the seat of a more or less luxuriant vegetation, which makes the healthy granulations persistent, extensive, bleeding, sometimes considerably exceeding the limits of the ulcer. Healthy granulations, to borrow the description given by my friend and colleague M. Charles Robin, " are conical and reddish eleva- tions developed on the surface of suppurating wounds where they determine cicatrisation. They are formed all the more quickly when the tissue is cellular and vascular; at first broad, soft and only slightly projecting, they soon constitute by their union a kind of membrane provided with blood-vessels. They are composed : 1, of a large pro- GRANULATIONS AND FUNGOSITIES 631 portion of amorphous granular paatter ; 2, of fibrillae of cellular tissue of new formation interlaced ; 3, of fibro-plastic elements with rather large and pale nuclei ; 4" of capillaries. They increase in size by the production of new elements added to those of the same kind throughout the whole thickness of their mass. The surface of these rudiments of cicatricial tissue is covered with pus and gradually with epithelial cells, which soon exceeding the pus in quantity form a thin and "whitish pellicle of epidermis continuous with that of the skin : this is called cicatrisation. As this epidermic pellicle is formed the granula- tions disappear, owing to the slow but energetic disappearance of the molecules of the amorphous matter by absorption, and the consequent bringing together of the fibrous elements; this is what determines retraction of the borders of the wound, leading to the belief in the contractility of cicatricial tissue." Absorption, continuing after cica- trisation is concluded, determines, as I think I was the first to teach,^ contraction of the cicatrix. Uterine granulations which are developed on the cervix are composed, like true cicatricial granulations, of the elements of fibrous tissue which enter into the composition of the cervix, of fibro-plastic elements whether pre-existing or of new forma- tion, of fibrillse of cellular tissue newly developed, and of granular amorphous matter. These elements, constituting a kind of hyper- trophy of the dermis of the mucous membrane, are traversed by capil- laries, the variable number of which renders cicatricial tissue more or less prone to bleed at the slightest contact. It is covered by epithe- lium, in which cells of new formation often strengthen the layer of the old cells ; the thickness of the epitheKum which results does not pre- vent the granulations from bleeding when rubbed with the tip of the finger or when wiped with cotton wool, because the cells of new forma- tion are always so soft and delicate as to off'er but little resistance; sometimes even the subjacent connective tissue is laid bare by a super- ficial erosion. — There is therefore a great resemblance between uterine granulations and the granulations of cicatricial tissue. Uterine granu- lations, however, besides being real tissue developed at the expense of the fibro-plastic or embryonic elements, are hypertrophied papillee of the dermis, either simple epithelial elements, like those entering into the structure of vegetations, or hypertrophied vascular elements of the papillse or capillaries interposed between the follicles or surrounding them, or else real hypertrophied follicles always characterised by a point at the summit of the granulation, the point being only the orifice of the follicle. Prognosis. — Uterine granulations do not involve any serious danger ; but they have a tendency to increase, they last a long time, often with- standing rest and treatment ; they are inconvenient from the mucous and sometimes sanguineous discharges which accompany them ; they cause more or less marked general debility, and prevent conception taking place. This prognosis makes it the duty of the physician to persuade patients to undergo necessary treatment. ^ Clinique chirurgicale.—Be la formation des cicatrices, de leur retractilite et des difformites qui en resultent, p. 291. Montpellier, 1851. 632 UTERINE DISEASES IN DETAIL Treatment — the indications. — According to 1, the nature of these granulations or the diversity of the affections or morbid processes by which they are kept up ; 2 , the analogy arrd variations of structure which they present in various cases ; and 3, the hypertrophic tendency which characterises them, it is evident that each of these three terms becomes the source of indications in proportion to the share which inflammation has in its development. I. I shall not speak of the treatment to be used in subduing the nature of the malady, except to mention that my opinion is contrary to that of those gynaecologists who regard uterine granulations as granular metritis to be treated by antiphlogistics local and general which usually produce no effect. Nevertheless when metritis exists, the inflammation should be treated by leeching the cervix, emollient baths, with prolonged irrigations, the application of mercurial oint- ment to the abdomen, groins and thighs, and by revulsive purgatives. After the cure of the metritis it will, however, be necessary to treat these granulations by suitable local means. In other cases we must treat the catarrhal affection or the constitutional diathesis whether scrofulous, rheumatic, herpetic or syphilitic before using local means or at least simultaneously with them. I could mention many cases in which patients have only been definitely cured after having undergone general treatment by mercury, iodide of potassium, cod-liver oil, iron, sea bathing, mineral waters, hydropathy, &c. It is the same with the chronic form, which may exist without being dependent on any dia- thesis and without presenting any inflammatory character which would allow of its being considered with chronic metritis as some writers have done. In such cases the organ may no longer be inflamed, even if it has previously been so, but it retains the habit of fluxionary movements, congestion, engorgement, hypertrophy, which are all the more difficult to eradicate because favoured by a condition of anaemia, thloro-anajmia and general debility. When this is the case restorative medication, tonics, a generous diet, iron, hydropathy, hot vaginal injections, blisters on the cervix, astringent and resolvent applications, with inert powders, and igni-punctures to destroy the granular surface produce the best results. II. As to the second indication, the state of hypertrophy which characterises uterine granulations and the hypertrophic tendency of the cervix which their existence increases, necessarily indicate the application of means the resolvent properties of which have the faculty of determining a tendency to absorption or atrophy. Therefore astringents of all kinds are employed in injections, e.g. the decoction of red roses, oak bark, rhatany, solutions of tannin, alum, nitrate of silver, &c., sulphur and iron waters whether natural or artificial have often been tried, although perhaps no case of cure can be attributed to them. Astringent powders, such as tannin and alum ; solvents, such as mercurial and iodide ointments, have also been applied unsuccess- fully to the seat of disease. They liave the drawback not only of acting very superficially on a lesion of considerable depth, but of necessitating the presence of a tampon in the vagina, the contact of GRANULATIONS AND FUNGOSITIES 633 which only irritates the cervix and the neighbouring parts, while it prevents other means of treatment (injections and irrigations) from which the patient would derive more benefit. Vaginal injections made on the bidet morning and evening with very hot water and a little carbolic acid is an excellent way of combating the congestion of the cervix and removing purulent liquids, the contact of which helps to keep up the granulations : but this is often insufficient to obtain a cure. III. The third indication, to subdue the hypertrophic tendency of the granulations, leads to the necessity of cauterisation, the most powerfully destructive as well as alterative local means that can be used. I have given up the use of liquid caustics with the exception of Tinct. Ferri Perchlor., Tinct. lodi, the concentrated solution of nitrate of silver, and a few others which only act slightly on the healthy sur- faces covered with epithelium. Solid caustics are either insufficient, like melted nitrate of silver, or too active like the Vienna paste or chloride of zinc. These latter caustics as well as arsenic and crystal- lised chromic acid, may be of great service in the treatment of cervical ulcerations; but in the treatment of granulations, the actual cautery seems to me very superior. The actual cautery is in fact that which requires least precaution, the action of which is the most easily limited throughout its whole extent, and that in which the consequences seem most favorable to speedy and complete cure on account of the nature of the cicatrix and of the good results experienced by the neighbouring tissues, nor do I know any drawback that it has. It is usually sufficient to use it once, in order to destroy the granulations and to modify the underlying tissues sufficiently. On the other hand I have often seen less energetic but frequently repeated cauterisation cause fluxionary and inflamma- tory symptoms which never foUow the use of the red iron. Cure is very rapid. Taking the average of several hundreds of cases it follows in six weeks, i.e. in the simplest cases and it may be obtained in three weeks ; in complicated cases requiring general treatment and a second cauterisation it may be delayed for three months. The surgeon is complete master of the caustic ; by varying the form of the cautery, the degree of heat applied, the duration of the application, &c. he can make the application as superficial or as chief, as limited or as extensive as he wishes. When made nothing is left in the vagina and uterus but the scar, so we have neither to consider how to get rid of the rest of the caustic, nor to contrive means for retaining it. The actual cautery may even be applied exceptionally in cases of pregnancy when formidable symptoms such as obstinate vomiting seems produced or kept up by granulations. I have long ago proved not only the innocuity and utility of the actual cautery applied to the cervix even during pregnancy,^ but also the consecutive accomplish- ment of the normal phenomena of parturition in pregnant women in whom granulations had been treated by cauterisation.^ ^ Annates cliniques de Montjpellier, Aug. 25, 1853. 5* Ibid., April 10, 1854. 634 UTERINE DISEASES IN DETAIL Lastly, when it is a question of uterine fiingosities situated in the cavity of the body and causing haemorrhage^ cauterisation is too pain- ful and difficult to be applied so deeply. In such cases we should commence by removing these fungosities with Recamier's or Sims's curette, and afterwards modify the surface of the mucous membrane by a caustic injection. Ulceration and Ulcers of the Uterine Cervix An ulcer is a morbid state characterised by a loss of substance of variable extent as regards both width and depth, kept up if not pro- duced by some internal cause or by local morbid action, and usually excreting a more or less purulent fluid. Ulceration is the pathological action which produces the ulcer. It is an alteration in the nutritive process as when decomposition is in excess of composition, disassimilation of assimilation. 1 may say of ulceration what I have already said of leucorrhosa, engorgement, in- flammation, that this malady may be developed at the close of another malady of which it seems to be the result or termination; but it may also be developed all at once under the influence of general causes and a local tendency. Sometimes it remains simple, pursuing its natural course, and passing through the various phases of its development without necessarily leading to new disturbances in the organ ; some- times on the contrary it is accompanied by other morbid states either as consequences or simple complications. It therefore happens that ulceration usually coincides with other diseases, and that if not the result of them it cannot last long without producing them. But it would be wrong to conclude from these coincidences that ulceration is the primary cause of these maladies as the ancients did, or as some gynsecologists in our own time have done ; nor would it be correct to conclude with Bennet, Aran and Nonat that it is the result of inflammation, nor withLisfranc and Duparcque that it is the con- sequence of engorgement, or with Gosselin, Tyler-Suiith and others, that it is produced by leucorrhoea; while West's opinion, that ulcers of the cervix are of no importance, ought to be refuted coming as it does from a writer so justly entitled to respect. If we investigate facts we shall admit with West that ulceration of the cervix is very common; but we shall not like him deduce from this fact of frequency that it is unimportant. 1 do not mean to say that its frequency necessarily involves its importance. Its importance depends on several causes : in the first place undoubtedly on the frequency of the lesion (we should always pay attention to a malady which occurs often) ; then on its varieties of aspect, on the ditt'erent causes which produce it, on its incurability when left to itself; lastly, on the necessity of applying a suitable local treatment. I have often endeavoured to measure the degree of importance wliich should be attached to ulceration of the cervix; I have frequently treated the engorgement, inflammation, leucorrhoea, without treating the ulcer; I ULCERATION AND ULCERS OF THE UTERINE CERVIX 635 have often employed the most powerful alterative general treatment, injections even, and I may say that 1 have hardly ever succeeded in curing the ulcer by these means alone. Local treatment, cauterisation and dressings have seemed to me indispensable in the great majority of cases. 1. Eruptions on the Cervix Eruptions of various kinds may be developed on the cervix. When we are fortunate enough to see their first appearance we can form an idea of the variety of forms which they assume, and when we compare them with those which are seen on the skin or on other mucous mem- branes, we are disposed to admit the difference of causes which influ- ence their development. These eruptions and other modifications in the structure of the cervix are conditions which prepare the way for ulceration. The most simple of these modifications of the cervix is redness or erythema, whether due to hypersemia, real erythema or to a large ecchymosis, or to a special congestive condition with softening of the tissue and a tendency to bleed. In addition to these morbid condi- tions there may also be leucorrhcea ; under the influence of which an abrasion of the epithelium of the mucous membrane is sometimes pro- duced which gives rise to the superficial exulceration designated by the name of erosion. Herpes, which is one of the forms of the vesicular variety, is very common on the cervix : it is constituted by a heap of small vesicles, all confluent, or some of which are discrete, grouped irregularly, forming a surface covered with small hollow eminences filled with transparent, citrine, whitish or slightly purulent serosity. It is limited by sinuous or jagged borders, rather redder than the neighbouring parts but gradually blending with the natural colour of the rest of the cervix. It is situated on one of the lips, in the central and most convex part, or near the orifice more frequently than on the external border. It resembles the herpetic eruption on the prepuce, and though it sometimes becomes the starting-point of an ulcer it is often cured spontaneously, disappearing in a few days, which is un- doubtedly the reason why it has not been seen more frequently. Eczema, whether simple or impetiginous, is also developed on the cervix. It is hardly ever seen in its first stage; but is known by its extent, secretion, and the denudation of the dermis. In place of being confined like herpes to a small surface or to one of the lips, it usually extends over the whole of one of the lips or over both. The surface is often covered by a fluid or semi-fluid secretion, which must be wiped off before the dermis can be seen. Pemphigus, of which I have seen some cases, has been described by Joulin.^ It is constituted by one large and transparent vesicle, formed by an elevation of the epithehum, containing a serous fluid like water. It has a globular or rather elliptical form, with irregular borders, re- sembling somewhat a large and thick drop of transparent and thready . ^ AcaAemie, de medecine, April 2, ISGl.. 636 UTERINE DISEASES IN DETAIL mucus secreted by the cervix. It is sometimes surrounded at its base by a very narrow bright-red border, which appears to consist of pure blood. The surface of the cervix on which it rests is perfectly normal, preserving its usual hue, and may show absolutely no alteration. The portion of epithelium which serves as a wall to the vesicle is so re- sistant that rubbing with cotton wool -will not always rupture it; if rubbed with the crayon of nitrate of silver the bulla is destroyed im- mediately, and the fragments of epithelium which are observed after this rupture form the only appreciable alteration. The fluid dis- charged does not appear to be viscous ; it seems to possess the proper- ties of ordinary serum. — Uterine pemphigus is a rare disease. Nelaton, Castelnau and Braun^ have observed a few cases. — It seems always to terminate spontaneously in three or four days without leaving any traces; it is accompanied by no symptom perceptible to the patient. It is therefore only accidentally observed on applying the speculum for some other cause. Folliculitis, true acne of the cervix, may assume various forms, from the most simple, that of punctated acne, to that of hypertrophic acne, depending on tlie share which iiiiiammation and the secretion of the Fig. 357. — Indurated acne of the cervix in a woman 42 years of age. Slight retroflexion and induration of the uterus. Round the os externum, there is considerable tumefaction, almost like a mushroom, extending to the vaginal portion as well as to the cervical cavity, and dotted over with a number of Naboth's eggs, some containing mucus, others pus (Virchow), follicles take in the malady.- — Sometimes the follicles are tumefied, prominent, and secrete more abundantly than usual ; we then see rising ' Medical Jahrbiicher, S. 182. Vienna, 1861. ULCERATION AND ULCERS OF THE UTERINE CERVIX 637 from the cervix discrete or confluent eminences formed by these organs, and small drops of a thick, viscous, transparent fluid oozing from their orifices ; the colour of these little eminences or their orifices is often slightly redder than that of the neighbouring parts of the mucous membrane, but frequently it does not greatly differ from it. Some- times the follicles, and especially their mouths, are very red as well as promineut : this bright redness contrasts so much with that of the mucous membrane surrounding them, that they might be taken for granulations or papillary eminences analogous to those of granular vaginitis. These eminences may be confluent, like granulations of the cervix ; greatly hypertrophied, of a light red or violet colour, complex like acne of the nose with considerable dilatations of the capillary net- work, or of the superficial venous network ; but usually they are dis- crete and scattered, and by this character, which attracts the attention of the physician, the differential diagnosis between these two diseases is facilitated. On pressure purulent mucus is seen to escape, in the form of a small yellow drop ; each small eminence then forms a well-marked red border round each little drop that escapes from its summit^ i. e. from its centre. This malady is quite distinct from the uterine granulations already described. The other pustular diseases of the cervix are very numerous, and are the most common origin of ulcers properly so called. Usually they con- sist in the development of a great number of small, contiguous, con- fluent pustules, easily torn, and exuding pus as in impetigo, and becoming the starting-point of a purulent secretion renewed incessantly on a base which is ulcerated and complicated by granulations, follicu- litis, mucous hypersecretion, &c. At other times they present the appearance of isolated pustules, broad and flat, resembling those of ecthyma, and terminating at times like the preceding ; but this form is much rarer than the other. It is probable that, independently of eruptions due to disordered local vitality, various eruptive forms are developed on the cervix under the influence of a diathetic affection. The mucous membrane of the cervix resembles the skin as regards her- petism and scrofula. As for venereal affections I may say that I have seen every kind of syphilide on the cervix, from erythema, small cir- cular patches, red and like rubeola, macula, spots, &c., to pityriasis, psoriasis, flat piistules di,ndi tubercles. In examining women in whom the uterus is supposed to be healthy, as well as those in whom it is diseased, we cannot fail to meet with these various eruptive forms, sometimes isolated, sometimes coexisting with a uterine malady, or partly assuming another form, or complicated with granulations or ulcers, 2. Ulcers of the Cervix Ulceration of the cervix is one of the most common diseases of this organ, in spite of what has been said by Robert Lee, whose statistics are opposed to those of West. I may say that my own experience has 638 UTERINE DISEASES IN DETAIL confirmed the results arrived at by West, and has justified the opinion that ulceration of the cervix is a morbid condition of great importance in uterine pathologv. The following are the results of some statistics on the frequency of ulcerations of the cervix, relatively to uterine and other diseases. Compared with uterine diseases we find : According to mj experience . 425 ulcerations out of 1563 uterine diseases. H. Benneti . . 222 „ „ 300 „ West^. ... 17 „ „ 29 Compared with other diseases we find : According to "West ... 17 cervical ulcerations in 65 autopsies. „ D. S. Stewart' 15 „ „ 50 „ „ Aran* ... 1 „ „ 10 ,, Diagnosis — suljective signs. — Superficial ulcerations or erosions, exulcerations and fissures generally pass unperceived, hke the erup- tions which have given rise to them. Ulcers properly so-called may exist for a long time without having determined leucorrhoea, men- strual disorders, local pain, or general disturbance of the health which would have attracted attention to them. This usual, though not constant, tolerance of the organism with regard to recent uterine ulceration makes the description of the symptoms which characterise it difficult. The frequency of complications is another cause which increases the difficulty. It is seldom indeed that ulceration exists alone for any length of time. When it has lasted for some time and is at all extensive, there is at least leucorrhoea. All the follicles con- tained in the ulcerated tissue and those of the neighbourhood are attacked by a morbid irritation, which determines on their part a hypersecretion the products of which are added to the pus secreted by the surface of the ulcer. I do not speak of congestion, fungos- ities, softening, hypertrophy of the organ, metritis, nor of other complications or concomitant morbid states giving rise to special symptoms previously enumerated. I try to distinguish the special symptoms of the ulcer from those which, although they may have first attracted attention to the uterine malady, may depend only on com- plications. Now in those cases in which I have not had to separate the ulcer from any other concomitant morbid state, but have treated it directly without being first obliged to resort to leeching or other medication, I have almost always found that patients had few local symptoms. These appear to be limited to lumbar and inguinal, or rather femoral pain shooting down the thighs to the knees ; as. a rule, there is no hypogastric pain ; sometimes there is pain in coitus or for I Op. cit., p. 37. " Op. cit., 1st edition, p. 119, omitted in 4th edition. ' H. Bennet, Op. cit., Appendix, Uterine Pathology in India, by D. S. Stewart, p. 587. * Op. cit., p. 485. ULCERATION AND ULCERS OF THE UTERINE CERVIX 639 a day or two afterwards ; sometimes after sexual intercourse there is a slight discharge of blood mixed with the leucorrhcea, and if the ulcer is fungous, there may even be haemorrhage, more or less abundant but always limited in duration. The general symptoms are usually more marked. Without presenting anything very special, they almost always attract attention to the uterus, even when there are no local symptoms. Amongst those which are common to all uterine diseases, disorders of the digestive functions I think occupy the first place in cases of obstinate ulceration. Patients almost always complain of dyspepsia ; they are languid and their suffering is increased by emaciation, anaemia, pale- ness, and the peculiar alteration of the features which has been desig- nated by the name o^ fades uterina. These symptoms, however, it will be seen, merely attract attention to the uterus and to the neces- sity of examination by speculum, which is indispensable in order to determine the existence and character of the lesion. The objective signs alone allow of a diagnosis being made. Objective signs — I. Diversity in the form of cervical ulcers. — Cer- vical ulceration is seldom deep. Its existence is manifested by the condition of the surface rather than by the loss of substance. The ulcers which least alter the aspect, form or structure of the cervical mucous membrane are erosions, exuberations, fissures. Next in order come ulcerations proper, some of which are distinguished by an exuberance of tissue, others by a more or less sensible loss of sub- stance. In the former category are granular, vegetating, fungous, varicose ulcers and generally those depending on chronic metritis, uterine catarrh, or merely on pregnancy ; in the latter, excavated ulcers, those with greyish base, indurated ulcers, ulcers with callous borders perpendicular to the surface or detached from it, corroding ulcers and generally those which are kept up by a diathetic affection. Fissures are chiefly found where the cervix has been lacerated by previous labours, and they are situated at the base of these old lacera- tions. Thence they may extend, forming, on a more or less consider- able portion of the cervix, exuberations which have a continual tendency to increase. When erosion of the cervix is left to itself for some time, or exposed for several months to the deleterious influence of external causes, e.g. want of cleanliness, venereal excesses, abor- tions, or repeated deliveries, it becomes transformed into an ulcera- tion, at first deep and accompanied by loss of substance, later on filled up by the development of granulations produced either from papillary hypertrophy, or rather from true cicatricial granulations which rise from the base and soon project beyond the smooth and healthy surface of the cervix. The hypertrophic tendency of these granulations is sometimes so considerable, that the ulcer may pass from the granular to the vegetating form, presenting excrescences of from 3 to 5 millime- tres in height of dark red colour similar to that of uterine granula- tions, formed like them and like true granulations of a very delicate and very vascular fibro-plastic tissue, often very near together, separ- ated by hollows, protruding more or less over the irregular border of the ulcer, sometimes projecting into the cervical cavity, giving rise to 640 UTEEIXE DISEASES IN DETAIL a very abundant purulent secretion requiring immediate treatment. As soon as discovered they should be treated energetically. Scanzoni ^ says that varicose ulceration is one of the forms least frequently seen. It is only developed after a chronic stasis of blood, within the uterine walls. The ulceration is consecutive to congestion of the organ ; not only is its colour bluish red, like that of the genital organs when gestation is advanced, but its surface is traversed by varicose veins. " In one case," adds this writer, " such an erosion was traversed by a vein about half an inch in length and dilated to the thickness of a crow's quill, from which there was discharged about two ounces of blood when we opened it." The ulcers kept up by diathetic disorders usually present different forms. The hypertrophic tendency of the uterine tissue may some- times render them granular or fungous like the preceding ; but fre- quently, in place of being exuberant [excedens] the diathetic ulcer is distinguished by loss of substance, by its colour, its consistency and its limits. Thus the base, instead of being granular and exuberant, is depressed, irregular, more or less hard, covered with a thick yellow or greyish secretion, which is sometimes adhesive and pseudo membranous, at other times, on the contrary, transparent, ichorous, sanious and san- guinolent. The borders, in place of being irregular, ill defined, and concealing the limits of the ulcer more or less, are, on the contrary, well marked, of a bright red, contrasting with the base of the ulcer as well as with the neighbouring tissues, following a regular curve, or ragged and spreading unequally in various directions, now detached, soft and pale, now adhesive, perpendicular and hard. II. Jjiverdty in the nature of cervical ulcers. — With regard to their nature, cervical ulcers depending on disordered local vitality, whether physiological or pathological, are easily distinguished from ulcers depending on general diathetic disorders. 1. Amongst the former, depending on an alteration of local vitality, one of the most remarkable is the ulcer produced or kept up hy preg- nancy. It is difficult to know whether pregnancy is the only cause of these ulcerations. It is probable that many of them are really due to the existence of some general undetermined affection or to a special tendency of the uterine tissue to become ulcerated as an effect of the special irritation or the epithelial maceration caused by the leucorrhoea produced by pregnancy. Pregnancy, however, by congesting the cervix with the rest of the organ, and especially by softening it and modifying its nutrition, has determined ulceration, even if it has not predisposed to it. However that may be, it is all the more important to pay attention to these ulcerations, as they seem actually to have produced abortion in some cases. The ulcer produced or kept up by uterine catarrh is recognised by the existence of a concomitant uterine leucorrhoea and by the presence in the midst of the granulations of inflamed hypertrophied follicles, ' Scanzoni, op. cit., p. 212. ULCERATION AND ULCEUS OF THE UTERINE CERVIX G41 producing an abundant hypersecretion. It is usually granular, some- times even fungous, and except at the commencement, when it is only slightly raised and has a velvety or strawberry aspect, the surface becomes irregular and broken, owing to the inequality in the size of the granulations; the fluid pellicle which covers it is not only purulent, but viscous, more or less tenacious and adherent ; usually the ulcer cannot be laid bare nor made to bleed without wiping it well. Never- theless we cannot cure the ulcer by merely curing the leucorrhoea ; unless the means of treatment, such as the introduction of nitrate of silver, be sufficient to modify profoundly the surface of the ulcer as well as the uterine cavity. Ulceration determined by the persistence of chronic metritis, especially of parenchymatous metritis, whilst occupying an important place in the production of cervical ulcers, is far from being as frequent as is represented by modern gyngecologists who describe cervical ulce- rations as the termination of metritis. Sometimes indeed their parts seem to me to be reversed, and especially in cases where the metritis is confined to the cervix, we may regard it as being as often the effect as the cause of ulceration. 2. Amongst ulcers depending on general diathetic alterations w^e may first of all distinguish her^Jetic ulcers, which may be recognised at the outset by the appearance of one of the eruptive forms which I have described as originating them ; later on, by the formation on the bor- ders or in the neighbourhood of the ulcer of vesicles, phlyctenes and pustules analogous to those from which they sprang. Scorbutic ulcers, which occur but seldom, are violet in colour, fungous, soft and bleed easily ; they are also engorged and oedematous at the base or at the part surrounding the cervix. Scrofulous ulcers have their edges de- tached and slimy, often spreading considerably over both cervical lips. Like most of the others, with the single exception perhaps of leucor- rhoeic ulcers, they are not confined to the posterior lip of the cervix, and they seem to be as common on the anterior as on the posterior lip. They secrete pus abundantly, which is often unhealthy, serous or sero-caseous. It would seem as if from their borders and from the anfractuosities hollowed out below them there flowed a thick pus, con- densed by its prolonged sojourn in these crevices and from which the serous part has already been discharged. I think it is this thickened pus, mixed with fragments of tissue separated by the progress of ulceration, which has sometimes been taken for tuberculous matter. Syphilitic ulcers are rare on the cervix when compared with their frequency on the vulva and other parts ; they are not, however, rare absolutely. I have frequently seen chancre of the anterior lip deter- mine by contagion, after the lapse of a few days, the appearance of a chancre on the corresponding part of the posterior vaginal wall which is constantly in contact with this portion of the anterior lip and on no other part. I have seen women who were accused of having infected men with whom they had had intercourse, and in whom I could not 41 642 UTERINE DISEASES IN DETAIL discover any ulcerated or chancrous surface, any syphilitic symptom or even any morbid symptom, with the exception of a leucorrhoeic drop escaping at intervals from the os uteri. After a few days I have seen the circumference of this orifice gradually attacked from within outwards by a chancrous ulceration commencing evidently in the cervical cavity and gradually extending to one of the lips; I have collected six well-authenticated cases of this development of iutra-cervico-uterine chancre. Chancres of the cervix have the same appearance that they present on other parts of the genital mucous membrane ; they are seldom indurated ; they have perpendicular edges, on a greyish base, are sometimes diphtheritic, or at least covered with a thick, hard, adhesive pseudo-membrane, and have apparently a phagedenic tendency. Lastly, the cancerous ulcer, variable in form with edges usually hard, unequal, friable and bleeding, with an ichorous rather than a muco-purulent secretion, presents characteristics so well marked that I cannot dwell on them here; they will be described when we come to Cancer of the Uterus. III. Diversity of the ulcerative or destructive tendency of ulcers of the Cervix. — Superficial ulcers, slightly granular exulcerations, erosions pro- duced by the various eruptions previously described, have frequently a natural tendency towards cicatrisation and may be called non-malignant. Simple granular or even fungous ulcers, those due to pregnancy, leu- corrhoea or chronic metritis, frequently also diathetic ulcers, although not naturally tending towards cicatrisation but on the contrary to further development, may also be ranked as non-malignant because prompt and energetic rational treatment succeeds in curing them. There are, however, ulcers which, on the contrary, have a destructive, fatal tendency, and which may be characterised as malignant. Can- cerous abscess may be placed in the front rank ; they are easily distin- guished from others. Are these the ulcers described by Clarke and Levers as ike corroding ulcer of the os uteri ? I am inclined to think with Kiwisch and Scanzoni^ that it is so; Rokitansky,^ however, de- scribes a corroding ulcer of the uterine orifice which is similar to the phagedenic ulcer of the skin. '^ Although it has no neoplasm for a starting point," he says, ''yet it gradually destroys the vaginal portion or even the greater part of the uterus, destroying at the same time the adjacent tissues as far as the rectum and bladder. It is an irregular ulcer with sinuous, indented outline, at the borders and base of which, from slow inflammation, the tissues are thickened, hypertrophied and hardened. The base is of a dirty green or brownish-green colour, secreting sometimes a small quantity of a viscous purulent fluid, at other times a more abundant and aqueous fluid; it presents no granu- lations, but a gelatinous exudation, in which the various tissues of the ulcerated surface liquefy.''^ This description evidently refers, if not to encephaloid or scirrhous cancer, at least to epithelioma of the cervix, and these ulcers may produce considerable destruction of the uterus. ' Op. cit., p. 214. - Anat. path., 1861, t. iii, p. 538. ULCERATION AND ULCERS OP THE UTERINE CERVIX 613 I have seen several cases of the kind, and they may be found in the admirable works of Cruveilhier and Lebert, But apart from this ten- dency, which is due to a diathetic affection, may not a similar tendency be developed in a cervical ulcer, especially if syphilitic ? I have seen one case so marked that I think the cervix would have been destroyed if I had not arrested the progress of the ulcer by repeated cauterisa- tions and frequent dressings. I willingly reserve the name of corroding or phagedenic to this form of ulceration. At other times without having so marked a destructive tendency, the ulceration pursues its course in one direction whilst cicatrisation is obtained in the other, and its existence is thus prolonged indefi- nitely. In such cases the ulcer may be called serpiginous, and should be carefully and energetically treated. But a well-marked destructive tendency is manifested in the ulcer when it becomes diphtheritic. Fortunately this case is very rare, and judging from the description which Boys de Loury and Costilhes^ give of it they do not seem to have observed it accurately. I think I have seen it as well as the phagedenic ulcer once. However, even when not truly diphtheritic, cervical ulcers may frequently be covered with pseudo- membranes of variable nature, like those on the tonsils, in the mouth and on the pharynx. I share the opinion^ of Laboulbene and other practitioners who have studied diphtheritic and pseudo- membranous products, that there are great differences in the nature and degree of maladies presenting this complication. I am convinced from frequent observation that cervical ulcers are also liable to be covered with membranous, pseudo-membranous and even diphtheritic products from the effects of an adynamic and cachectic condition. Without having the extreme gravity of true diphtheria, especially when left to itself, these products always indicate an unfavorable ten- dency and necessitate active and energetic treatment. They may be distinguished by the difficulty there is in getting rid of the yellowish or greenish layer covering the ulcer. The membrane has to be taken away in fragments with forceps before the base of the hollow bleeding ulcer is seen, which has extended in breadth as well as in depth under the shelter of this false membrane. The neighbouring parts are tumefied, violet red, sometimes livid and the neighbouring ganglia inflamed. Treatment. — Granular ulcerations of the cervix are never cured spontaneously, and they have a continual tendency to extend and to become fungous when left to themselves ; therefore they should be treated, care being taken to fulfil the indications in the order in which they present themselves. 1. The first indication is to treat the general or local cause which produces the ulcer, or which keeps it up. The patient should follow an antidiathetic treatment, the means of which will vary, not only according to the nature of the affection on which the ulcer depends, ' Gazette niedicale de Paris, 1845, p. 374. * Recherches sur les conditions mctcorologifiues du developpenient dti croup et dc la diphtkerie, p. 35. Moutpellier, 1862. 614 UTEEINE DISEASES IN DETAIL but also according to the condition of the various functions ; for the form in which the remedy is administered must vary according to whether the condition of the digestive functions is normal or not. As to the local state, we must not forget that fluxion, congestion, inflammation, hypertrophy or leucorrhcea may complicate the ulcer as cause, effect or simple coincidence. But whatever part these morbid states may play, they should be treated by bloodletting, rest, baths, prolonged irrigations, associated with general and local resolvents. 2. The second indication is to maintain great cleanliness of the ulcer and neighbouring tissues, sometimes isolating the ulcer from the contiguous surfaces. The necessary attentions to cleanliness con- sist in irrigations with tepid water repeated at least twice a day in order to prevent the fluids which are secreted from remaining in the vagina ; sometimes they require to be made every four hours. These sometimes suffice for the cure of erosions and exulcerations. They serve two purposes : by ridding the vagina of the abundant and irri- tating secretions which accumulate there, they prevent the contact of these fluids from keeping up and increasing the ulceration ; by clean- ing the ulcer itself, which is irritated and positively infected by its own secretion, they prevent its extension and also the transmission by contagion of the malady to the contiguous mucous surfaces. As a rule, simple irrigations should be made with tepid water in winter and at the temperature of the room in summer. Cold water should be used when the ulcer is fungous or bleeding. These irrigations may be rendered disinfecting by the addition of a little carbolic acid, vine- gar, permanganate of iron or chloride of lime. When there is conges- tion or a tendency to hsemorrhage I prescribe injections to be made three times a day with water as hot as can be borne (112° T.) with one or two tablespoonfuls of a solution of carbolic acid (75 gr. crys- tallised carbolic acid to a quart of water). These injections often suffice to cure certain kinds of ulcers. 3. The third indication is to modify the surface of the ulcer in such a way as to stimulate its vitality and to produce a tendency towards cicatrisation, a more or less marked resolvent action. A tampon applied every day to the cleansed cervix for a few hours is sometimes sufficient to give a favorable impulse to cicatrisation. At other times an inert powder, such as starch, will produce the same effect ; iji both cases unless there is no discharge the vagina should be syringed several times a day. The injections may be medicated, but previously to using them a simple or purely detersive lotion should be made. After having washed and wiped the cervix we may apply a little subnitrate of bismuth, calomel, alum, sulphate of zinc or acetate of lead to the ulcer, and then a spoonful of starch in powder to keep the drug in place, or a tampon will do as well. I generally place the powder on the tampon and then apply it to the cervix, pushing it close against the uterus while I withdraw the speculum, taking care not to allow the powder or fluid to come in contact with the vaginal wall. A ULCERATION AND ULCERS OF THE UTERINE CERVIX C45 number of drugs are employed in this way. I shall content myself with mentioning alum, tannin, sulphate of zinc, sulphate of copper, nitrate of silver, tincture of iodine, perchloride of iron. Each of these medicaments may answer to a special indication, which may be gra- duated according to the nature of the lesions. Thus it is sufficient to touch simple erosions with a weak solution of alum or nitrate of silver. When the ulceration is more extensive or deeper, these solutions may be made stronger, and when there is leucorriioea or excoriation of the vaginal culs-de-sac, as frequently happens, these drugs should be left for a few seconds in contact with the diseased surfaces in order to give them time to penetrate sufficiently. After having embraced the cervix with a wooden, porcelain, or glass speculum, and having wiped not only the whole surface of this organ, but the neighbouring portion of the vagina, we pour into the inclined speculum one or two teaspoon- fuls of a solution of nitrate of silver (30^ 20 or 10 per cent, according to whether we wish to use it as an alterative, a catheretic, or a mild caustic). It is left for a few seconds in contact with the diseased surfaces, then poured out of the speculum by depressing the instru- ment, what is left being removed with a little cotton wool to prevent any injury to the vagina or vulva. When only the surface of the ulcer requires treatment we simply touch it with the crayon, perchloride of iron or laudanum. These are the agents I use most frequently and lind successful. When the neck is engorged, (edematous, or when the ulcer is callous, the tincture of iodine has the advantage of being resolvent as well as catheretic. When the ulcer is fungous, varicose, bleeding, the perchloride of iron (30 per cent.), which acts not only as a caustic but as a powerful hemostatic, is of great use. In such cases I sometimes touch the ulcer with iodoform, creosote or crystallised chromic acid ; but these medicaments should be reserved for cases in which destructive action is desirable. When a specific action is required solutions of corrosive sublimate should be used. We may also have recourse to ointments, though I think they are less efficacious than other applications. If there is pain and hyperaes- thesia I use laudanum, as recommended by Aran, only instead of keeping it in place by powdered starch, after pouring in from 15 to 60 drops I introduce a tampon, which I push against the cervix, which the patient removes a few hours afterwards in order to make an injec- tion. In other cases I spread a thick layer of opiate ointment on the tampon and apply it to the ulcer. When I wish to excite a resolvent action I apply in the same way an ointment of iodide of lead and potassium or a glycerole of bromide or iodide of potassium. If specific action is needed as well I use mercurial and belladonna ointment, or ointment of red oxide of mercury, which is extremely resolvent, and in some cases hastens cicatrisation. In cases of acne or of ulcer kept up by folliculitis I apply an ointment of the double iodide and chloride of mercury, taking care to protect the vaginal walls, and I treat acne rosacea of the cervix like that of the face. Medicated pessaries are not so good, having the double drawback of not being always pushed as far as the cervix or of not remaining G46 UTEEINR DISEASES IN DETAIL there, and of acting on the vaginal mucous membrane as well as on the uterus. 4. The fourth indication is to destroy by cauterisation granula- tions, fungosities, callosities, in fact all pathological tissues. The sulphate of copper and the nitrate of silver are quite insufficient for this purpose, being only applicable to small ulcers, and only curing after a considerable number of cauterisations, and modifying the tissue so slightly that whilst they favour dessication of the ulcer and repro- duction of the epithelial covering of its surface, they leave the deeper alterations untouched, or may even increase them by the repeated irritation which their too frequent contact determines in the tissue. What I have just said of nitrate of silver may also be said of more energetic caustics, especially of the various acids, and in particular of the acid nitrate of mercury so much used at present. Their liquid form is also a drawback ; in the case of the acid nitrate of mercury there is the additional risk of salivation. The potential cautery, such as Vienna paste, is preferable to the means just enumerated, and would be indispensable in cases in which the size of the granulations necessi- tates deep destruction, were not the same effect produced with less danger with the actual cautery. Actual cauterisation may be either superficial or deep as required. It should be sufficiently energetic not to make a second apphcation necessary, remembering that the depth of the scar produced is really less than it seems to be. In such cases we must not fear to use more than one cautery to the portion of the cervix to be destroyed, especially if the fungosities of the ulcer are voluminous and bleeding, if the cervix is engorged and hypertrophied, if we require, in short, by suppurative action of some duration and by the cicatricial process which follows to produce absorption of the tissues or inter- stitial fluids and resolution of the tumour formed by the ulcerated cervix. I have seen ulcers of this kind resist cicatrisation so long as to force me to have recourse to the actual cautery every four or five weeks during general and local treatment; but I have never had a case that I could not cure. Actual cauterisation is also apphcabk to ulcers during pregnancy ; double care, however, is required to prevent any subsequent fluxionary movement towards the uterus. When rest, baths and cold fomentations are insufficient the best means of avoiding abortion is to subdue sanguineous fluxion of the uterus by revulsive bleedings of the arm, which may be repeated when necessary, but should not be copious. Lastly, we must not imagine that all local treatment is finished when we have burned the ulcer. As soon as elimination of the scar com- mences the physician should direct the cicatricial tendencies of the bleeding surface. In many cases this period is critical, and if a favor- able impulse is not given to the cure of this new wound it may relapse under the unfavorable influence which kept up the ulcer, and in a few days become as fungous as before owing to the hypertrophic tendencies of the uterine tissue. The wound should therefore be stimulated to form a good cicatrix in a few days. Lastly, we must be wilhng to wait for a considerable time after cauterisation before obtaining all the ULCERATION AND ULCERS OP THE UTERINE CERVIX 647 results that we have a right to expect from it, and we should use the general and local means of which I have so often spoken (especially hydropathy and mineral waters) to forward resolution and to prevent the renewal of ulceration or the development of some other affection on an organ too recently cured not to be liable to a relapse. CHAPTER IV ORGANIC ALTEBATIONS — FIBEOUS TUMOURS — POLYPI AND MOLES — TUBERCLE — CANCER Organic alterations differ from morbid states without neoplasm in the production of new elements appearing in the form of more or less voluminous tumours, and constituting the most important character of these diseases as regards diagnosis and treatment. These new elements may be the very elements of the uterine tissue or their analogues (homeomorphous tumours), or they may appear to have only a distant analogy with these elements and be developed in the uterus with the same characters which distinguish them in the parenchyma of any other organ (heteromorphous tumours). To the first category helov^^ fibroids, fibromata, myomata and polypi ; to the second tubercle and cancer. Fibrous Tumours The names fibrous tumours, fibrous bodies, myomata, leio-myomata, fibroids, hysteromata, &c., are used to designate tumours of a fibrous appearance which are frequently developed in the uterine parenchyma. They are excrescences from the uterine walls similar in structure to the uterine tissue. They are also the most common of all organic diseases of the womb. The name fibrous body given by Cruveilhier indicates the nature, the isolation and the independence of these productions, as well as the absence of pediculisation which distinguishes them from polypi. The expression interstitial fibrosis tumours is often employed to call attention to their development in the midst of the uterine tissue. The recent names of fibroids ^ and fibromata designate the principal aspects under which they are usually seen; that of myomata^ defines their muscular or fleshy texture ; whilst that of hysteromata (Broca) recalls their nature, which is no other than that of the uterus itself, their development appearing to be due, according to my own observations as well as that of Lebert and Kobin, to hypertrophy of the fibro- muscular element, of all the anatomical elements that which best characterises the uterine tissue. They are rounded tumours, slightly irregular or nodulated on the surface, formed of greyish fibres or fibrillar of considerable consistency, closely approximated, encircling a fictitious centre, or it may be several centres closely interlaced, inter- sected with dull white bands, distinct from the uterine wall in colour, * M. 11. Currey, On Fibroids of the Uterus {Philadelphia Med. and Surg. Report, March, 1874). ^ Vircliow, Die KranJchaften Geschwiilste. Berlin, 1803. lie calls them leio-uiyoraata, or tuuiours formed of smooth muscular fibres. FIBROUS TUMOUUR 649 consistency and in the absence of blood-vessels of any size. — Tliey occur at all ages^ before 20 and after 80.^ The site is in relation with the thickness of the uterine wall and the region of the uterus that they occupy. 1. As regards the wall, they may be developed in the central por- tion, in which case they remain sessile for a long time; or towards the free surfaces, in which case they are generally pediculated. The first class are interstitial. Those of the second class have been called su/j~ mucous or sub-peritoneal, according to whether they push before thtm in the direction of" least resistance the mucous membrane or the peritoneum ; but these expressions are incorrect, for the fact which they seem to imply does not occur : whether covered with uterine mucous membrane or peritoneum fibromata have always a thin layer of uterine tissue over them.'^ Even the interstitial tumours may become enor- FiG. 358. — Interstitial fibroid {ad nat., Farre). mous without being pediculated, although they are only separated from the uterine cavity by a thin layer of tissue proper. The uterus neces- sarily participates in this development, as if it contained a product of conception, a fact which to some extent justifies the expression of fibrous j)regnancy^ given to it. 2. As regards the region of the uterus, fibromata may arise from any point ; they are, however, produced more frequently in the body than in the cervix, almost in the proportion of 110 to 21.'' The latter segment may remain intact, whilst the body is loaded with them so as to resemble a bag filled with nuts.'^ 1 Engelmann {Zeitscliriftf. GeburtsJc, 1877, Bd. i, Heft 1.) ^ Cruveilliier, Anatoviie pathologique, t. iii, p. 667. Paris, 1865. Bnyle, Diet, des sciences onediccdes, vii, 72. Paris, 1813. ^ F. Gujon, Des tumeitrs fibreuses de i'utenis. p. 13. Paris, 1860. ^ Safford Lee, On Tumoiirs of the Uterus. London, 1847. ^ As in an anatomical preparation of Huguier's, quoted bj Guyon, (jp. cit;, p. 15. 650 UTERINE DISEASES IN DETAIL In fibromata of the body those of the posterior wall are the most frequent, those of the anterior wall come next, and those of the fundus last.i Those of the cervix are developed like the latter, and are usually pediculated towards the cervical cavity ; they escape from the uterine orifice much more easily than do those of the body. The size of uterine fibroids varies greatly, according to the stage of development and the arrest which the development may undergo ; they may be seen from the size of a pin's head to that of the head of an Fig. 359. — Fibroid tumour of enormous size, rising to the hTjiochondriac region (Graily Hewitt, op. cit., p. 498, fig. 102). adult. I have seen a patient who had one which could not have weighed less than 50 Ibs.'^ Binz^ examined one which weighed 62 lbs.; Walter one of 74 lbs. It is the same as regards number ; they may be single or multiple. In the latter case they are usually of various sizes, and they may also be found in the annexes.^ They do not occur singly as often as Cruveilhier thinks. Sub-peritoneal fibromata are sometimes very numerous, while the sub- mucous are usually single, probably from want of room, for abla- tion is commonly followed by the development of a fresh tumour. Interstitial tumours are sometimes multiple, one of them generally ' Houel, Manuel d' anatomie pathologique, p. 596. ' Courty, Excursion chirurgicale en Angleterre, p. 58. Montpellier, 186,3. ^ Gazette med. de Paris, 1858, p. 807. ■• Neugebauer {Prager Vierteljahrschrift, Bd. ii, S. 59, 1877). FIBROUS TUMOURS 651 being larger than the others. Lastly, we may observe fibromata belonging to all these three categories in the same uterus. The/brwx is usually spherical ; it may, however, assume various and curious shapes, e.g. pointed, bilobed, owing to the entrance of the tumour into the neck, or irregularly nodulated when a number of tumours are fused together. The texture is very dense ; the dull white or mother-of-pearl tissue is one of the most resisting that is known. The tumour is chiefly composed of amorphous matter finely granulated, fibrous or fibro- plastic elements and muscular elements, or smooth muscular fibre-cells which are larger than in the empty uterus but smaller than in preg- nancy,^ and which form a quarter or a half of the mass of the tumour. This composition, however, may vary according to the starting point of the hyperplasia and the predominance of any particular element : hence fibromata properly so-called, fibroids (in which the embryonic element predominates), fibro-myomata, or hard myomata (the most common), soft myomata (in which the muscular fibres and sometimes the vessels predominate, the connective tissue being thin and loose), vascular or telangiectatic myomata, cystic myomata, myo-sarcomata,^ &c. Evolution. — We must distinguish in fibromata a primary state of development and a secondary state in which they live their own life. a. Owing to our ignorance as to the commencement of the evil (from knowing only large tumours), it was believed that there was a want of primordial continuity between the myoma and the uterine tissue (Bayle, Cruveilhier). But after histological researches had proved the identity of the fibres of the myoma proper with the muscles of the uterus,^ these tumours, which at first were thought to be developed in an interposed blastema were then regarded as result- ing from local hypertrophy,* and at a later period as being all special hypertrophic forms of the uterine parenchyma.^ This connection is so close that sometimes it is impossible to limit even large tumours, especially if they are soft. Fibromata therefore seldom appear to be formed by the interstitial development of elements similar to those in the midst of which the fibro-plastic tissue is produced or their forma- tive blastema deposited, but more frequently by the proliferation of a limited group of uterine fibres, which become isolated from all the others just as adenoid tumours are developed in the glands, heter- adenoraata in their neighbourhood, pigment in the choroid,^ &c. ^ Yogel, Erlailterungstafeln zilr pathologischen Histologie. Leipsic, 1843. — Oldham, Guy's Hospital Reports, 1844. — Lebert, Societe de biologie, 1852, p. 68. Anat. pathol. gen., pi. 157, 32« liv., 1859. — Eobin, These de Ferrier, 1854, p. 41. " Virchow, Die JcranTchaften Geschwillste. Berlin, 1863, Bd. iii, S. 310, et seq. * Vogel, Icones histol. pathol. Leipsic, 1843. * Simpson, Obstetric. Mean. Edinburgh, 1855, vol. i, p. 115. * Virchow, Wiener med. Wochenschrift, 1856, No. 7. ^ An example of the law o£ homology or analogy o£ formation. — Vogel, Anat. path, gen., p. 100. Paris, 1847. — Coui-ty, Substitutions organiques,^. 33. Paris, 1847, and Gazette med. de Paris, 1847. 652 UTERINE DISEASES IN DETAIL Their origin seems to be a swelling of certain bundles of muscular fibres at a given point analogous to the tumefaction of nerves in neuroma. h. The life of fibromata may be said to be a parasitic one as soon as they are isolated from the tissue from which they have taken birth. The anatomical independence which they then acquire as regards the uterine fibres, the feeble vascularity which they enjoy, the capillarity of the vessels by which their periphery commu- nicates with the rest of the womb, all concur to prove their physiolo- gical independence. It is easily ascertained that, with the exception of some adhesions abnormally established, they have no continuity with the tissue of the womb, but are separated from it by a loose cel- lular tissue as if by a cyst, sometimes by accidental serous bursae.^ Sometimes even the nutrition of fibromata takes place by imbibition ; it is probable that it is so when they seem to be contained in an envelope or a kind of sac which isolates them in every direction ; it cannot be otherwise when they are perfectly free in the abdomen with- FiG. 360. — Large fibrous interstitial tumour of the uterus, making the size of this organ equal to that which it acquires at full term (Sims). out on that account experiencing any alteration, and even without ceasing to grow, which is accounted for by their being protected from contact with the air and from the obscurity of their life. The growth of fibromata is unlimited ; it is very variable according to whether their development is rapid, slow, stationary or even retrograde. It is not rare to meet with an interstitial fibroma the size of which is equal to that of a foetus of seven or even nine months. Occasionally they are seen still larger (see p. 650, and Figs. 359 and 360). Amongst the alterations which they may undergo the most uncommon is atrophy by retrograde evolution. Soft myomata may become in- durated in consequence of inflammation ; their muscular fibres disap- ' Vorneuil, Fenerly ; Bulletin de la Societe anatomique, xxxix, 346. FIBROUS TUMODTIS "oo pear, they become fibrous and may even assume a cartilaginous aspect. The density of the tumour increases much more when the fibres com- posing it become encrusted with calcareous matter and when the fibroid undergoes petrification. This petrification, to which the name of ossi- fication has been given, may occur in two ways, either by a simple ])eripheric encrustation forming a kind of shelP for the fibroma, or more frequently by a general calcareous infiltration, by the formation of multiple concretions in the interior of the tumour/ and the petrifica- tion of the whole of the fibrous body. The stony hardness of the whole mass may be gre?.t enough to allow of its being polished, as was done with one in the Middlesex Hospital Museum. The uterus some- times contains such stones of considerable size and enormous weight. I have seen one that weighed 22lbs. Arnott^ mentions another of 50lbs. weight, which caused death in an old woman by tearing the in- testine in a fall. Cruveilhier regards the petrification of fibrous bodies as a kind of atrophy, an opinion which seems shared by Louis/ who says that the calcareous transformations of fibromata occur chiefly after the menopause. — Another kind of atrophy is the regressive fatty transformation of the muscular fibres, which modifies in an opposite manner the consistency of fibrous tumours, softening them, and giving them a yellowish coloration and determining their partial liquefaction and the formation of cavities. This transformation (which bears some analogy to the retrograde evolution which brings back the uterine fibres from the state of pregnancy to that of vacuity) may promote the gradual diminution in size and even the disappearance of myomata, either spontaneously or under the influence of rational resolvent treat- ment. West draws attention to the analogies which may be estab- lished, from this point of view, between a myoma and a tuberculous bronchial ganglion, both being capable of undergoing softening as well as calcareous induration. West also thinks, and I share his opinion, that absorption of a myoma without notable alteration of the tissue is not impossible, but might take place by regressive evolution as opposed to the progressive evolution which has given it birth. Fibromata may be attacked by softening, liquefaction and suppura- tion. Sometimes they are red, the whole tumour appearing inflamed ; they become oedematous, fluctuating, giving rise to a collection of serosity, blood and pus, very difficult to diagnose and threatening to terminate by dangerous peritoneal rupture, or they may become sepa- rated towards the uterine cavity by a kind of maceration in the san- ' Bourdillet presented a specimen to the Societe anatomique ; the patient had been in M. Mauriac's ward in the Hosjnce des Menciges. - Michel Morus counted thirty-two calcareous nuclei in a fibrous tumour. Louis, R. Lee and Velpeau have also mentioned remarkable cases of the same alteration (Trumet, These sm- les tumeurs de Vuterus, p. 76. Paris, 1851). Ashwell mentions four cases in the Gazette hebdomad., 1854, p, 410. — Louis Mayer and Lehnerdt each describe a new case {Monatschrift fiir Gehurtsh, 1869, Bd. xxxiii, S. 241). — Also Lumpe {Gazette hehdomad., I860, p. 716). — ■ And Mordret {Annales de gynccologie, t. xi, p. 135). 3 Medic. -Chirwrg. Transactions, xxiii, 1840. '' Concretions caicvlcases dc la matrice. — Acad, de cliir., v, 1. 654 UTERINE DISEASES IN DETAIL guineous fluids which bathe them.— Sometimes they are only partially attacked by inflammation, softening, suppuration or gangrene, either on the surface or in the centre, where a cavity is hollowed out, com- pared by Cruveilhieri to an eagle-stone. — When clustered together, cysts, either single or multiple, may be developed in the tissue between the fibromata, which may acquire a great size and become the seat of hsemorrhage or suppuration and even be taken for ovarian cysts. — Fig. 361. — Uterus, containing an ovum with an embryo of about two months, compressed between two fibromata, a large posterior pelvic one and a smaller anterior hypogastric one. The^ patient was ojierated upon : she died thirty hours afterwards (Barnes, Mtudes cliniques sur les tumeurs retro-uterines, in Annates de gynecologic, t. ix, p. 443. Paris, 1878). Cancerous degeneration has not been observed in fibroma. It may be propagated from the neighbourhood, but is never developed there in the first instance ; and fibroma and cancer very seldom coincide. What influence do fibromata exercise Wi. fecundation , pregnancy and delivery?"" — There is no doubt that the presence of myomata diminishes the number of conceptions and increases that of abortions and miscar- riages. Out of 605 patients (of whom 500 were married and sterile or had become sterile) seen by Marion Sims, 119 had fibrous tumours (not including cases of polypi). — Pregnancy is not impossible, but it seldom follows its normal course : whether the presence of the fibrous tumour prevents the free development of the uterus or whether it de- termines haemorrhage it often causes abortion. — Delivery may be impossible; it is always difficult, dangerous, complicated, and it exposes to troublesome consequences. According to Tarnier,^ out of ' Anat. imtli., liv. 13, pi. 6. ^ Voch, Des hysteromes au point de vue de la generation. Those de Paris, lg74_ — Lefour, Bes fihromes utcrins au point de vue de la groasesse et de I' accouchement. Those de concours pour I'agregation. Paris, 1880. * Societe de chirurgie, Feb. 10, 18Bi). FIBROUS TUMOURS 65 42 cases, delivery only terminated spontaneously 8 times ; it required the use of forceps 6 times, version 6 times, induction of premature labour once, embryotomy once, enucleation of the tumour once, Csesarean operation 14 times ; the malady caused death 5 times before delivery (of these 43 patients only 13 were cured) ; sessile fibromata are displaced with the uterus ; their ascension at the time of delivery is produced by the contraction or shortening of the longitudinal fibres ; they are therefore less dangerous at this time than pediculated tumours ; but they expose more to haemorrhage afterwards ; patients who escape may succumb to metro-peritonitis, to softening, to suppuration de- veloped not only in the uterus but in the fibromata themselves (Bayle, Lisfranc, Barnetche). What infiv^ence does pregnancy in its turn exercise on the development of fibrous tumours'?^ In spite of the interest which Gueniot imparted to this question by showing that, apart from the influence of preg- nancy, a fibroma may be attacked by hypertrophy, softening and sup- puration, we must admit with Ashwell, West, Virchow and all pathologists, that pregnancy is one of the conditions which most pro- mote the development of these tumours. My experience accords with that of Guyon, Bailly and others, that there is no doubt that the increase in the size of myomata takes place at the menstrual period and during pregnancy; it is the same with their softening and change of position ; but it is more doubtful whether they resume their former size and still more whether they become atrophied in following the retrograde evolution of the organ after parturition. In speaking of the termination of these tumours I shall, however, mention cases in which they have disappeared after delivery, and even during pregnancy, according to some writers. Diagnosis — signs common to fibromata — subjective signs. — The first symptom which the patient notices is metrorrhagia, sometimes neither preceded by local pains nor by fatigue. The loss of blood usually coincides with the menstrual period, in the beginning at least, and is therefore menorrhagic; at other times, or at a later period, metror- rhagia occurs. Excessive menstruation and haemorrhages in the inter- calary period are, in half of the cases at least, the first symptoms which betray the presence of a fibroma.^ In women who have ceased to menstruate haemorrhage is also frequently the first symptom. It some- times alleviates the acute lumbar pains from which patients suffered and gives a false confidence by misleading them as to the real cause of this loss of blood. The haemorrhage depends on the fluxion which the ' See Forget, RecJierches sur les corps fibreux et les 'polypes de V uterus con- sideres pendant la grossesse et apres V accouchement, in Bulletin gen. de therap., 1846. — Forget, Gueniot, Tarnier, &c., Discussion on the same subject in Bulletin de la Societe de chirurg., 1868, 1869. — Em. J. Lambert, Essai sur les grossesses compliquees de myomes uterins. Paris, 1870. 2 In 88 women suffering from myoma before the menopause. West (op. cit., p. 272) observed 45 cases of disordered menstruation, either as to frequency or abundance, or both simultaneously ; 15 cases of dysmenorrhosa, 4 of diminu- tion in the quantity of menstnial blood, and 44 cases of haemorrhage occurring in the intercalary period. 656 UTEEINE DISEASES IN DETAIL increase of the fibroma keeps up in the womb and on the alteration of the uterine mucous membrane owing to the presence of this organic lesion. It increases when the fibrous body, in place of remaining interstitial, has become pediculated, being a still more prominent svmptom in the history of polypi than in that of fibroids. Expulsive hypogastric pains accompany the menses. They sometimes extend to the hips and thighs, and especially along the sciatic nerve. There is also dull mechanical pain, pelvic fulness, weight, painful pressure on the sacrum, dragging in the groins and loins. Earlier or later leucor- rhcEa supervenes, being sometimes a mucous, glairy, transparent or opaque discharge, sometimes sanguinolent or purulent, its viscosity in- dicating that it comes from the uterine cavity. This glairy discharge is very abundant in some patients. Dysuria, vesical tenesmus or complete retention of urine, produced by the pressure, elevation or dragging of the bladder by the uterus, may occur in the beginning or when the fibroids have attained a certain size or are situated in the periphery. These symptoms are very common, as West has noticed them in 21 patients out of 40; accord- ing to Hervez deChegoin, they may even be the first that are observed. They are often remarked before constipation. The difficulties of de- fecation, especially when marked, may be said to be less common than those of micturition. Constipation may not even exist: is this the result of the normal anteversion of the uterus or is it, as Clarke^ thought, because the tumour does not correspond in its form to the shape of the pelvis, and being prevented by its size from entering the cavity, rests on the pubis and on the promontory, without either com- pressing the rectum or the sigmoid flexure which is to the left? Con- stipation may, however, become so complete as entirely to prevent the normal passage of fecal matter, determining symptoms of strangula- tion. This occurs especially when the fibroid has become stony. Nekton,- in a case of absolute constipation in which the rectum was so flattened that no sound would pass, performed the operation for artificial anus as the only means of prolonging the life of the patient, who lived for eight days. I have seen analogous cases. Alterations of the neighbouring organs may extend much farther. Strange displace- ments have been described, e.g. the rectum pushed to the right, the bladder on one side or the other, or extending upwards as far as the navel ; gradual wearing away and perforation of the bladder and rectum have been seen. Soir^ has seen a fibrous tumour the size of the fist perforate the uterus and linea alba, and escape through the gangre- nous skin of the hypogastrium in the form of a black and fungous mass. Objective signs. — The speculum is of no use in the diagnosis of a fibroma. Palpation permits the assumption of the existence of these organic alterations, especially when much developed, multiple or pro- jecting towards the peritoneum, when they give a nodulated form to ' Ohserv. on Diseases of Females, i, 279. London, 1821. ^ Guyon, op. cit., p. 49. ' Man. dc la Soc. dc chirury. dc Paris, 1851. FIBROUS TDMOUES G57 the uterus or are distinctly perceived round this or^an. Vaginal touch, however, is infinitely superior to the two preceding means of exploration ; associated with palpation, rectal touch and the use of the sound, which serve as complementary or auxiliary means, it alone can lead to a certain diagnosis. The association of touch and palpation with the use of the sound not only allows the difference in thickness of the two uterine walls to be appreciated ; the mobility of the catheter and the direction in which it is carried, the reverse of the natural or apparent situation of the organ, show that the uterine cavity is both enlarged and deformed. Vaginal touch should be practised in different attitudes and at various times, especially during menstruation and metrorrhagia, when the cervix is open ; for fibrous bodies and polypi present themselves at the orifice at these times, returning into the uterine cavity aftei wards. In order to facilitate digital touch we may, like Simpson, dilate the cervix with sponge tents, only we must be prepared to act immediately in case of haemorrhage, either injecting iodine, giving ergot, and plugging if we have to do with an interstitial fibroma, or operating if the fibroma is pediculated. When a fibroma by its size and weight can overcome the natural means of fixity of the uterus, it forces this organ to incline towards the side which it occupies, more frequently in lateroversion than in anteversion and especially than in retroversion. When of considerable size the influence of volume is greater than that of weight : instead of bending the uterus to its own side it pushes it to the opposite side, taking its point d'appui on some portion of the pelvic cavity, the sacrum, the cotyloid surface or the margin of the coccyx. If it becomes so large as no longer to be contained in the pelvis it is forced to rise into the abdominal cavity, dragging the uterus with it, thus producing the opposite condition to the prolapsus which the presence of the fibroma had produced in the beginning. II. Distinctive signs of interstitial, sub-mucous, and sub-peritoneal fibromata. — Interstitial fibromata present different symptoms, accord- ing to whether they are' situated in the fundus of the uterus, enlarging its dimensions transversely, or occupying the walls and increasing its cavity longitudinally. Those of the fundus may completely reverse the position of the uterus, making the exact limit between the tumour and the uterus very difficult to define; sometimes the fundus of the uterus remains thick, whilst the layer which covers the fibroma on the side of the uterine cavity is so attenuated as to make spontaneous enucleation possible, of which Barth,^ Bernutz,^ and several other writers have given examples ; at other times the fundus of the organ is so equally divided, that the uterine cavity is preserved and may become the seat of a pregnancy, as in the cases mentioned by Cruveil- hier,^ and by others.'* Those of the walls are less favorable to the * Bulletin de la Societe anatomique, 1850, p. 82. ^ Gazette hehdomad., 1866, p. 763. ^ Anat. pathol., ii'= liv., p. 45. '' Ingleby, Gaz. vied., 1839, p. 73.— Pillore, Gaz. des hopit., 1854, p. 547. — 42 658 UTERINE DISEASES IN DETAIL accomplishment of the uterine functions ; they may be prolonged into the cervix where they can be reached by operation, they may efface the cavity of the body by pressing together the mucous membranes of the two uterine walls in their whole extent, or these membranes may even become inflamed^ ulcerate and adhere together at several points.^ The continuitv of the myoma with the fibrous bundles, the muscular trabeculffi and the vessels persisting longer here than in sub-mucous and sub-serous myomata, it is not surprising that these interstitial tumours attain a larger size than the others, sometimes simulating pregnancy. The entire wall of the uterus is in a condition analogous to that of pregnancy, the muscular fibres are hypertrophied, the vessels dilated, the mucous membrane hypersemiated.- Sometimes on the contrary, the uterus is atrophied ; then the myomata are small, they become indurated and calcareous ; occasionally they become very large ; in these cases the atrophy of the uterus seems to be produced secondarily.^ Interstitial fibromata whether simple or compound, most frequently occupy the posterior wall of the uterus which is normally the thickest. They produce in the womb changes of size, form, situation and capacity presenting the greatest varieties. Suh-mucous fibromata. — Though seldom multiple, they may coincide with intra-parietal and sub-serous myomata ; but when at all large, they are seldom accompanied by important intra-parietal tumours. "When voluminous, they may adhere to the uterus by a broad base, it being impossible for them to become pediculated or to descend into the uterine cavity without dragging after them the fundus of the uterus. Usually, however, before appearing at the orifice, they are sufficiently separated from the uterine wall to be only adherent by a pedicle like a cord of variable resistancy, very distinct from the tumour and apparently holding it suspended from the womb and liable to spontaneous rupture. One of the most important points to be decided with regard to treatment is whether there is a broad base or a pedicle. Scanzoni used to seize the portion of the tumour visible at the orifice with Museux's forceps and try to impart movements of rotation to it, which could only be possible in the case of a narrow pedicle. The migration of sub-mucous fibroids provokes very charac- teristic changes in the uterus. It excites in the raucous membrane an irritation producing softening, injection, hsemorrhages, oedema, a muco- saneuinolent or muco-purulent secretion; the uterine cavity is in- creased ill its vertical diameter, whilst the two opposite surfaces are placed more or less in contact with each other ; in the end the cervix Legnerie, Gaz. med., 1854, p. 412. — Weber, Monatschrift fiir GeburtsJc., 1864, Bd. XXV, S. 157. — Ostertag, id., id., Bd. xxv, S. 317. — Spiegelberg, id., id., Bd. xxviii, S. 426. — Lorimer, id., id., Bd. xxix, S. 394. — Gueniot, Des tumeurs fibreuses de V uterus pendant la grossesse et V accouchement. Paris, 1868. ' Chassaignac, Bulletin de la Societe anatoinique, t. xviii, p. 10. - Carl Venzel, Die KranJcheiten des Uterus. Mayence, 1816, Taf. xi, a, b. — Hooper, Morbid Anatomy of the Human Uterus, pi. v, a, h. — Robert Lee, Medico. -Chirurg. Transact., vol. xix, p. 122, i)\. ii. — Lebert, Traite d^anat. pathol.. Atlas, pi. dvii, fig. 2. ^ Walther, Ueber fibrose Korper, S. 16. FIBROUS TUMOURS 659 becomes softened, shortened and reduced to a simple ring, as in the last months of pregnancy, the os being enlarged to allow the fibroid to pass. Suh -peritoneal fibromata. — In place of presenting the characters of uterine tumours like the two preceding, they have those of abdominal tumours as regards situation and symptoms. The symptoms vary according to the part of the uterus from which they have originated, the portion of the abdomen where they are situated, the volume which they acquire, the transformations which they utidergo. They may cause errors of diagnosis and real danger from these various points of view. The origin of subperitoneal fibromata is near the peritoneum or just below this membrane. These tumours remain attached to the uterus, and if largely developed, the womb appears to be only an appendage to them [see fig. 862) ; they project more or less consider- FiG. 362. — Uterus surrounded and surmounted by pediculated sub-peritoneal fibroids {ad. nat. Farre). ably towards the pelvis or abdomen, even the largest being seldom completely freed from the uterine tissue. Some^ however, end by being only connected with the uterus by a long and narrow pedicle ; Martini has seen one weighing 6 lbs. connected with the uterus by a pedicle two inches long and one wide ; Gaubric ^ found in the right iliac fossa a tumour reaching to the gall bladder, attached by a thin pedicle to the right half of the cervix; Cruveilhier^ saw a fibroid 11 lbs. in weight connected by a long pedicle of the diameter of a quill pen with the right superior angle of the uterus. They seldom appear singly, they coexist with intra-parietal or with internal myomata. They are usually hard, having a tendency to become calcareous, proba- bly by muscular atrophy and arrested nutrition. These fibroids may even be detached spontaneously from the uterus and continue to live either completely free in the abdomen, or fixed by accidental adhe- sions; in such cases there was necessarily rupture of the pedicle. They often give rise to no symptom, and do not even affect the regu- ' Memoires de medecine et de chirurgie pratique, p. 271. Lyons, 1835, 2 Bidletin de la Soeiete anatomique, 1841, p. 235. ^ Anatomic pathologiqiie, t. iii, p. 667. 660 UTERINE DISEASES IN DETAIL larity of menstruation. Bayle^ has mentioned a remarkable case of this innocuity. Like interstitial or submucous fibromata they are, however, often accompanied by considerable haemorrhage. Some by their weight and displacement have been seen to produce torsion of the uterus on its axis (Fig. 363), or the spontaneous separation of the body and cervix, others have caused symptoms of intestinal strangula- tion by pressure on the intestine,^ or even laceration of the intestine owing to a fall on the belly in the case of an osseous tumour;^ lastly, general compression and difficulty of respiration and circulation, asphyxia in fact, may be produced owing to their size.* Subperitoneal fibromata are those which are most easily recognised by palpation and touch combined. There is no uncertainty except with regard to those which arise from the upper portion of the posterior wall, which must not be confounded with uterine flexions or peri-uterine tumours (the sound associated with vaginal and rectal touch enables a diagnosis to be made), or with hard pelvic or abdominal tumours, such as ovarian cysts and solid tumours (the general health is much more affected in these latter cases than in cases of subperitoneal tumours) . III. Distinctive signs of fibromata and other uterine and peri- uterine maladies. — Pregnancy is distinguished from them by the menses being suspended ; but there are abnormal pregnancies, either in aged women, or with continuation of the catamenia or haemorrhage, hence the error made by Bayle'^ in a case of this kind. In order to avoid such a mistake the patient should be examined frequently at regular intervals. Balottement should be tried after the fourth month, and the physician should endeavour to determine the absence of nodulations, and observe whether there is the wine-red colour, the softening of the cervix and the oedematous sensation which the poste- rior wall of the gravid uterus sometimes presents ; he must remember also that voluntary movements and foetal heart sounds observed in the fifth month are certain signs of pregnancy. The existence of a fibrous tumour may not prevent conception although not allowing of uterine pregnancy : there may then be a tubal pregnancy, as in the case seen by Stoltz.^ Extra-uterine pregnancy alone may also be taken for a fibrous tumour.'^ Lastly, as a distinctive sign, we should notice in cases of fibroids whether expulsive pains are developed; they are frequently present, and would produce abortion if the uterus contained ' Op. cit., p. 79. * It is the only mode of strangulation by fibromata that is known. Three cases are recorded : one by Nelaton, one by Duchaussoy, both mentioned by Guyon (op. cit., p. 77), and another by Holdouse : flattening of the rectum, lumbar anus, death the tenth day {Transact, of Path. Soc. of London, vol. iii, p. 371). ' Arnott, Med.-Chir. Transact., vol. xxiii, 1840. ■• Cruveilhier : two tumours in the same patient, one of 11 lbs. with a long thin pedicle, situated in the right hypochondrium ; the other of 22 lbs., filling the pelvis and abdomen. Op. cit., p. 6(58. * Op. cit., p. 80. — Fredet, Annates de la Societe de medecine de St.-i^tienne, 1865, p. 205. ^ Mentioned by Aran, op. cit., p. 850. ^ Jobeii (de Lambalic), Gaz. des hnpit., July 5, 1845. FIBROUS TUMOURS 661 a product of conception in place of a fibroid. — We should remember that after delivery the presence of a fibroma in the uterus may expose Fig. 363. — a, enormous sub-peritoneal pediculated fibroid, accompanied by intva-muscular myomata and complicated with pregnancy, in a woman of 42, who had a miscan'iage sixteen years previously ; transverse diameter, 32 in., vei-tical diameter 14 in. B, left kidney; c, WoliRan cyst; D, interstitial fibroid contained in the right cornu of the uterus ; E, inser- tion of the peduncle of the large tumour on a level with the left cornu (the uterus is twisted on its axis) ; r, left ovary and round ligament ; G, right ovary and round ligament ; H, cervix (Leon Labbe, Legons de clinique chirurgicale, pp. 447, 452. Paris, 1876). US to an error in diagnosis leading us to think there is a second child. Abortion is distinguished by the coincidence of pains and haeraor- rliage, the pains ceasing with the haemorrhage. Prolapsus of the uterus inverts the vaginal walls, which does not happen when a pedi- culated fibroid passes through the cervix. The mistake is more easily made if the fibroid has a cavity and a transverse fissure imitating tlie cervix into which the finger can penetrate. In such cases the fibroid has sometimes been removed under the impression that it was the uterus. Levret, Richerand, Cloquet_, Bosredon, Velpeau^ Maree and 662 UTERINE DISEASES IN DETAIL Dolbeau^ have mentioned cases of the kind. The key to the problem is in the diagnosis of the uterus by determination of the cervix, vaginal cul-de-sac, the relations of the fundus, the direction of the ureter, the displacement of the bladder. Inversion of the uterus may be still more easily mistaken for a fibroid. The error has been committed by W. Hunter and Denman and followed by death ;^ at other times patients have survived the mistake.^ In these cases, which are rather numerous, sometimes simple inversion has been taken for a fibroid, at other times the fibroid has been rightly diagnosed but not the inver- sion which complicated it. In order to distinguish the one from the other two facts should be remembered : 1, in inversion, above the ring which encircles the tumour, a furrow or closed sinus exists all round, a cul-de-sac of moderate depth which cannot be prolonged into a uterine cavity which no longer exists ; 2, the fundus no longer occupies its usual place in the pelvis ; by means of vesical catheterism and rectal touch, or by means of a male catheter introduced into the bladder, the point of which is directed towards the uterine infundibulum (Mal- gaigne), this characteristic displacement of inversion can easily be ascertained, at least in most cases ; 8, acupuncture may be utilised, as I have already said apropos of inversion. Cancer may be taken for a fibroma and vice versa, especially when, owing to the gangrene of several fibrous tumours, an abundant fcetid discharge escapes from the uterus ; but the odour of the discharge accompanying the presence and even the softening of the fibroid in the uterine cavity differs from that which characterises cancer : the former is acid, being the result of fermentation and heat ; that of cancer is not only foetid but nauseous and putrid, having the smell of decomposition. The general symptoms differ also ; in cancer they are very serious, characterised by cachexia and hectic fever, the course of the disease also is relatively rapid ; while in the case of fibroid they are almost limited to impoverishment of blood and to anaemia. The other uterine diseases are more easily distinguished from fibromata than the preceding. Hypertrophic elongation differs from it by its regularity of form and the cervical elongation ; uterine cysts by fluc- tuation, softening, or the cavities which they contain ;* anteflexion and retroflexion (Fig. 364) by the curve which has to be described by the catheter in penetrating the uterine cavity ; engorgement by an in- feriority of size and weight, a loss considerable displacement, a less irregular tumefaction, a previous delivery or abortion ; metritis, by the equal tumefaction of the two walls, the ease with which the sound passes, the elevation of temperature, the acuteness of the pains caused by pressure, redness, muco-purulent or purulent leucorrhoea, ulcera- tion, granulations, &c., as well as by the relative rarity of hsemor- ' Guyon, op. cit., p. 80. * Robert Lee, Med.-Chirurg. Trans., xx, 144. * American Journal of Med. Sciences, April, 1849. — Bloxam, Gaz. med. de Paris, 1837, p. 122. * "We may, like lluguier, complete the difFerential diagnosis between a hard fibroma and a utero-foUicnlar polypus, with its cavity distended by a fluid, by making an exploratory puncture. FIBROUS TUMOURS 663 rhage. Some tumours situated outside the uterus may easily be confounded with fibromata, especially with pediculated subperitoneal fibromata, if in diagnosing them we have not recourse to the most exact means of investigation, — The first of these in frequency is retro- uterine hematocele : the error has been made.^ However, the history, the frequent suddenness in the formation of the tumour, the acuteness of the first symptoms, the persistence of peri-uterine adhesions, the absence of a pedicle, the site in the retro- uterine cul-de-sac of the san- guineous effusion which is at last absorbed, the absence of haemor- rhage and of complication of the uterine cavity, the almost invariable Fig. 364. — Fibroma projecting trom the posterior wall of the uterus, com- pressing the rectvim and simulating uterine retroflexion (Barnes, AnnaXes de G-ynecologie, t. ix, p. 441). position of the uterus immediately behind the pubic symphyses and almost on the median line, are sufficiently distinctive signs. Recto- vaginal and vesico-vaginal- fibrous tumours are more easily distin- guished. They do not deform the cervix, but they displace it, raising the vaginal cul-de-sac, becomiug enveloped in it in place of depressing it, always having between their convexity and the corresponding por- tion of the uterus a cul-de-sac the presence or absence of which decides the question. It is less easy to distinguish hard, osseous or osteo- cartilaginous tumours,^ especially those of the anterior wall of the pelvis. Ovarian tumours, provided they are not too voluminous, pre- serve an evident mobility, the existence of which is undoubted when the patient is made to change her position or w'hen movements ^ Voisin, De I'liematocele retro-uterine, p. 193. Paris, 1860. ^ Dupuytren, Clinique, iii, 326. ^ Dolbeau, Mem-, sur Veuchondrome du bassin (Jmi^'n. du Progres), 1860. — Nelaton, Clinique, parW. Atlee, p. 707, quoted by GuTon, Tum.fibr., p. 49. 664 TTTEEINE DISEASES IN DETAIL are communicated to the tumour. If, however; it is difficult to con- found them with interstitial or submucous fibroids, it is not less so to distinguish them from subperitoneal fibrous tumours (especially when the latter have become free or abdominal). It is well to remark, with regard to all extra-uterine tumours, that they push the womb up or down, according to whether they arise from the abdomen or the pelvis, in place of dragging it directly with them as uterine fibromata do. We may also remark that difficulties of differential diagnosis increase when fibromata become inflamed, sup- purate or perforate the uterine wall. Treatment. — The frequency of fibromata ought to call attention to the treatment which these tumours require. Loir, in examining the uterus in 40 old women met with fibrous bodies 15 times. — Statistics prove that they are most frequent during the period of uterine activity. Dupuytren, out of 57 patients affected with fibroma, met with 52 in those from 20 to 50 years of age ; Malgaigne, out of 51 patients, found 40 from 30 to 50 years old; West, out of 76, mentions 67 between 20 and 50 years; Braun and Chiari have made analogous observations. We may, however, find them in young girls and in old women. Hardv^ operated on a girl of 17. One was observed in a child of 9. Trsezl^ saw a vaginal polypus in a child of 16 months. — They are not only developed in the uterus, but also in the appendages, in consequence of the identity of nature of the muscular envelope common to these organs : this frequency is proved as regards the ovaries, Fallopian tubes, broad ligaments, utero- rectal ligaments and the vagina; I have seen them in these various organs, with their characteristic aspect, rounded, firm, hard, elastic, white and fibrous, with fibres encircling several centres.^ The prognosis from the reproductive point of view is unfavorable : the presence of myomata in the uterus diminishes the chances of con- ception, increases those of abortion and leads to great dangers at de- livery ; it mechanically opposes the passage of the child, it prevents the uterus from contracting after the expulsion of the placenta and exposes to hsemorrhages, it prevents retrograde evolution of the organ and becomes the source of inflammation, softening, peritonitis and septicaemia. From the point of view of danger to life in a non-pregnant woman it is much less serious : undoubtedly the presence of myomata affects the general health seriously and permanently, owing to haemor- rhage and to the development of the parasitic tumour at the expense of nutrition : but though the malady is often incurable it is seldom fatal. The termination of the malady may be unfavorable or favorable. In the former case, it may threaten life in several ways : by haemor- rhage, by its rapid development which is sometimes arrested by the ' Monatschr . filr Gehurtsk., Bd. xxv, S. 358. 2 Ibid., Bd. xxii, S. 227. ' According to Virchow, if the usual seat of myoma is the body, i.e. the fart of the uterus which is richest in muscular tissue, it is also frequently ound in the ovary, rather less often in the uterine ligaments, less frequently still in the cervix, and most seldom of all in the vagina. i FIBROUS TUMOURS 665 menopause, by comj)ression of the rectum, by suppuration, by gan- grene (a termination in which cure may be bought too dearly), lastly, by perforation of the uterus and organs covering it, the vesico-vaginal or vagino- rectal mucous membrane, the abdominal wall and the peri- toneum in various directions. In the latter case, there is spontaneous retrocession, diminution, or expulsion. There may be simple tolerance of even large tumours sometimes covered with calcareous incrustations : this is what happens in old women, for in them fibrous bodies seem to become pediculated less frequently than in the young. Retrocession may take place spon- taneously either under the influence of iodine or after pregnancy and parturition. Theoretically pregnancy seems to promote the develop- ment as well as the absorption of tibromata ; but the physician ought to take advantage of the period following delivery to prescribe resol- vent treatment, as at that time there is a very energetic regressive tendency. Spontaneous expulsion is very rare; it is probable that the expulsion of polypi has often been confounded with that of true inter- stitial tumours; it coincides with the expulsion of the fa3tus or follows it closely, or it may take place independently of gestation and delivery, by enucleation and with laceration of the uterine tissue, usually with colics as acute as those of labour ; it may require surgical assistance, and is sometimes followed by profuse haemorrhage. Tnerefore though fibroids are not malignant, they become serious owing to the haemor- rhage which they provoke, to their becoming jammed into the pelvic cavity and to the enormous size which they may attain. Haemorrhage, however, may diminish under suitable treatment which brings into play the curative processes of nature (the tendency to enucleation and to the expulsion of the fibroma). It is the same with other sym- ptoms : the tumour may soften, decrease, shrivel, become encrusted, and even disappear at the menopause. It is therefore important to treat the symptoms, moderate the development of the tumour and keep up the general health of the patient till the climacteric age is reached; the danger is much less afterwards. West thinks that patients should be reassured, as out of 96 cases he has only had one death from haemorrhage and two from utero-peritoneal inflammation after delivery. However, that is no reason for neglecting to promote atrophy of the myoma, to assist the uterus to expel the tumour or to interfere directly when advisable. Medical treatment is more efficacious than might be supposed : no other should be used at first in cases of sub-peritoneal tumours ; as to other fibroids, it may at least be palliative and preparatory to surgical treatment. It includes many means rightly designated by Cruveilhier as atrophic treatment, the action of which may have a favorable result, especially when patients are near the menopause. It consists in sub- duing pain sometimes, haemorrhages frequently, in promoting the spontaneous enucleation of the fibroid, avoiding all causes which stimulate uterine circulation, in bracing the constitution and promot- ing the natural resolution of the tumour. Pain seldom requires treatment by opium or belladonna. Some- 666 UTERINE DISEASES IN DETAIL times we may follow Clarke's advice to push the uterus and the fibroid it contains above the brim, so that it can be developed without hindering the functions of the pelvic organs by painful pressure. At other times the patient may be eased by the use of Bourjeaurd's abdominal belt, which prevents the concussion of sub-peritoneal or abdominal tumours, at the same time that it promotes their resolution. Hsemostasis is obtained by abdominal applications, cold irriga- tions, long continued applications of ice, or better still very hot injec- tions morning and evening for ten minutes at a time, the general and local use of perchloride of iron, alum, acids, tincture of cinnamon, tannin, rhatany, and vaginal plugging. Savage, of the Samaritan Hos- pital in London, dilates the cervix with a sponge tent and then injects tincture of iodine (iodine thirty grains, iodide of potassium one drachm, rectified spirit two drachms, water three ounces), or pure offi- cinal tincture of iodine into the uterus ; the injection not only arrests the hsemorrhage but diminishes the size of the tumour, according to this surgeon, when repeated on each recurrence of the hsemorrhage for five or SIX months.^ In order to remove all causes of disordered uterine circulation, the patient should be told to keep her bowels regular by enemata or mild laxatives; to lie on her back with the knees drawn up, especially during menstruation and metrorrhagia ; lastly, complete rest should be prescribed for the diseased organ, i.e. patients should be dissuaded from marriage, while those who are married should be advised to dis- continue intercourse, with the double object of saving the uterus from excitement tending to produce haemorrhage and the hypernutrition of the fibroids, and of preventing the possibility of pregnancy. Ergot is the hemostatic which I prescribe most frequently with the double object of arresting ha3morrhage and of producing the spontaneous enucleation of the tumour. I usually prescribe four grains of freshly powdered ergot to be taken from one to six times a day ; I sometimes substitute pills of ergotine and continue the use of it for five or six days after every montlily period for some time." I know of few cases of fibroids which have not been improved if not cured by the use of this drug associated with other means of treatment which I shall describe. In cases of formidable hsemorrhage (where an operation is contra- indicated), McClintock and West assert that free incisions of the cervix almost always diminish the fiow of blood. Does this act by depleting the uterus, facilitating the escape of blood and thereby preventing the distension of the organ, or by producing a ' Siins, op. cit., p. 121. ^ Hildebrand of Kcjenigsberg has tried subcutaneous injections of a solution of extract of ergot (15 gr.) in water and glycerine (aa 105 gr.). Inject from 15 to 30 drops. Berlin Klin. Wochensch., June 17, 1872. — Baker Brown {American Journal of Obstetrics, 1877, p. 38) has seen eclampsia occur after injections of ergotine for a large fibroma, but this is the only case re- corded. They are now largely used. FIBROUS TUMOURS 667 certain amount of indurating and cicatrising metritis?^ It is not enough to subdue the hsemorrhage without dissipating its bad effects by tonics. As for the spontaneous absorption of the tumour, although this result cannot be counted on, remarkable cases of it have been known (I have myself seen such) ; therefore we must not hesitate to prescribe resolvents. Amongst other means we may try pills of hemlock, mer- cury, preparations of gold, bromine, iodine, the alkalis and the cura /amis. I prefer the following : the long-continued use of bromide or iodide of potassium, which may be increased from 15 gr. to 45 gr. a day, diuretics, milk, nitre, squills, daily friction of the abdomen and upper and inner parts of the thighs with mercurial and belladonna ointment ; pessaries and suppositories, or rather enemata, of this oint- ment; a large abdominal compress, or painting the hypogastrium with iodine, Vichy water or an alkaline solution taken before or during meals, alkaline baths and mineral waters (Vichy, Andabre, Vals, Boulou, Plombieres), associated with hydropathy. The medical treat- ment which I prescribe for fibro-myomata is the following : a diet of meat and fish, fresh vegetables, ripe fruit, stale bread, wine diluted with Bussang or Orezza water ; alteratives in the various forms just mentioned) ; I also specially recommend my patients : 1, to make vaginal iujections on the bidet for ten minutes with water as hot as can be borne, and to which has been added one or two dessert-spoon- fuls of a solution of carbolic acid (from ^ to 1 oz. of crystallised car- bolic acid to a quart of water) ; 2, three times a week a subcutaneous injection of 15 drops of a solution of ergotine (15 gr. of ergotine dissolved in 105 minims of water and 105 minims of glycerine) ; 3, three times a week the application for ten minutes of a rather strong con- tinuous current, rendered intermittent by means of a metronome, the positive pole being applied to the cervix and the negative pole to the abdomen. Although we cannot hope to cure all fibromata we may by these means keep them in check. Surgical treatment is very effectual. In the numerous cases in which it can be applied it is curative. It varies according to whether the fibrous body is interstitial or detached from the uterine wall and only connected with the peritoneum or mucous membrane by a more or less broad pedicle. In this latter case if the fibroma is subperitoneal or abdominal, and if operation is not contra-indicated, it may be removed by abdominal section performed in the same manner as for ex- tirpation of an ovarian cyst,^ an operation which wall be described when we come to ovariotomy. If the pediailated fibroma is submucous, and especially if it has escaped from the cervix, surgical intervention is indispensable : it consists in the extirpation or destruction of the tumour by one of the numerous methods applicable to the treatment of polypi. ^ Amilcar Eicordi, Traitement des fihromes par la inetliode des incisions multiples {Comment, di. medic, et chirurg. Milan, 1st year, No. 1). ^ W. Atlee, two cases : American Journ. of Med. Science, April, 1845, April, 1855. 068 UTERINE DISEASES IN DETAIL In the former case, i. e. of interstitial fibroma, surgical intervention is debateable ; it is surrounded with difficulties and often with danger. Its aim is to extirpate the tumour, but this can only be effected by enucleation. The methods differ as does the facility of operation according to the depth at which the fibroid is seated (in the cervix or in the body), the projection which it makes under the mucous membrane, the thick- ness of the layer of uterine tissue covering it, the adhesions which it has contracted in the kind of cyst in which it is contained, and lastly, the size it has attained. With regard to depth, if the fibroma is con- tained in the thickness of one of the two cervical lips it is easy, after having slightly drawn down this organ, or having separated the vagina] walls by means of dilators, to incise the mucous membrane and uterine tissue in the median Hue, to reach the tumour, to rupture with the finger or handle of the scalpel the connections which loosely unite it to the neighbouring parts, to seize it when necessary at the sides with tenaculum hook forceps or in the centre with a corkscrew driven into the tissue itself, and to enucleate it completely. In such cases, unless the tumour has acquired an enormous size, there is no contra-indication to operation. If the fibroma is contained in the cavity of the body the orifice must be previously dilated. Ergot often produces the double effect of pediculating the tumour and forcing it powerfully and continuously towards the orifice, by the contractions which it excites in the uterine tissue ; gradual dilatation of the cervix is produced by pressure of the tumour, a dilatation similar to that determined by pressure of the bag of waters during labour. When the dilatation of the cervix produced by the expulsive efforts is insufficient, it should be facilitated by the introduction of instru- ments into the uterine cavity to dilate or divide it. I prefer prepared sponge to more violent means because its slow but continuous action produces in the end complete dilatation almost without causing any pain. Dilatation is facilitated and the pain of it diminished by cover- ing the dilator with a little extract of belladonna. In 1814 Bonnie,^ having diagnosed a polypus in a woman subject to repeated haemor- rhages, by forcing his finger into the os, dilated this orifice with sponge tents till he was able to introduce several fingers into the uterus, and having discovered the insertion of the pedicle applied a ligature. Dupuytren- considers simple or multiple division of the cervix better than dilatation. This eminent surgeon divided it in one stroke from without inwards, whereby he avoided injuring everything except the tumour, whilst Velpeau performed the same operation in several little incisions from within outwards. The incisions should be made obliquely when possible, and should be multiple rather than single. Whilst recognising the utility of this method when there is danger of fatal haemorrhage and urgent necessity for the removal of the fibrous body, I think it is usually unnecessary, and that gentle mechanical dilatation associated with the use of ergot is sufficient in ' Bulletin de la Faculte, t iv. * Clinique cTiir., iii, .360. FIBROUS TUMOURS 669 submucous fibroids, as in polypi, to allow of the introduction of the fingers and instruments int(j the uterus. When the cervix is suffi- ciently dilated to admit of operation the uterus is drawn down if neces- sary, the index finger of the left hand is then introduced into the uterine cavity, the form of the tumour diagnosed, and the uterine tissue covering the central and most prominent portion incised from above downwards with a probe-pointed bistoury ; then with the fingers or the handle of the scalpel the fibroid is separated from its envelope and extracted. Amussat used to detach the tumour by beginning at the upper part and working downwards. The remaining fragments of mucous membrane or uterine tissue contract, cicatrise, or are partially destroyed by suppuration. This operation is not very difficult, and I think unattended with much danger when the tumour is not very large, when it is free from adhesions, when it projects towards the uterine cavity and when from the long-continued use of ergot it has a tendency to become pedicu- lated. I have performed it several times successfully. Ha3morrhage resulting from division of the vessels of the uterine wall need not be feared any more than spontaneous hsemorrhage. It is true that the uterine wall has been dragged away, that it has been divided and the peritoneal cavity penetrated ^ in this operation, but if under the influ- ence of the long-continued use of ergot the tumour has become suffi- ciently prominent to authorise the surgeon to decide on extraction, it is to be presumed that the subperitoneal portion of the uterine wall in the interstices of which the fibroma is contained, is thicker than the submucous portion, and consequently protected from the danger of these accidents. The important point is not to operate in a hurry or before enucleation has been facilitated. The adhesions which Berard ^ found between the fibrom:a and the cavity containing it are almost the only obstacles that cannot be foreseen, and which it is difficult to remove. But the chief difficulty is the size of the tumour. To this cause must be attributed the great mortality attending such operations.^ Amussat^ first performed ablation of these large fibroids; since then different methods have been adopted, varying with the site of the fibroids according as they are seated in the walls or fundus. — In cases of fibroids of the walls the tumour may be divided by two incisions, separated below but touching above, and enclosing a triangular seg- ment or the third of the fibroma, the ablation of which will greatly facilitate the extraction of the two remaining thirds. Or, like Maisson- neuve,^ after dividing the tumour longitudinally into halves and enucleating all the lower portion of one of these halves we may divide the latter from below upwards in a direction parallel to its surface and ' Le Piez, Journal de chir. de Malgaigne, 1845, p. 90. ^ Bulletin de la SociSte anatomique, 1849, p. 82. ^ Hutchinson {Med. Times and Gazette, August, 1857) has collected 39 cases of similar operations ; out o£ 18 enucleations with the hot iron there were 12 cures, 6 deaths ; out of 15 enucleations with caustics 9 cures, 6 deaths ; out of 6 unfinished operations 4 cures, 2 deaths. — Guyon (op. cit., p. 114) counts not less than 10 deaths out of 17 operations. * Bidletin de la Societe de chir., 1849. 670 UTEEINE DISEASES IN DETAIL thus, by the extraction of a superficial slice, facilitate the enucleation of the deep portion ; the other half is easily extracted afterwards. — Fig. 365. — Sub-mucous fibroma, projecting into the vagina through the dilated cervix. Attempted extraction by the vagina lasting two and a half hours. Death from htemorrhage and exhaustion nine and a half hours afterwards. (Emmet, op. cit., p. 582, fig. 100). I have seen a similar case, except that the patient died of septicasmia. With regard to interstitial fibromata ofthefunchis, it is difficult to reach them if they cannot be drawn through the cervix ; but even when this is the case two difficulties present themselves ; the thinness of the uterine wall which separates them from the peritoneum, and the difficulty of distinguishing the exact limit of the fibroid on the fundus of the womb, which is necessarily inverted by the descent of the tumour. When obliged to perform such operations we should adopt Jarja- vay's method. Instead of cutting the tumour transversely it should be divided longitudinally by a vertical section with great care, so that each hemisphere may be separated right and left and the upper boun- dary between the tumour and the uterine tissue easily defined. After operation the inversion is reduced. Whatever method be adopted we must endeavour to effect extraction. Such an operation is fatal if left unfinished. The denuded or divided fibrous body becomes softened and tumefied, causing ineffectual ex- pulsive efforts and infectious suppuration which always terminates fatally. To sum up, it is very difficult to estimate the dangers of the operation beforehand. Apart from hsemorrhage, death is too often caused by peritonitis, phlebitis, pysemia, resulting from traumatism of the uterus in FIBROUS TUMOURS G71 women exhausted by loss of blood. Therefore we should not under- take the extirpation of fibromata of any considerable size unless it is decidedly indicated, the life of the patient being in continual danger from haemorrhage.^ It should never be undertaken, moreover, until resolvent treatment has first been tried ; the continuous current^ sub- cutaneous injections of ergotine, very hot vaginal injections, perchloride of iron and bromide or iodide of potassium being the means most likely to succeed. When, however, operation is successful it may effect a radical cure and be followed by conception, normal pregnancy and delivery.^ When the fibromata are voluminous, multij)le and do not project towards the uterine cavity, extirpation of the whole uterus with its appendages has been attempted by abdominal section, as in ova- riotomy. Clay^ ties the vessels of the broad ligaments and then secures the cervix by a ligature of circular thread. Koeberle,^ by a single puncture from before backwards, passes two metallic ligatures through the uterine mass, and tying one on each side removes each half of the organ with the corresponding broad ligament successively by constriction. This method has been adopted by the majority of surgeons. I shall revert to this operation when describing that of ovariotomy, merely mentioning now in passing that this daring sur- gical operation has been successfully performed ; as, however, the mortality has hitherto been considerable,^ it is best to reserve our opinion upon the future of an undertaking which but a short time ago would have been condemned as unwarrantably rash. During pregnancy the indications presented by fibromata vary according to the symptoms produced ; it may be necessary to subdue uterine contractions, to induce abortion or to remove a tumour of the cervix when it causes serious haemorrhage.^ During labour*^ an inter- stitial fibrous tumour may force the surgeon to have recourse to forceps, version, embryotomy, CcEsarean section, puncture^ or ablation'' ^ Jarjavay, Des operations applicables aux corps fibreux de Vuterus. These de concours. Paris, 1852. ^ Grimsdale, A Case of Artificial Enucleation of a Large Fibroid Tumour of the Uterus, with some Remarks on the Surgical Treatment of these Tumours; in Liverpool Medico-Chirurg. Journal, Jan., 1857. 3 Observations on Ovariotomy, Statistical and Practical. Also a Successful Case of Entire Removal of the Uterus {Transact, of the Obstet. Soc. of London, vol. v, 1864). •• Documents pour servir a I'histoire de I' extirpation des tumeurs fibreuses de la matrice, par la methode sus-pubienne {Gaz. med. de Strasbourg, 1864).— Operations d'ovariotomie, pp. 79, 98, 105. Paris, 1865. ^ Routh, On some Points connected with the Pathology, Differential Diag- nosis and Treatment of Fibrous Tumours of the Utertis (Tlie Lancet, 1863, 1864). — Kceberle, OperaMons d'ovariotomie, p. 98. Paris, 1865. He lost three patients out of six. — Catcrnault, Essai sur la gastrotomie dans les cas de tumeurs fibreuses peri-uterines. Paris, 1866. List of 76 cases. Nearly two- thirds of the patients died from hsemorrhage. ^ Merrimann, polypus ligatured during pregnancy. Cure. Delivery one month afterwards. See also the remarkable work already mentioned of R. Lefour. 7 Puchelt, De tumoribus in pelvid. partum im/pedientihus. .Heidi&WyQvg, 1840. * Cazeaux, Bulletin de la Soc. de chir., 94. ^ Danyau, Bulletin de I' Acad, de med., 1851. — Revue medico.-chirurg., 1851. 672 UTEEINE DISEASES IN DETAIL of the tumour itself. We should, however, know when to wait ; for we know by experience that delivery may exceptionally take place spontaneously and almost without accidents. To sum up the indica- tions to be followed in such cases they may be arranged in the following order : 1, expectation ; 2, attempted reduction or retropulsion of the tumour above the brim (Stoltz places this foremost) ; 3, ordinary forceps with or without continuous traction (preferred by Depaul and Gueniot to version) ; 4, version (preferred by West and Tarnier to forceps), it may help in the reduction of the tumour;^ 5, embryotomy; 6, enu- cleation of the tumour (unfortunately the boundaries and connections of it are very uncertain and hsemorrhage is to be feared) ; 7, Caesarean section y' 8, induction of premature labour (a doubtful point, for the tumour may rise, even in the third month, as Blot's case shows) ; 9, induced abortion (to be reserved for cases in which the life of the mother is in serious danger). After delivery, if accidents occur which do not allow of our waiting till the fibroid, which hypertrophied during gestation, resumes its original size or atrophies, examples of which have been given by Chailly^ and Cazeaux,^ the tumour may be extracted immediately, as in the cases recorded by Guyot,^ Danyau,^ Langenbeck'^ and Keating,^ or only after the uterus had resumed its usual size, as Ramsbotham^ advised, in order to take advantage of the regressive tendency which the uterine tissue possesses at that time to institute energetic resolvent treatment, which, while it might cause the disappearance of the tumour, would at the same time exercise a favor- able action on the involution of the uterus. Polypi and Moles Poll/pi and moles are excrescences of various kinds having their origin in one or other of the uterine tissues or in certain elements of a fertilised ovum. The hypertrophy of these tissues, or rather the pro- perty which the uterine tissues and the embryonic envelopes possess of becoming hypertropliied, is the immediate cause of the development of both structures. Polypi are kinds of hypertrophic vegetations of a portion or of one of the elements of the uterine tissue proper, of its mucous membrane or of its vascular system. Moles are organised bodies arising from the envelopes of aproductof conception, implanted ' Too few cases have been recorded to allow of our deciding between these two methods (forceps or version). ^ Etlinger, Observationes obstetricia. Bonnse, 1854. ' Traite de I'art des accouchements, p. 572. Paris, 1861. * Ibid., p. 620. Paris, 1862. * Levret, op. cit., p. 220. * Recherches sur les polypes fibreux de I'uterus (Journ. de chir. de Mal- gaigne, 1846). ' Schmidt's Jahrbuch, August, 1851. Operation followed by death. ^ American Journal of Med. Sciences, May, 1858. Operation followed by death. ' Obstetric. Med. and Surg., p. 224. London, 1856. A woman of 30 years, delivered three weeks previously. Cure. POLYPI AND MOLES ^73 in the uterine tissue, deriving from it a morbid hypertrophic growth and presenting themselves under the two very di(Ferent forms of grape- like clusters and fleshy bodies. 1. Uterine Polypi Polypi 1 are tumours which differ from all others by the existence, if not of several feet as the etymology seems to indicate, at least of one foot or pedicle or contracted portion, by which they are attached to the uterus. Whether this pedicle is broad or narrow, short or long^ whether the tumour is contained in the womb or expelled by muscular contractions, the polypus is always characterised by the existence of a pedicle. These tumours are classed together because the presence of a pedicle suffices to produce a group of special symptoms and special indications common to all tumours of this kind. They are all due to the hypergenesis and hypertrophy of one or more of the elements which enter into the composition of the uterine substance. There are therefore only three principal kinds of uterine polypi : the fibrous or muscular, much the most common ; the mucous less common ; the vascular the rarest of all. Hypergenesis may affect several of the uterine elements simultaneously so as to produce composite polypi, in which these various elements enter in various proportions ; lastly, the polypi themselves are subject to various alterations which more or less modify their structure. 1. Fibrous polypi are nothing but interstitial fibromata or myomata which have become submucous and pediculated. They are sometimes enormous, sometimes multiple, at other times degenerated, fibro- cystic, softened in their centre, or, on the contrary, indurated, cartila- ginous, encrusted on their surface and stony throughout. 2. Mucous polypi are formed by the hypergenesis of the elements of the mucous membrane and especially of the follicles of this membrane. Sometimes they are very small, very transparent, more sub-epidermic than mucous, meriting the name of vesicular or epithelial." At other times they are produced by the accumulation of mucus in a cervical gland the orifice of which is obliterated, in one of Naboth's eggs which acquires a size varying from that of a pea to that of a large nut, and which, instead of remaining sessile or buried in the uterine tissue, is gradually detached from it, becoming pediculated ; at other times they are formed by the development of analogous phenomena in several follicles of the body or cervix in such proportions that they may form considerable tumours, cysts, cystic or hollow polypi, to which the name of follicular or utero-follicular ^ has rightly been given, producing sometimes simultaneously the hypertrophy of the ' The name polypus, applied to cei-tain tumours of the uterus, seems to date as far back as Moschion ; but it is only since the time o£ Rujsch {Obsera. Anat., 6) that this word, which till then was confined to polypi of the nose, has been generally employed to designate the analogous excrescences of the uterus. 2 Montfumat, Etudes sur les polypes cle I'uterus, 1867. ^ Huguier, Des Tcystes de la matrice et du vagin. Mem. de la Soc. de chirurg., t. i. — Luna, Des kystes folliculaires de la matrice et des polypes utero-folliculaires. Theses de Paris, 1852. 43 674 UTERINE DISEASES IN DETAIL fibro-plastic, fibrous and vascular elements of the uterine mucous membrane. These utero-follicular polypi may be vascular containing cavities in which sanguineous effusions are produced, and occasionally becoming in themselves the source of heemorrhages, un- like the majority of fibrous polypi which excite uterine haemorrhage without them- selves being the source of it. 3. Vascular polypi are rare, their ex- istence being denied by some writers, whilst by others they have been confounded with sanguineous or fibrinous polypi (hsemato- mata of Virchow), which are only fleshy Fig. 366. — Vesicular poly- moles or uterine clots ; by Levret they were pus of the cervix pro- recognised under the name of fungous jectiug beyond the os . ■ ^j^ ^^^ ^^^^^y ^^^^,1 ,^^^^^^ externuvi, seen through ^ , *^ , i r -, i i • ^ i the speculum (from a ^"" smaller when developed in the cervix, drawing by Meyer). softer, more spongy, more bleeding when developed in the uterine cavity. On section more blood is discharged than one would suppose. I have seen seven of the size of a cherry on the cervix ; two of them, of a dark red colour, seemed to be painfully swollen at certain periods, especially during menstruation, like hsemorrhoidal tumours. Perhaps they should be included in the class of mucous polypi rather than in that of fibrous polypi, the vascular hypertrophy which causes them only being produced at the expense of the vessels of the mucous mem- brane and not of the tissue proper of the uterus. Diagnosis — suhjective signs. — Usually at the commencement of the malady the general and local symptoms are very vague ; the polypus causes expulsive pains, to which later on are added radiating pains, dull achings and neighbouring disorders. — These are accompanied by menstrual disorders, at first by menorrhagia, afterwards by metror- rhagia, due in the majority of cases to thefluxionary movements which the presence of the polypus excites in the womb. Haemorrhage is the greatest danger, caused by the presence of polypi in the uterus; it may carry the patient off without medical intervention.^ I give the woodcut of a fibro-mucous polypus, which, notwithstanding its small size, caused such serious haemorrhage that if the patient had not suc- cumbed to an intercurrent malady ablation would have been required to save her life. — Mucous, purulent or sanguinolent leucorrhoeais pro- duced in the interval between the haemorrhages or simultaneously with them, owing to the irritation just described in the internal membrane of the uterus. Vomiting, dyspepsia, impoverishment of blood, are the usual consequences of the reaction produced upon the uterus and nervous system by the presence of a polypus. Conception is not impossible but abortion is very common. ' Saxinger (Monatsclir . fur Geburtslc, 1868, Bd. xxxii, S. 329) relates a case in which death was caused by spontaneous and repeated haemorrhage from a mucous polypus, the I'emoval of wliicli was not attempted. i POLYPI AND MOLES 675 Objective signs. — Direct examination is more or less easy and the results more or less satisfactory according to whether the pohpus is FIg. 367. — Fibrinous uterine polypus o£ Velpeau and Kiwisch, or free polypous hematoma o£ Virchow. A large portion of the foetal placenta is still adherent to the projecting placental insertion {Die Krankhaft. Geschwiilste). still hidden in the uterine cavity, plugging the orifice, floating in the Fig. 368. — Fibro-mucous polypus, I'e- markable for the abundance of the metrorrhagia produced in spite of its small size, a, tumour in situ ; b, tumour raised so as to show its pos- terior surface. vagina or invading the pelvic cavity. The tumour does not become 676 UTERINE DISEASES IN DETAIL pediculated in passing through the cervix : the pedicle is acquired whilst the tumour is still within the uterine cavity. When the tumour is still retained in the uterine cavity the cervix must be dilated ; the finger is then introduced into the uterus, and with the help of the sound we try to reach the highest part of the tumour in order to discover the pedicle. The tumour may even be seized with the forceps, when by a movement of rotation or torsion we find out whether it is sessile or pediculated. Fre- quently we can discover nothing unless the investigation is made during men- struation. The polypus often re-enters the uterine cavity after having been seen at the orifice. This alternate appearance and disappearance may occur several times. ^ When the tumours have de- scended into the cervix or into the vagina it is of capital importance to discover the cervix or os. After having ascertained the size and consistency of the intra-vaginal tumour the examining finger should discover the state of the cervix externally and internally, ex- ploring the external surface, the utero- vaginal culs-de-sac, the circumference of the orifice and the cervical cavity, and endeavouring to penetrate into the cavity of the body to discover the insertion of the pedicle. Bifferential diagnosis. — It is much easier to distinguish polypi than fibro- mata from other tumours producing deformity of the uterus. Preg- nancy, cystocele, vaginal hernia, prolapsus, cervical hypertrophy, cannot be confounded with them. There are only two diseases the diff'erential diagnosis of which is somewhat difficult : inversion and cancerous cauliflower excrescences. — With regard to inversion we must remember that the body of the uterus is no longer found in its normal position in the pelvic cavity, nor can the uterine cavity be traced beyond the circular cul-de-sac which forms the limit between the neck and the body of the womb. — As to cancer, even the cauliflower variety differs so greatly from polypus in the aspect and consistency of its tissue, the breadth of its insertion over the whole surface of the cervix or of one of its lips, the inequahty of its surface, &:c , that it is difficult to make a mistake as to its nature. ' Larcher, Contributions a I'histoire des polypes fibreux intra-uterins d apparitif/ns intermittentes (Archiv. gencr. de vied. Paris, 1867). — Robert .lolins (Gaz. med., 1858, p. 123). Fig. 369. — Pediculated cervical polypus (from Boivin and Duges). POLYPI AND MOLES 677 Treatment. — There are two principal indications : 1, to provoke the expulsion of the polypus or, by dilatation of the os, to facilitate the introduction of instruments for ablation ; 2, to remove the polypus by operation. I. The first indication is fulfilled by all the medical and surgical means which I have described as employed in the treatment of inter- stitial fibromata and submucous fibroids. The rules of their applica- tion are the same as in cases of submucous fibromata, induced abortion and extraction of any foreign body from the uterine cavity. - Some- times expulsion and even complete detachment is effected spontaneously (out of 13 cases of spontaneous cure it has been observed 10 times, in the 3 other cases the polypus was destroyed by suppuration), but the uterine contractions are sometimes so violent and continuous that they may produce attenuation, mortification, and perforation or rupture of the uterus.i II. The second indication is fulfilled by direct surgical intervention which, to the honour of the art be it said, is usually successful. The treatment of polypi constitutes, as Velpeau has justly remarked, one of the triumphs of surgery. The methods used for the destruction of polypi of the other organs have been successfully applied to the abla- tion of uterine polypi. They are : cauterisation, crushing, torsion, ulcerative ligature, extemporaneous ligature or ecrasement and exci- sion. These methods should neither be adopted nor rejected without consideration. There are some which are preferable to others, and applicable to the majority of cases, such as ligature, ecrasement and excision ; these may be regarded as the best methods. Cauterisation and crushing are extreme measures applicable to the body and not to the pedicle of the polypus ; torsion is not without danger, but this exceptional method has its indication and ought to be adopted in cases of polypi of a special nature or in certain conditions. The general methods themselves ought not to be apphed indifferently to all polypi ) one or other is preferable according to the point of insertion of the polypus, the size, consistency, structure and vascularity of the tumour. Before describing these various methods and their indica- tions or contra-indication& I may remark that cauterisation is only applicable to vascular or fungous tumours, or to those contained in the uterine cavity and which cannot be seized by any instrument ; crushing is" applicable in similar cases, especially to intra-uterine or very hard tumours, the pedicle of which can neither be reached nor divided nor yet ligatured, and upon which caustics would have but little effect. Torsion is applicable to the ablation of small mucous follicular or very vascular polypi, the pedicle of which may be ligatured beyond the point on which torsion is brought to bear, but is dangerous in cases of large and hard pediculated fibromata, the tissue of which is con- tinuous with the uterine fibres, for laceration may occur beyond the pedicle, affecting the uterine wall itself; ligature is preferable in cases ^ Larcher, De la rupture spontanee de I'uterus et de quelqiies autres particu- larites dans leurs rapports avec les polypes fibreux intra-utei'ins {Archiv. gen. de med., 1869). 678 UTEEINE DISEASES IN DETAIL of large, very vascular, utero-follicular, cjstic, or even fibrous polypi when there is a probability of the existence of large vessels in the pedicle, or when it is applicable as a precautionary measure to be followed immediately by excision; extemporaneous ligature and ecrasement are applicable under the same circumstances when the absence of hseraorrhage and tolerance on the part of the patient allow of constriction of the pedicle being carried to the point of section or laceration in place of waiting for ulceration, thus sparing the patient and surgeon the drawbacks of sloughing of the tumour; lastly, exci- sion is preferable in all cases of pediculated fibromata, for experience proves that there are no large vessels in the pedicle, and that it is even applicable to other polypi provided haemorrhage can be arrested by ice, very hot injections, cauterisation, perchloride of iron and plugging. 1. Cauterisation. — This is only employed for very small tumours of the cervix, or for larger polypi contained in the body, and which cannot be reached by instruments. It may be applied in the form of nitrate of silver, acids, caustic potash, the actual cautery for cervical polypi and even for a polypus of the body ; but it is dangerous in the latter case, and should only be applied very exceptionally. The gal- vano-cautery may also be used after Middeldorpf's^ method or Paque- liu's thermo-cautery. 2. Grushing. — This may be performed with my uterine forceps, either straight or curved. Simpson used very powerful small forceps; Thierry a pair of very strong curved toothed forceps; Nelaton a punch-forceps ; Eichet crushing forceps. It is, however, to be feared that the tissue of the polypus, being only partially crushed and not immediately extracted, may become tumefied, may mortify at some points and give rise to strangulation and putrefaction. 3. Evulsion is performed with polypus forceps with concave blades which are rough, perforated or grooved, so as to fit tightly together. It is applicable to the ablation of mucous polypi, small cystic, follicu- lar polypi and small vascular polypi of the cervix. The pedicle should always be compressed with elbow forceps above the point at which traction is made. 4. Torsion, though dangerous for fibcous polypi with a broad pedicle merging into the uterine tissue, is useful in the ablation of small mucous and vascular polypi on account of its rapidity and com- pleteness. I have frequently removed such tumours in a few seconds ; and for this purpose have had forceps made with elbowed blades deeply grooved fitting perfectly into each other, by means of which the pedicle of the fungous or varicose tumour is easily seized, whilst torsion is performed lower down with other forceps, till the tumour is detached from the uterus.^ My uterine forceps are usually sufficient for this operation. The actual cautery should be applied to the point of insertion in order to prevent reproduction of the polypus. ' Ressel, De polyjiorum uteri extirpatione vwthodo galvano-caustica in- stituta. Diss, inaug. Vratisl., 1857, with plates. ' Puech mentions two cases, proving that torsion is applicable even to large polypi when applied with proper precautions {Annales Cliniques de Montpellier, 18u7, p. 218). POLYPI AND MOLES 679 5. Ligature. — This was recommended bj Pare and Guillemeau, adopted by Levret ^ and Desault,^ and further improved by Niessen/ Mayor,*^ and others. The nature of the ligature, the manner of apply- ing it round the pedicle and the method of constriction are variable, Fi&. 370. — Ordinary polypus forceps -with ci'ossed blades. Fio. 371.— Polypus forceps with sliding: fastener. having been improved and modified so as to be applicable to all cases, and to allow of the ligature being introduced into the interior of the uterus provided the cervix is sufficiently dilated. Levret's ligature was silver wire, a means of constriction at once flexible and resistant, ^ Memoire sur les polypes de la Tnatrice et du vagin. Acad, de chinirg., 1749. — Observations sur la cure radicale des polypes de la matrice. Paris, 1759. 2 Journal de chirurgie, t. iv. — CEuvres cliirurg. ^ Dissertatio de 2)olypis uteri et vagina, novoque ad eorwyi ligatiirani in- strumento. Goettingen, 1785. * Nouveau systhne de deligation chirv/rgicale. Lausanne, 1837. 680 UTERINE DISEASES IN DETAIL and which can be managed by the fingers alone. Iron wire may be substituted, but it has the drawback of oxidising, and of breaking before the tumour falls ; ordinary strong waxed thread or whipcord is better; silk may also be used and when well waxed is the most flexible and resistant of all. I prefer an elastic ligature, however, to all of these. Instead of the ligature we may employ the method adopted by Gensoul ^ of seizing the pedicle with polypus forceps furnished with curved blades for continuous constriction. Aveling invented his polyptrite to serve instead of forceps. The mode of applying the ligature round the pedicle is equally variable. — Levret used two cannulse soldered together laterally, through which the silver thread was passed so as to form a loop between the two extremities at one end ; this loop was applied by the instrument and arranged round the pedicle by the fingers ; the liga- ture is arranged in the same way when de Graefe's serre-noeud is used or any analogous instrument of larger size to grasp the pedicle and increase the constriction day by day. Desault used two separate cannulse; one eiid of the ligature was passed into one of the cannulse, the other end was held by the double half ring at the end of a stylet passed into the second cannula which could be closed or opened at will ; the extremities of the two cannulse united by the loop being applied to the pedicle of the polypus, one was held fixed whilst the other was passed round the pedicle till meeting again with the former, it had completely surrounded the pedicle by the ligature. By rotat- ing the two cannulse the ligature was twisted and detached from the tubes, when the two ends were passed through a serre-noeud ; Niessen used two long separate silver cannulae with which the ligature could be passed round the pedicle of the polypus, after which they were held together side by side so as to allow the two ends of the liga- ture to be tightened. Two gutta-percha catheters - may be substi- tuted for Niessen^s double cannula, or two needles ^ a quarter of a yard long may be used, the eyes serving to carry the constricting ligature to the necessary depth. Lastly, we may like Mayor employ two or three stems of steel or whalebone terminating in a claw. The methods of constriction are as various. Levret, after having tightejied the loop as much as possible, tied the two ends of the hga- ture to the rings at the outer end of his double cannula, which he then rotated so as to twist the ligature on a level with the pedicle. Desault, after having detached the two ends of the ligature united them in one cord which he passed through the opening of a very 8iinj)le serre-noeud (a steel stem, one extremity of which is bent at right angles and pierced with a circular hole, the other being also bent at riglit angles like the first in order to hold the terminal extremity of the ligature passed into the upper ring) ; Sotto^s serre-nroud has been substituted for this. Niessen united his tubes by passing them into a short double nozzle similar to a portion of Levret's double cannula, ' Bevue medico-chirurg., 1851, p. 89. 2 Favrot, Bevue med.-chirurg., Jan., 1818. "^ Ilulin, Menioires dc med. pf. de chir. pratiques. Paris, 1862.- POLYPI AND MOLES 681 Gooch introduced the two tubes simultaneously into two double metallic rings united by a single stem. Bowman adapted a rack to the extremity of this little apparatus; De Graefe^s screw serre noeud Fig. 372. Fig. 373. Fig. 374. Fig. 375. Fig. 372. — Sotto's serre-noeud. Fig. 373. — Porte-ligature, a, holder; c, united in a serre-noeiid with screw D, invented to apply the ligature round the pedicle and to effect constriction ; this instrument may be substituted for those of Levret, Niessen, Gooch, Bowman and Graefe. Fig. 374. — Graefe's serre-noeud with perforated ivory balls. Fig. 375. — Gooch's apparatus modified by Courty for the application of the elastic ligature. //, india-rubber tube ; 7n, metallic guide, by means of which the india-rubber ligature is passed through tbe metallic tubes tt; a a a, rings and iron stem, into which the tubes are adjusted ; t r, rack, of no use when the elastic ligature is applied : the two ends of the india- rubber tube are fastened to it. and the other instruments of the same kind by which, when the ends 682 UTERINE DISEASES IN DETAIL of the ligatures are once fixed, constriction may be slowly and pro- gressively increased are usually preferable. 1 generally employ the elastic i'lgatnre, the loop of which is applied round the pedicle by Emmet's porte-ligature or porte-chain, the ends being passed by means of my metallic guide through two Gooch's tubes brought close together and held by double metallic rings. The elasticity of the elastic tube or ligature when once fastened to the rack at the end of this appa- ratus is sufficient to keep up the con- striction and produce ulceration of the pedicle. The ligature may cause immediate or subsequent accidents. The most serious primary accident is constric- tion of the uterine wall resulting from the application of the ligature above the insertion of the polypus ; but this is easily avoided with a little care if we remember that it is useless to apply constriction at the point of insertion of the pedicle, and that it is even better to run the risk of leaving a portion of the tumour; this portion usually mortifies and falls of itself like the end of the umbilical cord included between the ligature and umbihcus. — The drawbacks resulting from mor- tification of the tumour, fcetid dis- charges, purulent absorption, &c., have been very much exaggerated and may be generally avoided by frequent detersive lotions, by more rapid con- striction of the ligature or by complete and instantaneous division of the pedicle below the ligature. 6. Linear ecrasement. — This is preferable when the polypus is very vascular. I have performed it frequently and always successfully. — Lerpiniere,^ L. Boyer and Pajot suggested dividing the pedicle of the polypus by smving it through by alternate movements in opposite directions communicated to the extremities of a metallic loop or thread of whipcord passed round the pedicle. — Chassaignac^s instrument is undoubtedly preferable to the latter method ; a straight or curved in- strument is used according to the case. I think it is usually easier to pass a silk cord or metallic wire round the pedicle^ than the chain of ' Journal des connaissances mM.-cliir., 1834. ' To obviate this difficulty Sims lias invented a portd-chain (op. cit., pp. 79, 80, 81, figs. 28, 29, 30), and Emmet lias devised a still simpler way of adjusting the chain by means of a loop of thread carried to the end of the vagina by the terminal ring of a long stylet (see fijj. 376). Fig. 376. — Emmet's porte-chain round the pedicle of the tu- mour. POLYPI AND MOLES 683 the ^craseur, and as the extremities of this ligature may be attached to a good serre-nocud and tlie constriction increased as rapidly as is desirable, so as to divide the pedicle in the same way as with the Fig. 377. Fig. 378. Fig. 379. Fig. 377.— Serre-noeud for effecting section of the pedicle by extemporaneous ligature. Fig. 378. — Chassaignac's straight and curved linear dcraseurs. Fig. 379.— Section of the pedicle of a uterine polypus by Chassaignac's curved linear ecraseur. Fig. 380. — Aveling's polyptrite : c, hook of the female blade ; a, h, male blade. ecraseur, I think this method (called by Maisonneuve extemporaneous ligature) is preferable to ecrasement in such cases. — The difficulties of introducing the chain of the ecraseur suggested to Aveling^ the idea of a new instrument composed of a kind of pliable grooved hook, in the concavity of which the pedicle of the polypus may be seized and after- wards crushed by compressing it more and more strongly by means of a bent stem moved by a vice; this instrument is called ?i polyptrite. 7. Excision. — This is the quickest method. It has been adopted by almost all surgeons, especially for fibrous polypi, ever since Dupuy- tren showed its advantages and innocuity (out of 200 cases serious haemorrhage only occurred twice), and since Siebold" and Mayer^ ' Transactions of the Obstet. Soc, vol. iv. " Frauenzimmerhranlcheiten . ^ Dissertatio de polypis uteri. Berlin, 1821. 684 UTERINE DISEASES IX DETAIL publisTied an account of the success of their cases.^ The facility of the operation varies greatly according to whether the polypus has descended into the vaccina or is retained in the womb, whether it is of small size, allowing of its being encircled by the finger as a guide to the bistoury, or so large that it can only be detached from the uterus after being drawn down or divided into several fragments. Fig. 381. Fig. 382. Fig. 383. Fig. 384. Fig. 381. — Chassaignac's tenaculum hook forceps with concave blades. Fig. 382. — Greenhalgh's sliding tenaculum hook forceps. Fig. 383. — Robei-t's tenaculum hook forceps with independent blades and movable teeth. Fig. 384. — McClintock's screw. Means of prehension are applied generally to the periphery of the tumour. If the polypus is easily torn it may be better to seize it with polypus or ovum forceps ; if it is hard or sufficiently resistant it is better to employ tenaculum hooks, either hooks with a handle and ' It must not be forgotten that excision is not exempt from accidents common to all operations. Simpson has seen tetanus supervene {Gaz. hebdom., 1854, p. 686). rOLYPl AND MOLES 685 of which the claws may be concealed or opened at will, and the number of which may be multiplied according to necessity round the tumour; or Museux^s straight or curved tenaculum hook forceps; or Chas- saignac's tenaculum hook forceps with strong teeth and concave blades; or Greenhalgh's sliding forceps, the blades of which can be made to seize the tumour at different heights right and left ; or Eobert's strong forceps with movable teeth, which can penetrate the tumour and be detached from it at will. — When it is impossible to encircle the tumour other means of prehension may be resorted to : for example, piercing the accessible portion of the tumour with a curved needle carrying a cord, by traction on the two extremities of which the polypus may be drawn down and fixed ; or Luer's extractor, a kind of tenaculum hook with a handle, the diverging points of which cannot be detached from the tumour after they have penetrated it ; or lastly the ingenious in- strument in the form of a screw or corkscrew invented by McClintock,^ which is useful in extracting hard polypi. Instruments af section are also very numerous. Lobstein adopted the idea of Fabrice d^Aquapendente, and invented cutting spoons or scoops. Mikschik invented a kind of ring ending in a sharp blade, to be placed on the end of the index finger, allowing the pedicle of the polypus to be cut as with the nail. Richerand used special scissors ; Siebold and Mayer scissors with blunt points and bent in the form of an S. Usually simpler instruments suflfice : a long curved probe- pointed bistoury, or long scissors with a more or less marked terminal curvature or with excentric articulation, or the curved hook with con- cealed blade invented by Simpson under the name of polypotome.^ The instrument is applied to the pedicle guided by the index finger of one hand, and the tissue connecting the polypus with the uterus is divided by repeated small incisions till the tumour is completely sepa- rated. The operation is more difficult when the polypus is contained within the uterus. Herbiniaux^, being unable to separate a polypus by ligature, was the first to perform section of the pedicle in the uterus ; but the tumour had passed the cervix and had descended into the vagina. Dupuytren taught that the cervix should be divided by a puncture from without inwards when there is question of excision of a polypus contained within the uterus, and that even the vulva may be incised when extraction cannot otherwise be made : he disapproved of the previous use of dilators, which I on the contrary feel bound to recommend associated with ergot : in such cases the rules should be followed which I have laid down when describing the extraction of submucous fibroids, their spontaneous enucleation and their pediculisa- tion in the uterine cavity. Adhesions of the tumour to the vagina or pseudo-pedicles* ' Diseases of Women, p. 71. ^ For figures of Simpson's polypotome and the vai'ious tenacuhim hooks made by Aubvy, Collin, Mathieu, &c., see Trousse gynecologique by Courty, p. 37, and foUowinji:. Paris, 1878. ' Parallhle cles differcnts instruments pour le traitement des polypes de la matrice, p. 107. The Hague, 1771. ■• Berard, Arch. gSn. de tned., t. ii, p. 88. 686 UTERINE DISEASES IN DETAIL may increase the difficulties of extraction and necessitate fresh excisions which are not without danger. Another peril may arise from inversion of the uterus, which we should beware of pro- ducing by too strong traction, and the fatal consequences of which will be avoided by following the rules laid down in the case of fibrous bodies for distinguishing the tissue of the tumour from that of the uterus and for avoiding section of the latter. Lastly, the excessive size of the polypus may give rise to special indications. There may be disproportion between its diameters and those of the vulva or even of the outlet. In such cases there are only two courses to take : 1, to make an incision in the vulva behind, towards the perinseum as Dujjuytren did, or two lateral incisions, as advised by Dubois in cer- tain cases of dystocia; 2, to diminish the size of the tumour, which is better ; this latter result is obtained by first incising the envelope of the polypus and afterwards enucleating it; or by separating a cunei- form^ segment of it and bringing the two remaining halves together; or by removing the tumour piecemeal, as one does the foetus in embryotomy. Subsequent treatment. — After extraction of the polypus, if there is haemorrhage it may be arrested by injections, styptics and plugging. The patient should be confined to bed in a posture of semi-flexion, pain being alleviated by the use of narcotics in various forms, and the impoverished constitution restored by the use of tonics, bark, iron, good wine and generous diet. Recovery is so speedy that it is usually difficult to prevent patients from rising too soon : they should, however, be kept in bed for a week or even a fortnight. The origin of polypi shows that these tumours are liable to return. Although recurrence is not common, it has been frequently observed,^ therefore patients should be watched. When pregnancy and labour are complicated by the presence of a polypus I recommend expectation lest haemorrhage should follow excision. The reader may be referred to the precepts already, laid down for the treatment of fibrous tumours in similar circumstances. 2. Uterme Moles Moles, false germs , degenerated germs, are always degenerations of one or other of the princij)al portions of the membranes of the ovum which are destined to envelope the embryo and to serve for its protec- tion and nutrition.^ They result from two causes : 1, from the death of the germ or embryo, the body of which, being macerated and dis- solved in the waters of the amnion, is absorbed, leaving no other trace • Velpeau and Chassaignac, Bulletin cle la Societe anatomique, 1833, p. 113. The uterus was momentarily inverted, but was reduced spontaneously. ' Braxton Hicks mentions three cases of recurrence out of forty-two cases {Guy's Hospital Reports, 3rd series, vol. xiii, p. 128, 1868). ^ Murat, Diet, des Sciences medicales, art. Mole, 1819.— Mme. Boivin, Nouvelles recherches sur I'origine, la nature et le traitement de la mule vrsi- culaire. Paris, 1827. — Granville, Illustrations of Abortion, 183 L — Cruveilliier, Anat. patlioL, liv. i and xvi. POLYPI AND MOLES 687 than a fragment of the umbilical cord; 2, from the plastic, nutritive and hypertrophic tendency with which the appendages of the embryo are endowed independently of the impulse conveyed to them by the germ. The plastic tendency, nisusformativns, being developed to the highest degree, may persist even after the death of the embryo, even in the transitory organs which constitute its apparatus for absorption and nutrition. The energy and persistency of this tendency, diverted from the young being that no longer exists, are transferred to its appendages, which continue to preserve their normal intimacy of connection with the uterus, and the faculty of absorbing and assimi- lating nourishment, and which from that time turn to their own profit the materials of nutrition intended for the embryo. Hence the hypertrophic and progressive but at the same time irregular and terato- logical evolu-tion which the various embryonic envelopes undergo at some point or another. When this evolution takes place in the pla- centa or in the superimposed elements of the various membranes, sepa- rated it may be by interstitial clots, it gives rise to a fleshy mole ; if it goes on in the villi of the first chorion or allantois, with or without par- ticipation in its vascular ramifications, the hydatidiform mole is pro- duced (wrongly attributed to the production of hydatids). This origin sufficiently justifies the names o^ false germs, degenerated germs, by which these moles have been designated. 1. The fleshy mole differs in appearance according to the time at which it is expelled. It varies in size from that of an egg to that of a child's head. When expelled shortly after the death of a very young embryo, it preserves the form of an ^^^g with or without the debris of the embryo in its cavity ; this is the false germ^ of Boivin and Duges ; when expelled long afterwards it has the appearance of a more or less hypertrophied placenta. Should the amniotic fluid not have escaped before the expulsion of the mole, the size of the tumour is larger, its tissue often gorged with blood, its central cavity visible and filled with serum ; if this fluid has escaped beforehand the tumour is harder, the cavity narrower, sometimes filled with effused blood or with clots arranged in successive layers, at other times containing fragments of the foetus, bones, hair or some trace of the umbilical cord; the surface of the mole may be en- crusted with calcareous salts. These moles must not be confounded with simple clots or fibrinous concretions formed in the uterine cavity. 2. The vesicular or hydatidiform mole is a kind of dropsy of the villi of the chorion. The clusters are only ramifications of chorial or placental villi, the subdivisions of which are dilated space by space without the vesicles communicating with each other. This increase of the vesicles and their distension with serum is due to the fact that, after the death of the embryo, the chorion continues to receive materials for nutrition from the uterine decidua in such propor- tions that the size of the expelled mass may be very considerable. The size of each vesicle varies from that of a millet seed to a pigeon^s e«To-. The entire mole often escapes surrounded by the thickened decidua. 1 Op. cit., t. i, p. 276. — Courty, Mecanisme de I'avortement. Montpellier, 1860, and Montpellier medical, 1860. 688 UTEEINE DISEASES IN DETAIL Diagnosis. — Moles often present symptoms of pregnancy. The patient believes at first, and with reason, that she is pregnant. After some time, whether the embryo dies owing to haemorrhage from the chorion or placenta and sanguineous effusion between the membranes of the ovum,^ or whether the membranes are torn as a consequence of dropsy of the amnion, sanguineous efi'usion, or any other morbid con- dition of the ovum, there may occur a discharge of amniotic fluid, mucus, blood, or expulsion of the fragments of the ovum or embryo ; or it may happen that the patient has not observed the escape of any fragments coming from the product of conception or from the elements contained in the uterus. However that may be, the symptoms of pregnancy gradually disappear or, on the contrary, even when haemor- rhage has occurred and the patient believes she has aborted, these symptoms continue indefinitely without the size of the uterus and abdomen increasing in proportion to the length of time which has elapsed since conception. Therefore the duration of abdominal tume- faction symptomatic of pregnancy beyond the ordinary term of gesta- tion, the irregular form of the belly, the disproportion between the size of the tumour and that which the abdomen ought to have at that period of ])regnancy, the absence of foetal movements and cardiac sounds combined with the appearance of the presumptive signs of conception and pregnancy at the commencement of the malady : such are the principal elements of a differential diagnosis be- tween pregnancy and the presence of a mole in the uterus. Amongst the most frequent symptoms which I have noticed are: vomiting, great debility, leucorrhoea, foetid sero-purulent discharge, oedema of the feet (seven times), great antemia (five times), metror- rhagia (forty-one times), and internal metrorrhagia followed by death (once). In 9 cases the development of the uterus was not iu propor- tion with the period of pregnancy." After some time the symptoms of pregnancy gradually disajjpear, being replaced by those characteristic of uterine polypi. We must remember that in double pregnancies one embryo may be replaced by a mole, or that a uterus containing a mole may exceptionally become the seat of another conception or of a kind of superfcetation. In these cases the expulsion of the foetus almost always occurs before the end of pregnancy, the mole being expelled either simultaneously or afterwards.^ Fourteen times the mole has been found in the os at the moment of delivery ; in seven cases a portion of the mole was discharged, four times shortly before delivery, three times several weeks previously ; six times a foetus was present ; twice there was double pregnancy ; once there was a placenta as well ; four times there was multiple pregnancy. Lastly, the expulsion of the mole may occur from the third to the fifth month, usually before the end of ))regiiaiicy, but sometimes it occurs later. Madame Boivin* ' Courty, Mecanisme de I'avortement dans les premiers mois de la grossesse, Monipellier medicaJe, 1860, p, 215. ^ Hayem, Remie des Sciences medicales, 1873, p. 734. ' Fabrice de Hilden, cent, ii, obs. 52. — Duges and Boivin, op. cit., p. 279. * Op. cit., p. 288. TUBERCLE 689 mentions a case of this kind in which the expulsion took place twelve and a half months after conception ; while some moles have remained in the uterus for several years. The weight of a mole may vary from h lb. to G lbs. Treatment, consists almost exclusively in the extraction of the mole. We should wait till uterine contraction or hfemorrhage occurs. Some- times nature herself effects the expulsion of the organic product and there is a true deUvery of the mole. If, however, there is h.nmor- rhage and other serious symptoms we may have to induce expulsion : hemostatics, ))lLigging, dilatation of the cervix by sponge tents aud the administration of ergot excite uterine contractions and provoke spontaneous expulsion. \\'hen this expulsion is not effected, or only produced incompletely or too slowly, if the mole is adherent to the uterine tissue it should be extracted without delay. The same instru- ments are used for this purpose as in cases of soft polypi, the best being Levret's ovum forceps. Care must be taken to remove the whole : after extraction, the same care is necessary as after delivery : rest, tonics, generous diet, iron (if there is impoverishment of blood), ergot and hydropathy (if indicated by softening, defective involution, the persistence of hypertrophy or chronic congestion of the uterus) : such is the treatment required. Tubercle Tubercular disease of the uterus and its appendages is probably the rarest disorder of these organs, the least easy to diagnose and the most difficult to cure. In fact the tubercular diathesis^ which so frequently manifests itself in the lungs and other organs, so seldom attacks the female genital organs that cases of real tubercle confirmed by autopsy may be counted. I have collected 4 cases of general tuberculisation of the genital organs diagnosed during life and verified by autopsy : 1 of tubercular disease confined to the ovaries^ especially to the right ovary, coinciding with pulmonary tubercle; 2 of utero-ovarian tuber- culisation, also coinciding with pulmonary tubercle ; in one of these latter patients tuberculo-purulent products had been expelled from the uterus on several occasions during the latter months. It is remarkable that these alterations are sometimes manifested from childhood. Talaraon {Annales de Gi/necologie, t. ix, p. 416. Paris, 1878) has mentioned a case of ovarian tuberculisation with tubercular pelvic peritonitis and suppurative and encysted metritis in a child of 6 years old. The ovaries as well as the uterus may be attacked by tubercle ; only they are perhaps less frequently attacked primarily : judging from the cases which I have collected, it is seldom that they alone are attacked. The case is different with the Fallopian tubes: they may be tubercular to the exclusion of other organs, and although I cannot agree with Namias, Cristoforis and Rokitansky, that the malady always commences with them, I must admit it very fre- quently does so. It may be the same with the uterus ; but it very (300 UTERIXF, DISEASES IN DETAIL seldom happens that this organ is attacked by real tubercle without the annexes and peritoneum being affected. Of all portions of the genital economy the vagina is most seldom attacked. In these various organs, especially in the tubes and uterus, tubercle may be met with in a state of crudity, softening or suppuration ; even caverns may be met with : in one patient there was such a loss of sub- stance on a level with the recto-uterine and vesico-uterine culs de-sac that progressive degeneration might have caused perforation of the bladder and rectum had life been prolonged. The mucous membrane is sometimes softened, decomposed, even detached by suppuration in more or less extensive patches, laying bare the already partially de- stroyed fibres of muscular tissue. The genital organs are so seldom affected by tubercle that in the immense majority of cases their tuber- culosis coincides with pulmonary or general tuberculisation. Accord- ing to the highest statistics, those of Naraias, tubercle of the genital organs is met with 12 times in 100 phthisical patients; in the records of the Institute of Pathological Anatomy of Prague, published by Dit- trich, we find 1 case of uterine tuberculisation in 40 autopsies on tuberculous women ; Puech has only met with 3 cases in 150 autop- sies; Cless of Stuttgart 1 in 70; and as for myself I have certainly not met with more than 2 in 100. Tuberculisation of the genital organs does not only coincide with pulmonary phthisis, but is also met with in connection with osseous lesions, tubercle in the bones, articulations^ and other organs. In the numerous coincidences just mentioned tuberculisation of the genital organs usually follows pulmonary phthisis, being the result of the serious alteration of nutrition or cachexia, which often passes un- noticed amidst the general disorder of all the functions. It may, however, precede it. Tyler Smith has published a case of primary tuberculosis of the uterus and ovaries followed by pulmonary phthisis causing death. It may even exist alone and be discovered by autopsy at a period in its development when the lungs are not as yet affected : Siredey^ has published a remarkable case of isolated tubercle of the Fallopian tubes and peritoneum ; Tomlinson^ one of tubercle of the uterus, tubes and ovaries, with this peculiarity, that the uterus had acquired a considerable size before the appearance of tubercle in any other organ. In these cases in which, contrary to the law laid down by Louis, the lungs are healthy or at least not attacked by the morbid product, tubercle of the genital organs attracts the attention of the physician to the phenomena manifested in the pelvis. Diagnosis. — It is often ignored, sometimes suspected, seldom con- firmed ; for there are no symptoms which allow of genital phthisis being diagnosed with certainty .* It can never be ascertained with certainty at one visit, as Brouardel has justly remarked; for of the three ' Cruveilhier, Anat. path., iv, 674.— Crocq, Arch. gen. de mod., 1860. ^ Be la frequence des alterations des annexes de V uterus dans les affections dites uterines. Tliese de Paris, 1860. 3 Ohnfet. Transact., 1864. ^ Lebert {Archivfiir Gynehologie, iv. Heft 3, 1872). TUBERCLE 691 elements on which it may be based, the general condition, the local state and the course of the disease, the latter is the most important. Subjective signs. — The general symptoms are the most prominent, the expression of the face, the phthisical habit of the body, symptoms of tubercle in the lungs or other organs coinciding with the local phe- nomena, vague pains in the hypogastrium or loins, a disagreeable sen- sation of fullness and weight in the pelvis and, when the uterus is enlarged, frequent desire for micturition, constipation alternating with diarrhoea, difficult micturition and defecation. I'rom the beginning menstruation is suppressed, especially when the ovaries are affected or atrophied and there is amenorrha3a, as in the patients that I have seen. Brouardel considers leucorrhroa to be the prelude to the disease : this may be the case if the seat of the disease is in the uterus and especially in its mucous membrane; but usually the peritoneum is afl'ected simul- taneously with the genital organs, or at least is inflamed all round them. Hence acute pain, nausea, vomiting, distension, fever, &c., due to limited peritonitis recurring at intervals, to inflammatory exacerba- tions and to attacks of acute inflammation which is grafted on to the chronic phlegmasy. Lastly, when the malady progresses slowly, invad- ing the whole of the genital economy, ascites is sometimes produced. Objective signs. — Palpation shows increased size of the uterus or the existence of a peri-uterine tumour, as well as the resistance indicative of chronic peritonitis : the intestines are bound together by false membranes and distended by gas. — Digital touch reveals a displace- ment of the uterus ; this organ is carried out of the axis of the vagina, especially behind, fixed and sometimes retroflexed. In the vagino- uterine culs-de-sac we perceive inequalities, nodulations and bands of adhesion, painful on pressure : small, rounded, hard, non-fluctuating nodes are observed on depressing these culs-de-sac, especially the pos- terior or lateral one, or by rectal touch. — The diagnosis is somewhat facilitated by speculum examination, which discloses cervical erosions and the existence of a leucorrhoeal discharge, which may be submitted to microscopical examination. Treatment. — The prognosis of this disease is very serious, though less so than that of pulmonary phthisis : if phthisis is exceptionally curable tuberculosis of the genital organs ought to be more so, as these organs are not indispensable to life. The prognosis is probably also less serious when tubercle is limited to the uterus and there is neither peritonitis nor ascites : in this case we may hope to arrest the disease. — We can, however, only treat the affection, having but little direct influence on its local manifestation. Residence in a warm climate and in the country, moderate exercise, generous diet, tonics, cod-liver oil, preparations of iodine, sulphur waters and sea bathing should be recom- mended. Attention should be paid to the chest, and the digestive func- tions regulated and the strength supported. We must try to prevent relapses by prescribing absolute rest for the genital economy. 692 UTKHINK DISEASES IN DETAIL Cancer Under the name of cancer I include every disease characterised by the double tendency : 1, to destroy the tissue of the organ ; 2, to extend to the neighbouring organs more or less rapidly, whatever may be the affections which assist in the development of this disease or the anatomical forms which it assumes. The great number of women attacked by uterine cancer shows the importance of studying the commencement of this disease. Out of 87,348 persons who died of cancer in England between the years 1847 and 1861, of whom 25,633 were men and 61,715 were women, there were about 3000 cases of cancer of the uterus.^ In 1875, 3640 men and 7766 women died of cancer in England.^ According to Tanchou^ the relative pro- portions are 2996 cases of uterine cancer against 1147 cases of cancer of the breast. Out of 8500 women observed by Mayer/ 332 were affected with malignant tumours, 119 with cancer of the cervix, 146 with cancer of the uterus and vagina, 8 with cancer of the vagina, 10 with cancer of the vulva, 2 with ovarian cancer, 8 with mammary cancer and 39 with cancer of organs not connected with the sexual economy. Diagnosis. — This is especially difficult at the commencement. I shall describe successively the signs of the -first period, those of con- firmed cancer and those of the subsequent cachexia. I. Uterine cancer at the commencement — subjective signs. — The symptoms which may become presumptive signs are very equivocal at the commencement of the malady. They ought to arouse the anxiety of the physician who should attract the attention of his patients to them. The local sijmptoms are pain, hsemorrhage and leucorrhcea.^ 1. Spontaneous pain and even induced pain is often absent. Pain occasioned by walking is absent more frequently than that produced by coitus, pressure and touch. This symptom, which becomes the source of great suff'ering when the cancer is in full development, when its ravages have destroyed a portion of the organ and especially when it makes itself felt anatomically and physiologically by the neighbour- ing organs, is on the contrary absent at the commencement of the disease and even at a period when not only other symptoms have attracted the attention of the patient, but when direct examination proves to the physician that the most energetic treatment is powerless ' Simpson, op. cit., p. 140. ^ West, op. cit., p. y67. 3 Becherches sur le traitement medical des tumeurs cancereuses du sein, p. 258. Paris, 1844 * Monatsch., 1868, Bd. xxxii, S. 245. * According to West, out of 106 cases the ^^rs^ local symptom was: In 30, pains of different kinds, var^^ing in intensity. „ 77, liLcniorrhage usually profuse and without pain. ,, 23, hjemorrhage accompanied by pain. „ 15, leucorrlioca, sometimes infectious, with pain. ,, 21, leucorrhcea or other discharges without pain. CANCER 693 before such extensive organic disease. I have seen women only suc- cumb to uterine cancer several years, sometimes seven or eight years, after the probable period of its first development. I therefore regard statistics on this point as mere approximations; the average duration of the life of a woman from the time she is attacked by cancer of the womb is according to Lebert ^ a little more than sixteen months and according to West ^ a little more than seventeen months. On the other hand there are cancers which run through their several stages much more rapidly, e.g. in three and a half months; West, who gives them the name of acute cancers, says that he has only observed these very rare cases in young women shortly after delivery or miscarriage. I have difficulty in accounting for the silence of writers as to the absence of pain in the first period of the development of uterine cancer. Many have been struck by the pains felt by patients at the time when they were consulted ; few have inquired about the pains experienced before this time. As for myself, I have observed that epithelioma is usually indolent even at an advanced period, and indeed till its size, by caus- ing an increase of weight and discomfort in the vagina, a difficulty in marital intercourse, &c., produces a feeling first of discomfort and then of pain ; but as to these acute, darting pains, described as characteris- tic of cancer, I have never known them appear till an advanced period of the disease. I have often been consulted by women in whom I discovered upon examination an incurable disease, death following within three months, and yet the symptoms were so slight from the absence of acute pain that attention had never been called to the uterus. Some have been able to continue marital intercourse without suffering and have become pregnant; others have undergone great fatigue without inconvenience. The majority have continued to sleep the whole night without being awakened by pain. Even the most characteristic forms of cancer, scirrhus and encephaloid may reach an advanced period of their development without having produced pain, at least those acute, darting pains described as characteristic of this affection. I have seen a case of scirrhus which had destroyed the posterior lip of the cervix and even a portion of the body of the womb, reducing the patient almost to a state of marasmus, without pain having ever assumed the acute character supposed to be characteristic of cancer. Thus pain, far from being in proportion to the gravity of the disease, is frequently the reverse, and indeed w^e may boldly lay down as an axiom in such cases Nimiiim ne crede dolori. 2. KcBmorrhage is seldom absent at the commencement of this terrible disease. Constant in internal and interstitial cancer it is even usual in cancer of the cervix and in the most superficial cancroid tumour of this organ. At first the loss of blood usually assumes the simple form of menorrhagia. This, however, is soon followed by metrorrhagia, occur- ring at longer or shorter intervals in the intercalary period ; these heemorrhages at last become almost continuous and are so abundant "ty- ^ M.al. cancer., p. 269. "" Op. fit., p. 39(3. 694 UTERINE DISEASES IN DETAIL that they enfeeble the patient and produce anseraia. They are arrested but recur agaiu till at last they cease either spontaneously or under the influence of the general and local hemostatics that have been administered. 3. Lencorrhcea. — This symptom sometimes precedes haemorrhage, frequently accompanies it, follows it, and may be considered a pre- sumptive sign the value of which is greater than that of haemorrhage owing to the coexistence or succession of these two symptoms. The leucorrhoea may be mucous when it expresses the reaction on the uterine mucous membrane of cancer cells or cancerous infiltration into the muscular tissue of the womb; it is more frequently serous, result- ing from the superficial exudations of a fluid on the internal surface of the body or cervix, the papillary or epithelial element of which begins to undergo a modification, soon giving rise to cancroidal vege- tations which may be developed into cauliflower excrescences projecting into the vagina. Serous in its origin before the appearance of haemorrhage, it sometimes preserves this character in the interval between these discharges of blood ; more frequently it becomes sero- sanguinoleut, sero-purulent, and at last ichorous. It differs entirely from the glairy discharge of catarrh, the purulent discharge of inflam- mation of the uterine mucous membrane, and from the muco-purulent discharge which partakes of the characters of the two preceding in its aspect and origin. It usually only becomes sero-purulent after the haemorrhagic period, and ichorous after confirmed disease has made such progress that ulceration is imminent or even declared at some points. "Whether partly sanguinolent and partly purulent the loss always assumes a very marked serous character ; it is abundant, stain- ing the linen like reddish M'ater in place of making a spot like milk, starch or yellowish-green pus. This discharge, as described by patients arouses the suspicion of the physician ; it is sometimes very acrid, and cannot fail to be an important presumptive sign at the com- mencement of the disease. Although it may not yet have acquired the foetid odour which characterises it when ulceration and destruction of the tissues have rendered it ichorous and mingled with it fragments of normal or pathological tissue, yet the absence of this odour, which afterwards becomes so characteristic, ought not to inspire the practi- tioner M'ith false security. General symploms are usually slight or altogether absent. Neither digestion nor nutrition is disordered. These functions are only dis- turbed when the disease, by its extension and ulceration, and by the inflammation of the neighbouring tissues has reacted on the whole economy, setting up fever, and revealing by undoubted local sym- ptoms the existence of the organic lesion. Of all the general sym- ptoms, the first to appear are usually sympathetic nervous disorders, vague symptoms of vital uneasiness, hysterical symptoms, dragging at the epigastrium and between the shoulders, &c., but it is very difficult for patients to suspect the nature, gravity and even the seat of disease from these symptoms. I do not think the age and history of the patient are of much help to the practitioner. The climacteric has CANCER 695 been mentioned as a favorable age for the development of this malady. My experience does not confirm this opinion. The most common period for cancer as for most uterine maladies is that of sexual activity, between the ages of thirty and fifty. I have, however, seen it in young women of twenty and twenty-five, and in old women of sixty and seventy. Nor must it be tliought that married women alone are subject to this disease, I have frequently seen virgins attacked by it, but in the latter the development of cancer seems more frequently to coincide with the approach of the menopause. As to heredity I think its influence is undoubted notwithstandiag the contrary opinion expressed by Lebert.^ This circumstance should be taken into ac- count not only in reference to the diagnosis but also in the prognosis and treatment. 1 have seen a great many examples of heredity in cancer of the uterus. Sometimes it can be traced to the mother, grandmother, aunts or sisters of the patient, and sometimes to the father or paternal side of the family. I attended a patient for cancer of the cervix in whom the influence of heredity both as to nature and locality was remarkably exemplified : two aunts had succumbed to cancer of the cervix, and the father to cancer of the prostate. I am at present attending a lady suffering from advanced uterine cancer, whose mother died ten years ago of the same disease. I have another patient who is almost in the same condition, whilst her daughter, aged twenty-one, who was only married three months, having lost her husband two years ago, has sufl"ered since her marriage from metritis accompanied by uterine granulations. Ohjeclive signs. — These may enable us to form a certain diagnosis fiom the very commencement of uterine cancer. The pain produced by pressure, especially by the association of palpation with digital touch, the increased size of the organ, its partial tumefaction on one surface or point, the globular form of one or more tumours, the multiple and submucous indurations of the cervix, or the development of hard resisting excrescences which are at the same time friable and bleed- ing : the dilatability of the cervix, the appearance of its nodosities, its patches of violet colour with vascular venous injection round (hem, or the appearance of characteristic excrescences of which I shall speak immediately, are all symptoms which, when added to those of pain and previous haemorrhage, of serous, or sero-sanguinolent discharges, dis- ordered nutrition, puffiness of the face or emaciation, feverishness, &c., soon become certain signs of the existence of cancer of the womb. II. Confirmed nterine cancer. — When cancer is confirmed, or rather when it has reached the period of ulceration, doubt is no longer possi- ble. At this period the general symptoms are considerably aggra- vated. They vary in different patients; but disorders of nutrition always occur, emaciation follows, often accompanied by fever. When a patient complains of pain, metrorrhagia, or serous leucorrhcea, we may suspect the gravity of the malady by merely feeling the pulse : its frequency, the dryness and heat of the skin, especially the palm of the hand, are alarming presumptive symptoms. Pains, ichorous dis- ' Op. cit., p. 273. 696 UTERINE DISEASES IN DETAIL charges, emaciation, debility, fever, the alteration of the features and colour of the face leave no doubt as to the existence and nature of the disease ; we have merely to ascertain the extent of it, and institute the most appropriate treatment for arresting its progress and mitigating its effects. During this period, which may have a rapid evolution, although its course is usually slow, the constitution of the patient is gradually impaired by the establishment of the cancerous cachexia although haemorrhage has often ceased. There are, however, fungous cancers or tumours which are developed rapidly and characterised by rich venous circulation, great friability and a tendency to destruction : iu this case heemorrhage continues to recur ; I have seen cases in which it recurred to the very end, and so abundantly as to determine great ansemia, hastening the end in such a marked way that death seemed to be the immediate result of the loss of blood. With the exception of these cases leucorrhcEa is the only discharge which characterises the advanced period of the disease. These discharges are reddish, sero- sanguinolent, ichorous, fetid, and very abundant, and so characteris- tic that they enable the experienced physician to form a probable if not a certain diagnosis as soon as he enters the room or raises the dress of the patient. The pain is not less characteristic ; in addition to the feeling of weight and discomfort in the pelvis, aching in the groins and thighs and the pain produced by pressure, there is dull constant suffering aggravated at intervals, sometimes increased to an excruciat- ing degree. The continuity, nature and acuteness of the pain depend on several causes. The nature of the tumour and especially its increasing size, its extension to the sensitive orgaiis whose functions it disturbs, the inflammatory symptoms which it evokes in the neighbouring organs (the vagina, bladder, rectum, and peritoneum), making the performance of their functions difficult if not impossible, preventing all exercise and change of posture owing to its extension as far as the neurilemma of the nerves belonging to this region ; these are the causes of those exacerbartions of pain which digital touch almost always produces with significant intensity. The most serious local symptoms are then mani- fested, in consequence of the invasion and destruction of the organs contained in the pelvis. The inflamed bladder immovably fixed by the invading cancer and compressed on a level with the cervix can no longer expel the urine -^ the j^atient requires to be catheter- ised, as spontaneous contractions of the viscus cause the most acute pain. In the end a vesico-vaginal or vesico-uterine fistula is formed by ulceration, so that patients after having experienced great diffi- culty in passing their urine find it impossible to retain it. The same phenomena take place in the rectum, the vagina becoming a cloaca in which cancerous ichor and uterine discharges are mingled with urine and fecal matters and are discharged by the vulva, tllceration ' One of the ureters may be invaded, contracted, even obliterated, and after- •wards dilated above the contracted point, as well as the calices of the kidney, the glandular substance of which atrophies. CANCEU G97 of the uterine tissue may hasten the result when the body and especi- ally the fundus of the uterus is attacked by cancer : I have seen a Fig. 385. — Cancer of the cervix extending to the bladder, rectum and upper portion of the vagina ; communication established by ulceration between these three organs : u, uterus ; v. vagina ; r r, rectum ; h, bladder. patient succumb to rapid peritonitis caused by perforation of the fundus of the uterus ; another succumbed in a few days to pelvic peritonitis consecutive to a similar ulceration of the posterior wall of the organ. Digital touch enables us to ascertain the progress of the disease, its seat, and the exact degree it has reached in its destructive course. Sight confirms the information, but the use of the speculum is often interdicted, owing to the pain caused by the introduction of the instrument and the frequent impossibility of embracing the cervix or even of discovering the orifice, on account of its position behind and of the enormous tumefaction of its two lips, and also to the facility with which the tissue may be lacerated and give rise to fresh haemorrhage. Diversify of seat and form of uterine cancer. — It is at the period when the malady is. confirmed that we can distinguish the various forms of cancer,^ at least from tlie symptomatic point of view. These are the elements which sight, vaginal and rectal touch, combined with palpation and the use of the sound, furnish for the differential diag- nosis of the various forms of cancerous disease. * Ernest Wagner, Zre&s der Gehdrmutter. Leipsic, 1858. — Cornil, Des tumeiirs epitheliales du col uterin {Journal d'Anatoviie et de Physiologie de Robin, 1864). Scirrhusand encephaloid only differ in the density or rarefaction of the solid elements proportionally to the abundance of the cancerous fluid (see Be- cherches sur Vhistologie du cancer, in my CUniqiie chiritry., p. 59. Montpellier, 1851). Cancroid, so named by hahevt [Physiologie pathologiqne. Paris, 1846), better known by the name of e2yHhelionia, given to it by Hannover {Das Epi- thelioma. Leipsic, 1852), and under which it has been described by Paget {Lectures on Tumours, vol. ii. London, 1852), is placed by Houel (Cruvcilhier, Anat. path, gen., t. v, p. 296. Paris, 1864) with fibro-pfastic tumours in the 698 UTERINE DISEASES IN DETAIL A. Cancer of the Cervix 1. Ejnthelioma of the vaginal portion of the cervix. — The first modification made in the normal form and structure of the cervix by the development of epithelioma on its vaginal portion is the alteration of its surface, which becomes irregular, being covered with numerous elevations irregularly developed, situated like granulations round the orifice or on one of the lips, always more on one lip than the other although adjoining the orifice, having the appearance of papillary hypertrophy, afi'ecting the epithelial element much more than the dermis of the papillse and presenting a striking analogy with epi- thelioma developed on other parts of the body, especially at thejiatural orifices, the vulva, anus, eyelids, and above all round the mouth, in fact, with the usual form of buccal and particularly labial cancer. — frequently it is developed over the whole surface of the cervix, con- tinuing regularly and forming a large excrescence in the form of a cauliflower like an inverted mushroom, projecting in every direction beyond the surface of the cervix itself, the orifice of which is often found with difficulty. Frequently while produced in the same way it invades the two lips unequally or is only manifested on one of them, leaving the os uteri behind or in front according to whether the ex- crescence is situated on the anterior lip, as occurs most frequently, or, as is more rarely the case, on the posterior lip. At this period it is important to distinguish epithelioma from other organic alterations of the cervix, such as diphtheritic or fungous ulcers, granulations and vegetations. This distinction is easy, for the principal characters of epithelioma are : inequality of development of the elementary and secondary groups, the latter being more voluminous and formed by the association of epithelial cells, which the microscope reveals as essential elements of their structure ; compactness of tissue, the rela- tive fragility of which depends on this very compactness, hardness and non-elasticity; a tendency to bleed after the lacerations caused by touch ; if the epithelioma is not vegetating, it offers a characteristic aspect ; hard, nodulated, irregular, vascular and, on microscopical examination, disclosing to view the epithelial cells; there is a serous or sero-sanguinolent secretion from the surface of the epithelioma, or there is a purulent ichorous secretion from the ulcerated points of class of pseudo-cancers. It is of little practical importance whether, after Lebert and the French school, cancer is distinguished from cancroid by the expressions heteroniorphous and homtcomorphous, the former being attributed to the organisation of new elements in a diseased blastema, and the latter to the morbid proliferation of normal ejntlielial cells ; or whether, after Virchow, whose ideas have been adopted by the German and English schools, both of these tumours are attributed to a morbid hyperplasia of normal cells deviated from their type and urged into a course of pathological proliferation by the unknown cause which presides over the development of cancerous affections. Tlie development of cancer in the uterus does not exclude that of fibroma in the same organ, tubercle in tlie lungs if not in tiie womb, nor of syphilitic chancre on tlie cancerous ulcer itself. Such cases have been known, and far from neutralising each other these various aifcctions seem to concur to hasten death. CANCER 699 the tumour, it being seldom that some portion, some exuberance, is not attacked by ulceration. This form of cancer if not arrested by ablation is developed with frightful rapidity. The tumour formed by these excrescences, the various branches of which press against each other, presenting the appearance of the vegetable from which they take their name, soon exceeds the dimensions of an e^g and sometimes acquires an enormous size, even filling the cavity of the distended vagina, compressing the neighbouring organs and mechanically hindering their functions, even before it has invaded the upper portion of the uterus. As a rule, how- ever, it gradually extends to other points; it may even assume this mode of development altogether, only giving rise to sliglit excres- cences, but spreading in every direction over a large surface all round the central excrescence or starting-poiut. At first the vaginal portion of the cervix is attacked and soon afterwards the vaginal mucous membrane itself, behind, before, and on both sides ; the finger perceives nodules of induration pressed one against the other round the cervix, isolated a little further on, often disseminated at a great distance, pre- ceding the excrescences which are soon developed on these centres ; one would say that the cancer had spread its roots in these different directions, or they are like suckers or seeds scattered profusely near the centre of the disease and more sparsely further off. The tumour next invades the uterine cavities, beginning with the cervix and ending with the body. Epithelioma of the cervical cavity is less easy to diagnose as its situation conceals it from sight. The same circumstance hinders its development as a vegetating excrescence, in consequence of which it may extend more deeply, either towards the uterine cavity or in the thickness of the muscular tissue before showing itself at the orifice. It produces hsemorrhages and leucorrhoeal discharges, however, even perhaps at an earlier date ; and, as it tends to vegetate, it dilates the cervical cavity, softens this organ and presents itself at the point which offers the least resistance, ?". e. the softened and dilated os, which soon participates in the progress of the organic degeneration. 2. Parenc/iT/matous cancer of the cervix, if it is allowable thus to name cancer which is developed within the tissue proper of this organ, especially in its muscular tissue, may also be diagnosed at an early period and more easily than cancer of the body of the womb. It is cha- racterised by increase of size and heat of the cervix, by its general in- duration, irregularity and the sensation of hard, globular, often multiple bodies on one of the lips observed in the thickness of the cervix at a variable depth ; there is no resistance nor sensation of fluctuation, no primary degeneration of the mucous membrane nor of its epidermis; but there is a congestive condition, an unequal dark red coloration, red on the projecting portions, violet on other parts, especially on the cir- cumference of the globular projections, and capillary venous injection round these deep tumours or nodulations which are sometimes very painful on pressure (Fig. 134', p. 139). Cancer developed in the tissue of the cervix may assume the form of scirrhus or encephaloid 700 UTERINE DISEASES IN DETAIL according to tbe density of its tissue, the closer grouping of its ele- ments, the predominance of fibres and fibro-plastic elements over the cancer cells or the presence of a variable quantity of cancerous tluid ; but as these forms when developed in the uterine tissue do not present different characters from those which they offer when developed in other tissues I shall not here give a comparative description of them, but merely make two remarks on the subject. The first is that scirrhus has seemed to me more common than encephaloid ; the second, that when ulceration attacks these tumours and has a destructive tendency it may cause as extensive destruction in scirrhus as in encephaloid. I remember having sefu a young lady in whom scirrhus of the cervix, which was easily diagnosed by the tumefaction and hardness of the anterior lip and of the rest of the uterus, and which was developt^d originally in the cervix, had very soon extended to the whole body, and when attacked by ulceration in a short time caused such destruc- tion that the whole posterior lip and almost the entire posterior seg- ment of the uterus had disappeared, allowing the finger to penetrate behind the cervix and the anterior segment of the organ into a vast cavity full of ichor and cancerous detritus, at the end of which the fundus of the womb could be felt. B. Cancer of the Body of the Vterus^ 1. There is no doubt that epithelioma may be developed in the uterine cavity on the mucous membrane of the body as well as on that of the cervix, and as on the vaginal portion of the latter assume the vegetating form and propagate itself over the whole womb to the neighbouring organs. Having ascertained the existence of the pre- sumptive symptoms just described, direct examination by digital touch, speculum and sound leads to a certain diaguosis. In the case of cancer of the uterine cavity, as in that of polypi or any other pro- duct developed in this natural cavity, contractility of the organ is excited and is manifested by expulsive efforts, the effect of which is to tumefy, soften, and dilate the cervix. If we take advantage of this tendency, encouraging it by the introduction of dilators, not only may the sound be introduced into the uterus but the finger itself, the deli- cate sensibility of which discovers sufficient elements for forming a certain diagnosis in the inequality of the cervix, the fragility of the tissue, the form of the excrescences, and the presence of detritus apart from the ichor, a certain quantity of which it brings away mingled ' Although cancer of the body is undoubtedly less common than that of the cervix, it is not very rare. I have seen some 20 cases, Seyfert has seen 5, Kiwisch 2, Dittrich 2, Lebert 2, and Scanzoni 2. Out of 429 cases of uterine cancer seen in the hospital at Vienna, there was only one case of primarv cancer of the body. 8axinger (Monatsch., xxiv, 71) has collected 2 cases, Simpson 1 {Gaz. hebdom., 1854, p. 389), Ballard 1 (Provincial Medic. Journal, May, 1851), Recklinghausen 1 {Monatsch., xx, 1G9), Forget (Gaz. mcd., 1851, p. 04^)) has published 2 cases ; lastly ia Gazette dcs h<'ipitan,t , 1861, p. 208, has recorded 3 cases taken from Huguier and Demarquay's practice. See also Pichot, Etude clinique gur le cancer du corjps et de la cavitC de I'uteru)^. Those dc Paris, 1876. CANCER 701 with small fragments of epithelioma. This examination should be made with great care, as cancer of the cervix does not always prevent pregnancy. 1 But when recent haemorrhage and presumptive signs of cancer of the body remove all idea of pregnancy, we may make such an exami- nation in order to determine whether it is a case of cancer, uterine catarrh, granulations, uterine fungosities, or polypi, because these latter maladies are curable and require prompt and active therapeutical treatment. We must, however, remember that if the malady is ad- vanced perforation of the uterus weakened by ulceration is to be feared {see -p. 697). 2. Interstitial or parenchimatous cancer, developed in the thick- ness, in the interstices of the tissue proper of the organ may, as has been demonstrated by autopsy, be either scirrhus or encephaloid ; may be developed in either of the two walls before extending to the rest of the organ ; may, like fibroids, increase towards the external surface of the uterus or towards its cavity, projecting in one direc- tion or another ; and may, lastly, ulcerate at some point, especially on the side which looks towards the uterine cavity. Apart, however, from the general symptoms and from the tardy proof afforded by products of ulceration, no symptom can be considered as certain nor distinguish it positively from fibroids, tuberculous masses, or other interstitial changes of the body of the womb. Besides, cancer may exist in the uterus simultaneously with tubercle, pus, or fibroids. Although, however, several practitioners have met with fibroids and cancer in the same uterus, they have never seen fibroid bodies dege- nerate into cancer .2 Only the differential diagnosis is more difficult than the anatomo-pathological distinction. In such cases, therefore, we must take into consideration the history of the patient, heredity, general symptoms, and all the subjective signs which can increase the mass of evidence, though it may not lead us to a certain diagnosis until the disease has reached an advanced stage. III. Cancerous cachexia. — Cancer invades the cervix from the body and vice versa ; from these it extends to the vagina, bladder, rectum, and the fibrous tissue interposed between these organs. The Fallo- pian tubes and ovaries are affected less frequently, whilst on the con- trary they participate more often in the extension of tubercular dis- ease. The inguinal and pelvic ganglia are seldom enlarged in the beginning but are attacked at a later period, especially the latter, as well as the lumbar and mesenteric ganglia in cases of considerable generalisation of these diathetic localisations. The lymphatic vessels, even the thoracic duct, may like the ganglia be affected by the disease • It would seem that pregnancy arrests the course of cancer, except in the cases in which it teruiinates prematurely by abortion. But it would also seem that the course of the disease recommences more rapidly after delivery, hasten ing the death of patients. See West, op. cit. p. 409. London, 1864. - Cruveilhier, Anat. paih. gen., t. iii, p. ()93, and t. v, pp. 183, 288. Paris, ISGt. 702 UTEEINE DISEASES IX DETAIL or contain cancerous fluid. ^ Lastly, the neighbouring veins are often attacked, either from the malady invading the tissue, or from the transport of the cancerous fluid giving rise to malignant vegetations on their internal membrane.^ The nerves themselves do not escape from this propagation.^ Cancer does not increase without damage to the surrounding tissues and organs. The extension of the tumour and the ulcerative pro- cess which manifests itself simultaneously determine the development of inflammatory phenomena not only in the affected organs but in neighbouring tissues within a certain radius, assuming different forms according to the nature of the organs and tissues. For example, in parenchymatous and in fibrous tissue, inflammation produces indura- tion ; at a later period it may cause softening and, though rarely, abscesses, assisting the cancerous ulceration by acting in the same direction and producing analogous results. On the surface of the peritoneum, on the contrary, it produces albuminous, fibrinous and purulent exudations which give rise almost always to adhesions between the two contiguous surfaces of this serous membrane which help to keep up displacement of the organs, to hold them fixed in vicious positions and to increase pain ; thus the folds of the broad ligaments adhere to each other, the Fallopian tubes or ovaries may adhere to the uterus, rectum, and intestines, leaving between the adhe- sions winding cavities filled with serum, the last retreat of chronic inflammation of the peritoneal membrane. — Peri-uterine inflammation is not the only cause of the immobility and pain ; the invasion of the organs contained in the pelvis gives rise to the formation of a can- cerous mass in the period of cachexia which sometimes confuses together the vagina, bladder and rectum, preventing the accomplish- ment of their respective functions, or what is worse establishing a communication between them so that the vagina becomes a kind of cloaca common to all the excretions (Fig. 385). Happily for the patient the cachexia gradually produces exhaustion and consumption ; when a continued fever, increasing in the evening and assuming the hectic form, soon produces the last stage of marasmus quickly followed by death. Treatment.— There is no absolute cure for cancer as far as we know; and the relative curability of uterine cancer appears to depend on the nature of the malady, and on its position in the various parts of the womb. With regard to the nature of cancer epithelioma is evidently more curable than scirrhus and encephaloid ; the vegetating form of epithe- lioma seems to me also more curable than its corroding form, tuberous cancer more so than ulcerous, and dry more so than moist cancer. Epithehoma, whether of the uterus or lips, is usually less dependent ' Hourman, Mlimoire sur le cancer nterin {Bevue med. frang. et Strang., 1837). — And Lebert, Maladies cancerevses. ■ Cruveilliier, Anat. imth. du corps humain, t. ii, hv. 23, and Anat. path, gen., t. V, pp. 226, 275. Paris, 1864. 3 V. Supra, p. 696. OANHER 703 on a general affection than on an alteration of local vitality. There are more examples of labial epithelioma successfully treated by opera- tion without return than of scirrhus or encephaloid. It is the same with epithelioma of the cervix ; I have seen so many examples of epi- thelioma being operated on successfully and not followed by relapse that I never despair of attempting complete ablation. Therefore it is well worth while to discover the best methods of treatment and operation. With regard to the seat, cancer of the cervix is the only one which admits of curative treatment. In the cervix itself scirrhus or ence- phaloid, apart from being manifestations of a diathetic affection for which we know no remedy, are usually develoj)ed too deeply to allow of our exceeding the limits of the disease ; and operation in their case is only practicable when they present themselves under certain favor- able conditions. These conditions are the following : — The cancer must occupy the vaginal portion of the cervix ; it must not extend to the vaginal insertions still less to the vagina itself, as often occurs ; the cervix above the organic alteration must be indolent, only slightly tumefied, supple, soft, without suspicious indurations, in short, in a normal condition. I. Curative treatment. — We cannot count on any specific but must limit ourselves to restoring the constitution by tonics and alteratives, the value of which has been proved by experience. We should pre- scribe a strengthening diet, milk, residence in the country, or at a watering place appropriate to the temperament, hydropathy and, according to the requirements of the case, the use of iron, preparations of gold, arsenic and even of hemlock. Ablation, however, is the only curative treatment effected either by the use of caustics or by operation. A. The destruction of cervical cancer by caustics is the most seduc- tive means for an inexperienced practitioner. Unfortunately it is not successful whilst its innocuity is only apparent. Caustics are useless because they cannot reach even by repeated applications the whole extent of the evil : caustics or solvents of cancerous elements such as gastric juice (Sennebier of Geneva), acetic acid (Broadbent), tincture of sesquichloride of iron (Kiwisch), the solution of nitrate of silver (Thiersch, Hermann, Laurent, Kuhn, Nussbaum ^), perchloride of iron (Gallard),^ only destroy a small portion of the tumour and may set up fatal inflammation. Caustics are hurtful not only because they may by spreading attack other parts than those to which they are applied, but because their action, though incomplete as a destructive, is energetic as an excitant and frequently determines a proliferation the effects of which have always seemed to me to increase the evil it was intended to lessen. I neither except acids, nor acid nitrate of mercury, nor Canquoin^s caustic, nor the actual cautery. I would only sanction the use of the Monatsch. filr Geburtsh., 1867, Bd. xxx, S. 230. — Bayerisches aerztUchea Intellujenzbl., Heft 17, 23 April, 1867.— G^az. hebdom., 1867, p. 333. '^ Gaz, des hopitaux, July 6, 1867. 704 UTERINE DISEASES IN DETAIL latter oji a very superficial surface of epithelioma or on a very limited corroding cancer which could be destroyed entirely by one application. This is sometimes effected by applying a small circle of Canquoin's caustic to the cervix and a cylinder of the same plaster in its cavity ; I have for a long time adopted this method, which is somewhat similar to that recommended by ]\Jaissoneuve under the name of cauterisation enjieche. We may also make an interstitial injection of a solution of chloride of zinc (Guichard, Annates de Gynecologies 1877). In what- ever way the Canquoin is applied we should prevent the possibility of its displacement and the consequent destruction of healthy parts by retaining it in position by methodic plugging of the vagina with oiled cotton wool and by keeping the patient in bed. It is left for a longer or shorter period according to the depth of destruction required; and it may be re-applied for several days, the plugging being continued to prevent cauterisation of the vaginal mucous membrane by the detach- ment of fragments from the scar of the cervix. It will be seen that this application requires great care and cannot be made without danger by an inexperienced practitioner. B. Amputation of the cervix \S'i}\Q only means of completely removing the disease. I have already laid down the indications and contra- indications for and against amputation^ of the cervix. They may be resumed as follows : amputation is contra-indicated when the cervix is not the only point of localisation of the cancerous affection, even when this diathetic affection has not reached the stage of cachexia; when the cancer, however local it appears, is deeply seated not only in the body but also on the supra- vaginal portion of the cervix ; when, having began at the free extremity of the cervix, it is propagated even beyond the level of the vaginal insertions of this organ ; when, the supra- vaginal portion of the cervix remaining healthy, the vagina is invaded by the cancer, even to a slight extent, except when under the form of very superficial excrescences without deep roots, easily removed by scissors without prejudice to a subsequent cauterisation, the conse- quences of which cannot compromise the integrity of the bladder or rectum. Amputation is indicated when the cancer is situated on the free extremity of the cervix, whatever its size may be ; when no other localisations exist either in the upper portion of this organ, or in the body of the uterus, or in any other viscus; when the supravaginal portion corresponding to the vaginal insertions, and especially that part comprised between these insertions and the tumour, have pre- served their normal size, suppleness and insensibility; lastly, when the organic alteration is not propagated in any direction on the vaginal raucous membrane : under these circumstances amputation of the cervix ' Amputation of the cervix was first performed in 1802 by Osiander, who repeated it 28 times {Heilung ties Mutterkrebses, &c., durch Schnitt., in Eeich- anzeiger, 1803). — Langenbeck (i>e totius uteri e.dirpatione. Gcettingen, 1842, p. 2(J). — Since then it lias l)een often performed by Dupuytren {Journ. gen. de med., cix, 214), and by Lisfranc (Gaz. mrd. de Paris, 1824, p. 387. Clinique de la Pitio, iii, 645. Paris, 1843), Pauly {Maladies de I'lderus. Paris, 1836), Simpson {Edinb. Med. and Surq. Journ., 1811; Dublin Journal, 1846; Medical Times, 1859). &c. CANCER 705 ought to be performed, this operation being the only means of saving life.i I say under these c'lrcuhistances, and I only speak of mnputating the intra-vaginal portion of the cervix ; i.e. I reject as useless or dangerous amputation of the supra-vaginal portion of the cervix and, still more so, extirpation of the whole uterus in cases of cancer. Unfortunately these operations were common enough at one period to afford materials upon which to base a serious opinion as to their advisability,^ 1. When the cervix is amputated by linear ecrasement, chloroform should first be administered. The patient should be in the lithotomy position. An assistant on each side by passing a hand or arm under the knee and seizing the instep with the other hand can hold the leg flexed, separate the thighs, raise or depress the buttocks according as the operator may require. If the uterus can be displaced easily 1 do not see any contraindication to drawing it down gently to a level with the vulva, which greatly facilitates the operation -, if not, a curved ecraseur should be used, or better still a simple iron wire in place of a chain which is passed round the pedicle of the tumour. To do this the tumour must be seized as if it were to be drawn towards the vulva. By fixing it in this manner we facihtate the application of the chain. Museux^s tenaculum hook forceps may be used for the purpose or any other form of polypus forcej)s (see p. 684) : the tumour is seized at various points, a little behind if possible in order to run less chance of lacerating it and to be more sure of apply- ing the ecraseur beyond the limits of the disease. Robert's tenaculum hook forceps although rather strong are sometimes better when we wish to ensure their insertion into the deep portion of the cancer towards the upper border of the tumour : their introduction is, besides, very easy ; they are applied one after the other right and left of the cervix and are then articulated hke forceps ; they are separated more easily than Museux's forceps. Chassaignac's tenaculum hook with diverging branches may also be used ; it is introduced closed into the cervical cavity; the hooks are then made to diverge and by exercising traction upon them the cervix is hooked from within and can be drawn down more easily than by the claws of forceps. Here, however, a difficulty presents itself. Whilst on the lower side we may be afraid of not reaching the limits of the cancer, on the upper side, on the contrary, there is- reason to fear that a portion of the vagina may be included in the chain with the cervix, especially if, owing to the obhquity of the cervix, the greater development of the tumour on one of the lips than on the other, the traction exercised on the cervix and the movements imparted to it in order to facilitate the passage of the ' As to the advantages and drawbacks o£ this operation consult Simpson, op. cit., p. 169 ; West, op. cit., p. 415 ; Velpeau, Mklecine operatoire, iv, 413. Paris, 1839. 2 West, Diseases of Women, p. 412.— Serre, Pathologie et tMrapeutiqtie des maladies pour lesquelles 0)1 a prescrit diverses amputations de la matrice; examen critique de ces vioyens, et description des diverses metliodcs de ces amputations. Moutpellier, 1834. — Langenbeck, op. cit.— llobcrt, Des affections granuleuses ulcereuses et carcinomateitses du col de I'uterus. Paris, 1848. 45 706 UTEEINE DISEASES IN DETAIL chain, we fail to give it a direction perpendicular to the plane of section passing through all the radii of the circle described by the metallic ring of the ecraseur. This danger is not imaginary ; a real difficulty is experienced in preventing the chain, ^vhen it has been adjusted on one side to the desired portion of the cervix, from Fig. 386. — Chassaignac's diverg- ing' tenaculum hooks. Fig. 387. — Amputation of the cervix by linear ecrasement. embracing on the other side a part of the vagina and with it a portion of the bladder or rectum or at least of the utero-vagino-rectal ^ peri- toneum. A ligature of thread should be first employed as Chas- saignac recommends, as a preliminary in every operation for ecrase- ' Scanzoni's Beitrdge, iii, 80. Wurzburg, 1858. — Monatsach. fur Gehurtsh., March, 1858. CANCER 707 ment ; but it is not much easier to adjust this Hgature in the exact situation than to fix the chain. With the object of preventing this accident I have invented an instrument which is nothing but a pair of long disarticulating forceps, the branches of which can be introduced successively and articulated afterwards, their concave blades, which are bent at right angles, forming when united a kind of ring which embraces the cervix above the diseased part. It is easy then to grasp the organ and to make sure with the index finger that it alone is seized by the instrument, or, if otherwise, to push back the portion of the vagina which has been included, to bring the axis of the cervix once more into a position perpendicular to the circular surface of the projected section, to keep it there by tightening the blades of the forceps, and to adjust with precision around the cervix, immediately below the forceps, the metallic ligature or the chain of the ecraseur, which may then be pushed back towards the blades as it is tightened, so as to avoid the double danger of dividing the cervix too high or too low.^ As soon as we are sure of the point of application the operation proceeds by itself, its only drawback being its slowness; every two or three minutes the chain is tightened by one notch, the patient being kept under chloroform till the section is finished. Sometimes I have performed the same operation with a metallic wire and a good serre-noeud, effecting constriction slowly by turning the screw every quarter of an hour. I have done it in a day without having recourse to chloroform, except at the commencement of the operation which is always painful, and without causing the least hae- morrhage. The operation may be extended over a still longer period without harm if hot detersive injections are made from time to time, as is done in cases of simple application of the ulcerative ligature. Immediately after the fall of the tumour a hemostatic injection is made, and care should be taken to ascertain by digital touch that no suspicious tissue is left on the cervix, and a wooden speculum should be introduced into the vagina in order to examine the wound. If any can- cerous indurations are left, they may be excised with a long narrow bistoury, perchloride of iron being afterwards applied to the womb to stop haemorrhage, or better still a mushroom-shaped cautery or a jet of gas which has the advantage of destroying all traces of the cancer, acting as a hemostatic as well as modifying the uterine tissues and encouraging resolution of the chronic phlegmasia which has been kept up to some depth by the long duration of the development of the cancerous tumour. 2. When excision is performed we may dispense with chloroform on account of the rapidity of the operation ; the patient should be in the same position as for ecrasement; the cervix is seized by tenaculum forceps and is either drawn down to the vulva or operated on in sitil? ' Simon of Darmstadt, Monatsch. fiir Geburtsh., xiii, 418 and 434. - I do not enumerate the various methods of excision of the cervix performed by Osiander, Eecamier, Dupuytren, Lisfranc and Simpson, or those invented by Hatin {Amputation du col cle la matrice. Paris, 1827), Colombat {Hysteroto- mie. Paris, 1828), CaneUa {Cenni suit' estirpazione delta bocca del collo dell' utero. MiUm, 1821) and Arousohn {Zeitschrift fiir die gesammte Medicin,\, -idG). 708 UTERIXE DISEASES IN DETAIL The first method is undoubtedly the best, for by operating on the uncovered tumour if" there are any adhesions with the vagina we do not run the risk of including them in the section. This danger is to be feared when the cervix is left in place, but in such cases we may apply the forceps with bent blades behind the line of projected section, immediately in front of the vaginal insertions, or we may attack the cervix from various directions, inclining it alternately in one direction or another, always to the side opposite to that by which we wish to attack it and protecting the corresponding portion of the vaginal wall with dilators. When section is begun in this way all round, it is easy by taking this first groove as a guide to finish ablation of the tumour. If it is necessary to dissect the vaginal insertion at some point or to pare the cervix into the shape of a funnel or hollow cone (which is a good precaution to take when we suspect that the cancer is propagated towards the cervical cavity) the bistoury is necessary ; it is better to choose one with a long handle as being easier to manage, and with a short blade which is easily inclined in various directions and which can be carried all round the pedicle represented by the cervix. We may even require a bistoury with a very long handle and a very short blade, bent or concave like a small pruning hook when excision has to be performed at the further extremity of the vagina. If we are sure of removing all by one stroke, and without injuring any surrounding organ, we may use very strong scissors slightly curved, when the cervix is drawn dovrn to the vulva. The same instrument with blunt points, guided by the index finger, is very useful in commencing sec- tion of the cervix at the further extremity of the vagina. It does not, like the bistoury, present the risk of cutting the cervix at other points than that to which it is applied. Whether the choice falls on a knife or scissors section of the cervix should usually be begun at the poste- rior lip and terminated at the anterior one, so as to begin with the most difficult section and to avoid the blood issuing from the parts already divided. After complete separation of the cervix perchlo'ride of iron or the actual cautery should be applied, the same precautions being used as after ablation of the cervix by the linear ecraseur. This operation is not so free from risk as might be supposed. Cruveil- hier mentions the case of a young lady who died a few hours after- wards, therefore it should only be performed when really indicated and with all necessary precautions. Except in the rare cases in which it has been followed by death the symptoms of reaction which it pro- duces are usually moderate. In some patients there is perfect toler- ance; but in the majority symptoms of metritis are manifested. The loss of blood is not usually great; it can be arrested when necessary by perchloride of iron and plugging. Lumbar pain, however, due to the dragging exercised on the uterus during the operation, lasts for some hours and often for days. Pain is developed in the vagina and hypogastrium and is aggravated by pressure, but is rarely of an alarm- ing character, simple emollient cataplasms, sedative fomentations, embrocations with camphorated oil sufficing to alleviate it. But CANCER 709 however slight the symptoms of metritis or peritonitis appear, no time should be lost in treating them by the application of a number of leeches, by frictions with mercurial and belladonna ointment made every two hours, and afterwards by mild laxatives, emollient cataplasms, and all the antiphlogistic and resolvent means apphed to the treatment of acute metritis. Patients should be confined to bed till these sym- ptoms have disappeared. We should then await the fall of the scar and pay attention to the cicatrisation of the \vound. Even when cicatrisation is neither slow nor irregular, if unhealthy looking granu- lations appear on the surface of the wound we must not fear to destroy them quickly and completely, by the actual cautery, Vienna or arsenical paste, which may be retained against the cervix with a pledget of lint or cotton wool. I have found the latter method of great use in such cases, as it induces speedy and healthy cicatrisation. I consider it as a good supplement to the other caustics which effect mortification or destruction of a certain depth of tissue, but the scar of which does not always present the subjacent formation of a true cicatrix after its fall. Arsenical paste applied at this time has usually seemed to me to possess the property of producing real cicatrisation of the wound in place of fresh destruction. In order to profit by the advantages offered by the elastic ligature and Paquelin's thermo-cautery, I have modified the operation in the following way. Let us take the case of a voluminous tumour of vegetating epithelioma. And here I may remark that the analogy of aspect to which the English have drawn attention between the vegetating epithelioma of the cervix and the cauHflower (cauli- flower excrescence) is more real than one would suppose on a super- ficial examination. I have always remarked in these cancerous or caucroidal cauliflower excrescences two distinct portions : 1, an exu- berant friable part, formed of voluminous epithelial elements appended to vascular arborisations which support them like grapes in a cluster; these parts form lobules and lobes the removal of which is often easy, not being even accompanied by serious haemorrhage : therefore they can always be removed more or less readily. Sometimes it is necessary to have recourse to a ligature and then they fall very easily. When I use the ligature it is to remove more of the tumour, or else because the tissue of it is diff'erent ; 2, a dense resistant portion, also sub- divided into tapering parts which correspond with the principal and even secondary lobes which they sustain and of which they form the trunk and principal branches. This trunk, formed of much smaller and denser epithelial elements than the preceding, of conical, oval, tapering cells and of longer or shorter fibriUse and fibres, is hard and resistant although sometimes very vascular and penetrating more or less into the tissue from which it has arisen (the border of the lip, its external or internal surface) and in which it is inserted by a more or less broad base. It is this portion (the root of the vegetating pro- duct) which must be destroyed as deeply as possible, at first with instruments or the cautery, afterwards with caustics (arsenical paste) so as to avoid fresh vegetation of the epithelioma. In order to use all the precautions which prudence suggests, supposing the cauliflower 10 UTERINE DISEASES IN DETAIL tumour is very large, I try to constrict the pedicle behind the vegeta- tion by an elastic ligature. This produces ulceration of the trunk, or at least the vegetations fall rapidly, leaving bare the trunk from which they rose, which is of denser tissue. It is this portion that must be completely removed if we would avoid a recurrence of the disease. In order to succeed with as little pain and haemorrhage as possible we should amputate the whole cervix (if it is the whole cervix which forms the base of the tumour) by means of the galvano-caustic wire, or else excise the root of the disease Fig. ."^SS. — Excision of a cancerous tumour of the anterior lip of the cervix bj the actual cautery, s, a boxwood speculum, depressing the posterior vaginal wall ; P, tenaculum forceps seizing the tumour ; c, cautery excising the tumour, hollowing out the tissue of the anterior lip in order to reach the extremity of its root. (usually inserted in one of the lips) with curved sharp cauteries or with the curved knife of the thermo-cautery (Collin has made a thermo-cautery knife for me which has a curve fitting it for this little operation). The vagina is protected by means of univalve boxwood specula. The tumour is then seized by tenaculum forceps and inclined in various directions, so that its root may be separated from the healthy tissue as deeply as appears necessary by means of a cautery in the form of a straight or curved knife. The third part of the operation consists in directing the cicatrisation of the ulcer which follows excision of the root of the cauliflower, and to attain this end CANCER 711 no preparations seem to me so good as those of arsenic, Fowler^s solu- tion or Friar Gome's powder : these should be employed with great care, for if too much is used at once poisoning may be produced.^ Is surgical intervention impossible for epithelioma of the uterine cavities? Whilst admitting that it is far less effectual than in the pre- ceding case, I do not think it should be neglected. "When epithelioma is developed on the mucous membrane of the fundus, surgical intervention ought to be confined to dilatation of the cervix with sponge tents, scraping with the curette and the apphcation of soHd or liquid caustic to the abraded surfaces. When epithelioma is developed on the mucous membrane of the cavity of the cervix, especially when it assumes the form of cauliflower excrescence, we may hope to destroy it even if forced to incise one of the lips of the uterus, especially the one that is healthy and distended by the development of the diseased segment. II. Palliative treatment. — 1. General palliative treatment consists in giving tone to the organism and in subduing nervous symptoms, especially pain. — The physician ought to initiate an intelligent, ener- getic and continuous struggle between the lesion which attacks and the organism which defends itself. The best means for restoring the con- stitution and so enabling it to resist the progress of cancer as much as possible are : residence in the country, generous diet with plenty of milk and the use of the medicaments which I have indicated as suit- able to the treatment of tne accompanying dyspepsia : bitters, bark and iron. — The nervous symptoms and paroxysms of pain should be treated by antispasmodics or narcotics : preparations of hemlock, hen- bane, belladonna, Indian hemp, opium and the different salts of morphia alone or combined with ether and administered by the mouth, or subcutaneously ; sedative embrocations with the oil of henbane or belladonna either alone or mixed with chloroform ; laudanum in small rectal injections given with a long cannula ; linseed poultices made with the infusion of poppy-heads ; sitz-baths and even general baths containing decoctions of poppy-heads, henbane or hemlock leaves ; suppositories containing gr. \ of the extract of belladonna and an equal portion of the extract of opium, which the patient may intro- duce into the rectum every 24 hours or oftener. Vaginal pessaries of iodoform (15 grains made with cacao butter"), &c. The poultices, sitz-baths or general baths ought to be hot or tepid. 2. Local palliative treatment consists in the use of resolvents, hemostatics and disinfectants. The resolvents are : mercurial and belladonna ointment or an ointment composed of equal parts of the iodide of lead and potassium applied by friction to the hypogastrium and groins. Eesolvents may also be apphed to the cervix in the form of plasters of hemlock and tampons saturated with strong solu- tion of chlorate of potassium (said by Bergeron to be effectual in epi- ' Traitement palliatif clu cancer de V uterus. Communication made to the Association for the Promotion of Science in France, 27 August, 1877. Gaz. hebdomadaire de medecine et de chirurgie, Sept., 1877. ^ Greenhalgh, Eastlake {Obstet. Soc. of London, 1866 ; British Med. Journ., 1866) ; Demarquay {Bulletin de Therapeutique, 1867) ; G. Wolker (id., ibid.). 712 UTERINE DISEASES IN DETAIL thelioma of the lips). These local applications prepare the tissues for the direct and energetic action of other medicaments ; the latter espe- cially seems to soften the pathological tissue and facilitate its subse- quent destruction. — Hemostatics are useful in preventing patients from being weakened by Ifemorrhage. The tincture of cinnamon, ergot and the various hemostatic waters may be given internally, or 12 gr. of tannic or gallic acid may be given every 4 hours, or rhatany, catechu, or 5 to 20 drops of perchloride of iron twice a day in a little water, followed by a cup of milk. — As for the local application of hemostatics, injections should be made with vinegar and cold w^ater or with perchloride of iron (5iss to the quart of water) or with infusion of matico or oak-bark ; or perchloride of iron may be applied undiluted after having washed the ulcer well with injections of cold water, taking care to remove all that remains of the perchloride with a little cotton wool.^ Indirect means of hemostasis should also be em- ployed, such as semi-flexion in a horizontal posture, very hot injections morning and evening, absolute rest during menstruation, moderate exercise in the intercalary period, the interruption of marital inter- course, milk diet, &c. Tlie daily use of disinfectants is indispensable. In addition to baths vaginal injections should be prescribed morning and evening, in order to expel the ichor of the cancerous surfaces as well as the decomposed debris. — Sedative injections have very little effect owing to the very slight absorbing power of the vagina ; this defect, however, is compensated for by the facility of applying narcotics to the rectum, and the same remark applies to medicated pessa- ries. The only injections that are of any use are those that are disinfectant and detersive ; they should be made with very hot water, to which is added a spoonful of the solution of permanganate of iron or potassium (1 per cent.) or carbolic acid. Some patients find aromatic injections useful. After the injection the diseased surface may be touched with one of the following medicaments : creasote, chromic, boracic or carbolic acid, perchloride of iron, solution of tannin, concentrated solution of nitrate of silver (10 per cent.) or Fowler's solution. They have the effect of preventing the exudation of blood, of coagulating lymph and albumen and contracting the tissues ; in fact of tanning the surface of the tumour to a considerable extent, as they can be applied with a brush to the interstices and infractuosities of the cancerous excrescence ; the result is a superficial desiccation of the tumour or ulcer, and sometimes the course of the organic altera- tion is arrested. I have found these local applications of great use associated with other local and general means ; they make the cancer tolerable till the period of cachexia arrives ; in fact this treatment may prolong life when the cancer has not a very progressive tendency and when the corroding ulcer is not very extensive. I will end this chapter by a few words on the course to be pursued during gestation or labour. If we have reason to hope that the life of ' Siiris's speculum sliould be used, the patient being in the elbow and knee position, which is the most convenient for dressings in cancerous diseases. CANCER 713 the patient may be prolonged, whilst the disease is such as to render delivery dangerous, we may produce abortion or premature delivery ; if not we should wait. If labour has commenced we should wait till expulsive efforts have become ineffectual ; if after a certain time no part of the orifice Tior inferior segment is sufficiently dilated to allow of the passage of the child, deep incisions into the cervix and cervical canal are indicated, and in desperate cases Caesarean section may be necessitated (West, op. cit., p. 410). CHAPTER V DISEASES OF THE UTEBrNE APPENDAGES — PELVIC HJIMOBEHAGES AND PEBI- rjEBrVE HEMATOCELE — CYST OF THE OVAEY AND GENITO-PELVIC TUMOIJE — STEBILITT The number of diseases which remain to be described is reduced to three : 1, pelvic haemorrhages and hematocele which is often the consequence of them; 2, tumours of the ovaries and tubes, especi- ally ovarian cysts, in the description of which I have included not only ovariotomy but hysterectomy ; 3, sterility, the incurable causes of which must not be confounded with those residing in the vagina or uterus, which are more accessible to investigation and less difficult to treat. Pelvic H^moerhages and Peri-uterine Hematocele 1. Pelvic Hcemorrhages Haemorrhages which occur in the cavity of the pelvis may arise from different sources ; for the cavity contains, besides very vascular organs, important arterial and venous vessels. We shall confine our study to those which, having their starting- point in the uterine system in the state of vacuity, are capable of forming a tumour and of being produced under the three following conditions : absence of pregnancy, starting-point in the uterine system, sufficient quantity. With regard to the theories which have been expressed as to the origin of the extravasated blood, I shall make the following remarks : 1. The theory of Nelaton and Laugier (menstrual haemorrhage of the Graafian follicle and morbid vesicular haemorrhage^), has no founda- tion from a physiological point of view, since a Graafian vesicle may be ruptured without any discharge of blood, and morbid vesi- cular haemorrhage gives rise to passive effusions which are easily absorbed on the spot.^ ^ The exaggerated natural hsemoiThage of the Graafian vesicle may occur at the moment of dehiscence (Xelaton), or at repeated dehiscences (Laugier), or from the passive exudation which precedes or accompanies the formation in the vesicle of the corpus luteum. Morbid or pathological haemorrhage of the ovary is produced either in the vesicle or in the parenchyma (in the latter case it is called apoplectic, from its analogy with the haemorrhage which causes apoplexy). ^ Robert, Gaz. vied, de Taris, 1857, p. 1. — Pnech. De I'hematocele peri- uterine. Paris, 1861, p. 9. PELVIC HEMORRHAGES AND PERI-UTERINE HEMATOCELE 715 2. The theory developed by Gallard,^ who considers hematocele an extra-uterine dehiscence, an extra-uterine pregnancy without the product of conception, has by no means been proved. Where is the proof that the ovule determines hajinorrhage on falling into the serous membrane ? As to haemorrhage due to extra-uterine preg- nancy, it is possible though rare, the principal fact in such a case being the extra-uterine pregnancy itself, that is, Huguier's pseudo-heina- tocele. 3. Other writers, including Beau and Tardieu, think there is a sanguineous exudation from the serous membrane of the pelvis ; Perber^ has adopted this hypothesis, urging that some autopsies have revealed hyjjersemia and capillary vessels of new formation, and that it is nothing less than hsemorrhagic pelvic peritonitis (Virchow). 4. We have still another hypothesis to examine, that put forth by Bernutz in 1848 and again in 1860 ; he admits that the lumen of the cervico- uterine canal may be closed by an obstacle depending on the contractility of the uterus and that the blood may accumulate in the cavity of the body, after having dilated which it enters the Fallopian tubes and passes into the peritoneum. There is no doubt that the blood may follow this course when there is any obstacle, whether congenital or acquired, in the vulvo-uterine canal ; but it has not been proved that it may occur when there is none. If, on the one hand, the narrowness of the ostia uterina, their slight per- meability and the relatively large size of the cervico-uterine canal, are anatomical arguments which should not be forgotten, on the other hand we have no right to avail ourselves in the argument of what occurs in cases of atresia of the genital canal, that is to say in the conditions most favorable to the reflex tlieory, as Aran calls it ; Puech^ has proved that the fact is excessively rare; it only occurred 16 times out of 310 cases, and it never occurred suddenly; excruciating suffering was endured by the patients for several years before the blood invaded the peritoneal cavity."* Therefore pelvic hBemorrhages can only have their source in the Fallopian tube, ovary, utero-ovarian plexus, and in hsemorrhagiparous pachy-peritonitis. I. Hcemorrhage from the Fallopian tube. — Indicated by Tilt in 1850 and by Eenerly in 1855, tubal hgemorrhage has only taken its place in science with the works of Puech. A sufficient number of cases are recorded to prove that the Fallopian tube is far from pos- sessing immunity in this respect ; but in all these cases we may recog- nise as a preliminary condition sanguineous congestion of the tube, and although we know that the exanthemata, such as measles, small- pox, and scarlet fever, encourage hsemorrhages, as in the cases seen by Laboulbene,^ Helie,^ Scanzoni"^ and Puech, we are inclined to ^ Gaz. hebdom., 1858, p. 481, Archives de Medecine, 1860. * Arcliiv. der Heilkicnde, 1862, 8th year, part 5. ^ Des atresies desvoies genitales. Paris, 1863, p. 61. ■* See p. 279, chapter on Retention of the Menses. * Gaz. med. de Paris, 1853, p. 78. ® Journal de medecine de la Loii'e-Inferieure, 1858, p. 30. 7 Op. cit., p. 363. 716 UTERINE DISEASES IN DETAIL admit that there is always acute fluxion or congestion. At other times, on the contrary, we find in the previous history symptoms of chronic sanguineous congestion, Bernutz's first case being a typical example.^ Whatever be the cause which has produced it, the haemorrhage may make its way either by the ostia uterina, by the abdominal opening, or by rupture of the organ. The discharges of blood from these different points are sometimes simultaneous and sometimes isolated ; if they escape notice when the fluid is discharged by the first exit, it is otherwise when the blood escapes by the latter channels. The patient suffers pain in the lumbo-sacral region, and has colics suc- ceeded by syncope and a feeling of weakness. Sometimes these with paleness of the face are the only symptoms, at other times, when the hsemorrhage endangers life, the pains are more violent, and there is vomiting, hiccough, buzzing in the ears, abdominal distension and cold sweats, soon followed by death. When on the contrary the hgemorrhage is not great enough to cause this result, as seen by Follin,^ Oulmont,^ Seuvre,* and othersj a peri-uterine sanguineous tumour is formed. II. Ovarian hemorrhage. — These haemorrhages are frequently described.^ Here also a marked alteration of the ovaries exists pre- vious to any haemorrhage ; apart from a case mentioned by Neuman, of Berlin,^ in which hydatids were found, acute inflammation and chronic congestion are the lesions which have been more specially noticed. In acute inflammation the size of the organ is increased, the colour is violet, and on section the blood gushes out, the cut surface showing considerable hypersemia. In this state the tissues can neither resist nor be distended ; they are easily ruptured, as remarked by Denonvilliers'^ and Demarquay.^ Chronic congestion is, I believe, the most active cause of these haemorrhages. The ovary is increased in size, its outline is normal, but the stroma is hyperaemiated, presenting slight effusions of blood. As a rule this state is only manifested externally by excessive menstruation ; at other times there is a sen- sation of weight and burning heat in the pelvis, draggings in the kidneys and groins, and colics, which are sometimes very acute, before menstruation. Menstruation, besides being too abundant, is ])rolonged more and more, leaving each time a marked aggravation of the congestive phenomena. In this state accidents are imminent, and menstruation is sometimes sufficient to produce haemorrhage; but it does not follow that there is a relation of cause and effect between 1 Nouveau Diction, de mcd. et de chiriirg. iiratiques, article Hematocele TiTEKiNE, t. xvii, p. 310, fig. 29. In this figure a clot is seen emerging from the P'allopian tube. ' Gaz. des hopitaux, 1855, p. 403. ^ Union medicale, 1858, p. 530. * Progres medical, 1874, pp. 815, 224. •^ Nouveau Diction, de med. et de cJdrurgie pratiques, article Hematocele UTERINE. ^ Bibliotheque medicale de Boyer-Collard, i. Ixxviii, p. 113. 7 Gaz. med., 1856, p. 7(5. * Gaz. dea hopitaux, 18G2, p. 21. PELVIC HJIMOREHAGES AND PERI-UTEEINE HEMATOCELE 717 the peri-uterine hematocele which may be developed afterwards and menstruation ; disorders of this function are only the index of the concomitant state of the uterine system. At other times the sym- ptoms are those of acute sanguineous congestion, apoplectic haemor- rhage occurring in the midst of apparently perfect health ; only in such cases fluxion is more active and the alflux of blood more con- siderable. Whether the ovary is healthy or otherwise the hgemorrhage may be intra-ovarian only, or both intra and extra-ovarian ; whilst in the interesting case published by Puech intra-ovarian hsemorrhage was followed, four months afterwards, by fresh congestion, which on this occasion ruptured the membrane, causing death by peritonitis. If symptoms of intra-ovarian haemorrhage often escape notice, or at least are misinterpreted, it is very different when haemorrhage occurs in the pelvis ; in such cases we either see the signs of inter- nal haemorrhage which soon ends fatally, or the physical signs which characterise sanguineous tumours of the pelvis. III. Hcemorrh age from the iitero- ovarian plexiis. — Although analogy would seem to indicate the possibility of rupture of the utero-ovariau plexus, this source of haemorrhage has been slow in taking the place to which it is entitled. In vain two cases of it were published in 1S53 and 1854, even in 1857 it was in vain that Eichet brought ' forward a new argument in support of the fact,^ attention was directed elsewhere, and it was only in 1858, in the works of Puech ^ and Devalz,^ that these venous lesions obtained the rank that they deserve as causes of pelvic haemorrhage. This rupture may be followed by extravasation of blood under the peritoneum, and between the folds of the broad ligament (Raciborski), by a simple intra-pelvic thrombus or by a more considerable haemorrhage and a more or less abundant san- guineous effusion into the pelvis. It affects the pampiniform plexus whether varicose or not. Doubtless the nodosities presented at inter- vals by the varicose veins and the attenuation of their walls favour this accident ; but unfortunately these conditions are not indispensable for its production : severe exercise, or external violence, sexual excite- ment, or great menstrual fluxion, or the concurrence of these two last circumstances may cause the malady. The haemorrhage which occurs is more or less violent ; in twelve cases it caused death rapidly;^ in others, amongst which Saexinger^s case may be included,^ it was fol- lowed by the formation of a peri-uterine hematocele.^ lY. Hemorrhages from hcemorrhagiparous pachy -peritonitis. — Bes- nier has tried to furnish additional proofs of this theory in a long 1 Anai. med.-chinirg., 1857, p. 735. '- Op. cit., pp. 80—100. ^ Du varicocele ovarien. Paris, 1858. •* In the case recorded by Maschka death was caused by the rupture of a varicose vein attached to the fundus of the uterus {Wiener Medieinische Wo- chenschrift, I860, No. 102). * Monatschriftfth- GebiirtsJc., 1864, Bd. xxiii, S. 476. ^ Of the four sources of hematocele, this and the following may coincide with regularity of the menstrual function. 718 UTERINE DISEASES IN DETAIL paper published in 1877 in the Atiuales cle Gynecologie, the conclu- sions of which are : *'l. Amongst intra-peritoneal hematoceles there is one which com- mences with primary or secondary pelvic peritonitis, either menstrual or inter-menstrual, which is benignant or moderate on its appearance, and increases progressively or by fits. In this form of hematocele, which is very diti'erent from those which commence suddenly and violently and end fatally, the tumour, which is but a pathognomonic sign of the affection, is only verified at a late period relatively to the commencement of the symptoms, and as a rule the termination is favorable. 2. The cases included in this group cannot be regarded as hematoceles connected with dehiscence or extra-uterine pregnancy, nor with an ovarian lesion, nor with a sanguineous reflux by the tubes, nor with rupture of the tubo-ovarian veins, &c. ; they ought to be considered as hematoceles due to pelvic neo-raembraues. Taken as a whole these maladies are therefore cases of peritonitis which have become hemorrhagic accidentally or secondarily, otherwise called hcemorrhagic pachy- peritonitis. 3. From a clinical point of view, these cases being the most numerous of all, as we may say they are the only hematoceles which end in cure, it follows that ordinary intra-peritoneal hematocele terminating favorably is, in most if not in all cases, a hemorrhagic pachy -peritonitis, either menstrual or inter-menstrual, usually the former, that is to say, having commenced at a menstrual period.'" I do not deny the possibility of hsemorrhagiparous pachy-peritonitis. I admit this new source of hematocele by analogy with neo-membranes developed on other serous membranes (meningeal, vaginal, synovial, &c.) and giving rise to loss of blood ; but I am far from regarding it as the most frequent, as this would imply in all cases the existence of previous peritonitis, slowness of the sanguineous effusion and a number of other circumstances totally opposed to most of the sym- ptoms on which we found the diagnosis of hematocele. Besnier's case moreover does not seem absolutely decisive ; no autopsy, abortion preceding the hematocele, rapidity in the invasion of the attack and in the symptomatic manifestation, in short, nothing justifying the asserted slowness of invasion and symptomatic obscurity of the com- mencement. ]\Iy own conclusion is that; of the various sources of sanguineous effusion which can account for the formation of peri- uterine hematocele, four only may be considered as proved by autopsy. These are, in order of frequency : apoplectic haemorrhage from the ovaries, hsemorrhagic pachy-peritonitis, rupture of one of the vessels composing the utero-ovarian plexus and tubal hsemorrhage. These hemorrhages terminate either fatally, or by absorption of the extrava- sated blood, or by the formation of a sanguineous tumour (hematocele, hematoma). In the latter case the hemorrhage is the cause, the hematocele the effect ; but the effect becomes in its turn a malady, having its symptoms, its course, its termination, its indications. PELVIC HJ]MORRHAGES AND PERI-UTERINE HEMATOCELE 719 2. Peri-Uterine Hematocele Hematocele'^ is an encysted tumour developed round the uterus and formed of blood proceeding from the lesion of one or two of the appendages, or from a cyst of extra-uterine pregnancy, from a rupture of the utero-ovarian plexus, or from the peritoneum itself, more frequently from a chronic inflammation of this serous membrane with thickening and vascular hypertrophy. The various sources of haemorrhage explain the seat of the effusion, and the frequency of this seat in any particular spot is the consequence of the frequency of the hemorrhage at that point. Therefore whether the haemorrhage come from the ovary, from the Fallopian tube, from Pig. 389. — Typical retro-uterine hematocele (intra-peritoneal) caused by ruj^ture of a diseased ovary, a, Iiematocele ; u, uterus pushed forward ; e, rectum compressed behind (St. Thomas's Museum, Barnes). an extra-uterine pregnancy or from pachy-peritonitis, the sanguineous effasion must take place into the peritoneal cavity (which is the most common case), preferably behind the uterus, where the serous mem- brane is most developed ; the ovaries are also to be found there and the Fallopian tubes always directed backwards and never forwards (on this account hematocele is more frequently retro-uterine than peri-uterine). This rule is so general that ante-uterine hematocele is considered as being only secondary, formed only as a consequence of the peri-uterine or retro-uterine hematocele which has preceded it, the continuation of "which has become impossible owing to adhesions and fibrous bands ^ Poncet of Jjjons, De I'hematocele peri-uterine. These d'agi'egation. Paris, 1878. 720 UTEEINE DISEASES IN DETAIL uniting the uterus to the rectum and sacrum so as to prevent the con- tinuation of any sanguineous effusion into Douglas's space. Such is the case published by Schroeder in Wiener Medicin. Wochenschrift, 1873 ; and in Archlvfur Gi/n., 1873. If the haemorrhage come from the tubo-ovarian plexus the hemato- cele may be limited to a thrombus of the broad ligament or be in- sinuated under the peritoneum covering the uterus, in the peri-uterine cellular tissue, not only behind and in the broad ligament of the other side, but also in front under the peritoneal fold which covers the an- terior wall of the uterus and bladder. These sanguineous effusions Fig. 390. — Lateral and ante-uterine hematocele (intm-peritofleal), due to utero-rectal adhesions in Douglas's space, where the hematocele, which at fii-st was retro-uterine, was first produced, aaaa, solid blood and adhe- sions ; h b, fluid blood ; d, extra-uterine tubal pregnancy, cause of the hematocele ; from Schroeder (Archiv.fur Gtjn., Bd. v, S. 357. Berlin, 1873). into the broad ligament and peri-uterine connective tissue have been well uamQd peri-7iferi7ie Jiematomata by Kuhn (These de Zurich, 1874), a name which distinguishes this sanguineous tumour from hematocele which is in the peritoneum and from hematometna which is in the uterus, a name very preferable to that of extra-peritoneal or vaginal hematocele, by which it was formerly designated. The blood is gra- dually absorbed and the most frequent termination is in cure. The prognosis, however, is jnore unfavorable than in the case of hemato- cele, for this reason, that the opening of the tumour into the peri- toneum is very dangerous, usually causing death. I copy a figure (from Emmet) of a very rare case of such a hematocele or hematoma formed in the right broad ligament and in front of the bladder, which caused death by its rupture into the peritoneum (Fig. 392). Whatever be the source of the hseniorrhage and wherever the blood may be effused it is not long before it undergoes certain modifications PELVIO HEMORRHAGES AND PERI-UTERINE HEMATOCELE 721 producing around it an interesting pathological process. The blood, which at first is liquid, soon coagulates into more or less voluminous resistant clots, the presence of which irritates the serous membrane with which it is usually in contact; false membranes are produced; some which are filamentous pass above the sanguineous mass, others resembling bands of cellular tissue divide the collection by forming partitions through it. At other times there are no fibrous adhesions but a kind of membranous covering, which, spreading like a sheet, seems to form a continuation of the peritoneum and has frequently been taken for it. In other cases this is absent and the intestinal loops, united and glued together, constitute the upper wall of the cyst. When the adhesions are detached we penetrate into a winding sac sometimes containing from 7 to 77 ounces of a wine-coloured viscous fluid holding dark clots in suspension, or when the malady is of longer standing a yellowish or more or less discoloured fibrinous mass. The bladder, rectum and upper extremity of the vagina are compressed ; when there has been suj)puration and evacuation of pus the walls of the rectum or vagina are perforated, either simultaneously or singly. The uterus, dragged down by adhesions and inclined to the right or left, has in some cases effected rotation on its axis, in others it is Fig. 391. — Sub-peritoneal latere and retro-uterine hematoma or hematocele (extra-peritoneal) formed in the broad ligament. The posterior vaginal wall was still more pushed forward (after Emmet). inclined forwards or backwards without being fixed in its position. As it usually shares in the congestion of which the annexes are the seat, it is more frequently increased in size ; its walls may be softened and in- filtrated with blood, the cavity containing either mucous or sanguineous clots. The annexes are more or less changed : if there are cases in which we can discover the source of the lipemorrhago, there are others in which 46 722 UTERINE DISEASES IN DETAIL we can only guess at it. Thus the ovaries, or at least one of them, may be reduced to a shell; at other times they are hypertrophied and hollowed out into a cavity communicating with the principal centre. In other cases or even simultaneously the tubes have their fimbriated extremity and canal partly obliterated; or else they are diseased, containing de- composed blood or presenting a dilatation which constitutes a part of the centre of the tumour. Besides these lesions we find others dependent on the general- ised peritonitis or on purulent infection. In the former case the abdominal viscera bear the more or less marked impress of in- flammation. The intestines are shortened sometimes to half their length, whilst some circumvolutions are drawn together and united by false membranes. Sometimes the abdominal cavity is dis- tended by a yellowish serum or by a milky fluid mixed with albumi- nous flakes ; sometimes there is hardly any effusion, but the roughened serous membrane presents patches of a blackish hue ; lastlv, if the cyst has been perforated and the contents have escaped we may find a portion of this fluid poured out into the peritoneal cavity. As to purulent infection it leaves behind it well-known lesions on which it is needless here to dwell. Fig. 392. — Sub-peritoneal ante-uterine hematoma or hematocele (veiy rare) opened by laceration or ulceration into the peritoneum, where the blood has been effused and has formed an intra-peritoneal peri-uterine hematocele which was the cause of death (after Emmet). Diagnosis — subjective signs. — Peri-uterine hematocele being a hae- morrhage followed by peritonitis we should find in its first stage the characteristic symptoms of internal hcBmorrJiage : they exist in fact ; but as they are obscure they generally escape observation. The period which follows and of which the features are borrowed ixova peritonitis, PELVIC HiEMOEEHAGES AND PEEI-UTEEINE HEMATOCELE 723 is more marked, although it does not oflPer any very striking symptoms : hence the possibility of committing errors of diagnosis. Pain is the first phenomenon which shows itself : it is constant, but it varies greatly in intensity. It is sometimes manifested under the form of intestinal colics, sometimes under that of expulsive pains. It is often remittent, but is aggravated by the least pressure or by the slightest movement. Disorders of the digestive economy are intimately connected with these pains : when the latter are intense there is nausea and vomiting ;^ if they are moderate there is frequently want of appetite. Thirst is generally great, the abdomen is more or less distended, and there is usually obstinate constipation, anal and sometimes also vesical tenesmus, and even retention of urine. When the tumour compresses the crural and sciatic nerves radiating pains and numbness are observed in the lower limbs. (Edema has also been seen in addition to the preceding symptoms, affecting either the side corresponding to the largest portion of the pelvic tumour or the opposite one ; in the former case it would be due to impeded venous circulation, in the second to phlebitis of the corresponding veins. Fig. 393. — Peri-uterine hematocele spreading uniformly round the uterus, which has hardly undergone any displacement. Owen's case, University College Hospital, 1866. Front view (after Graily Hewitt). Objective signs. — The seat of pain and the distension of the belly attract the attention of the physician to the hypogastric region and enable him to verify the existence of a peri-uterine tumour. Sometimes it is diagnosed immediately on account of the projection and the size which it presents ; at other times it is only discovered after careful palpation. Two tumours are then found in the pelvic cavity : the anterior one is the uterus, the other, posterior and more or less lateral, is the morbid tumour, the hematocele. The size of the latter varies from that of an apple to a child^s head. It is usually confined to the pelvis, but may rise above the brim towards the umbilicus ; I do not think, however, that it ever rises beyond the navel : observers who have mentioned such cases have ' There may even be symptoms of internal strangulation as Hergott has remarked ; they seem caused by an anomaly of the sigmoid flexure (ikfem. Soc. met. Strasbourg, 1872, p. 149). 724 UTERINE DISEASES IN DETAIL forgotten to take into account the inflammatory zone, which has led them into error. As to the consistency of the tumour, it may be Fig. 394. — Intra-peritoneal peri-uterine hematocele, seen in profile, spread uniformly round and above the uterus, which has not been displaced at all (after Emmet). fluid and fluctuating ; but unless it suppurates it becomes solid, hard and immobile. Diagnosed in the abdomen by hypogastric pal|)ation, in the pelvis the tumour is defined by vaginal touch ; it is found behind and at the sides of the uterus ; in three cases it extended in front of this organ ; in a case published by Chassaignaci it was situated entirely between the bladder and uterus. Usually it pushes down the posterior cul-de-sac, contracting the vagina. Eectal examination reveals the compression which it exerci; The Lancet, Dec, 1849, Feb., March, 1850. ' The seat of ovarian tumours is according to Chereau, out of 215 cases, 109 to the right, 78 to the left, 28 on both sides. Lee, „ 93 „ 50 „ 35 „ 8 Scanzoni, „ 41 „ 14 „ 13 „ 14 „ West, „ 92 „ 35 „ 38 „ 19 BlofE, „ 54 „ 31 ., 23 „ OVARIAN CVSTS 7-U dominal cavity are distended to their utmost limits. Ai other tiiries the increase of the tumour is intermittent, the fits of development often corresponding with the menstrual period. The compression of neighbouring organs, whether in the pelvic or abdominal cavity, gives rise to new symptoms. The bladder being at first compressed on a level with the cervix, and afterwards pushed against the pubis, or raised upwards towards the abdomen, there is at one time dysuria, vesical tenesmus and retention, and at another incontinence of urine. If the ureters themselves are compressed the catheter is powerless, and the urine accumulates in these excretory canals which become enor- mously distended. Compression of the intestines often causes con- stipation and occasionally alternations of constipation and diarrhoea; but I have seen many patients in whom the bowels acted regularly owing to the fact that the sigmoid flexure and rectum experienced but slight compression from the tumour, as it had risen into the abdomen ; on the other hand compression may be strong enough to determine intestinal occlusion^ and stricture of the rectum. Compression of the intra-abdominal vessels causes dilatation of the superficial ab- dominal veins, which form blue networks under the skin to take the place of the deep venous circulation, oedema of the vulva, especially of the labia majora, more rarely oedema of the lower limbs and ab- dominal walls and, more rarely still, ascites. Pressure on the sciatic nerve determines a pricking sensation, pulsating, darting pains shooting down the thigh of the diseased side. The phenomena of compression of the pelvic organs are manifested especially at the beginning, when the cyst is contained in the pelvis ; in proportion as it rises and as the utero-ovarian pedicle is elongated, these phenomena disappear, and it is on this account that we often see the lower limbs emaciated and wrinkled, and forming a singular contrast with the enormous disten- sion of the belly. 1 have even seen cases in which the excavated form of the tumour behind (owing to a movement of torsion effected by the ovary in the first period of the development of the tumour) allowed the large vessels in the abdomen to escape all pressure. Lastly, at the most advanced period the effect of the compression exercised by the cyst is felt especially by the thoracic organs, disturb- ing respiration and the cardiac circulation. Menstruation is variable. In some patients the appearance of the tumour is preceded by menstrual disorders (according to Scanzoni, .37 times out of 57); after the cyst is developed it may seem to exer- cise no influence on the regularity of the monthly period, especially if one ovary remains normal; it sometimes is accompanied by metror- rhagia, more frequently by dysmenorrhea or amenorrhcca ; the per- sistence of the cystic tumour does not prevent the menopause from being established normally ; the definite increase of the cyst and the cessation of the catamenia seem in a few patients to be two concurrent phenomena. When the menses cease completely from the commence- ment of the malady we may suppose that there is some serious disorder, i. e. a cancerous or other degeneration of the tissue of both ovaries ; ' CViiveilliier, A)ud. luiUi. (/en., iii, p. 112. 742 UTERINE DISEASES IN DETAIL for the menses continue even with cjsts in the two ovaries if any portion of the organs preserves its normal structure and is able to perform its functions. It is impossible for so large a tumour to distend the abdominal cavity without the general health suffering greatly ; therefore, although some patients only succumb after repeated punc-= tures, and after carrying the tumour for more than twenty years, there are others in whom the cyst reaches an enormous size in six months, weighing 55 lbs., and rapidly ending fatally. The average duration Fig. 409. — " Fades ovariana," from the pliotograph of a patient of 42 who had a compound ovarian cyst, operated on and cured hy Spencer Wells. Fig. 410. — External aspect of the ab- dominal tumour formed by a multilocular ovarian cyst in a woman of 32 (ovariotomy, cure, birth of a child 15 months after- wards). (After Spencer Wells.) of life is from two to three years. The tumour injures the con- stitution in three ways : by the mechanical obstacle it opposes to the movements of the organs, to their circulation and to the accom- plishment of their functions ; by the irritation or sympathetic dis- orders which it occasions in others ; lastly, by the change of direc- tion given to nutrition, the growth of the cyst and the increase in its secretion taking place at the expense of the general assimilation throughout the system. The alteration in the general health is especially noticeable in young women and when the tumour is rapidly developed. Without speaking of such complications as inflammation of the cyst, secretion of pus, OVARIAN CYSTS 743 &c., which greatly accelerate the course of the disease, we may say that in such cases digestion is difficult and slow, the intestines swell, respiration is impeded, especially after meals ; circulation is not per- ceptibly affected, there is little or no fever, but the difficulty which the blood has in circulating through the large vessels causes a small and frequent pulse, palpitations and a tendency to syncope. Under the in- fluence of these disorders of the principal functions, of their reaction on the nervous system, of the anaemia which results, and of the attraction exercised by the cyst on the elements of nutrition, increasing emaciation is produced. The lower extremities when not (Edematous acquire a dryness and spareness contrasting with the infiltration to which they are subject in the case of ascites ; the hands and arms become thin; the chest and neck contrast by the angular projection of their bones with the spheroidal tumefaction of the upper portion of the abdomen ; the face, too, is affected by this general emaciation ; it becomes wrinkled, the lips are pinched, the nose pointed, the eyes sunk, all the features acquiring the look of premature old age, although the still brilliant eye shows that vitality is stifled by the de- velopment of a parasite rather than disorganised in its constituent elements. This appearance differs considerably from that which cancer, chlorosis, chloro-ansemia, and even recent delivery and uterine diseases impart to the countenance, so much so that Spencer Wells has designated it by the name of '' facies ovariaua " to contrast it with the " facies uterina" which I have already described. Objective signs. — Palpation must be combined with vaginal and rectal touch in order at the beginning to be able to diagnose in the pelvis the presence of a tumour which is often indolent, varying in size from that of a nut to that of a foetal head; round, resistant, but depressible and elastic, or soft and fluctuating, escaping from the grasp of the fingers, mobile in several directions, pushing the uterus for- wards or on one side, and compressing the rectum more or less. When the cyst is situated above the brim it increases the size of the belly. This symptom seems to strike the patient less than the phy- sician, wheu the tumour is indolent; but the increased size of the abdomen as ascertained by measurement, the form of the tumour, the results furnished by palpation, percussion and touch, leave no doubt as to the origin and nature of the malady. The abdomen is not only tumefied but altered in its form. In place of being distended in every direction as by ascites it is manifestly raised by a globular tumour, recalling that of the gravid uterus, but sometimes nodulated instead of simple, less central, less inclined to the right, commencing usually on one side and directed towards the hypogastrium, making the abdomen project in its median portion where it yields more than elsewhere, and rising towards the epigastrium or hypochoudrium. Ovarian cysts may acquire an enormous size, filling the whole belly and distending the envelopes and skin excessively, producing streaks and vibices and describing broad blue undulating lines due to the dis- tension of the subcutaneous veins, descending in front of the thio-hs to the knees and pushing the false ribs and xiphoid cartilage of the 744 UTERINE DISEASES IN DETAIL sternum upwards and outwards, weighing as much or even more than the patient herself. I have seen some which measured more than two yards in circumference, and from which I extracted thirty quarts of fluid.i The density of this fluid being greater than that of water and the weight of the cystic envelope and of the tumours adhering to it varying from eleven to thirty-three pounds, we can judge of the enormous weight which the presence of such a tumour adds to that of the patient, which emaciation sometimes reduces below 110 pounds. The weight of the tumour has been known to exceed 165 pounds (Kimball). Palpation discovers the size and limits of a round tumour, occasion- ally nodulated, regularly circumscribed, usually indolent; sometimes mobile, being easily displaced under the combined influence of palpa- tion and change of posture, falling to the most dependent side ; some- times retained in one of the iliac fossse or towards the upper portion of the abdomen ; usually tense, seldom depressible or soft ; however mobile, fixed in the pelvis by a more or less loose pedicle ; difficult to circumscribe and still more so to move when it completely fills the abdominal cavity and distends the cutaneous envelope excessively. Palpation often enables us to verify the simultaneous presence of solid tumours and of an encysted fluid by the difference in consistency, hardness, or resistance. On percussion dulness is perceived through- out the whole extent of the tumour, at its summit, at the apex of the belly if the patient is lying, as well as near the pubis and iliac fossfe. There is tympanitic resonance in the posterior portions, in the flanks, towards the loins, in the epigastrium and in the hypochondriac regions, especially on the left side. The dulness does not change per- ceptibly on the patient changing her position. Fluctuation should be carefully sought for. It is well marked when the cyst is large, serous and unilocular ; in other cases it is obscure and may even be absent. Sometimes in trying to discover fluctuation the displacement en masse of the contents of the cyst is perceived, pushed back by one hand of the examiner towards the other ; but what Cruveilhier calls the choc par contre-conp is not perceived ; that is when the contained matter is soft rather than fluid or when there are several contiguous cysts. At other times we perceive very distinctly this choc par contre- coup, i.e. the result of the molecular disturbance produced by very rapid percussion suddenly imprinted on the point diametrically oppo- site that on which the hand is placed ; but this shock can only be felt at short distances, the undulation is shut off" (multilocular cysts), or it is perceived from one i)ole of the tumour to the other (unilocular cysts) ; sometimes a multilocular cyst with one large predominating cyst is diagnosed in this way. Vaginal touch (which when necessary should be followed by rectal touch), either alone or combined with palpation and percussion, enables us to diagnose deviations and even displacements of the uterus, ' I have recently extracted nearly 50 quarts from an enormous cyst, which I have reason to suppose was developed from the broad ligament, for the transparent, serous, slightly yellowish fluid did not coagulate on boiling. OVARIAN CYSTS 745 sometimes ascent, sometimes prolapsus, at other times compression towards the pubic symphysis and anteversion, more frequently a lateral or posterior inclination,' and a certain degree of torsion. It is impor- tant to determine at the same time whether the uterus is mobile; this mobility depends on the variable length of the pedicle of the ovarian tumour formed by the Tallopian tube and the peritoneal fold enclosing the ovarian vessels and nerves. Vaginal touch also reveals the pre- FiG. 411. — External aspect of the abdominal tumour formed by a compound ovarian cyst in a woman of 34, complicated with ascites, dilatation of the subcutaneous veins, impossibility of sleeping except in a chair, &c. (ovari- otomy and death the fifth day). After Spencer Wells. sence of the cyst in the pelvic cavity when the tumour is as yet but slightly developed, or when it presents prolongations and inequalities on its lower portion. In other cases it hardly allows of our reaching the cyst, or only when pressure of the other hand on the abdomen pushes down the cyst and enables the tip of the finger to perceive its rounded surface, and to recognise its resistance, depressibility and fluctuation. It also enables us to form au opinion as to whether the cyst is in the right or left ovary, according to whether the uterus inclines to right or left. The sound will help us to judge of the mobility of the uterus, of the length of the pedicle, of the presejice or absence of adhesions between the cyst and the uterus, &c. Auscultation furnishes valuable indications as to the presence of vessels in the pedicle or in the broad ligament in front of the tumour in consequence of torsion, enabling us to avoid wounding them by puncture. It also enables us to perceive the vibrations resulting from friction of the tumour against the parietal peritoneum due to the absence of adhesions, whilst in other cases it allows us to hear a rougher and more or less extensive friction, coinciding with a thrii. (falsely attributed to hydatids) caused by inequalities produced on the ^ According to Boinet, the cervix is always puslied to tlio o]iposite side from the cvst. 746 UTERINE DISEASES IN DETAIL serous membrane by an inflammation which has only developed partial adhesions more or less distant from each other. Differential diagnosis : 1. Oiker tumours which may he confounded with ovarian cysts. — 1. Amongst pelvic tumours parovarian cysts of the broad ligament are developed more slowly, are smaller, are hardly ever adherent, may be enucleated from the peritoneum, the two folds of which cover them and contain a limpid, slightly salt but never paralbuminous fluid, and never emaciate the patient so much as ovarian cysts. However, they also may become very voluminous, giving rise to errors of diagnosis.^ Peritoneal and subperitoneal serous cysts analogous to the preceding, with walls constituted by false membranes or a kind of ectasia of the lymphatic vessels, seldom attain a considerable size, contain albumen but not paralbumen and have sometimes a pediculated form.- As for other pelvic tumours I have described them sufiiciently when treating of ovaritis, tumefaction and inflammation of the tubes, dropsy of these organs, anteflexion, retroflexion, extra-uterine pregnancy, uterine tumours, especially fibromata, commencing pregnancy, hematocele, &c., to make it unnecessary to distinguish them here from ovarian cysts. 2. Amongst abdominal tumoiirs ascites is easily distinguished by the uniform distension of the belly, the absence of any tumour percep- tible to palpation, the marked tympanitic note at the summit of the abdomen with dulness in the dependent parts, the displacement of the resonance and dulness agreeing with change of position of the trunk, pelvis and abdominal cavity, the frequent oedema of the lower limbs or real anasarca, &c. Serous, purulent, or hydatid cysts or solid tumours of the abdominal walls, of the peritoneum, epiploon, mesentery, liver, spleen or kidneys are usually distinguished by the origin of the tumour, its initial seat above, in front, to right or to left, its develop- ment from above downwards, from one side to the other or from before backwards, instead of from below upwards, the possibihty of limiting the tumour beneath with the hand and of defining its lower outline, the absence of any pedicle or pelvic adhesions, verified by raising the pelvis and lowering the shoulders so as to make the abdominal organs weigh on the diaphragm and not on the pelvis, the independence of the uterus with regard to these tumours, an independence verified by digi- tal touch, and lastly, by the local or general symptoms manifested in the organ in which the abdominal tumour is developed. Nevertheless there are tumours the diagnosis of which is very difticult, all the more so that fluctuating tumours, encysted peritonitis,^ cysts analogous to ^ Arning of Hamburg successfully operated upon an enormous cyst of the broad ligament, taken by Spencer Wells himself for an ovarian cyst {Annales Gynecol., 1877). ^ Ka'berle (Gaz. med. de Strasbourg, 1876, No. 1). ^ Puistienne, Remarques et observations siir quelques tumeurs eiikystees jyelviennes ou ubdominales chez la femme, p. 82. Paris, 1867.^Kua<.'kenbusch of Albany (the Medical Record, Feb , 1875. — Annales de Gynecologic, vi., 237) relates two cases of sub-peritoneal cystic tumours which were taken for cysts of the ovary. OVARIAN CYSTS 747 areolar gelatiniform cysts of the ovary/ and hydatid cysts/ may originate in the subperitoneal cellular tissue intermediate between the uterus and bladder, or retro-uterine or even in the broad ligament. Such tumours of the epiploon ^ have been taken for ovarian cysts. When the tumour is a hydatid cyst enclosing echinococci, more fre- quent in the liver, spleen, kidneys and epiploon than in the other abdominal organs, the thrill which is said to be pathognomonic can be felt by palpation. Fibrous or fibro-cystic tumours of the womb, all the more difficult to diagnose that they may be complicated with ovarian cysts, are distinguished by the countenance of the patient which is usually normal, and by the uniformly hard or flabby consis- tency of the tumour. I do not speak of advanced extra-uterine preg- nancy nor of advanced normal pregnancy characterised by the signs of gestation, nor of retention of urine nor of the accumulation of fsecal matters which are easily recognised. II. The different varieties of cysts and other ovarian tumours. — Multilocular cysts are sometimes distinguished from unilocular cysts by the appearance of several globular or spheroidal projections; more frequently by the impossibility of perceiving fluctuation except by placing the hands at a short distance from each other, or of emptying the cyst by an exploratory puncture unless the several divisions can be punctured successively by inclining the trocar in different directions after the contents of the first sac have been evacuated ; even then we frequently only succeed in withdrawing small quantities of fluid and in slightly diminishing the size of the tumour. We can also ascertain the nature of the fluid which is more gelatinous and thicker in multi- locular cysts, or which may differ in one secondary cyst from another. Compound cysts may be recognised by the presence of hard, resistant, non-elastic, non-fluctuating, solid portions, having a dulness more marked at some point of the periphery of the cyst, either at its upper portion and sides or at its lower portion. Diagnosis becomes easier ■when the exploratory puncture has evacuated a part or the whole of the fluid contained in the cyst. Like other ovarian tumours, cysts may be developed either to the right or left ; we can easily ascertain this when the cyst is only slightly developed, and we may suspect it in other cases from various indica- tions given by the patient. In rarer cases they are simultaneously developed on both sides. It is important to diagnose this before operating. Solid tumours of the ovary are usually distinguished by being harder and smaller than cysts, by the irregularity of their form and the sym- ptoms of compression of the pelvic and abdominal organs which are more marked than in cysts; for the latter on account of their globular form, their elasticity, &c., are displaced more easily. Benignant tumours, such as fibroids, are tolerated as easily as cysts, the general symptoms which they produce being more dependent on their size than on their ^ Cmveilhier, Anat. path, gen., v, p. 191. ^ Puistienne, op. cit., p. 12. ^ Cruveilliier, quoted by Puistienne, op. cit., pp. 34 and 36. y 748 UTERINE DISEASES IN DETAIL reaction on the economy. Malignant tumours, cancer, scirrhus, ence- phaloid, colloid, rarely reach the size of cysts,^ and are nodulated and •constituted by the aggregation of multiple tumours of variable size and consistency, foriuiiig globular excrescences of the ovary rather than a regularly rounded tumour. They compress the neighbouring organs more and have more intimate relations with the uterus. They more frequently determine oedema in the lower limbs or anasarca, as well as aticites and partial peritonitis. 111. Complications of ovarian cysts and their relations xvitlt the neighbouring parts. — 1. The principal complications of ovarian cysts are the following : rupture, which when preceded by adhesions with the neighbouring parts, by discharging the fluid incessantly into the peritoneum may induce the cure of a unilocular cyst; but, if produced suddenly, it gives rise to acute peritonitis, and if the fluid is discharged into an adherent organ (bladder,^ intestine, v.tgina, abdominal wall, &c.) the patient succumbs to suppuration or septicaemia. Haemorrhage may be suspected from the occurrence of symptoms of internal hfcmor- rhage ; but it can only be diagnosed by the sanguinolent appearance of the fluid withdrawn by puncture. Partial or general inflammation is recognised by the symptoms of ovaritis ; by rigors, feverish attacks symptomatic of suppuration, by the pains, nausea and tympanitis which accompany the development of peritonitis, &c. Ascites may conceal the presence of an ovarian cyst when the peritoneal cavity is much distended by the fluid ; it is, however, seldom that some of the charac- teristic signs of these two maladies are not observed simultaneously, especially in emptying either the peritoneal fluid or the contents of the cyst. The siniultaneous existence of pregnancy and an ovarian cyst may be very difficult to diagnose in the first period of gestation, espe- cially if the cyst has existed for some time and has attained a consi- derable develojjment ; later on, the characteristic signs of the presence of the fcetus leave no doubt. The simultaneous existence of a cyst and of another tumour, whether uterine, ovarian or independent of the genital organs is more easily determined at the commencement of the development of the two tumours, especially when the tumour which complicates the cyst comes from some organ situated at a distance from the ovary. 2. The relations of the cyst with the neighbouring parts are perceived on the patient assuming difl'erent postures, by raising the cyst in different directions, either through the abdominal wall or by the vagina, by pushing it by graduated pressure in a certain direction, by examining the woman when standing and observing the tympanitic note between the diaphragm and the upper surface of the cyst, by ascertaining that the various displacements do not produce pain, and lastly by observ- ing the retraction of the cyst after puncture and evacuation of its ' Clarens, however, once found in a woman of 42 a medullary sarcoma of the left ovary weigliing 80 lbs. {Deutsche Klinih, 1873, No. 3), and I have dis- sected one of more than 50 lbs. in weight. - liicisky of Borne (Revue de Haijcm, v, 178). l\u|)ture of ovarian cyst into 111' l)hicUIcr, with wliich adhesidii.s had l)oen formed. OVARIAN CYSTS 749 contents. We may then be almost certain of the independence of the cyst ; besides, deep adiiesioiis of the pelvic cavity seldom exist in the absence of abdominal adhesions. The spontaneous pain, on the contrary, experienced previously by the patient at those spots where mobility of the tumour is doubtful or absent, the other symptoms of peritonitis, whether circumscribed or otherwise, having possibly been already developed, the acute pains of dragging or tearing produced by attempts made to remove the cyst from the organs to which it seems to adhere (from the Hver, spleen, abdominal wall and iliac fossa), the im])ossibility of verifying this separation after repeated ineffectual attempts, the pain experienced by patients either from a full or em])ty stomach, from the peristaltic movements of the intestine during di- gestion and from the contractions of the rectum for the expulsion of fcetal matters, are symptoms which prevent us from making a mistake as to the existence of adhesions between the cyst and the parts with which it is in contact. According to Koeberle abdominal adhesions are observed more especially round the umbilicus ; adhesions to the epiploon are known by the absence of vibrations at this point ; adhesions to the liver, diaphragm and edge of the ribs can only be ascertained by puncture ; those with the intestines cannot be diagnosed beforehand, even under such conditions; those with the pelvic cavity are recognised when the cyst cannot be pushed back into the abdomen, even after puncture. Shortness of the pedicle may be presumed from the impossibility of raising the tumour in the abdomen or of imparting to it the slightest movement, from the defective mobility of the uterus, from the presence of globular tumours in the cavity behind or around the uterus, pro- jecting more or less into the vagina, contributing to fix the womb and experiencing a direct reaction from movements transmitted to the cyst. When the pedicle is long, the tumour is sufficiently raised above the pelvis to prevent the finger reaching more than a spheroidal, broad surface, more or less independent of the uterus, which has pre- served to some extent its mobility. Treatment. — Medical treatment ought to be tried, for there are ex- amples of spontaneous absorption of the contents of the cyst followed by cure, but they are very rare. No one knows better than I do the resistance usually offered by ovarian cysts to all medical treatment. Nevertheless, I have never undertaken ovariotomy without having previously tried all other rational means of treatment, and have been so fortunate as to see the use of these means succeed in two very characteristic cases^ in which I had little hope that resolvent treatment would prove effectual. The treatment employed in these cases may be summed up as follows : chloride of gold and sodium, from two milli- * Large right ovarian cyst, probably unilocular, which had never been punc- tured, in a single woman of 43 ; circumference of the abdomen at the umbilicus, one yard. Cure eight years ago. Right ovarian cyst, apparently multilocular, never punctured, in a child of 12 who had never menstruated ; circumference of the abdomen at the umbilicus, J yard. Cure six years ago. The enormous size of the cysts in both cases authorised the presumption that they were ovarian and not connected with the Wolffian bodies or the broad ligaments. 750 UTERINE DISEASES IX DETAIL grammes to five centigrammes daily ; tonics and restoratives, iron, bark, &:c. ; solvents, Tichy water, bicarbonate of soda; resolvent ab- dominal frictions of iodide of lead and potassium ; diuretics, squills, digitalis, nitre ; lastly, and above all, methodic and increasing com- pression of the whole abdominal surface by means of Bourjeaurd's^ excellent elastic belts. In other patients (about a twentieth of the whole) the cyst has appeared to remain stationary or even to diminish in size for some time under the influence of this treatment (sometimes preceded by the evacuation of the fluid), which was tolerated for several years without seriously injuring the health of patients aff'ected by them. Torsion of the pedicle of the tumour is another means of spon- taneous cure. It may extend from half to two and a half turns, and is probably dependent on movements made by the patient while lying and while the tumour is still small. Cysts and even fibrous tumours of the ovary sometimes undergo natural torsion round their axis, which may explain spontaneous core. This torsion, recently de- scribed by Eokitansky and Klob,- has been attributed by the latter (after experiments made on a dead body to the ovary of which he had attached a membranous sac of the size of an orange) to the rotation imparted to the ovary, always in the same direction, by the alternate repletion of the bladder, which makes the sac turn from within outwards, and depletion of this organ, which lets it fall without turning in the opposite direction. Por this eff'ect to be produced the sac must be attached to the external side of the ovary ; if on the in- ternal side the same effects are produced, but in the opposite direc- tion. It is accompanied by strangulation of the vessels of the pedicle, the result being, according to Koeberle, congestion of the cyst, in- ternal haemorrhage, inflammation and even mortification of the cyst, and complete rupture of the pedicle. Unfortunately we cannot help nature in accomplishing this singular phenomena. The natural evacuation of the contents externally, after the forma- tion of salutary adhesions, may produce cure, amelioration (especially when the cyst is evacuated through the vagina or abdominal wall), or inflammation of the sac, septicaemia and death (especially in cases where the cyst opens into the intestine or bladder). — Rupture with effusion of the fluid into the closed cavity of the peritoneum is still more frequently a cause of death ;'^ Thomas Keith (the Lancet, 10th March, 1877j has, notwithstanding, performed ovariotomy successfully in a case of rupture ; it is the result of a suppurative inflammation, gangrene of the cyst, traumatism, or puncture. Chereau has collected 70 cases of rupture of ovarian cysts with effusion of fluid into the peritoneum, or evacuation through the bladder, uterus, vagina, and abdominal wall. Puech, by collecting 33 additional cases, has raised the total number of these ruptures to 103 ; out of this number there were 33 deaths, 22 ameliorations, and 48 cures ; as examples of the ' ^ote sur les kystes de I'ovaire ; Bulletin de I'Acad. de med., 1857. " CEsterreichische Zeitschrift, No. 18, 1865. ^ Spiegelberg has recorded three new cases {Archiv fiir Gynak., 1870). OVARIAN CYSTS 751 latter Eichard^ has added 5 cases to some others already known of cominuiiication between the ovary and Fallopian tube, and of the evacuation of the fluid by this means. ^ We have therefore still less hope from this mode of natural termination or its imitation than from torsion of the pedicle. Injlammation may attack the internal membrane of the cyst making the contents purulent, or it may extend from the sac to the entire ovary and be propagated to the peritoneum, determining adhesions or suppuration. Whether spontaneous or excited by a puncture, injection of iodine, a seton, &c., as has too often happened, it is soon fatal. Recovery after such an accident is quite exceptional. Exhaustion is the usual termination ; most frequently, the progress of the tumour alone suffices to cause a daily increasing emaciation, exciting a hectic fever which consumes the strength of the patient, throwing her into a state of marasmus quickly followed by death. The physician therefore has to do with a tumour which may be developed at any age, making continuous and usually rapid progress and resisting all treatment, whilst occupying an organ the preservation of which is not necessary to life and the ablation of which is the only means of obtaining definite cure. We shall now compare the various means of surgical treatment, some of which (puncture, aspiration, injection, drainage, seton, incision, excision) usually only- procure a palliation of the evil whilst seriously endangering life, whilst others, on the contrary (extirpation), without being really more dangerous, offer the hope of radical cure. I. Puncture. — This is a purely palliative means which alleviates the patient temporarily when threatened with asphyxia and helps the diagnosis. But this operation, although apparently simple, is not free from danger. Death may occur instantaneously from syncope or haemorrhage, or at a later period from peritonitis or from inflammation of the sac and suppuration in the cyst, or from the rapid reproduction of the fluid. Puncture ought therefore to be deferred as long as possible, as it is evident that additional punctures will probably be necessary at increasingly shortened intervals, the patient at last suc- cumbing to exhaustion.^ When it has been decided on we must make sure that the patient is not pregnant and that there is no urine in the bladder. This operation is usually performed with a large trocar on account of the consistency and viscosity of the fluid. It is usually made on the abdomen, on the linea alba, in the centre of the space separating the umbilicus from the pubis : at that point there is no fear of encountering the vessels of the abdominal walls and still less chance of opening one of the large arteries which rise from the base of the cyst and ramify in it. It must be previously ascertained by ausculta- 1 Sur les Icystes tubo-ovariques {Mem. de la Soc. cle cliirurg., 1853, t. iii, P- 121). - Nepveu {Ann. de Gynec, i. iv, p. 14, juillet, 1875). — Brjzan {Dissertat. inmtyurale. Halle, 1875). •^ Vast {Soc. de cliirurg., 1875). — Bezard {Bulletin de la Soc. vied, d' emula- tion, 1815. Bevue de Hayem, vi, 168). 752 UTEEIKE DISEASES IN DETAIL tion that there is no vascular souffle at this point. Care should be taken to compress the abdomen strongly when the fluid is evacuated, either by means of my belt or by that of Bourjeaurd. If haemorrhage occurs it should be arrested by means of acupressure, applied according to Simpson^si ingenious method. The cannula invented by Panas may be used in puncturing ovarian cysts in order to avoid accidents from haemorrhage and from the escape of liquid into the peritoneum. II. Asinration. — Buys^ has recently proposed sustained aspiration in order to provoke the continuous discharge of fluid and retraction of the cyst whilst preventing the entrance of air and the development of inflammation and suppuration in the sac, these accidents having led to the abandonment of the plan of leaving a cannula in the wound. In place of aspirating the fluid suddenly and only at intervals, as can be done by means of the instruments invented by Monro, Guerin, and Boinet, it should, according to Buys, be aspirated slowly but con- tinuously and with increasing force so as : 1st, to evacuate the tumour slowly and prevent the patient from being inconvenienced by a too sudden raptus ; 2ndly, to maintain the vacuity of the cyst by a more energetic suction, aspirating each drop of serum as soon as it is formed and thus exciting contraction of the sac; 3rdly, to stimulate the retrac- tion of the cyst, producing an exudation of plastic lymph fitted to make the opposite surfaces of its internal wall adhere together. It is useless to describe the trocar a ciirseur, or tlj€ sort of india-rubber bags of different degrees of thickness invented by this surgeon to increase the strength of aspiration gradually, experience not having yet decided as to the value of this method. III. Barth's cannula. — A cannula for perforating the abdomen and cyst at two points so as to remain there without allowing the sac to become separated from the abdominal wall, was first proposed by Barth,^ and was the subject of the academic discussion on ovarian cysts and of Bauchet's paper. The simple seton and Chassaignac^s^ drainage are only different ways of carrying out the same method, and can none of them be applied without risking the danger of the entrance of air, inflammation of the sac, destructive suppuration, kc. I think that in the small number of cases in which they have been employed they have always been followed by death. IV. Iodine injections. — Iodine injections preceded and followed by other injections (gas, hot wine,^ solution of nitrate of silver, weak solution of caustic potash or tincture of cautharides,** or an alkaline ^ Acwpressure, a New Method of Arresting Surgical Hamorrhage and of Accelerating the Healing of Wounds. Edinburgh, 1864. * Journal de medecine et de chirurgie, t. xl, 33. Biuxelles, 1865. — Traite- vient des Icystes de I'ovaire, du pyothorax, de Vhydrothorax, des 2Jlaies, &c., par la compression et I'aspiration continues, procedes et appareils nouveaux, by Buys. Biuxelles, 1870. ^ Jialletin de I' Acad, de med., xxi, 583. Paris, 1855-6. ■• Soc. de chirurg., 27 Nov., 1861. * Holschcr, Archiv, 1838, i, 221.. " Ollenroth, London Med. Gaz., 1835. OVARIAN CYSTS 753 sulphite^), have been employed and recommended by Boinet.^ But iodine injections can only be attempted with any chance of success in the case of unilocular cysts containing a serous fluid, and success even then is so doubtful that Boinet himself seems to be converted to ovariotomy. V. Licision and excision. — These are still less acceptable methods ; their object usually is to provoke suppuration of the cyst and that is enough to condemn them. It is evident that before incising the cyst, adhesions should be established by only incising as far as the peri- toneum, as advised by Graves in 1827 for abscesses of the liver, and by Begin ^ in 1830 for all fluid collections in the abdomen, or by making successive cauterisations of the walls of the abdomen and cyst as performed by Uecamier in the same circumstances. Supposing, however, that inflammation and suppuration are not developed in the cyst and that we may hope for amelioration and contraction of the sac, we must never count on a definite cure as long as there is a fistulous opening. The excision of a portion of the walls of the cyst, the object of which is to allow the contents to be evacuated into the peritoneum in order to be reabsorbed, or rather to provoke suppuration there, is an almost necessarily fatal operation ; therefore it has only been per- formed in cases in which extirpation has been undertaken and could not be finished, owing to the adhesions being too strong or too numerous. VI. Enucleation. — Miner of Buffalo {Americ. Journ. of Med. Science, October, 1873) proposed ovariotomy by enucleation, with- out clamp, ligature or cauterisation, a method which he had been led to adopt by chance (Hayem, Revue des Sciences med., i, 200). He per- formed it thrice without haemorrhage, but he lost two patients. Meade, of Bradford, has published a successful case, and Gaillard Thomas three. Enucleation has also been performed by Logan and Ford (Hayem, id., 1873, p. 748), and by Burnham {id., id.). It is certainly very wonderful to be able by one simple dissection, one detachment gradu- ally effected, to enucleate a cyst entirely without having to cut the pedicle or to ligature any vessel. This operation is probably only practicable for cysts of the broad ligament (Rosen miiller^s organ or others), enclosed between the two layers of this great peritoneal fold, without pedicle and without vascular connections, and should not be attempted in the case of other tumours. If the cyst upon which we intend to operate by enucleation has a pedicle, and if haemorrhage occurs it should be arrested by one of the means which I shall describe when treating of ovariotomy. VII. Ovariotomy. — However serious this operation may appear, it is now so well managed that in spite of the gravity imparted to it by the size and connections of the tumour, and in spite of other unfore- seen dangers, it takes an increasingly important place among surgical * Grritti, Annali universali di medicina, 1864, p. 272. 2 lodotherapie, ou de I'emploi medico-cJiirurgical de I'iode et de ses com- poses, 2" edit., p. 531. Paris, 1865. 3 Journal hebdom. de med.. i, 417. Paris. 1830, 48 754 TJTEPilNE DISEASES IX DETAIL operations. In comparing ovariotomy with the other major opera- tions we find by statistics that the rate of mortality is lower than in operations for strangulated hernia, than in lithotomy in the adult, ligature of the subclavian, kc; i.e. than in all the great surgical operations indicated and performed daily for incurable lesions for which they afford the only chance of recovery to the patient. The comparison would not be justifiable if ovarian tumours were curable by less dangerous operations ; but with the exception of a few cases which may be treated by puncture or iodine injections, ovarian cysts, especially those that are multilocular and complicated by the presence of solid tumours, are ceeessarily fatal within a variable but short period. Death is advanced rather than retarded by punctures and iodine injections. Extirpation therefore is the only chance of safety for patients. Xot only is the rate of mortaHty greatly diminished, but peritonitis, the accident most to be feared, has become much rarer, experience having proved that extensive wounds of the peritoneum are not necessarily fatal. It is more than forty years ago since Blundell, in a paper printed in his Physiological Researches, tried to prove that the danger of peritonitis consecutive to local lesions was exaggerated, and he appealed from the opinion of his contemporaries to that of posterity. "When we consider the larsre wounds made by MacDowel, Walne, Clay, Koeberle, Pean and others, in order to allow of large tumours being extracted from the abdominal cavity without previous puncture, we cannot doubt the comparative tolerance of the peritoneum for long incisions. It is true that we regard the reduced size of the incisions as a progress ; but the incision itself does not seem to have a direct influence on the development of peritonitis. Spencer Wells has recently proved by his remarkable success, not only that peritonitis is not necessarily developed after operation, but further, that pre-existing peritonitis or even the complication of pregnancy, do not necessarily contra-indicate ovariotomy when performed by a skilful surgeon. However exceptional this success may be it is too remark- able not to be recorded here.^ We have now to consider the question of the indications and contra- indications for ovariotomy. 1. The indications become increasingly easy to determine. In this respect there are tumours which may be left to themselves ; there are some which may be treated by puncture or iodine injections ; and others which should be extirpated ; whilst there are some which the surgeon should leave alone for fear of compromising surgery by under- taking impossible operations. It is right to remark that neither puncture nor injections on the one hand nor ovariotomy on the other ought to be applied to the treatment of all ovarian cysts indiscrimi- nately, and it would be wrong to compare the results of the one ' Case. — Ovariotomy performed euccessfuUy in the fourth, month of pregnancy after rvpture of the cyst and pjeritonitis (tihe Lancet, Sept. 18, 1869. — Lyon medical, 7 Nov., 18C9). There are several other cases on record of ovariotomy performed during pregnancy (Annales de Gynecologie, viii, 1.53. Paris, 1877, p. 1280). I OVARIAN CTSTS 755 method with the other as an exclusive method. It appears to me on the contrary rational to make a distinction between the cysts to which puncture or iodine injections maij be applied, and those which require extirpation. — Puncture and iodine injections may be very successful in simple serous unilocular cysts, only exceptionally developing formid- able and fatal symptoms. If applied, on the contrary, to viscous, purulent, complex, multilocular cysts they cannot ameliorate and usually develop rapidly fatal symptoms. — Applied to cysts of the first class ovariotomy is very frequently successful ; but it is not indis- pensable, and as it may be followed by formidable accidents inherent to the method itself, it should be reserved for more serious cases. Applied, on the contrary, to cysts of the second class, or to those of the first which have passed into the second from the ineffectual use of punctures and injections, it is doubly superior to puncture and injec- tion because it then becomes a rational means of treatment, and besides is the only means of cure for a malady which puncture and injection could only increase and render rapidly fatal. Therefore, on the one hand puncture and injections may be attempted in cysts of the first kind, because they may be curative means or at least sufficiently palliative, while their failure would not absolutely prevent the application of the radical method of extirpa- tion, although lessening the chances of cure. On the other hand ovariotomy is the only practicable method for cysts of the second class, to which puncture is only applicable as an exploratory means. Such is, according to my opinion, the limit between the indication and contra-indication of punctures or iodine injections, and such is the limit between the contra-indication and the indication for ovario- tomy. 3. As for the contra-indications for ovariotomy there are some which may be drawn from the age and strength, or on the contrary from the extreme debility of patients; but these are not only common to ovariotomy but to all operations of equal gravity. They are not of less consequence on that account : for experience proves that the danger of death after ovariotomy depends more on the general state of health than on complications of the malady, such as the size of the tumour, adhesions and difiiculties attending the operation.^ Nevertheless, I shall only occupy myself with the special contra-indications connected with the operation itself. One of these is the existence of solid constituents and especially cancer in the tumour, which may make pediculisation of the latter impossible or relapse likely ; hence the utter inutility of the operation in such cases. I know that Koeberle has set an example which might be followed by removing the uterus as well as the ovaries and so making pediculisation of the tumour absolutely possible. Some day we shall perha))s enter on the path opened up by Atlee and Clay for the extirpation of utero-peritoneal fibrous tumours. These * Spencer Wells, Fifty Cases of Ovariotomy, second series. London, 1S67 ; from the Medico-Chirurgical Transactions, I860. 756 UTERINE DISEASES IN DETAIL cases, however, are too exceptional to authorise our introducing into practice precepts contrary to those which I think should form the basis of these contra-indications for ovariotomy. Another contra-indication is the number, extent and solidity of adhesions (especially in multilocular cysts), either with the abdominal wall or viscera, especially with those which are high up, such as the stomach, liver, &c. I saw with Simpson a girl of 15 affected with an enormous multilocular cyst, with viscous greenish-grey contents, the puncture of which, after several sacs had been evacuated, did not determine retraction at any point, from the epigastrium to the pubis or from one flank to the other. It seemed imprudent to attempt the extirpation of such a tumour, the adhesions of which were so strong and so extensive, and yet the operation was performed by Keith with complete success. Such adhesions, with the existence of solid tumours, as well as errors of diagnosis may account for the operations which were undertaken by some of the first ovariotomists, but which could not be terminated. Lastly, after having endeavoured to arrive at the most probable diagnosis by all ordinary means, especially by puncture, we may attempt to convert this probability into certainty by an escploratory incmon ; for experience proves that, when carefully done, this incision does not greatly increase the chances of death. Supposing that this last element of diagnosis is in favour of operation the latter is in such a case already begun, and the surgeon has only to continue it. Preparatory treatment was considered a few years ago to have more influence on the success of the operation than is now admitted. This influence, however, although indirect is not the less real, and when the operation can be delayed I think the preceding time should be taken advantage of for putting the patient into the best possible conditions. The best means for preventing the most dangerous accidents attending ovariotomy, such as hemorrhage, debility, suppuration and purulent or putrid infection are : strengthening and nourishing diet; residence in a bracing climate, baths followed by frictions and other hygienic mea- sures ; to which we may also add the use of iron and other tonics. Simpson attached great value to the latter agent in preparing patients for operations, and preferred the tincture of the perchloride. The use of iron preparations should not be reserved for the days previous to operation ; it is quite as useful after ovariotomy. Like all other serious operations the extirpation of ovarian cysts should be per- formed when menstrual congestion has entirely passed, i. e. about eight days after the cessation of the monthly period. Although Koeberle performed an operation during the catamenial period and succeeded, that is no reason for admitting that there is not more danger in performing ovariotomy then than at another time. In order that the intestines may have rest after ovariotomy, it is useful to emj)ty them not only by an enema but also by a mild purgative given the day previous to operation. I agree with Koeberle in preferring au ounce of castor oil, mixed with an ounce of syrup of tartaric acid, followed in the evening by 30 to 60 grains of I OVARIAN CYSTS 757 subnitrate of bismuth, in order to decompose the sulphurous gases remaining in the digestive canal. The first operations having been performed before the discovery of ana3sthetics, the patients were not able to have the benefit of such relief. But since its introduction into surgery no operator has failed to employ it before proceeding to the extirpation of ovarian cysts. We should remember that the opening of a large cavity like the abdomen and its prolonged exposure to the air have a tendency to chill the body considerably : therefore the chest and lower limbs should be covered with warm flannel. The operation strictly speaking is divided into six stages : abdominal section; puncture and evacuation of the cyst; rupture of adhesions and extraction of the ovary ; constriction and section of the pedicle ; cleansing of the abdominal and pelvic cavities ; closing of the wound. 1. Abdominal section (including that of the teguments and perito- neum) is always made on the linea alba. An incision of 4 or 5 inches at equal distances from the umbilicus and pubis suffices as an explora- FlG. 412. — Incision in the direction of the linea alba without touching the peritoneum, enlarged with scissors guidod by the index finger or the direc- tor (after Savage, as well as the following figures relating to ovariotomy). tory incision, and it can be increased when necessary. If circum- stances require its being extended beyond the umbilicus care should be taken to direct it to the left so as to avoid the navel. In such cases Koeberle incises the umbilicus directly, and if there is an umbili- cal hernia he incises the sac at the same time to obtain a radical cure. When the peritoneum is reached the incision presents some diffi- culty. Tlie wound should be kept dry by sponging and by seizing with artery forceps the veins, which are sometimes very much deve- loped, and which may give rise to profuse hsemorrhage. Next it is important to distinguish the peritoneum from the wall of the cyst. 758 UTERINE DISEASES IN DETA.IL The serous membrane is raised with a tenaculum hook or mouse- toothed forceps, and a small opening is made through which an ordi- Fig. 413. — Manner of opening Fig. 414. — The operator, by passing his the peritoneum, which is hand round in various directions incised in the same direc- between the tumour and the peri- tion and to the same extent toneum, assures himself of the as the teguments. extent and nature of the adhesions if there are any. nary director or the index finger can pass from above downwards, the serous membrane being divided by passing a bistoury or scissors along the director so as to give the same extent to this incision as to that of the teguments. 2. Funcinre (preceded by separation of adhesions) and evacuation of the cyst {preventing at the same time the escape of the fluid into the peritoneal cavity) constitute the second part of the operation. Before performing these the hand should be passed between the ab- dominal wall and the cyst to ensure there being no adhesions, any slight ones wliich may exist being ruptured by the finger. The nature of the tumour is verified at the same time, as weU as the relative size of the cysts composing it, as the largest and the one which should be punctured first may not be directly opposite the abdominal opening. Fig. 415. — Spencer "Wells's ingenious trocar in the form of a wide tube, bevelled off at one of its extremities into a veiy shaii) point which makes the puncture ; towards its central part there is a circular and notched catch, into which fit two strong semicircular claws, which retain the cyst on a level with the puncture ; the other extremity is funiished with a raised bordei-, to which a large india-rubber tube can be fastened, allowing of the rapid evacuation of the fluid without its escaping externally. We should, however, beware of using much force in separating adhesions, especially if there is rea^son to suppose that the wall of the cyst is thin, as there would be a risk of ruj)turing it and of determin- ing evacuation of the whole of the fluid into the abdominal cavity. OVARIAN CYSTS 759 After this exploration has been made the cyst is punctured. The best instrument for the purpose is Spencer Wells's trocar, the point of which is hollowed out into a tube, like the cannula, and may be con- tained within the latter, or project beyond it according to the wish of the operator, and the cannula of which itself holds a secondary cannula, soldered on to it at right angles and furnished with an india-rubber drainage tube, at the extremity of which is a weight, directing it into a tub placed on the right-hand side of the bed ready to receive the fluid from the cyst. The instrument has a sufficient diameter to allow of the fluid, which is usually thick and viscous, being discharged without difficulty. As the cyst is emptied care should be taken to keep the edges closely applied to the cannula of the trocar, lest the contents should escape into the abdomen. Evacu- ation of the fluid is then completed without further precaution ; any other secondary cyst or chamber, which is too much distended to Fig. 416. — Puncture of the tumour by means of the trocar and syphon cannula. allow of the passage of the tumour through the abdominal orifice, is punctured in the same manner, and in this way (unless there are solid tumours or a considerable agglomeration of small cysts) we are able to make the ovary supple and mobile enough to allow of its passing, when drawn carefully little by little, through the abdomi- nal opening. If this evacuation is too slow it is better to enlarge the opening of the sac and even the abdominal incision with the bistoury, in order to facilitate the escape of the cyst, than to lose time and run the risk of haemorrhage by puncturing the secondary cysts. 3. Extraction of the cyst (assisted h/ raising the cyst and breaking 760 UTEEINJ5 DISEASES IN DETAIL %ip secondary cysts, and especially by the rupture of adhesions) may be very simple or very complicated. The breaking up of secondary cysts and the raising of the tumour do not present serious difficulties, but it is different with regard to adhesions. When adhesions do not exist or are few and unresisting, extraction of the cysts is playwork. When, on the contrary, they are numerous and resistant this part of the operation may become dangerous, necessitating manoeuvres which may afterwards determine serious accidents compromising the success of the operation. When I have finished the description of the opera- tion I shall speak of the conditions which may make it impossible for the surgeon to terminate it ; but for the present I take for granted that it can be accomplished. This result is obtained more frequently than formerly, as the operator does not now allow himself to be discouraged by the existence even of very firm adhesions except that he leaves Fig. 417.— Method of preventing the escape of the fluid into the abdominal cavity from the opening made by the trocar. An assistant withbotb bands aids the withdrawal of the cyst. portions of the cyst on the organs to which they adhere. Experience has proved that success may be obtained even in apparently very un- favorable circumstances. But great precautions should be taken in the rupture or dissection of these adhesions, not only of those which unite the cyst to the abdominal wall and epiploon, but especially of those which unite it to the intestines, stomach, liver, spleen, or pelvic cavity, to the uterus, other ovary, bladder, &c. We not only run the risk of injuring these organs, and in such a case it is better to leave a portion of the cyst, which should be cut off round the adhesion, making it as thin as possible ; but we also risk causing hemorrhage, and this is why we should try to staunch the blood, tyiug all the divided vessels which threaten a secondary heemorrhage, cither on the epiploon, where this most frequently occurs, or elsewhere. Sometimes we must first of all search for the pedicle. OVARIAN CYSTS 761 and ligature it if possible before destroying the adhesions in order to stop the hsemorrhage. After having succeeded by this manoeuvre Fig. 418. — The operator is obliged to complete the withdrawal of the cyst by the introduc- tion of the other hand below, with which he raises the cyst. Fig. 419. — The operator reduces the size of a multilocular cyst incompletely evacuated by breaking up the remaining cysts with his hand, whicb he introduces into the interior, keeping hold at the same time of the borders so that the fluid cannot escape into the peritoneum. in isolating the whole of the cyst, or in removing successively the various fragments of the tumour which are detached (of which I have given examples), the rest of the tumour is drawn outside the abdominal opening, which can be enlarged when necessary, and the pedicle is seized firmly. At this difficult and dangerous period of the operation we must not fear to give the necessary time required. The gravity of ovariotomy is always in proportion to the complications that it presents, and the best means of diminishing the influence of these complications is the use of the most effectual methods ; now, rupture of adhesions and hemostasis after this rupture, either by momentary compression (by artery forceps) or by astringents (alcohol, perchloride of iron, &c.), by the cautery, or by metallic, silk, or catgut hga- ture, are necessary proceedings to prevent troublesome results from these local complications. The actual cautery and the short ligature are the most certain hemostatics. 4. The fourth part of the operation is the constriction and section of the pedicle which varies according to whether the pedicle is retained in the angle of the wound or is returned to the pelvic cavity. It may be that we have no choice as to the various methods successively employed to attain this end, and if the pedicle is short, or if it cannot be lengthened artificially by applying constriction to the base of the cyst 762 UTERINE DISEASES IX DETAIL when firmly folded in place of applying it to the utero-tubo-ovariau pedicle, it is necessary to employ one of the means which I shall describe. At first it was thought better to keep the pedicle attached to the abdo- minal wound and as much as possible outside this wound, in order to avoid suppuration in the pelvic cavity. Although Tyler Smith's success seemed to remove all ground for exaggerated fears on this point Langenbeck was the first who laid down and applied this precept. One suture may be passed at once through the pedicle and the two lips of the lower angle of the wound, or the pedicle may be retained at this point by a strong needle or it may simply be compressed against one of the Hps of the wound or against the neighbouring portion of the abdominal Avail (when it is too short), by means of the ingenious method of acupressure invented by Simpson.^ But the clamp or clipper invented by Hutchin- son in 1S3S is preferable. Kceberle also has a clamp, but he prefers his serre- nmuls. The most convenient of these instruments is one which I have seen Spencer "Wells use. Constriction should be made carefully, not only to prevent consecutive hsemorrhage but also be- cause tetanus has been occasionally de- veloped from incomplete constriction of the pedicle. Cases of death from tetanus have occurred after ovario- tomv. [Annales de Gynecologie, t. xi, p. 231.) Whatever method be employed, all that remains to be done to complete the ex- traction of the cyst is to cut the corre- sponding portion of the pedicle, at five or six millimetres from the constriction. When the pedicle is very short and cannot be drawn into the lower angle of the wound on a level with the in- tegument without considerably twisting or dragging the uterus it has necessarily to be left at a more or less considerable depth. If it is thin, if it can be com- pressed by a thread in one or two liga- tures, and if it can be cut close to the thread, I see no reason against imitating Tyler Smith and letting it fall back into the pelvis, except in those cases in which the ' Acupressure, a New Method of Arresting Surcfical Hceviorrhage. &c. Edinburgh, 1864. Fig. 42<1.— Clamp, the handles of which may be re- moved by the catches, A A. It resembles that of Spencer Wells, except in the absence of the small triangular blade which re- stores the parallelism of the branches when they are close toocether. OVARIAN CYSTS 763 rupture of numerous adhesions may lead us to fear the establishment of suppuration. In the contrary case, especially if it is necessary to apply more than one ligature, or to extirpate both ovaries and there- fore to multiply the ligatures, I think it is better to keep the threads in the lower angle of the wound, stretching them by means of an india-rubber catheter or director passed through the loops of the various ligatures and resting across the wound so as to retain them with more or less force against the teguments, or to maintain constric- tion of the pedicle by means of a serre-nceud as Koeberlc does.^ This surgeon interposes between the lower portion of the lips of the abdo- minal incision two valves of lead, intended to prevent the occlusion of the wound before the end of suppuration, to keep open a kind of drain for promoting the escape of fluid and pus, and to isolate this from the rest of the abdominal cavity, and especially from the rest of the wound. Section of the pedicle by the ecraseur has even been proposed which would facilitate union of the wound and prevent the drawback of leaving the ligature of the pedicle in its lower angle ; but I confess that I should be too much afraid of secondary hgemorrhage from the arteries of the pedicle to venture to prefer this means to those just described, or to section of the pedicle by the cautery, or to its return to the pelvis with a short ligature. Netzel, of Stockholm, who has em- ployed the clamp forty -seven times, and cauterisation eight times, as Fig. 421. — Tumour, just withdrawn, is held by an assistant so as to prevent laceration of the pedicle, whilst the operator compresses it in a metallic clamp and divides the pedicle with the actual cautery. well as the silk ligature left in the pelvic cavity with the stump of the pedicle, prefers the latter method {jbmales de G^necologie, t. ix, p. 464). Terrier once found in a patient who died two years after ovari- ' Ligature of the pedicle in on'i or two masses separated by double ii'on wire by means of Koeberle's little serre-nwud may be adopted as a general method. 764 UTERINE DISEASES IN DETAIL otomy, two silver sutures, which could not be removed at the time of the operation. They were discovered in the midst of the cellular adipose tissue dragged to the side of the peritoneal cavity by the retraction of the epiploon,, not encysted, slightly blackened by the sulphide of silver, surrounded on every side by adipose cellular tissue and perfectly tolerated, a fact which authorises our giving the preference to the short ligature {Annates de Gynecol., t. vii, p. 459). Alban Doran has seen exudations of plastic lymph surrounding and isolating the pedicle in a woman of 37 who died of septicsemia six days after ovariotomy, whilst in another woman operated on by Bantock the hempen thread had disappeared seven months after the operation and the pedicle had contracted adhesions with the epiploon and the broad ligament [St. Bartholomew's Hospital Reports, vol. xiii, p. 195, 1877). Now that antiseptic precautions are taken the clamp is seldom used, the pedicle being returned to the pelvis after having been compressed by a strong ligature which is cut close to the section of the pedicle, or cauterised with the actual cautery whilst constriction is maintained by means of Baker-Brown's clamp. This latter method is chiefly employed when the pedicle is short and broad, and has often been used by Baker-Brown, Krassowsky, Pean, and Koeberle. In order to liberate the pedicle after it has been cauterised the clamp should be loosened slowly and without shaking, so as to avoid lacerating the walls of the compressed vessels. The short ligature may be of catgut, silk, or metal, single or multiple, according to the size of the pedicle. The other ovary should then be examined and should be extirpated if it is found to be the seat of commencing disease. At other times it is plain from the beginning that the case is one for doiMe ovariotomy, Winkler of Dresden has even had to perform a triple ovariotomy necessitated by the presence of a supernumerary ovary also the seat of a cyst {Ann. de Gynecol., t. xi, p. 74). 5. Cleansing of the at) dominal and pelvic cavities. — If blood, cystic fluid, clots or fragments of the tumour are still found in the peritoneal cavity they should be removed most scrupulously. English surgeons rightly ascribe a great deal of their success to this precaution. There need be no fear of introducing the hand several times into the pelvic cavity and of afterwards applying thoroughly clean sponges, in order to ensure the peritoneum being perfectly dry, and by sufficient delay or the application of fresh ligatures to prevent consecutive haemorrhage. It is however right to mention that Koeberle is not so strict with regard to the cleansing of the peritoneum ; he uses soft napkins and hot flan- nels in preference to sponges. 6. Tlie last part of the operation is union of the lips of the wound, which should take place if possible by first intention. Care is taken to replace the epiploon and intestines into the abdominal cavity if they have escaped. (During the operation an assistant is entrusted with the task of pushing them back with hot wet flannels whenever they present themselves at the upper angle of the wound.) The pedicle, well com- pressed and cauterised, is either left in the pelvic cavity or else maiu- taiued by the clamp in the lower angle, the lips of the wound are then OVARIAN CYSTS '65 seized and the suture applied in superimposed layers, i.e. a deep and a superficial suture. Kccberle used to employ the quilled suture for the deep suture, but now contents himself with the interrupted suture not involving the peritoneum. The simple zigzag suture may also be used after the manner of the English surgeons. Spencer Wells, who only leaves the sutures in place for the few days necessary for union, merely uses ordinary strong thread. The ends of each suture are passed through the eyes of two needles and he then pushes each needle alternately from the peritoneum (at five or six millimetres from the incision) to the skin (at the distance of about from two to three centi- metres from the wound), he then secures the two ends on the line of union. The sutures are placed at the distance of two centimetres apart. Fig. 422. Fig. 423. Fig. 422. — The method of passing the needle for the metallic suture, including the perifoneum. Fig. 423. — Wound closed, edges united, pedicle secured by a permanent clamp. and in the intervals a few superficial sutures are passed. The last deep suture passes close to the clamp so as to retain the pedicle in place without piercing it. The other London surgeons whom I have seen operate do not pierce the peritoneum and make use of silver sutures. Simpson employed iron wire, which he left indefinitely in the wound. Like Spencer Wells, Simpson and Keith included the peritoneum in the suture, and I have always done the same. Since 1874 Koeberle leaves the peritoneum, only piercing the fibrous tissues by a deep inter- rupted suture, the ends of which directly cross the wound, and he uses a harelip suture to unite the skin. The pins of this harelip suture only remain in place for twenty-four hours and are then replaced (with the exception of the last which remains) by a dry collodion suture which remains sohd for four weeks. The deep sutures fall from the eighth to the fifteenth day. We have now to speak of the immediate results of ovariotomy as regards the operation and the means for preventing or overcoming accidents. The knowledge of these means is all the more important, as all ovariotomists agree in thinking that it is to the after-treatment, in a great measure, that the success of the operation is due. Acci- 766 UTERINE DISEASES IN DETAIL dents may occur even during operation. Nussbaum once divided the right ureter ; Simon and Tauffer of Fribourg the left ureter {Annales de Gynec, vii, 466. Paris, 1877). Nussbaum made an artificial ureter, Tauffer sutured the upper border of the bladder, and the patient recovered ; Simon performed nephrotomy successfully. Chambers wounded the intestine and cured it by a continued suture two inches in length ; in another case of intestinal wound he was equally successful {Lancet, 1877, p. 312). Lyon [Glasgow Med. Jour 71., ^^Q'^) has seen an abnormal anus formed after an intestinal wound which in spite of energetic treatment was not cured at the end of a year. Keith {Glasgow Med. Journ., 1869, No. 2) has seen an intestinal fistula originating in the same way and persisting after twenty-five months. Spencer Wells (id., No. 86), Atlee {American Journ. of Med. Science, 1872), and Hennig {Archiv fiir Gynaec., iii, 287) have observed analogous cases. Heath {Lancet, 1871, Nos. 4 and 11) has seen an abnormal anus follow an intestinal wound made directly with scissors. Elischer {Centralhlatt f. Gynaecol., 1877, p. 204) has observed ah analogous case : the wound was sutured, cure following immediately. Pean has twice wounded the intestine : in such cases the wound should be united with sutures of carbolised cat- gut, and this portion of the intestine must be retained near the lower angle of the wound, as in Chambers's case. If the bladder is injured the edges should be sewed together and a catheter left in the urethra. This accident happened to Lauffer once and the patient recovered; to Pean once, his patient also recovered ; once to Henry Smith, when the accident ended fatally ; twice to Spencer Wells, one patient recovered, the other died j three times to Thornton, in two cases recovery was rapid, the other patient died; once to Bantok, the patient died ; once to Eustache, when the patient recovered (Eustache, Be la lesion des organs tirinaires pendant Voperation de Vovariotomie. Journ. des Sciences med. de Lille, 1880). The most formidable accidents after operation are : shock, exhaustion, . hsemorrhage, accumulation of pus, purulent infection, and lastly peri- tonitis, which according to some surgeons is the most frequent accident, whilst Spencer Wells, on the contrary, thinks it rarer than cither puru- lent or putrid fever, or exhaustion. According to Marion Sims septi- caemia is the most frequent cause of death ; therefore he advises perforation of Douglases cul-de-sac and Lister's antiseptic dressings. Ansesthesia is one of the best means of preventing shock ; when it occurs the patient should be covered with flannel and have hot-water bottles placed at the extremities to warm her ; anti-spasmodics may be administered when necessary, or stimulants, such as wine, brandy, carbonate of ammonia. Exhaustion should be prevented by perfect rest and by giving small quantities of beef tea and wine, as well as tonics, remembering that the risk of hfcmorrhage and peritoneal in- flammation requires us to prescribe a somewhat strict diet for some days in order to give absolute rest to the digestive canal. Tyler Smith carries precautions so far as to leave a catheter in the bladder in order to avoid the movements necessitated by micturition. Uterine and in- OVARIAN CYSTS 767 testinal cramp, hiccough and vomiting may be developed, placing patients in danger by rupturing sutures, and the same may be said of tympanitis. They should be soothed by means of chloroform or other ansesthetics, and antispasmodics. In order to prevent the fluxionary abdominal movements, which may determine ha3morrhage, or the deve- lopment of peritonitis, Kocberle applies ice to the abdomen in two bladders placed one on each side of the wound for a few days. I have never seen this precaution used by English surgeons, and their patients do not succumb any oftener than others to the accidents which the con- tinuous application of ice seems fitted to prevent. It is of great importance to ensure rest to the intestines and to prevent all movement and dragging in the belly which could draw down the pedicle, rupture the healthy adhesions established in the wound, or by repeated dis- placements of the organs produce hsemorrhage or peritonitis. This condition is fulfilled by covering the abdomen with cotton wool and a bandage, which maintains it in a state of absolute immobility by moderate but methodic compression. It is also fulfilled by the administration of opium or morphia. Koeberle is in the habit of giving morphia to all his patients after operation. In England, how- ever, narcotics are only resorted to when there is pain or sleeplessness. During the course of peritonitis it is useful to empty the stomach and to wash it out with the oesophageal sound, and to retard organic fermentation by the administration of sulphate of quinine (Koeberle). Alcohol and opium associated with anti-emetics have been of great service to me in these circumstances. Lastly, there is an accident which it is important to prevent or subdue, that is, suppuration of the wound itself, which may gradually produce that of the peritoneum ; the accumulation of pus is not long in engendering septicaemia or pyaemia; suppuration or rather putre- faction of the pedicle mortified by constriction is sufficient by contact or absorption to produce not only inflammation of the peritoneum but purulent and putrid fever. Hence the necessity of maintaining great cleanliness of the wound by dressings repeated three times a day, by the frequent change of lint, by removing some of the sutures the first day, and others the fourth or fifth day when they are not metallic, by laying little bags filled with absorbent powders, such as calcined oyster shells and quinine, rhubarb and chalk, magnesia and cinnamon (Spencer Wells), on the parts from which fluid is oozing out; lastly, by mum- mification of the pedicle painted with caustic perchloride of iron (Koeberle, Keith, Simpson), and even by irrigation of the wound and neighbouring parts which threaten to become inflamed with an aqueous solution of sulphate of iron (Koeberle). If in spite of these precautions pus is produced in the pelvic cavity, its accumulation should be prevented either by the introduction of a glass tube or a vulcanised caoutchouc drainage tube through the lower angle of the wound (Koeberle), or by drainage giving exit to the pus by the posterior vaginal cul-de-sac ^ as performed by Spencer Wells, 1 The drainage of the peritoneal cavity by Douglas's cul-de-sac has been practised by Peaslee {Americ. Journ. of Med. Science, 1856, 1863 and 1864). 768 UTERINE DISEASES IN DETAIL Koeberle, or Pean. The latter surgeon pierces the cul-de-sac tvrice from within outwards bj means of a trocar, guided by the finger passed through an incision made above the crural arch, and leaves in it an india-rubber tube, the loop of which is in the retro-uterine cavity whilst the two ends hang from the vagina. As a rule, however, peri- toneo-vaginal drainage has been abandoned for peritoneo-abdominal drainage which is rightly considered quite as useful and less dangerous. Fortunately the antiseptic treatment, i.e. the application of Lister's method to ovariotomy (during operation as well as in the dressings) by diminishing the chances of septicaemia, has given fresh guarantees of success to ovariotomy. To sum up, the dangerous accidents of ovariotomy seem to be san- guineous oozing into the peritoneum and the accumulation of pus followed by septicaemia. We must therefore try to prevent the devel- opment of these accidents. Keith's great success is apparently due to the application of as many hemostatic ligatures as the sanguineous oozing necessitates, to peritoneo-abdominal drainage when indicated, and to the use of Lis- terism, both preventive and consecutive, other circumstances being seemingly secondary to this kind of therapeutic tripod on which the operative success of ovariotomy appears to rest.^ It is needless to add that supposing the consequences of operation have been benignant and that nothing has hindered the regular course towards cure, the quantity of food administered to the patient ought only to be in- creased gradually, and the permission to rise, and especially to walk, ought to be delayed as long as possible, for it should always be remembered that a certain time is required to give to recent adhesions sufficient firmness to enable them to withstand the various movements natural to women in normal health. I have mentioned the impossibility of terminating operation as one of the most serious accidents of ovariotomy. This danger becomes less frequent every day. It is evident that if adhesions absolutely prevented the extraction of the cyst it would be necessary to reunite the lips of the abdominal wound and to enclose the walls of the cyst in such a way as to make them adhere to it, either by trying to obtain the obliteration of its opening, which would turn the operation into one of simple puncture, or by leaving the orifice of the cyst open, by enlarging it even, and so preserving the possibility of introducing into its cavity various alterative fluids or perchloride of iron, which would almost reduce the operation to incision of the cyst, as advised by Ledran and performed by several modern surgeons, but, according to Fock's statistics, not very successfully. Pean has brought this method again into favour by his success in cases where he could not complete extraction : in order to succeed, it is very important to make the borders of the cyst adhere exactly to ' Mr. Lawson Tait lias published an account of 186 cases of abdominal section he has performed since Nov., 1879, with only 14 deaths. He has entirely abandoned Lister's antiseptic treatment, considennfj that it is productive of more harm than good {Papei' read before the Birmingham Branch of the Brit. Med. Assoc, Nov. 11, 1H80.—Med. Times and Gazette, Nov. 5, 1881.— Trans. OVARIAN CYSTS 769 the edges of the abclomical wound and to prevent all communication with the peritoneal cavity. Before these surgical improvements exci- sion of a portion of the cyst had only given poor results/ therefore when it is possible we should try to reduce the operation, by the exact union of the wound, to the conditions of a simple puncture. The remote conseque^ices of ovariotomy are usually as satisfactory as could be desired. Patients recover perfectly, perform all their func- tions and regain flesh. I have seen some who had been operated on ten years previously and who had been in perfect health ever since. Nevertheless painful sensations of dragging may persist for some time, due to the slight displacement undergone by the uterus, to the adhe- sion of the pedicle to the abdominal wall and to cicatrix of the ovarian ligament. I have seen patients in whom, owing to defective union of the linea alba at some point below the skin, there existed real eventration and enterocele of the linea alba, the retention of which necessitated the use of a belt or a bandage with a large pad similar to Fig. 424. — Appearance of the abdomen with cicatrix three weeks after extirpa- tion of a small ovarian cyst without adhesions (after Spencer Wells). the umbilical bandage. When both ovaries have been removed men- struation does not return and there is absolute steriKty ; but when one only has been extirpated, menstruation returns after operation, resum- ing its usual course. In the latter case conception may take place and be followed by normal pregnancy. ' See Clay's statistics at the end of his translation of Iviwisch. 49 770 UTERINE DISEASES IN DETAIL More than twentj of Spencer Wells's ' patients, three of Koeberle's, and several operated on by other surgeons have become pregnant, and each time the pregnancy has terminated normally; the first patient operated on by Koeberle (June, 1862) has had seven children since, two of which were twins, A woman operated on by Lane, who had had an abundant suppuration and phlebitis for fifteen days previously, has had five children since. Lastly, relapse, i.e. development of the disease in the other ovary, lias sometimes been observed. Atlee, Bird, Spencer Wells, Boinet, Joiion of Nantes have had to extirpate a second ovarian cyst some months and even years after ablation of the first in the same patient. Out of seven operations performed on the second ovary, Spencer Wells has had five successes. The integrity of the tissues correspond- in cr with the cicatrix of the first operation was ascertained, no trace of the latter being discovered in the majority of cases. Once even, as I have already mentioned, a triple ovariotomy was successfully performed. VIIL Extirpation of normal ovaries. — This operation, which is nothing else than castration, and which has received the name of Batte>/'s operation, or that of normal ovariotomy/, has been performed so olten on various occasions that there can be no doubt as to the possibility of terminating it successfully, and of saving patients in a threat number of cases. In 1863 Kccberle performed this operation and recommended simultaneous extirpation of both ovaries and of the womb in cases of hysterectomy or supra-vaginal amputation of the uterus when attacked by fibrous tumours. Nevertheless till 1872 no gynsecologist had proposed the extraction of apparently healthy ovaries (or castration) with the sole object of modifying disorders of innerva- tion, the starting-point of which seemed to be in the organs them- selves. It was at this time that Battey performed what he calls normal ovariotomy, ''with the object,^' he says, "of producing an artificial change in the conditions of existence, and of suppressing maladies which may depend on them, such as neuralgia, dysmenor- rhoea, hysteria, mental derangement," &c. According to this surgeon the indications for the operation are: " 1, absence of the uterus and serious permanent disorders caused by the presence of the ovaries; 2, obliteration of the uterus and vagina beyond the possibility of restoration; 3, the exceptional gravity of nervous, hysteriform and epileptiform disorders depending on an ovarian affection and resisting all ordinary means of treatment; 4, mental and physical sufferings produced by congestion of the ovaries which have resisted all treat- ment" [Transact, of the American Gmiecol. Soc, 1876). In 1878 Battey had performed a dozen ovariotomies (two by the abdomen, the others by the vagina) with the object of curing obstinate nervous afl'eclions; in four cases there was complete cure, in six cases the result was nil, in the remaining two the patients died. Another indication is uncontrollable metrorrhagia, especially dan- gerous catamenial haemorrhage. Hegar of Fribourg, who, in 1876, > Gaz. mcd. de Paris, 20 Oct., 1809. Since then the number of these cases has considerably increased. OVARIAN CYSTS 771 removed the ovaries of two women affected in this way, with the object of arresting the loss of blood and of putting a stop to the congestion dependent on ovulation, performed the operation by the abdomen with short ligatures, and had the satisfaction of saving his patients after having seen them pass through the greatest danger. Sims, out of seven operations by the abdomen, saved six patients; but out of four operations by the vagina for dysmenorrhojic ovarialgia, he lost all {Diet, de med. et de chir., art. Ovaire). If the efficacy of castration in the case of nervous affections is problematical, there is hardly any doubt as to the services this operation might render by bringing on the menopause prema- turely in women affected vrith dangerous haemorrhage. This is the opinion of Sims, Hegar, and of several others {Medical Times and Gazette, 1877). Goodell {American Journal, July, 1878) also per- formed castration for a large posterior fibroma with symptomatic menorrhagia; after eight months the hsemorrhage had ceased, the tumour had diminished to less than half its size, and the patient''*^ health was excellent. Exceptionally, menstruation has continued after castration. Goodell mentions two cases of double normal ovariotomy in which a more or less regular and abundant discharge of blood like menstruation continued afterwards; but in seventy-eight other cases oi ablation of both ovaries collected by the same writer menstruation was completely suspended. Unfortunately the operation, serious as it is by the abdomen, is still more so by the vagina on account of the adhe- sions and variations in the size and position of the ovaries, which have always suffered from inflammatory or other maladies when operation is indicated, and which are therefore far from being in the favorable con- ditions in which the same organs are when they have never been diseased. Goodell rejects Battey's expression of normal ovariotomy, preferring that of castration. Trenholme had a case {Obstet. Journ., Oct., 1876) in which both ovaries were removed and the pedicles left in the abdomen, with the object of diminishing uterine fibroids, by taking from them their means of existence by the suppression of erec- tion and of the monthly ovarian congestion which react on the whole genital economy. It is certainly very problematical; nevertheless two cases of Hegar's and one of Nussbaum's seem to justify the idea. Goodell also has performed it with the same object and operates in the following way. The vagina is depressed by a Sims's speculum whilst a fold of the mucous membrane is seized by a tenaculum hook behind the cervix. An incision of 4 centimetres is made there with Kiichenmeister's scissors; the peritoneum is then divided and the index finger of the left hand being introduced, it follows the course of the I'allopian tube, hooks the two ovaries successively, seizes them with a pair of fenestrated forceps and brings them into the vagina where they are hgatured and excised. Their pedicles are firmly liga- tured with antiseptic silk and replaced in the pelvic cavity. There is little haemorrhage and no suture in the vaginal wound. In GoodelPs operation which I have just mentioned the fibroid was discovered with great difficulty six months afterwards, although previously it had been 772 UTERINE DISEASES IN DETAIL very painful and had formed one body with the uterus in acute anti- flexion. As for the other cases of dangerous haemorrhage and of nervous, organic or psychical symptoms which have withstood all means of treatment, I do not see any formal contraindication. Opera- tion may also be indicated when the life of the patient is endangered by a malady which no other treatment can cure. In spite, however, of the advantage presented by operation by the vagina, if we were certain of finding the organs in normal condition, the absence of certi- tude is a sufficient reason for preferring operation by the abdomen. IX. Extirjmtion of Jibrous tumonrs and of the iderushy gastrotomy. — Gastrotomy has also been applied to the ablation of large uterine sub-peritoneal myomata, either in consequence of an error of diagnosis which led to the discovery of a fibrous tumour in place of the ovarian cyst which was expected, or else from the express desire to apply the radical cure of the latter malady in the treatment of the former. The first attempt at extirpation of the uterus and of peritoneal fibromata was made by Heath (of Manchester) in 1843, in consequence of an error of diagnosis ; he thought he had a case of ovarian cyst ; the patient died. The first successful operations were performed by two American surgeons, Burnham in 1853, and Kimball in 1855. Some years ago. Clay (of Manchester), beheving that he had to do with a multilocular cyst and discovering instead uterine fibrous tumours, removed the uterus, or at least the fundus of the organ with the tumours, ovaries and Pallopian tube, after having applied a strong ligature to the cervix immediately above the vaginal insertion which he retained in the inferior angle of the wound till it fell : the patient was cured. The fibroids with the portion of uterus and the ovaries weighed eight pounds ; the anatomical preparation is in Edinburgh.^ About the same time Koeberlc successfully extirpated a uterine fibroid and the two ovaries, also amputating the whole of the supra- vaginal portion of the womb.- This operation which at first was called hysterotomy has since received the more correct name of hysterectomy, since it is a question of extirpating and not only of dividing the uterus. In my opinion we do not yet possess a sufficient number of cases to authorise our forming a judgment as to the justifiability of the opera- tion,^ but I must admit that the number of successful cases seems to increase in proportion to the number of operations performed and with improved methods. Amongst the encouraging cases I may mention that of Storer (of Boston) quoted by Koiberle which was followed by cure ; one of Spencer AVells's,^ in which the fibroma was separated from the fundus of the uterus by hnear ecrasement^ hsemorrhage was arrested by ligature and the point of section of the womb was retained in the lower angle of the wound; the patient recovered ; that of Tran- holme in which there was ablation of the uterus and both ovaries for a fibro-cystic tumour in a negress of about 10, who recovered and soon 1 London Med. Gaz., 18 April, 1863. ' Communication to the Acad, des Sciences, 15 June, 1863. ^ Pozzi, Valeur de I'kysterotomie dans le traitement des tumeurs fibreiises de I'uterus. Paris, 1875. * Med. Times, 1871. OVARIAN CYSTS' 773 afterwards resumed marital intercourse {llai/ em Revue, t. v j)}). 1 7'J', 761); Tillaux's case { Annates de Gynecol., 1879, t. xii, p. ] 18) of uterine fibroma in the left lateral wall with dangerous hemorrhage, unbearable pain, intestinal occlusion from compression, extirpation and success ; KimbalFs successful case {Annates de Gj/nccol. t. ix, p. (51), which however did not prevent the operator from condemning hysterectomy at the Congress of Chicago in 1877; a number of other cases might be mentioned. There can however be no doubt that hysterectomy is more dangerous than ovariotomy. Koeberle {Diet, de vied, ei ckir. prat., art. Ovaire, t. XXV, p. 594), out of 20 cases of hysterectomy performed by himself, counts 10 deaths and 3 cures. Terrier has performed hysterectomy twice and has lost both patients. Pean has performed the operation 43 times, has had 33 successful cases, and 10 deaths (oral communication). These are, I think, the most favorable statistics known, and they are not very encouraging. These cases do not include operations performed for cancer : they may be analysed thus : hysterectomy has been performed by Pean 35 times for fibromata (23 cures, 13 deaths), of this number one was complicated with an ovarian cyst, another with a cyst of the broad ligament; once for hypertrophy complicated with pelvic cyst (cure) ; eight times for fibro-cystic tumours (5 cures, 3 deaths) ; four times for uterine cystic tumours (4 cures) ; once for hypertrophy from sarcomatous degeneration of the mucous membrane and retention (cure).^ Whilst admitting that hysterectomy may be resorted to when nothing can be expected from any other treatment, we should be all the more disposed to delay decision if the tumour does not progress rapidly, as experience has proved the occasional efficacy of the continuous current, ergotine, hot injections, resolvent alteratives and other means in arresting the development and even in producing diminution of these tumours. We shall therefore limit the indications to the following cases : danger from haemorrhage, threaten- ing of rapid and enormous development of the tumour, compression of the ureters, which has caused death (Matthews Duncan, Brit. Med. Jonrn., 29th April, 1877), fibroma of the posterior wall wedged tightly into the pelvis causing constipation and threatening death. X. Puerperal hysterectomy of Porro. — Laparo-etytroiomy of Thomas. — Ovariotomy has so familiarised surgeons with opening the peritoneum, and hysterotomy for fibroids has so frequently led gyneco- logists to consider the best manner of reaching the uterus either to open it or to excise a more or less considerable portion of it, that they have led to the practice of Cresarian section, i.e. hysterotomy in the puerperal state, and to the invention of new methods with the object of facilitating extraction of the foetus and of saving the life of the mother. I shall merely say a few words about these operations which belong exclusively to obstetrics. 1 Pean and Urdy, De V ablation partielle ou totale de V uterus imr la gas- trotomie. Paris, 1873. — Diagnostic et traitement des tumours de Vabdomen et du hassin. Paris, 1830. 774 UTERINE DISEASES IN DETAIL The idea was conceived of performing amputation of the uterus after Cperation. We must admit that the judgment which attributed the subsequent dangers of Caesarian section to the presence of the wounded uterus and which regarded extirpation of this organ as the radical remedy of the evil was correct, and that the conditions of success were to be found in the performance of the operation assisted by antiseptic treatment. Since then, out of 33 patients who have undergone Porro^s operation in maternity hospitals, J 5 have died, 18 have been cured, and the majority of the children have been saved, a far more favor- able result than had ever been attained by the ancient method of Csesarian section (Pinard, De V operation cesarienne sidvie de V ampu- tation utero-ovarique ou operation de Porro. Annates de Gynecol,, 1879. Masson, Be la gastro-elytrotomie. Theses de Paris, 1877). The laparo-elytrotomy of Gaillard Thomas is a lateral incision from the spine of the pubis to the antero-posterior iliac spine parallel to and above the crural arch, through which the vagina is opened at its junction with the uterus, so as to allow of extracting the child from it in place of extracting it from the fundus of the uterus through the linea alba which constitutes Csesarian section. Gaillard Thomas com- municated this method to the Academy of Medicine of New York on the 21st March, 1878; out of five operations he had saved four children and three mothers {^Annates de Gynecol., t. x, p. 232). Lateral incision is necessary here, laparotomy meaning lumbar incision, which was resorted to in the first ovariotomy ; afterwards, however, MacDoweil adopted the central line. 2. Tumours of the Annexes and Pelvic Cavity. According to Leopold (Archiv f. Gyn., Bd. vi, 2) solid tumours of the ovaries are rare, in the proportion of 1*5 per cent, of liquid tumours or cysts. They retain the normal shape of the organ by which they are distinguished from cysts. They have a variable con- sistency, from that of false fluctuation to that of stony hardness. Their exterior wall has also a variable thickness. The pedicle is usually short, and although the tumour may be closely attached to the uterus the latter remains normal. Among these tumours we may distinguish : 1. Fibromata, simple or complex (fibro-myomata, fibro-sarcomata), or with sanguineous lacunary spaces interposed (Waldeyer), or presenting an analogy with certain osteoid tumours, i.e. points of ossification ;i there are also areolar fibromata (Spiegelberg) , presenting a frame- ' K(p1)orle does not believe in fibro-myoma of the ovaries {Diet, de ined. et de rMr. xrratiq., art. Ovaihes, t. xxv, p. 508). I have imdoubtedly seen them. PELVIC TUMOURS 775 work of fusiform cells with a cavernous vascular development like that of sarcoma. 2. Enahondromala (exceptional), which must not be confounded with fibromata of cartilaf^inous consistency. 3. Sarco- mata (rare), the blood-vessels of which are numerous and small in little tumours, but in large tumours, on the contrary, are very much dilated, have a thin wall without any muscular tunic or tunica adven- titia, and furnished with simple endothelium. 4. Carcinoma, which I shall afterwards describe. 5. Ci/stomatous lymphaiKjiomata have also been seen in the ovary (cysts remarkable for the dilatation of the lymphatics and the proliferation of the stroma). Ziembicki {Essai cUnique sur les iumeurs solides des ovaireH. Theses de Paris, 1875) has collected 38 cases (11 of sarcoma, 10 of fibroma, 6 of carcinoma, 3 of colloid tumours, .5 of cystic adenoma, 3 undeter- mined), the result of which is that solid ovarian tumours are more apt to be met with in young women. The peripheric vessels were very large in five cases only. We know, however, that very small tumours, a hematic cyst of the right ovary for examj)le of the size of a chest- nut, may cause intra-peritoneal hajmorrhage ending in death in thirty- six hours (Curt Wallis and Linden, II)/geia, 1876; Hayem, Revue, t. ix, p. 623). As a rule ovaries attacked by these tumours have itvf or no adhesions. Ascites is common without ])eritonitis or vascular com- pression; it is a serious sign when the tumour occupies the iliac fossa, which it usually does. The writer has divided them into three groups : one including tumours of rapid formation developed in from three months to two years (carcinoma, sarcoma) ; another, tumours of slow formation of from two to ten years (fibromata, dermoid cysts, cysts with thick contents) ; and another rare form in which ascites is absent, and the economy does not seem to be disturbed, although this is of the worst kind. We must beware of making an exploratory puncture in such cases, it being better to perform ovariotomy early. In these cases, however, success is not common : out of eight opera- tions mentioned by Leopold only three were successful. Menstruation may continue in spite of the most serious degeneration of both ovaries ; conception and pregnancy may even occur (Treille, Tumeurs de I'ovaire dans leurs rapports avec Vohstetriqiie, c'est-a-dire avec la conception, la grossesse, I' accouchement, la puerperalite. Theses de Paris, 1873). Yernich thinks that an ovarian tumour may become malignant through pregnancy and the puerperal state. He mentions the case of a young woman attacked by a tumour which for a long time was painless, but which increased during pregnancy, and at the autopsy proved to be a medullary carcinoma {Bu pronostic des tumeurs ovariques com- plujuant la grossesse. Beitraege zur Geburtsk. und Gynecol., Bd. ii, 2). Hempel {drc/dv f. Gynecol., Bd. vii, 3, 1875) mentions a case of carcinomatous degeneration of both ovaries during ])regnancy. Several analogous cases have been published by Braxton Hicks, Kiirsteiner, Spencer Wells, Hecker, Buhl, Hempel, WaUis, Linden, &c. I. Malignant tumours of the ovaries. — These are nothing but cancer under various forms. Whether classed as scirrhus, encei)haloid. 776 UTEEINE DISEASES IN DETAIL cephaloina, hematoma, fungus hematoides, fibro-medullary carcinoma, cysto-carcinoma, melanic cancer, &c., they have all the aggressive, destructive and cachectic tendency which characterises cancer. How- ever, the various forms which these names recall may be met with in the different cases of cancer of the ovaries; this organic alteration may be combined with the existence of colloid or gelatinous matter, with the so-called areolar degeneration, as well as with the production of fibroids, or the development of cysts whether follicular or interstitial. Fig. 425. — Colloid cancer of the ovary (Cruveilhier). The uterus and Fallo- pian tube remaining attached to the tumour by the ligament of the diseased ovary, we may form an idea of the enormous development of this tumour. i.e. vesicular dropsies or cystoids. These morbid associations and the varieties which they engender depend on the real identity which cancer may present under these various appearances, and on the natural ten- dencies which the development of the degenerated tissue brings into play in an organ so disposed to hypertrophy in the form of fibromata or cysts. Cancer of the ovary seems to present itself more frequently under the form of encephaloid than of any other tissue.^ It may- attain considerable dimensions. I have lately seen one occupying the right ovary, weighing more than 11 lbs., forming a globular nodu- lated mass with very distinct spheroidal projections, of considerable size and occupying the whole of the right iliac and hypogastric regions, associated with integrity of the tube, congestive hypertrophy of the uterus and the recurrence of haemorrhage simulating menstrua- tion in a woman who had passed the menopause. The encephaloid masses, diffluent at several points, appeared to have originated in Graafian vesicles they were so well encysted; they seemed even, in several of these cysts, to have vegetated on the internal membrane of the vesicle, preserving an areolar or alveolar aspect, whilst the centre ' Lebert, oji. cit., p. 323. PELVIC TUMOURS 777 was filled with fluid and especially with blood ; several of these cysts were distended by black blood, partly coagulated, apparently poured out by internal hsemorrhages, analogous to those which endanger the life of patients in cases of external encephaloid ; lastly, in several cysts was to be seen yellow matter similar not only to that which is some- times met with in cancer, but also to that of a corpus luteum, situated in a superficial portion of the sac, and suggesting the idea that the ence- phaloid had been developed in ruptured Graafian vesicles and in the midst of true degenerated corpora lutea, an alteration mentioned by Rokitansky ; in others, black pigment was seen accumulated against the wall of the cyst between its internal membrane and the encepha- loid tissue occupying the cavity of the chamber. The signs of ovarian cancer are those of all ovarian tumours, especi- ally of cysts ; but there are other difTerential signs. They are : the more advanced age at which it is usually manifested (after 40 and even 50),^ the rapidity of its development and course (patients usually succumb within the year), the nodulated form, the smaller size, the hardness and sensitiveness of the tumour, the pains (?) experi- enced by the patient, the symptoms of internal or intra-cystic haemor- rhage which may occur, the premature disturbance of the functions and of the general health, oedema of the lower limbs, ascites (which may conceal the evil, but the evacuation of which by puncture allows of a most certain diagnosis and procures temporary alleviation to the patient), lastly, the engorgement of the mesenteric ganglia, the earthy look of the skin, the straw or leaden-coloured, complexion, hectic fever and the signs of cachexia. Treatment is merely palliative. Attention to hygiene, plenty of good air and milk, associated with tonics, preparations of iron, arsenic, hemlock ; narcotics, sedatives by the rectum or skin ; abdominal para- centesis to evacuate the fluid accumulated in the peritoneum, repeated as frequently as may be necessary; these are the means to be em- ployed. II. Av2ilsion and transmutation of the degenerated ovary. — What- ever difficulty there may be in diagnosing this malady in practice, it is well to know that the ovary sometimes contracts such adhesions with the pelvic walls or abdominal viscera that the dragging produced by the subsequent development of these viscera or of the uterus may lacerate its natural attachments rather than its abnormal adhesions. Eokitansky^ published seven cases of this very rare pathological fact. In all of them the ovary was degenerated : three times into a cyst filled with fat ; twice into osteo-calcareous tissue ; once into a sac filled with blood J once into a sac containing fatty and calcareous matter. In all the cases except one avulsion had occurred in the left ovary. In all the displaced ovary adhered either to Douglas's cul-de-sac, to the sig- moid flexure or to the pubis, rectum, epiploon, mesentery, or abdomi- ^ Bucquoy {Soc. med. des Hopitaux, Dec, 1866), quoted by Mauriac in his translation of West. ^ Mcmoire sur V arrachement des trompes et des ovaires, &c. {Allgemeine Wiener medizinische Zeitung, 18J0, Nos. 2 — 4). 778 UTERINE DISEASES IN DETAIL nal wall, the adhesions being the last traces of circamscribed peritoni- tis. In cases of intestinal adhesions laceration appeared to be caused by the dragging resulting from the alternations of distension and vacuity, and from the peristaltic and antiperistaltic movements of the intestine. In two other cases, originating probably in childhood, the cause of avulsion was undoubtedly the physiological development of the uterus, and in two others gestatory hypertrophy. In one case there was strangulation of the Fallopian tube and ovary from twistiug round their axis. Turner^ found in the necropsy of a woman of 75 a tumour of the size of a fcEtal head firmly adherent to the peritoneum on a level with the sacro-vertebral angle, rising above the brim, fixed by adhesions and presenting all the characters of an ovarian cyst. It appeared that the uterus had been united to the floor and to the left wall of the pelvis by long-standing perimetritis. The left ovary, increasing in size in consequence of its cystic degeneration, had probably risen gradually out of the pelvis, dragging the Fallopian tube and broad ligament to the left side. These organs not having been able to yield more on account of the uterine adhesions and of the contraction of these adhe- sions, had become atrophied, and finally the left ovary had separated from the uterus. HI. I'uhal tumours. — I have already spoken of several maladies which may produce general or partial increase of size and even a solution of continuity of the tubes : inflammation, catarrh, circum- scribed obliterations, the accumulation of mucus, of epithelial ele- ments, suppuration, abscesses, haemorrhages, with free discharge or retention of blood and pus, with peripheric adhesions, dilatation or ruptures of the oviducts, fibroids, tubercle, &c. Cancer is rarely seen in the tubes. It is more apt to appear there as an extension of uterine cancer than of cancer of the ovaries ; for the Fallopian tube may be seen in a healthy state lying on the diseased ovary, contrasting by its small size and integrity with the enormous tumefaction and serious degeneration of the germinative organ. The only tumours which yet remain to be described are tubal dilatations, due either to excessive or disordered mucous secretion, usually coinciding with contraction or atresia of their canal, either from a cyst developed within their walls, in their neighbourhood, or even in the cor- responding ovary, and possibly communicating with the enlarged cavity. I. When there is tubal dropsi/, i. e. dilatation of these organs by the accumulation of a sero-sanguinolent fluid or of a mass of cells or debris of epithelium which may have been taken for tuberculous matter, the malady may appear under various aspects. Sometimes only one tube is aftected, sometimes both organs are attacked almost equally and symmetrically, llarely the diseased oviduct is free and presents no alteration at its peri])hery : usually it bears traces of pre- vious inflammation, and is connected with the neighbouring parts, with the posterior surface of the uterus or ovary by pseudo-mera- ' Edinburgh Medical Journal, 18G1. PELVIC TUMOURS 779 branou8 adhesions which deprive it of all mobility. The disorder may extend the whole length of tiie tube, but more frequently it is limited to one half of this canal : the portion which appears the most prone to disease, the one in which the mucus accumulates in greatest quantity and the distension of which is most frequent and most con- siderable is the external or ovarian half. When the whole tube, or half of it, is dilated by the uniform accumulation of fluid, the organ in spite of its dilatation preserves to some extent its normal form and presents the appearance of a portion of the intestine with somewhat incomplete circumvolutions, unequally distended by its contents; when on the contrary the dilatation is limited by neighbouring oblite- rations, or by the resistance of a cystic envelope in which the fluid Fig. 426. — Fallopian tubes distended in their external or ovarian portion by a fluid collection, and a small cyst attached to one of the tubes (Hooper). which occasions the distension is contained, the tumour is circum- scribed and globular, and the rest of the organ, hardly exceeding its normal size, is neither perceptible to touch nor to sight. I have sometimes seen tumours like those I have just described and similar to those mentioned by De Haen,^ Monro,^ Boivin and Duges,^ Kiwisch,* Becquerel,^ Scanzoni,^ Eokitansky,''' Klob,® &c. ^ Prad. Med., iii, 313. ^ An Essay on Dropsy. London, 1765. 2 Op. cit., ii, 590. Atlas, pi. xxxv, fig. 1. ■» Klinih. Wortrug., ii, 202. Prague, 1849. 6 Op. cit., t. ii, p. 278. ^ Op. cit., p. 371. ' Lelirbuch cler pathol. Anat., iii, 41.0. Vienna, 1864. ® Path. Anat. der weib. Sexmdorganen, p. 288. Vienna, 1864. 780 UTERINE DISEASES IN DETAIL It is evident that there are no other elements for diagnosis than those which I have already described in speaking of salpingitis and tubal abscesses ; and there is no doubt that the difficulties of diagnosis have frequently led to tubal cysts being taken for ovarian tumours.^ 2. The existence of tubo-ovarian cysts is estabhshed by five very interesting cases described by Adolphe Richard/ and by others already quoted by Morgagni, Franck, Chambon, Boivin and Duges, Kiwisch, FoUin, &c. It is proved by these cases that ovarian cysts may open into the uterus by the medium of the tube ; that after having received the cystic fluid the Fallopian tube continues to undergo patho- logical change ; that its calibre increases, its length doubles, its walls thicken, and the folds of its mucous membrane partly disappear; that the dilatation gradually reaches the internal portion of the oviduct, that a communication is established between the canal of the dilated tube and the cyst, and that from that time the complex cyst is formed, rightly designated as tubo-ovarian by Richard, which is probably somewhat allied to the malady described by Rokitansky under the name of profiuent dropsy of the tubes. It is in cases of this kind that cathe- terism of the tubes may be performed. Although in normal conditions tubal catheterism is absolutely impossible, nevertheless in cases of menstrual retention or of dragging upon the tube by a fibroma above and in the axis of the uterus or of profluent tubal dropsy, the sound can really be passed from the uterus into the tube. This penetration, seen by Biedert and others, has been verified at an autopsy made by BischofF (Hayem, Revue des sciences med., 1878, t. xi, p. 583). This malady or a tubal abscess is apt to be confounded with a purulent col- lection, circumscribed by peritoneal adhesions round the ovary and tube, and evacuated directly by the genital canal through the medium of the oviduct, a disease which was once seen by Koeberle [Nouv. Did. de med. et de chir. prat., art. Ovaire, t. xxv, p. 500, fig. Paris, 1878. It is not possible to give any rule of treatment for these cysts or for tubal dropsies. Nevertheless evacuation by the vagina may be tried if symptoms occur which seem to indicate it, and in the absence of any contra-iudication. IV. Tumours of the broad ligaments. — These are fibrous tumours, myomata, cysts of Rosenmiiller's organ, hydatid cysts, &c., without counting the abscesses described when treatiag of perimetritis and tumours of the tubes, ovaries, or uterus insinuated by their progressive development between the folds of these ligaments. 1. Fibrous tumours and myomata of the broad ligaments. — These must not be confounded with sub-serous or intra-parietal myomata of the displaced uterus which have been expelled as an effect of their development and have become intra-ligamental. They may also be developed in the round ligament, as in the case of stone in the round ligament mentioned by Walter. Diagnosis is uncertain, treatment is the same as that for ovarian and peri-uterine fibroma. ' Puistienne, op. cit., p. -47. '^ Memoircs de la Societe de chi'rurgie, t. iii, p. 121. Paris, 1856. PELVIC TUMOURS 781 2. C^sts of the broad ligaments occur more frequently in children than in adult women, in the folds of the broad ligament, between the Fallopian tube and ovary, and especially in the lower portion of the tube near the fimbriated extremity; they are small cysts varying in size from that of a millet seed to a small nut, sometimes sessile, more frequently attached by a pedicle of from one quarter to two inches long ; the envelope and contents are transparent and are usually regarded as the remains of one or more blind tubes of Eosenmiiller's organ (fragments of the Wolffian body).i Whether they are produced by an abnormal dilatation of one of the elements of the Wolffian body, or whether they result from a new formation, as Virchow^ supposes, pediculated cysts are chiefly met with in children and cannot be diag- nosed during life ; interstitial cysts (between the folds of the broad ligament) may attain the size of an t^'^, an apple, or even of a foetal head. They have a tendency to remain stationary, and may disappear suddenly by rupture.^ Diagnosis is uncertain. If they do not dis- appear by resolution, and if they become large, they may be removed by operation similar to that for ovarian cysts. It is for these cysts that enucleation without either section or hgature of the pedicle may be tried. As for hydatid cysts of the ovaries and broad ligaments, the same re- marks apply to them as to the same tumours in any other part of the abdominal or pelvic cavities. V. Abdominal and pelvic tumours common to loth sexes, hut giving rise in the woman to errors of diagnosis. — Those which seem to me to have a special claim to mention are : the so-called encysted dropsy of the peritoneum, hydatid cysts, and floating tumours of the abdomen. 1. Sero-purulent cysts of the peritoneum. — These are serous and sometimes purulent collections between the peritoneum and the abdo- minal muscles, or rather abdominal walls, in the sub-peritoneal cellular tissue, sometimes between the parietal or visceral peritoneum and a broad false membrane limiting an enclosed space in some region of the serous membrane, especially in the pelvic cavity. Therefore we may distinguish : parietal cysts and intra-abdominal cysts. The former are usually situated in front, but are occasionally found behind.* The latter are formed either in the epiploon or by adhesion and the encyst- ing of a fluid in an accidental intra-peritoneal cavity. Sometimes even a hydatid cyst may exist simultaneously in the abdominal wall.* These collections, described as early as the 16th century, were attributed by Nuck^ to an effusion in the space between the peritoneal fold which was supposed to be double ; but they could not have such an origin. Not only do they seem to be exclusively situated either in the sub-peritoneal ' Verneuil, Recherches sur les Jcystes de I'organe de Wolff {Mcmoires de la Sac. de chir., t. iv, p. 58. Paris, 1854). — Kocberle, ai-t. Ovaiee in Diet., &c. 2 Op. cit., t. i, p. 260. ' West, op. cit., p. 521. * Boinet, Bulletin de la Soc. Anat., t. xix, p. 285 ; t. xxvii, p. 20. — Puis- tlenne, Tmneurs enhystees pelviennes et abdominales, p. 75. Paris, 1866. 5 Degner, Act. nov. curios, natures, t. v, Obs. 2. " Ohset-vations rares de medecine, t. ii, p. 176. Paris, 1758. 7«2 UTERINE DISEASES IN DETAIL cellular tissue or in an adventitious^ intra-peritoneal cavity, but they are apparently almost always the consequence of peritonitis. The researches of Bernutz- tend to include the so-called encysted dropsy of the peritoneum among cases of perito'aitis encysted by adhesions, as they have also included the majority of peri-uterine phlegmons among cases of adhesive suppurative and "incysted peritonitis. Bernutz has compared all the cases of encysted dropsy of the peritoneum analysed by Morgagni, as well as ail those indicated more recently, as examples of this so-called encysted dropsy ; he has collected in all 36 cases, and has not found in one any proof of the reality of this malady. The diagnosis is sometimes so difficult that they have been taken for ovarian cysts. The treatment, more difficult still, does not differ from that of pelvic peritonitis or of other sero-purulent intra- peritoneal collections. 2. Hydatid cysts. — Charcot^ has collected 12 cases of hydatids of the pelvis, 6 in women, 2 in which the hydatids were originally de- veloped in the ovary. Several coincided with the development of hydatids in other parts of the body. Their usual starting-point is the sub-peritoneal cellular tissue, either between the rectum, vagina and uterus, under the peritoneum which forms the recto-vaginal cul-de- sac, or between the uterus and bladder, or in the broad ligaments, forming a tumour to the right and left in the vagina (Roux). In cases in -which the ovary appeared to be transformed into a hydatid cyst it had fallen into the vagino-rectal cul-de-sac and had contracted adhesions with the neighbouring parts. Hydatids of the pelvis form, in woman, a smooth, rounded, fluctuating, indolent tumour, project- ing towards the rectum and vagina, or even above the pubis, when it is developed in front of the uterus. The symptoms are those of com- pression and sometimes of inflammation. The presence of hydatid tumours in other parts of the body is a valuable element of diagnosis. The hydatid thrill is seldom perceived. The escape of the hydatids is the only certain sign. These tumours are often confounded with commencing or even with large cysts of the ovary, especially when they are developed in front of the uterus, or in the epiploon, in the left hypochondriac region, in the liver, and even in the kidney. The treatment is the same as for hydatid cysts of the abdomen in man : the potential cautery, opening of the sac, destruction and expulsion of the hydatids, injection and compression of the cyst. 3. Floating tumours of the abdomen are ovoid, of the size of a turkey's egg, solid in consistency, usually situated in the right hypo- chondriac region or in the loins, rarely on the left, sometimes on both sides symmetrically, descending even to the iliac region ; they are seldom seen in man but frequently in women. According to Cru- veilhier,* Fritz,^ West,^ and other observers they are only Jloating ' Guyon, Diet, encydopedique des sc. medic, art. Abdomen, i, 183. ^ Unpublished paper, quoted by Puistienne, op. cit., p. 76. ' Mem. sur les tumeurs hydatiques du petit bassin {Gazette medicale de Paris, 1852). ■• Anatom. patholog. generate, t. ii, p. 723. * Archiv. gen. de med., 1859, t. ii, pp. 158, 301. * Up. cit., p. 559. PELVIC TUMOURS 783 kidneys, expelled from their natural position by a sudden shock or by the exaggerated and continuous compression of corsets (Cruveilhier), They are more easily distinguished from tumours of the ovaries, broad ligaments and tubes than the majority of the other abdominal or pelvic tumours which I have just described. VI. Extra-uterine pregnancy. — Wherever the seat of the extra- uterine pregnancy may be, whether it is ovarian, tubal, tubo-inter- stitial or abdominal, it has among other consequences that of pro- ducing a tumour which owing to its position and the variable sym- ptoms by which it is accompanied, often passes either for a malady of the uterus or of the annexes. I shall only consider it from this point of view ; for its complete history special works should be con- sulted.^ Diagnosis. — Three periods should be distinguished : 1, that which corresponds with the beginning of pregnancy and extends to the fourth or fifth month, till the fcBtal movements are perceptible ; 2, that which extends from this time to the natural term of gestation ; 3, that which follows the normal period when delivery should take place, and which is characterised by the death of the foetus, its mummification, its various alterations, the suppuration of the sac, &c. 1. Interrupted menstruation, which is so important in the diagnosis of simple pregnancy, is much less so here : whilst there are cases in which the menses continue abundantly and normally during the first period, there are others in which they cease to flow from the first appear- ance of pregnancy, only reappearing after the death of the child. In the majority of cases vomiting occurs ; it appears even more obstinate and violent than in normal pregnancy. The mammary glands are also usually enlarged, the areola becomes brown, the tubercles described by Montgomery are developed, but it may be that this change of size is not very marked, and that the colour of the areola loses its importance from the fact of a previous pregnancy. A more marked phenomenon, described in all cases that have been carefully observed, is a more or less acute abdominal pain analogous to that which is designated under the name of uterine colic. Commencing in most cases shortly after conception it lasts to the end of pregnancy, with alternations of in- crease and diminution ; the seat of this pain is in the hypogastrium and the flanks. To give an idea of the difliculties of such a diagnosis I reproduce the accompanying figure which shows the general appear- ance of a tubal pregnancy and the interesting peculiarities which characterised this ad-uterine pregnancy (i. e. in one cornu of the uterus), which in this exceptional case was taken for a tubal preg- nancy. 2. Towards the fourth month, and especially in the beginning of the fifth, we are authorised to be more explicit, without, however, being secure from all error. There was a well-known case not long ago of a woman who was examined by most of the physicians and 1 Velpean, Did. de mcd. en 30 vol., t. xiv. — Dezeimeris, Journ. des connais- sances viedico-chirurgicales, 1836. — Triadou, Des grossesses extra-uterines. These d'agvegation. Montpellier, 1866. 784 UTEEINE DISEASES IN DETAIL Fio. '127. — Pregnancy in a closed cornu of a uterus bicornis, taken for a tubal pregnancy (Kussmaul, op. cit., p. 155, fig. 45 ; from a preparation by Heyfelder) : a, body of the right unicorn uterus, the cavity of which was lined with a decidua ; b, its cervix ; c, vagina ; d, top of the riglit cornu ; /, right ovary ; e, right oviduct ; g, right round ligament ; h, left rudimentary cornu in gestation ; i, tissue uniting the left to the right cornu, in the midst of which were found the remains of a canal destined probably for a means of communication between the cavities of the two horns ; k, left round ligament ; I, muscular fibres proceeding from it to be inserted into the body of tbe right horn ; m, peritoneum ; n, left oviduct ; o, left ovary, with a very large corpus luteum ; p, laceration of the gestatory portion ; q, placenta ; r, membranes of the ovum ; s, umbilical cord ; t, embryo. PELVIC TUMOURS 785 surgeons of the Paris liospitalsj aiul considered as having an extra- uterine pregnancy, and who was delivered naturally at the end of the ninth month to the great astonishment of Hiiguier, who published the instructive case : it is right to mention that Dubois was not mistaken in it. In an analogous circumstance Pajot diagnosed a normal pregnancy in an exceptionally attenuated uterus, a diagnosis which proved to be correct. I have seen a similar case taken for extra- uterine pregnancy by a justly esteemed practitioner ; I not only cor- rected the diagnosis but prognosed premature delivery, which soon occurred. In another case Schlesinger^ diagnosed an ovarian preg- nancy in a woman who was delivered normally at term : the cause of this error was a tumour in the right inguinal region. Though in such cases it is easy to make a mistake, there are nume- rous indications authorising the physician to pronounce a decided opinion. We observe on the one hand that there is pregnancy, from the foetal movenaents and from the information furnished by ausculta- tion ; on the other hand, that it has an unusual position, as examina- tion by the vagina and abdomen discovers a tumour situated on one side, painful on pressure and distinct from the uterus, the upper limits of vi'hich can often be felt. The difficulty of effecting intra-uterine hallottement, the small size of the womb, the displacements of this organ above, below, or to one side, according to the position of the extra-uterine cyst, are all indi- cations of extra- uterine pregnancy. Lastly, when the natural term of pregnancy arrives, the patient is attacked by labour pains ; these pains are prolonged for three or four days, cease and return at intervals without effecting anything. This symptom alone would serve as a certain basis for diagnosis if any was required at this period. 3. When the foetus is dead, we must judge from the history of the case, i.e. from the previous symptoms which may pass as signs of ges- tation and of extra-uterine pregnancy. Besides these, direct examina- tion, palpation, touch, the perception of irregularities characteristic of the various segments of the foetus through the sac which encloses them, &c., will help in distinguishing the foetal cyst from ovarian, tubal or abdominal tumours, whether solid or fluid, serous or puru- lent, traumatic, inflammatory, or diathetic, with which they might be confounded. Treatment. — It is rare for extra-uterine pregnancy to reach its natural term : the statistics of Campbell, Hecker and Mattel, as well as those which Puech has communicated to me, prove that it is quite an exceptional circumstance. In three quarters of the cases the cyst is ruptured before this period. This termination, which is rather less frequent in abdominal pregnancy, may be said to be the rule in inter- stitial, tubal and ovarian pregnancies. Extra-uterine pregnancies are susceptible of different terminations. Sometimes the cyst is ruptured, and then this rupture either produces a haemorrhage which is fatal in a few hours, or acute peritonitis fatal 1 Casper's Wochenschrift, 1845, No. 31. 50 786 UTERINE DISEASES IN DETAIL in from two to ten days, or circumscribed peritonitis which may be successfully treated. In the latter case, matters may go on just as when the cvst does not rupture. Sometimes the cyst does not rupture and resists* the pressure exercised on it from within by its contents. The embryo then dies prematurely, or it reaches the ultimate limits of its development and dies from insufficient nutrition. In both cases it may happen that the cyst is tolerated, or that nature makes efi'orts to expel it. When tolerance is established the cystic walls are modified, vascularisation diminishes and the amniotic fluid is absorbed ; the product of conception shrinks and shrivels up, and undergoes the waxv transformation of which there are numerous examples, Puech having collected 35 cases. When tolerance cannot be established, which is especially observed when the foetus is large, the latter irri- tates the neighbouring parts by its presence, provoking expulsive eff'orts. The cystic walls become inflamed, contract adhesions with the neighbouring parts and cause death more or less rapidly, accord- ing to the degree of inflammation, and also according to the strength of the patient. Peritonitis is therefore the most frequent cause of death ; next to it come exhaustion, hectic fever and purulent infec- tion. More frequently nature creates an exit for the contents of the cyst, either externally or into a cavity. After more or less serious svmptoms have lasted for some time, an abscess is formed and opens at some part of the abdominal walls, into the interior of the rectum, or more rarely into some other point of the intestinal tube, into the vagina, into the bladder, or it may be that it escapes by several of these channels simultaneously : vagina and umbilicus, rectum and bladder, rectum and vagina. Nothing is more variable than the period when this work of elimination commences ; it has occurred immediately after the death of the foetus, and at other times ten or twenty-five years later. Of all points of exit the rectum is undoubt- edly the most dangerous, but it is not so serious as has been said, for out of 69 cases there were 45 cures. It is, however, serious enough, causing as many deaths as all the others put together. Extra-uterine pregnancy is one of the most dangerous conditions that can be met with ; although the maximum of danger is at the beginning, since a woman in apparent heaUh may succumb in a few hours, it must not be forgotten that danger continues to the end ; hence the necessity of medical intervention and the obligation of laying down rules for the conduct of such cases. The indications vary according to the three principal periods of the disease already men- tioned. 1. In consequence of the danger which threatens the mother, and the inevitable death of the child, we are justified in considering whether it would not be better to arrest this pregnancy from the beginning by preventing the development of the embryo. There are, however, serious practical difficulties in the way of various kinds, especially those relating to the difficulty of diagnosis ; for it is really impossible to diagnose an extra-uterine pregnancy with certainty before the second month. Now statistics prove that it is at this STEEILITY 787 period that the most serious consequences of interstitial or tubal preg- nancies might be most certainly prevented, and that there is some chance of triumphing over the dangers inherent to this state. However that may be, if we succeed in making a diagnosis we should not hesitate to inject atropine or morphia into the tumour, using a syringe with a long cannula, as l\"iedreich ^ did, to arrest the development of the embryo and the increase of the tumour simultane- ously. We could also arrive at the same result by electro-acupunc- ture as employed by Burci and Bartoloni ^ in a case of tubal pregnancy at the third month ; I should however prefer the former method. 2. The difficulties of diagnosis diminish in the fourth and fifth month ; therefore I hesitate less to recommend injections being made into the cyst at that time, being convinced that they would be useful and that we could act with more chance of certainty. It is true that at that time the fffitus would only be sacrificed at an advanced stage of gestation, and that the ulterior accidents of elimina- tion would not be so surely prevented. This serious decision however should never be made without a consultation ; even at this period it is not always easy to diagnose extra-uterine pregnancy. If the child has reached the ninth month and is still living and if the mother desires an operation, gastrotomy might be attempted, although there is little hope of success. In this case as in those in which the child is dead, an incision should be made as nearly as possible at the point where the foetal head is supposed to be, the only reason for another point being chosen would be the fact of its being lower down and of the skin being thinner. 8. When pregnancy is more advanced, when the child is dead and the mother suffers only moderately, we may wait, but if a process of elimination is developed, intervention is indicated, either by opening the tumour with Vienna paste, or, if it is already opened, by enlarging the orifice with the bistoury, so as to be able to extract the bones and foetal fragments more rapidly. As for the point of incision in such cases it ought to be where this work of elimination is being carried on; if this points in several directions, the abdominal wall should be preferred. Sterility Sterility^ may be the result of three distinct conditions, the cause of which is more especially dependent on the woman, the seat of which is deeper, and the cure more difficult in proportion as we pass from the first to the second and from the second to the third. 1 Gaz. hebdom., 1864, p. 716 ^ Union medicale, 4 April, 1857. ^ As for the importance of sterility in gynrecology, it is sufficient to mention that Simpson, making investigations as to the frequency of sterility, found that out of 1252 marriages, 146, that is, ahout 1 in 8*5, were sterile. Spencer Wells found also that 1 out of every 8 married women is sterile. Sims arrived at the same result, and I am surprised at the increasing number of women who consult me on this matter. 788 UTERINE DISEASES IN DETAIL These three conditions are : 1. Inaptitude for coitus or impotence. 2. Inaptitude for conception or infertility. 3. Inaptitude for germination or sterility strictly speaking. These various inaptitudes may be temporary or permanent, relative or absolute, curable or incurable. They are so in different degrees : inaptitude for germination, for example, is the one which is most frequently incurable and the most complete. I. Inaptitude for coitus or impotence. — It is more limited in the woman than in the man. The woman in a manner playing a passive part in coitus it suffices for the vulva and vagina to be sufficiently open to receive the penis and permit of copulation. There are, however, malformations of the external genital organs, congenital or accidental, teratological or pathological, which may render a woman temporarily or permanently impotent. Vulva. — Apart from adhesions of the labia, which are always of accidental origin and which hinder intercourse, I do not know of any vulval lesions, strictly speaking, capable of causing sterility except the conformation designated by the name of transverse female herma- phrodism, for in such cases, although menstruation is regular preg- nancy is exceptional. If consulted for a case of this kind, we should imitate Coste^ in making a vagina and amputating the clitoris : and perhaps the desired result would be obtained. It is needless to say that this attempt should not be made unless one is assured of the existence of menstrua- tion and of the development of the uterus. The same precautions should be taken in a case of absence of the vulva ; for, with the exception of Magee's" and Rossi's^ cases, this is usually accompanied by the absence or atrophy of the uterus. I have seen women in whom excessive length of the nymphse, inclining towards the vagina at the moment of intromission, constituted, if not an insurmountable obstacle, at least a serious difficulty in the way of coitus : in one case I removed them, and attributed to this circumstance the cessation of absolute steriHty which had lasted for five years ; in another case, this excessive length coincided with a congenitally narrow os. The influence of the nympha3 on sterility ought to be much more marked when they are aff'ected with elephantiasis or even with simple hyper- trophy, the consequence of syphilis for example. Va/jma. — The anomalies of deficiency, bifidity, and the abnormal opening of this canal may be causes of impotence. Anomalies of deficiency may be either congenital or accidental, partial or total. The total or partial absence of the vagina from defective formation or arrest of development, imjierforate hymeu, membranous occlusion of the lower part of the vagina, and extreme narrowness of this canal^ ' Journ. des connaissances med.-chir., t. iii, p, 276, 1835. " The Lancet, 23 July, 1842, p. 575. 3 Annales de Montpellier, t. xiii, p. 39. ■• Delaunay, Etude stir le cloisonnement transversal dti vagin. Theses de Paris, 1877. STERILITY 789 should be mentioned in the first rank. I shall confine myself to men- tioning that_, in such cases, the treatment instituted for the re- establishment of menstruation is the approjjriate one for the cure of sterility. Only it is to be remarked that, when retention of blood is prolonged for several years, subsequent disorders of the uterus, ovaries and tubes may result, rendering conception impossible. The sterility observed by Bccasseau, Kluyskens, Chevalier and Patry^ in the patients on whom they operated may be explained in this way. Congenital narrowness of the vagina throughout its whole extent is rare. Nevertheless, Antoine,^ de la Toison,'^ Plenck,'*' Benevoli,'' Denman** and Scanzoni'^ have given very curious examples of it. In these cases it was not so much menstrual disorders as difficulties in the way of coitus that attracted the attention of these physicians. The remedy for this condition is dilatation. When occlusion of the vagina is not complete conception may occur exceptionally, even when intro- mission is impossible. I knew a woman in whom the vesico- vaginal septum was destroyed and the vagina obliterated at the vulva, except at one point, where there was an opening large enough to admit a female catheter, by which the urine escaped ; since her confinement, the cause of this lesion, more than a year before, menstruation had not occurred; in spite, however, of these unfavorable conditions, conception took place, pregnancy arrived at term, and the patient died from the consequences of labour. Bifidity of the vagina, i. e. its longitudinal division, is only a cause of sterility when the calibre of the two vaginal canals is so contracted as only to allow of imperfect intromission, or when the half of the organ in which coitus is practicable ends in an atrophied half of a uterus. Laaser^s^ case may be mentioned as an example of the latter category. In such circumstances the physician may dilate one of the two vaginse artificially, or, if dilatation be insufficient, the division may be removed as was done by Laaser. In a case of the same kind (double uterus, double vagina and congenital vagino-rectal fistula) I succeeded in destroying the longitudinal division of the two vaginse by the application of a long enterotome and the obliteration of the fistula by suture. There may be abnormal orifices from the vagina into the bladder, urethra or rectum. The first anomaly, which is the rarest, has only been observed four times.^ It is only curable by surgical interven- tion, i. e. by the formation of a vagina, and the obliteration of the ^ Puech, Bes atresies des votes genitales de lafemme, p. 131. Paris, 1864. ^ Histoire de V Academic des sciences, 1712, p. 36. ^ Ibid., 1738, p. 58. ■* L'art d'accoucher, translated by Pitt, p. 119. '' Delle hernie intest. Florence, 1747. ^ Diet, en 60 volumes, art. Vagin. ? Op. cit., p. 4.80. ** Monatsehrift fiir GehurtsTcunde, 1864, Bd. xxiv, S. 441. •^ Clievreuil, Journ. de med. et de chir., 1772, t. xli, p. 447. — Kins^don, Gaz. med. de Paris, 1838, p. 283. — Costc, Journ. des conn, med.-chir., 1835, t. iii, p. 276. — Huguicr, in Lefort, op. cit., p. 203.— Puech, Mem. sur le cloaqae uro- genital {Montjpellier medical, 1868). 790 UTERINE DISEASES IN DETAIL abnormal opening : by enabling the menstrual blood to escape by the normal channel we may at the same time restore the power of concep- tion to the woman. The opening of the vagina into the rectum ^ is observed, on the contrary, much more frequently : it would take too long to mention all the cases that I have collected, nor is this the place to establish between them distinctions and divisions interesting from other points of view ; it is enough to add that the artificial /ormation of that portion of the vulvo -uterine canal which is wanting and obliteration of the abnormal opening are indicated. There are cases in which the vagina, though apparently normal, is nevertheless affected with some imperfection the influence of which on sterility is more real than would be supposed. Such are extreme shortness of the vagina,^ which favours the formation of a copulative sac and projec- tion of the semen outside the axis of the uterine canal; excessive length and breadth of this organ, which greatly increases the chances of the fertilising fluid being lost in the anfractuosities of this mem- branous canal without penetrating the uterus ; lastly, inequality of the two vaginal walls, the posterior one which is usually the longer form- ing a cul-de-sac behind the cervix, in which the sperm is acclimuiated. "When a congenital or acquired narrowness is added to extreme short- ness of the vagina it may lead to most troublesome consequences. Barnes says (op. cit., p. 113) that after the menopause, especially in women who have not had uninterrupted conjugal relations, the uterus, vagina and vulva undergo a kind of atrophic involution, by which they lose their dilatability, and which may render coitus not only pain- ful but dangerous. In the museum of St. George's Hospital (series xiv, 108) is to be seen a vagina the fundus of which was lacerated in coitus. Vicious insertions of tJie vagina into the uterus are also causes of inaptitude for fecundation. An anterior or lateral copulative sac is formed, or oftener still a posterior one (the uterus apparently being inserted in the anterior wall of the vagina, sometimes very near the vulva). This sac, most frequently congenital, sometimes acquired, forms a receptacle for the sperm, which is always unfavorable to fecundation. In place of being originally narrow, or subsequently contracted, the vagina and vulva may be in a state of coarctation produced by vaginismus or spasmodic contraction of the vagina and of the sphincter cunni. The efl'ect of this nervous malady is, that the introduction of even a small foreign body into the vaginal canal sometimes determines such acute pain as to produce syncope, which makes coitus for the time impossible. This state may last for years if not remedied by forced dilatation or other means. In a case of the kind conception was effected during anaesthetic sleep.^ 1 Murat, Diet, en 60 vol., art. Vagin. — Isid. Geo£Eroy-Saiut-Hilaire, Ano- malies de V organisation, t. i, p. 501. — Bouisson, Des vices de conformation de I'anus et du rectum, p. 39. Paris, 1851. Roubaud, op. cit., t. ii. "^ I have several times seen the vagina shorter tlian usual, as in Pfau's case, where after marriage it was only I5 inch long. * Sims, op. cit., p. 343. STERILITY 791 II. Inaptitude for conception or infertilitij may eitlier depend on mechanical or physiological causes. The sperm is hindered from coming in contact with the ovum sometimes by direct obstacles to the penetration of the semen, or by disease of the parts which the sperma- tozoa have to traverse ; sometimes by a merely functional impo- tence, a physiological alteration of the means of transport for tlie fertilising iluid or the localisation in these organs of a general morbid condition. Obstacles to concej)tion are the most common ctuses of sterility : some are incurable ; others, although numerous and depen- dent on various conditions, may be overcome and frequently yield to local or general treatment which may be applied according to the indications. 1. Mechanical and organic obstacles to conception. — They may exist in the uterus or in the tubes, or may result from the presence of pathological fluids in these organs, or of secretions unfavorable to the preservation of the germs. The sterility is sometimes incurable, at other times, on the contrary, it may be treated with more or less chance of cure, according to the nature and extent of these obstacles. Absence of the uterus and the emhryonic condition of this organ cause absolute sterility .1 The uterus sometimes preserves its fcBtal or infantile characteristics even after puberty; it may be either simple, imperforate (Duplay), or bicorn (Wehr of Cassel). This condition is apparently incurable, whichever variety occurs. Meadows,^ in a case of this kind, has tried galvanic sounds and pessaries, which however only produced acute irritation. Under the name of pubescent^ uterus Puech has designated the uterus which preserves after puberty the characteristics peculiar to this organ during the period of transition between childhood and puberty. He has seen two cases, one of which was confirmed by autopsy. In the latter case, although the woman had been a prostitute for twelve years, she had never menstruated; in the other, a woman of forty, haemorrhage from the vulva had only occurred three times at long intervals. The vaginal portion of the cervix is small and conical or presenting a warty projection of the size of a pea, the meatus is very small. The incomplete development of the uterus is discovered by vaginal and rectal touch ; by the latter, the upper borders of the organ are easily reached or exceeded. A probe introduced through the cervix demonstrates with certainty the defective length. Notwith- standing what has been said by Scanzoni as to the incurability of this lesion, it should be treated by the means indicated for uterine atrophy, ^ If absence of tlie uterus is the result of an operation, sterility is not absoUite. I have mentioned the case of a ladj on whom Kccberlo had operated (ablation of the uterus), but in whom be had unfortunately left the ovaries. A small fistula having persisted, which formed a communication between the vagina and abdominal cavity, this unfortunate woman had an extra- uterine abdominal pregnancy, a most remarkable occurrence, showing the limited part which the uterus plays in the accomplishment of reproduction. 2 Gaz. vied., 1805, p. 10. ^ Incomplete development of Kiwisch, Rokitansky and Scanzoni. See l^. 80. 792 UTEEINE DISEASES IN DETAIL especially by electricity or by Simpson's galvanic pessary, the intro- duction of which may be accompanied when necessary by dilatation. Iron and other tonics should also be administered. The uterus may be to all appearance normally developed and yet have no cavity, either owing to arrested development of Miiller's canals when they are still solid, from the eighth to the tenth week, or as the result of precocious adhesions of the opposite walls of the mucous membrane. This very rare state, of which Boivin and Duges give an example, is like the pre- ceding compatible with perfect health, and is manifested by the absence of menstruation, and of the signs of menstrual retention, not- withstanding the existence of symptoms of monthly ovulation ; by the impossibility of conception, although intercourse may be easy ; by the imperforation and impenetrability of the uterus in spite of the deve- lopment and external appearance of this organ being almost normal. Uterine atrophy is all the more deserving of attention because it may be followed by cure, and consequently by the cessation of sterility. It is caused in the same way as atrophy of the ovaries or is produced after labour from the excessive retrograde evolution which takes place in the uterus at this period (p. 621). I have already spoken of the cases mentioned by Simpson in describing this remarkable malady ; I have seen several myself ; Puech has observed the same disease in a woman after delivery and eleven months' lactation ; and in another after repeated miscarriages. Although there is little hope of cure for this state when it is of long standmg, the physician should not remain inactive; he should on the contrary strengthen the constitution by tonics, hydropathy and sea-bathing, and also apply electricity to the uterus, introduce galvanic stems, and so endeavour to produce new vitality in the organ. There will be all the more chance of success, if treatment is instituted soon after delivery. Uterine atrophy may affect the whole uterus, or only one of its segments. The same treatment is applicable to either segment, and to the whole uterus. Simple or complicated imperforation of the cervix is a cause of sterility which may be treated successfully, especially if it coincides with normal conformation j for it is frequently accompanied by an abnormal position and form. It is the same with septa situated in the vagina more or less near the cervix, imperforate or pierced with a hole, or membranous contractions of this canal which, without being a cause of impotence, yet prevent conception ; it is the same with con- genital narrowness or accidental contractions of the os, which is so frequent a cause of mechanical dysmenorrhcea.^ I have already spoken of these pathological states (p. 305) ; and shall only remark here that they play an important part in sterility, and that as they are not always accompanied by menstrual disorders, it is easy to misinterpret the real cause of sterility in these cases if a direct examination is not made. I have also described the treatment which is suitable for them during the paroxysms of pain attending menstruation, as well as in the inter- calary periods, in palliative as well as in radical cure ; and shall only further remark, that radical cure is only produced by dilatation or Oldham wa-s the first to use this name (Lotidon Med. Gaz., vol. ii, p. 91U). STERILITY 793 double incision of the cervix (p. 313). Local treatment should always be followed by general tonic treatment and diathetics, according to the case, and by the use of ergot, electricity, purgatives, &c., with the object of resolving the congestive condition due to the long-standing atresia or contraction. Congenital or consecutive contractions may affect the os internum. They should be treated in the same way as those of the vaginal orifice, by gradual dilatation, which is less dangerous and more lasting in its effects than simple incision. It is the same when they affect the two orifices of the cervix simultaneously, and provided there is neither contraction nor atrophy of the cervical cavity, we may hope for cure. Dilatation has the great advantage of \>m\^^Tesohent as well as dilative; so that in some cases gradual dilatation by sponge tents may not only procure a palliative but a radical cure in contractions of the uterus as in contractions of the urethra, especially if we associate with the mechanical action the chemical one of medicaments such as bella- donna, the red oxide of mercury and others, in the form of resolvent ointment covering the tent ; it is also useful to administer these drugs in enemata, and to pour glycerine on the cervix, keeping it there by a large plug of cotton wool; for it softens the cervix as well as con- tributing to the cessation of the contraction or relaxation of the orifice. Torsion of the body on the cervix (pp. 309, 430) is another mecha- nical alteration producing effects of the same kind, and in consequence of which a deviation occurs vrhich renders penetration of the sperm difficult or impossible. The long continued use of laminaria tents, which act simultaneously by enlarging and straightening the isthmus, greatly facilitates conception. It is unnecessary to say, that the asso- ciation of general means with local applications is still more important here than in the preceding cases ; for torsion of the isthmus is almost always dependent on flexion, softening of the uterine tissue, or con- secutive chronic congestion, and consequently requires the use of resolvents, restoratives, tonics, sea-bathing and especially hydro- pathy. Flexions ^ are causes of sterility when well marked, and the sterility is incurable when the flexion is kept up by adhesions and cicatricial bands which make it impossible to straighten the uterus. There are two causes of sterility in such cases : the first is the mechanical obstacle, which hinders facility of communication between the cervical and uterine cavities at the isthmus : the second, the alteration of tissue, the morbid state, the softening under the influence of which flexion is produced and maintained. It is unnecessary to add that when adhesions prevent reduction of the flexion, especially of retro- flexion, these adhesions not only prevent conception by hindering the straightening of the organ, but further, are the indications of a previous inflammation of the uterus. Fallopian tubes and ovaries, or of peri- uterine inflammation. In such cases there are almost always altera- 1 Lumpe, Considerations sur la sterilite causee par I'injiexion de I'lderus {Monatschr., &c., 1864, Bd. xxiv, S. G9). 794 UTERINE DISEASES IN DETAIL tions of the uterine mucous membrane, obliterations of the tubes, alteration of the normal relationship of the ovary with the oviduct, vicious adhesions of the uterus and annexes, which are additional causes of sterility. I do not therefore speak of the means of treat- meut^to be employed in such circumstances. In the case of simple flexion we must endeavour, especially in a young woman, to straighten the organ (p. 420). In cases of complex flexion we may be obliged to perform partial section of the convex lip of the cervix, in order to form a direct course for the semen through the cervico- uterine canal (see Fig. 283, p 426). Sometimes simple version, or defective relations between the male organ which ejaculates the semen and the uterine meatus which ought to receive it, is suflicient to render penetration of the sperm very difficult if not impossible and to prevent conception. ^ Sterility caused by retroversion may be remedied by means of Hodge^s, Meigs^s or Sims's ring pessaries, which take up very little room in the vagina and which are no obstacle to marital intercourse. Sims ^ gives several examples, among others that of a lady who had three children, conception being due to the use of an annular pessary during coitus ; he mentions the case of other women who by the use of these pessaries till the fifth month were able to bring their preg- nancy to the full term. If permanent cure cannot be obtained tem- porary replacement is easily effected by posture, the association of palpation with digital touch, and by the use of the sound. Provided this replacement lasts for some hours, or can be effected by the husband during intercourse, it is sufficient to make conception pos- sible. I have seen several remarkable cases of this kind. Every alteration in the cervix and os uteri (alteration in size, form and structure, ulcerations, induration, &c.) becomes a cause of sterility from the difficulty which it places in the way of the accom- plishment of the cervical functions. The erection of the uterus ex- cited by ovulation and coitus, as Rouget's researches show, plays an important part in conception. The effects of this erection on the cervical portion cause an increase in its size and induration, suc- ceeded by relaxations and divergence of the walls, producing actual aspiration,^ as observed by Beck^ on the cervix of a multipara affected with prolapsus, which, when lightly touched, made five or six move- ments of aspiration within twelve seconds, accompanied by a voluptuous 1 According to Sims (op. cit., p. 237), out of 250 married women, who had nevei' had children, 103 were affected with anteversion and 68 with retro- version ; out of 255 who had had children, but who had ceased to conceive before the menopause, 61 were ai¥ected with anteversion and 111 with retro- version ; that is to say, out of 505 patients affected with sterility, natural or acquired, 343 presented deviations or flexions of the womb ; besides, as about one half of these women had previously been pregnant, it is probable that their acquired sterility depended on the mechanical lesion of the organ. 2 Op. cit., p. 281. ^ Weniich (Beitrdge zur Gehurtshunde v. Gyndc, i, 296, 308). '' How do the si^ermatozoa enter the uterus? (Med, and Surg. Reporter, 1872). STERILITY 795 sensation. It is easy to understand the importance of any alteration which prevents the production of these movements. Hypertrophy is the simph^st of all these alterations. Sterility usually accompanies the hypertrophic elongation of the supra-vaginal portion which simulates prolapsus. Sterihty is never more certain than when there is a concurrent alteration in the tubes or ovaries, often consecutive to hypertrophic elongation and prolapsus of the uterus. Huguier^ says — "I never knew a woman to conceive when once the elongated uterus had been so prolapsed as to have caused com- plete procidentia and inversion of the vagina, by which I do not mean to say that it has never occurred ; science would refute this assertion ; all that is necessary to make conception possible being for the utero- ovarian canal to be free.'" Hypertrophy of the vaginal portion is also a cause of inaptitude for conception, whether this slight hypertrophy is associated with marked conicity of the cervix, or whether it affects the whole of the cervix, or only attacks one lip. It was Lisfranc^ who first recognised conicity of the cervix as a cause of sterility, and who recommended section of the cone as the best treatment. There is no doubt that it is usually in cases of conical cervix that the penis slips over the cervix, dis- charging the sperm in an accidental copulative sac in which it runs a great chance of being lost. It is certain also that in such cases the os, whether situated at the apex of the cone or on one of its surfaces, is very narrow and circular, and may be included in the class of orifices con- genitally contracted, for which I have advised dilatation and division. A considerable sub-vaginal hypertrophy, whether with elongation or with tumefaction of the lower portion of the cervix, is also a cause of sterility. This cause is not absolute, but it only yields to surgical treatment ; if therefore we can be sure that it is not incurable, we may also be certain that it cannot be cured without amputation of the hypertrophied portion. Dupuytren^ has mentioned cases in which excision of the cervix was followed by conception. I have seen a sufficient number of cases to convince me on this point, and I can affirm that this operation affords patients a great chance of being cured when there are no complications. It is the same with hyper- trophy confined to one lip, for the orifice is then necessarily deviated, or partly obliterated, or at least concealed by the hypertrophied lip. If the reader wish to consider the causes of sterility due to hyper- trophy of the cervix from an exclusively practical point of view, he may refer to what I have said as to the various forms which hyper- trophy may assume, and which may be summed up in the following table : 1 Op. cit., p. 123. '■' Clinique de la Pitie, ii, 139. ^ F. G. Dumont, 8ur I'agenesie, V-wipuissance et la dysgenesia These de Paris, 1830. 796 UTERINE DISEASES IN DETAIL 1. Hypertrophy of the whole j ^^^^^^ ^^ ^^^.^-^ ^^^^ -^ ^,. -^^^ cervix ) T, , . 1 1 , , c C Supra- vao^inal — Almost always morbid. Partial _ hypertrophy of 3 ^ _= ^ Con-enitaL the cervix i bub-vaginai Hypertrophy of one seg- ment, anterior or posterior, of the cervix. fTotal I I ^Partial X Acquired. Very rare ; it causes incurvation. f Of the central portion or of the pilaster, the remains of the raphe of the cervical portion. Of the upper extremity (uterine .-{ uvula). /'Exuberance of Of the lower \ one lip. extremity . J Dovetailing of V^ the two lips. Hypertrojihij of the wJiole of one of the segments causes incurvation of the cervix^ the convexity corresponding to the hypertrophied seg- ment (usually the posterior one), and, like flexion of the cervix, some- FlG. 428. — Total hypertrophy of tlie posterior segment with in- curvation. 1. section of the free extremity of the vaginal portion (1st part of the opera- tion). Fig. 429. — Total hypertrophy of the posterior segment. 2. me- dian division of the remain- ing vaginal portion (2nd part of the operation). times necessitates amputation of the lip corresponding to this segment (Eig. 428, 1), followed by division of the rest of the vaginal portion of this segment on the median line (rig. 429, 2), so as to make a direct course for the penetration of the semen into the uterine canal ^ {seeY\^. 283, p. 426). Partial hypertrophy of one of the segments affecting the median portion has especially the effect of developing the size of the central pilaster, which is the trace of the raphe of the two primitive uteri, and of exaggerating the dovetailing of this central column of the arbor vitce with that of the opposite segment, or of one of the secondary fleshy columns which are connected with it with the corresponding columns in the other segment. It is often indeed complicated with unequal hypertrophies, either sessile or partly pediculated, which give to the cavity of the cervix a broken and mammillated appearance. The best surgical treatment, in addition to resolvent medical treatment, consists 1 Sims, op. cit., p. 214. STERILITY 797 in introducing sponge tents repeatedly and iu performing excision or simply abrasion of the dilated cervical cavity, as well as in the local application of resolvents, with which the sponge may be saturated or covered, and finally in the cauterisation of projecting portions of the bypertrophied organ which impede conception. In order to make 1, B Fig. 430. m Fig. 431. Fig. 430. — ^Valvular projection of the anterior portion of the isthmus. Fig. 431. — Sims's curette. I have had the concavity sharpened, so as to use it for abrading the valvular projection of the isthmus, when caught in the terminal fenestra of the instrument. By suppressing one side of this fenestra we have a small pruning hook, still more convenient than the curette, and which I have frequently had occasion to use. this cauterisation easily and to preserve the healthy segment from contact with or from the radiation of tiie actual cautery, I take care to seize the cervix with divergent tenaculum hook forceps or to intro- duce one of Recamier's large curettes, the blade of which serves as a conductor for the very small cautery employed for this purpose. Partial hypertrophy affecting one of the segments at its upper extremity sometimes gives rise to a kind of valve or jirnjecting tubercle (uterine uvula), which must not be confounded with a projecting angle of flexion, with which it sometimes coexists. The cervix having 798 UTERINE DISEASES IN DETAIL * been previously dilated by sponge tents, this little projection (Fig. 430, 3) may be abraded by means of a small hook with a somewhat malleable stem, to allow of variation of its inclination. Partial hypertrophy of the lower extremity of one of the segments, i.e. one of the lips, has a different effect according to whether it most affects the lip on the side of the vaginal surface or on the side of the cervical cavity. If it affects it on the vaginal side it renders the hp exuberant, so that it projects beyond the orifice which is above or below it ; hence the acuminated and rostral forms of the conical cervix, the blade and apron-like forms (by flexion) of the cuneiform cervix, and the snout-like forms of the cylindrical cervix; in such cases it should be cauterised or amputated. If the hypertrophy affects it on the side of the cervical cavity, it distends the opposite lip, attenuates it, becomes embedded in it, giving to the orifice a characteristic semi- lunar form (see p. 618, Figs. 355, 356). As a rule I content myself with applying the actual cautery, more or less deeply, to the centre of the hypertrophied lip, thereby provoking suppuration, which being followed by resolution and contraction, raises the convex border of this lip and rectifies the upper outline of the orifice (Fig. 193, p. 213). I have often seen conception follow this little operation. In such cases the patient should be advised to adopt the prone posture during coitus. In case the difficulty of rectifying the uterine canal should suggest to any practitioner the idea of attempting artificial fecundation, I will here describe the best method of proceeding so as to preserve the vitality of the sperm and the characteristic movements of the sperma- tozoa. The male organ should be covered with a shield, care being taken not to apply it tightly. Coitus being terminated the ejaculated fluid will remain in the shield which is then cut and the fluid received into a small glass syringe (previously heated by being placed for a few minutes in water at a temperature of 40° C.) furnished with a metallic or gutta-percha sound, by means of which and by using great care it will be easy to make it penetrate into the cavity -, the patient should then rest for a day. U'ujuVitij of the cervix may be the consequence of long-standing continuous congestion, or of indurated metritis. It should be treated successively by antiphlogistics, glycerine, alkaliues, and resolvents capable of softening the uterine tissue, then by sponge tents and scarifications, ignipuncture and, lastly, by division and, if necessary, by section of a pyramidal fragment of the tissue of one of the lips. Or- ganic alterations, fibroids, polypi and cancer, although not necessarily causes of sterility (I have mentioned cases of pregnancy in all these cases), considerably hinder the uterine functions, preventing in most cases the contact of the sperm with the ovum, or uterine pregnancy, or the continuation of a pregnancy beyond a few wei^ks. Lastly, abundant or abnormal secretions may prevent conception in two ways : mechanically or chemically. By a purely mechanical action an abundant leucorrhoca filling the uterus (even without going so far as to form hydrometria and pneumatosis), or a viscous, coherent. STERILITY 799 tenacious leucorrhoea, completely obstructing the cervix by a gela- tinous plug (analogous to that of pregnancy), make conception very difficult, either by preventing the semen from penetrating into the uterine cavity or by expelHng the sperm (supposing it has penetrated) by their abundance and the uterine contractions which impel them naturally towards the vagina.^ Chemically, the abnormal secretions of the utero-vaginal fluid (from the mucus of the womb being too alka- line or from that of the vagina being too acid) may kill the sperma- tozoa.^ It is probable that the latter, unless very abundant and very acid, has not much action on the mass of the ejaculation, the central portion of which it can hardly reach ; but it is probable that the former has an injurious influence on the relatively small quantity which penetrates into the uterine cavity.^ In a number of cases the abund- ance of the leucorrhoea and even its purulence does not prevent con- ception. Tubal maladies cause sterility by preventing the ovum from being received and the sperm from being transported by these canals, or both these elements from coming into contact and from undergoing the reciprocal influence known as fecundation. They may exist either without or within these organs. 2. Physiological obstacles to conception. — They depend on con- genital or acquired physiological imperfection or on functional dis- order caused by some morbid state. With regard to disorder of the normal physiological act, it may either be one of defect or excess. I have already mentioned the conditions of erection, general muscular contraction and orgasm in which the genital economy of woman should be at the time of periodical dehiscence, menstruation and coitus ;. there is no doubt that the divergence of the uterine walls, and the dilatation of its cavities produced by erection, greatly facilitate the entrance of the sperm. It is easy to understand that defect of orgasm, indicated by the absence of any voluptuous sensation, suffices to prevent erection and consequently the bringing into play of utero-tubal conditions equally favorable to the transport of the ovum and to that of the sperm. We do not know all the conditions connected with the accom- plishment of the internal acts of this function; for instance it has been asserted that women have conceived in spite of themselves, after rape, or unknown to themselves, during intoxication and sleep, or even after intercourse to which they had consented, but which had given them no pleasure. Although these facts can only be received with reserve I can affirm that I have known women who not only have never experienced the least pleasure, but have felt positive repugnance for an act which they only performed from duty, and yet have had several pregnancies. That is undoubtedly because vital orgasm, erection, ' Jobert de Lamballe published a worli on dropsy of the cervix and its in- fluence on conception in 1843. - Donne, Experiences sur les animalcules spermatiques et sur quelqties-unes des causes de la sterilite de lafemme {Gaz. vied., 1837). It should be remem- bered that alkaline fluids excite the movements and prolong the life of sperma- tozoa. 3 Joulin, op. cit., p. 162. 800 UTEEINE DISEASES IN DETAIL and the involuntary movements of the uterus and tubes may escape sensibility and perception, and may be produced independently of all voluntary participation and of all voluptuous feeling. These cases, however, are exceptional. The proof of this is, that in most women the voluptuous sentiment is only gradually awakened, as if by the education of a new sense, and that in such cases conception only occurs some time after marriage. According to Spencer Wells, out of seven fertile marriages delivery only occurs four times before eighteen months. When alteration of the physiological acts which influence impreg- nation depends on a definite morbid condition it is easier to seize the indications and to apply an appropriate treatment. These morbid states, or rather the general affections which keep them up (inflam- mation, rheumatism, scrofula, herpetism, &c.), usually cause sterility on account of the material alterations which they effect in the tissues of the internal sexual organs, such as tumefaction, ulceration, &c., or from alterations of secretion, such as leucorrhcea, or from haemor- rhage.i These morbid states often produce functional disorder, amenorrhoea, dysmenorrhoea, pains, absence of desire, &c. ; hence the repugnance which a number of women affected with uterine disease experience for coitus. III. Inaptitude for germination or ovulation. — This is the most certain cause of sterility strictly speaking ; for inaptitude for fecun- dation (whether for the transport and union of germs or for the reception of the semen) is only an accident preventing the evolution or development of the germ, but in nowise affecting aptitude for repro- duction. Ovulation is the best proof that a woman can give of her aptitude for procreation. If the ova are formed normally in the ovary, if they reacli their maturity there and are expelled periodically, the woman furnishes the reproductive element peculiar to her, and thereby gives the best proof of reproductive capacity. If this physiological act cannot be established, or is suspended, or extinct, the woman becomes sterile. Sterility in such a case is often permanent ; it may however be relative or temporary : the former depends on the absence of the reproductive organ, on defective development, atrophy, or on an organic alteration or disorganisation of the ovary ; the latter on the suspension of the reproductive function of this organ under the influence of a local pathological state, of a more or less considerable partial degenera- tion of its tissue, or else on the reaction which it experiences from a general morbid affection, from the debilitating influence which is exercised upon it by a serious disorder of the health and con- stitution. Menstruation in its relations with sterility. — The causes of sterility which I have just rapidly reviewed are really so numerous that, in order to diagnose them, it is necessary to follow an artificial method based on 1 Menorrhagia is particularly formidable on account of its tendency to be reproduced when the ovum is newly fertilised, in which case there is abortion. In these instances sterility does not arise from defective conception but from some inpediment to gestation. STERILITY 801 the alterations which the most apparent sexual phenomenon, menstrua- tion, may undergo. We should therefore, first of all, ask a sterile woman whether this function is absent, anomalous, or regular. Absence of menstruation may depend on congenital absence, atrophy, arrest of development, or imperfection of some portions of the sexual economy, or on accidental lesions, suppuration, gangrene, adhesions, or obliterations of the same parts. The prognosis is almost always serious as regards the fertility of the woman ; except in slight uterine atrophy there is hardl)' anything to hope from treatment. Absence of menstruation may be associated, although rarely, wilh normal con- formation of the genital organs, merely constituting a physiological anomaly or imperfection, as is proved by the fact that women who have never menstruated have had children. Eondelet and Joubert^ have both published cases ; the former of a woman, who had twelve children, the latter of one who had eighteen, neither of whom had ever menstruated ; Colombat" knew another who had a child ; Tlechner^ speaks of a woman in similar conditions having had six pregnancies in thirteen years ; Barbieri,^ Bruck^ and Elsasser have each seen a case of the same kind. Stark's^ work on this subject should be consulted. It must however, be admitted that the physiological absence of menstruation is usually accompanied by sterility, and it is not certain whether it does not sometimes depend on a serious disorder, not only of the function but of the sexual economy. Therefore when consulted about a case of this kind, we cannot be too careful in giving an opinion, which cannot be based on a complete examination of organs inaccessible to our investigations. Anomalies of menstruation are produced either by mechanical causes or morbid states. The former are manifested under the form of menstrual retention, deviated menstruation, dysmenorrhcea, &c. ; the physician should discover the congenital or acquired origin and the superficial or internal seat of the obstacle to the free discharge of blood. The latter include amenorrhoea, leucorrhoea, dysmenorrhcea, menorrhagia, &c. ; it is important to know whether they depend on a merely local or a general condition, whether there is disease of the uterine mucous membrane, deviation or flexion of the womb, active or passive congestion, &c. ; or whether the patient is suf- fering from chlorosis, ana3mia, plethora, organic disorders, scrofula, constitutional syphilis, or any other diathesis. As these maladies do not always produce menstrual disorders, they ought to receive great attention when they do so and they then indicate the neces- sity for the association of general with local treatment. There is one which is all the more deserving of attention because apparently it does not prevent conception. 1 mean menorrhagia or metrorrhagia ; * Erreurs populaires, liv. ii, cli. I. 2 Op. cit., p. 34. 3 Gaz. med., 1841, p. 91. ' Gaz. med., 1843, p. 207. * Allgem. medic, central. Zeitung, 1854, No. 14. * Des grossesses stirvenues en Vabsence de la menstruaiion, Starh's Arcliiv filr die Gehurtshillfe. Jena, 1787. 51 802 TJTEEINE DISEASES IN DETAIL these are not in one sense absolute causes of sterility, because when hsemorrhage is arrested conception may occur (and frequently does) ; but from their tendency to be reproduced periodically, or under the influence of the slightest provocation, or even without any known cause, they expel the recently impregnated ovum, causing early abortion and recurring so frequently as to be equivalent to sterility. Lastly, whilst regularity of menstruation cannot coexist with certain malformations and organic disorders, or even with certain morbid conditions just described, it may do so with lesions of the uterine economy, with diseases of the neighbouring organs, or with general affections which cause sterility. The true cause of sterility, therefore, must be sought in one of the conditions just enumerated. If it cannot be so explained, it would yet be unjustifiable to assume the existence of one of the causes hypo- thetically suggested by investigators of this subject, such as defective sympathy or physiological incompatibility between the husband and wife. If we succeed in identifying the cause, it will still be necessary to act with great caution ; holding out only moderate hopes to those whom we expect to cure -, while we abstain from disclosing abruptly or unnecessarily to others the fact that in their case there is Httle ground for a favorable prognosis. INDEX Abdominal tumours, 774 Ablation of polypi, 229 — of fibroids, 229 Abortion, influence of, on uterine disease, 236 Abrasion of uterine fungous growths, 225 Abscess, pelvic, v. Peri-uterine inflam- mation. — peri-uterine, 556, 566 Acid nitrate of mercury as a uterine caustic, 209 Adenitis and angioleucitis, peri-uterine, 537 Age, influence of, on the development of uterine disease, 238 Amenorrhoea, 259 — symptomatic, 260 — idiopathic, 261 — sympathetic, 261 — psychical, 261 Amputation of the cervix uteri, 387 AnsBmia, symptomatic of uterine disease, 104 Anatomical characteristics of the sexual system in woman (variability of), 3 Anomalies of the genital apparatus, 65 — of the ovaries, 70 — of the tubes, 73 — of the uterus, 75 Apoplectic dysmenorrhcea, 323 Appearance, external, of abdomen (signs of uterine disease furnished by), 122 Appendages, inflammation of, v. Peri- uterine inflammation. Arsenical powder of Friar Come, 210 Arteries, helicine, of uterus, 36, 47 Ascent of uterus, 355 Ascites, uterine, 581 Asthenia, a characteristic of certain uterine diseases, 156 Atresia, vulval, 271, 274 — vaginal, 271, 275 — uterine, 271, 275 — congenital (imperforation), 271 — accidental (obliteration), 272 Atrophy of the womb, 620 — excentric, 620 — concentric, 621 Auscultation, a means of diagnosis, 121 Autoplasty, gynaecological, 229 — after amputation of cervix, 229 — of cervical orifice, 316 Ballottement in diagnosis of uterine disease, 121 Baths, use of, in the treatment of uterine disease, 176 — hot, 176 — cold, 179 — medicated, 183 Belts in the treatment of uterine diseases, 190 — abdominal, 190 — Courty's, for methodic compression, 191 — hypogastric, 191 Bleeding, 169 Blisters to the cervix, 190 Cancer of the uterus, 692 — diagnosis, 692 — subjective signs, local symptoms, pain, 692 — hsemorrhage, 693 — cauliflower excrescence, 698 — distinction between scirrhus and encephaloid, 700 — treatment, 702 by caustics, 703 by amputation of the cervix, 704 — — by ecrasement, 705 by excision, 707 Cancroid, v. Cancer of the uterus. Carbonic acid, application of, to cervix, 205 Castration, 770 Cataplasms to cervix, 202 Catarrh, uterine, v. Leucorrhoea. — of the Graafian follicles, 738 Cauliflower excrescence, 698 804 INDEX Causes, predisposing, of uterine diseases, 234, 238 Caustics, liquid, 209 — acid, 209 — alkaline, 209 — solid, 209 — canquoin, 209 — Vienna paste, 209 — chloride of zinc, 210 — Friar Gome's arsenical powder, 210 — nitrate of silver, 210 Cauteries, 211 — gas, 215 — galvanic, 216 — Paquelin's thermo-cautery, 216 Cauterisation of the cervix, 208 — — by potential cautery, 209 by actual cautery, 211 by ignipuncture, 211 by gas, 215 by electrolysis, 216 — of uterine cavity, 218 by intra-uterine injections, 219 by nitrate of silver crayon, 221 Cavity, pelvic, division of, 24 — uterine (means of exploration of), 147 Celibacy, influence of, on uterine diseases, 238 Cellular tissue of broad ligaments, 26 Cellulitis, pelvic, v. Peri-uterine inflam- mation. Cervix uteri, 28, 32, 40 — anomalies of, 80 Changes of position, 343 — of the rectum, due to development producing changes of situation in the uterus (Freund), 345 — displacements, 346 — deviations, 388 — flexions, 407 — inversion, 441 Characteristics, general, of uterine dis- eases, 233 — their frequency, 233 — preponderating influence of predis- posing causes, 233 — their double nature, general or dia- thetic and local, 246 — their ohronicity, 249 — difficulty of cure, 250 — diversity, 251 Chlorate of potassium, its use In mem- branous dysmenorrhoea, 330 Chloride of zinc for cauterisation of uterus, 210 Chloroform, vaginal injections of, 206 Chlorosis, symptomatic of uterine dis- eases, 104 Chronicity of uterine maladies, 157, 249 Cicatrisation after cauterisation, applica- tions for hastening, 218 Classification of uterine diseases, 253 Climate in the treatment of uterine diseases, 169 Cloaca, 58 CoUi.iiion, painting the cervix with, 203 Colpodesmoraphy, 382 Colporaphy, 383 Complexity of uterine diseases, 252 Complications as a source of indications in treatment, 160 — of uterine diseases, 248 Congestion, uterine, 466 physiological and pathological, 466 idiopathic and symptomatic, 466 active and passive, 467 — — anatomical changes consequent on, 467 diagnosis, 467 subjective signs, 467 objective signs, 468 — — treatment, 469 — peri-uterine, v. Peri-uterine inflam- mation. Constipation, its disastrous efi'ects (co- prajmia), 105, 106 Constitution, influence of the, upon the development of uterine diseases, 239 Contusions of the uterus, v. Traumatism. Coprsemia, 106 Corpus luteum, 9 Cough, uterine, 102 Cupping in uterine diseases, 170, 173, 226 Cura famis, 186 Cure, spontaneous, rare in uterine dis- eases, 151, 250 Curette, Recamier's, 225 — Sims's, 225 — buttonhook, 225 — Courty's, 226 Curvature of the uterus, 409 Cysts of the ovary, 733 — — composition, 734 unilocular, 734 — — multiple or mnltilocular, 734 compound, 736 origin and development, 738 in the newly born, 739, note in the married and single, 739 duration, 742 termination, 742 — — deterioration of health, fades ovariana, 743 — — treatment, 749 ovariotomy, 753 — tubo-ovarian, 780 — hydatid, 782 Depots laiteux, 556 Descent of uterus, v. Prolapsus. Deviation of the menses, 292 — diagnosis, 293 — treatment, 298 INDEX 805 Deviations, 388 — tliree degrees, 388 — anteversion, retroversion, and latero- version, 388 Diagnosis of uterine diseases in general, 96 Diathesis, influence of, on the develop- ment of uterine diseases, 240 Digestion, disorders of, 99 Dilatation in stenosis of the cervix, 309 — by dilating instruments, sounds and bougies, 309 — by sponge tents, 310 — by incision, 310 Dilator, uterine, of Lemenant-Deschenais, 147 of Mathieu, 147 of Busch and Huguier, 147 of Aussandon, 148 — — intra-uterine pessary, 148 Diseases of the appendages, 714 Dispareunia, 110 Displacements, 346 — of the ovaries, 346 — of the Fallopian tube, 348 — of the uterus, 344 (hernia), 351 horizontal displacements, 354 — — ascent, 355 descent, 356 Diversity of uterine diseases, 251 Division of cervix, 227, 311 Double character of uterine diseases, diathetic and local, 246 Douglas, folds of, pouch of, 23, 24 Dropsy of the uterus, 581 — encysted of the ovary, 733 — profluent of the tubes, 780 Dysmeuorrhcea, 300 — idiopathic, 301 — congestive, 302 — ovarian, 302 — treatment, 303, 309, 328 — mechanical, 305 — obstructive, 305 — dilatation of cervix, 309 — incision of cervix, 310 — division of cervix by elastic ligature, 315. — autoplasty, 316 — membranous, 319 — villous, 322 — apoplectic, 323 Ectropion of the cervix, 441 Electricity, use of, 184 Elytroraphy. 383 Eniaciatioa sjnnptomatic of uterine dis- eases, 104 Eucephaloid of uterus, v. Cancer. Endometritis, 477 — exfoliative, 323, note Eugorgemeut, uterine, 472 Engorgement, uterine, anatomical cha- racters and definition, 472 — — diagnosis, 473 — — treatment, 474 Episio-perineoraphy, 381 PJpisioraphy, 380 Epispastics in treatment of uterine dis- eases, 189 Epithelioma of uterus, v. Caucer of uterus. Erectility of uterus, 47 — of the ovary, 48 — erection produced artificially on the cadaver, 48 — absence of erectility in vagina and Fallopian lube, 48 — of bulbs of the vagina and of the clitoris, 49 — connection between utero-ovarian erection and coitus, ovulation and menstruation, 49 Eruptions on the cervix uteri, v. Ulcera- tions. — different forms, as in cutaneous diseases, 635 Evacuants in the treatment of uterine diseases, 174 E version of the cervix, 441 Examination, complementary means of external, 120 — percussion, 120 — fluctuation, 121 — ballottement, 121 — change of posture, 121 — auscultation, 121 — external appearance of abdomen, 122 — exploratory puncture, 122 — tapping, 122 Exercise in the treatment of uterine diseases, 167 Exfoliation of the uterine mucous mem- brane, 319 Exfoliative eudometritiSj 823, note Exometritis, puerperal, 503 Exploration of the uterine cavity (com- plementary means), 147 Extirpation of normal ovaries (Battey's operation), 770 Extra-uterine pregnancy, 783 — differential diagnosis, 783 — treatment, 785 E.xutories in the treatment of uterine diseases, 189 Fades ovariana, 743 — nterina, 105 Fallopian tube, 13 — develoiiment of, 56 — anomalies of, 73 — hernia of, 348 — inflammation of, 526 — and ovary, inflammation of, 530 — ■ tumours of, 778 806 INDEX False conceptions, v. Moles. Fibroids, v. Fibrous tumours. Fibromata, v. Fibrous tumours. Fibrous tumours of the uterus, 648 — interstitial, 649, 657 — sub-mucous, 649, 658 — sub-peritoneal, 649, 659 ^- their influence upon conception, pregnancy and delivery, 654 — influence of pregnancy upon, 655 — diagnosis, 655 — prognosis, 664 — medical treatment, 665 — surgical treatment, 667 — hysterectomy, 668 — treatment of, during pregnancy, 671 delivery, 671 Fistulae, congenital, 61 Flexions of the uterus, 407 — congenital, 407 — accidental, 407 — simple, 408 — complicated, 408 — seat of. 408 — degree of, 409 — curvature, 409 — diagnosis, 417 — subjective signs, 417 — common symptoms, 418 — objective signs, 419 — treatment, 420 — reduction, 421 — retention, 422 — mechanical means of retention, 422 — flexion of the cervix, 425 — anteflexion, 428 — retroflexion, 433 — lateroflexion, 431 — torsion, 431 — changes in the uterine tissue, 434 Floating tumours of the abdomen, 782 Fluctuation, signs of uterine disease furnished by, 121 Fluor albus, v. Leucorrhoea. Fluxion, 461 — diagnosis, 462 — treatment, 463 Fluxions, methodical treatment of, ap- plied to uterine diseases, 172 Forceps, Courty's, 201 — tenaculum, 208 Frequency of uterine diseases, 233 — relative, of uterine diseases, 255 Functional disorders, 257 Fungosities, uterine, v. Granulations. Gaertner's canal, 57 Galvanic stem pessary, 200 Gas, application of, to cervix, 205 carbonic acid, 205 apparatus for, 206 Gastrotomy, 772 Genital system of woman, v. System. Girald^s, corpus innominatum of, 57 Glycerine, application of, to cervix, 202 Graaf, De, vesicles of, 5 Granulations, uterine, 623 predisposing causes, 623 — — influence of diathesis, 624 — — varieties, 627 treatment, 632 Haemorrhage, uterine, 334 — idiopathic, 335 — symptomatic, 335 — diagnosis, 336 — predisposing causes, 336 — determining causes, 337 — symptoms, 337 — treatment, 338 — hemostatics, 341 Haemorrhage, pelvic, 714 tubal, 715 ovarian, 716 from the utero-ovarian plexus, 717 haemorrhagiparous pachyperito- nitis, 717 Hematocele, peri-uterine, 719 — retro-uterine, 719 — latero-uterine, 720 — ante-uterine, 720 — hematoma, 720 — modifications undergone by the eff'used blood, 721 — diagnosis, 722 — prognosis, 731 — treatment, 731 — puncture, 733 Hermaphrodism, true, 67 — lateral, 69 — vertical or double, 69 — transverse, 69 — coincides with imperfect develop- ment, 69 — apparent, 70 — female, 70 — male, 70 Hernia of uterus, 351 during pregnancy, 351 of the liuea alba, 351 of the unimpregnated uterus, 352 — — inguinal, 353 crural, 353 umbilical, 353 ventral, 353 diagnosis, 354 — — treatment, 354 — of the ovary, 346 inguinal, 347 crural, 347 ischiatic, 347 — — umbilical, 347 — — simple and double, 347 congenital (inguinal), 348 accidental (generally crural), 348 Fallopian tube, 348 — diagnosis, 349 INDEX 807 Hernia, treatment, 350 Hydatid cysts, 782 Hydrometria, 581 Hydrorrhoea, 580 Hydrotherapy in the treatment of ute- rine disease, 179 Hymen, v. Vulva. Hypertrophic tendency of the uterus, its part in the production and cure of uterine disease, 243, 244 — elongation of the cervix, 370 Hypertrophy, uterine, 590 — — common, 590 special, 591 — — essential, 591 arrested involution, 594 — partial, of cervix, 598 subvaginal, 598 — — supra-vaginal, 609 — — limited to one segment or to one lip, 616 Hysteralgia, 330 Hysterectomy, 228 Hysteria symptomatic of uterine disease, 101 Hysterocele, 351 Hysteromata, v. Fibrous tumours. Hysterotoine, simple, 228, 311 — double, 228, 311 Hysterotomy, 310 — Porro's operation, 773 Ice, plugging with, 203 Idiometritis, 482 Ignipuncture of the cervix, 211 Impotence, 788 Inclination of the uterus, 388 Incurvation of the uterus, 407 Indications to fulfil in the treatment of uterine diseases, 151 Inertia, uterine, 100 Infarctus (engorgement), 472 Infecundity or inaptitude for impregna- tion, 791 Inflammation, necessity of subduing, in the treatment of uterine diseases, 156 Inflammation, the only contra-indication to the use of the cautery, 217 Inflexions of the uterus, 407 Infraction of the uterus, 409 Injections, vaginal, 176 — intra-uterine, 219 — hot, in metrorrhagia, 341 Injuries of the uterus, v. Traumatism. Inversion, uterine, 441 — — its difl:erent degrees, 442 — — incomplete or partial, 442 complete or total, 442 — — causes, 443 — — mechanism, 445 — — diagnosis, subjective signs, 445 — — objective signs, 446 — — differential diagnosis, 447 Inversion, uterine, treatment, 477 Involution of the uterus, arrest of, 594 — — subinvolution, 595 — — superinvolution, 595 — — diagnosis, 595 subjective signs, 596 treatment, 596 Irrigation, vaginal, 178 single vaginal irrigator, 178 — — double vaginal irrigator, 178 Irritable uterus, 331 Isthmus, torsion of the, 309, 414 Lactation, neglect of, its influence on the development of diseases, 237 Laminaria digitata (tents of) for dilata- tion of the cervix, 149 Leiomyomata, v. Fibrous tumours. Leucorrhcea, 569 — idiopathic, 573 — symptomatic, 575 — herpetic or dartrous, 575 — catarrhal, scrofulous, 576 — vulval, 576 — vaginal, 576 — uterine, 576 — differential diagnosis of the different forms of infantile leucorrhoea, 577 — "^ydrorrhcea, 580 — treatment, 582 Ligaments of the uterus, 20 means of suspension, 20 broad ligaments, 20 round ligaments, 22 utero-sacral, 23 utero-vesical adhesions, 23 — — suspensory ring, 23 — broad (tumours of), 780 — — fibrous tumours and myomata of, 780 cysts of, 781 Ligature, elastic, for section of the cervix, 315 Lotion, vaginal, 177 Lymphatics of the uterus, 36 — their importance, 37 Means of exploration of the uterine cavity, 147 — intra-uterine speculum, 148 — uterine dilator, 148 Mechanical dysmenorrhoea, 305 Medications employed in the treatment of uterine diseases, 161 — common, 162 — special, 163 Membranous dysmenorrhoea, 319 Menorrhagia, 334 Menstrual disorders, 257 Menstruation, 257 — its influence upon uterine disease, 235 Mensuration, abdominal, 122 Methods of treatment, 160 808 INDEX Methods of treatment, generally analyt- ical and empirical, 161 Metritis, 476 — pathological anatomy, 476 — divisions, 480 — causes, 482 — course, 484 — subjective signs, 486 — local symptoms, 486 — general symptoms, 487 — objective signs, 489 — uterine abscess, 493 — table of differential diagnosis, 494 — treatment, 497 — — of complications, 501 — — of metrorrhagia, 501 — — of leucorrhoea, &c., 502 — puerperal, 503 — of the fundus, 506 — of the cervix, 506 — endometritis, 507 — parenchymatous metritis, 508 — treatment, 509 Metrorrhagia, 334 Metrotome, 227 Moles, uterine, 686 fleshy, 687 vesicular or hydatidiform, 687 diagnosis, 688 * treatment, 689 Morbid states without neoplasm, 461 Mucous membrane of the uterus, 38 — of the fundus, 38 — its tubular glands, 39 — its periodical thickening, 40 — of the cervix, 40 — its glands, 40 — Naboth's eggs, 40 — mucus of the uterus, alkaline, 40 — uterine (monthly formation of), 324 Muller's ducts, 56 — their separation, 58 — their approximation, 58 — their union, 58 — anomalies of development, 75 Muscles of the uterus, 40 — three layers, 43 — their continuity with the muscular layers of the tubes, 43 — their connections with the ovaries and oviducts by the muscular layer of the broad ligament, 45 Myomata of the uterus, v. Fibrous tu- mours. Naboth's eggs, 40 Necessity for treating uterine maladies, 151 Neoplasms (morbid states without), 460 Nerves of the uterus, 37 Nervous disorders, 100 Neuralgia, symptomatic of uterine dis- eases, 101 — uterine, 330 Nutrition, disorders of, symptomatic of uterine disease, 104 Obesity, symptomatic of uterine disease 105 Obliquity of the uterus, 388 Obliteration of the vagina, 387 (Edema, acute purulent peri-uterine, 532 Oophoritis, 510 Ovaries, anatomy of, 4 — ectopia of, 72, 346 — extirpation of (Battey's operation), 770 Ovarioncia, 346 Ovariotomy, 753 — indications for, 754 — pregnancy as a complication, 754 — contra-iuclications, 755 — preparatory treatment, 756 — adhesions as coutra-indications, 756 — six principal stages of the operation, 757 — treatment of adhesions, 760 — immediate consequences, 765 — accidents, 766 — shock, 766 — exhaustion, 766 — hsemorrhage, 767 — purulent infection, 767 — antiseptic precautions, 768 — remote consequences, 769 Ovaritis, 510 Ovary, cysts of, 733 — solid tumours of, 774 Oviducts, 13 Ovisacs, 6 Ovum, 8 Pad, perineal, 192 Pain, 107 — symptomatic of uterine diseases, 107 — spontaneous, 107 — caused by mode of decubitus, 108 — by sitting, 108 — by standing, 109 — by movements and walking, 109 — by coitus, 109 — by tight garments, 110 — elicited artificially, 110 — by movement, 110 — by palpation, 110 — by the touch, 110 — three principal seats of. 111 — iliac. 111 — lumbar. 111 — hypogastric, 112 — three secondary seats of, 112 — anal, 112 — vaginal, 112 — pelvic, 112 — radiating, 112 — continuous, 113 — intermittent, 113 Painting the cervix with collodion, 203 INDEX 809 Palpation, abdominal, 118 — rectal, 131 Paralysis symptomatic of uterine disease, 103 Parametritis, 531. v. Peri-uterine in- flammation. Parturition, influence of, on the develop- ment of uterine disease, 236 Pelvic cavity, division of, by the broad ligaments, 2h — peritonitis, 531. v. Peri-uterine in- flammation. — tumours, 774 Perforation of tlie bymen, 228 Perimetritis, 531, 534 Peritoneum, sero-puruleut cysts of the, 781 Peritonitis, peri-uterine, 534 Peri-uterine inthimniation, 531 — adenitis and angioleucitis, 537 Pessaries, 193 Phlegmon of the broad ligament, 533 — peri-uterine, 535 Physometria, 582 • Pneumatosis, 582 PoIy[)i of tlie uterus, 673 — fibrous, 673 — mucous, 673 — vascular, 674 — diagnosis, 674 — treatment, 677 Position of patient for operations, 207 Posture, signs furnished by change of, 121 Pregnancy, in relation to the symptoms of uterine disease, 107 — influence of, on the development of uterine diseases, 236 — extra-uterine, 783 diagnosis, 783 — — treatment, 785 — — modes of termination, 785 Prolapsus uteri, 356 — degrees of, 356 — cystocele and rectocele, 359 — of the vvliole uterus or of the cervix only, 357 — anatomo- pathological alterations, 357 — causes, 360 — relaxation of suspensory ligaments, 361 — frequency, 362 — diagnosis, 363 — subjective signs, 363 — objective siuns, 366 — differential diagnosis, 368 — treatment, 370 — hypertrophic elongation (prolapsus without procidentia of the fun- dus), 370 — reduction, 373 — retention, 374 — episioraphy, 380 Prolapsus uteri, episio-perineoraphy,^381 — colpodesmoraphj', 382 — elytroraphy or colporaphy, 383 — obliteration of the vagina, 387 — amputation of the cervi.v, 387 Prolapsus of uterus without descent of the fundus (Virchow), 370 Pruritus, vulval, 118 Pueri)eral metritis, 503 I'uncture, exploratory, 229 Purgatives, use of, l74 Rectal palpation, 131 Reduction of prolapsus, 373 — of flexions, 420 — of inversions, 449 Regimen as a means of treatment, 168 Resolvents, their use, 184 Retention of the menses, 270 Ring, suspensory, of the uterus, 23 Rosenmiiller (organ of), 56 Salpingitis, 526 Scirrhus of uterus, 699, 701 Sedatives in the treatment of uterine diseases, 188 Serous membrane of uterus, 38 Signs, presumptive, of uterine disease, 98 — furnished by direct examination of the genital organs, 118 Situation and structure of the uterus, influence of, on development of uterine disease, 234 Sound, uterine, 144 — — its use as a means of diagnosis, 144 — — its invention, 144 — — mode of introducing, 145 Speculum, Fergusson's, 134 — tri valve, 134 — bivalve, 135 — quadrivalve, 135 — Cusco's, 136 — Jobert's, 136 — Bozemau's, 137 — Sims's, 137 Sponge tents, method of preparing, 148 — tlieir introduction, 149 — exploration of uterus after dilatation by, 149 Stenosis of cervix uteri, 305 Sterility, 787 — symptomatic of uterine disease, 107 Strangury, uterine, 302 Subinvolution, 595 Superinvolution, 621 Suppositories, 204 Suspension, means of, of the uterus, 20 of the fundus, 20 — — of the cervix, 23 Suspensoi-y ring of the viterus, 23 Symptoms, general, of uterine disease, 98 — local, of uterine disease, 105 — of neighbourhood, 105 52 810 INDEX Syringe, uterine, 219 System, genital, of woman, 3 its constant mutability, 3 its development, 55 — — comparison of, with male genital system, 62 — — teratology, 65 Teratology of the sexual organs, 65 Therapeutics of uterine diseases in general, 96 Thermocautery of Paquelin, 216 Tonics in the treatment of uterine diseases, 186 Topical applications to the cervix, 203 Torsion of the isthmus, 309, 430 Touch, vaginal, 123 — rectal, 130 — vesical, 133 Traumatisms of the uterus, 483 Treatment of uterine diseases in general, 151 Tubercle of uterus, 689 Tubo-ovaritis, 530 Tumours, fibrous, of uterus, 648 — of the annexes and pelvic cavity, 774 — solid, of ovary, 774 — of Fallopian tubes, 778 — of broad ligaments, 780 — floating, of abdomen, 782 Tympanitis, uterine, 582 Ulcer of pregnancy, 640 — of uterine catarrh, 640 — of chronic metritis, 641 — dartrous, 641 — scorbutic, 641 — scrofulous, 641 — syphilitic, 641 — cancerous, 642 Ulcer of pregnancy, rodent, 642 — diphtheritic, 643 Ulceration and ulcers of the cervix uteri, 634 Urethra, female, 65 Urogenital groove, 61 Uterine cough, 102 Uterus, 16 — changes in, at different ages, 28 — structure of, 36 — deficiens, 75 — unicornis, 75 — duplex, didelphis, 76 — bicornis, 76 — cordiformis, 78 — globularis, 78 — septus, bilocularis, bipartitus, 79 — subseptus, semipartitus, 79 — embryonic, foetal, infantile, 79 Vagina, 49 — absence of, 86 — anomalies of, 86 — double, 88 Veins, uterine, 36 Versions of the uterus, 388 — treatment of, 397 Vesical irritation symptomatic of uterine disease, 106 Vesicles of De Graaf, 6 Villous dysmenorrhoea, 322 Vulva, 49 — glaads of, 53 — anomalies of, 89 — absence of, 89 Vulval pruritus, 118 Waters, mineral, in treatment of uterine disease, 182 WolflSan bodies, 55 ERRATA. Page 79, line 3rcl,/or " bipartitis," read " bipartitus." „ 118, „ 12th, /or " pruritis," reac/ "pruritus." „ 302, note 2, /or " Philosophical," read " Obstetrical." „ 304, line 16th from bottom, /or "attractions," read " attractives." „ 392, note 1,/or " nMario," read " Marion." „ 498, Hne 12th from bottom, /or " mauve," read " marshmallow." „ 563, „ 2iid, for " h," read " are." „ 628, „ 2n(l from bottom, /or " liysteralgia uterine colics, and" rM<< " hysteralgia and uterine colics." „ 642, „ 18th from bottom, /or "abscess," rfa<< "abscesses." FEINTED BT J. E. ADLAED, BABTHOLOMEW CLOSB. Catalogue B] London^ New Bitrlmgtoti Street July. 1S82 SELECTION FROM J. k A. CHURCHILL'S GENERAL CATALOGUE COMPRISING ALL RECENT WORKS PUBLISHED BY THEM ON THE AHT A^D SCIENCE OF MEDICIKE N.B.— As far as possible, this List is arranged in the order in which medical study is usually pursued. A SELECTION FROM J. & A. CHURCHILL'S GENERAL CATALOGUE, COMPRISING ALL RECENT WORKS PUBLISHED BY THEM ON THE ART AND SCIENCE OF MEDICINE. N.B. — J. & A. ChiirchiW s Descriptive List of Works on Chemistry, Materia Medica, Pharmacy, Botany, Photography, Zoology, the Microscope, and other Branches of Science, can he had on application. Practical Anatomy : A Manual of Dissections. By Christopher Heath, Surgeon to University College Hospital. Fifth Edition. Crown 8vo, with 24 Coloured Plates and 269 Engrav- ings, 15s. Wilson's Anatomist's Vade- Mecum. Tenth Edition. By George Buchanan, Professor of Clinical Surgery in the University of Glasgow; and Henry E. Clark, M. R.C.S., Lecturer on Ana- tomy at the Glasgow Royal Infirmary School of Medicine. Crown 8vo, with 450 Engravings (including 26 Coloured Plates), i8s. Braune's Atlas of Topographi- cal Anatomy, after Plane Sections of Frozen Bodies, Translated by Edward Bellamy, Surgeon to, and Lecturer on Anatomy, &c., at. Charing Cross Hos- pital. Large Imp. 8vo, with 34 Photo- lithographic Plates and 46 Woodcuts, 40s. An Atlas of Human Anatomy. By RicKMAN T- Godlee, M.S., F.R.C.S., Assistant Surgeon and Senior Demonstrator of Anatomy, University College Hospital. With 48 Imp. 4to Plates (112 figures), and a volume of Ex- planatory Te.xt, 8vo, £\ 14s. 6d. Surgical Anatomy : A Series of Dissections, illustrating the Principal Regions of the Human Body. By Joseph Maclise. Second Edition. 52 folio Plates and Text. Cloth, ;^3 12s. Medical Anatomy. By Francis Sibson, M.D., F.R.C.P., F.R.S. Imp. folio, with 21 Coloured Plates, cloth, 42s., half-morocco, 50s. Anatomy of the Joints of Man. By Henry Morris, Surgeon to, and Lecturer on Anatomy and Practical Sur- gery at, the Middlesex Hospital. 8vo, with 44 Lithographic Plates (several being coloured) and 13 Wood Engravings, i6s. Manual of the Dissection of the Human Body. By Luther Holden, Consulting Surgeon to St. Bartholomew's and the Foundling Hospitals, and John Langton, F. 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Diagrams of the Nerves of the Human Body, exhibiting their Origin, Divisions, and Connections, with their Distribution to the Various Regions of the Cutaneous Surface, and to all the Muscles. By William H. Flower, F.R.C.S., F.R.S., Hunterian Professor of Comparative Anatomy to the Royal College of Surgeons. Third Edition, with 6 Plates. Royal 4to, 12s. Atlas of Pathological Anatomy. By Dr. Lancereaux. Translated by W. S. Greenfield, M.D., Professor of Pathology in the University of Edin- burgh. Imp. 8vo, with 70 Coloured Plates, ;^5 5s. A Manual of Pathological Ana- tomy. By C. Handfield Jones, M.B., F.R.S.; and Edward H. Sieve- king, M.D., F.R.C.P. Edited (with considerable enlargement) by J. F. Payne, M.D., F.R.C.P., Lecturer on General Pathology at St. Thomas's Hospital. Second Edition. Crown 8vo, with 195 Engravings, i6s. Lectures on Pathological Ana- tomy. By Samuel Wilks, M.D., F. 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