4 y . iaT >hj . (^^. dd' y-:j\c\^c^ \l\l \^)'- , -r_ MAPLEWOOD. PRACTICAL TREATISE DISEASES OF WOMEN BY T. GAILLARD THOMAS, M.D., PKOFliSSOR OF DISEASES OF WOMEN IN THE COLLEGE OF PHYSICIAXS AXD SURGEONS, NEW TOKK ; PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETr FOR 1879; VICE-PRESIDENT OF THE NEW YORK ACADEMY OF MEDICINE ; SURGEON TO THE NEW YORK STATE WOMAN'S HOSPITAL ; PRESIDE! OP THE MEDICAL BOARD OF THE NURSERY AND CHILD'S HOSPITAL, ;«EW YORK , CONSULTING PHYSICIAN TO ST. MARY'S HOSPITAL FOR WOMEN, BROOKLYN ; HONORARY FELLOW OF THE OBSTETRICAL SOCIETY OF LONDON ; CORRESPONDING FELLOW OF THE OBSTETRICAL SOCIETY OF BERLIN, OF THE MEDICAL SOCIETY OF LIMA, AND OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA ; HONORARY MEMBER OF THE SOUTH CAROLINA MEDICAL ASSOCIATION AND OF THE LOUISVILLE OBSTETRICAL SOCIETY. FIFTH EDITION. ENLARGED AND THOROUGHLY REVISED. CONTAINING TWO HUNDRED AND SIXTY-SIX ENGRAVINGS ON WOOD. LIBRARY OF THE Pittshiirg AcaileDiy of Mmt NOT TO BE REMGV c^U PHILADELPHIA: HENRY C. LEA'S SON" & CO. 1880. ^ y Entered according to Act of Congress, in the year 1880., bj HENRY C. LEA'S SON & CO. in the Office of the Librarian of Congress. All rights reserved. DOFNAN, PRINTER. TO JOHN T. METC ALFE, M.D., NEW YORK. My Dkar Doctor : I DEDICATE to you the fifth as I have done the four previous editions of this work. If its merits liave grown with time as steadily as our friendship has done, I shall feel fully satisfied with the results of my labors ; and if it receive from my professional brethren only a tithe of such kindness as that for wliich during a quarter of a century I have been indebted to you, I shall be grateful indeed. Sincerely your friend, T. GAILLARD THOMAS. (iii) PREFACE TO THE FIFTH EDITION. Twelve years have elapsed since the publication of the first edition of this work. In that time four successive editions have appeared, and its author, recognizing the great advances which during that period have been made in gynecology, fully appreciates the fact that a text-book which aspires to meet the demands of 1880 must of necessity be very different from one which was offered to supply those of 1868. He has devoted two years of labor to the endeavor to bring this edition to the level of the present state of the science of which it treats ; with what success the reader will judge. That many new views, new methods, and new remedies which have of late years been lauded in gynecology pass unmentioned will at once be apparent. The author's object has been to write a practical work, not an encyclopedia; to record views and methods which recommend themselves on account of their merit, not merely of their novelty. So rapidly do new things present themselves in this active department of medicine, however, that it must be stated that some innovations which apparently possess merit have been left unmentioned because sufficient time has not elapsed for their trial. To the medical profession in America the author would express his sincere thanks for numberless acts of kindness, (v) VI PREFACE TO THE FIFTH EDITION. encouragement, and courtesy, which have stimulated his ambi- tion to improve a work which has met their generous endorse- ment and lightened the labor which has attended his eiforts. The kindly reception of previous editions of this work in Europe, as evidenced by its translation into German, French, Italian, and Spanish, has given the author sincere gratification, and he avails himself of this opportunity of thanking the translators for the very careful manner in which they have performed their work, and the uniform courtesy which they have shown to him. Upon two points he would ask the lenient judgment of his readers : first, the mechanical contrivances for the treatment of flexions of the uterus, which should be honestly tried before being judged; and second, the diagrams illustrative of the perineum and its injuries, which to one who has not carefully considered the subject may appear exaggerated. For the index of this edition, which the author regards as a good type of what an index should be, he is indebted to his friend Dr. S. Beach Jones. New York, 294 Fifth Avenue, Sept. 26, 1880. CONTENTS. CHAPTER I. PAGE Historical Sketch of Gynecology ••....,. 17 A CHAPTER II. The Etiology of Uterine Disease 41 Neglect of Exercise and Physical Development ...... 43 Excessive Development of the Nervous System ...... 45 Improprieties of Dress .......... 45 Imprudence during Menstruation ........ 47 Imprudence after Parturition ......... 48 Non-recognition or Neglect of Injuries due to Parturition .... 49 Prevention of Conception and Induction of Abortion ..... 50 Marriage with Existing Uterine Disease ....... 51 Insufficient Food ............ 51 Habitual Constipation ........... 52 A CHAPTER III. General Considerations upon Uterine Pathology and Treatment . . 54 Prognosis in Uterine Affections 60 Reasons for the Frequency of Failure in the Treatment of Uterine Diseases . 61 ^ CHAPTER IV. General Considerations upon some op the most Important Therapeutic Resources of Gynecology General System of Diet and Exercise . Pessaries ...... Precautions to be Observed in Operations Vaginal Injections .... The Tampon ..... Means for Controlling Temperature / CHAPTER V. Diagnosis of the Diseases of the Female Genital Organs Rational Signs of these Diseases ..... Management of Patient during Physical Examination Means of Physical Diagnosis ..... Ansesthesia ...... v 66 66 67 70 74 77 78 80 82 84 86 87 (vii) Viii CONTENTS. PAGE Vaginal Touch 87 Conjoined Manipulation, or Bimanual Palpation . , . . 88 Abdominal Palpation ........ 89 Abdominal Palpation conjoined with tlie use of the Sound . . 90 Inspection ........... 90 Rectal Touch , , 91 Simon's Method of Rectal Exploration ...... 91 Vesico-rectal Exploration ........ 92 The Speculum 93 The Uterine Sound and Probe ....... 100 Tents 102 The Exploring Needle 109 The Aspirator . 109 The Microscope 110 Auscultation and Percussion ........ Ill Recapitulation of Means for Exploring Pelvic Viscera and Tissues . Ill V CHAPTER VI. Congenital and Infantile Malformations of the P'emale Sexual Organs . 112 Hypertrophy 114 Absence and Rudimentary Development of the Uterus and Ovaries . . llf* Congenital Misplacement of the Uterus 119 Absence and Rudimentary State of the Ovaries ...... 119 Absence and Rudimentary State of the Vagina ...... 119 Anomalies of Uterine Development during Childhood ..... 119 ^' CHAPTER VII. Diseases of the Vulva 121 Normal Anatomy 121 Vulvitis . . 122 Purulent Vulvitis 122 Follicular Vulvitis .......... 124 Cyst and Abscess of the Vulvo-vaginal Glands 126 Eruptive Diseases of the Vulva 128 Phlegmonous Inflammation of the Labia Majora 129 Rupture of the Bulbs of the Vestibule 130 Pudendal Hemorrhage 130 Pudendal Hematocele . . . . . . • - . .131 Pudendal Hernia 134 Hydrocele 136 . CHAPTER VIII. Pruritus Vulvae 138 Hypersesthesia of the Vulva . 145 Irritable Urethral Caruncle 147 Urethral Venous Angioma 150 Prolapsus Urethrse 150 Coccyodynia .,.....••••■ 151 CONTENTS, IX ^CHAPTER IX. The Female Perineum ; its Anatomy, Physiology, and Pathology v^ CHAPTER X. Prolapse of Vagina, Bladder, Rectum, and Intestines ProlaiDse of the Vagina .... Cystocele, or Prolapse of the Bladder . Rectocele, or Prolapse of the Rectum Enterocele, or Prolapse of the Intestines Treatment of Vaginal Prolapse and Hernise Colpori-haphy or Elytrorrhaphy . PAGE 154 168 168 172 172 173 174 176 i/ CHAPTER XI. Surgical Means Adapted' to Restoration of the Perineal Body . . . 182 Varieties of Perineal Laceration ......... 186 Time for Operation . . . . . . . • • • .188 Treatment of Cases which have Cicatrized ....... 190 Operation for Partial Rupture 192 Operation for Complete Rupture ......... 198 / CHAPTER XII. Vaginismus 203 \l CHAPTER XIII. Vaginitis . . . . . . . . . • • • .211 Simple Vaginitis ............ 212 Specific Vaginitis or (xonorrhcea ......... 21.') Granular Vaginitis . . . . . . . . • • .218 ^ CHAPTER XIV. Atresia of the Genital Tract and Retention within it of Menstrual Blood and other Fluids ........... 220 Atresia of the Uterus . 221 Atresia of the Vagina 224 Operative Procedures ........... 229 ^ CHAPTER XV. Fistula of the Female Genital Organs . . . . • • ' • 233 Urinary Fistulse .........••• 233 Vesico-vaginal Fistula ......•••• 233 Urethro-vaginal Fistula ......•••• 234 Vesico-uterine FistuL-e . . . . . ... • • 234 Vesico-utero-vaginal Fistulas ......-•• 234 0^ X CONTENTS. PAGE Treatment 245 Cauterization •••........ 245 Suture ............. 245 Sims's Operation .......... 24(i Simon's Operation .......... 252 Elytroplasty 258 Closure of the Vagina .......... 259 Urinary Fistulse requiring Special Treatment 261 Vesico-uterine Fistulse .......... 261 Vesico-utero-vaginal Fistulas 262 Fistulse with Extensive Destruction of the Base of the Bladder . . 262 Uretero-uterine and Uretero-vagiual Fistulje 263 i CHAPTER XVI. Fecal Fistul^^ 265 Entero-vaginal Fistulse . . . 267 Simple Vaginal Fistulse 267 4 CHAPTER XVII. Acute Exdometkitis 268 4 CHAPTER XVIII. Chronic Cervical Endometritis ......... 275 vi CHAPTER XIX. Chronic Corporeal Endometritis 290 Injections into the Uterine Cavity 301 CHAPTER XX. Areolar Hyperplasia of the Uterus — The so-called Chronic Parenchyma- tous Metritis ........... 307 CHAPTER XXI. Granular and Cystic Degeneration of the Cervix Uteri .... 336 Granular Degeneration of the Cervix ........ 337 Cystic or Follicular Degeneration of the Cervix ...... 342 CHAPTER XXII. Syphilitic Ulcer of the Cervix Uteri ........ 344 CHAPTER XXIII. Uterine Fungosities ........... 346 CONTENTS. XI CHAPTER XXIV. PAGE Laceration of the Cervix Uteri ...... . . 352 Tracheloriaphj 359 CHAPTER XXV. General Considerations upon Displacements of the Uterus . . . 363 CHAPTER XXVI. Ascent and Descent of the Uterus 381 Ascent of the Uterus ........... 381 Descent or Prolapsus of the Uterus ........ 381 Methods of Replacing the Uterus ......... 394 Methods of Sustaining the Uterus 395 Pessaries ............. 401 CHAPTER XXVII. Anterior Displacements of the Uterts ....... 405 Anteversion ............. 405 Anteflexion 410 Treatment of Anterior Displacements ........ 413 Means for Reduction ........... 413 Means for Retention of the Uterus in Position ...... 417 Pessaries 420 Operation for Irreducible Cervical, Corporeal, or Cervico-corporeal Flexion . 429 CHAPTER XXVIII. Posterior Displacements of the Uterus 432 Retroversion and Retroflexion ......... 432 Methods of Reduction 438 Means for Retaining the Uterus in Position 442 Pessaries ............. 445 Lateroflexion ............ 452 CHAPTER XXIX. Inversion of the Uterus .......... 453 Methods of Checking Hemorrhage, the Uterus being left in situ . . . 462 Methods of Replacing the Uterus ......... 463 Gradual Reduction 465 Rapid Reduction ............. 467 Methods of Amputating the Uterus ........ 471 CHAPTER XXX. Peri-Utekine Cellulitis 475 Xll CONTENTS. CHAPTER XXXI, PAGE Pelvic Peritonitis 487 CHAPTER XXXII. Pelvic Abscess 502 Methods of Operating 507 Means for causing closure of the sac ........ 508 CHAPTER XXXIII. Pelvic H^iimatocele ........... 509 Methods of Operating 518 CHAPTER XXXIV. Myo-Fibromata or Fibroid Tumors of the Uterus ..... 519 Palliative Treatment 528 Curative Medicinal Means 529 Curative Surgical Procedures . . . . . . . . . 532 Laparotomy ............. 545 Methods of removal of the Uterus 548 CHAPTER XXXV. Cysto-fibromata, or Fibeo-cystic Tumors of the Uterus 551 CHAPTER XXXVI. Uterine Polypi Palliative Treatment Curative Treatment 558 563 563 CHAPTER XXXVII. Sarcoma and Adenoma of the Uterus Sarcoma ..... Adenoma ..... 566 566 570 Cancer op the Uterus Schirrous Cancer . Encephaloid Cancer Epithelial Cancer . Surgical procedures CHAPTER XXXVIII. 571 575 576 577 592 CONTENTS. Xlll CHAPTER XXXIX. PAGE Diseases Resulting from Retention and Alteration of the Fcetal Envelopes 602 Uterine Moles 602 Cjstic Degeneration of the Chorion, or Uterine Hydatids .... 604 CHAPTER XL. Dysmenorrhea ............ 606 Neuralgic Dysmenorrhoea .......... 609 Congestive or Inflammatory Dysmenorrhoea ....„., 611 Obstructive Dysmenorrhoea . . . . . . . . . .613 Membranous Dysmenorrhoea ......... 620 Ovarian Dysmenorrhoea .......... 625 CHAPTER XLI. Menorrhagia and Metrorrhagia ....,....• 628 CHAPTER XLII. Amenorrhcea ....I........ 635 CHAPTER XLIII. Leucorrucea ............ 642 CHAPTER XLIV. Sterility ............. 648 CHAPTER XLV. Amputation of the Neck of the Uterus ....... 652 Operation by Bistoury or Scissors ........ 654 Operation by Ecraseur ........... 654 Operation by Galvano-Cautery ......... 655 CHAPTER XLVJ. Diseases op the Ovaries . 656 Absence . ........... 660 Imperfect Development .......... 660 Atrophy 662 Ovarian Apoplexy ............ 663 Displacement ............ 664 Ovaritis 665 Acute Ovaritis ........... 666 Chronic Ovaritis ........... 669 Xiv CONTENTS. CHAPTER XLVII. PAOE Ovarian Tumors 672 Carcinoma ............. 673 Fibroma or Fibrous Tumor .......... 675 Cysto-Carcinoma ............ 676 Cysto-Fibroma or Cysto-Sarcoma 677 Dermoid Cysts 679 Colloid Degeneration . . . . . . . . . - .680 CHAPTER XLVIII. Ovarian Cysts and Cystomata 682 Cysts of the Broad Ligaments 696 Parasitic or Hydatid Cysts 697 Tubal Dropsy 697 Subperitoneal Cysts ........... 699 Cysts connected with the Spinal Cord 699 Aspiration . . . . . . . . . . . . .715 Tapping 716 CHAPTER XLIX. Ovariotomy ............. 722 Vaginal Ovariotomy ........... 731 Abdominal Ovariotomy .......... 733 CHAPTER L. Oophorectomy ............ 756 CHAPTER LI. Diseases of the Fallopian Tubes ...... 760 CHAPTER LII. Extra-uterine Pregnancy ......... 765 CHAPTER LIII. Chlorosis 778 LIST OF ILLUSTRATIONS. peculuin (Lebloud) no. 1. Ancient valvular specula (Scultetiis) 2. Thomas's dressing forceps 3. Davidson's syringe .... 4. Vaginal syringe nozzle, with reverse current 5. Sims's screw for removing a tampon 6. Thomas's gynecological table . 7. Thomas's gynecological table . 8. Practice of conjoined manipulation (Sims) 9. Fergusson's speculum .... 10. Thomas's telescopic speculum 11. Cusco's speculum ..... 12. Howard's modification of Cusco's speculum 13. Neugebauer's speculum .... 14. Sims's speculum ..... 15. Sims's depressor ..... 16. Nott's speculum closed . 17. Hunter's speculum .... IS. Thomas's modification of Sims's speculum 19. Nurse holding Sims's speculum (Sims) . 20. Position of woman in examining with Sims's s 21. Sounds of Simpson and Sims compared . 22. Jenks's elastic sound .... 23. A sponge-tent, with thread passing through it 24. A sea-tangle tent ..... 25. A tupelo tent before and after introduction and expansion 26. Tenaculum for fixing the uterus 27. Introduction of a tent (Sims) . 28. Dieulafoy's aspirator .... 29. Manikin figure for teaching diagnosis 30. Coalescence of MuUerian ducts in a foetal sheep (I. Miiller) 31. A. S., aged 4 years and 9 months. Menstruated regularly from the age of 21 months ....... 32. Bow-shaped rudiment of uterus (Nega) . 33. Bicorn uterus (Schroeder) ..... 34. Unicorn uterus (Schroeder) ..... 35. Double uterus (from specimen in possession of author) 36. Divided uterus (Kussmaul) ..... 37. Development of Graafian vesicles (Kuss. Physiology) 38. Follicular vulvitis (Huguier) 39. Plexus of veins of the vestibule (Kobelt) (XV) PAGE 23 74 76 76 78 85 86 89 93 94 94 95 95 96 96 97 97 97 99 99 101 102 103 104 105 106 106 109 112 113 114 115 118 118 118 118 119 125 130 XVI LIST OF ILLUSTRATIONS, 40. Paquelin's therino-cautery ..... 41. Diagram ordinarily used for representing the perineum 42. Transverse section of vagina ..... 43. Normal relation of the pelvic viscera 44. Schematic diagram of perineal body 45. The same, perineal body removed .... 46. The perineal body destroyed, the rectal wall descends 47. The perineal body destroyed, both rectal and vesical walls descend 48. An elastic rod when bent yields towards its convex surface . 49. An elastic rod with double curves yields in opposite directions 50. An elastic strip, with decided convex curve below, will very decidedly yield in the direction of lower arrow ..... 51. Sims's operation for colporrhaphy (Sims) .... 52. Sims"s operation. Shape of denudation and position of uterus 53. Emmet's operation : first step ...... 54. Emmet's operation : second step ...... 55. Ovoid denudation, with sutures passed ..... 56. Perineal body perfect ; both vaginal walls sustained 57. Perineal body removed by rupture ; both vaginal walls robbed of support 58. Perineum improperly repaired ..... 59. Thomas's tooth forceps ....... 60. Slightly curved scissors ....... 61. Emmet's scissors, sharply curved ..... 62. Profile view of perineum ...... 63. Schematic view of part to be denuded .... 64. Denudation for repair of perineum (Savage) . 65. One of the bleeding triangles which are to be created 66. The two bleeding triangles about to be united 67. Shows surface denuded and sutures in position 68. Profile view of recently closed perineum, sutures in place 69. Method of securing the ends of the sutures (Emmet) 70. Diagram of perfect sphincter .... 71. Sphincter ruptured, sutures passed 72. Ends of muscle approximated 73. Ends of muscle in apposition .... 74. Schematic diagram showing the ruptured bowel 75. Surface denuded in complete perineal rupture, and first two sutures in position ....... 76. Jenks's operationj^eolpo-perineorrhaphy 77. Pubo-coccygeus«sRi^s ....... 227. A submucous fibroid being gradually transformed into a fibrous polypus 228. Simpson's polyptome ....... 229. Hicks's wire rope ecraseur ...... 230. Cancer of mamma ; stroma and cells (Billroth) . 231. Connective tissue framework of cancer of mamma. Brushed prei)aration (Billroth) ...... 232. Flat epithelial cancer of cheek. Glandular ingrowth of rete into connective tissue (Billroth) .... 233. Tranverse section of a vegetating epithelioma (VirchoM) 234. Vegetating epithelioma (Simpson) .... 235. Forceps for amputating the cervix .... 236. Cervix amputated and parts above cut out . 237. Simon's scoop ........ 238. Cystic degeneration of chorion (Boivin and Duges) 239. Priestly's dilator for the cervix ..... 240. Schultze's dilator 241. Simpson's hysterotomy ...... 242. Stohlman's hysterotomy ...... 243. White's hysterotome ....... 244. DysmenorrhcBal membran(f (Coste) .... 245. Thomas's wire curette ....... 246. Syringe for dry cupping the cervix .... 247. Galvanic pessary ........ 248. Vaginal leucorrhoea under the microscope (Smith) 249. Cervical leucorrhoea under the microscope (Smith) 250. Conoidal cervix (Sims) . . . . 251. Byrne's galvano-caustic battery ..... 252. Microscopic appearance of ovarian fluid (Drysdale) 253. Tubal dropsy (Hooper) ....... 254. Spencer Wells's trocar ....... 255. Spencer Wells's trocar ....... 256. Bozeman's securing apparatus ..... 257. Emmet's trocar and canula for tapping cysts 258. Dawson's temporary clami) ...... 259. Thomas's clamp ........ 260. Storer's clamp-shield ....... 261. Thomas's drainage tube of metal, vulcanite, or glass . 262. Record of temperature in a case of ovariotomy 263. Record of temperature in a case of ovariotomy 264. Record of temperature in a case of ovariotomy 265. Kibbee's fever-cot ....... 266. Tubal dropsy (Boivin and Dugfes) .... THE DISEASES OF WOMEN. CHAPTER I. HISTORICAL SKETCH OF GYNECOLOGY. At the present day, when so much attention is being paid to the diseases peculiar to women, it becomes almost necessary that a chapter upon the liistory of the subject should precede otliers ot" a more practical character in a systematic work. A knowledge of what has been accomplished in reference to any subject, and what was known concerning it in previous ages, cannot fail to interest the student, and render him more capable of appreciating recent advances. In this way, too, a taste for the study of ancient literature may be inculcated, and many a useful hint, many a sug- gestive statement may be met with which will germinate for the common good. Some of the most valuable contributions to modern gynecology will be found to be foreshadowed, or even plainly noticed, by the writers of a past age, and afterwards entirely overlooked. As examples may be cited, the use of the uterine sound, sponge-tents, dilatation of the constricted cer- vix, and even the speculum itself. Indeed, we need not seek in ancient literature for illustrations of this fact, for nowhere could a more striking one be found than that of so valuable a procedure as Sims's operation for vesico-vaginal fistula being fully described in every detail in 1834, and so completely forgotten in twenty years as to be accepted as entirely new at the end of that time. There can be no doubt that a knowledge of medicine was possessed by the ancient Egyptians, whose literature has only within the last cen- tury been opened to profitable investigation. Until 1799, all concerning it was enshrouded in darkness. At that time a French engineer, while tlirowing up earthworks at Rosetta, discovered an insignificant looking stone, which has since furnished the wanting key, its inscription being written in Greek as well as in the ancient hieroglyphics. Since then valu- able papyri have been, thanks to the researches of De Sacy, Akerblad, and Champollion, fully and satisfactorily deciphered. The data thus obtained 2 ' (17) 18 HISTORICAL SKETCH carry the knowledge of medicine back to a period previous to 3000 years before Christ, and evince an attempt at rational treatment, Egyptologists declare, which surpasses that displayed by the early Greeks. The "papy- rus of Berlin," the earliest record of medicine, is singularly free from superstitious doctrines and use of charms in the treatment of disease, which at a later period crept in. Pliny informs us that in the times of the Ptolemies a medical school was established at Alexandria, and dissec- tions of the human body legalized. Tiie Egyptians appear to have been especially skilful as oculists, and i^ is probable that attention was paid to the diseases of women, for among the six medical books in the collection Thoth, consisting of forty-two volumes, one devoted to this subject is particularly mentioned. Some modern Egyptologists have even stated that among the hieroglyphics the shajjc of the uterus can be recognized. But Egyptology is certainly to-day only in its first infancy. Hope that the future may bring forth a great deal more than the past has done with reference to it may be further founded upon the fact that Herodotus' distinctly announces that specialties existed among this primeval people. " Here," says he, "each physician applies himself to one disease only, and not more. All places abound in physicians; some for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal diseases." From Biblical literature, which is so abundantly at our command, we learn almost as little upon our subject; and from the time of Moses, about 1500 B.C., to that of Hippocrates, 400 B.C., testimony of pre- cise knowledge upon it is almost entirely wanting. This is the more astonishing wiien we bear in mind that in the Talmud are found evi- dences of a great deal of knowledge concerning the Cajsarean section and other subjects in obstetrics ; that in the books of Moses we find intelligent refei'ence to the hymen and menstruation ; and that in the New Testa- ment we see St. Luke, a physician of the time, recording the fact of " a woman having an issue of blood twelve years, which had spent all her liv- ing upon physicians, neither could be healed of any," etc. Although we know so little concerning the knowledge possessed upon this subject by those who preceded the Greeks in civilization, we cannot doubt that they did much to instruct the latter in this as in other depart- ments of learning. History everywhere records the fact that the Greeks were instructed by the Egyptians, as the Romans subsequently were by the Greeks. With our present knowledge of the literature of the most ancient civili- zations, we must admit that with the writings of the Greek school, founded by Hippocrates, commences the history of gynecology. Three volumes were written upon the subject by authors contemporaneous with Hippo- ' Book ii. c. 84. or GYNECOLOGY. 19 crates. They have ordinarily been attributed to him, but Dr. Francis Adams, the translator of the works of Hippocrates for the Sydenham Society, declares them to be, "ancient but spurious, whose autlior is not known." In these books the subjects of metritis, induration, menstrual disorders, displacements, etc., are discussed. Aretasus, Galen, Archigenes, and Celsus, who probably lived in the first and second centuries, all treated of gynecology ; the first describing the vaginal touch, the varieties of leucorrhcea, and ulceration of the womb: while the second makes the first allusion on record to the speculum vaginae, as being a distinct instru- ment from the speculum ani, and the third gives a description of peri- uterine cellulitis which shows him to have been at least familiar with the fact that the tissues immediately connected with the uterus were liable to suppurative inflammation, the purulent products of which discharge themselves through the vagina or rectum. Soranus, the younger, made important contributions to gynecology. He was educated at Alexandria, and went to Rome in the year 220 B. C, where he wrote his celebrated work De Utero et Pudendo Muliebri. He is the oldest historian of medicine, and the biographer of Hippocrates. His accurate descriptions of the sexual organs were much admired. He takes pains to assure his readers that he dissected the human cadaver, and not monkeys, as did Galen and others. He compared the form of the uterus to a cupping-glass, showed the relation of this viscus to the ilium and sacrum, and made known the changes which the os undergoes durino- pregnancy. He attributes procidentia to a separation of the internal mem- brane of the uterus, speaks of the sympathy which exists between the womb and the mammary gland, and describes the hymen and clitoris. He understood digital exploration and the use of the uterine sound and vaginal speculum. Many of the ancient writers confounded the uterus with the vagina ; he distinguished the one from the other very clearly. Soranus likewise differentiated pregnancy from ascites and solid tumors, and laid stress upon the absence of tympanites and fluctuation in solid tumors as a means of distinguishing them from ascites, in which they are present. From this time for centuries, there is abundant evidence that the study of the subject was pursued with vigor, but so many of the works of the authors of those periods exist only in fragments, and so many are strongly suspected of being fictitious, that we pass them over to stop at the faithful compilation of Aetius,^ who flourished at Alexandria in the sixth century after Christ. His works, compiled in the great library at Alexandria, contain a digest of what was known and done by his predecessors and con- temporaries, and offer the fullest and most reliable evidence concerning ' I am indebted to the library of the New York Hospital for an opportunity of fully consulting this and other rare works which were accumulated by the late Dr. John Watsou. 20 HISTORICAL SKETCH the knowledge of those times. In quoting him, and his immediate suc- cessor, Paulus ^gineta, who was also a compiler, though a far less con- scientious one, I must be understood as recording, not the views of these individuals, but those entertained by physicians who lived from the time of Hippocrates to the time of their writing, a period of about one thousand years. In his 16th book Aetius treats of the diseases of women in such a manner as to leave no doubt as to his having had a thorough knowledge of many disorders and means of investigation and treatment, which, being rediscovered thirteen hundred years afterwards, have, in many instances, been regarded by us as entirely new. Thus he speaks of the speculum sponge-tents, peri-uterine cellulitis, medicated pessaries, vaginal injections, caustics for ulcers of the cervix, dilatation of the constricted cervix, a sound for replacing the uterus, etc. As I have already stated, Soranus before Christ, and Galen in the second century, speak of the speculum vaginae ; but Aetius still more clearly men- tions it, and gives rules for its introduction, which are copied almost ver- batim by Paulus without acknowledgment. The use of sponge-tents he very fully describes, telling of their mode of preparation, and even advis- ing that a thread should be passed through them for removal, and that a succession of them should be employed till complete dilatation is accom- plished.' The importance of injections, the douche, hip-baths, and appli- cation of caustics (or ulcers of the cervix, he also dwells upon, and advises the dilatation of a constricted cervix by means of a tin tube. The variety of vaginal injections in use among the Greeks was as great as that of to-day. As astringents, pomegranate rind, galls, plantain, rose oil, alum, sumach, etc., were employed ; and as emollients, linseed, poppies, barley, etc., exactly as we use them now. They relied to a great extent upon the use of medicated pessaries in the cure of ulcerations and inflammatory engorgements, employing wool covered with wax, or butter mixed with saffron, verdigris, litharge, etc. Octavius Hoiatianus even goes so far as to advise a mixture of arsenic, quicklime, and sandarach in very foul ulcers. In addition to injections and pessaries, Aetius mentions the use of vapor, medicated or simple, conducted to the cervix by means of a reed passed up the vagina. The use of a uterine sound, passed into the uterus and employed as a repositor, is likewise alluded to by this author, in a passage where he advises that displacements of the uterus should be corrected specillo et digito. Paul of ^gina, who succeeded Aetius, alludes distinctly to the speculum as an instrument in general use before his time. " If, therefore," says he, " the ulceration be within reach, it is detected by the dioptra ; but if I Dr. H. G. Wright, Med.-Chir. Rev., Ixxi. OF GYNECOLOGY. 21 deep seated, by the discharges." And again, " The person using the speculum should measure with a probe the depth of the woman's vagina, lest, the tube of the speculum being too long, it should happen that the uterus be pressed upon." It is curious to see how, even in many minor matters, the ancients an- ticipated discoveries which our contemporaries have brought forward as entirely new. For example, the air-pessary, made so popular in France and other countries by Gariel, is described and recommended by the Greeks. Colombat^ declares that, '' The ancient Greek physicians made use of pessaries like those just mentioned (air pessaries), of the form and length of the male organ, which is the reason why they are called ftpiartiaxtoia, or priapiform pessaries." Albucasis, in 110-i, describes herpes uterinus ; and uterine hemorrhoids are alluded to by Paulus -^gi- neta^ in this explicit manner : " Hemorrhoids form about the mouth and neck of the uterus, which will be discovered by the speculum." And thus it is with so many other modern suggestions, that the student of ancient medical literature is most willing to admit the truth of the proposition, formulated by Aristotle over two thousand years ago, that " probably all art and all wisdom have often been already fully explored and again quite forgotten." The learning of the Greek School was appropriated by the Roman, which was an offshoot from it, as the writings of Celsus, Aspasia, Mos- chion, and Antyllus abundantly testify. But the knowledge of the scliools of Greece and Rome was destined to be scattered abroad. At the period of the subjugation of Egypt and the destruction of the celebrated library at Alexandria by the Saracens, A. D. 640, it passed as a trophy of war into the hands of the Moslem invaders. " In a few centuries the fanatics of Mohammed had altogether changed their appearance," says the learned Draper.* " When the Arabs conquered Egypt, their conduct was that of bigoted fanatics ; it justified the accusation made by some against them, that they burned the Alexandrian library for the purpose of heating the baths. But scarcely were they settled in their new dominion, when they exhibited an extraordinary change. At once they became lovers and zeal- ous cultivators of learning." The physicians of Alexandria were greeted by them as instructors, and from the seed thus planted sprang the Arabian School. With other information, of course, they gained that pertaining to gynecology, but, the Mohammedan laws forbidding the examination of women by one of the opposite sex, the study languished in their hands ; and although Rhazes, Avicenna, and their successors copied from Greek writers upon it, a want of zeal, due to want of personal observation and ' Diseases of Females, Meigs's translation, p. 152. 2 Sydenham Society's edition, vol. i. p. 645. ^ Intellectual Development of Europe, p. 285. 22 HISTORICAL SKETCH experience, allowed a retrograde movement to occur which left tlie subject enveloped in darkness for centuries afterwards. Albucasis, one of the last of this school, flourished at the end of the eleventh century, and after him, although from time to time writers of greater or less merit on dis- eases peculiar to women appeared, nothing worthy of special note occurs, except the occasional allusion to the speculum, which had evidently fallen almost entirely into disuse. We have then sufficient data to warrant the belief that the physicians who flourished from the foundation of the Greek School of Medicine, 400 years before Christ, to the dispersion of the Alexandrian School by the Saracens, 640 years after Christ, were well informed in gynecology, and were familiar with means of investigation which were subsequently lost, or ceased to be appreciated. They fully sustain the statement of the English translator of the works of Hippocrates, that "they furnish the most indu- bitable proof that the obstetrical art had been cultivated with most extraor- dinary ability at an early period." It must not, however, be supposed that the knowledge of the ancients was of the same exact and scientific nature as that which has prevailed since the modern introduction of the speculum. He who seeks in this literature for distinct and lucid pathological data will surely meet with disappointment. Tliey did not sufficiently separate inflammations of the puerperal and non-puerperal uterus, confounded affections of that organ with those of the pelvic areolar tissue, and made no distinctions between diseases of the mucous membrane and parenchyma, nor the morbid states of the neck and body. Among their remedies were numerous articles wliich to-day we regard as inert or even injurious, as pigeon's dung, wo- man's milk, stag's marrow, etc. ; and Aetius and Paulus seem to have been as partial to the " grease of geese" as our lower classes are at present. To make amends for this many a valuable and suggestive thought may be gleaned with reference to diagnosis and treatment. This has certainly been proved by our experience of the past, and we have no evidence to warrant the belief that these rich mines have yet been exhausted. The learning of the Arabians was in time, like that of the rest of the world, gradually enshrouded by the ignorance and superstition of the period termed the " Dark Ages." During that time many of their writ- ings, as well as those of the Greek and Roman schools, were destroyed or lost ; but as society emerged from the darkness which overshadowed its intelligence, we see the thread at once taken up and followed, though lan- guidly and without vigor, to the beginning of the nineteenth century. Toward the middle of the seventeenth century we find very special and full allusion made to the speculum and its uses by Ambrose Pare and Scultetus ; the instrument being well represented by diagrams, with de- scriptions attached. " Fig. 1," says Scultetus, " is an instrument which they call ' speculum OF GYNECOLOGY. 23 ani, vaginae et uteri,' in that by its help ulcers of the rectum, vagina, and uterus may be seen, to be carefully observed, according to their extent and kind." Aetius and Paulus evidently knew of a tubular speculum, since they say, " lest the tube of the speculum be too long," etc. ■, but Scultetus, as Fig. 1. Ancient valvular specula. (Scultetus.) already shown, figures a bi-valve and quadri-valve, closely resembling those in our hands at present. It is worthy of mention, in this connec- tion, that there is now preserved, in the Museo Borbonico at Naples, a bi- valve speculum which was removed from the ruins of Pompeii. It has already been stated that Aetius makes reference to a sound for replacing the uterus. This is by no means the first notice of this useful instrument, for it is repeatedly mentioned by Hippocrates. One of six passages from writings imputed to him, I translate from the work of Monsieur T. Gallard.' " Treatment for rendering fertile a sterile woman; attention is directed to that part ivhich ronsists in replacing a displaced neck of the uterus. " Just after the patient has taken a bath and a fumigation, open the uterine mouth and replace it at the same time, if necessary, with a .sound of tin or lead, at first small in size, then larger, if it passes, until the difficulty seems remedied ; dip the sound in any emollient preparation which may be thought best, and which should be rendered liquid by melting."'^ ' Lepons Cliniques siir les Maladies des Femmes, p. 115. 2 Hippocrates (Euvres Completes. Tome vii. p. 379. 24 HISTORICAL SKETCH A recent biographer of Harvey^ remarks, " That the older writers looked upon the vagina and uterus as one organ, and wlien they spoke of the former, they either called it ' uterus' or ' cervix uteri.' What we now call the cervix uteri, they called the internal cervix ; and, as far as my read- ing goes, no operative procedure upon this part of the womb, when in its unimpregnated state, had ever been attempted before Harvey invented his dilator, and used intra-uterine injections of sulphate of iron." If the passage recently quoted does not carry conviction that the man- ipulations recommended have reference to the neck of the uterus and not to the vagina, the following, from the same source, will do so : — " Treatment^ of cases in which the seminal Jiuid is not retained on ac- count of an imperfection of the uterine oinfice. " In those cases in which seminal fluid escapes immediately after intei'- course, the cause is in the mouth of the womb. They should be treated thus : if the orifice is very much contracted it should be dilated with small bits of pine wood and lead." We cannot suppose that in cases in which intercourse was practicable any contraction below the os externum uteri could exist, rendering such dilatation necessary. Professor Simpson' asserts that among the ancients the sound was re- sorted to only for dilatation of the cervix, and not for exploration and measurement. The specillum mentioned by Aetius was employed for re- position, while Hippocrates advises the use of a sound hollowed out on one side, and covered by medicated ointments : this, " the operator intro- duces into the uterine orifice, and pushes onwards so as to make it enter the interior of the uterus. When the medicinal substance is melted, the sound is withdrawn."* In 1657, a probe, used as we now employ the uterine sound, and intended especially for uterine exploration, was actually described by Wierus,^ and alluded to by Hilken, Cooke, and others. In 1771 it was employed by Levret for measuring tlie length of the uterine cavity in hypertrophy of the cervix, and subsequently as an aid to diag- nosis by Chambon, Vigorous, and Desormaux. As we pass in review the chief works which appeared upon our subject in the eighteenth century, we find frequent mention of the speculum, which is spoken of as a matter of course in the treatment of uterine affec- tions, and yet was evidently not so employed as to render it really a valu- able aid in diagnosis or treatment. This constitutes one of the most curious episodes met with in the history of any discovery with which we are acquainted. A most simple and useful instrument was not only well known in ancient times, and subsequently fell into disuse, but fell ' Obstet. Journ. Great Britain and Ireland, vol. i. p. 26. 2 Gallard, op. cit., p. 116. 3 Obstet. Works. * Gallard, op. cit., p. 116. * Dr. H. G. Wright, Diseases of Women, Eng. ed., vol. i. p. 135. OF GYNECOLOGY. 25 into disuse without having ever been really forgotten. It was described by successive writers up to the nineteenth century in language as distinct as words could make it ; and yet not only did they who read, but they who wrote it, not comprehend its meaning or appreciate its signiticance. Like the Indians possessed of the diamond, all saw and yet none valued. How could Ambrose Pare, for example, writing in 1640, have indicated its use more clearly than when he tells us, in chapter xix., that ulcers of the womb may be recognized, " by the sight, or by putting in a specu- lum ?" In a copy of his works, in the library of Prof. W. A. Hammond, the word speculum is italicized in this sentence. Scultetus, as we have seen, not only described, but figured the instrument in 1683. In 1761, Astruc, " Royal Prof, of Physic at Paris," in describing oc- clusion of the vagina and obstruction to the menstrual flow, says : " There is nothing more required than to examine the vagina by introducing the finger into it, rubbed previously with oil or pomatum ; but, if that be not sufficient, a speculum uteri may be used, or some other more simple in- strument for dilatation, in order to be able, by means of the dilatation of the vagina, to judge by the sight of what the touch could not decide." In 1801, forty years after this, Recamier is supposed by many to have invented the speculum. Most assuredly it was not for tlie invention, but for the regeneration of an instrument which had been curiously lost sight of, that the world was indebted to this great man, who was really the founder of the modern school of gynecology. Guided by the advice found in many works which his library must have contained, works with wliich to suppose liim not to have been perfectly familiar would be to cast a slur upon his medical research, he employed a speculum vagina; in 1801. Like his predecessors, he did not appreciate the great results which were to flow from it ; nor does he appear to have regarded himself as having in- vented it. It was not until 1818 that he introduced it to the profession, and gave i+ its place as a valuable addition to science. Can any one sup- pose that it could have required seventeen years of experimentation and study for a man with the talent of Recamier, to have applied this simple and useful instrument to purposes of utility? Is it not more likely that the experience of seventeen years taught him the full value of the instru- ment ? The credit which belongs to Recamier is not that of an inventor, but that which is equally great, of having recognized the value of what was well known, but not appreciated by his predecessors and contempo- raries. Even before this fortunate revival, as the eighteenth century approached its close, the glimmer of the new era which was about to dawn could clearly be detected in the advanced views which were promulgated by Garangeot and Astruc in France, and Denman, John Clark, and Hamilton in England. The early part of the nineteentli century found the field occupied chiefly by Sir Charles Clarke and Dr. Gooch in England, and 26 HISTORICAL SKETCH llecamier and Lisfranc in France. These were not the only eminent writers of that time, but they were unquestionably those who chiefly moulded professional opinion. Even at that period gynecologists divided themselves into two parties, which may be said to have coalesced only within the last decade. In Eng- land the feeling was strongly in favor of regarding the local disorder as the result and not the cause of concomitant constitutional derangement ; while in France the uterine disease was viewed as the main element, and the general condition regarded as dependent upon and resulting from it. The great advantages of the speculum secured its rapid adoption in France. More slowly it forced its way, in spite of many prejudices, in Great Britain, and before a great many years had passed, it was, through- out the civilized world, placed upon an enduring basis as one of the many boons bestowed by medicine upon humanity. The way being opened for investigation by this instrument, new aids to diagnosis and treatment were rapidly brought forward. In 1826, Guilbert read before the Academy of Medicine of Paris an essay proposing the application of leeches to the cervix. In 1828, Samuel Lair read before the same body a paper in which he counselled the use of the uterine sound, which had never been utilized. In 1832, M. Melier presented an essay, in which he offered two new sug- gestions in the treatment of uterine diseases — one, injections into the cavity of the cervix ; the other, local applications through the vagina by dossils of lint saturated with astringents, narcotics, etc. His views are quoted extensively by French writers, and Nonat says that the author recognizes, " avec une franchise qui I'honore," that Boyle, Chaussier, Guillou, and others had a short time before him used similar means. Very curiously neither Melier nor his commentators mention that both these suggestions are made and fully elaborated by Astruc, in his excellent article upon "Ulcers of the Uterus." He describes these applications of medicated charpie very carefully, remarking that it is advisable to " tie a thread to every pledget, in order to draw it out again when it is proper to renew the dressing." And he not only advises injections of water, impregnated with dilFei-ent substances, into the cavity of the womb, but also the juices of plantain, houseleek, nightshade, etc. " For," says he, " as it is of con- sequence that these injections should enter into the uterus, where the ulcer has its seat, it is proper .they should be made by a professor of midwifery, capable of introducing skilfully the end of the canula into the oriHce of the uterus," etc. At this time arose the question as to cancer of the uterus, whether it was the local manifestation of a general blood state, or the result of an inflammatory engorgement long neglected ; a question which excited warm discussion, and brought forth the most opposite views. The ambition of Recamier was not satisfied with exposing the cervix uteri to view. He had the boldness to explore the cavity of the body of OF GYNECOLOGY. 27 the organ, almost establishing the use of the sound, and even, by means of a species of scoop called a curette, ventured in certain cases to scrape its investing mucous membi'ane. In addition he described, through one of his students, pelvic cellulitis, and gave the first intimation which modern observers have had of the possibility of pelvic hematocele. The impulse given by Recamier to gynecology cannot be overestimated, for the instrument which he had rediscovered, and the merits of which he had appreciated, was destined to remove it from the field of speculation and theory, and to place it in that of exact science. From about the year 1820, «it began to attract general attention, and to receive the endorsement of the profession. The subject at that time received more notice in France than in any other country, and for the next twenty years Lisfranc, Boivin, Colombat, I'Heritier, Imbert, and others enriched its literature and advanced its in- terests. But it was not until towards the end of that time that any really remarkable advance was effected. Then it was that Kiwisch, in Germany, Huguier, in France, and Simpson, in Great Britain, took the lead in their respective countries. It has been already stated that from the earliest period of medicine the uterine sound had been recommended, and that in the seventeenth, the eio-hteenth, and the nineteenth centuries this recommendation had been repeated. In spite of this it had never become an instrument of practical value, and even after 1828, when Lair recommended it, it fell entirely out of notice. By a curious coincidence Kiwisch, Simpson, and Huguier, without concert or communication with each other, about the same time urged its adoption, and by vigorous efforts forced it upon the attention of all interested in gynecology as a diagnostic means of inestimable value. Before this time the sound was practically unknown ; after it, it held its place as one of our most valuable diagnostic resources. The labors of Recamier marked an era in gynecology. One scarcely less important was effected by those of Sim[)son, who, appearing in tlie field about the year 1843, created an enthusiasm for the department, and gave an impulse to it by the vigor and originality of his writings, and the brilliancy of his contributions. His articles, indeed, first incited the study of uterine displacements in Great Britain, and to his efforts may be traced, in great degree, the interest which has been of late years aroused in that country with reference to uterine pathology. Until this time the subject had attracted very little attention there, and advances which had been made in it were due almost entirely to French pathologists. It is true that the excellent work of Sir Charles Clarke existed ; but that warm and zealous interest which has since resulted in so much benefit to gynecology had not then been excited. But Prof. Simpson was not alone in this work. Dr. J. H. Bennet, of London, at that time a young physician, who had for some years served as interne in the hospitals of Paris, returned to his 28 HISTORICAL SKETCH own country imbued with the views which Recamier and Lisfranc had disseminated among a large circle of followers. In 1845, the first edition of his work on Inflammation of the Uterus appeared, and it is safe to as- sert that no work of modern times, written upon any subject connected with our profession, has exerted a more decided and profound influence. Taking up the matter with a vigor and energy which forced attention, if not conviction, he produced an undeniable impression upon the profession, not only in his own country, but in Germany, France, and America. The chief points insisted upon in his work are these : 1. That inilammation is the chief factor in uterine affections, and that from it follow, as results, displacements, ulcerations, and affections of the appendages. 2. That menstrual troubles and leucorrhoea are merely symptoms of this morbid state. 3. That in the vast majority of cases, inflammatory action will be found to confine itself to the cervical canal, and not to affect the cavity of the body. 4. The propriety of attacking the disease in its habitat by strong caustics. It is now over a quarter of a century since the appearance of the first edition of Dr. Bennet's work, and since during that period his views have been freely canvassed and vehemently opposed, since too his own experi- ence has ripened and he has had abundant time for more mature reflec- tion, it must be a matter of great interest to know to what extent his opinions have been modified. In the London Lancet appears the abstract of a paper read by him before the British Medical Association in 1870, which serves to contrast his more recent with his former views. The purport of this paper will be best given in the recapitulation by which the author concludes it : — "1. I consider that, under the influence of mechanical doctrines pushed to an extreme, uterine displacements are by many too much studied j;er se, independently of the inflammatory lesions that complicate and often occa- sion them. 2. That the examinations made to ascertain the existence of inflammatory complications are often not made with sufficient care and minuteness, as evidenced by the fact that I constantly see in practice cases in which inflammatory lesions have been entirely neglected, and the second- ary displacements alone treated. 3. That inflammatory lesions are often the principal cause of the uterine displacements through the enlargement and increased weight of the uterus, or of a portion of its tissues, which they occasion. 4. That when such inflammatory conditions exist, as a rule they should be treated and cured, and then time given to nature to absorb morbid enlargements before mechanical means of treatment are resorted to." Soon after the appearance of Dr. Bennet's work, a discussion sprang up between its author on one side, and Drs. Robert Lee, West, and Tyler Smith on the other, with reference to the true character of ulceration of the neck ; Dr. Bennet supporting the view that the cervix is often affected by inflammatory ulceration, and his opponents denying it. The import- OF GYNECOLOGY. 29 ance which he attached to the matter may be appreciated from the follow- ing quotation. In reviewing the state of uterine pathology in Great Britain, as illustrated by the standard work of Sir Charles Clarke, he says : " Various forms of cancerous idceration are carefully described, but the very existence of inflammatory ulceration is not mentioned. Now, when we reflect that, as I shall hereafter show, in nearly five cases out of six of confirmed uterine disease, in which chronic discharges, mucous, puriform, or sanguinoleut, or other well-marked uterine symptoms are present, there exists inflammation or inflammatory ulceration of the cer- vix, it is easy to conceive how erroneous must be the views respecting uterine pathology, of a medical school ignorant of so vitally important a circumstance." The last edition of Dr. Bennet's work was published in 1861, and a quotation of the views held by him in 1870 shows that they were essen- tially unaltered. Yet I believe that I am correct in saying that the great majority of the progressive gynecologists of our time sustain the views which are opposed to his. I find myself to-day endorsing the action of Sir Charles Clarke in publishing a work on diseases of women " in which the very existence of inflammatory ulceration is not mentioned," or is mentioned only for the purpose of disputing its validity. One great advance which was effected by tlie work of Dr. Bennct was the placing upon a surer basis than it had yet occupied, the differentiation of engorgement and induration from commencing cancer of the neck. It would be well, before proceeding further, to consider very briefly the different pathological views which from this time, and even somewhat before it, were offered to the profession, and more or less generally adopted. They may be thus enumerated : — 1st. That inflammation is the starting-point of most of the aflx'Ctions of the uterus, and that a large number of evils follow this morbid state as results. 2d. That uterine disorder is dependent upon a constitutional derange- ment, and would yield without other treatment than that directed to the removal of the general condition. 3d. The view of Dr. Bennet, which is similar to the first mentioned, with this additional point, that metritis generally limits itself to the neck, and only exceptionally affects the body. 4th. The view of Dr. Tyler Smith, that leucorrhoea arising from glandu- lar inflammation in the cervix is the cause of granular deranorement of this part, and of subsequent engorgement. 5th. The view that uterine disorders often, if not generally, commence in displacement, which is a primary and not a secondary condition, and that to relieve the train of morbid symptoms, this, its exciting cause, should be first removed. 6th. The view that uterine disorder is commonly" the result of ovarian 30 HISTORICAL SKETCH inflammation, which reacting on the womb is the prime mover, in many cases, of its morbid states. I have no intention of fully discussing here the merits of these theories, but will limit myself to a few words connected with each. The theory mentioned first in this enumeration is the oldest on record, the writers of the Greek School, even, adopting it. Thus Paulus ^gi- neta heads his chapter on the subject, " Inflammation of the uterus and change of its position." One of the symptoms of such inflammation he considers to be retroversion of the uterus. In the beginning of the pre- sent century this was generally accepted in France. Lisfranc and Re- camier adopted it, and it was transferred to, and advocated in. Great Britain by the writings of Dr. Bennet. The views of this last author, appearing as they did at a time when the field of uterine pathology was almost entirely uncultivated, and character- ized as they were by a great deal of persuasive force, produced in this country a marked impression. As to myself I am forced freely to confess that since the publication of the first edition of this work my opinions with regard to them have undergone a material alteration. This alteration has resulted not from theoretical reasoning, but from careful and candid inves- tigation and experimentation at the bedside. I have come to regard the belief of Dr. Bennet in inflammation as the great moving cause, the com- mon factor, in the production of uterine diseases, as an error. And as my views have thus altered with reference to pathology, they have, neces- sarily, likewise changed with reference to treatment. It appears to me that the time has arrived when many who formerly accepted the opinions of Dr. Bennet will be prepared to admit the fact that his treatment is too severe ; his use of caustics too heroic ; and his neglect of artificial support to the displaced uterus too decided. No one could have accepted his views more cordially than I did. They were seductive by reason of their sim- plicity, and plausible from their apparent rationality. Careful observation at the bedside, in as large a field as could be desired, has led me to feel that evil, rather than good, results from an adherence to them. Feeling this, I shall strive in the work which I am now undertaking so to modify my statements as to meet what I regard as the true requirements of the subject. Let us however bear in mind, while venturing to criticize the views and practice of Dr. Bennet, that science is progressive, and that what was good a quarter of a century ago has simply given place to what is better. If, with all the lights of modern pathology, we stood now where Dr. Bennet stood when he wrote, the discredit would have been with us ; it is not with him that we do not do so. However others may differ from him, no candid mind can deny the obligation under which he has placed his brethren by arousing their attention and directing their investigations into proper channels. OF GYNECOLOGY. 31 No one can devote himself to the practical study of uterine diseases without being impressed with the strong grounds which exist for. the main- tenance of the second of the theories mentioned. JVo grave uterine trouble affects the system for any length of time without reacting to a greater or less extent upon the general health. The nervous system becomes greatly disordered, the functions under its influence are badly performed, and de- rangement in hematosis is the invariable result. As the local disease often approaches stealthily, and may exist ibr a length of time without exciting suspicion, what is more natural than that many should view it as one of the numerous results of the general depreciation ? These three lacts, however, which will constantly repeat themselves, as often, I may say, as favorable cases offer for testing the question, will, I think, very generally lead to a distrust of the doctrine : 1st, the fact that uterine disease and constitutional derangement existing together, a cure can rarely be effected by general means alone ; 2d, that the uterine affec- tion being removed, the general state is at once improved ; and 3d, that those general conditions which prostrate the vital forces to the last degree, as, for instance, tuberculosis, uraemia, scurvy, leucocythaiuiia, etc., destroy life without ever showing, unless as an exception to a rule, uterine disease as a consequence. The constitutional depreciation of a woman will, however, sometimes prove a predisposing cause of local disease. As granular degeneration under the eyelids will arise from this cause, so will a kindred condition often occur on the cervix uteri, yet both will require local as well as gene- ral treatment. The enfeebled woman is more liable to subinvolution, passive congestion, and displacements, after delivery, than the strong ; and inflammation of the glands of the cervix is a well-known result of phthisis pulmonalis, tertiary syphilis, and aniemia. The theory of Dr. Tyler Smith^ I lay before the reader in his own words : " It is my conviction, notwithstanding, that in the majority of cases in which morbid states of the os and cervix are present, cervical leucorrhoea, or, in other words, a morbidly augmented secretion from the mucous glands of the cervical canal, is the most essential part of the dis- order, and that the diseased conditions of the lower segment of the uterus, which have been made so prominent, are often secondary affections result- ing from the leucorrhceal malady." This theory was by no means a new one when advanced as above mentioned, for Lisfranc^ mentions it thus: " Observation proves that leucorrhoea can in the first place cause uterine engorgements, and that later it may be kept up by them ; it occasions them often." Lisfranc, however, says " often," while Dr. Smith says, " in the ma- jority of cases." But even before Lisfranc it had attracted attention, for ' Oil Leucorrhoea.- * Clin. Chirurg., vol. ii. p. 303. 32 HISTORICAL SKETCH Paulus iEginela^ gives " defluxion" as one of the causes of " ulceration of the womb." That an acrid leucorrlioeal discliarge will create abrasion of the OS, follicular vaginitis, urethritis, pudendal inflammation, and pruritus, no one will deny. AVe see a similar irritation occurring on the upper lip in nasal catarrh in children, which sometimes spreads as an eruption over the whole face. The leucorrhoea regarded by Dr. Smith as the primary disease is, however, only a symptom of cervical endometritis, which may disorder nutrition in the deep tissues of the cervix, and result in enlarge- ment and induration. The views of Dr. Smith were brought forth at a time when Dr. Bennet was pressing the theory of inflammation as the key- stone of uterine pathology, and in combating the idea of parenchymatous inflammation, he recorded the important fact that the morbid state de- scribed under that name is very often preceded by, and results from disease taking its rise in the mucous lining of the canal. Dr. Smith's position was maintained with all that ability and force which have rendered him so popular as an author amongst us in America, and the influence of his writings upon uterine pathology can be, at present, clearly traced in this country. In the year 18.54, a discussion, which soon assumed extensive propor- tions and elicited great warmth, arose in the Academy of Medicine of Paris, with reference to the treatment of uterine displacements. M. Vel- peau stood forth as champion of the view which is here expressed in his own words. " I declare, nevertheless, that the majority of the women treated for other aifections of the uterus have only displacements, and I affirm that, eighteen times out of twenty, patients suffering from disease of the womb, or of some other part of this region, those for instance in whom they diagnose inflammation (engorgements), are affiicted by displace- ments." In this and subsequent discussions he was upheld by some of the most eminent practitioners of Paris, and by many the view then expressed is still adhered to. No one of experience will question the fact that a dis- order of position of the uterus will often result in subsequent disorder in nutrition and sensibility. Every one must have repeatedly met with cases in which the reposition and support of a displaced uterus have at once dissipated a collection of symptoms which by many would have been attributed to inflammation of the mucous lining or parenchyma. Every one must have found in many cases the relief of a displacement, which was regarded as only an unimportant concomitant of the morbid state, result in complete cure. But admitting this is merely admitting the propriety of regarding displacement as one of many untoward influences which may dis- order the innervation, circulation, and nutrition of the uterus ; not making it the chief factor in the production of uterine diseases. The primary importance of displacement was long ably maintained in ' Op. cit., p. 624, OF GYNECOLOGY. 33 this country hy the late Prof. Hugh L. Hodge, of Philadelpliia, and the adherents of this theory are numerous. The most signal instance of its adoption which has recently occurred is that of Dr. Graily Hewitt, of London. While he does not make displace- ment absolutely essential as a primary factor of uterine disease, and limits his belief in its agency almost entirely to flexions or deformities of shape, the importance which he attaches to such displacements may be gathered from the following quotations from the third edition of his valuable work upon the diseases of women. " a. Patients suffering from symptoms of uterine inflammation (or, more properly, from symptoms referable to the uterus) are almost univei'sally found to be affected with flexion or alterations in the shape of the uterus of easily recognized character, but varying in degree. " b. The change in the form and shape of the uterus is frequently brought about in consequence of the tissues of the uterus being previously in a state of unusual softness, or what may be often correctly designated as chronic inflammation. "^. The flexion once produced is not only liable to perpetuate itself, so to speak, but continues to act incessantly as the cause of the chronic in- flammation present." In a certain number of cases very grave and annoying symptoms of uterine disease will be found due to chronic ovaritis, an affection in which treatment is so inefficient that every practitioner must dread to meet it. The symptoms of uterine disease being present, an exploration of the pelvic organs is made. No uterine disease of any kind is found to exist, but prolapsed into Douglas's cul-de-sac are found the ovaries, large, tender, and tumefied. In other cases uterine disease will be found coexistent with enlargement, tenderness, and displacement of ovaries, and the practitioner indulges the hope that so soon as the uterine disorder shall be cured the ovarian trouble will disappear. Such a sequence, however, does not occur, and he recognizes, to his disappointment, that what he regarded as a secondary matter is really one of primary importance. For this reason no examination of the pelvic viscera should be considered complete which does not involve a careful investigation of the state of the ovaries. For many years a thorough sceptic as to the frequency of ovarian dis- order as a cause of the ordinary symptoms of uterine disease, I am now convinced of its truth, and in few cases do I give more guarded prognoses than in those in which I find one or both ovaries enlarged, tender, and prolapsed. Since the year 1850, when he published his well-known work upon the subject of Ovarian Inflammation, no one has been a more constant or con- sistent advocate of the claims of ovarian pathology upon the notice of the gynecologist than Dr. Tilt, of London. At a meeting of the London Obstetrical Society, in April, 1873, he recapitulated his views, and it 3 34 HISTORICAL SKETCH cannot fail to be a matter of interest to see how time and experience have affected them. The positions which he originally took were these: 1st. That the recognized frequency of inflammatory lesions in the ovaries and in the tissues that surround tliem is of much greater practical importance than is generally admitted. 2d. That of all inflammatory lesions of the ovary those involving destruction to the whole organ are very rare, whilst the most numerous, and, therefore, the most important, may be ascribed to a disease that may be called either chronic or subacute ovaritis. 3d. That, as a rule, pelvic diseases of women radiate from morbid ovulation. 4th. That morbid ovulation is a most frequent cause of ovaritis. 5th. That ovaritis frequently causes pelvic peritonitis. Gth. That blood is frequently poured out from the ovary and the oviducts into the peritoneum. 7th. That subacute ovaritis not unfrequently causes and prolongs metritis. 8th. That ovaritis generally leads to considerable and varied disturbance of menstruation. 9th. Tliat some chronic ovarian tumors may be consid- ered as aberrations from the normal structure of the Graafian cells. Dr. Tilt pointed out that although these views, when promulgated, had been adversely criticized by Drs. Rigby, West, Bennet, and Churchill, they were now to a great extent accepted, and that they have been amply demonstrated both clinically and microscopically by Aran, Bernutz, Gal- lard, Negrier, and Siredey. I would emphatically dissent from his 3d postulate, which I regard as entirely too sweejiing an assertion, but with the remaining eight I fully agree. Of late years rapid advances have been made in the surgical treatment of the diseases of women. Under the lead of Simpson, Wells, Brown, and Keith, in Great Britain ; of Simon, Esmarch, Ulrich, Hegar, Spiegel- berg, and Schroeder, in Germany ; and of Sims, Atlee, Emmet, Peaslee, Dunlap, Agnew, and Kimball, in the United States ; operations for ovariotomy, the cure of ruptured perineum, vesico-vaginal fistulte, con- striction, or tortuosity of the cervix, prolapsus uteri, laceration of the cer- vix, etc., have been perfected and are now constantly practised. During the last quarter of a century three men have led the profession in the surgical portion of this department, and by their originality done a great deal to create what exists to-day ; Sims in America, Baker Brown in England, and Simon in Germany. Before their period aneesthesia was unknown and their predecessors lacked its aid. For them it offered its rare advantages, and they had the genius to make good use of them. Both the science and art of gynecology have been greatly advanced by the pathological researches of the German school. To-day confessedly in advance of all other nations in the study of pathology, the laborious, con- scientious, and persevering scholars of that country are altering and im- proving our views in reference to this subject, while contributions of great practical value are coming forth from them to enrich our literature. Among these may be especially mentioned those by Kiwisch, Hennig, OF GYNECOLOGY. 35 Wiildeyer, Simon, Spiegelberg, Martin, Scanzoni, Klob, Schroeder, Veit, and Schultze. It is a great source of pleasure to me before closing this sketch to be able to record the fact that America has not been wanting in her contribu- tion towards the progress of this branch of medicine. While the interests of gynecology were, during the early part of the present century, advanced in other lands by those whose names have been mentioned, in America they were pressed upon the attention of the profession and assiduously cultivated by tliree able advocates, all, singular to relate, from the same city, — Dewees, Meigs, and Hodge. Each of these observers brought to his work the most signal ability and enthusiasm, and, having abundant opportunities, as public teachers and writers, of disseminating their views, they each exerted a decided influence upon the mind of the profession. To the last of these gentlemen the profession throughout the world is more deeply indebted for means of properly sustaining the uterus by pes- saries than to any one else who has ever labored in this field, and we see in our day his determined opposition to the phlogistic theory of uterine disorders I'apidly gaining advocates amongst the ablest and most philo- sophical in our ranks. From this country have emanated, as contributions to this importnnt department of medicine, anaesthesia, ovariotomy, the revival of the method by which vaginal fistulse have been made amenable to systematic treat- ment, and which since the time of Gossett had been entirely forgotten ; and last, but by no means least, the introduction into ordinary pi-actice oi Sims's methods of exploring the pelvic viscera. I have elsewhere called the results of the labors of Recamier and Simp- son eras in the progress of this department. I now venture so to stvle those of Marion Sims. In doing this I make no reference to the improve- ments inaugurated by him in the treatment of injuries to the genital organs; my allusion is to the great advantages which now flow and are to flow from the invention of his speculum, which exposes the uterus by a new principle, and opens the way to a more complete examination of that organ. Recamier marked an era by improving our powers of diagnosis in exposing the cervix uteri ; Simpson another, by opening to investigation the body of the uterus; and Sims a third, by rendering both invesiigations more simple, complete, and satisfactory. There is no more certain way of nppreciating the effect of light than by withdrawing it and marking the degree of darkness which results. If all that Sims has done for gynecology were suppressed, we should find that we had retrograded at least a quarter of a century. The ordinary specula in use before the discovery of Sims's, simply sepa- rate the vaginal walls mechanically, and thus expose the uterus. Sims's instrument, on the other liand, elevates the posterior vaginal wall, which allows the entrance of air to distend the whole passage, the woman lying 36 HISTORICAL SKETCH on her side in such a manner that the cavity can be probed with the mos'; perfect ease, and applications made to the fundus. I am fully aware that many will differ from me in this opinion, but being entirely free from preju- dice in favor of this instrument, or against the ordinary varieties, I main- tain it fearlessly, feeling confident that time will prove it to be correct. No one who has not tested the two methods of examination is really enti- tled to an opinion upon the point, and I cannot doubt the conclusion of him who has done so faithfully and intelligently. It may very pertinently be asked how I reconcile this opinion with the facts that with the exception of Emmet in his recent work, and myself, no other writer of a systematic treatise on gynecology recommends this method of exploration in preference to that by the cylindrical speculum in daily practice ; that few, if any, of the gynecologists of Great Britain or the continent of Europe employ it to the exclusion of the old plan in ordi- nary cases; and that even in this city, where the personal advocacy of Sims himself and the wide-spread influence of the Woman's Hospital which he has founded are felt, only a score of practitioners do so, most of ■whom are connected with this hospital. My explanation of the facts is this : to employ Sims's speculum efficiently considerable experience with it is necessary. One who has not practised with it so as to become skilful will find it far less useful than the cylindrical and valvular specula in ordi- nary use. I feel sure that most of those who have tried it and cast it aside, except for operations on the vagina or uterus, have attributed their own shortcomings to an instrument the use of which they had not mastered. Again, it is necessary to have an assistant, and highly desirable to have a practised assistant, to hold the speculum. None of the substitutes for such an assistant have ever proved or, I think, will ever prove effectual. For this reason also the use of this instrument has not become more general. It is becoming customary, with those who practise gynecology as special- ists in this city and employ this speculum, to see their patients almost universally at their offices, and to have in attendance a trained nurse who manages both patient and instrument during examinations. One prac- tising in this manner places himself, I am confident, on a vantage ground, which can scarcely be imagined by him who clings to the old methods of exploration. The experience required, however, to use this speculum with advantage, and the disadvantage of its requiring the aid of a nurse, will prevent its universal or even very general adoption. I do not believe that the practitioner who sees very little of uterine disease will ever employ it. But there are at present many who are studying and practising gynecology extensively and scientifically. It is to such that these remarks are espe- cially addressed. In stating all this thus plainly and positively, I am by no means igno- rant of the criticism to which I expose myself from an overwhelming and OF GYNECOLOGY. 37 most influential majority. I confess that even to me the slow advance made by Sims's speculum, as an instrument for every-day use, has been a matter of great surprise. Familiarized, however, by years of practice with both methods of examination, and prejudiced in favor of neither, I cannot doubt the result. The assertion of its rights by the new method will give an impetus to the advance of gynecology which in some degree it has even now effected. I cannot close this part of my subject without appealing to those work- ino- in this department who are willing to test the matter, in the following manner. Learn the use of Sims's speculum, not by personal labor and experiment, but from one who is fully master of it ; have at your disposal a trained nurse, and persevere with the method for three months, and you will endorse the statement as to the vantage ground which you will occupy, which just now appears so exaggerated to you. Nothing is easier than to attack upon paper such a position as that which I have here assumed ; nothing more tempting than a half humorous, half sarcastic review of it. But the question is one of too great moment to be thus dealt with. All earnest workers in our ranks are in search after truth, not striving to prove themselves right ; all wise men are eager to avail themselves of improve- ments in their calling, not to find warrant for hugging what is old. Although the scope of this chapter will not admit of the mention of all the works which have recently appeared upon this subject, I cannot refrain from mentioning one which comes to us offering, among other valuable contributions, one of the most important pathological facts, and with it its corresponding surgical resource, which the last half century has yielded. The work is the highly original and valuable one of Dr. Thomas Addis Emmet, of New York ; the pathological contribution which, even if this eminent author had done nothing else to lay his profession under obliga- tion, would indelibly write his name upon the records of gynecology, is the diagnosis and treatment of laceration of the cervix uteri. No one contribution to this department which has been made in tlie period men- tioned has exerted a more marked influence upon uterine pathology tlian this is now doing, and will do in the future. None will have more influ- ence in abolishing useless and hurtful therapeutical resources. During the past thirty years a decided eftbrt has been made all over the civilized world to introduce into medicine a remarkable innovation — the opening of its doors to the entrance of women as practitioners. The prevalent and very just sentiment, that- the gentle and sympathetic nature of woman would, in this department of labor, find an appropriate field of action, at that period began to be clearly expressed, and the urgent de- mand which was made by progressive minds in different countries has at the present day been fully met. Tliis has not been accomplished without opposition. The usual adverse striving of narrow and non-progressive minds has not been wanting to retard the advance of the movement, but 38 HISTORICAL SKETCH in spite of this, with an almost unprecedented rapidity when its magnitude is considered, it has arrived at assui'ed success. The connection of woman with the practice of medicine is a matter of no recent date. The sentiment which fosters it now has existed in an un- developed state from the earliest ages. Aetius makes mention of the writ- ings and practice of Aspasia, who was a doctress at Rome about the third century, and copies extensively from her upon ulceration and displace- ments of the womb. Paulus ^gineta is, for some of his chapters, in- debted to Cleopatra, fragments of whose writings he has preserved for us. He evidently apjotes her with respect, and credits her with what he bor- rows. In the thirteenth century an Arabian woman, Trotula by name, published a treatise, in which she mentions that many Saracenic women pi'actised the art of obstetrics at Salerno. In later times, during the seventeenth and eighteenth centuries, women were graduated as Doctors of Medicine in the Italian Universities, and as such enjoyed great con- sideration. In 1732, La Dottoressa Laura Bassi graduated at Bologna, and filled the chair of Natural Philosophy for six years. In the last part of the eighteenth century. Madonna Mazzonlina lectured on anatomy at Bologna, while others of lesser note filled positions of minor importance. To the women of Arabian civilization the department of obstetrics was entirely surrendered ; for so great were the sensuality and libertinism of the Saracens, that the Mahommedan laws prohibited the attendance of males upon females ; and thus their whole treatment, except in extreme cases, devolved upon the midwives. In France a portion of the work of medicine has long been allotted to " Sages Femmes" or midwives, and the names of Mmes. La Chapelle and Boivin, who lived in the last part of the eighteenth and the beginning of the nineteenth centuries, come to us clothed with great authority. The demand of our time then is not that woman may practise medicine, but that she should have every opportunity which that time ofl^'ers her to prepare herself for the work. Many have doubted, and upon excellent grounds, the ability of woman to cope with man in this field of labor, for there is no resisting the evidences of history, that, in spite of opportunities and incentives, female practitioners have failed in time past, not only to advance, but even to maintain the integrity of the art intrusted to their hands. The experience of the future may contradict that of the past ; but even its doing so will oifer no good reason for despising the lesson which the past has left on record. As futile would it be, however, to resist the overwhelming " logic of events," and to shut our eyes to the fact that the "woman movement" has conquered for itself in medicine a position which entitles it to consideration and respect. The opportunity which is now offered to woman for retrieving what has been lost in former ages is certainly all that the most exacting of modern reformers could require. The prejudice which for years existed against OP GYNECOLOGY. 39 her in this connection appears to be, in this country and in Europe, almost entirely eradicated. In many of the most ancient and eminent of the uni- versities of Europe they are free to matriculate, and in most of the largest cities both of Europe and America female medical colleges exist. In this city, some of the most able of our junior teachers are engaged in instruc- tion in the Female Medical College, and many of the most eminent and conservative of the senior members of the medical profession have accepted positions as consultants to the hospital attached to the college. Female practitioners are freely met in consultation in general practice, and the County Medical Society, one of the two representative associations of the city, admits them to its ranks -as members. The general and sincere feel- ing of the progressive and most prominent members of the medical profes- sion here is unquestionably this, to allow to females a fair opportunity to enter the field of medicine, and strive to establish their ability to perform its arduous functions, however much they may doubt the success of the enterprise. All appear willing to intrust the solution of the problem of woman's fitness for the duties of medicine to time, the great crucible of human theories. "The burning question," says J. R. Chadwick, in an excellent review of this subject, "is no longer, shall women be allowed to jiractise medi- cine? They are practising it; not by ones or twos, but by hundreds; and the only problem now is, shall we give them opportunities for study- ing medicine before they avail themselves of the already acquired riglit of practising it?" Admitting that this question is justly put, can any one wishing well to humanity and to science venture to array himself on the negative side? An innovation in general surgery which bids fair to be one of the greatest improvements which has ever been effected in that art has been reserved for our time — the establishment upon a systematic basis of anti- septic surgery. No departments of surgery will feel, indeed are now feel- ing, the influence of this more decidedly than those of gynecology and obstetrics. The great evil from which they have suffered is septicaemia, and this it is the special object of Listerism to prevent and overcome. Not only does this method offer great advantages in ovariotomy, in all its details except the use of the spray it may with the greatest advantage be applied to all operations within the pelvis. 1 am so often consulted by recent graduates as to the works which they should make the basis of a library upon gynecology, that I feel that I may lender a service by the following list. Only such works are recorded as will prove of absolute service to the active practitioner who seeks know- ledge chiefly upon practical points : — Nonat — Maladies de I'Uterus, 1 vol. Aran— Maladies de I'Uterus, 1 vol. Becquerel — Maladies de I'Uterus, 2 vols. 40 HISTORICAL SKETCH OF GYNECOLOGY. Blatin et Nivet — Maladies des Femmes, 1 vol. West — Diseases of Women, 1 vol. Tilt — Uterine and Ovarian Inflammation, 1 vol. Bennet— On the Uterus, 1 vol. Simpson — Diseases of Women, 1 vol. Hewitt — Diseases of Women, 1 vol. Churchill^Diseases of Women, 1 vol. Byford — Medical and Surgical Treatment of Women, 1 vol. Sims — Uterine Surgery, 1 vol. Baker Brown — Surgical Diseases of Women, 1 vol. Tilt — Uterine Therapeutics, 1 vol. Scanzoni— Diseases of Females, 1 vol. Meigs — Diseases Peculiar to Females, 1 vol. Bedford — Diseases of Women and Children, 1 vol. Colombat — On Females (annotated by Meigs) , 1 vol. Ashwell — Diseases of Women, 1 vol. McClintock — Diseases of Women, 1 vol. Courty— Maladies de 1 'Uterus et de ses Annexes, 1 vol. Hodge — Diseases Peculiar to Women, 1 vol. Klob— Pathological Anatomy of the Female Genital Organs, 1 vol. Spencer Wells — On Diseases of the Ovaries. Kiwisch — On Diseases of the Ovaries, 1 vol. Wright — Diseases of Women, 1 vol. Emmet — On Yesico-Yaginal Fistulse, 1 vol. Duncan — Parametritis and Perimetritis, 1 vol. Duncan — Fecundity, Fertility, and Sterility, 1 vol. Athill — Diseases of Women, 1 vol. Gallard — Lemons Clinique sur les Maladies des Femmes, 1 vol. Peaslee— Ovarian Tumors, 1 vol. Atlee — Ovarian Tumors, 1 vol. Barnes — Treatise on Diseases of Women. Goodell — Clinical Lectures on Diseases of Women, 1 vol. Leblond — Traite Elementaire de Chirurgie Gynecologique, 1 vol. Schroeder— Diseases of Female Sexual Organs, 1 vol. Tait— Diseases of Women, 1 vol. Emmet — Principles and Practice of Gynecology, 1 vol. Hegar and Kaltenbach— Die Operative Gyniikologie, 1 vol. Skene — Diseases of the Bladder and Urethra in Women, 1 vol. Mary Putnam Jacobi — The Question of Kest for Women. Martineau— Traite Clin, des Aftec. de I'Uterus. The following journals are now devoted to this subject: — Centralblatt fiir Gynecologic. Annales de Gynecologic. Obstetrical Journal of Great Britain and Ireland. American Journal of Obstetrics and Diseases of Women and Children. Obstetric Gazette.. Archiv fiir Gyniikologie. ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 41 CHAPTER II. THE ETIOLOGY OF THE DISEASES PECULIAR TO WOMEN. In investigating the causes of the diseases peculiar to women I shall especially refer to those which are active in this country. In doing this I desire to avoid all comparison between the frequency of such affections here and abroad, for in the absence of statistical evidence such an attempt would necessarily prove futile. My chief reason for giving myself the limits herein prescribed is my desire to base the views advanced in this chapter entirely upon personal observation, to offer to the reader not the conventional doctrines prevalent upon the subject of which it treats, but those views which have impressed themselves upon my own mind as valid and valuable. "With this object in view, it is manifestly easier to write of habits and influences which come under one's daily observation and con- nect themselves with the experience of his daily life. I shall divide the causes to which I shall draw attention into predis-j posing and exciting, premising their enumeration by the announcement! that I do not propose to mention all of the former wliich are active, but to limit myself to those which are most prominent, and which are to a great degree avoidable. Others, such, for example, as inherited constitu- tional vices, will be spoken of in connection with special diseases as they come under notice. Considering very fully the predisposing causes, I shall give merely an enumeration of the chief exciting ones, leaving the fuller consideration of the latter also for chapters devoted to special affections. If we compare the present state of women in refined society over the world with that of the working peasants of the same latitudes, or with the North American squaws, or the powerful negresses of the Southern States, we can with difficulty believe that they all sprung from the same parent stem, and originally possessed the same physical capacities. Observation proves that women who are not exposed to depreciating influences can compete in strength and endurance with the men of their races, and in savage countries they are sometimes regarded as superior to them. In the lower orders of animals this equality is still more marked. The mare endures as much as the horse, and some of our most celebrated racers have represented the female sex. The lioness is fully as dangerous to the hun- ter as her more majestic consort, and the bitch proves as untiring in the chase as the most muscular dog in the pack From all these facts we may logically argue, that the human female, if 42 ETIOLOGY OF THE DISEASES properly developed and placed beyond causes which militate against her physical well-being, would be ir no great degree the inferior of the male. This position I now assume, and maintain that the customs of civilized life have depreciated her powers of endurance and capacity for resisting disease. My efforts will be directed to an endeavor to point out what these habits and influences are. I do not, of course, advance the state- ment that uterine diseases are unknown among uncivilized women, for I have too often seen prolapsus, retroversion, granular degeneration, and kindred disorders among the former slaves of this country to do so. These affections were, however, rare among them, and not exceedingly common, as they are amongst our white women, and even when they existed, they did not so profoundly affect the constitutions of those suffering from them. As I shall hereafter point out, injuries inflicted by parturition play a most important role in the causation of these disorders. To such injuries as laceration of the peri-neum and cervix, disorders of involution, etc., the savage woman is unquestionably liable, and their occurrence would entail upon her the same evils which would result from them in the civilized Yet how much less liable to their occurrence is the strong, well-developed, muscular frame of the former than the delicate sensitive organization of the latter ! And even if exposed to the baneful influence of these acci- dents, how much more able is she to resist their depreciating influences ! There are in this city to-day thousands of poor women who go through with the labors of their lives of drudgery with the uterus, vagina, and por- tions of the bladder and rectum in the condition of complete prolapse, the first two organs entirely, and the last two in great degree, outside of their bodies. How differently would the refined woman of a higher sphere be affected by a similar condition, and how utterly wretched would her life ordinarily be rendered ! In a woman of robust frame, healthy nervous system, and perfect blood state, who lives a rational and carefully regulated life, an accident, occur- ring at parturition, during menstruation, or at any time disconnected with these trying periods, may produce serious disease. But in such a woman accidents are much less likely to occur, and even if they did so would pro- duce much less serious consequences than in one in whom the predisposing causes of disease of the genital system had for a lifetime, and even longer, for hereditary influences are powerful for evil in this connection, prepared the way for the easy establishment of pathological conditions. Those influences which, growing out of the physically depreciating liabits of civilized life, tend most decidedly to develop a predisposition to diseases of the female genitalia may thus be enumerated : — Neglect of out-door exercise and physical development. Overwork of brain, and excessive development of nervous system. Improprieties of dress. Imprudence during menstruation. PECULIAR TO WOMEN. 45 Imprudence after parturition. Non-recognition or neglect, on the part of the obstetrician, of injuries due to parturition. Prevention of conception and induction of abortion. Marriage with existing disease of genitalia. Insufficient food. Habitual constipation. Neglect of Exercise and Physical Development There can be no doubt of the fact that, as a general rule, in the higher walks of life throughout the civilized world, the female, from infancy to old age, takes much less exercise than the male, and in the United States, owing to pe- culiarities of climate, this disproportion is probably more marked than in the countries of Europe. It is true that the last decade has seen a most gratifying improvement in this respect, and that the practice of out- door amusements, such as rowing, bowling, archery, walking, croquet, horseback exercise, etc., has become much more general. Tliis, however, is greatly confined to the inhabitants of cities and to very young women, and even among these it must become much more general than it is to-day for it to produce the results which may in time be expected from it. The female by nature is as a rule much more inclined to a sedentary life than the male, and as her occupations keep her indoors she is apt, whether living in city or country, to lose all taste for out-door amusements, and to confine herself to the close, heated air of inhabited apartments. Among our farming population, where all the out-door work is done by the males, the women commonly take less exercise in the open air than do those in our cities, and much of their time is spent in rooms heated by stoves which cook the air and render it dry and unwholesome. In spite of the improvement we have mentioned, in our cities will, to- day, be found hundreds of ladies who do not walk a mile a day for weeks together, and many more who have never engaged in any exercise which called forth the action of other muscles than those employed in the quietest locomotion. But nowhere is the neglect of early physical development more marked than in our boarding-schools and female seminaries, where every hour of the day from six in the morning to nine at night is allotted by rule to some special task. Instead of the girls being encouraged to engage in out- door pursuits calculated to create muscular power, they are reared in the belief that such pastimes are hoydenish, unbecoming, and fit only for rough boys. Their hours of leisure are occupied by reading, music, draw- ing, or some similar light task, and an hour's walk every day is regarded as a degree of exercise quite sufficient for the requirements of health. By this plan the mind is constantly kept in the thraldom of control, and chafes under the depressing influence of a never-ending surveillance. A set of 44 ETIOLOGY OF THE DISEASES romping school-girls could as profitably laugh by rule as really enjoy and improve by exercise under the eye of an instructress or professor of calis- thenics. It is not the mere bodily exertion which is of benefit, but the total mental relaxation, the exhilaration and the abandon which accom- pany it. The prisoner working for eight hours on the treadmill does not profit by it as the free and happy equestrian or oarsman does by one- eighth the time of exercise. One of the most important results of exercise is the increase of the peripheral circulation. This increases cutaneous exhalation, and tends to equalize the circulation. The woman who neglects it is peculiarly prone to excessive uterine and ovarian congestion at menstrual epochs, and to sluggish circulation in these parts at all times. It is this fact which explains the excellent results attainable in cases of uterine and ovarian disease from the use of passive motion by the Swedish movement cure, the Turkish bath, surf bathing, and other methods which create turges- cence of the cutaneous capillaries, and exalt metamorphosis of tissue in the periphery of the body. One of the most valuable and beneficent means of treating these diseases that I know of is the use night and morning of a ; warm sponge-bath of water strongly impregnated with salt, followed by thorough friction with a rough towel and calisthenic exercises for five or ten minutes. Excessive Development of the Nervous System — The necessity for a due proportion existing between the development and strength of the nervous and muscular systems has always been recognized, and has given rise to the trite formula, "mens sana in corpore sano," as essential to health. Unfortunately the restless, energetic, and ambitious spirit which actuates the people of the United States, has i)rompted a plan of education which by its severity creates a vast disproportion between these two systems, and its effects are more especially exerted upon the female sex, in which the tendency to such loss of balance is much more marked than in the male. Girls of tender age are required to apply their minds too constantly, to master studies which are too difficult, and to tax their intellects by efforts of thought and memory which are too prolonged and laborious. The results are, rapid development of brain and nervous system, ^Ji'ccocious talent, refined and cultivated taste, and a fascinating vivacity on the one hand ; a morbid impressibility, great feebleness of muscular system, and marked tendency to disease in the generative organs, on the other. That this statement of the advantages which are gained and the price which is paid for them is perfectly true, no American practitioner will deny. But the mere existence of the fact is not the most melancholy feature of the case ; it is far more painful to see mothers listening to it, admitting its truth, and yet calmly and dispassionately choosing to make the trial, as we see them doing constantly. PECULIAR TO WOMEN. 45 When the day arrives in which our young growing girls are educated physically with the assiduity and system now bestowed upon their mental culture ; when mothers desire to see their daughters grow up strong, well developed, muscular women, and not merely highly educated and accom- plished valetudinarians, one of the most prolific of the predisposing causes of disease of the genital organs will have disappeared. ISo amount of mental labor, no degree of mental culture will fit a woman for the physical duties of wife and mother, or render her capable of bearing children com- petent to resist the inroads of disease. In a woman developed by this pernicious system, the physiological congestion of the pelvic organs attending ovulation produces pain which is known as " neuralgic dysmenorrhcea ;" ovulation becomes irregular and abnormal, favoring the development of subacute ovaritis; the normal hy- pertrophy of the uterus consequent upon utero-gestation slowly and imper- fectly passes off, subinvolution often remaining ; while the enfeebled mus- cular supports of the heavy organ allow it to lapse from its position and assume that of flexion or version. Improprieties of Dress — The dress adopted by the women of our times may be very graceful and becoming, it may possess the great advantages of developing the beauties of the figure and concealing its defects, but it certainly is conducive to the development of uterine diseases, and proves not merely a predisposing, but an exciting cause of them. For the proper performance of the function of respiration, an entire freedom of action should be given to the chest, and more especially is this needed at the base of the thorax, opposite the attachment of the important respiratory muscle, the diaphragm. The habit of contracting the body at the waist by tight clothing confines this part as if by splints; indeed it accom- plishes just what the surgeon does who bandages the chest for a fractured rib, with the intent of limiting thoracic, and substituting abdominal respi- ration. As the diaphragm, thus fettered, contracts, all lateral expansion being prevented, it presses the intestines upon the movable uterus, and forces this organ down upon the floor of the pelvis, or lays it across it. In addi- tion to the force thus exerted, a number of pounds, say from five to ten, are bound around the contracted waist, and held up by the hips and the abdominal walls, which are rendered protuberant by the compression al- luded to. The uterus is exposed to this downward pressure for fourteen hours out of every twenty-four; at stated intervals being still further pressed upon by a distended stomach. In estimating the effects of direct pressure upon the position of the ute- rus, its extreme mobility must be constantly borne in mind. No more striking evidence' of this can be cited than the fact, that in examining it by Sims's speculum, if the clothing be not loosened around the waist, the 46 ETIOLOGY OF THE DISEASES cervix is thrown so far back into the hollow of tlie sacrum as to make its engagement in the field of the instrument often very difficult, and that attention to this point in the arrangement of the patient will at once re- move the difficulty. Wliile the uterus is exposed by the speculum, it will be found to ascend with every expiratory effi:)rt, and descend with every inspiration ; and so distinct and constant are the rapid alterations of posi- tion thus induced, that in operations in the vaginal canal the surgeon can tell with great certainty how respiration is being affiicted by the anaesthetic employed. An organ so easily and decidedly influenced as to position by such slight causes must necessarily be aflfected by a constriction which, in autopsy, will sometimes be found to have left the impress of the ribs upon the liver, producing depressions corresponding to them. Corseting, lacing, and the wearing of tight and heavy clothing, also produce a deleterious effect in quite another way. Pressure against the abdominal and thoracic muscles, and over the diaphragm, produces in them a partial paresis. This impairs abdominal as well as thoracic respi- ration, to a great extent counteracts the important retentive power of the abdomen over the pelvic viscera, and allows the influence of gravitation, which before was by that means antagonized, to cause displacement. This result of a pernicious habit cannot be too thoroughly appreciated or too much insisted upon. So prominent is it in etiology that I might well have considered it under the head of exciting causes. By tlie direct influences of pressure just considered, and the paresis of thoracic, abdominal, and diaphragmatic muscular fibres now alluded to, the abdominal viscera px'ess upon the growing uterus of the young girl, and the fundus being bent towards the cervix, one uterine wall develops much more rapidly than the other, and at puberty the menstrual effort finds itself interfered with by closure of the cervical canal, and an origin for uterine disease is created thereby. To a woman who has systematically displaced her uterus by years of imprudence, the act of sexual intercourse, which, in one whose organs maintain a normal position, is a physiological process devoid of pathologi- cal results, becomes an absolute and positive source of disease. The axis of the uterus is not identical with that of the vagina. While the latter has an axis coincident with that of the inferior strait, the former has one similar to that of the superior. This arrangement provides for the passage of the male organ below the cervix into the posterior cul-de-sac, the cervix thus escaping injury. But let the uterus be forced down, as it is by the prevailing styles of fasliionable dress, even to the distance of one inch, and the natural relation of the parts is altered. The cervix is directly injured, and thus a physiological process is insensibly merged into one productive of pathological results. How often do we see uterine disease occur just after matrimony, even where no excesses have been committed. It is not an excessive indulgence in coition which so often produces this PECULIAR TO WOMEN. 47 result, but the indulgence to any degree on the part of a woman who has distorted the natural relations of the genital organs. But this is by no means the only method by which displacement of the uterus may induce disease of its structures. It disorders the circulation in the displaced organ, and produces passive congestion and its resulting hypertrophy, prevents the free escape of menstrual blood by pressing the OS ao-ainst the vagina, creates flexion, causes friction of the cervix against the floor of the pelvis, and stretches the uterine ligaments and destroys their power and efficiency. These facts should be carefully borne in mind by the physician who attempts to relieve uterine displacements by the use of pessaries. If he merely replaces the displaced organ and relies for its support upon a pes- sary, he will often fail in accomplishing the desired result. He is striving at great disadvantage with a short lever power against the weight, not of the uterus alone, but of the super-imposed viscera pressed downwards by several pounds of clothing, which add their weight at the same time that they constrict the waist and substitute abdominal for thoracic respiration. Thus employed the pessary will often give great pain, and so injure the parts upon which it rests as to necessitate removal, and the practitioner will find himself cut off from one of his most valuable resources. Should he, on the other hand, before employing a pessary, remove all constriction and weight from the abdominal walls, apply a well-fitting abdominal sup- porter over the hypogastrium so as to aid the exhausted abdominal mus- cles in their work, keep the displaced and congested uterus out of the cavity of the pelvis by a tampon of medicated cotton, or bring gravitation to his assistance by the position of the patient, he will ordinarily at the end of a week be able to employ with great advantage the same pessary, which at first seemed to accomplish evil and not good. Imprudence dnring Menstruation is a prolific source of disease. Some women, through ignorance, many through recklessness, and a few from necessity, go out lightly clad in the most inclementweather during this period, and many suffer in consequence from violent congestive dysmenor- rhcea, and often from endometritis. Every practitioner will meet with a certain number of cases of uterine disease which have this origin, and run on for years, ending, perhaps, in parenchymatous disease, which may prove incurable. During a period in which the ovaries and uterus are intensely engorged, in which the surface of the ovary is broken through by the escaping ovule, and the nervous system is in an unusual state of excitability, ordinary prudence would suggest that the body should be well covered, that the congested organs should be left at rest, and that exposure to cold and moisture should be sedulously avoided. I need not say that these rules are commonly neglected; and in evidence of the fact I will venture the 48 ETIOLOGY OF THE DISEASES assertion that, on this very day, the thermometer 15° above zero, the skating pond of our park contains scores of delicate and refined women who are showing a disregard of them by tlieir presence there. The immediate result of exposure during menstruation is most com- monly inflammation of the mucous membrane of the uterus. Such an inflammation once excited will often go on for years and in time end in parenchymatous disease, entailing in its progress dysmenorrhoea, sterility, pelvic pain, and gastric disorders, which impair digestion and nutrition. Many cases, too, of pelvic peritonitis, cellulitis, and hematocele develop at this trying period of congestion and nervous exaltation. Imprudence after Parturition. — No sooner does fixation of the impreg- nated ovum upon the uterine surface occur than a surprising stimulation is exerted upon the fibre-cells forming part of the uterine parenchyma, which grow with rapidity, enlarging the organ, pari passu, with the requirements of its increasing contents. After the expulsion of the embryo, either at full time or at any period of pregnancy, the fibres thus developed undergo a fatty degeneration and absorption, which has received the name of involution. This process occurs rapidly after abortion, but after labor at term it requires six weeks for its full accomplishment. In order that it may proceed with normal rapidity and certainty, perfect rest is essential; and the woman who rises too soon, and i-esumes her usual occupations, while the lochial discharge is still existing, risks the results of interference with it. Besides this, the uterus is much heavier than usual, and the additional danger of the induction of displacement is incurred by too early exertion. Lastly, the mucous membrane lining the cavity of the uterus is for some time after parturition in an abnormal state, and is peculiarly liable to disease from exposure to cold and moisture. A very valid objection may be made to this view, that in the lower walks of life women rise after labor, and attend to their duties with impunity on about the ninth day, and yet enjoy a marked immunity from uterine affections. This is true ; but let it be remembered that they are unaffected by the influences to whicli I have alluded as calculated to enfeeble and deteriorate their generative systems. Another influence connected with parturition, which develops itself much more decidedly among the higher than the lower classes, is the per- nicious habit of tight bandaging. For three or four weeks after delivery the nurse commonly applies two folded towels over the enlarged uterus, and by powerful compression by a bandage forces the organ backwards into the hollow of the sacrum. This is supposed to preserve the comeliness of the figure, and the reputation of many a nurse rests mainly upon the thoroughness with which she develops an influence that is fruitful of evil in displacing an enlarged uterus in a woman who for a fortnight at least lies chiefly upon her back. That a well-fitting bandage, only tiglit enough PECULIAR TO WOMExN. 49 to give support, applied after delivery, proves Obstet. Works, vol. i. p. 277, Am. ed. PUDENDAL HEMATOCELE. 131 number of instances in which from a verj slight rupture of one labium fatal iiemorrhage took place. He declared that criminal cases had repeat- edly occurred in Scotland, in which women, both pregnant and non- pregnant, liad suddenly died from [)udendal hemorrhage, arising from rupture of the bulbs of the vestibule. Suspicion of injury, at the hands of the husbands or neighbox's, had been entertained in most or all of the instances referred to. The accident is a rare one. But two instances have come under my notice, one occurring in consequence of puncture of the labium by a stick, the woman falling in crossing a fence ; the other the result of a similar puncture by a piece of china, from the breaking of a pot de chambre. Both these cases readily yielded to the recumbent posture, and the application of cold and styptic compresses. A very interesting case, the details of which I cannot now find, was [)ublished some time ago in one of the journals of the day. A lady, standing upon a chair to mount a horse, slipped and fell, so as to cause the sharp extremity of one of the upright pieces to puncture one labium. Bleeding was profuse, and so obstinate as to require several attem[)ts at checking it before it was finally controlled. This was in the end accom[)lished by a tampon in the vagina and firm compression by a T bandage. Causes — Tlie great predisposing causes are pregnancy, varicose condi- tion of the veins, and a large pelvic tumor. The exciting causes ai'e — Great muscular efJbrts ;' Blows rupturing the labium ; Incisions or punctures. Symptoms — The hemorrhage that announces the accident will lead to a physical exploration, which will at once reveal the nature of the lesion. Treatment — The nature of the accident being once recognized, the control of the How will not usually be difficult. If it be not effected by cold and astringents, sucli as ice, the persulphate of iron, or tannin, the vagina should be filled with a firm tamjion of cotton, a folded towel ap[)lied as a compress over the vulva, and a T bandage made to press this forcibly against the body. Siiould tiiis plan fail, the wound should be enlarged by incision and filled with pledgets of cotton saturated with solution of per- sulphate of iron ; then the tampon should be applied in the vagina and a compress carefully adjusted by means of a T bandage. It is difficult to conceive of any case occurring in the non-pregnant woman which could resist this method if etf'ectually employed. Pudendal Hematocele. Definition and Synonyms — The term thrombus, derived from the Greek 0po^i3oid, " I coagulate," and which is used synonymously with hema- ' Prof. Simpson records a case due to straining at stool. 132 DISEASES OF THE VULVA. toma and sanguineous tumor, is that which is generally applied to this condition. I have preferred the appellation of pudendal hematocele, given to the disorder by Dr. A. H. McClintock, from its pointing out the similarity between it and pelvic hematocele, which resembles it in patho- logy, and because the term thrombus is now commonly applied to the coagulation of blood in a bloodvessel. A pudendal hematocele is a tumor formed by a mass of clotted blood effused into the tissue of one labium, or the areolar tissue immediately surrounding the wall of the vagina. History As early as 1554, the disease was mentioned by Rueff, of Zurich, and in 1647, Veslingius is said by Dr. Merrimen to have noticed it. It attracted the attention of Kronauer, of Basle, in 1734, and sub- sequently that of Levret, Boer, Audibert, and others.^ In time it passed somewhat out of notice, until the researches of Deneux,* in 1830, drew attention to it in more recent times. It is generally alluded to by authors only as one of the results of pregnancy and parturition, though it is incon- testably proved that it may occur in the non-pregnant and even in the virgin state. Velpeau records an instance in a girl of fourteen years, who had not yet arrived at puberty, and declares as the result of his experience, that "thrombus vulvas occurs almost as frequently in non-pregnant women as in those who are in labor." He declares that he has, in the course of one year, observed six cases in the non-pregnant woman ; and in his whole experience he has met with twenty instances of the affection. At the same time that I defer to the statement of so reliable an authority as Velpeau, I must express surprise at it. The accident in the puerperal woman is not very rare, but my experience would lead me to regard it as extremely so in the non-puerperal, since in a practice of twenty-seven years I have met with but four cases. These occurred as direct results of injuries done to one labium by a severe blow, and resembled very closely the same accident which occurs so often around the eye. Another fact which adds to my surprise is this: in connection with this subject I have carefully examined the current medical literature of the day, and, although it teems with reports of this affection as a complication or sequel of labor, 1 find few reports of instances in the non-pregnant woman. Nevertheless, as I am in this work strictly avoiding the study of the diseased states constituting the complications and sequelae of labor, I shall specially con- sider that form of the affection which occurs in the non-puerperal state. Pathology The pathology of this condition is similar to that of pudendal hemorrhage, which has just received notice, for both are results of rupture of the bulbs of the vestibule. In that which we are now con- sidering, the effused blood, instead of pouring away, collects in the tissue ' Velpeau, Diet, de Med., vol. xxx. 2 Sur les Tumeurs sanguines de la Vulve et du Vagin. i PUDENDAL HEMATOCELE. 133 of one labium, under the vagina, or even in the areolar tissue of the pelvis, and forms a coagulum. It bears to pudendal hemorrhage the same relation which a simple fracture bears to one of compound character. Rupture of a branch of the ischiatic or pudic artery may, during labor, likewise produce a bloody tumor,* but this should not be treated of under the technical head of pudendal hematocele, for it would really constitute a case of sub-peritoneal hematocele. Mode of Development. — When a large vessel has been injured, a tumor, perhaps the size of an orange, is suddenly discovered at the vulva. At other times the tumor is quite small, not larger than a walnut. The ex- tent of the laceration likewise governs the rapidity with which the tumor forms after the injury has been inflicted. In some instances a slight flow slowly continues until compression from the clot checks it. When the accident occurs in the non-pregnant state, the amount of blood effused is generally less extensive than in pregnancy, and is usually confined to the vulva. Causes. — The causes are similar to those of pudendal hemorrhage, namely : — Muscular efforts ; Blows injuring the labia; Punctures by small instruments. Symptoms The symptoms are usually a sense of discQmfort, with pain and throbbing, and if the effusion reaches the urethra, there is obstruction to urination. The patient or attendant will often first recognize the fact that something abnormal has occurred by the sense of touch, practised without a suspicion as to the nature of the real difficulty. Differentiation.''^ — Care must be observed not to confound this affection with — Abscess of the labia ; Pudendal hernia; Inflammation of vulvo-vaginal glands ; Oedema labiorum. The mere announcement of the possibility of error in diagnosis is all that is necessary, for the physical characteristics, mode of development, and rational signs of these affections are so different from those of pudendal hematocele, that examination will always settle the point with certainty. Prognosis — If the sanguineous collection be small, it will, especially in ' Meigs's Treatise on Obstetrics, 5th ed., p. 94. * I have ventured to use this term in place of "differential diagnosis," giving it the signification which it has in Natural History, instead of that which belongs to it in Mathematics. This use is sanctioned by Worcester ; and Agassiz speaks of the "differentiation of species." Its cognate verb is equally necessary and convenient. 134 DISEASES OF THE VULVA. the non-pregnant state, generally disappear spontaneously. If, however, it be large, and if tlie patient have recently been delivered, there are always two dangers to be apprehended. The lesser of these is hemorrhage; the greater, purulent infection through the walls of the cyst, or the forma- tion of an extensive abscess, which may produce the same result. These may follow in the non-puerperal form of the affection, but the danger of both is much less great than in the puerperal, where the vessels of the part are largely distended, in consequence of excessive growth, and where the blood state is one of hydrjemia and hyperinosis. Natural Course Should the tumor be left to itself, it maybe absorbed in a short time and leave no trace ; in five or six days it may burst and discharge; the clot may become encysted, and remain indefinitely in the tissues ; or the irritation of the clot may create suppurative infiammation, and abscess of the labium be the consequence. Treatment — Should the tumor be small, and not excite much pain, a cooling lotion of lead and opium should be applied, the patient kept quiet, and the evacuations of the bladder and rectum regulated, in the hope that absorption will take place. As soon as evidences of phlegmonous inflam- mation around the tumor appear, suppuration and discharge should be encouraged by poultices. When the tumor is large, and experiment has demonstrated that it will not undergo absorption, it is advisable to evacu- ate the blood-clot by incision. This should be done by means of a bis- toury, upon the mucous face of the labium majus, the patient being placed under the influence of an anaesthetic. After an incision has been made, one finger should be inserted and the clot tm-ned out of its nidus. If he- morrhages ensue, the sac should be thoroughly washed out with a solution of the persulphate of iron, and pressure exerted. Should this not check it, pledgets of lint soaked in this astringent should be passed into the sac, and, if necessary, counter-pressure exerted per vaginam by a tampon of cotton. In case no hemorrhage should follow evacuation of the cavity, no vaginal tampon should be employed, nor should the empty sac be tilled with cotton. A better plan under these circumstances would be to wash out the cavity thoroughly with a weak solution of carbolic acid in water, for the more certain avoidance of septicjemia and of phlegmonous inflam- mation. Pudendal Hernia. ^^naiomy — By some anatomists it is stated that the round ligaments of the uterus end in the mons veneris; but this view is incorrect. A more careful dissection traces them through the internal abdominal rings, along the inguinal canals, to the labia majora, where they are lost in the dartoid sacs; described by Broca as passing through these folds. The labia ma- jora are unquestionably the analogues of the scrotum of the male, and tlie round ligaments correspond to the spermatic cords. Into the inguinal J PUDENDAL HERNIA. 135 canals these ligaments are attended by a prolongation of peritoneum which has received the name of the canal of" Nuck. This ordinarily becomes obliterated at full term of foetal life, but not always. When it remains pervious, the formation of inguinal hernia is favored. Definition Down one of the inguinal canals, by the side of the round ligament, a loop of intestine, and sometimes a portion of the mesentery, an ovary, the bladder, or the entire uterus, may pass, as inguinal hernia occurs in the male. The fact that this disease is by no means frequent, makes its recog- nition the more important, for were the practitioner not aware of the possibility of its occurrence, the intestine might be wounded, under the supposition that the labial enlargement was due to abscess, or distention of the vulvo-vaginal glands. Causes The displacement may be produced by violent muscular efforts, or blows, or falls, as in the male. Symptoms. — Strangulation of the intestine with its characteristic signs may occur, according to Sir Astley Cooper and Scarpa,* although it is very rare. The hernia may usually be overcome by taxis. In one case with which I met, reduction was extremely difficult, and could only be accomplished by prolonged effort. When the intestine becomes pro- lapsed, no strangulation existing, a sense of discomfort, upon bending the body or even upon walking, directs the patient's attention to the affected part, and leads her to apply to the physician. By him the nature of the case will at once be suspected, from the peculiar gaseous or airy sensation yielded to the touch. Certainty of diagnosis will be arrived at by absence of all signs of inflammation or oedema, the detection of impulse upon coughing, and resonance upon percussion, and the possibility of diminish- ing the volume of the tumor by taxis and position. There are no very great difficulties attending the differentiation of the disease. The danger is that" the possibility of hernia at this point may be forgotten, and deduc- tions drawn without considering it. Although the probability of error be not great, the appalling nature of the accident in which it would result, warrants the relation of the following case, which is illustrative of its pos- sibility. A patient called upon me with the following history: she had had an abscess just below the external abdominal ring, which, after poul- ticing, had been evacuated by her physician, about a month before the time of her visit to me. After this, she had felt well until a week before, when, after a muscular effort, the pain had returned with all the original signs of abscess, and these had continued, although she had painted the part steadily with tincture of iodine, as she had been directed to do in case of such an occurrence. Being in great haste at the moment, I examined the enlargement while the patient was standing, and under a recent cica- ' Scanzoui, op. cit., p. 560. 136 DISEASES OF THE VULVA. trix, which was painted with iodine, I discovered what I supposed to be a reaccumulation of pus. As the patient came to me in the absence of her physician, merely for the evacuation of this, I placed her in the recumbent posture, and, lancet in hand, proceeded to operate. But, to my surprise, I discovered that change of posture diminished the size of the enlargement. This excited my suspicions, and I found that a recent hernia had occurred under the old cicatrix. Treatment.— The patient having been placed upon the back with the hips elevated by a large cushion, or, as is better, by elevation of the foot of the bed or table upon which she lies, the tumor should be grasped, com- pressed, and pushed up the canal, down which it has descended, until it returns to the abdomen. Then a truss, so arranged as to press upon the inguinal canal, sliould be adjusted, and worn with a perineal strap, to keep the compress of the instrument sufficiently low down to effectually close the point of exit. Should strangulation have occurred, and return of the prolapsed part by taxis prove impossible, the case will require the surgical operation for that condition, for a description of which the reader is referred to works on general surgery. Hydrocele. Definition and Frequency This affection, which consists in a collec- tion of fluid in the inguinal canal, around the round ligament, is one of such rarity in the female that its very existence is commonly ignored, and mention of it is rarely made by systematic writers.^ Anatomy It has been already stated that the labia majora of the female are analogous to the scrotum of the male, and that the round liga- ments, which are analogous to the spermatic cords, do not end in the mons veneris, as was formerly supposed, but passing downwards enter the labia majora and distribute their filaments within the dartoid sacs, which ex- tend like glove-fingers downwards towards the fourchette. The interest- ing and valuable article of M. Broca upon this subject will be found quoted at length in Cruveilhier's Anatomy. The peritoneal covering of these ligaments usually extend to the inguinal canals, but occasionally in young subjects it is prolonged through a portion of the canal constituting the canal of Nuck.'^ In adults this is ordinarily obliterated, and hence the rarity of hydrocele and hernia in the female. Sometimes it remains per- manently open, when not only may the intestines descend, but even the ovary may pass down, making an attempt to enter the dartoid sacs and imitate the entrance of the testes into the scrotum. Pathology The affection which we are now considering is the result of excessive secretion on the part of this serous membrane, which, by the • Scanzoni's work upon Diseases of "Women contains an account of it. 2 Cyclopedia of Anat. and Phys., Supplement, p. 706. HYDROCELE. 137 fluid collected within it, is distended laterally and downwards. Should the abdominal opening of such a sac remain pervious, the fluid thus collecting could readily be forced upwards as in the same atlection in the male, but if that opening has become impervious, the fluid becomes sacculated and such return is impossible. So rare is this affection that I offer no apology for the introduction of the following instance of it,^ reported by Dr. E. P. Bennett, of Danbury, Connecticut. "In an extensive practice of over forty years, but one single case has come under my observation. This case occurred recently in a young married female residmg in Putnam County, and was mistaken by a surgeon of some eminence for a case of inguinal hernia, who.endeavored to reduce it, but failing to do so, pronounced it adherent, and irreducible, and ad- vised to let it alone. That such a mistake should have been made is not at all surprising, as it was a hydrocele of the round ligament coming down through the inguinal canal, and occupying exactly the place of inguinal hernia, and closely resembling one. She subsequently came under my care, and upon inquiry I learned that about five years since a small tumor had made its appearance, which had slowly and steadily increased in size until it had attained its present size, which was about as large as a turkey's egg. It had not been painful, was not attended with abdominal disturbance, had never receded when recumbent, and gave to the touch a feeling of tluid contents instead of the doughy feel of hernia, and I therefore thought that, Whatever it might be, it was not hernia ; and, upon closer inspection, I diagnosed hydrocele of the round ligament, although it was not diaphanous. So sure was I of a correct diagnosis that I at once proposed an operation, to which she readily consented ; and, with the aid of a professional brother, who coincided with me in my diagnosis, I proceeded to cautiously lay open the sac, when we found, to our great satisfaction, that we had not blundered in our opinion. The serous contents of the sac having been evacuated, I injected it with a saturated tincture of iodine, and she speedily recovered without the supervention of a single unpleasant symptom. This case is only important from its rarity, and the fact that most physicians are not aware that hydrocele can, or ever does, occur in the female ; and my object in writing this article is not to record any remarkal)le achievement in sur- gery, but to call the attention of physicians to this subject, and thereby prevent mistakes which might be attended with disastrous results.'' A pamphlet has been published upon the subject by Dr. Hart, of this city. In it he details an operation for hernia performed in a case of hydrocele from a mistake in diagnosis. The fluid 'of the hydrocele being evacuated, the wound was closed by silver suture, and the patient recovered. He declai-es that the disease is mentioned by Aetius, Pare, Scarpa, Meckel, and Poland. Differentiation. — The greatest circumspection should be observed before a diagnosis of this rare malady is arrived at. The sense of fluctuation, » N. Y. Med. Record, Nov. 15, 1870. 138 DISEASES OF THE VULVA. with entire absence of symptoms of inflammation, the absence of reso- nance on percnssion, and tlie ordinary signs of hernia, the existence of translucency, and the gradual development of the tumor without pain or constitutional excitement, would all be reasons for suspecting it. But, before ultimate measures are adopted for its cure, a very fine exploring needle, such, for example, as that of the ordinary hypodermic syringe, should be passed in, in order that the contents of the sac may be carefully examined. Should the character of this fluid not assure us that hernia exists, the smallest needle of the aspirator should be introduced, and all the fluid drawn off. Even where hernia exists, such a procedure has been found to favor return of the sac, and to do no harm by rendering it subsequently pervious. Treatment — The diagnosis being made, the treatment should consist in evacuation by means of the aspirator, and, if cure do not follow this, in the injection of tincture of iodine in addition, which may be done by revers- ingr the action of the same instrument. CHAPTER VIII. PRURITUS VULV^. Definition. — This affection consists in irritability of the nerves supply- ing the vulva, which induces the most intense itching and desire to scratch and rub the parts. Although not itself a disease, it is always so important, and often so obscure a symptom, that it requires special notice and in- vestigation. Pathology It has just been stated that it consists in disorder of the nerves supplying the vulva. It matters not whether this be a true neu- rosis or one secondary to some other pathological state, the great element of pruritus vulva; is nervous irritability or hypercesthesia. That it is often excited by irritating discharges and eruptive disorders there can be no question. Whether it ever depends upon idiopathic nervous hypcriKSthe- sia, as some suppose, is doubtful. I have never met with an instance in which it appeared to do so. Mode of Development and Course In the beginning, the irritability and tendency to scratch are sometimes very slight, so as to annoy the patient very little and give her but trifling uneasiness. Sometimes they exist only after exertion in warm weather, upon exposure to artificial heat, or just before and after menstruation. The disorder is aggravated by the PRURITUS VULV^. 139 counter-irritation which it demands for its relief. The rubbing and scratching that are practised cause an afflux of blood, render the skin ten- der and its nerves sensitive, and in time greatly augment the evil by pro- ducing a papular eruption. The disease and the remedy which instinct suggests, react upon each other, the lirst requiring the second, and the second aggravating the first, until a most rebellious and deplorable condi- tion is developed. It would be difficult to exaggerate the misery in some of these cases. The patient is bereft of sleep by night, and tormented constantly by day, so that society becomes distasteful to her, and she gives way to despondency and depression. The itching is generally intermit- tent, in some cases occurring at night, in others only at certain periods of the day. In two cases that I have met, the patients were free from all irritation except at night, wlien the disturbance and nervous anxiety be- came so intense as to prevent sleep, except when large doses of opium were given. Loss of sleep, the use of opium, and the nervous disturbance incident to the disease, often prostrate and exhaust the patient to an astonishing extent. This disorder is to some degree paroxysmal, any influence which pro- duces congestion of the genital organs aggravating it very much. Lying in a warm bed, sexual intercourse, eating and drinking, more especially highly seasoned food and stimulating beverages, and the act of ovulation, all produce this result. Its duration has no limit ; months, and even years, sometimes passing before relief is obtained. Although the term "pruritus vulvae" is tliat ordinarily applied to it, it must not be supposed that the irritation is always confined to the vulva. It often extends up the vagina, to the anus, and down the thighs. In pregnant women I have repeatedly known it to spread over the abdomen. It may be asked why such a state should be styled " pruritus vulvae?" These extensions are merely complications of the original malady which really deserves that name, and are due to contamination, by scratching, with an ichorous element which constitutes, as I believe, the prominent exciting cause of the trouble. Causes — Every practitioner dreads to meet with an aggravated case of pruritus vulvaa, for he knows how obstinate the malady commonly proves. The only reasonable hope of controlling it must rest in viewing it strictly as a symptom, and striving to discover and remove its cause. No fixed prescriptions, however much lauded for their efficacy, should be relied upon. The primary disorder should be sought for and cured, in the liope of removing that one of its results which is most pressing in its demands for relief. Should the case have progressed for some time, it will often be found impossible to decide as to its cause, for the scratching induced by it will frequently establish a cutaneous disorder, the connection of which with the pruritus, whether as cause or effijct, will be doubtful. 140 DISEASES OF THE VULVA. The predisposing causes of pruritus are the following : — Uterine, vaginal, or urethral disease ; Pregnancy ; Depreciated general health ; Habits of indolence, luxuiy, or vice ; Uterine or abdominal tumors ; "Want of cleanliness ; Constitutional syphilis; Severe exercise in one of sedentary habits. It will be observed that most of these influences are those which pre- dispose to the development of abnormal secretion by the mucous membrane lining the genital tract. Such excessive and deranged secretion I believe to be in the great majority of cases the immediate, exciting cause of the nervous irritation. That there are otlier causes, it will be seen that I admit, but to treat this condition successfully, I am convinced that special reference must be had to this element. He who simply keeps in view the local trouble, in the majority of cases will be striving merely against the branches of an evil, the root of which consists in tlie ichorous material, which bathes and excoriates the terminal extremities of the nerves of the vulva and vagina. In all the instances of pruritus vulvae that I have been able to examine early enough to determine as to the etiology, I have found one of the fol- lowing conditions to exist as the apparent cause of the hypersesthetic con- dition of the nerves : — 1st. Contact of an irritating discharge — Leucorrhoea; Hydrorrhcea ; Discharge of cancer; Dribbling of urine; Diabetes. 2d. Local inflammation — Vulvitis; Urethritis ; Vaginitis; Aphthous ulcers. Zd. Local irritation — Eruptions on the vulva; Animal parasites; Onanism ; Vegetations on the vulva; Vascular urethral caruncles; Growth of short, bristly hair on mucous face of labia. Of all these, leucorrhoea is the most frequent cause. This symptom of uterine disorder fortunately produces pruritus only as an exception to a PRURITUS VULViE. 141 rule. Under certain circumstances it appears to possess peculiarly irri- tating and excoriating qualities, which, even when the flow is insignificant in amount, wiU excite the most intolerable itching. This feature is most commonly observed in the discharge attending pregnancy ; and in that of senile endometritis, which covers the vagina with bright red spots, and wives it a glazed look like serous membrane. In an exceedingly obstinate case, occurring in a woman of seventy years, the leucorrhoeal discharge was so small in amount that the patient was not aware of its existence, nor did I appreciate its connection with the disorder until I discovered accidentally that the only relief which could be obtained followed the ap- plication of a wad of cotton against tlie cervix uteri. In every case of pruritus the vagina should be carefully investigated for evidence of leu- corrhcca, unless some other sufficient cause is apparent. In the same manner the other discharges mentioned may cause nervous irritability in the vulva. It is not, however, usually vagnial leucorrhcea which produces the re- sult; it is mucli more commonly due to the discharge arising from cervical or corporeal endometritis, and the obstinacy of these affections accounts to some extent for that of the secondary one. I have so often found diabetes accompanied by this symptom that I always examine the urine in obscure cases. It is by many attributed to tlie constitutional agency of the disease. The marked relief afforded by the systematic use of the catheter has led me to think otherwise. My impression is that the pruritus is probably not connected with the consti- tutional effects of the disease upon the nerves, but with the direct and local influence exerted by the disordered secretion. Local inflammation, by the discharge which it excites and the itching which attends it, is very evidently calculated to give rise to pruritus; and yet cases thus established are not the most rebellious with which we meet. Any form of eruption upon or around the vulva may, and usually does, excite itching. Eczema, prurigo, lichen, and many others, may do so here as they do elsewhere, and the natural warmth of the part, formed as it is of folds of tissue and covered by hair which is thickly interspersed with sebaceous and piliferous glands, makes them the more likely to prove active in causing it. Animal parasites of two varieties may give rise to it, the pediculus pubis and the acarus scabiei. The first excites through irritation a liche- noid eruption, while the second produces scabies, or itch. One of these causes will generally be found to have given rise to pruritus vulviE, but it is only in originating the difficulty that it will prove active. Very soon secondary influences, as eruptions, excoriations, ulcerations, and increased discharges, the results of scratching, superadd themselves as auxiliary agents, and keep up the disorder. Treatment It has been stated that the first effort of the practitioner 142 DISEASES OF THE VULVA. should always be to discover the disease of which the pruritus is a symp- tom, and then to endeavor to remove it by appropriate means. Should leucorrhoea be the cause, the uterine or vaginal affection which gives rise to it should be treated. Should an eruptive disorder be found to be the source of the difficulty, the measures which would be advisable for this affection elsewhere developed, laxatives, baths, change of air, tonics, and arsenic, would be equally beneficial here. But this alouB will not be sufficient. "While eradication of the mischief is thus attempted, palliative means must be vigorously adopted for the sake of present relief. Should the t'ase be regarded, upon careful investi- gation, as due to contact of an irritating fluid with the nerves of the vulva, perfect cleanliness should be secured by three, four, or, if necessary, a larger number of sitz baths daily, and the vagina should, at the time of taking each bath, be syringed out with pure or medicated water. The irritated surface should be protected by unctuous substances, or inert pow- ders, such as bismuth, lycopodium, or starch, from the injurious contact, and in case the discharge comes from the uterus, a wad of cotton should be placed daily against the cervix uteri to prevent its escape to the vulva, or, as is better, after a thorough use of the vaginal douche the vagina should be thoroughly tamponed daily with cotton saturated with glycerine to which has been added borax or acetate of lead, two drachms to the ounce. Of this plan, which I should mention does not confine the patient to bed, T can speak in high terms. While it protects the vulva from ichorous discharges, it does not prevent ablution and applications to the point of maximum irritation. A very useful vaginal injection, and wash for the vulva, under these circumstances, is the following: — I^. Plumbi acetatis, 5iJ- Acidi carbolici, 9ij. Tr. opii, 5j. Aquffi, Oiv. — M. This may relieve itching for a time, until removal of the cause of the symptom is accomplished. In case the pruritus is the result of a local inflammation, this should be treated as elsewhere recommended, by poultices of linseed, potato, or slip- pery elm, to which have been added a proper amount of lead and opium ; or fomentations of lead and opium wash, or poppy-heads may be used in their stead. If vaginitis or vulvitis be present, great relief will often be obtained by painting the lining membrane of the diseased part over with a strong solution of nitrate of silver, or by touching the whole surface very lightly with the solid stick, and then using the tampon of cotton and glycerine. Should an eruptive disorder be the exciting cause, it should, as already stated, be treated upon general principles. Meantime temporary relief may be obtained by painting the surface of the vulva over with a solution PRURITUS VULV^. 143 of nitrate of silver, or the use of the ungt. creasoti, ungt. chloroformi, or ungt. atropiae of the U. S. Dispensatory. Dr. Simpson advises an infu- sion of tobacco, and Dr. J. C. Osborn,^ of Alabama, in an interesting article upon the medicinal use of this drug, declares that he always re- sorts to a strong decoction of it as a wash for the vagina and vulva in this aflection, and for the anus in "prurigo podicis." According to the latter gentleman the local sedative effects of tobacco are very useful in the control of prurigo. My own experience agrees with his. Although the fact will probably not prove one of practical value, it is certainly one of interest that cases have recently been reported in which smoking tobacco has appeared to relieve pruritus. As an illustration I quote the following: "Mrs. W.,^ a woman of nervous temperan)ent, be- came pregnant a few months after her marriage. In addition to the usual derangement of the alimentary canal, she soon experienced a severe itching all over her body. The skin was of a perfectly normal appearance ; the pruritus, however, caused her great excitement and soon produced nervous spasms. For several weeks every possible external and internal remedy was used in vain. A decoction of walnut leaves gave her some relief when in the seventh month of pregnancy. Then a violent pyrosis and neuralgia of the dental nerves supervened. In order to alleviate the latter, she was advised by her husband to try the effect of smoking, when the pain as well as the itching and pyrosis disappeared immediately. Mrs. AV. smoked one cigar every evening until slie was prematurely delivered by a fright, after 8^ months. "Fourteen months afterwards, Mrs. W. again became pregnant, and was again affected in the fourth month of pregnancy with pruritus followed by pyrosis. She did not immediately resort to smoking, from the dislike of this habit, until the evil increased, when the smoking of one cigar again rendered her perfectly comfortable." No local application has acquired a more universal popularity in the treatment of pruritus vulvae than solutions of corrosive sublimate. The following formula is a good one of its kind : — I^. Hydrarg. biclilorldi, 5ss. Tr. opii, §j. Aquae, §vij. — M. S. For external use only. Should eczema or lichen have produced inflammatory action in the skin and subcutaneous areolar tissue, poultices, etc., should be employed, as if local inflammation were the cause of the affection. While these palliative and curative means are being adopted,- sleep should be secured by preparations of opium, or one of its substitutes, ' N. O. Med. and Surg. Journal, Nov. 1866. 2 Tribune Med., Jan. 31, 1869; Wiener Med. Wochenschrift, No. 22, 1869. 144 DISEASES OF THE VULVA. codeine, chloral, hyoscyamus, or chlorodyne. At the same time the general state of the patient should be improved by vegetable and mineral tonics, good food, and fresh air. In some cases more benefit will arise from the use of iron, the mineral acids, and sea-bathing, than from any other means. In certain cases dependent upon chronic vaginitis, or chronic endo- metritis -which has resulted in vaginitis, the disorder will be found to be rather "pruritus vaginae" than " pruritus vulvae," and under these circum- stances the severity of the local and general disturbance may be very great. In such cases I have found great benefit from the frequent use of copious vaginal injections of warm infusion of bran. The patient, in the semi- recumbent posture, with the nates over a tub containing three or four quarts of this, with from six to eight drachms of laudanum, and one to two drachms of acetate of lead dissolved in it, should inject the vagina freely for from ten to fifteen minutes, and this should be repeated four or five times a day. After a short time the soothing and alterative influence which it exerts will show itself so decidedly that less assiduous attention to the disorder will be demanded. In the same way infusion of tobacco and solutions containing borax, lead, alum, zinc, or carbolic acid will be found to be very valuable remedies. They should be used very freely, and after previous cleansing of the vagina by pure water. One great difficulty in the treatment of the disease con- sists of the inefficient manner in which vaginal injections are practised by patients. This should be guarded against by explicit directions, and the use of the means suggested hereafter in connection with that subject. The following prescriptions have obtained a reputation for the treatment of pruritus ; and I know by experience that they deserve it : — ^.. Chloroformi, 5)' 01. amygdalarum, ^j. — M. S. Apply to vulva and outlet of vagina. ^. Acidi liydrocyan. dil. SU- Plumbi diacetati, 9j. Olei cacao, §ij. — M. S. Apply after washing with cold water. Ic^. Lotionis nigri, Oj. Sodse biborat. §j. Morphise sulphat. gr. v. — M. S. Apply after bathing the part. ]^. Acidi tannici, gr. c. Belladonnse ext. gr. x. Butyr. cacao, q. s. M. et ft. supposit. vag. xx. S. Let the patient place one in contact with the cervix uteri, every night, after thoroughly syringing the vagina. HYPERESTHESIA OF THE VULVA. 145 Where diabetes exists as a cause, the patient should bathe the parts after urination, and be instructed to keep the vulva thoroughly covered and protected by one of the ointments already mentioned. Where the pediculus pubis is found to exist, mild mercurial ointment should be applied ; and for the acarus scabiei, sulphur ointment will be found sufficient as a parasiticide. When the itching is located in the skin of the mons veneris and sur- rounding parts, rubbing it freely with a moist stick of nitrate of silver is often of great service. The following prescription I have never employed, but it is highly rec- ommended by good authority : — R. Zinci sulpho-carbolat. 3j. Aquae destillat. ,^ij. S. After careful bathing use as a wash once or twice a day. Where short, bristly hairs are found growing from the inner or mucous surface of the labia majora, great relief follows depilation. Each hair should be seized by forceps, the operator using a magnifying glass, and jerked from its place. Dr. Stevens, of Cincinnati, reports excellent results from the use of undi- luted sulphurous acid as a wash applied freely to the vulva. He declares that prompt relief is in that way attainable. Hyperaesthesia of the Vulva. Definition. — The disease which I proceed to describe under this name, although to all appearances one of trivial character, really constitutes, on account of its excessive obstinacy and the great influence which it obtains over the mind of the patient, a malady of a great deal of importance. It consists in an excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva ; sometimes the area of tenderness is confined to the vestibule, at other times to one labium minus, at others to the meatus urinarius ; and again a number of these parts may be simultaneously affected. It is a condition of the vulva closely resemblino- that hypersesthetic state of the remains of the hymen which constitutes one form of vaginismus. In two cases I have seen the whole surface of the vulva, except the labia majora, affected by an excessive sensibility which extended along the urethra. Frequency — This disorder, although fortunately not very frequent, is by no means very rare. So commonly is it met with at least, that it be- comes a matter of surprise that it has not been more generally and fully described. Pathology — It is not a true neuralgia, but an abnormal sensitiveness ; " a plus state of excitability" in the diseased nerves. No inflammatory action affects the tender surface, no pruritus attends the condition, and 10 146 DISEASES OF THE VULVA. physical examination reveals nothing except occasional spots of erythema- tous redness scattered here and there. The nerve state appears identical with that which sometimes develops in the scalp, and on parts of the cutaneous surface. The slightest friction excites intolerable pain and nervousness ; even a cold and unexpected current of air produces discom- fort ; and any degree of pressure is absolutely intolerable. For this reason sexual intercourse becomes a source of great discomfort, even when the ostium vagintB is large and free from disease. It is this difficulty which generally first causes the patient to apply to a physician for relief. Causes. — The predisposing causes appear to be the period of life near or at the menopause, the hysterical diathesis, or a morbid mental state characterized by tendency to depression of spirits. As exciting causes I have found chronic vulvitis and irritable urethral tumors to exist in some cases, but in others *no cause whatever has been apparent. Symptoms — I have said so much on this subject, under the head of de- finition, that I have little more to add. The patient applies for relief because the act of sexual intercourse is painful, and because in the sensi- tive spot there is always a degree of discomfort, which is increased by bathing the part, or even by the friction incident to walking. Upon questioning her, it will be observed that her mind is disproportionately disturbed and depressed by this. In some cases it seems to absorb all the thoughts, and to produce a state bordering upon monomania. Differentiation It should be distinguished from irritable urethral tumor and vaginismus, which will be readily accomplished by inspection and touch. Treatment The treatment of this condition is most unsatisfactory. I have met with a number of cases of marked character, and in not one was complete relief given by treatment. Whether they subsequently recovered I cannot say, but they certainly were not cui-ed while under my observa- tion. In one case, which I saw with Dr, Metcalfe, the sensitive area was the vestibule, and to this we applied nitric acid so as to destroy the mucous membrane completely and followed this up by local sedatives, but to no purpose. In another, which I attended with Dr. Sims, he removed por- tions of the labia minora and of the vulvar mucous membrane, without suc- cess. In another case I dissected oflt' all the sensitive tissue, which was quite extensive. This patient, the wife of a clergyman, left me well, and was greatly rejoiced ; but, in six months, I received a letter from her de- claring that she was worse than before the operation. The treatment which I would recommend from my experience is this : to send the patient away from home where, in addition to enjoying change of air, scene, and surroundings, she would live absque marito : to put her upon the use of general tonics, as arsenic, strychnine, quinine, and iron ; and after having cured any local exciting disease, like vulvitis or urethral vegetations or tumors, to make frequent ablutions with warm water and apply sedative IRRITABLE URETHRAL CARUNCLE. 147 and calmative substances in the form of lotions or ointments. As examples of these, I would mention opium or its salts, carbolic acid, chloroform, belladonna, and iodoform. Sometimes benefit seems to result from strong solutions of alum, tannin, and similar agents. My observation of the results of caustics and the knife is not such as to inspire me with confidence in them. Irritable Urethral Caruncle. This affection has, likewise, received the names of vascular tumor, and irritable vascular excrescence of the urethra. Just at the edges of the meatus urinarius, and, sometimes, along its walls for some distance, little vascular tumors develop themselves, which render this canal very irritable, and in this way produce a great deal of discomfort. Pathology According to Wedl^ they consist of hypertrophied papillfe, which, as they enlarge, are accompanied by excessive growth of areolar tissue. They are extremely vascular, capillary vessels of considerable size being found within them, ramifying in transverse sections, very much like the vasa vorticosa of the choroid. Dr. Reid,^ of Edinburgh, declares that they are richly supplied with nervous filaments. These two anatomical facts account for two corresponding clinical observations, that they bleed very freely and readily, and that they are almost as sensitive to the touch as a neuroma. Savage styles these curious growths " pseudo-angiomata," and asserts that within them, cystic cavities, probably the remains of ure- thral glands, are occasionally found, filled with mucus. Causes — Of the etiology of this affection nothing is known. It develops in the young and old ; the married and single. Symptoms — The patient complains of pain upon sexual intercourse, in passing urine, in walking, and upon the slightest contact of the clothing. Sleep is disturbed by these means, and by the increase of sensitiveness engendered by the warmth of the bed. As a consequence, she becomes nervous, hysterical, and greatly depressed in spirits. Her whole thoughts often become fixed upon this one painfully absorbing topic, and a most wretched mental state is at times produced. Of course these grave results occur only in very aggravated cases ; but, even in minor ones they are present in slight degree. Dr. T. F. Cock informed me of a case in which a patient became so much depressed from this cause that she committed suicide, and I have a similar statement of another case from a non-professional source. In ,the latter, the time had been appointed for removal of the growth when the patient destroyed her life. I should be sorry to leave the impression, that mental alienation of grave character is likely to develop from these little 1 Pathological Anatomy. ^ Simpson, Diseases of Women, p. 276. 148 DISEASES OF THE VULVA. growths ; it is not. A certain degree of it is very apt to be met with ; and, in rare cases, where the suffering is very great, it sometimes becomes excessive. To convey some idea of the amount of pain ifiduced by urina- tion in some cases, I quote the following: " I was told by a sheplierd's wife, who had one of tliese sensitive caruncles at the orifice of the urethra, that, whenever she was obliged to pass water, she was in the habit of going to some distance away from her cottage, in order that she might moan and scream unheard, and not distress her family with the sound of her cries, so intense and intolerable was the suffering which at such times she experienced."^ Physical Signs. — The patient being placed upon the back with the thighs flexed and the knees separated, inspection shows, at the meatus uri- narius, a florid, vascular growth, varying in size from that of a cherry- stone to that of a pigeon's egg. Scanzoni declares that they may grow to the size of a goose's egg. Sometimes, instead of one, quite a number may be found, of small size, extending around the meatus or up the canal. Where the canal itself is invaded, the cases are always very difficult of cure, on account of the difficulty in reaching the morbid developments. Differentiation There are but two conditions with which 1 have ever known the disease confounded. One is prolapsus urethree or eversion of the mucous membrane of the canal; the other syphilitic growths of warty character. From the first a careful examination will readily distinguish it, and when the second exists similar developments will be found upon other parts of the vulva. Besides neither of these conditions is nearly so annoying and painful as that which we are considering. Course and Duration It is impossible to say how long these growths will continue to exist when not interfered- with. I have known them lust for years without continuing to develop, but retaining a small size, and being always excessively sensitive and annoying. Prognosis In case a single large caruncle exist, an almost positive promise of relief may be held out from its removal ; but where a number of small, fungous, warty growths surround the meatus and extend up the urethra, cure is extremely difficult, for no sooner are they removed than the morbid process of development rapidly produces more. Another dis- couraging feature of these cases is this, a nervous hypertesthesia is engen- dered by the growth, which lasts long after its removal. It behooves the operator in such cases always to be guarded in his promises, at the same time that he urges interference as the only hope for relief in the present, and safety from increased trouble in the future. Treatment Before operating the patient should be thoroughly ansEsthe- tized and placed upon the back, with the thighs flexed and the knees widely separated. The labia being then separated by an assistant on each ' Simpson, op. cit. IKRITABLE URETHRAL CARUNCLE. 149 side, the tumor should be seized near its base by forceps, pulled towards the operator, and its attachment cut by scissors. Very free hemorrhage may occur. To control this, the raw surface should be wiped dry and thoroughly touched with fuming nitric acid, a stick of nitrate of silver, or the actual cautery. This operation may be very nicely performed by galvano-cautery, if an instrument be attainable. By this means not only is hemorrhage pre- vented, the base is also thoroughly cauterized, which is a great safeguard against return of the growth. Where tlie urethra has been invaded it should be thoroughly stretched by little retractors introduced within it, and held by assistants, and the growths thus exposed be cut off" by scissors, or scraped from their attach- ments by a steel curette. After removal, their bases should be very cau- FiG. 40. Paquelin's Thermo-Cautery. The apparatus consists of a hollow handle, insulated with wood, to protect the hands from the heat. It is furnished with three movable, hollow, platinum cauteries ; into these, after they have been heated to blackness in the flame of a spirit lamp, a blast of benzine vapor is introduced by means of a Richardson's spray bellows, which at once raises them to and maintains them at a state of vivid incandescence. The heat thus produced can be kept up for an indefinite time by slightly compressing the bellows occasionally. tiously touched with nitric acid, or, what is still better as preventive of return, the actual cautery. A few years ago the actual cautery was an instrument so unmanageable and difficult of employment that it was rarely used for slight operations. Now, thanks to the genius of M. Paquelin, whose instrument is shown above, it is used as easily as the stick of nitrate of silver. 150 DISEASES OF THE VULVA. Urethral Venous Angioma. This is a disease affecting the urethro-vaginal tubercle or anterior half of the urethro-vaginal septum. It sometimes attains large size, and pro- jects between the labia. From irritable caruncle or vascular excrescence it can be differentiated by its want of sensitiveness. It appears, says Savage,' to be due to venous congestion, analogous to that giving rise to priapism. Its treatment is identical with that of urethral caruncle. Prolapsus Urethras. This accident, which has likewise been described as procidentia and eversio urethrae, consists of prolapse of the urethral mucous membrane, with proliferation of the underlying connective tissue. It is not commonly met with, but at times produces considerable irritation of the urethra and bladder, and leads to an erroneous diagnosis of irritable caruncle. I have met with it only in adults of enfeebled constitution and advanced age ; but Guersant, in the Revue de Tliei-apeutique, declares that he has seen fifteen cases in little girls between two and twelve years of age. Diag- nosis is easy. A roseate projection encircles the meatus, which is sensi- tive and liable to bleed. The only diseases with which it could be con- founded are, irritable caruncle, urethral polypus, and venous angioma. From all these it can readily be differentiated by careful examination, which shows that it entirely surrounds the meatus, while they do so only in part. The extreme sensitiveness of irritable caruncle is not a differen- tial sign which can be relied upon, for I have seen prolapse of the urethra develop this symptom very decidedly. It may for some time exist without symptoms, but usually soon creates difficult and painful micturition, pruritus vulvse, and leucorrhceal discharge. Treatment The simplest method of treatment is to seize the prolapsed circle with tooth-forceps, the patient being anajsthetized, draw it down with very little force, and cut it off with curved scissors. The resulting hemorrhage will readily be controlled by applying a pledget of lint or cotton, saturated with a solution of persulphate of iron, one-third of the full strength, against the raw surface, and making pressure by the finger for some minutes. Should it be deemed necessaiy to continue it longer, this may be done by a T bandage. If great vascularity leads to fear of hemorrhage, the ingenious method of Sequin may be adopted with advantage. This consists in introducing a female catheter into the bladder, and ligating the prolapsed part to it so as to strangulate it entirely. The catheter is left in sitii until released by sloughing off of the ligated part. 1 Savage, op. cit. COCCYODYNIA. 151 In one case I drew down the prolapsed tissue, passed a double silk ligature through its base, and tied the two halves. The cure was perfect. A better operation than either of these would be encircling the pro- lapsed tissue, which should be well drawn down, by the galvano-caustic wire, removing the mass in this way, and keeping a catheter in the blad- der for some days if necessary. Should obstinate hemorrhage follow any of these operations upon the urethra or vulva, a firm vaginal tampon with a T bandage used so as to press its lowest portion against the bleeding surface will readily control it. The former presses the urethra upwards and the labia outwards, while at the same time it gives a firm, fixed point, against which direct pressure by a T bandage and compress may be made. It possesses more real value than all the other means, usually mentioned for the control of such hemorrhages, combined ; such, for example,- as Monsell's salt, the actual cautery, strong acids, etc. The vulva is so exquisitely sensitive that the patient is apt to rebel against these, and in addition ihey often fail in accomplishing the result. Coccyodynia. Definition and Frequency This affection consists in a morbid state of the coccyx, or the muscles attached to it, which renders their contraction, and the consequent movement of the bone, very painful. It is of frequent occurrence, numerous cases having been observed, since attention has been called to it, by practitioners who saw it previously without regarding it as a special disorder. Historrj Coccyodynia was first described, in 184-i, by the late Dr. IS'ott. Under the name of neuralgia of the coccyx he described a case which fully embodies the symptoms and treatment of the affection by sur- gical resource.^ Although Dr. Nott gave every detail with which we are now familiar, as to the symptomatology and treatment of this affection, the subject was nearly forgotten until the year 1861, when it was again described, almost simultaneously, by Simpson, of Scotland, who gave it its name,'' and Scanzoni, of Germany. We have in this another instance, of which so many exist, of the complete oblivion into which a few years may cast a valuable contribution to science. Surely in such a case he who revives what is forgotten deserves as much credit as he who originally made the discovery. Anatomy The coccyx serves as a point of attachment for the greater ' N. 0. Med. Journ., May, 1844. 2 111 Prof. Alexander Simpson's edition of Sir James Simpson's posthumous volume on Diseases of Women, the name coccygodynia is used. In liis Clinical Lectures, published in Philadelphia, 1863, the name which I here employ appears. 152 DISEASES OF THE VULVA. and lesser sacro-sciatic ligaments, the ischio-coccygei muscles, tlie sphinc- ter ani, levatores ani, and some of the fibres of the glutei muscles. These are thrown into activity by certain movements, as rising from the sitting into the standing posture, the act of defecation, etc., and" in such acts the existence of the disorder which we are considering is revealed. Pathology. — The peculiar pain which characterizes this disease has, according to my experience, a variety of causes; I have removed one coccyx in which a fracture with dislocation, received in early life, which caused it to jut in at a right angle to the sacrum, w^as its source; another in which, as in Dr. Nott's case, just recorded, caries existed ; while in still a third no abnormal condition could be discovered. In such cases as the last, the pain wliich characterizes it is probably due to a hyper-sensi- tive state of the fibrous tissues surrounding the coccyx, or of that making up the tendinous expansions of the muscles. This may at times be, as Prof. Simpson has suggested, of rheumatic character; but it appears to me that it is very generally a neuralgic state, due to uterine or ovarian disease, of which coccyodynia is a frequent consequence. As a rule, so long as the bone is uninfluenced by contraction of the muscles attached to it, no pain is experienced, but as soon as contraction produces motion it is excited. Causes It occurs most frequently in women who have borne children, but it is by no means confined to them. I have on two occasions met with it in young, unmarried ladies, and Herschelman reports two cases in children from four to five years of age. Its chief causes are the following: — Blows or falls upon the coccyx. Injuries inflicted by parturition. The influence of cold and exposure. Uterine and ovarian disease. Horseback exercise.^ (?) In a case mentioned by Courty the patient had the peculiar habit of sleeping with the buttocks uncovered, and the sacrum pressed against the wall. In nine of Scanzoni's cases the condition followed parturition; in five, the use of the obstetric forceps ; and in two, horseback exercise was the only cause ascertainable. Symptoms The patient, upon sitting down, rising, making any effort, or passing feces through the rectum, experiences severe pain over the coccyx. In some cases this is so severe as to cause the greatest dread of sudden or violent movement. In others, the patient is unable to sit, on account of the discomfort caused by pressure on the bone. The most try- ing process is that of rising from a low seat, and, to accomplish this, the sufferer will obtain all the aid that is practicable, by assistance with the ' Scauzoui, op. cit. COCCYODYNIA. 153 hands, which will be placed as auxiliary supports upon the edges of the chair or stool upon which she rests. Differentiation The only conditions with which this may be con- fmmded are painful hemorrhoids, fissure of the anus, and a spasmodic condition about the muscles of this part, due to ascarides in the rectum. From these a careful and thorough physical examination will always readily distinguish it. Prognosis. — Coccyodynia often lasts for years, annoying and distressing the patient, but never to any degree depreciating her health or constitu- tional state. If left to nature it may wear itself out, but it is probable that it would generally remain for a long time if not relieved by art. Treatment Before any plan of treatment is adopted, care must be taken to discover whether the disorder is secondary to uterine disease or anal fissure. If it be so, the primary disorders, and not their results, should receive attention. If the coccygeal disease be primary, blistering, the use of morphia by the hypodermic method, and the persistent use of the galvanic current will often eflfect a cure. While they are being tried, the use of iodoform as a rectal suppository may be with advantage employed together wnth all general means calculated to improve the tone of the nervous system. Should these means do no good, and the patient's condition demand relief, recourse should be had to one of two radical methods of cure, section of the diseased muscles, or amputation of the bone to which they are attached. The first, placed at our disposal by the late Prof. Simpson, consists in severing the attachments of all the coccygeal muscles ; the second, in extirpating the coccyx itself, after the plan of Dr. Nott, The first operation may be performed subcutaneously by an ordinary tenotomy knife. This is passed under the skin at the lowest point of tlie coccyx, turned flat, and carried up between the skin and cellular tissue until its point reaches tlie sacro-coccygeal junction. Then it is turned so that in withdrawing it an incision may be made which entirely frees the coccyx from muscular attachments. The knife is then introduced on the other side so as to repeat the section there. As is usually the case in subcutaneous operations, no hemorrhage occurs unless some large vessel be injured. I have resorted to this procedure but once, when I found it exceedingly difficult of accomplishment, and it proved an entire failure in giving relief. In fat women subcutaneous section of the muscles attached to the coccyx is by no means so easy a matter as one would suppose who has not made the experiment. Under these circumstances the operation is sim- plified and rendered more certain by making an incision down upon the coccyx, lifting the exposed extremity of this bone with the finger, and then with a pair of scissors severing the muscles. This {irocedure is both 154 THE FEMALE PERINEUM; easy of performance and certain as to result ; that is, supposing that it is resorted to in a case really demanding it. Should detachment of the muscles fail, as it will do if the bone be diseased, an incision should be made over the coccyx, the bone laid bare by severance of its attachments, and the whole of it removed by a pair of bone i'orceps, or disarticulated by the knife as practised by Dr. Nott in the case already mentioned. By one of these procedures cure can be con- fidently promised, .and as neither is attended by danger, our resources in this affection may be regarded with great satisfaction. Many slight cases of coccyodynia occur, however, which pass away with time and palliative treatment. The gynecologist should take care that operation is not resorted to too early. Tumors of considerable size may spring from the external organs of generation. Thus we may have tumors resulting from hypertrophy of the clitoris, or of the nympha;, lipoma of the labia majora, and cystic tumors of large size growing by a pedicle from the same site. Malignant disease also frequently attacks these organs, where it runs its usual course : dif- ferino; in nothing from its career in other locations. We have now considered the most important of the diseases of tlie vulva. To treat of them all would be to devote a larger space to the subject than a work of this character could afford. Certain important pathological conditions of the hymen would be treated of here were it not that they will receive notice under the head of retention of menstrual blood. I have usually considered in this connection rupture of the perineum, but as a very obvious advantage, which I feel sure the reader will appre- ciate, attends having that subject succeed prolapse of the vagina, bladder, and rectum, I have transferred it. CHAPTER IX, THE FEMALE PERINEUM; ITS ANATOMY, PHYSIOLOGY, AND PATHOLOCIY. A GREAT deal of the diversity of opinion concerning the propriety of the repair of the ruptured perineum, as well as of the difficulty attending the comprehension and performance of the operation, is, I think, due to an incorrect understanding of the anatomy of this part. While the anatomy of the male perineum has been conscientiously studied, that of the female has been singularly neglected, and this neglect has reflected a ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 155 decided influence upon the knowledge of its physiology, pathology, and surgery. The conventional method of dealing with the anatomy of the female perineum is to pronounce it the floor of the pelvis ; the space extending from the inferior commissure of the vulva to the anus, and composed of skin, cellular tissue, aponeurotic union of muscles, and the mucous mem- brane of the vagina. Tyler Smith begins his remarks upon this subject with these words, " To the obstetrician the anatomy of this part is matter of great interest," and yet he gives such a description of it as I have stated above, and represents it by an illustration showing the union of the sphincters of the anus and vagina, etc. Playfair, in his late excellent work, dismisses the subject, which he pronounces one "of great obstetric interest," with less than eight lines, just three more than Leishman has allotted to it, and four more than it receives in Meadows' Manual of Midwifery. Upon such topics French writers are usually quite minute and full ; but Cazeaux deals with the female perineum, in his " Traite de I'art des Accouchements," in three lines and a half, and Joulin does not mention it. A few words now as to some of our own authors. Meigs, who describes the fourchette quite at length, does not describe the perineum at all, nor is any mention made of its anatomy by Bedford, Byford, or Miller. Obstetric writers may defend this omission by the assertion that they do not write of anatomy but of obstetrics, and that the student should come to them informed upon this subject. Let us, then, turn to the writers on anatomy upon whom our students at present rely. Cruveilhier, one of the most accurate and exhaustive w-riters upon gross anatomy, after describing quite fully all the external organs of generation, limits his remarks upon the female perineum to an enumeration of its muscles and fasciae, saying not one word of its functions, its shape, or its important relation to the pelvic viscera. Wilson and Gray, after enumerating the organs of generation in the woman, say nothing of the perineum. But Holden^ promises better things. On t?he middle of a page, in large letters, appear the words, "The Dissection of the Female Perineum;" then follows a study of all the external organs of generation, and nowhere appears one word about the perineum which he started out to dissect, except an allusion to its vessels ; and for these the reader is referred to tlie male perineum. Even if the plea which I have mentioned were available for obstet- rical writers, it would not be so for those upon gynecology, and yet in not one systematic treatise does any description of this organ appear; except in the last edition of my own, and that is, I regret to say, very imper- fect indeed. A vast deal is said about the causes of rupture and methods ' Holden's Manual, 2d Ed., p. 378. 156 THE FEMALE PERINEUM; of cure, but nothing about the mechanics, the physiology, the philosophy, if I might be allowed the phrase, of this important organ, v/hich is calcu- lated to make the student otherwise than superficial with reference to the subject. So far as my knowledge extends, we owe to Dr. Savage, of London, the demonstration of the fact that the perineum or perineal body is, in the female, a triangular wedge composed of fascia and areolar tissue, which fills the space intervening between the backward curve of the rectum and the forward curve of the vagina. Long before his writing, sections of frozen bodies had been made, showing this anatomical fact; but he, I be- lieve, first named this triangle the "perineal body" and drew our atten- tion to its significance and uses. The diagram ordinarily employed to convey to the student an idea of the anatomy of the perineum and the relations of the pelvic organs of the female is that represented in Fig. 4L Fig. 41. Diagram ordinarily used for representing the perineum. This certainly portrays a state of things which never exists, unless arti- ficially produced, and distorts the reality to such an extent as to be pro- ductive of absolute evil, yet this is the diagram employed by Gray, Wil- son, and many others, and even to-day it is quite commonly copied into works dealing with this subject in a special manner. It-is, I think, incumbent upon the obstetrical and gynecologicfil writer to give to the student a correct idea of the perineum. It appears to me ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 157 that the anatomy and uses of a part should be simultaneously described, if any practical utility is to arise from the description. Present to the stu- dent a hypothetical, supposititious diagram of the female perineum — such as that seen in Fig. 41 — and one can readily look with charity upon his regarding it as a part of little importance, and pardon the young practi- tioner who talks flippantly about the triviality of its rupture, and is apa- thetic at the bedside as to prevention of the accident. In the living and, indeed, in the dead body, the vagina never gapes, as represented in this diagram, and never so distorts itself unless distended by some foreign body which separates wall from wall. It no more stands distended without some such influence than the urethra does when undis- tended by a sound or catheter. The normal vagina is a collapsed canal, and its anterior wall rests directly upon the posterior, and is sustained by it. The gentle passage of a small cylindrical speculum, the patient lying upon her back, or of a small Sims' speculum as she lies upon the side, will make this fact quite evident. To the finger gently passed up it is ^ ' made equally apparent. Henle has made a study of the vagina by transverse section, and represents it by the following dia- gram : — Here the anterior and posterior Transverse section of vagina ; a, anterior walls are seen lying directly and wall ;p, posterior wall (Henie). closely in contact. Fig. 43 represents my idea of the true relations of the vagina, bladder, uterus, rectum, and perineum to each other. At first sight it resembles closely Dr. Savage's diagram, but examination will show that it differs materially from it in these respects — the uterus is lower in the pelvis, more inclined forwards, and the vagina, instead of consisting of a canal with a single curve from behind forwards, presents a double curve : first, a decided one, from behind forwards, and second, a very slight one, from above downwards and backwards. It is the result of careful observation at the bedside for years, with special reference to this point, and I cannot doubt that every one examining upon the living subject with reference to the position of uterus, bladder, and rectum, and the shape and direction of the vaginal canal which it portrays, must admit its accuracy. One thus examining is apt to regard the perineal body as exaggerated ; but the prominence given to this is fully endorsed by Savage, and it must be borne in mind that this represents a perfect and typical organ, unimpaired, as it so often is, by influences which will soon be considered. Here the perineum is represented in all its importance of function and essential bearing upon the maintenance of a proper relation of surrounding parts. Instead of appearing as a flat surface consisting of skin, areolar 158 THE FEMALE PERINEUM: tissue, and tendinous expansion of muscles filling the space intervening between the anus and vulva, it is seen as the "perineal body." Triangu- lar in shape, composed of strong and elastic connective tissue, it is bounded upon its superficial face by the plane ordinarily described as the female Normal relation of the pelvic viscera. perineum. It is a concavo-convex triangle. Its anterior side, very slightly convex, sustains the inferior wall of the vagina, while its posterior side, decidedly concave, supports the anterior wall of the rectum, which naturally arches forwards to fill its concavity, and prevents its prolapsing into the vagina and out of the vulva. At its upper portion, the vagina, it will be observed by reference to the diagram, forms a depression which receives the cervix uteri which rests within it, impinges upon the rectum, and is to a certain extent sustained by the shelf-like action of the tissue at the junctian of the upper and lower vaginal curves. All this is fact, not theory, and all of it can be verified at the bedside by an unbiased investigator. If the perineal body just described be regarded merely from a mechani- cal point of view, as an inactive mass of tissue, its influence in the co- ordination of pelvic support may well be doubted. Let it be remembei-ed that it rests inferiorly upon a set of muscles whose union occurs at the space between the anus and vulva. The contraction of these throws the perineal body forwards and upwards, presses it against the anterior wall of the vagina, and thus makes of it an active agent in giving support. In ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 159 some cases this action is so strong as to become abnormal and to cause dyspareunia, or to render coition entirely impracticable. So marked is this at times that the perineal body has to be cut through by the knife to overcome the difficulty. We are now prepared to appreciate the functions of the female perineum or perineal body ; for I feel that the whole triangle must be described as the female perineum, if we ever intend to inculcate true, rational, and reliable precepts as to management of this part during labor, and in refer- ence to uterine displacements. Its functions are the following : 1st, it sustains the anterior wall of the rectum, and prevents a prolapse of this, which would inevitably drag downwards the upper vaginal concavity, and with it the cervix uteri, and destroy the equilibrium of the uterus ; 2d, it sustains the posterior vaginal wall, and prevents a prolapse of this, which would allow of rectocele ; 3d, upon the posterior vaginal wall rests the anterior, upon this the bladder, and against the bladder the uterus ; all of which depend in great degree for support upon the perineal body ; 4th, it preserves a proper line of projection of the contents of bladder and rectum, and thus prevents the occurrence of tenesmus, a frequent cause of pelvic displacements. Remove this triangle, and the relations of the pelvic viscera are liable to grave distortion ; as the removal of the keystone of an arch of masonry would effect the same result in the structure which it supports. The change is not immediate or so striking, for there we deal with inelastic and brittle substances, here with elastic and resilient ones ; there with parts unattached to outside supports, here with those attached through the areolar tissue of the pelvis to its bony walls. Let me show the keystone action of the perineum by means of two schematic diagrams, which con- siderably exaggerate its dimensions. The triangle in black in Fig. 44 represents the perineal body in exag- gerated form, and shows its action as the keystone of an arch, the sides of which are made up of the anterior rectal and posterior vaginal walls which rest upon it and are sustained by it. Fig. 45 shows the effect of removal of this. Now no longer do the parts which rest against it receive support, and their immediate tendency is to fall downwards and outwards. I now remove these exaggerated diagrams and show the effect of destruction of the perineal body by others. As the posterior vaginal wall prolapses, it is followed by the anterior rectal wall ; this effaces the superior vaginal depression and drags directly upon the cervix uteri which descends likewise. As the anterior wall descends, it is followed by the posterior wall of the bladder, this to a certain' extent by the whole organ, and this, being attached to the uterus, by it likewise. Previous to the establishment of this abnormal relation of the pelvic viscera to each other, the bladder was, by its apposition with the uterus, 160 THE FEMALE PERINEUM; a means of anterior support to it. Now it not only ceases to perform this useful function, but becomes an absolute and direct tractor upon it. Fig. 44. Schematic diagram of perineal body. Fig. 45. The same, perineal hody removed. It may be objected that the keystone in this case is an inverted one, and that therefore the comparison does not hold good. But this is not a ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 161 valid criticism, for the inverted keystone is attached above, and therefore has an action which it would not otlierwise possess. Fig. 46. The perineal boly destroyed, the rectal wall lescends. FiG. 47. ,11 p '4WMl\%i^'¥ The perineal body destroyed, both rectal aud vesical walls descend. 11 162 THE FEMALE PERINEUM; I now proceed to point out another mechanical principle involved in the support of the pelvic viscera and afforded by the anatomical arrangement of these parts. An examination of Fig. 43 will show that the posterior vaginal wall is decidedly concave in its upper half, and very slightly con vex in its lower. Let us examine first the mechanism of the upper half, and then of the lower. Take a strip of steel or whalebone (Fig. 48), put one end (A) upon a table, and giving it the shape of the letter C, make pressure upon its upper end B, and the elastic band will always yield in one direction — towards its convex surface — in the direction shown by the arrows. Fig. 48. Fig. 49. ^m — ^ An elastic rod when bent yields towards its convex snrface. An elastic rod with double curves yields in opposite directions. Now change the shape of the elastic strip, so as to give its lower half a slight anterior curve in a direction opposite to that of the upper, and make pressure as before. The upper half will yield towards its convex surface, in the line of the arrows (Fig. 49) ; but not so the lower. This will yield towards its convex surface and in an opposite direction. Now apply this to the posterior vaginal wall under the influence of pressure. The upper concave portion will yield towards the rectum, and receive support from it and other structures resting in the hollow of the sacrum. The lower, slightly convex portion will tend to fall forwards, and, if the pressure be exaggerated, downwards. But in a normal state of the parts, the anterior vaginal wall and bladder arrest this tendency and the posterior wall is supported. Let us carry this a little further and see what the effect of destruction of the perineal body would be. The condition shown in Fig. 49 is then ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY, 163 greatly exaggerated, an absolute S being created, and the lower portion of that being without support from the bladder, which is no longer in con- tact with it, prolapse becomes almost inevitable. Fig. 50 will demon- strate this. But it must not be supposed that gravitation is the only influence which, under these circumstances, disturbs the relations of the pelvic viscera. Two other influences add themselves to those just mentioned to still farther force downwards the anterior and posterior vaginal walls. Pro- lapse of bladder and rectum distort the line of extrusion of the contents of these viscera, and thus to mere traction upon the parts above, direct expulsive power is brought to bear. And now, too, the uterus, dragged ^''^' "^' downwards from its position by the heavy vagina and still heavier blad- der, adds its weight as an influence calculated to increase the existing tendency to prolapse of all the vis- cera of the pelvis. It falls down- wards, forwards, or backwards, offer- ing an instance of some one of those uterine displacements which we so often meet with, and which cause practitioners so much annoyance and patients so much discouragement. One approaching the subject in this way is prepared to com[)rehend the significance of the destruction of this body, and to appreciate the effect which its withdrawal would exert upon the relations of the pelvic vis- cera. Appreciating the important relation of the little studied and little recognized triangular perineal body, he recognizes in it a wedge turned base downwards and acting as the keystone of an arch upon the integrity of which depends the support of organs which, deprived of its co-ordinating mechanical influence, would tend to fall downwards, bringing with them other parts which they in turn sustain. Let us now inquire what those influences are which commonly disable this wedge or keystone, and render it inefficient and worthless. The perineal body may lose its tonicity and efficiency from the following causes : — 1st. From constitutional feebleness. 2d. From feebleness the result of prolonged overdistention. 3d. From subinvolution. 4th. From senile atrophy. 5th. From laceration. rotrude over the ineffectual perineal barrier. Instances of this pathological condition are very common, and uterine displacement, as a result of it, will be frequently seen. Cases of complete uterine prolapse in very old women, in whom both ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 165 Uterus and vagina have long undergone senile atrophy, are not by any means rare. Here the uterus does not descend primarily, but an absorp- tion of the adipose tissue, which is stored away around the vagina, and serves as a support for it, occurs as the decadence of advancing age shows itself, and a perineum hitherto strong becomes inefficient and inactive. Rupture of the perineum may simply be described as a splitting of the perineal body. Laceration in the first degree splits the triangle, one side of which is covered by the vagina, only for a short distance; one in the second degree splits it to its centre ; while those in the third and fourth divide the triangle entirely tlirough, and at once remove the keystone from its place in the arch. Destruction of the power and function of the perineal body, more fre- quently than anything else, induces anterior and posterior displacements of the uterus and prolapsus in its three degrees. Removal of the perineum does not take away support from the uterus, but it alters the shape and removes the supports of the vagina, and causes it to drag upon and displace the uterus as a direct tractor. A curious phenomenon, which occurs in about one out of a hundred cases of destruction of the power of the perineal body, while in itself not important, serves to show how markedly the relations of the pelvic organs are in this way impaired. I allude to entrance of air into the vagina. While the pelvic organs are in normal condition, the close apposition of the vaginal walls, already alluded to, entirely excludes the spontaneous entrance of air, and at once expels it if forced in. Let the perineal body be entirely exhausted, however, and certain positions assumed by the woman draw air into the canal, which subsequently escapes with a dis- agreeably explosive sound. This occurrence has been described* under the names of garrulitas vulva? or flatus vaginalis, and deserves some atten- tion, in view of the fact that it alarms patients who are at a loss to account for it, and mortifies them by its happening at untoward times. So intimately are gynecology and obstetrics connected, in reference to this subject, that a few words upon its relations to the latter wiU not be inappropriate. It is no exaggeration to say that a very large proportion of female diseases take their origin in the mismanagement of the lying-in chamber. If this be so, and no gynecologist will deny it, to the obstetrician the importance of the perineum in this connection cannot be exaggerated. Its rupture furnishes one of the most fruitful sources for the absorption of septic elements, and I do not hesitate to say that thousands of women suffer throughout their lives from uterine displacements, engorgements, and vesical and rectal prolapse in consequence of injuries inflicted Upon it during the parturient act. To an imperfect comprehension of the anatomy ' See an essay by Lohlein : Zoitschrift fiir Ge])urtsliGlfe und Grynakologie, Bd, v., Hft. 1. 166 THE FEMALE PERINEUM; and functions of the perineum 1 attribute, in great degree, the impression entertained by many practitioners that, in spite of all tluit is said, its rupture, so long as it does not involve the anal sphincter, is a matter of little moment. This dangerous dogma' — which, in ray mind, renders him who entertains it an unfit person to be intrusted with the grave responsi- bilities of the lying-in chamber — is always based upon the fact that such a practitioner lias seen many perineums ruptured during labor, and even without interference on his part has, to use the common phrase, "heard nothing of them afterwards." But such a loose method of drawing deduc- tions is hazardous as well as unphilosophical. How do they who draw them know how many cases of septicoemia which have occurred in their practice have been due to the exposure of lymphatics and bloodvessels to the entrance of septic poison, or how many cases of uterine displacement, or vesical and rectal prolapse, treated by themselves or others, have been the remote consequences of perineal lacerations, regarded at the time of their occurrence as of no importance? If septic poisoning destroy his pa- tient, the medical attendant perhaps attributes her death to " puerperal lever," that hydra-headed monster of the lying-in chamber, which he is satisfied that neither he nor any other practitioner could have prevented. To account for remote troubles occurring years afterwards is equally sim- ple in his philosophy, for has not the patient lifted heavy weights, or fallen, or does not the displaced and congested uterus present sufficient signs of "chronic metritis" to offer this as a scapegoat? Let us suppose that the perineum has been torn during labor down to the sphincter ani muscle. In this accident the vagina is always torn, though the grave consequences attending that accident when occurring in the upper half of the canal, are here prevented by the intervention of the triangle of dense elastic tissue which exists between the vagina and the rectum. An immediate consequence is the exposure of an extensive raw surface indisposed to heal by first intention, richly supplied with blood and lymph vessels, and quite near to chains of lymphatic glands, intra- pelvic and inguinal. Over this surface the flow of an ichorous, fetid, and semi-putrid animal fluid must, in spite of the greatest precautions, steadih pass for from two to three weeks ; a fluid consisting of decaying and flaking decidua, disorganized blood, and quantities of muco-pus. The wonder is, not that septicemia occurs so often under these circumstances, but that so many cases escape it, where everything seems so perfectly arranged to favor it. Let one imagine a wound an inch deep and an inch and a half long, made in the thigh near the groin, or on the arm near the axilla, and bathed every hour of the day with the lochial discharges of a parturient woman ! Would he regard the occurrence of lymphangitis, phlebitis, and • See upon this subject an excellent paper in vol. iv. of the Am. Gynecological Society's Trans., by Dr. J. Taber Johnson. ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 167 erysipelas as being unlikely consequences? And yet this is what occurs to every lacerated perineum ; the wound thus treated being in no manner protected against the evils incident to such exposure. If cases of decided laceration of the perineum were closely followed up from the lying-in room to the end of life, and all the evils which imme- diately and remotely arise from this accident intelligently noted, the list would be a long one ; all not, of course, showing themselves in every case, but some occurring to one woman and some to another. It may be thus presented : — Septicaemia. Anterior and posterior uterine displacement. Prolapsus. Cystocele. Rectocele. Chronic cystitis. Chronic rectitis. Uterine engorgement and hyperplasia. Subinvolution of uterus and vagina. Destruction of power of uterine ligaments. Development of a tendency to abortion. Impairment of sexual gratification to the male. Neuralgia affecting the site of rupture. Presented thus, this array may appear unnecessarily formidable, but there is not one pathological condition mentioned which practical meh will feel inclined to question the occurrence of, as a consequence of puer- peral laceration of the perineal body. As for me, I freely confess that, at the moment of labor, I would rather have a patient sustain a fracture of the radius than a laceration of the perineum down to the sphincter ani. The broken bone would cause pain, sleeplessness, nervousness, and perhaps fever ; but it would not expose the patient to the same danger of septicasmia, or of subsequent uterine, vaginal, rectal, and vesical displacement. A decided laceration having occurred, if the obstetrician be a man who has familiarized himself with the anatomy and physiology of the perineum, it is difficult to understand how he can doubt the propriety of early closure of the wound, both as immediately preventive of septicaemia, for for forty- eight hours, during which the healing process seals together the freshly-cut surfaces, the uterine discharges are innocuous, and as remotely preventive of all the evils which have just been enumerated. Should the operation prove a success, the gain to the patient will be great ; if it prove d. failure, no evil will have been done. That there are sources of failure for immediate operation inherent tc the condition itself cannot be denied ; but equally fruitful sources for it are to be found in ignorance of the anatomy of the part to be repaired, the 168 PROLAPSE OF PELVIC VISCERA. performance of the operation hurriedly and without system, and the fact that the obstetrician has cultivated no ca[)acity for surgery. This question may here be very pertinently asked : If in the non-puer- peral state the perineum should be severed completely down to the sphinc- ter ani muscle, would prolapse of vaginal, rectal, and vesical walls neces- sarily occur? No; not necessarily ; though in time probably. On three occasions I have done this for the delivery from the vagina of very large tumors, and to test the question, I have delayed closure of the perineum. In no case did prolapse occur. And why did it not do so when it so com- monly ensues upon rupture of the perineum in labor ? Because laceration of the perineum during labor or abortion is very commonly the cause of subinvolution of vagina and perineal body. The former remains a large, lax, uncontracting bag ; the latter, a yielding, unresisting mass of adipose tissue and skin. Even after labor, prolapse of these parts does not always ensue upon rupture, even though the sphincter ani and posterior vaginal wall, for some distance up the rectum, be involved. In spite of the accident, in- volution goes on, the strength of the vaginal walls is recovered, and they are sustained, although their shape and direction are altered, and they lack the support of the perineal body. But such an occurrence as this is the exception and not the rule, and in spite of many such the rule stands unquestionable. CHAPTER X. ^ PROLAPSE OP VAGINA, BLADDER, RECTUM, AND INTESTINES. Prolapsiis of the Vagina. The remarks made in the preceding chapter being distinctly borne in mind, it will be easy for the student to get a comprehensive idea of pro- lapse of the pelvic viscera as a consequence of disability on the part of the perineum, and the subject may be dealt with much more cursorily than it could have been without them. It might upon very valid grounds be maintained that prolapse of the vagina, or rectum and bladder are so intimately connected with prolapsus uteri, that this chapter sliould have been united with that upon the latter condition. I have especially avoided this course, for the reason that I wish to direct tlie reader's attention particularly to j)rolapse of the vagina as a primary condition, one often long existing without uterine descent, and very frequently preceding that state as a causative influence. For any repetition which may occur in the two chapters, I offer no apology, in view of the great importance of both subjects. PROLAPSUS OF THE VAGINA. 169 Definition and Synonyms — The mechanism by which the pelvic organs of the female are kept in their proper positions, and relations to each other, offers, in its simplicity and perfection, an excellent example of that adaptation of means to an end which is so often repeated in the animal economy. The uterus is so sustained that when necessity requires it, not only in pregnancy but under a number of other circumstances, it may rise or fall, or tilt backwards or forwards, while the rectum, bladder, and lowest layer of small intestines are kept in place and allowed to dis- ten, it is necessary for us, before proceeding, to compre- hend its definition with perfect clearness. By some it is maintained that hernia of neighboring viscera into the vagina should not be included under the head of prolapsus, which, as Colombat declares, is an " inver- sion of the internal lining membrane, caused by infiltration of the cellular texture that unites the mucous to the subjacent membranes." By others it is believed that true prolapse is impossible without simultaneous dis- placement of one or more of the surrounding pelvic organs. All admit, of course, that in such an exuberant development or hypertrophy as that which occurs during pregnancy, a portion of the canal may be forced out of the vulva, but this is not what is ordinarily meant by the term prolap- sus vaginae. Dr. Savage' expresses himself thus upon the point : " Pro- lapse of the vagina alone, or ])ro]apse of the vaginal mucous membrane alone, are two affections which, anatomically considered, would seem impossible." It is an important question whether there can be prolapse of the vagina without rectocele, cystocele, or uterine prolapse. The anterior or upper wall of the vagina is closely bound to the base of the bladder and the front of the cervix uteri, and by means of the utero-sacral ligaments it is indirectly attached to the sacrum. This wall aids in support of the uterus, bladder, and small intestines. The posterior wall is not so firmly bound to the rectum, though the adhesion at the extremity of the utero- rectal pouch of peritoneum is quite strong. At the perineal septum, a point a short distance above the vulva, and just at the upper edge of the perineal body, the muscular walls of the vagina pass off to attach them- selves to the ischio-pubic rami. At that point the canal is constricted by the pubo-coccygeus, the true sphincter vaginas muscle. The mucous mem- ' Female Pelvic OrLrans. 170 PROLAPSE OF PELVIC VISCERA. brane of the canal passes down to the fourchette. These anatomical arrangements account for the fact that prolapse of the vagina without simultaneous displacement of one or more of its surrounding viscera is exceedingly rare, and that when it does occur as a distinct disease it is very generally found to affect only the posterior wall. I have met with no case in which the anterior wall has decidedly prolapsed without coinci- dent descent of the bladder, but I have seen repeated instances of pro- lapse of the posterior wall without alteration of the position of the rectum. Pathology Any influence which impairs the natural tonicity and strength of the vaginal canal, rendering it abnormally voluminous and lax ; which alters its natural shape and the incurvation of its walls ; or which destroys its lower buttress or support, will tend to induce this affi^c- tion. As pregnancy and parturition combine most, and often all of these, they very generally furnish both predisf)Osing and exciting causes. The development of the vagina, and increased Aveight of the uterus dependent upon the former, and the distention of the canal and enfeebling of the sphincter muscle incident to the latter, all unite in favoring prolapsus. As the fibre cells, which constitute the nascent state of the uterine mus- cular fibres, develop, so as to make of the insignificant non-pregnant uterus the powerful organ which expels the child at full term, so do those of the vagina, the Fallopian tubes, and the uterine ligaments. By the process of involution which diminishes the size and weight of the uterus, these parts likewise return to their original dimensions. Those influences which arrest this important process in the uterus, resulting in subinvolu- tion, likewise affect it in the other parts mentioned, and render them atonic and feeble. Prolapsus vaginae is very rare, except in those who have borne children, although it may occur. Sir Astley Cooper met with it in a girl, aged seventeen, who was admitted into Guy's Hospital, for supposed prolapsus uteri, and Prof. Meigs' mentions that Dr. Mutter, of Philadelphia, saw it occur in a child six months old in consequence of a convulsion. Causes From what has just been said the following causes will naturally suggest themselves as those most likely to produce this dis- placement : — Violent efforts of the abdominal muscles ; Repeated parturition ; Senile atrophy of vaginal walls ; Rupture of perineum ; Previous distention by tumors ; Long-continued vaginitis ; Subinvolution of the vagina and perineum. Of all these causes the last is the most frequent, more especially when ' Meiss's Translation of Colombat. PROLAPSUS OF THE VAGINA. 171 it accompanies, as it often does, partial rupture of the perineum. Next in frequency stand senile atrophy and absorption of surrounding adipose tissue. It is evident that all act either by debilitating the power of the vaginal walls by mere mechanical distention, by specifically robbing them of their tonicity, or by removing the buttress against wliich the canal rests at the vulva. Varieties The displacement may be of two forms, acute and chronic. The power of the canal may be overcome by a violent elFort, a fit of cough- in"-, uterine or abdominal contractions, or similar acts, which with great suddenness, force the contents of the abdomen down upon the pelvic vis- cera. This occurrence, which is very rare, is generally accompanied by sudden descent of the uterus, or occurs soon after parturition. The ordi- nary form of the atfection is that in which by the slow and steady action of one or more of the causes enumerated, the resistance of the vagina is gradually overcome, and little by little a fold is forced downwards towards and through the vulva. The first variety is the result of a few minutes' efforts; the second, that of months, or even years of morbid action. Pro- lapse of one wall, partial prolapsus, as it has been styled, is often lost sight of in view of the hernia of the bladder, rectum, or small intestines, which accompanies it. Hence cystocele, rectocele, and enterocele may be regarded as complications of the affection. Course, Duration, arid Treatment — A sudden attack of prolapsus being overcome by proper means, and the patient kept quiet, may disappear, and not return ; but in that variety which occurs gradually there is no limit to the duration of the disease. Generally, the physician is not called until it has existed for a long time and become chronic. The most important results of the condition are prolapse of the uterus, bladder, and rectum, one or more of which are almost sure to ensue. Prognosis The prognosis as to cure will depend upon the degree and duration of the malady. It is always, whatever be its extent, susceptible of considerable relief by surgical means, but generally proves incurable by those of medical character. Symptoms — Should displacement of the vagina exist alone, that is, without creating hernia of surrounding organs, the patient will complain of a sense of discomfort in the vagina, with a tendency to bearing down, as if to expel some foreign body ; a feeling of heat, fulness, and throbbing of the vulva ; a certain amount of pelvic uneasiness in walking or making any muscular effort, and a tendency to become fatigued, if the condition be one of aggravated character. Physical exploration will reveal the presence of a tumor, between the labia, which touch will demonstrate to contain no liquid, and yet not to be solid in its nature. Sometimes the mucous membrane covering it is excoriated, ulcerated, and purple in color; at other times it will be smooth, shining, tough, and covered by pavement 172 PROLAPSE OF PELVIC VISCERA. epithelium. A simple vaginal prolapse of any extent is, as has been stated, quite rare. When it does occur it generally affects the postinior wall, but prolapse, accompanied by hernia, is more commonly found to affect the anterior wall, cystocele existing. Should the case be complicated by vesical or rectal prolapse, the symptoms just enumerated will present themselves with the addition of others dependent upon disturbance of the functions of the part which forms the hernia. In one case the prominent symptoms will point to the bladder; in another, to the rectum; and, in very rare instances, to the small intestines. As the treatment of prolapsus vaginae is, with slight modifications, the same for uncomplicated and complicated cases, it will be considered after the subject of vaginal hernias has been discussed. Cystocele, or Prolapse of the Bladder. Cystocele, or vesico-vaginal hernia, consists of descent of the bladder towards the vulva, so as to impinge upon the vaginal canal. When the anterior wall of the vagina, which is closely adherent to the bladder, the base of which it in part sustains, ceases to afford the required resistance, the bladder, partly under this influence and partly under that of traction, descends and forms a small pouch in the vagina. This is at first very small, but gradually it increases, until at last it forms a decided tumor, which protrudes between the labia majora. The pouch tlius created be- comes filled with urine, which, in the ordinary act of micturition, cannot be evacuated, from its being contained in a species of diverticulum. This undergoes decomposition, free ammonia is formed, and cystitis or vesical catarrh is established, which annoys the patient by pain, heat, vesical tenesmus, and scalding in urination. Should any doubt exist as to the character of the tumor felt in the vagina, a curved sound or catheter may be passed into it through the urethra tor the settlement of the question. It is an interesting question whether cystocele is ever the cause instead of the result of prolapse of the vagina. It is probable that it may be so in very rare cases, though such a connection between the two affections must be uncommon, since the former generally occurs in women v/ho have borne children, and thus been exposed to influences which tend to diminish vaginal resistance. Scanzoni^ is convinced that the vesical prolapse is sometimes primary, and due to irregular spasmodic contraction of the fibres of the body of the bladder while the neck remains firm. This forces the urine to the fundus, which dilates and undergoes displacement. Rectocele, or Prolapse of the Rectum. Rectocele, or recto-vaginal hernia, occurs in a manner similar to that by which the bladder descends. The posterior wall of the vagina not only • Op. cit., p. 497. ENTEROCELE, OR PROLAPSE OF THE INTESTINES. 173 ceasing to give proper support to the anterior wall of the rectum, but drao'ging it obliquely downwards, this forms a pouch which soon fills with fecal matters. The feces, becoming hard, and, in consequence, irritating, create mucous inflammation and discharge, with tenesmus, obstinate con- stipation, and hemorrhoids. The tumor thus formed will sometimes equal in size a man's fist, and protruding over the perineum give some difficulty in diagnosis from its size and solidity. This difficulty will at once disaf)- pear upon rectal exploration and the use of an enema of ox gall and warm water. In one instance I saw a patient confined to bed for three or four months from one of these sacculated accumulations of feces, under the supposition that cellulitis existed, which by effused lymph had completely blocked up the pelvis. It may be supposed that such an error will rarely be met with, yet the case which I have just mentioned occurred to a prac- titioner of great experience and ability. Enterocele, or Prolapse of the Intestines. Enterocele, or entero-vaginal hernia, consists in descent of a portion of the small intestines into the pelvis, so as to encroach upon the vaginal canal. Such a descent usually occurs in this manner : a loop of intestine resting in Douglas's cul-de-sac stretches this serous prolongation, and, advancing between the rectum and vagina, pushes the posterior wall of the latter before it so as to form a tumor at the vulva. In a similar man- ner it is stated that the intestine may advance between the bladder and uterus and depress the anterior vaginal wall, but this must be rare, as authors of extensive experience assert that they have never met with it. Enterocele is not an accident likely to produce evil results unless it occur during labor, when strangulation may take place. Even at this time such a complication is very rare, for the free passage affiarded the displaced intestine back to the abdomen will almost always preclude this difficulty. Dr. Meigs^ relates a case occurring during labor, in which the progress of the parturient process was checked by a large mass of intestines until he succeeded in reducing the hernia. He says, with reason, tli;it in such a case strangulation or contusion was to have been feared. One very momentous aspect in which these hernise must be viewed is in relation to puncture of vaginal tumors, occurring during labor, for ascertaining their contents. No such explorative means should be re- sorted to without careful differentiation of vaginal hernia? of all descrip- tions, and especially of that of which we have last spoken. The peculiar sensation to the touch, of a 'tumor filled with air, a resonant sound upon percussion, the detection of peristaltic movements, and carefulexclusion of all other forms of tumor which might appear under the circumstances, will serve to avoid error. When it is borne in mind that vaginal tumors • Notes to Colombat on Diseases of Women, p. 211. 174 PROLAPSE OF PELVIC VISCERA. are very near the inflated intestines, and that they often yield to the touch an airy sensation, it will be appreciated that great caution is neces- sary in arriving at a diagnosis. Even when the investigator feels posi- tive in his diagnosis, it is always advisable to test the question by capil- lary puncture and aspiration. Should an intestine be punctured by the little needle employed, no evil will result. The following case illustrates the dangers and possibilities of erroneous diagnosis in these cases : — * A widow a3t. 52, mother of twelve children, the last born twelve years ago. A year since she suffered from prolapsus uteri, whicii was replaced. Patient presents, on examination, a swelling about three inches long, red- dish-blue in color, protruding between the labia majora, covered with granulations and pus. Diagnosis — Polypus of the uterus ; operation for removal. After suffering severe pain in the abdominal regions for several hours, death ensued. Autopsy — In the pelvis was found a half pound of liquid blood. Uterus and ovaries atrophied. A portion of the great omentum and a piece of the transverse colon were carried away with the mass. In the posterior wall of the vagina, was an opening about 5 cm. in diameter. 24 cm. of omentum and 10 cm. of the colon were excised. Treatment of Vaginal Prolapse and Hernice. — Should the accident have occurred suddenly, reduction should at once be accomplished, and the rcurrence of the displacement prevented by appropriate means. The bladder and rectum being evacuated, the patient should be placed in the knee-chest position, and, the fingers being well oiled, steady pressure should be exerted in coincidence with the axis of the inferior strait, until the prolapsed part is returned to its place. In the case of enterocele already referred to as treated by Prof. Meigs, the patient was placed upon the left side, and taxis being practised, the mass suddenly slipped above the superior strait, into which the next uterine contraction forced the child's head. To prevent a relapse the pelvis should be elevated, the patient kept perfectly quiet, tenesmus, if present, relieved by the use of opium, and the vagina constricted by astringent injections. But sudden cases of vaginal prolapse and hernia are very rarely met with. It is usually those which have slowly and gradually established themselves that we are called upon to treat, and these are always obstinate and rebellious. The means at our command for overcoming such cases are the following : — 1st. Local astringents and tonics ; 2d. Development of retentive power of the abdomen ; 3d. Supplementary support ; 4th. Surgical procedures. The first of these may be effectual in slight cases, but in those of graver • CentralWatt fur Chir., May 3, 1879, p. 303 ; Hosp. Gazette. ENTEROCELE, OR PROLAPSE OF THE INTESTINES. 175 character they will prove insufficient. The tone and strength of the vagina may be temporarily restored by the use of injections of large amounts of water medicated with tannin, alum, or zinc, employed night and morning. The patient should be sent during the summer to a water- ing-place, where sea-bathing and injections of sea-water into the vagina may be employed. A very excellent result will also sometimes follow the use of vaginal suppositories containing one of the astringents mentioned. Too much stress cannot be laid upon the influence of the abdomen in sustaining the pelvic viscera. An impairment of its force by want of ex- ercise, and the pernicious habit of disabling the power, and impeding the function of the diaphragm and chest muscles, by tight lacing and the wearing of heavy clothing, is one great cause of their displacement. Im- provement in this respect, by removal of the depreciating influences men- tioned, and recovery of lost power by appropriate exercises, is a matter of great moment. But this will be left for consideration under the head of Uterine Displacements. Supplementary Support — In stout women an abdominal bandage with perineal pad, by relieving pressure from above may accomplish a great deal of good when combined with complete removal of all constriction and weight of clothing about the waist. In thin women it accomplishes nothing. The vaginal pessary, an instrument of decided value in all the dis- placements of the uterus, does little or no good here. In many cases no pessary which rests upon the walls of the vagina can be retained within the distended canal ; in others none can be found capable of resisting the downward pressure ; while in all increase of dilatation and atony is effected by them. It is true that for a time apparent good results from them, but the hope to which this gives rise is very generally delusive, and very soon they must be abandoned. The function of a vaginal pessary is to support the uterus ; not to sustain the vagina. In some cases an ex- ception will be found to this rule in Cutter's cup pessary or some similar instrument supported by an external attachment. Here suflUcient power is afforded for support of the uterus at a high point in the pelvis, which mechanically puts the lax vagina on the stretch and prevents its prolapse together with that of the bladder and rectum. This instrument will be shown in connection with prolapsus uteri. Surgical Procedures Of these there are three which may prove effectual. If a ruptured perineum seem to produce the want of support, the operation of perineorrhaphy may be all that will be necessary. This is described in the next chapter. Should this not be sufficient, colpor- rhaphy should be performed upon the anterior or posterior vaginal wall, as one or the other seems most at fault ; and, should even this not relieve the condition, the remaining wall should be likewise diminished in extent by the same procedure. 176 PROLAPSE OF PELVIC VISCERA. Almost all, except the most aggravated cases, which are accompanied by great hypertrophy in the vaginal walls, will yield to these three pro- cedures, alone or combined. Colporrhaphy or Elytrorrhaphy} — The idea of constricting the vagina so as to diminish its calibre, and by this to remove the traction exerted by its fall upon rectum, bladder, and uterus, long ago suggested itself to the minds of surgeons. In 1823, M. Romain GAiardin made the sug- gestion before tiie Medical Society of Metz, but the operation does not appear to have been essayed, for the writer with a great deal of patriotic zeal states, in a subsequent essay upon the subject,* that " his desire had been to put beyond controversy the origin of the operation, and to preserve for French surgery the priority of its conception, if not of its execution." While this surgeon was felicitating his country upon the conception of an idea, DiefFenbach, in Germany, and Heming, in England, proved its practicability by absolute performance. Dieffen- bach probably operated as early as 1830, as a report of his having done so was published in June, 1831. In November, 1831, the late Dr. Marshall Ilall, of England, published a case, in which at his suggestion it had been performed by Dr. Heming, the translator of Boivin and Duges on the Diseases of the Uterus, with complete success. Subse- quent to this period it was performed, with various modifications, by Fricke, Scanzoni, Velpeau, Roux, Stolz, and others ; the operation always consisting in "the removal of a band of vaginal mucous membrane and union of the two lips of the wound in such a manner as to diminish the calibre of the vagina Diefl^enbach refers to a great numl>er of women who were completely cured by the procedure Fricke out of four cases cured three." ^ Judging from these quotations, it appears that the operation has been known and practised for a long time on the continent of Europe, especially in Germany. In England it had not been resorted to up to the year 1865, if we may judge from the statement of Dr. Sims* that, after a discussion upon an essay presented by himself to the London Obstetrical Society in that year, Mr. Spencer Wells called his attention to the operation of Mr. Heming, already referred to, with the assertion that " at least one case had been successfully operated upon." The operation, probably for reasons which I shall mention hereafter, had fallen entirely into disuse when Dr. Sims^ revived it in 1858, with certain modifications. His operation, which I shall soon describe, differs very essentially from that adopted by his predecessors, and should in ' KoXttoj or fXi/Tfjov, "the vagina," and (a^n, " suture." 2 Gazette Medicale, 1835, p. 558. ' Wieland and Dubrisay, op. cit., p. 533. * Uterhie Surgery, Eng. ed., p. 319. * Uterine Surgery, Eng. ed., p. 308. COLPORRIIAPIIY OR ELYTRORRII A Pll Y . 177 justice be regarded as the parent of the numerous, I had almost said innumerable, modifications of it which have since appeared. It is a mischievous error to describe this operation as one performed for prolapsus uteri. That that displacement is one of the complications often existing as a consequence of prolapse of the vagina is true, but the operation is often necessary when vagina, bladder, and rectum alone are seriously involved. The traction exerted by the descent of these viscera is frequently the cause of uterine displacements of various kinds, and that being removed by the operation, the consequent displacement disappears. But the student must remember that colporrhaphy is the legitimate surgical resource for loss of power and displacement of the vagina. To take a different view is to obscure the subject, and to substitute a purely empirical for a scientific and rational arrangement. This error is based upon the belief that the vagina is a uterine support, and that its prolapse alloios of descent of the pelvic viscera; not that it drags them down by its own inherent tractile power. Some writers describe two operations for narrowing the vagina, one for the cure of pro- lapsus uteri, and another, both being for anterior elytrorrhaphy, for prolapsus vesicte ! This is surely a useless and mistaken technicality. Whatever supports vagina, bladder, or rectum takes away direct traction from the uterus, and ullotos other influences, the retentive power of the abdomen chief among them, to keep the uterus in position. Carl Schroe- der' strikes the true key-note of this subject when he declares that "the only circumstances under which we may expect a satisfactory result from this operation are when the vaginal prolapse was the primary one." Situs's Operation of Colporrhaphy The patient, being put under the influence of an anaesthetic, is laid upon a table, upon the left side as for an ordinary speculum examination, and Sims's largest speculum intro- duced. A curved sound, with forked tenaculum points, is fixed in the cervix uteri and made to cause a fold in the anterior vaginal wall, as shown in Fig. 51. The parts being steadied by this instrument, the operator, by means of two tenacula, folds over the opposite walls of the vagina so as to decide where union is to be effected. Having settled this point, the mucous membrane is hooked up by a tenaculum several lines above the meatus and cut by curved scissors. The tenaculum lifting the piece thus cut, and when necessary being again attached to the mucous membrane, the incision is carried upwards so as to cut out a strip extending to one side of the cervix. Then another furrow is cut in the same manner on the other side. The sound being removed, and the cervix pulled down by a small ten- aculum, the two transverse lines of denudation, shown in Fig. 52, nearly uniting the two arms of the V, are made. ' Dis. of Female Sexual Organs, Am. ed., p. 208. 12 178 PROLAPSE OF PELVIC VISCERA. Sutures of silk are then inserted after the plan employed in vaginal tis- tuliE, and by them silver sutures are drawn into position. The passage of sutures should be commenced at the apex of the triangle and continued upwards. Fig. 51. fl.J m Sims's operation for colporrhaphy. (Sims.) The after treatment consists in perfect quietude in the horizontal pos- ture, frequent removal of urine by a catheter, and the production of con- stipation by the use of opium. The lower sutures may be removed in ten days, and the upper in a fortnight. The patient should be kept in the recumbent posture for two or three weeks, and cautioned against immod- erate muscular eflfort for some time afterwards. Dr. Emmet, finding that the pouch left posterior to the uterine neck by this procedure was sometimes entered by the cervix, improved the opera- tion by extending the transverse denudations so as to make them meet. He has since the introduction of this procedure still further simplified it, in the following manner. At the commencement he catches up with a tenaculum a patch of mucous membrane at the proper distance to one side of the cervix, and snips this out with scissors. On the other side he does COLPORRIIAPUY OR ELYTRORRII A PIl Y . 179 the same thing, and also on the posterior wall of the cervix. lie then passes a wire suture so as to bring all these denuded points together, face to face, and twists the wire so as to fix them. The result is that the Fig. 52. i '' V, - — \-'' t / Sime's operation Shape of denndatioo and positioD of ntcrns. Fio. 53. Fig. 54. Emmet's operatiou : first step. folding of the vagina accomplished by the sound, as shown in Fig. 51, occurs without the use of that instrument. Catching up a piece of mucous membrane on the vaginal fold of each side with the tenaculum, he now Emmet's operation ; second step. 180 PROLAPSE OF PELVIC VISCERA. cuts it out and at once passes a suture, and thus he proceeds, step by step, avoiding a great flow ol' blood, and opposing tlie abraded surfaces immediately, accurately, and without danger of passing the sutures so that they will not be symmetricaL As I have already mentioned, there are numerous modifications of this operation, but I sliall mention only two more, one for elytrorrhaphy upon the posterior wall, or posterior elytrorrhaphy; the other for the anterior operation. The peculiarly shaped triangle of Sims is by no means necessary for this operation. Any figure which results in constriction of the vaginal wall will remove traction Irom the uterus and keep the vagina from pro- lapsing. Thus Hegar turns the apex of the triangle up, and the base down, while others resort to variously shaped denudations. One of the simplest for both posterior and anterior wall is an ovoid figure, the whole of the extent of which is denuded. This form dates back as far as Dief- fenbach. It is shown in Fig. 55. Fig. r-f). Oval denudation, with sutures passed. This operation is easier of performance than the two preceding ones, and gives a stronger and more perfect union of tissues which is less likely to yield to pressure. When it is performed upon the anterior wall the patient should lie as in Sims's operation just described; when upon tiie posterior wall, upon the back, the thighs flexed upon the abdomen, and the lateral walls of the vagina retracted by right angled retractors held by assistants. Simon's oi)eratiou of " posterior colporrhaphy" is only a modi- fication of this. Very generally both anterior and posterior elytrorrhaphy are entirely imperfect resources unless combined with perineorrhaphy, and the latter COLPORRHAPIIY OR ELYTRORRH API! Y . 181 is often very advantageously united with these under the name of elytro- perineorrhaphy or colpo-perineorrhaphy. I now proceed to describe an operation which has acquired considerable reputation in France, and which seems to have a future before it. It is that of M. Leon Le Fort, and is thus described by him.' " The uterus being entirely outside of the vulva, without reducing it, I make on the anterior wall of the vagina, the patient lying on the back, four incisions, cutting out a portion of mucous membrane which yields me a raw surface about six centimetres long by two wide upon the part nearest to the vulva. Then, lifting towards the abdomen the prolapsed uterus so as to see the posterior face of the tumor, I make on this part a raw surface similar to that on the anterior wall. That being done, I in part replace the uterus so as to bring the extremities of the two raw surfaces in con- tact where they are nearest the uterus. I then apply on the transverse border three sutures, reuniting longitudinally the anterior and posterior walls of the vagina ; I then proceed to the reunion of the lateral borders by passing from each side a silver thread, traversing the border of the ante- rior freshened surface, then the corresponding border of the posterior freshened surface. A thread being placed in a similar manner on the opposite side and at the same level, it is sufficient to tie these sutures to increase by the apposition of the opposite vaginal walls the reduction of the uterus. This reduction is completed gradually as the sutures are put in place, and, when the two raw surfaces have been united throughout their extent, the reduction is complete. The threads which have served as sutures for the transverse border nearest the uterus, being hidden in the depth of the vagina, are difficult of access when after several days union is effected; therefore it is wise to give to these threads sufficiently great length in their twisted part, in order to seize them easily when they become free after section of the part embraced in these loops." That the operation of elytrorrhaphy has effected excellent results, there can be no doubt. The journals of the day contain numerous reports of cases successfully operated upon by slight modifications of the methods here described. Its disadvantages are, that it is a very tedious process, difficult of performance for one not familiar with this kind of surgery, and liable to failure even if carefully and thoroughly accomplished. Further than this, it is unquestionable that in a large number of cases expansion of the vagina recurs in time in spite of it. Scanzoni^ goes so far as to say that the operation always fails. After employing it thirteen times he says: *' From the results obtained in our own cases, we can by no means pro- nounce favorably on these operations." Courty' says, in speaking of the operation, " The majority of surgeons to-day regard as useless a method ' Le Blond, Traite Elementaire de Cliir. Gyn., p. 49(3. 2 Op. cit.,p. 159. =» Mai. de rUterus, p. 748. 182 RUPTURE OF THE PERINEUM, of treatm* nt, which is likewise not devoid of danger." A reviewer of the New York Medii-al JournaP says : " We have now under our charge, a patient operated upon nine years ago by Sims's method ; in a year the cicatrices had given way, and the procidentia returned. Three years ago, she was operated on twice by Emmet's method; in little more than a year the bands gave way, and her condition was worse than before, tor the vagina was so deformed by the cicatrices that it became impossible to adjust a pessary;" 1 shall not, however, strive to accumulate evidence of this kind ; I have offered this merely to sustain my statement that there are certain disadvantages attaching to the procedure. In spite of all this my experience with the operation, combined, be it understood, with perineorrhaphy, leads me to place a very high estimate upon its merits, and to regard it as meeting a difficulty in many cases for which no other resource is offered either by medicine or surgery. CHAPTER XI. SURGICAL MEANS ADAPTED TO RESTORATION OF THE PERINEAL BODY. The pathological conditions treated of in the two preceding chapters are so directly connected with loss of power in the perineal body that the i^^urgical procedure adapted to the restoration of that part very naturally comes next under consideration. I beg the reader to observe that the operative procedure about to be described is not limited to the cure of laceration of the perineum. It is appropriate to the restoration of the perineal body which has lost its power and function from any cause — rupture, subinvolution, senile atrophy, constitutional debility, or prolonged overdistention. The indication is to till the triangular space created by the anterior curve of the posterior wall of the vagina and the posterior curve of the anterior wall of the rectum with a dense, resisting body, which will fit into the space, support the walls just mentioned, and act as the keystone of an arch which directly or indirectly sustains the bladder, the rectum, the uterus, and the intestines above. This is the comprehensive and broad view which should be taken of the operation, and upon its thorough ap[)reciation and acceptance much will depend which is to follow. All that is said as to the importance and treatment of destruction of the perineum in this chapter is based upon the facts stated in Ciiapter IX. ' Vol. viii. p. 523. RUPTURE OF THE PERINEUM. 183 IJet'ore reading this tlie student is, therefore, urged to peruse that. With- out that this Avould be superficial and imperfect; by its aid it will become much more thorough and comprehensive. In spite of the fulness with which the subject is dealt with there, I deem a slight recapitulation of salient points advisable here. In doing this I offer no apology for repe- tition of former statements, for I am an advocate of the plan of a popular teacher of the French language who instructs by "repetition sans cesse." Anatomy. — Proceeding in close proximity with each other towards the pelvic outlet, the vagina and rectum diverge at a point above the peri- neum ; the one arching forwards in coincidence with the pelvic curve, the other slightly backwards towards the coccyx. In this way an irregular triangle is created, of which the base is the skin between the fourchette and anus, one side the posterior vaginal wall, and the other the anterior wall of the rectum. This space is filled by a body, having the union of muscular tendons as its base, and which is itself composed of fibro-elastic tissue. One of its sides resting upon the rectum, the other gives strength, elasticity, and firmness directly to the posterior wall of the vagina; while this wall, being by it pressed against the anterior or upper vaginal wall, sustains it and the bladder which lies upon it. Figs. 56 and 57 will show Fig. 56. ;iv t s I Periueai body perfect; both vaginal w.ills sustained. the relations of the perineal body and the effect of its removal upon tlie vaginal walls. Tlie anterior or upper wall, after its removal by rupture, lacks support and falls downwards, prolapse of this wall occurring, with 184 KUPTURE or THE PERINEUM. cystocele. The normul direction of the posterior wjill is also destroyed. Instead of its arching forwards, with a gentle curve, towards the vtilva, its lower portion runs like the letter S, to the anus. The result of this change of direction, with the coincident loss of support from the strong, elastic perineal body, is to create a sagging forwards, and soon prolapse of this wall follows that of the anterior, and uterine displacement is a consequence. It may with some justice be remarked that Fig. 57 represents the peri- neal body, not simply exhausted but split through, as can only be done by laceration. It is true that in other conditions of loss of power there is an appearance of a perineum left, but it is the semblance of a departed powder, and the diagram must, in such eases, to a certain extent, be regarded as schematic, referring to absence of function rather than of tissue. Fig. 57. £: Perineal body removed by rupture; buth vaginal walls robbed of support. When a woman with a normal perineum is placed upon the back, and the finger of the examiner is passed into the vagina, as it passes over tlie perineal body it will be firmly pi-essed against the upper vaginal wall. Upon the withdrawal of the finger, tlie separated walls will be observed to come in contact at once by the rising of the posterior wall. If the perineal body have lost its power, no such upward pressure is found to exist, and the vaginal walls are discovered to be in less close contact. After operation for restoration of the destroyed perineum, an examina- tion of this kind should be made. If the upward pressure of the perineal RUPTURE OF THE PERINEUM. 185 body is found to be sufficient to bring the postei-ior in contact with the anterior vaginal wall, the object of the operation has been attained. If it do not so, both walls will lack support, in spite of the fact that the super- ficial perineum, the base of the perineal triangle, has been united and appears perfect. The latter result will deceive the patient, and may de- ceive the surgeon, with false hopes. The former will alone give future immunity from the dangers of vaginal prolapse and its consequences. Fro. 58. Perineum improperly repaired ; perineal body not restored to place ; vaginal walls not sustained. Those influences which destroy the power of the perineum and I'ender it incapable of its important functions are the following : — Constitutional feebleness ; Prolonged overdistention ; Senile atrophy ; Subinvolution ; Laceration. All these, with the exception of the last, have been considered with sufficient fulness in Chapter IX. ; laceration requires more careful study here. It being now understood that the repair of a perineum the 'power of which has been destroyed from any of the causes mentioned is to be con- ducted upon exactly the same principles as those which apply to the opera- tion for laceration, I shall use this accident as a means of illustrating it and confine my remarks to it during the rest of this chapter. 186 RUPTURE OF THE PERINEUM, Varieties of Perineal Laceration. — All cases may be classed under two heads : — Complete and Partial Rupture. These include the following degrees of destruction : — Superficial rupture of the fourchette and perineum, not involving the sphincters ; Rupture to the sphincter ani ; Rupture through the sphincter ani ; Rupture through the sphincter ani and involving the recto-vaginal septum. Complete rupture presents such serious discomforts as a consequence, that partial rupture is by many viewed as a trivial circumstance. So it is by comparison, but so likely is it to be followed by prolapse of one or both vaginal walls that it should never be undervalued. As soon as such prolapse occurs, uterine, vesical, and rectal troubles become almost in- evitable. The evils resulting from partial rupture are by no means insignificant, but they are more remote and more tolerable than those which follow com- plete. When the sphincter ani is torn through, and still more markedly when the rectal wall is ruptured, incontinence of feces and rectal gases occurs to such an extent as to embitter the life of the unfortunate patient. The consequences of rupture of the perineum may thus be presented : — Subinvolution of the vagina ; Prolapsus vaginae with cystocele or rectocele ; Prolapsus uteri ; Incontinence of feces and intestinal gases ; Prolapsus recti. The first three of these may result from both varieties of rupture, com- plete and incomplete. The last two attend only the former. Even when the two passages are laid into one, it is sometimes surprising to see how little the patient may suffer ; but generally, under these circumstances, her condition is truly deplorable. Fecal matters and gases pass without control, and the uterus, vagina, bladder, and rectum tend so strongly to descend, that exercise, muscular efforts, or tenesmus produce weariness, pelvic pain, and traction upon the broad ligaments. In some instances, so great is the disturbance of function, that the unfortunate woman finds herself an object of disgust to her associates and even of loathing to her husband. Subinvolution of the vagina is rarely alluded to as a consequence of rupture of the perineum ; but I see the two conditions too often coexistent to regard it as a mere coincidence. " The muscular walls of the vagina," says Savage, " are not separable into coats or layers. Two-thii"ds of the thickness of the vagina, varying from 2-3 lines above to 5-6 below, is made up of this muscular portion ; the inner third consists of a dense, NATURAL HISTORY. 187 cellular lining mcmbmne, inseparably united to it." The elastic, con- tractile elements of this canal are identical in structure with uterine fibre ; and development occurs in them as in those of the uterus under the stimulus of gestation. A retrograde metamorphosis likewise affects them subsequent to labor. As this process is often interfered with in the uterus by rupture of the cervix, so is it in the vagina by rupture of the perineum. Let any one appeal to his own experience for the frequency of subinvolution of the vagina as a concomitant of rupture of the peri- neum. It may be objected that the latter often results from difficult and particularly from instrumental delivery, which may produce both condi- tions. An examination into the histories of cases will refute this ; the result is often produced when the labor has been very rapid and unaided. It may again be suggested that prolapse of the vagina, a consequence of the rupture, excites excessive growth in its walls ; but the two things co- exist whei-e perineal rupture has not resulted in vaginal prolapse, almost as often as where it has done so. Causes The power of the perineum may be destroyed by a number of influences, for which the reader is referred to Chapter IX. of this work. For laceration of the perineum tliere is but one cause — parturition. Minute details upon this subject, and upon means which should be adopted for prevention, will be found in works upon obstetrics. All that it is necessary to state here is that parturition is the great exciting cause of the accident, and that it is almost never met with in nulliparous women, except after removal of large tumors per vaginam, and then it is usually of little moment. Prognosis. — In an incomplete case of slight character, where the four- chette and only a small portion of the perineal body are involved, no evil usually results. Laceration of this character and to this extent is the rule in first labors, and not the exception. It requires no interference, and is so insignificant in consequence, that it is not included under the sub- divisions which I have mentioned. Even the first and second degrees of laceration which I have tabulated are often productive of no evil, and may, unless careful inspection be made, pass unrecognized by both physician and patient. But this is the exception and not the rule. The third degree is always an accident of gravity ; while the fourtli re- presents the most serious form of the condition. The greater the injury the less likely will be spontaneous recovery, and the more probable the complications and results which have been mentioned. Natural History of Perineal Laceration It is the general impres- sion, and one which I formerly shared, that any laceration which does not entirely sever the sphincter ani may unite by first intention without surgical treatment, and that none which converts the two passages into one will do so. Even, however, when the rupture has been complete, it has been asserted that spontaneous cure has taken place. For example, 188 RUPTURE OF THE PERINEUM. Peu^ once affirmed that be had seen a woman tlius injured, and v;ho passed her feces involuntarily, entirely recover. De la Motte declares that thirty years afterwards he met and examined Peu's patient in Normandy, and found that no recovery had occurred. Observation at the bedside has led me to question whether union by adhesion of the lips of these wounds ever occurs spontaneously. Very certain am I that in my own experience I have never seen one do so. Let the limbs be bound together ever so closely, the inevitable passage of lochial material between the cut sur- faces prevents union by first intention. Repair is effected by granulation, and is often very good, but it is never perfect. I am not prepared to say that the statement is absolutely and universally true, but I believe it to be so as a general rule, that a lacerated perineum left to nature for repair is never afterwards as perfect as it was before the occurrence of the injury or as it usually is after proper repair by surgical means. How then is it, it may be asked, that so many women who suffer from laceration of the perineal body do not suffer from the consequences which have been mentioned ? First, because, if the laceration does not interfere with vaginal involution, it often does no harm, or at least not for many years, when its connection with displacements is entirely forgotten ; and second, because the imperfect repair effected by granulation is commonly sufficient to answer all purposes. I am fully aware that many will be found who will positively affirm that they have seen even lacerations in the third and fourth degrees entirely repaired by first intention. "False facts," eays Cullen, "are more dangerous than false theories." This I strongly suspect, though, as I have stated, I cannot assert, to be one. The ostium vaginae just after delivery is, in its overdistended and always slightly lacerated condition, with folds of redundant vagina pressing down upon it, a most deceptive part. I have myself often been deceived as to serious laceration just after delivery, and I have frequently seen others similarly misled. A .prolific field is thus open for error to the superficial and inexperienced examiner, who, having mistaken a slight laceration for one of aggravated character, and finding that repair has been effected by nature, asserts in future that he has known spontaneous recovery even after most extensive destruction of the perineum. Should the case really be a serious one, however, and the practitioner one who believes that nature will in all probability repair the accident and restore the perineal body to its important functions, a golden Ofjportunity will be lost, and the patient in all likelihood remain a sufferer in consequence. Time for Operation Upon this point authorities differ widely, some urging immediate action, some advising delay until the effects of [larturi- tion have entirely passed away, while others compromise the matter by 1 Velpeau, Traite do I'Art des Accoucheineuts, vol. ii. p. 633. TIME FOR OPERATION. 189 giving preference to tlie plan of waiting a few days only. To the first class belong Baker Brown, Demarquay, Scanzoni, Simon, and others of equal weight. Scanzoni thus clearly points out the advantage of early interference: "The operation should be performed just after the delivery, because it is more likely that the bleeding lips of the wound will then unite, and because, vivitication of the edges not being necessary, the pro- cedure is simpler and less dangerous." The worst cases of the accident with which we meet generally follow instrumental or manual delivery, and when the discovery of its occurrence is made the patient will usually be in , a profound ana3sthetic sleep. Every operator should be prepared, under such circumstances, to attempt repair of the injury, for, if he succeed, the patient will be saved Aiuch suffering, while failure will not in any wise depreciate her condition. For this reason no case of obstetrical instru- ments should be considered complete which has not in it needles and sutures for performance of this operation. I have commonly resorted to immediate operation, and the result of my experience leads me always to adopt it, unless the sphincter ani and recto-vaginal wall be so profoundly im[)licated in the laceration as to make the operation a serious and lengthy one, or necessarily to insure the passage of lochial discharge between the , / j s^ lips of the wound. Among those who are opposed to immediate inter- ^il^ , ference are Roux and Velpeau ; while Nelaton, Verneuil, and Maison- l^^ - neute advise delay for a few days, when all hemorrhage will have ceased j^^ctn^ioA' and the edges of the wound be covered by granulations,* There are jU'-'^ y'^'' ~, three circumstances which tend to defeat the success of immediate opera- ^iaaaa/ kaa/ tion. First, it is often performed by one not habituated to its peformance; and, being practised upon a woman who, having just been delivered, is exposed to the danger of post-partum hemorrhage, and surrounded by anxious friends, it is likely to be finished too hastily. Second, the lochial discharge, constantly passing over the lips of the wound, is very likely to enter and prevent union. Third, the operator having been taught to regard the perineum as the superficial layer of tissues intervening between the fourchette and anus, closes this by correspondingly superficial sutures, leaves the upper portion of the perineal body open, creates a pouch for the accumulation of putrefying materials, and leaves the anterior vaginal wall and bladder without support in the future. My advice and practice with regard to this point are decidedly to give the patient the benefit of the doubt and to close the ru[)ture at once. If failure follow, however, never, unless there be some special reason for so doing, attempt another operation before the results of parturition have entirely passed away. This will not be before the lapse of tw'o months from the time of delivery ; just after delivery there is a reason for operating which has passed away in a fortnight. * Wieland and Dubrisay, French Trans, of Churchill on Dis. of Women. 190 RUPTURE OF THE PERINEUM. As I have elsewhere already remarked, it is my conviction that a very large number of cases of uterine disease take tlieir origin in the lying-in chamber, and a lar"-e proportion of these in unrepaired cases of lacerated perineum. When immediate operation becomes tlie rule of obstetric prac- tice, the number-of cases of disease thus occurring will at once and very decidedly diminish. But the full results of immediate operation will never be exhibited until the obstetrician studies the anatomy of this part, and learns how to api)roximate its entire divided surface by sutures carried up to the highest point at which solution of continuity has occurred. Treatment of Cases ivlnch have Cicatrized — The operation which is now generally adopted in these cases, and which has received the name of perineorraphy, consists in vivification of the edges of the lips of the wound and their approximation by sutures. Although the accident for which this procedure is instituted was described by the ancients, no sur- sical means of cure were ever advised for it until the time of Ambrose Pare. He advised the suture, and was followed in its use by his pupil Guillemeau. Subsequently it was employed by Delamotte, Saucerotte. Trainel, Noel, and others. Dieffenbach employed it successfully, adding to the operation oblique lateral incisions involving the skin and areolar tissue, for the pur[)Ose of relieving tension upon the parts brought together by suture. About the year 183'2, Roux, of Paris, obtained the most brilliant re- sults from the operation, and probably its elevation to the position of a reliable suro-ical procedure was due more to his achievements than to those of any other individual. He employed the quilled suture, and cured by it four out of the first five cases operated upon. Although such success was obtained in France at this period, Ave find English writers, as late as 1852 and 1853,^ doubting the efficacy of sutures, and advising that assist- ance should be limited to aiding the efforts of nature. Of late years great advances have been made in the operation by Mr. Brown in England ; Verneuil, Laugier, Demarquay, and others in France ; Langenbeck and Simon in Germany ; and Sims, Emmet, Agnew, and others in the United States. To no department of gynecology does there attach more surgical rubbish which needs a thorough clearing away than to perineorraphy. It has afforded a fruitful field for attempts at originality and innovation ; succes- sive investigators too often seeming to strive not so much for simplicity as for some peculiarity of procedure which they could call their own. Stripped of this, the operation is a simple one, and, under the influence of advancing anatomical knowledge, has reached a point at which operators may stand in unison. Among tlie methods which I think should at present be cast aside as effete material, I would cite the use of the quill • Baker Brown, Surgical Diseases of Women. INSTRUMENTS. 191 suture, cutting the tissue alongside of the perineum, cutting the sphincter ani, dissecting flaps from the neighboring cutaneous surfaces, and many- others. Let the operator fully understand what he sets out to accomplish, which is by no means always done in a surgical procedure, and he will readily appreciate that the simplest, easiest, and surest method of doing this is the best. Let him, on the other hand, have in his mind a dim, uncertain knowledge of what he desires to accomplish, and let him till his mind with the details of the special plan of this or that operator, and he will be led to adopt complicated and uncertain procedures. In description I shall adhere to no one particular and exact method,' but describe that combination which I liave selected as best in my own practice. Preparation of the Patient — The general health should be carefully investigated. If it be bad, the operation should be delayed, and the patient put upon tonics and placed under the best hygienic circumstances. For a week before operation, the bowels should be kept lax by some mild cathartic, in order that after that time cure shall not be jeopardized by the coming down of scybalie, which have not been removed by a cathartic given twenty-four hours before operation. This point is one of a great deal of moment, and should not be overlooked. In cases of complete rup- ture it is better even to give a fortnight to the fulfilment of this indication. A compound cathartic or compound aloetic or rhubarb pill may be given every twelve hours, or a saline cathartic at the same intervals. Free alvine evacuation, not hypercatharsis, is what is required. During this time the vagina should every night and morning be thoroughly syringed out with warm water to remove secretions and quiet local irritation. Instruments and Appliances needed. — These will consist of a long han- dled curved scissors; a bistoury with narrow blade; a tooth forceps and Fig. 59. G.J lEMANN - CQ-Ny Thomas's tooth forceps. Fig. 60. Slightly curved scissors. tenaculum; one dozen small sponges (size of a walnut), fixed in handles ten inches long ; artery forceps ; silk ligatures; and straight darning needles, threaded with silk, which is double and tied at the eye of the needle by as small a knot as possible. A basin of water should be in readiness to 192 RUPTURE OF THE PERINEUM. receive the bloody sponpjes, and a pitcher, bucket, or otlier reservoir at hand to supply more when this is to be changed. The instruments should be kept immersed in carbolized water, with which the parts should be freely bathed. Fig. CI. Emmet's scissors sharply curved. Operation for Partial Rwptrire It is a matter of great surprise to me that no distinct separation sliould be made by writers between the descrip- tions of operations for partial and complete rupture. The first is a proced- ure in which the merest tyro should succeed. The second is one of the most delicate and uncertain operations in gynecology, in which even the most skilful may fail. I feel sure that evil has arisen from confounding a simpl-e and difficult procedure, and shall make a wide difference between them. The operation for partial rupture has for its sole object the restitution of the perineal body. That for complete rupture has for its main object the restoration of the power and functions of the sphincter ani. After the main object of the second operation has been attained, that of the first should claim attention. Before describing these operations, I would say a few words upon divi- sion of the sphincter ani. I have operated a great many times for rupture of the perineum, and cannnot recall a case of final failure ; thus far I have never cut the sphincter. My experience, confirmed by that of many others, leads me to indorse Dr. Savage's statement, that " the success of operations for the closure of perineal lacerations is obviously not promoted by the division of the superficial anal sphincter." Let the operator keep clearly in mind the shape and dimensions of the body which he is about to restore. It is a triangle with apex above and base below. Two sur- faces of this shape are to be vivified and held face to face by sutures. That is the whole operation. First part of the Operation. — The pa- tient, dressed for bed, should be placed upon a table before a window ad- mitting a strong light, in the position for lithotomy, and put under the Fig. 62. A Profile view of perineum. A C, rectal wall. A B, cutaneous surface. B C, vaginal wall. (Parvin.) OPERATION FUR PARTIAL RUPTURE. 193 influence of ether. Four assistants will be serviceable, altiiough three would answer the purpose. One ot" these should administer the anajsthetic, one shoidd hold each knee, and a fourth should attend to the duty of handing the required instruments to the operator, and washing the sponges as they become bloody. Tlie assistants, lifting the feet from the table and flexing the thighs so that the edges of the tibiae will be horizontal, should hold the knees clasped under the arms and steady the feet with the hands of the same side, while the unoccupied hands of the other side retract the labia and expose the ruptured part. These directions should be observed by the assistant holding the right knee; he who holds the left should do so with the right arm, clasping it with this and retracting the labium with the right hand, while with the left he sponges the wound with sponges held in long handles, which do not cause his hand to obstruct the operator's view. It will at first appear that it would be diflicult for one assistant to do all this. Let him who thinks so try it, and he will find that it is not so, and that such arrangement of his aids will be greatly to his advantage. This operation, like so many others in surgery, often fails, or at least drags heavily in its progress, from the want of a suflicient number of assistants, to each of whom is allotted an especial duty. All being now ready, the index and middle fingers of the two assistants who hold the knees are fixed upon the labia by the operator, and, the degree of traction which they are to practise being regulated, the opera- tion is begun. Seizing the tissue just above the anus with tooth forceps or a tenaculum, a strip of mucous membrane is removed from the posterior vaginal wall and from the original site of the perineal body upwards as far as it is proposed to extend to the rectal side of ^^' the triangular denunation to be created on each side. fd^\ Fig. 63 will show this very well. The furrow just al- . / W J luded to will extend from D to B. It should always // ^X be carried to the point where the noi'mal curve of the I ^\y posterior vaginal wall is altered in its course, by loss of \ perineal power, and begins to take an excessive and \ abnormal curve, the whole wall being now shaped like \ S. One great object of the operation is to change the V shape of this wall of the vagina from A B D to A B C. I \ Before this is done, pressure upon it will cause the rs. ^ \r lower portion of the S to sag forwards. After it ti b" done the whole wall under pressure from above down- Schematic view of wards will be supported by the sacrum and the tissues ^^^ ° ^ which lie upon it for its upper curve, and by the perineal body for its lower. The rectal side of the new perineal triangle then is created by denuda- tion of the posterior vaginal wall. If the base or rectal side of this trian- 13 194 RUPTURE OF THE PERINEUM. Fig. (;4. gle does not involve the posterior vaginal wall, what does it involve? This was the original site of the perineal body. Its anterior or vaginal side was originally vagina, and the posterior vaginal wall now prolapses and usurps the place of this body. Baker Brown's operation for recto- cele^ consisted of a colpo-perineor- rhaphy based upon this fact, and every one who has closed a peri- neum since his time, and not lim- ited himself to a mere episior- rhaphy, has performed the same. Mr. Brown was very soon followed by Savage, wlio gives the accompa- nying diagram. Savage says that his plan " in- cludes in the resection all the re- dundant vagina at its ano-vulvar margin, in the first place ; and in the second, the removal of a trian- gular portion of vaginal mucous membrane, the middle angle ex- pending to some distance upwards along the posterior wall of the vagina," etc. He then declares that it "causes the posterior segment of vagina to approach the pubis so as to oflfer an eifectual obstacle to the prolapse." This method of operating was the natural and inevitable outcome of an effort to replace the perineal body, and every operator making this attempt performed more or less perfectly colpo-perineorrhaphy. In reference to the origination of the present operation of perineorrhaphy, or at least as regards all its essential features, it may be stated tliat the credit of making it a colpo-perineorrhaphy and rendering it a remedy for rectocele belongs to Baker Brown. A reference to his work will put this beyond question, as he represents the operation in a diagram with this descriptive statement, " Operation for rectocele." His operation combined all that is essential in that which is now, with little modification, generally accepted. Since his publication of it, no one has materially altered it, except Marion Sims, who performed the important function of stripping the procedure of certain superfluities, like section of the sphincter and the use of quills, which were not merely useless, but absolutely hurtful. We have now formed what is to be the base and line of union of two triangles, which meet upon the furrow just created. Now catching up the Denudation for repair of perineum. (Savage.) • Surg. Dis. of Women, 3d Eng. ed., p. 94. OPERATION FOR PARTIAL RUPTURE, 195 tissue on the inner side of one labium majus, about midway between meatus and anus, another furrow is cut extending down to the anal origin of the first furrow, and another is then carried from the point selected on the labium backwards to the upper or vaginal extremity of the basic fur- FiG. 65. row. A triangular space, covered by mucous membrane, mapped out by three bleeding furrows, will be left, as shown in Fig. 65. C A, furrow extending from anus up the vagina (the rectal side) ; C B, furrow extend- ing from anus to point midway up labium majus (cutaneous side) ; B A, furrow extend- ing from point ijn labium to vaginal extremity of rectal furrow (vaginal side). Now the tis- sue in the unabraded triangle D is removed by tenaculum and scissors, as little tissue as pos- sible being cut away, and a bleeding triangle is left. The opposite side is similarly treated, and the result is two such triangles placed base to base upon the line C A. The dou- bling over of these upon each other, and the securing them in contact by suture, constitute the second part of the operation, as shown in Fig. GG. Fig. 6G. One of the bleeding triangles which are to be created. The two bleeding triauL'lo.s about to be united. If the student will cut two triangles shaped like Fig. Go out of thin board and unite them by linen pasted upon both sides, so that it will act as a hinge, he will be able immediately and perfectly to comprehend both the first and second steps of the operation. It is in that way that I have best succeeded in explaining them in didactic lectures. 196 RUPTURE OF THE PERINEUM. In performing the first part of the operation, I very commonly begin on one side and cut successive strips across until the wliole surface is pared ; but the method which I have mentioned simplifies the procedure, and after adopting it once for the complete understanding of the operation the ope- rator may aftervrards do otherwise. This part of the operation may be performed by the knife, but it is done more expeditiously and with less hemorrhage by the scissors, as Emmet has so justly pointed out. Prof. E. W. Jenks, of Chicago, has proposed another method of denudation which will be found described in an inter- esting article by him in the American Journal of Obstetrics and Diseases of Women and Children.^ This consists in the introduction beneath the mucous membrane of a pair of sharp-pointed scissors by which, without for a moment removing them, he by rapid snips separates the membrane from its attachment and removes it with great rapidity and little loss of blood. All the denudation done is effected in this manner. Dr. Albert Smith, of Philadelphia, has employed in these cases and recommends the use of a large dentist's burr^ with cutting flanges, which is made to revolve rapidly by a treadle which dentists now so commonly employ. By this the surface is rapidly, thoroughly, and bloodlessly de- nuded of its mucous covering. The whole surface having been pared, the operator stops and carefully examines to see if any arteries are spouting, and if any undenuded sur- faces still remain. If he find the former he twists them, and, if necessary, ties them with very delicate silk ligatures, which he cuts short ; if the latter he catches them with the tenaculum, and with the bistoury cuts them away. The first step of the operation is now finished. The operator should not hasten to the second, for the tissues should be exposed for a while that he may be assured against hemorrhage. Sutures should never be applied until all hemorrhage has been checked. 2d part of the Operation Now taking in the needle-holder a round, curved or straight needle, about two and five-eighths inches long, which will cause less hemorrhage than the needle with cutting edges, armed with a doubled silk thread, giving a loop about eight or ten inches long ; he in- serts it opposite the lowest external angle of the vivified triangle, which would be a little above the level of the anus, and makes it pass across the middle of the united bases of the triangles, over the rectum, and emerge at a corresponding point on the opposite side. This suture is nowhere visible within the vagina, for it lies embedded in the tissues lying over 1 Am. Journ. Obstet., vol. xii. No. 11, Ap. 1879. 2 This instrument was first used by myself in the operation for vesico-vaginal fistula, but shortly afterwards Dr. Smith, without a knowledge of the fact, em- ployed it in this procedure. OPERATION FOR PARTIAL RUPTURE. 197 Fig. 67. the rectum. It may be passed by one sweep, or, if this prove difficult, may be drawn out at the middle of its course, and reinserted. This suture is twisted at its extremities and left in position, and, another being taken, it is inserted above the first, and made to pass through the tissues at a higher point of the vivified surface. Guided by the finger in the rectum, it is kept embedded in the recto-vaginal septum, and emerges at a point on the other side corresponding to that of entrance. This, like its predecessor, I am in the habit of concealing in the tissues, so that after its passage it is nowhere visible within the vagina. I believe that an embedded suture excites much less irritation on the denuded surface, and acts less like a seton upon it than an exposed one. In this way sutures of silk are passed, and by them those of silver are immediately drawn into place, about one-third of an inch apart, and inserted at a quai-ter or half an inch from the edges of the wound. All these are concealed from view except the last one or two, which should pass under the upper angles of the triangles, and catcliing up the vaginal tissue at the highest point of the de- nudation should bring them all together. At each side of the pe- rineal triangle thus form- ed, two pockets may be created in vi^hich putrid materials may collect. To avoid this great care should be taken to conceal the su- tures especially at these points. Denudation should likewise be most carefully practised there. For the details, as to the method of drawing the wires into place and twisting them, the reader is referred to the article on Vesico-va- ginal Fistula. After the plan there described, he twists them one after the other from below u[)wards. If it appear neces- sary, superficial sutures are then passed between the deep ones to approxi- mate the cutaneous surface more completely. At the risk of being considered prolix, I offer still another diagram giving a profile view of the sutures in position, and pressing one triangle against its opposite. The sutures will be seen to run back and pass through Shows surface denuded and sulures in ]iositiou. 198 RUPTURE OF THE PERINEUM. the posterior vaginal wall, dragging this forward as a background or base to the two opposed triangles now to become an artificial perineal body. The sutures should not be cut short but left about two inches long, then twisted together and secured by a small piece of India-rubber tubing, after a plan suggested by Emmet and shown in Fig. 69. The patient is then put to bed ; the knees are bound together ; the dorsal or lateral decubitus preserved ; the urine drawn by catheter every six hours ; the vagina kept clean by syringing with tepid water ; and the diet made nutritious, though mild and unstimulating. On the eighth or ninth day, the sutures should all be removed, and on the next, the bowels should be acted on by a saline cathartic, great care being observed to prevent tenesmus. Fig. 68. Fig. 69. Profile view of recently closed perineum, sutures in place. Method of securing the ends of the sutures. (Emmet.) Operation for Co^nplete Rupture. — Complete perineal laceration always involves rupture to a greater or less extent of the anterior wall of the rectum. If rupture of the bowel extend for more than from one inch to an inch and a half above the upper edge of the sphincter ani, it is better to close it by a primary operation consisting of vivifying its edges and unit- ing them down to the anus. After union of these parts, closure of the perineum may be practised. If the bowel be not injured above an inch and a half from the sphincter, one operation will suffice to close the whole. I would not be understood as making this a dogmatic rule, but merely one which approximates the line of conduct which I deem best. The sole object of the operation for partial rupture is restoration of the perineal body. The objects of the operation for complete rupture are ; first, restoration of the sphincter ani muscle to all its power and functions ; second, closure of the rectal opening ; and tliird, restoration of the peri- neal body. What constitutes the main object in the first operation, is the OPERATION FOR COMPLETE RUPTURE. 199 least important of those striven after in the second. The operator must then appreciate that mere closure of the rent in the genital fissure is not what is desired. He may gain this, and not benefit his patient in the least, for incontinence of feces and gases may continue. Success involves always complete union of the ends of the severed muscle and complete closure of the rent in the bowel. To secure these the ends of the muscle, spread out and expanded, must be curled up and approximated, and the recto- vaginal septum must be drawn up and united to them. With these facts in view, clearly defined and appreciated, the difficulties of the operation greatly diminish. To no one are we so much indebted for tlieir demon- stration and illustration by practical results, as to Dr. Emmet, of this city, who, in 1873, wrote a valuable paper upon the subject, giving a clear exposition of the peculiar action of this accident upon the sphincter ani and of the best method of restoring it to its normal shape and functions. Let Fig. 70 represent the perfect sphincter. Fig. 71 will show it rup- tured and spread out, with the point of insertion and exit of the needles. Fig. 70 Fin. 72. Fig. 73. The dotted line shows the course of the metallic sutures embedded in the tissue. It will be seen that the remaining recto-vaginal wall is a fixed point, and that as the wire is twisted, the ends of the muscle are elevated, and the three points approach each other as shown at c. As the twisting goes on, these points come nearer and nearer together as seen in Fig. 72, until at last they unite as shown in Fig. 73. 200 RUPTURE OF THE PERINEUM, Fig. 74. Should the tirst needle be inserted and drawn out above the end of the broken muscle, as shown in B b, Fig. 71, the tissue at this point will be approximated, and the ends of the muscle brought close together, but absolute and complete union will not have been attained, and loss of func- tion will still exist. The first suture is the important one, and must catch the ends of the broken and expanded muscle so as to lift them upwards into contact with each other and with the l-ecto-vaginal septum. In vivifying the parts before insertion of the needles the two lateral triangles representing tlie perineal body split in two are denuded, and the line of denudation is prolonged backwards along the edge of the recto-vaginal septum. The border of the rectal mucous membrane at the extremities of the broken muscle as far as the upper end of the rent in the bowel is the e coccyx. Fig. 77 , shows a portion of this muscle. (Savage.) I ' Simpson, Clin. Lee. Dis. of Women. 2 Bui. G^n. de Therap. Med. et Chir., 1861. Fig. 77. CAUSES. 205 Certain morbid states produce so great a degree of irritability in the nerves supplying the vulva and lower part of the vagina, that upon con- tact with foreign bodies a spasm occurs in this and in neighboring mus- cles, which constitutes the disease that now engages us. The attention of some has been chiefly fixed upon the nervous condition, the pubic nerve being, according to them, the seat of the difficulty, while others have espe- cially regarded the resulting muscular spasm. It is curious to perceive liow, from different standpoints, both parties were led to the same surgical resource. Causes i-This affection bears to the vagina the same relation which blepharospasm does to the eyelids, or laryngismus to the larynx; and, like those affections, is not ordinarily a primary disorder, but one which results from some special local cause. It may arise from excessive nervous irri- tability affecting the whole system, as is often seen in hysterical women, or be produced by some local disorder of apparently insignificant character. Prof. Willard Parker^ reports a case which was due to an irritable carun- cle of the meatus not larger than a flaxseed, removal of which resulted in cure. In other words, it may be an idiopathic affection, or symptomatic only of some other disorder. The recognized causes of the disease are — The hysterical diathesis; Excoriations or fissures at the vulva; Irritable caruncle of the meatus; Chronic endometritis or vaginitis ; Pustular or vesicular eruptions on the vulva; Neuromata f Fissure of the anus;^ Hyperaesthesia of the remains of the hymen ; An abnormally rigid perineum ; Disproportionately large size of male organ. Professor Scanzoni in August, 1868, published his views upon this subject. During the preceding three years he had seen thirty-four marked cases, due chiefly, he thought, to violent efforts at sexual intercourse, practised upon women having small vaginas and well-developed hymens. Scanzoni found that twenty-five of his tliirty-four patients had various functional and organic difficulties, which in twenty cases had come on after marriage ; in eleven, there was congestive dysmenorrhoea ; in one, amenorrhoea had existed for three years; in thirteen, there wai chronic metritis ; four had either ante- or retroversion ; in one, there was perime- tritis; in seventeen, chronic uterine catarrh ; in fourteen, vaginal catarrh; ' Bui. N. Y. Acad. Med., vol. i. p. 439. 2 Simpson, Med. Times and Gaz., 1857, vol. i. p. 336. 3 H. Dewees. Baker Brown. 206 VAGINISMUS. in one, anteflexion; in two, retroflexion ; nine had urinal difficulties ; one had inflammation of the right Bartholin's gland; in fourteen, there were symptoms of anaemia; and in seventeen, of hysteria. Although the sexual act could not be fully completed, conception was not entirely impossible, as out of the thirty-four cases two had conceived ; in the other thirty-two, sterile marriages had existed from one to eleven years. This sterility was not due to want of sexual desii-e, but arose entirely from sjjasm involving all the muscles of the pelvis, which also rendered examination, either by the touch or speculum, impossible without the use of an anaesthetic.^ Some of the causes which I have enumerated produce vaginismus by direct irritation of the nerves of the vaginal mucous membrane ; others, by creating a discharge which indirectly establishes the same condition. Dr. William Neftel, of this city, has recently published some very inter- esting observations upon the influence of lead poisoning in creating this neurosis. He records four very striking cases, having this as a cause, and in one, the vaginismus was the symptom which incited an examination for poisoning by lead. These cases Avere successfully treated by electricity. Symptoms and Physical Signs. — The patient will generally complain of excessive pain upon sexual intercourse, the mere attempt at which will throw her into a state of nervous trepidation and apprehension. This and sterility will probably be all that will have attracted her attention, though in some cases a marked tendency to spasm will have been noticed upon sudden changes of position, or washing the genital fissure. One or more of these symptoms call for a physical exploration, when the following facts will be recognized. As soon as the finger is brought into contact with the site of the hymen, the patient will probably spring from her place, com- plain of agonizing pain, and evince great nervous disturbance. Should the examination be persisted in, introduction of the finger will be found to be almost impossible, and if it be forced into the canal, a violent muscular contraction wdll be perceived. If, instead of the finger, a camel's hair brush or a feather be employed, severe pain and contraction will follow even this application to the surface. Differentiation There is no other aflfection with which this can be confounded. All that it will be necessary to decide concerning it will be, whether it is an idiopathic or a symptomatic disorder. Course and Duration In its duration it is unlimited. Cases are re- corded in which it lasted for twenty-five and thirty years, and unless relieved by art, it will probably, in its worst forms, become a permanent condition. In its less severe type, and more particularly when dependent upon some other diseased state, it may often be relieved by mild means, or pass away without treatment. Prognosis " From personal experience," remarks Dr. Sims, " I can ' New York Med. Journal, vol. ix. p. 181. TREATMENT. 207 confidently assert that I know of no disease capable of producing so much unhappiness to both parties to the marriage contract, and I am happy to state that I know of no serious trouble that can be so easily, so safely, and so certainly cured." Tiie experience of Scanzoni, Tilt, and others, who have adopted an entirely different treatment from that pursued by the last-mentioned author, and who deprecate the use of the knife, leads them to the same favorable conclusion. In my own experience I have met with no case in which I have not been able to give relief, either by operative interference, or by the complete removal of the disease of which this condition was a symp- tom. Treatment Careful search should be made, before the adoption of treatment, for the cause of the affection. Should this be discovered, hope may be entertained that its removal will effect a cure. Should no cause be discovered, or its treatment not be followed by recovery, the general state of the patient should be altered and imi)roved by exercise, change of air and scene, vegetable and mineral tonics, sea bathing, and cheerful society. Riding on horseback has been especially advised, but rowing, bowling, walking, or any other exercise which develops the system and improves the tone of the nervous organism, will probably answer as well. Local treatment calculated to soothe the excited vaginal nerves should then be resorted to. The free use of vaginal injections containing lauda- num, creasote, or acetate of lead is sometimes productive of good. Dr. Peaslee thought highly of an ointment composed of two grains of atropine to an ounce of lard. This alkaloid, or the extracts of opium, belladonna, hyoscyamus, or stramonium, may be incorporated in an ointment or in Fig. 78. Sims's vaginal dilator. suppositories, and applied freely to the sensitive part. In some cases sup- positories containing from five to ten grains of iodoform prove very bene- ficial. At the same time the glass tube represented in Fig. 78 should be gently inserted into the vagina, and kept there for as many hourS' a day as practicable. Its presence will tend to benumb the nervous sensibility, distend the vagina, and produce a tolerance of foreign bodies. During this treatment the patient should live apart from her husband. This plan of treatment, simple as it is, combined with copious vaginal injections 208 VAGINISMUS. used night and morning for the complete removal of irritating discharges, as well as for their own direct sedative effects, will often prove etlectual and avoid the necessity for a snrgical procedure of some gravit3^ That the operation proposed by Dr. Sims for the cure of this condition is effectual, there can be no doubt. I have myself resorted to it in a large number of very aggravated cases, and in all with perfect success. But there has been for some time in the minds of many gynecologists a grow- ing distrust of tlie necessity of a resort to a procedure, which is reported in one case to have resulted in fatal hemorrhage. In many cases, even of grave character, it has been proved that by distention of the vagina, either with the fingers or by expanding instruments, and subsequent maintenance in the canal of a vaginal plug, cure can be accomplished as perfectly and even as rapidly as by the cutting method. Two eminent authorities, Scanzoni and Tilt, have especially advocated this plan and opposed the operation of Sims. Their views, as reported in medical journals, I here place before the reader. "Of more than 100 cases that have fallen under Scanzoni's observation, in times past, he has been completely successful in the treatment of all to which he was able to give his personal attention, without in a single case having recourse to the knife. The first condition of success is complete sexual abstinence ; for the first three or four days, a tepid sitz-bath should be used night and morning ; warm local bathing, with aq. Goulardi, or the same applied with lint, several times a day. Defecation must be regulated, and friction from motion carefully avoided. After a few days, the sensi- bility of the parts will be so much allayed that a solution of arg. nit. x-xx grs. to .f j of water, may be applied with a brush. After about eight days' continuance of this treatment, vaginal suppositories of ext. belladonna and cacao-butter may be placed behind the hymen, and in contact with it, daily. These remedies, either alternately or simultaneously, must be continued until every trace of inflammatian has disappeared, and the normal sens-i- bility is restored. Generally two or three weeks will be required to attain these objects. Then dilatation must be commenced ; but for this purpose sponge-tents are useless. A graduated series of glass conical specula are best adapted to this object. After the first slightly painful attempt, the patient generally will be able to introduce it with facility, and it may be allowed to remain from one-half to one hour. Even when the hymen re- mains, it will not be necessary to incise it, as dilatation can be effected without recourse to that measure. At first, the dilator may be used every two or three days, then every day or twice a day for two or three hours, gradually increasing the size of the dilator until the object shall have been attained, which in some instances may require an instrument admitting dilatation, as that of Segalas. Sitz-baths, belladonna, and pencilling with nitrate of silver may be required from time to time, and the cure will usually be completed in from six to eight weeks. It will be seen that, al- though the treatment of Sims is attended with an equally satisfactory result, it is of a much more serious character than the treatment adopted by Scan- 1 SIMS'S OPERATION. 209 zoni ; and, after the operation, the success of the treatment depends gene- rally upon the subsequent dilatation. The time required, moreover, is nearly the same by either process.'" Dr. Tilt takes the same position in deprecating resort to the knife and giving preference to forcible distention. He anaesthetizes his patient, and introducing both thumbs, back to back, forcibly distends the ostium vaginae for five or six minutes. He then keeps a large vaginal plug in situ by a T bandage for a number of days. This author lays especial stress upon the necessity, already alluded to, of first removing any exist- ing uterine or vaginal disease, in the hope of simultaneously curing the secondary trouble, before having recourse even to the process of distention. Should these means fail, the operation of removal of the hymen and section of the perineal body may be practised. It will be observed that I do not say of the sphincter vaginae muscle. This is certainly not severed to any extent ; and it is highly probable, if we accept Dr. Savage's anatomy of it, that its fibres are nowhere involved in the section. My impression is, that Sims's operation accomplishes two things : first, ablation of the hymen often removes nerves which are in a condition of hypertesthesia ; second, section through the perineum enlarges the ostium vaginoe, and thus removes an obstacle to intercourse. If I be correct in this, we have here an instance of the injury done by theorizing with reference to a subject which should be put beyond doubt by anatomical demonstration on the cadaver. No one would have done mischief, if told to enlarge the ostium vaginae by section ; many have caused serious hemorrhage by endeavoring to sever the bulbo-cavernosus muscle, which good authorities declare to be no sphincter at all. Sims's Operation The patient having been anaesthetized, and placed on the back, upon a table, the remains of the hymen are entirely excised by a pair of curved scissors. The slight hemorrhage resulting from this will soon cease under the application of a compress wet with ice-water, or of a solution of the persulphate of iron. The index and middle fingers of the left hand are then passed into the vagina, so as to put the fourchette on the stretch. By means of a scalpel a deep incision is then made on the right of the mesial line, terminating at the raphe of the perineum. A similar incision is then made on the other side, the two being united at the raphe, and extended to the perineal integument and through its upper border. Each of these incisions will extend from about half an inch above the upper border of the sphincter (meaning evidently the bulbo-cavernosus), to the perineal raphe, thus passing across the muscle, and measuring nearly two inches. After this, the vaginal dilator is placed in the canal, and worn for two hours in. the morning, and three or four in the evening, according to the • N. Y. Med. Journal, loc. cit. 14 210 VAGINISMUS. tolerance for it which is manifested. Fig. 78 represents the glass vaginal dilator, which is three inches long, slightly conical, open at one end and closed at the other, and varying in size from an inch to an inch and a half in diameter. This instrument iskept in place by a T bandage, and should be worn for two or three weeks. Burns's operation, more recently endorsed and practised by Sir James Simpson, rests, it appears to me, upon too weak a basis to warrant its use. It consists- in section of the pudic nerve, which Sir James says " may be exposed by cutting through the skin and fascia, at the side of the labium and perineum ; beginning on a line with the front of the vaginal orifice, and carrying the incision back for two inches. The nerve, being blended with cellular substance, is not easily seen in such an opera- tion ; but it may be divided by turning the blade of the knife and cutting through the vagina to its inner coat, but not injuring tliat. It may be more easily divided by cutting from the vagina. Slitting merely the ori- fice of the vagina will not do ; we must carry the incision fully half an inch up from the orifice, and also divide the raucous membrane freely in a lateral direction." Now let the reader examine Savage's plate, show- ing the pudic nerve, and he will see, that to sever it " by cutting from the vagina," the incision would have to be carried as far as the ramus of the ischium on each side, where it lies in direct contact with the pudic artery. No one can examine a diagram showing the course of this nerve with- out strongly suspecting, that its section is an operation which has existed in the mind of the operator, and never really been performed upon the living being. Upon what then did this procedure rest for its good effects ? Upon the same basis as that for the supposed section of the sphincter ; severance of the tissues at the ostium vaginae and consequent enlai'gement of the en- trance to the vagina. The practice which I should recommend in vaginismus, with the light which we at present have for our guidance, is the following : — 1st. Remove existing uterine, ovarian, vaginal, urethral, or rectal dis- ease, if any can be discovered ; insist upon the patient's living absque marito; let her use copious vaginal injections of warm water twice daily ; use the local anodynes mentioned by rectal or vaginal suppository, or throw into the vagina, every night, by means of a syringe, a pint of fluid, in which are dissolved twenty grains of chloral ; have a plug inserted into the vagina by the patient and retained for several hours every day ; give such tonics as quinine, strychnine, and iron freely ; and, if it can be ac- complished, let the patient have a change of air and scene, and indulge in sea bathing. 2d. Should this plan fail, anaesthetize the patient, and by means of the blades of a trivalve or quadrivalve speculum, distend the ostium vaginas VAGINITIS. 211 thoroughly ; follow this by the use of the vaginal plug, and resort to the means above given for locally soothing and generally sustaining. 3d. Should this method likewise fail, anaesthetize the patient; remove the hymen by scissors, a simple procedure ; incise the perineal body ex- actly as it is torn in parturition, introduce the plug, and keep it in situ for a week, removing it and cleansing it daily. After this, let the patient use it herself, and follow out the directions given under my first caption. The act of parturition would be very likely to remove this condition entirely, but unfortunately one of the most constant of the results of vaginismus is sterility. This arises from the fact that sexual intercourse is so painful that it is imperfectly performed, or, as is more commonly the case, all efforts at overcoming the obstacle to it cease, and the woman lives a single life. Should this state of things be found to exist, the patient may be thoroughly anesthetized, in the hope that complete connection, accomplished under these circumstances, may result in pregnancy. CHAPTER XIII. VAGINITIS. Definition and Synonyms. — The mucous membrane lining the vagina is subject to inflammatory action, which receives the name of vaginitis. It is tlie same disease which by certain authors has been described under the titles of blennorrhcea and blennorrhagia. Anatomy of the Vagina. — The vagina is a canal formed of strong, muscular elements and lined by mucous membrane. At its upper ex- tremity it is attached to the cervix uteri, with which it unites at a vari- able point, but usually midway between the os internum and os externum. This canal consists of three coats: 1st, an outer coat, formed of fibrous and elastic tissue ; 2d, a middle coat, formed of unstriped muscular fibre and fibre-cell, which are subject like the same structures in the uterus to great hypertrophy during utero-gestation ; and, 3d, an inner coat or lining mucous membrane, composed of connective tissue and elastic fibre, and covered over with squamous epithelium. The 3d extends to the four- chette ; the 1st and 2d spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. Its general form has been aptly likened, by Dr. Savage,' to that which would be assumed by u flexible tube if shortened to nearly half its ' Op. uit. 212 VAGINITIS, Filiform papillas of the vagina. (Kiliau.) Fig. 7!). length by a cord passed from end to end through one of its sides. Trie ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum. It is about two inches long, while the poste- rior wall, the posterior column, as it is called, is twice that length. The anterior column, or cord, which shortens the vagina, puckers its investing mucous membrane and throws it into folds or rugaj, which run transversely towards the posterior column. This mu- cous membrane is studded with papilla, which are covered by pave- ment epithelium. The papilliE of the vagina, which were first fully de- scribed by Dr. Franz Kiliau, were regarded by him as having for their function the transmission of sensation. He represents them as being thread-like and filiform, as shown in Fig. 79. Much discussion has occurred among anatomists as to the presence of muciparous glands between the folds of the vaginal mucous membrane, some asserting and others as positively denying their existence. The re- searches of Huschke, Jarjavay, Jamain, Farre, and other eminent inves- tigators, enable us to accept their existence as an undoubted fact, though it is curious that Charles Robiu^ and Sappey^ have been unable to discover them. The vagina may then be said to be lined by a mucous membrane which is covered by epithelium, and thrown into folds which are studded by projecting, filiform papillai, between which lie numerous muciparous follicles. Varieties of Vaginitis Vaginitis assumes three forms, which differ from each other sutticiently to require separate investigation. They are denominated as follows : — Simple vaginitis ; Specific vaginitis ; Granular vaginitis. Prof. Hildebrandt, of Germany, has recently described another variety which he styles " adhesive" for the reason that its chief characteristic is to produce adhesions between the vagina and uterus. It occupies the upper third of the vagina : the mucous membrane bleeds readily; and the discharge is thick, creamy, and sanguinolent. Simple Vaginitis. Definition — This variety of vaginitis consists in inflammation of the mucous membrane of the vaginal canal from some cause other than gonor- rhocal contagion. Njsteu's Dictionary. 2 Descriptive Anatomy. SliMPLE VAGINITIS. 213 Varieties It may exist in acute or chronic form, either of which types may appear originally or be the result one of the other. The acute form may be excited by some special cause and rapidly pass into the chronic ; or, originating as a low grade of inflammation, the disease may at any time take on the characters of virulence and acuity. Two sub- divisions of simple vaginitis, the recognition of which at the bedside constitutes an important point, are, primary and secondary. Sometimes the disease exists as a primary lesion, but very commonly it depends upon the excoriating properties of a fluid discharged by the mucous membrane of the uterus. Under these circumstances no treatment addressed to the vaginal surface will effect a cure, for even if the disorder existing there be removed, it must inevitably return so long as the cause which origi- nally produced it remains. Caicses In the great majority of instances this aflfection, more par- ticularly in its chronic form, depends upon a discharge from the uterus, to which it is secondary. It may, however, arise from any of the following exciting influences: — Exposure to cold and moisture ; Injury from pessaries or coition ; Disordered blood states, as those of phthisis and the exanthemata ; Retained and putrefying secretions ; Chemical agents ; Parturition. After matrimony the acute form is not unfrequently excited, and in prostitutes, whose occupation involves an abuse of sexual intercourse, it is quite common. A bit of sponge, or other substance which retains the natural secretions, left in the vagina until putrefaction occurs, will often induce the affection, and three of the most virulent cases that I have ever seen were caused by contact of a solution of chromic acid with the vaginal walls in making an application to the uterus. Pathology — At the commencement of the disease, the mucous mem- brane of the vagina becomes highly vascular and its arterioles are dis- tended. There is a rapid moulting of epithelium, so that abrasions often exist, and at times follicular ulcerations and diphtheritic deposits make their appearance. Sometimes, though rarely, the epithelium lining of the vagina is flirown off entire, constituting a cast or mould of the canal very similar in character to the dysmenorrhcEal membrane which is occasion- ally expelled from the uterus. In very severe cases the inflammatory action passes down intb the sub- mucous tissues, and a true phlegmonous process is established which may result in abscess. For a period varying from fifteen to thirty hours after the inception of the disease, the natural secretion of the part is checked ; 214 VAGINITIS. then pus of acrid and offensive character pours forth freely, whicli, in a week or ten days, is replaced by muco-purulent material. This discliarge is found to consist of serum, large numbers of epithelial cells, pus, blood- globules, and an infusorial animalcule called the trichomonas vaginalis by M. Donne, who first described it. By some the last has been regarded as ciliated epithelium separated from the uterus, but it is probably an ani- malcule which exists in vaginal mucus of unhealthy character. M. Donr6 at first regarded it as characteristic of specific vaginitis, but subsequently renounced the view. Symptoms Acute vaginitis manifests itself by the following symp- toms : — A sense of heat and burning in the vagina; Aching and weight at the perineum ; Frequent desire for micturition; Profuse, purulent discharge of offensive character; Violent pelvic pain and throbbing; Excoriation of the parts around the vulva. In the chronic form the disease shows the same symptoms, though with much less severity. In very mild cases, only a slight itching or burning sensation is experienced, with discharge of the leucorrhoeal matter. Physical Signs. — When the inflammation is acute the labia are found swollen and tense, the mucous membrane of the vaginal canal red and covered with pus, and the animal heat very much increased. Introduction of the finger produces great pain, and of- ten cannot be tolerated. As the labia are separated a flow of fetid muco-pus is discharged. If the canal be explored by means of the speculum, its surface will be found congested, while at nu- merous points abrasions, and perhaps follicular ulcerations, will be noticed. The inflammatory appearances of the vagina will be seen to have extended to the cervix uteri, and very generally from the os will be found to hang a plug of mucus secreted by the irritated, or even inflamed, Nabothian follicles. Prognosis In its acute form it usually runs its course in about two weeks. In the chronic form it lasts for an indefinite time, often subsiding into ordinary vaginal leucorrhoea, or rather into a state of which this is the only prominent symptom. Fig. 80. Epithelium la all stages of development, in simple vaginitis. 220 diameters. (T. Smith.) SPECIFIC VAGINITIS, OR GONORRHCEA. 216 Differentiation Simple vaginitis may be confounded with — Gonorrhoea; Endometritis; Pelvic abscess ; Granular degeneration of cervix. From the first the differentiation is always difficult and frequently im- possible. The means by which it may sometimes be accomplished will be mentioned in the article relating to Specific Vaginitis. From the three remaining affections it is readily distinguishable by the speculum and vaginal touch. An error will be committed only when the practitioner is not mindful of the possibility of its occurrence, and draws his conclusions from insufficient data. I have seen two cases of profuse and obstinate vaginal discharge regarded as the result of vaginitis, which were in reality produced by pelvic abscesses that emptied their contents into the upper part of the canal. An element in such cases calculated to mislead a super- ficial examiner is the fact that vaginitis does really exist to a limited extent as a result of the purulent flow from the abscess. This remark likewise holds true in reference to endometritis and granular degeneration. Complications Vaginitis sometimes produces violent urethritis, and less frequently results in endometritis, Fallopian salpingitis, and pelvic peritonitis. Specific Vaginitis, or Gonorrhoea. Definition This variety of the affection consists in inflammation of the vulva, vagina, and urethra, arising from a specific contagion which is transmitted by a yellow, purulent discharge. Pathology The purulent material which is the contagious element, after remaining for some time in contact with the vaginal walls, excites in their investing mucous membrane an active hyperaemia which results in heat, swelling, pain, and an ichorous and abundant purulent secretion. This inflammation may be simulated by simple acute vaginitis, but its most characteristic features are usually excited by the contagious influence just alluded to. The disease may affect all the localities above mentioned at the same time, but very often it is limited to the upper part of the vagina, to the vulva, or to the urethra. In some cases it is for a length of time concealed in the vaginal cul-de-sac, no other part of the vagina being affected. This fact explains, says Alphonse Guerin,^ how women apparently healthy transmit gonorrhoea. Causes As there is but one cause for scarlet fever, for measles, and for variola, namely, absorption of a specific poison or contagious material, so is there, it appears to me, but one cause for gonorrhoea. It is true that simple acute vaginitis may simulate gonorrhoea so closely that the • Maladies des Organes Genitaux, p. 285. ' 216 VAGINITIS. most experienced observer will be foiled in diagnosis, but this fact does not prove the diseases to be identical. The poison of gonorrhoea produces inflammatory results as a certain consequence of contact; the causes of acute vaginitis produce them as an accident which probably in a different state of the patient's system would not have occurred.' Symptoms. — The symptoms of this variety of vaginitis differ very little, indeed in many cases not at all, from those of the simple acute form. They may be thus enumerated : — Heat and burning in the vagina; Aching and sense of weight at the perineum ; Frequent desire for micturition ; Scalding in the passage of urine ; Profuse purulent leucorrhoea of offensive character ; Violent pelvic pain and throbbing; Excoriation of the parts around the vulva. Physical Signs. — The vulva, vagina, and urethra will be found swollen, tense, red, and hot. In the beginning they are unnaturally dry, but very soon a profuse secretion bathes them with a creamy pus, sometimes streaked with blood. Should the affection have exerted its influence chiefly upon the vulva, pruritus, excoriation, and intense heat will be observed. Should the urethra be chiefly or solely diseased, instances of which are recorded by Ricord and Cullerier, the most violent scalding upon the passage of urine will especially annoy the patient. Differentiation — It will be seen, from what has been already stated, that the differentiation of this disease from simple acute vaginitis must be extremely difficult. In many cases it is impossible, for there are no signs which can be regarded as positively conclusive. The trichomonas vagi- nalis, once supposed by Donne to be pathognomonic of specific vaginitis, is now known to exist in the pus of that which is simple; and urethritis, formerly viewed as diagnostic by many, is sometimes a complication of the simple form and is sometimes absent in the specific. The following are the symptoms which should lead us strongly to sus- pect the specific nature of a case : — Great virulence and acuity in development ; Development in a woman previously free from vaginal discharges ; Marked urethral complication ; Copious purulent discharge ; Transmission to the male from coition. Although it is true that in many cases these symptoms will render us ' This view is denied by many of the best authorities, who re.cjard gonorrhoea as having nothing specific about its nature. At the same time that I have no wish to ignore the opinion with which mine conflicts, I have preferred to give my own impressions without discussing the matter. SPECIFIC VAGINITIS, OR GONORRHCEA. 217 certain in our conclusions, in many others they will exist in cases certainly of non-specific character. I have on two occasions seen them all attend cases of vaginitis, excited by accidental contact of chromic acid with the vaginal walls. Course, Duration, and Termination The duration of the disease will depend in great degree upon the character of the treatment adopted. Under a proper management even a severe case may often be cured in from two to three weeks, but if neglected, it may continue for months and per- haps years. The morbid action passing up into the uterus may exist as an endometritis long after the vaginal trouble has disappeared ; or it may pass into the bladder and excite cystitis ; or down their narrow ducts into the vulvo-vaginal glands. Dr. Noeggerath, in 1873, published a remarkable paper on " Latent Gonorrhoea in the Female Sex,"' in which he declares, that certain morbid phenomena in the female organs, which have hitherto been considered as separate, and treated independently, possess a common basis from which they collectively and separately take their origin — this being nothing more nor less than gonorrhoea. " I have," he says, " undertaken to show that the wife of every husband, who, at any time of his life before marriage, has contracted a gonorrlioea, with very few exceptions, is affected with latent gonorrhoea, which sooner or later brings its existence into view through some one of the forms of disease about to be described. I believe I do not go too far when I assert that of every 100 wives who marry husbands who have previously had gonorrhoea, scarcely 10 remain healthy ; the rest suffer from it or some other of the diseases which it is the task of this paper to describe. And, of the ten that are spared, we can positively ailirm that in some of them, through some accidental cause, the hidden mischief will sooner or later develop itself." The diseases to which this author refers as remote consequences of latent gonorrhoea are perimetric inflammations, both acute and chronic, ovaritis, and catarrh of the genital tract. These when once excited are, he de- clares, incurable, and render the life of the female one of misery and danger. These women rarely become pregnant, or, if they do so, either miscarry or bear only one child. To sustain this assertion he gives the statistics of 81 cases, of which 31 only became pregnant. Of the 31, only 23 went to full term ; 3 were prematurely delivered, and 5 aborted. Of the 23 who went to full term, 12 had one child each during married life ; 7 had two children each ; 3 had three ; 1 had four ; and among the 23 women there were five abortions. He asserts that although apparently cured, gonorrhoea may exist both in the male and female an entire lifetime in a latent form, which may at any moment burst forth into acute gonor- rhoeal inflammation, or excite serious uterine or periuterine inflammation. ' Die Latente Gonorrhoe im Weiblichen Geschlecht. Bonn. 218 VAGINITIS, Since the appearance of these views I have considered this subject very carefully. While I admit, that even years after a gonorrhoea has been considered cured some larking infectious element dammed up perhaps be- hind a stricture may transmit the disease, I have failed to get evidence of the truth of Dr. Noeggerath's assumptions as to the universality of such transmission of disease. Were they true indeed, it appears to me that a healthy woman would be a rare exception to a very general rule. Coynplications The complications of gonorrhoea in the female are numerous and important. The disorder sometimes becomes an exceed- ingly grave one, and, in some instances, destroys life. It may induce the following results : — Buboes ; Vulvar abscesses ; Cystitis ; Inflammation of vulvo-vaginal glands ; Endometritis ; Fallopian salpingitis ; Pelvic peritonitis. Mr. Salmon,^ who first drew attention to inflammation of the vulvo- vaginal glands as a result of the disease which we are considering, declares that it is quite common. The passage of the disordered action into the uterus, through the tubes, and into the peritoneum is the most dangerous of all its consequences, and produces great risk to life from the pelvic peritonitis which it excites. Granular Vaginitis. Definition and Synonyms. — This variety of vaginitis was first described by Ricord, under the name of Psorolytrie. In 1844, M. Deville,^ a pupil of Ricord, described it fully, and it was subsequently treated of by Blatin, Guerin, and others, under the names of papular, glandular, and granular vaginitis. Pathology By these writers it was regarded as an hypertrophy of the muciparous follicles, lying embedded between the rugae of the vagina. This hypertrophy, it was thought, was generally the result of pregnancy, though it was admitted that it might arise from simple or specific vaginitis. Many recent writers deny the existence of this variety of vaginitis, and view it only as an hypertrophy of vaginal papillte, the result of the forms of the affection already mentioned. Thus Dr. Bumstead,^ in speaking of granulations found in the vagina as a result of vaginitis, says, " They have been erroneously regarded by Dr. Deville as peculiar to the vaginitis of 1 Bumstead on Veneral Dis., p. 172. 2 Archiv. de Med., 4th series, t. v. » Op. cit. GRANULAR VAGINITIS. 219 pregnant women." Scanzoni^ and West'^ both deny its existence, and upon the same ground, viz., the fact that Mandl and Kolliker have dis- covered very few mucous follicles in the vaginal mucous membrane. When, however, in opposition to the negative fact that these excellent observers, supported by Robin and Sappey, have not discovered these glands, is arrayed the positive fact that Huschke, Jamain, Richet, Bec- querel, Guerin, and others have done so, the grounds for denial must be admitted to be insufficient. Even if such evidence of the propriety of admitting this variety of vaginitis did not exist, clinical research would corroborate the truthfulness of the deductions of M. Deville. The disease is characterized by hemispherical granulations, about as large as half a millet-seed, scattered thickly over the mucous membrane of the vagina and over the cervix uteri. This variety of the disease ap- pears to bear the same relation to simple vaginitis that follicular vulvitis does to the purulent form of that affection. I once saw a case of granular vaginitis, so striking in its features that the attending physician had ex- pressed to the patient's family his fears that malignant disease was devel- oping. He became at once convinced of his grave error, when shown a description of the disease which really existed, and with which he had never before met. Although I believe in the validity of this variety o^ vaginitis, I must declare that I have rarely met with it out of the condi- tion of pregnancy. Causes The glandular hypertrophy which gives to the disease its cha- racteristic features and name, generally results directly from pregnancy, though it may be produced by either simple or specific vaginitis. Some women suffer from it in successive pregnancies. Symptoms. — It demonstrates its presence by the symptoms already re- corded as characteristic of simple and specific vaginitis. With these, pruritus vulvae and a lichenous eruption about the pubesare apt to appear. As parturition comes on and puts an end to pregnancy, it usually disap- pears, very often without any treatment whatever. Treatment of Vaginitis. — The treatment of the various forms of this disease is so similar that it may be described under one head, modifications being suggested for those cases which have assumed a subacute or chronic aspect. If the case be one of acute character, the patient should be kept perfectly quiet in bed, and locomotion and sexual intercourse strictly in- terdicted. Pain should be relieved by opiate or other anodyne supposi- tories placed in the rectum, and febrile action prevented or combated by mild, unstimulating diet and refrigerants. Every fifth or sixth hour the patient, placing under the buttocks a bed-pan, upon which she lies, and between the thighs a vessel of warm water, should, by means of a syringe, ' Disbases of Females, Am. ed., p. 529. 2 Diseases of Women, Eng. ed., p. 640. 220 ATRESIA OF THE GENITAL TRACT. throw a steady stream against the cervix uteri for fifteen or twenty minutes, or even for a longer time. The methods most appropriate for syringing the vagina are fully described in chapter four. The bowels should be kept in a lax condition by saline cathartics^ and the ardor urinse relieved by the use of alkaline diuretics. Should inflammatory action run very high, and much pain be experienced, great benefit will be derived from the free administration of opium, which should be given until complete quiescence of the nervous system is accomplished. When the severity of the symptoms has been relieved by this combi- nation of general and local means, Sims's small speculum should be passed, the cervix and vaginal walls cleansed with absorbent cotton, the whole canal washed over with a solution of nitrate of silver, 9j to ^j of water, and a tampon of carbolized cotton soaked in glycerine applied, so as to prevent all contact of the opposing walls. This should be renewed once in every twenty-four hours. But lengthy renewal will not be found neces- sary, for cure will, as a rule, very soon occur. CHAPTER XIV. ATRESIA OF THE GENITAL TRACT AND RETENTION WITHIN IT OF MENSTRUAL BLOOD AND OTHER FLUIDS. Definition and Synonyms The term atresia, derived from o, privative, and rpoio, " I perforate," signifies an imperforate condition, and should in its strict import be limited to complete closure of an aperture or canal. Any obliteration or occlusion which is so extreme as to remove the case from the class of strictures, and yet is not complete, should be styled ste- nosis. The genital canal of the female may be imperforate at the vulva, in the vagina, or in the canal of the uterus itself. Any one of these atresise may act as a barrier to the escape of menstrual blood, and create a dangerous retention of that fluid with coincident over- distention of the vagina, uterus, and Fallopian tubes, which may become so excessive as to end in rupture, peritonitis, and death. As this is the chief relation in which they are to be considered, it seems best to study the varieties of atresia under one head. Congenital atresia never attracts notice until pube'*ty has arrived, and then an examination is instituted on account of non-appearance of the menstrual flow, the presence of an abdominal tumor caused by uterine or vaginal distention, or the suspicion of pregnancy, some of the prominent signs of which are present under these circumstances. Acquired atresia is suspected for the same reasons. ATRESIA OF THE UTERUS. 221 In general terms it may be stated that the higher up the atresia be, the greater the danger arising from its existence. Thus, an atresia of the hymen is the least dangerous of all ; one as high as the os internum uteri the most so. The reason for this is evident : the former has above it, for accommodation of retained fluid, the distensible vagina and cervical canal; the latter has only the uterus itself Then, too, distention of the vagina produces less marked influence upon the Fallopian tubes than that of the uterus. Distention of the latter does not, it is now thought, cause a re- flux through the tubes, but creates a species of vicarious menstruation from their walls. This gives rise to hsemato-salpinx, which so often ends in rupture of the tube that that accident should be feared as one of the most decided dangers connected with the condition. This tubal rupture may occur in two ways: first, sudden emptying of the uterine contents creates uterine contraction which at once extends to the muscular fibres of the tubes, and rupture is the result ; or, previous peritonitis having fixed the tubes, descent of the uterus drags upon them so powerfully as to cause their rupture, or laceration of the false membranes which hold them. It must not be forgotten, however, that, although it is an exception to the rule, vaginal atresia may cause distention of the uterus and tubes by gradually dilating the uterine tract, and before every operation this efiect should be considered. Atresia of the Uterus. Definition and Frequency. — This consists in closure of the canal of the cervix so that no fluid can escape. In its partial form, that of stenosis, it is by no means rare, but fortunately complete atresia is decidedly so. Varieties. — Uterine atresia may be either congenital or acquired. When it is congenital it may exist at the os internum, at the os externum, or involve the whole cervical canal. Sometimes the cervix is exceedingly small while the body is greatly distended by fluids. When the condition is acquired, it may also be limited to one or both ora or involve the whole extent of the canal. The causes which most commonly induce it are the following : — ■ The use of caustics ; Cervical endometritis ; Irritation from neoplasms in the canal ; Senile atrophy ; Sloughing after parturition ; Amputation of uterine neck ; The use of the steel curette. The first of these is a very common cause of severe stenosis, and sometimes produces even complete atresia. The second, involving the Nabothian follicles, sometimes ends in adhesive inflammation. The third 222 ATRESIA OF THE GENITAL TRACT. I have seen produce the condition in three cases. The fourth is so very common in old age that Hennig declares, that, out of one hundred women who had passed fifty years of age, about twenty-eight, over a quarter, suffered from it. The fifth and sixth are often met with as causes, and the seventh I once had occur in my own practice. Results. — It might at first thought be supposed that uterine atresia occur- ring after the menopause would be, as it usually is before puberty, a matter of no moment. As a rule this is so, but there are exceptions to both rules. In the old woman a watery secretion sometimes takes place, giving rise to hydroraetra; suppurative action may occur, creating pyometra; and de- composition of the imprisoned fluid gives rise very rarely to a develop- ment of air, physometra. Very rarely hydrometra is found before puberty and hsematometra in old women. The evils which result from uterine atresia are — Hsematometra ; Hsematosalpinx ; Hydrometra. And the consequences of these, if they be left uninterfered with, may be— Peritonitis ; Pelvic hematocele ; Rupture of the vagina, uterus, or tubes; Septicemia. Prognosis. — Whatever course be pursued, in a patient suflTering from uterine atresia with retention of menstrual blood, the prognosis is neces- sarily a grave one. Non-interference may, and probably sooner or later will, end in the development of one of the accidents just recorded. Sur- gical interference, on the other hand, is attended by the dangers of rupture of the tubes, laceration of the false membranous attachments, and the development of septicaemia from the admission of air to the distended uterine cavity. Dlaf/nosis and Differentiation. — It is sometimes exceedingly diflBcult to diflTerentiate retained menstrual blood in the uterine tract from fibrous tumors, malignant growths, ovarian cysts, hsematocele, and pregnancy. The rational signs which enable us to do so are these : in all but the last, menstruation is commonly increased, while here it is suppressed ; the tumor is surely uterine and not ovarian, retro-uterine, or ante-uterine ; it has come on slowly, and not suddenly as the tumor of hsematocele does, and at every monthly epoch an increase of inconvenience is noticeable from its presence. Physical signs yield more important results still. If an attempt be made cautiously to pass the uterine sound or probe, the cervical canal will be found to be closed. This constitutes the crucial test. The diagrams. Figs. 81 and 82, show the varieties of hsematometra occurring in cervical atresia. ATRESIA OF THE UTERUS. 223 Fig. 83 presents an instance of atresia in one of the uteri in a case of double uterus, the other being free to perform all its functions. Fig. 81. Fig. 82. Uterine atresia at os externum. Uterine atresia at os internum. In the last case menstruation would be regular, the uterus be susceptible of recognition by conjoined manipulation and the passage of the sound to Fig. 83. Atresia in one-half of a double uterus. the fundus, while one half of the abnormally developed organ would present the large tumor seen in the diagram. Diagnosis would be possible here only by very careful conjoined manipulation. 224 ATRESIA OF THE GENITAL TRACT. Atresia of the Vagina. Like the uterus the vagina is in foetal life created from the approxima- tion and amalgamation of the Miillerian ducts upon tlie median line. In the former a great variety of congenital malformations are the result of arrest of development of these parts. So is it also with the latter; the chief of its anomalies being double, unilateral, diminutive, and rudimen- tary vagina, or no vestige of it may exist. The condition which is now to engage our attention may be due to such congenital arrest of develop- ment or to accidental causes developing after adult life has been reached. History Hippocrates' refers to this condition as a result of labor ; Aristotle speaks of the accidental and congenital varieties ; Celsus devotes a chapter to it, and it claims attention, as we come down to subsequent times, from Aetius, Avicenna, Lanfranc, Wierus, Ruysch, Mauriceau, and Roonhuysen. Heister and Boyer advanced our knowledge of it, but it was left for the daring enterprise of Dupuytren, Amussat, and Debrou, to place its cure among the achievements of modern surgery. Fig. 84. Fig. 85. The vagina distended by blood from imper- forate liyiiien. Vagina and uterus both distended with blood in consequence of an impervious hyuieu. Varieties There may be no trace of the canal, the ducts of Miiller seemin"- to have failed entirely to develop ; there may be a distinct fibrous cord marking the site which it should have occupied, some slight develop- « Puesch, De I'Atresie des Voies Geu. de la Femme. ATRESIA OF THE VAGINA. 225 nient appearing to have occurred; development may exist for some dis- tance up the canal, failure having taken place above; oroneMiillerianduct has developed in part above and another below, giving two cul-de-sacs separated from each other by impervious tissue. The whole canal is not rarely well developed, while the hymen guards its outlet as an unyielding and completely closed obturator membrane. The last of these vaginal atresia, and, fortunately, the most frequently met with, is depicted in Figs. 84 and 85. Not only is the operation for relief in such a case much more simple than in other varieties of atresia, the uterus is usually not involved in the dilatation and the danger of trouble after operation is not so great. PatJiology. — As a result of injury from mechanical, chemical, or patho- logical agencies, a vagina once fully developed may close from adhesion of its walls ; its calibre may be diminished by absolute removal of its component structures in consequence of ulceration or sloughing; or the other parts of the female genital system may go on to full development while this is arrested in its growth and remains a fibrous cord instead of a distensible canal. Causes. — The following special causes may be enumerated as productive of it :— Impervious hymen ; Arrest of development of vagina ; Prolonged and difficult labor ; Chemical agents locally applied ; Mechanical agencies exciting inflammation ; Sloughing, the result of impaired vitality; Syphilitic or other extensive ulcerations. One of the cases which have come under ray observation resulted from syphilis; several from prolonged labor; one from the accidental passage of a sharp bit of wood up the vagina ; another from retention of the foetal body for two hours after delivery of the head ; and one from a tampon of cotton saturated with persulphate of iron. Among the causes of sloughing from impaired vital forceshould be especially mentioned the continued and eruptive fevers, typhus fever, scarlatina, variola, etc. ; and cholera as a cause of the accident is referred to by M. Courty. Dr. Trask, of Astoria, N. Y., has written an excellent article upon this subject, his conclusions being bused upon thirty -six cases, of which fifteen were due to prolonged labor. Symptoms. — The disorder will demonstrate its existence only by inca- pacitating the vaginal canal for its important functions, copulation and transmission of menstrual blood. Should it occur in one too young or too old to require such functions from the vagina, no suspicion will be aroused as to its existence. The notice of the practitioner will generally be called to the patient by ameuorrhoea or by an inability to perform the act of 15 226 ATRESIA OF THE GENITAL TRACT. coition. Should the menstrual hemorrhage have taken place, a large amount of blood will generally be found confined above the constricted part of the canal, and violent contractions will have demonstrated the efforts which the parts have made to expel the accumulation. Besides these, no other rational signs will show themselves, but they will be suffi- cient to urge upon the attendant the necessity for a physical exploration. Physical Signs. — The patient being placed upon the back, and vaginal touch attempted, entrance of the finger into and up the vagina will be found to be impossible. Investigation will prove that this is not due to vaginismus, or adhesion of the labia majora, and rectal touch will, in cases involving the vagina, usually discover that canal running up the pelvic cavity as a fibrous cord, though sometimes no trace of it will be found. Results. — From the mere occlusion of the vagina there is no imme- diate or direct derangement. But in cases where menstrual blood is poured out by the vessels of the uterine mucous membrane, and is accumu- lated at each monthly epoch in the portion of the canal above the stric- ture, or in the uterus, which is dilated by its retention, rupture of these organs or of the Fallopian tubes may occur ; discharge from these tubes into the peritoneum may take place, and pelvic hsematocele be the conse- quence ; or the retention of the menstrual flow may produce all those nei'vous and cerebral symptoms so characteristic of such an occurrence. Prognosis. — The prognosis of these cases, as regards the possibility of removal of the abnormal state, will depend upon the extent and complete- ness of the obliteration and destruction of tissue. The smaller the amount of vaginal tissue found by rectal touch and examination by a sound in the bladder to exist, and the more complete and extensive the adhesion of the vaginal walls, the more closely will the case resemble one of entire absence of the vagina. The prognosis as to permanent cure will greatly depend upon the patient. If she be a woman of good sense and perse- verance, and keep up, after operation, distention by the vaginal plug, not for months, but for years, the result is often a very good and permanent one. If, on the other hand, she ignores the risk attendant upon the cessa- tion of its use, contraction will probably recur. During the process of making a canal between the bladder and rectum, one of these viscera is very apt to be cut into, or the peritoneum may be opened at the fornix vaginse. If a depot of menstrual blood be reached and evacuated, death is by no means rai'e from septicsemia, purulent absorption, or a septic endometritis which ends in lymphangitis, or in salpingitis and peritonitis. The prognosis is greatly governed, too, by the variety of atresia with which we deal. Occlusion due to impervious hymen warrants a very favorable prognosis ; that arising from accidental causes, likewise; that from congenital cause in which the uterus and vagina can be distinctly discovered as existing, a less favorable one ; while that due to absence of vagina and uterus, as far as clinical observation can verify the fact, a ATRESIA OF THE VAGINA. 227 well-nigh hopeless one. In other words, the more complete the absence of vaginal tissue and that of other organs of the pelvis, the more unfavor- able will be the prognosis as to recovery from surgical interference. Should deformity of the external genitals exist, the uterus not be dis- coverable, and no signs of distress at menstrual epochs show themselves, it may be concluded that the case is one of absence of the vagina, and not of complete atresia. But, thanks to the boldness of Amussat, even absence of the vagina does not preclude the possibility of establishing an artificial canal. The importance of the diiferentiation consists in the fact that the surgeon should in such a case be doubly cautious and circum- spect in his efforts, and guarded in his prognosis. It may at first thought appear that in case there be no evidence of the existence of uterus or ovaries, and no inconvenience be experienced from retention of menstrual blood, it would not become necessary to resort to an operation to render the vagina pervious. But so great is the unhappiness often resulting from incapacity of the woman for the sexual act, that this becomes a reason for her to demand the resources of art, and a valid ground for interference on the part of the surgeon. If no such demand is made for surgical interference, it would, in such a case as that just depicted, be an unwarrantable procedure. ^ot only is the patient exposed to danger without sufficient indication ; she is thus exposed for the opening of a canal which has a marked tendency to close completely. The rule with reference to operation for atresia due to congenital closure or absence of the vaginal canal itself should, it seems to me, be this : it should be resorted to (a) if menstrual blood be imprisoned ; (b) if a uterus can be distinctly discovered and the patient be suffering from absence of menstruation ; (c) if the necessity for sexual intercourse be imperative : it should be avoided unless demanded by one of these con- siderations. Treatment To surgery alone can we look for any hope of recovery or of safety in cases of atresia of the female genital canal. I shall treat of this part of the subject, as it applies to all varieties of atresia — uterine, vaginal, and their subdivisions. It is evident that, to do justice to it, operative interference must be described as applying to the following cases : — 1st. Where there is atresia of the uterine neck. 2d. Where there is atresia of the hymen alone. 3d. Where the vaginal canal is closed only for a small portion of its course. 4th. Where there is complete closure or entire absence of the vagina. Where there is Atresia of the Uterine Neck The operator should decide, by careful conjoined manipulation, as to the degree of uterine distention which exists above the cervical closure. If this be slight, the obstruction may at once be overcome ; if it be very decided, it will be 228 ATRESIA OF THE GENITAL TRACT. safer to draw off the fluid gradually, in order to avoid violent uterine contractions, which may, as Barnes^ suggests, force fluid from the cavity of the uterus through the tubes, or aifect the tubes by sympathy, or by sudden dragging downwards. Let us suppose that the uterine tumor is quite large : the patient should be placed in Sims's position, and, his speculum being introduced, the cervix uteri should be caught with a tenaculum, and the point at which puncture is to be practised carefully selected. The smallest needle of Dieulafoy's aspirator should be, with the tube of the instrument attached to it, fixed upon this point, and then, the vagina being filled with carbolized spray, it should be passed into the uterus and the blood drawn off by suction. When the uterine tumor is diminished about one-third, the needle should be rapidly withdrawn and the vagina tamponed with carbolized cotton, saturated at the moment of use with carbolized water. This tampon may be left in place for forty-eight hours and tl.en re- moved, and in a week or two, as seems best to the operator, this process of gradual withdrawal of the retained menstrual blood may be repeated, until the uterus has become small and nearly empty. Then, or at once, in case the uterus be not originally much distended, the operation for cure of the atresia may be practised. The following method I have resorted to in two cases with excellent results, and it appears to me to recommend itself on account of its simplicity and safety. The patient being arranged as for aspiration which has just been described, under a very slight car- bolized spray which does not obscure vision, the cervix should be steadied by a tenaculum and along exploring needle passed into the uterine cavity. The sense of resistance overcome, and the escape of a drop of blood will assure the operator of his success in reaching it. Then putting into the gutter of the needle a delicate tenotome, he pushes it upwards to the re- quired distance to open the canal. This section is repeated on the other three sides, the cavity of the uterus is syringed out with carbolized water very gently forced from a small syringe ; a small glass plug is inserted in the cervix, and the vagina tamponed as after aspiration. Where Vaginal Atresia is due to closure by a Diaphragm or by the Hymen The same rule of practice should be observed, and the same antiseptic precautions adopted. If gradual evacuation be resorted to and septic fever begin to develop, recourse should at once be had to the rapid method. Gradual evacuation should be accomplished exactly as in uter- ine atresia, for it is always safe to conclude that with vaginal distention there is probably uterine. Section of the hymen may be practised in two ways : first, by passing the exploring needle, sliding a knife up its groove and making a free crucial incision ; second, by catching the bulging sep- tum, as Puesch has advised, and cutting out a large circular piece. • Dis. of Women, 2d Am. ed., p. 214. ATRESIA OF THE VAGINA. . 229 After the occluding septum has been destroyed, the cavity above should be freely syringed out with carbolized water, and Sims's glass vaginal plug introduced. Where there is entire Closure or Absence of the Vagina In the first case a hard, fibrous cord will mark the position of the vagina ; in the second no indication' of it will be found, and a canal must be created between rectum and bladder, out of a space occupied by areolar tissue. Sliould accumulation of menstrual blood have occurred, the operation will prove much easier than if it has not, for its greatest difficulty consists in findijig the cervix uteri, and in cases of accumulation this is an easy matter. The other operations for atresia become insignificant when compared with this one, which as Courty well observes especially calls for an " alli- ance of caution with skill." Before operation, if there be any doubt as to the presence of the uterus or as to its size or position, the hand, except the tliumb, may be introduced into the rectum, after stretching the sphincter, and a full and satisfactory exploration made. If on account of great obesity it be found impossible to api)reciate by conjoined manipulation the extent of tissue existing between the bladder and rectum, and consequently in the course in which the vagina is to be opened, or perhaps absolutely constructed, the urethra may be rapidly' distended by sounds so as to admit the finger to the bladder. Then the index and middle fingers of the right hand being carried up the rectum, and the index of the left introduced into the bladder, this important point may be ascertained. Before operating, the patient should be anaesthetized, and the bladder and rectum emptied of their contents. She should be placed in the li- thotomy position upon a table before a good light, and the operator should have four assistants at his disposal. The operation may be performed by two methods : that of Dupuytren (1818), which consists of breaking a passage by the finger, cutting ob- structions which cannot thus be overcome, and syringing out the cavity afterwards, the whole operation being finished at one sitting ; and that of Amussat (1832), which consists of working with the finger and dull in- struments, overcoming resistance by pressure rather than by incision, and completing the operation not in one but in several sittings. Bupuytren's Operation — Barnes^ expresses a decided preference for this over Amussat's operation, and my experience leads me to agree with him. Courty^ thus describes Dupuytren's procedure : '•The procedure devised by Dupuytren, about the year 1817, consists in the combined use of a cutting instrument and tearing of the cellular ' Diseases of Women, p. 212, 2d Am. ed. 2 Mai. de I'uterus, p. 381. 1866. 230 ATRESIA OF THE GENITAL TRACT. tissue. It is Accomplished in a single sitting, and appears to me preferable to the preceding one ( Amussat's). "The following is the description of it, with the modifications which M. Puesch has added : — " After having arranged the woman in a convenient position, the blad- der is emptied by means of a male catheter which is given to an assistant who holds it turned upwards. It is not removed during the operation ex- cept where the obliquity of the part would render it troublesome. The index finger of the left hand is then carried into the intestine as far as possible, in order to serve as a guide for the bistoury and at the same time as a protection to the rectum. After these preliminary steps the operator, placed between the thighs of the patient, makes a transverse incision at the certtre of the obstacle, or in the vulvar orifice if the vagina is com- pletely wanting ; if the cellular tissue is lax, he can tear with his finger, the sound, or the handle of the bistoury the vesical and rectal walls till he reaches the tumor; if it is tense or too resistant, the surgeon dissects by gentle efforts, separating the tissues with the handle or the finger rather than cutting them, and, if it be necessary, breaking them down at the edges with a button bistoury. In each case he proceeds slowly and care- fully, stopping from time to time to examine with the finger and be certain at what distance those oi'gans are situated which it is necessary to avoid. When the canal which has been reopened will admit the index finger easily, and when a more distinct perception of fluctuation announces the proximity of the sanguineous collection, the operator is warranted in plunging a trocar into this, tuid the pouring out of a syrupy, brown liquid, like the lees of wine, will show that the end has been reached. The pres- sure upon the uterus is then stopped, a large part of the fluid is allowed to flow away through the canula, and then, substituting for this instrument a perforated sound, the operator increases the size of the opening by nu- merous incisions upon its sides and thus renders certain the final result. Afterwards he carries a gum-elastic sound into the uterine cavity, and throws through this, but with very little force, several injections of warm water. The dressing having been finished, the parts are sponged and dried, and the patient is placed in a bed protected by cloths so as to pre- vent the bedding from being soiled by the mucous and sanguinolent dis- charges which flow during the first days." Atnussafs Operation. The labia being retracted by the fingers of two assistants, holding the thighs, the finger of a third,^ vvho kneels by the side of the operator, is introduced into the rectum, with its palmar surface looking backward. A steel sound is then passed into the bladder, which the assistant, on the left of the woman, holds in the right hand. At this moment, this assistant holds the woman's knee under his left arm, retracts • The arrangement of assistants is my own. ATRESIA OF THE VAGINA. 231 the labium by his left hand, and holds the sound in his right hand. The sound he must press upon gently, so as to let the operator's finger recog- nize its presence as it works its way up the vagina. By means of a pair of curved scissors, conducted up to the point of obliteration upon one finger, the tissue between the urethra and rectum should then be very cautiously cut, in a transverse direction, and the finger introduced into the opening made. This is really almost all the cutting which should be done ; the rest should be accomplished chiefly by the finger. This, by the sense of touch, tells the operator exactly how near he approaches the sound in the bladder on one side, and the finger in the rectum on the other. To one who has not tried this plan, the facility with which the adherent vaginal walls may be separated, or a new tract torn through the tissues, will be surprising. Now and then, the application of the scissors or of a curved, probe-pointed bistoury will become necessary, but every such necessity constitutes an element of danger. As the operator approaches the regions around the cervix, he may be- come bewildered as to its position. Under these circumstances, let him make pressure by his unoccupied hand, over the hypogastr ium, so as to force the hard cervix down upon his finger, or stop and make a careful exploration by conjoined manipulation, two fingers in the rectum and one hand over the abdomen. Having thus reassured himself he may pro- ceed. However the operation for atresia be performed, there is always great danger of relapse, and unless special means be adopted for maintaining the perviousness of the canal, it will probably occur. To prevent this unfortunate result the French operators,^ to whom we are indebted for most of our surgical resources in this difficulty, used bougies wrapped with linen, tampons of lint, and India-rubber bags filled with air; but we have a much cleaner and more effectual means for doing it, in the glass vaginal plug of Sims. If menstrual blood have been imprisoned above the strictured portion of the vagina, the canal should, for a fortnight after operation, be kept scrupulously clean by injections of tepid water practised twice a day. If the uterus and tubes have been distended by retained fluid, the cavity of the former should, just after the operation, be carefully washed out with tepid water very slightly impregnated with carbolic acid, tincture of iodine, or Labarraque's solution of soda, as advised by Courty. The pa- tient should then be kept as quiet as possible in the recumbent posture, and slightly under the influence of opium. The period at which operation should be resorted- to for congenital atresia is a subject of importance. Velpeau advocates operating in in- fancy, but Peusch, Boyer, and others regard the age of puberty and ap- ' Courty, op. cit., p. 386. 232 ATRESIA OF THE GENITAL TRACT, proach of menstruation as a more appropriate time. Should the meno- pause have arrived, no operation will be called for, unless hydrometra exist or marital relations demand it. It should not be forgotten that delay in interference is often very dis- astrous during the period of menstrual activity, for lives have, in numer- ous instances, been destroyed by rupture of the Fallopian tubes, and even of the uterus itself, as seen by Peusch. This observer drew his conclusions from 258 cases of atresia, in 18 of which rupture of the Fallopian tubes from distention by menstrual blood occurred. In one instance of atresia, I saw an htematocele the size of an infant's head result from discharge of blood from the tubes into the peritoneal cavity. It is possible that the mental emotion of the patient, and her struggles during the operation, may account for the escape of blood into the peritoneum as noted by Bernutz. Hence, every effort should be made to avoid these, by complete anaesthesia, and care should be taken not to allow of pressure upon the uterus either intentional or accidental. In cases in which vaginal and uterine atresia have existed together, and the uterus only is distended by blood, there can be no good reason urged for completing the removal of both atresias at one sitting. It is far safer to secure complete liberation of the uterine neck, and perviousness of the vaginal canal, unless delay be absolutely dangerous, and then, after the dangers arising from this procedure have passed away, to perform tlie other operation. Certainly, combining the two would not diminish the danger of either, while delay would not ordinarily increase the risk in any way, since the closure of the cervix is so complete as entirely to exclude the admission of air. Lefort has advised and practised the creation of a new vagina by elec- trolysis. The following is the description given of the procedure by Le Blond in his admirable treatise upon Gynecological Surgery.^ The operation rests upon the fact that a mild continuous current of electricity passing through tissues by means of a metallic pole destroys them. " M. Lefort employs for the purpose a cylinder of boxwood, the extremity of which ends in a copper bulb connected with the negative pole of a pile of Morin elements in sulphate of copper. The circuit of the pile is estab- lished by applying a metallic plate communicating with the positive pole on the stomach with the interposition of compresses soaked in a solution of sodium chloride. The apparatus is put in position only at night. At the end of a short time the existence of a canal of seven or eight centi- metres in depth is found to exist, then when the uterine neck is reached the menstrual flow occurs freely." I have no experience in this method, but Le Blond speaks with confidence concerning it, and gives it preierence over the surgical procedures which have been detailed. ' Traite Eleinentaire de Chirurg. Gynecol. Paris, 1878. URINARY FISTULiB. 233 CHAPTER XV. FISTULA OF THE FEMALE GENITAL ORGANS. Definition As a result of ce^tain traumatic and morbid processes, the continuity of the vaginal and uterine walls may be destroyed and commu- nication established with adjacent viscera. To the tracts or passages thus opened, the name of fistulte has been given. Varieties. — These communications connect the vagina or uterus with some viscus in immediate proximity, for the natural outlet of which they act vicariously, or with some neighboring part, as the peritoneum, the vulva, or the pelvic areolar tissue. Their varieties have received the following descriptive appellations : — Urinary Fistulce. Vesico-vaginal fistula; Urethro- vaginal fistula; Vesico-utero-vaginal fistula ; Vesico-uterine fistula ; Uretero-uterine fistula ; Uretero-vaginal fistula. Fecal Fistulce. Kecto-vaginal fistula; Entero-vaginal fistula ; Recto-labial fistula. Simple Vaginal Fistulce. Peritoneo- vaginal fistula; Perineo-vaginal fistula; Blind vaginal fistula. Urinary Fistulas. Urinary fistulce may occur on any part of the anterior surface of the genital canal intervening between the vulva and fundus uteri. Fig. 86 displays the points at which they are usually observed. Vesica- Vaginal Fistula (2) is a communication between the bladder and vagina, either at the trigone or the bas-fond, Avhich may involve only enough tissue to admit a small probe, or entirely destroy the vesico-vaginal wall. Such an opening may be oval, angular, elliptical, or linear in shape, 234 FISTULA OF THE FEMALE GENITAL ORGANS, and its borders may be thick or thin, soft or indurated, rough or smooth, pale or vascular. Urethro- Vaginal Fistula (1) resembles that just mentioned, except in the fact that the destruction of tissue which has produced it involves the wall of the urethra, and not that of the bladder. Fig. 86. Varieties of urinary fistulje : 1. Urethro-vaginal fistula; 2. Vesico- Vaginal fistula ; 3. Vesico- utero-vaginal fistula ; 4. Vesico-uteriue fistula. Vesico- Uterine Fistnlce (4) are those in which there is a direct commu- nication between the bladder and uterus above the point of vaginal attach- ment. The vagina is consequently not involved, and the urine passing into the uterus escapes at tlie os. Vesico-Utero- Vaginal Fistnlce (3) are those in the production of which a lesion occurs in both uterus and vagina, as is imperfectly shown by (3). At the vaginal junction there is a perforation of the bladder, but this does not penetrate to the cavity of the uterus. A canal is created in its wall, and through this tlie urine escapes into the vagina. The last two forms of fistulae were first accurately described by Jobert, who made of the last, two varieties, superficial and deep. In the first a canal is channelled out on the vesical surface of the cervix uteri ; in the second, the cervix is to a greater or less extent destroyed by the process of sloughing, and through it the urine passes. In the first form the lesion is chiefiy vesical and ute- rine, the vagina not being much injured; in the other it affects three URINARY FISTULA CAUSES. 235 organs, the bladder, the uterus, and the vagina. All these forms of fistulas may thus be grouped into classes : — 1st Class. Those involving the urethra. 2d Class. Those involving the base of the bladder. 3d Class. Those involving the uterus. 4th Class. Those involving the ureters. In some cases, however, multiple fistuljB exist, and no special classifi- cation can be made. Causes. — Any influence which is capable of destroying the continuity of the vaginal walls, either by mechanical, chemical, or vital action, would of course give rise to this condition. Those which are found in actual practice to have proved most commonly efficient, are the following : — 1st. Prolonged or very severe pressure ; 2d. Direct injury ; 3d. Ulceration or abscess. Pressure, which is more frequently a cause than any of the others mentioned, is generally produced by the child's head remaining too long in the pelvis during labor. This is beyond all doubt the most prolific source of the accident, though it may also attend a rapid labor in which the vagina has been pressed against some point of the pelvis with great violence. Such pressure produces sloughing of the part of the vagina receiving it, and at that spot a deficiency of tissue in future exists, which constitutes a fistula. The process of slougiiing occurs from pressure of the foetal head, exactly as a bedsore takes place in one who lies for too long a time in the same position, the sequence being, disturbed and re- tarded circulation, impaired nutrition, and local death. Or a puerperal vaginitis may be established, which runs a violent course, and may end in sloughing after several weeks' duration. An involuntary flow of urine usually announces the existence of a fistula within three or four days after delivery, though, when it is the result of injury inflicted by instruments employed in delivery, it may occur immediately. On the other hand, the separation of the slough, which will entail deficiency of tissue and its results, may not take place until much later, when perhaps all fears are allayed, and the case is regarded as progressing favorably. Jean Louis Petit records one case developing its symptoms after a month ; Jobert one in which on the twenty-second day after delivery the slough was found at the mouth of the vagina ; Adler, of Iowa, one in which after twenty-nine days the slough was only partially separated ; and Agnew, of Philadelphia, another, in which it separated on the twenty-first day. Other agencies which may create fistulae, but which have been rarely noticed to do so, are pessaries, stones in the bladder, fecal accumulation, etc. 236 FISTUL.E OF THE FEMALE GENITAL ORGANS. Direct injury may produce the accident by contusing or laceratino- the vaginal walls, as may occur during delivery by the forceps or craniotomy. That these operations when carelessly or unskilfully performed may pro- duce a fistula, no one will pretend to deny, but there can, with the evi- dence now recorded, be no doubt that they have often been credited with unfortunate results which were in reality due to tardiness in their employ- ment. Very often, where a labor has been allowed to be prolonged in the second stage until the vitality of certain points in the vagina has become irremediably impaired, and the process of sloughing has been already in- augurated, subsequent delivery by forceps or craniotomy has been regarded as producing fistula. Under such circumstances the real morbid agency, prolonged and violent pressure, is lost sight of, and the more palpable agents, the instruments employed, are viewed as the source of the acci- dent. The truth with reference to this point should be well understood by every practitioner, for unless it be so, an incompetent person may shield himself from merited blame by casting censure upon a consulting physician by whose efforts the lives of both mother and child have been saved, or a skilful operator may suffer unjustly in a suit for malpractice. In a report upon tliis subject by Mr. I. Baker Brown^ to the Obstetrical Society of London, in 18G3, the following statements are made: "With regard to the causes of vesico-vaginal fistula, of the 58 cases admitted into the London Surgical Home, 47 were over 24 hours in labor, and 39 were as much as 36 hours or more ; 7 were two days ; IG were three days ; 3 were four days ; 2 were five days ; 2 six days ; and 1 seven days. " In the whole number of cases instruments were used in 29, exactly one-half, and in 4 only of these was the labor less than twenty-four hours, and with seven exceptions the patient had been thirty-six hours or more in labor before instruments were used. " Of the 58 cases, in 24 only the injury happened at the first labor ; in 7 at the second ; in 5 at the third ; in 4 at the fourth ; in 6 at the fifth ; in 2 at the sixth ; in 5 at the eighth ; in 1 at the ninth ; 1 at the thir- teenth ; 1 at the fifteenth ; and 2 not mentioned." " From the foregoinsr statistics it is evident that the cause of the lesion is protracted labor, and not the use of the instruments or deformity of the pelvis." "As a necessary deduction from what has been stated, it follows that vesico-vaginal fistula would scarcely if ever occur, if a labor were not allowed to become protracted ; and this is a point for the careful consider- ation of practitioners in midwifery." The experience of Dr. Sims'^ is confirmatory of that of Mr. Brown. Emmet, whose authority in this ' Obstet. Trans., voL v. p. 23. 2 Gardner's Notes to Scauzoni, p. 503. URINARY FISTULA SYMPTOMS. 2o7 matter is very high, gives the causes of 179 cases/ and 171 of the number originated in childbirth. It may be said in a general way then that the cause of urinary fistulge in the female is parturition, a few exceptions to the rule occurring; that protracted labor is very generally productive of them ; and that the prompt use of instruments is, as a rule, preventive of them. It is a curious fact that, when for the relief of chronic cystitis a vesico- vaginal fistula is intentionally created by the knife, it is difficult to keep it open. In spite of the occasional introduction of the sound for this purpose, such openings obstinately heal of their own accord, so that it becomes necessary to place a species of button or stud in the opening to prevent an issue which, under these circumstances, is undesirable. This case seems parallel with that of perforation -of the tympanum, which, being effiicted by an instrument, heals rapidly ; while the closure of an opening, the result of disease, is usually impossible. About thirty years ago Dieffenbach'^ recoided a case of vesico-vaginal fistula, the cause of which had been the presence of a stone in the bladder, complicating labor ; and Baker Brown^ mentions another instance of this kind in 18G1. Ulceration or Abscess Tiie vaginal walls may be eaten through by cancerous, syphilitic, or phagedenic ulcers, or a communication may be established by an abscess opening into the vagina and into a neighboring viscus or part. In one case I found, in the autopsy of a woman who had died from a profuse diarrhoea, in which the feces had passed by the vagina, a communication created by abscess between the caput coli and that canal. Cancerous disease often destroys the vesico-vaginal septum, but as these fistulas are irremediable, and attend upon a rapidly fatal disorder, they attract little attention in themselves. Lastly, certain diseases pro- ducing deficiency of nutrition, as, tor example, the continued fevers, may cause slougliing of the vaginal walls or phagedenic ulceration. Symptoms — The prominent sym])toms and signs of urinary fistulje may be grouped under three heads: first, those furnished by a character- istic discharge ; second, those arising from the irritant action of such discharge upon the part over which it fiows ; and, third, those afforded by physical examination. Sometimes the escape of urine is so excessive as to preclude the neces- sity of a discharge per vlas naturales ; at others the excretion is partly ' Principles and Practice of Gynecology. The author gives in his tables 202 cases, but I subtract 23 which were intentionally produced for removal of stone and cure of cystitis. Evidently these are not admissible in tlie study of Etiology. « Med. Record, vol. i. 321. 3 Op. cit. 238 FISTULA OF THE FEMALE GENITAL ORGANS. evacuated by the natural and partly by the vicarious outlet. This symp- tom shows at times eccentric variations. When the fistula is seated in the urethra, the bladder may be distended without loss, which may take place into tlie vagina during micturition. Sometimes while in the hori- zontal posture the escape will cease, the anterior vesical wall being pressed by the intestines against the bas-tbnd so as to close the opening ; and in other cases, where the fistula is above the orifice of the ureters, the fiow will take place while the patient lies, and cease when she stands. The passage of excrementitious material through a canal and over a tissue not intended by nature to tolerate it, produces inflammatory action, pruritus, eruptions, and excessive irritability. In urinary fistuliB the vulva and thighs are usually red, excoriated, and covered by a vesicular eruption. The vagina is sometimes covered by urinary concretions, and a highly offensive odor emanates from the patient's body. The genei-al health is very likely in time to give way, and hysteria, chlorosis, and graver disorders often show themselves. Physical Signs If the fistulous orifice be a large one, even'a super- ficial examination by touch, the patient lying upon her back, will gene- rally serve to reveal the nature and extent of the lesion. It is different, however, with very small fistulse, which will sometimes elude the most careful investigation. For their detection Sims's speculum should be employed, and in many cases it will be found advisable to place the woman in the knee-elbow position, instead of that on the side, before its intro- duction, and to have the buttocks and labia pulled apart by the hands of assistants. Even this method is not effectual in revealing the opening if it be very minute. Under these circumstances the bladder should be injected with water, and its escape into the vagina carefully watched for. Sometimes, by this means, a capillary opening, just at the junction of the vagina and cervix, will be detected. Kiwisch, Meyer, Veit, and others have used for this purpose water colored with substances which will im- part a bright tinge to it. Infusion of cochineal, madder, or indigo may be thus employed. The opening being once detected, the probe and finger will readily reveal the course, extent, and terminus of tlie tract. Complications — The comj)lications which these fistulaj develop are vaginitis, vulvitis, stricture of urethra and vagina, and sometimes endo- metritis and periuterine inflammation. The most constant and important of these is the formation of bands, which contract the vagina, and which often require severance before operative procedure can be practised. Prognosis. — Previous to the year 1852, the prognosis of all cases in which the orifice acted as a vicarious outlet, for example, vesico-vaginal, recto-vaginal, and vesico-utero-vaginal fistulse, was eminently unfavorable, URINARY FISTULA. HISTORY. 239 for they very rarely undergo spontaneous recovery, and the means of cure at our command up to that time were uncertain and full of discouragement. In 18G0, Dr. Sims' stated, " Of 2G1 cases of vaginal fistula (vesical and rectal) 216 have been permanently cured by the silver wire suture, 36 are curable, and 9 incurable. livery case is curable when the operation is practicable, provided there is no constitutional vice to interfere with the powers of union. Success is the rule, failure the exception." The enlarged experience of the profession has fully corroborated these assertions, made twenty years ago, and it may now be accepted as a true statement as to the prognosis of all fistulse of the female genital organs except cases of vesico-uterine fistula, in which the point of rupture is out of reach of surgical interference. History The history of this subject dates back only to the sixteenth century, when attention was called to it, and a plan of treatment proposed by Ambrose Pare. Before the discovery of the forceps, the accident must have been one of very frequent occurrence, for then powerless labor was not under the control of the obstetrician, except by resort to a set of badly constructed instruments for craniotomy, which in themselves presented serious dangers of laceration. The symptoms wdiich mark its existence are so palpable and distressing that it does not require a physician to diagnosticate it, and no case of any gravity could have escaped notice. And yet, curious to relate, there are few diseases to which woman is liable, which have received so little notice at the hands of the ancients. Even pelvic cellulitis and other affections, which have but lately attracted atten- tion from the physicians of our day, are distinctly alluded to by the writers of the Greek school ; but this one, so annoying, so destructive of happiness, and so urgent in its demands for relief, has received scarcely any mention. It is true that Hippocrates makes some slight allusion to involuntary dis- charge of urine following difficult labors, but his remarks upon the condi- tion are meagre and unimportant. I do not claim to have made a full examination of the writings of the Greeks and Romans with reference to the subject, but base the statement which I have advanced chiefly upon the fact that the two great compilers of their periods, Aetius and Paulus ^gineta, make no mention of it. The work of Aetius upon diseases of women (Tetrabiblos IV.) is made up of quotations from Soranus, Aspasia, Galen, Philumenus, Archigenes, Leo- nidas, Rufus, Philagrius, Asclepiades, in fact of all worthy of note, whose writings were stored in the Alexandrian Library, which was the seat ot his labors. By none of these is mention made of the affection. The works of Paul of ^gina, enriched as they have been by the copious notes of Dr. Adams, their translator, are equally silent ; and the researches of ' Gardner's Notes to Scanzoni, p. 515. 2-10 FISTULA OF THE FEMALE GENITAL ORGANS. those who have examined the writings of the Arabians record no discovery of any description of it at tlieir hands. At any rate, it is quite certain that no contributions to the treatment of the difficulty were made by the writers of the Greek, Roman, or Arabian schools. Bc-inning at the seventeenth century, I will allude only to those who have made some advance in treatment, and not endeavor to record the names of all who have reported cures, or advised procedures which liave not been of subsequent utility. Before proceeding with the historical sketch which ensues, I would draw the attention of the reader to two interesting facts wliich it will demon- strate. It will be seen that for centuries steady, persevering, and syste- matic efforts have been made to render tliis revolting malady curable, and that, as has often been the case in other great discoveries, the minds of several investigators pursued the same course until at last success was reached. After a discovery has been made it is always easy to point out the elements upon which it rests for its success, and even to follow the process of reasoning by which each in turn was supplied. There can be no doubt that the three elements necessary for successful treatment of the lesion which we are considering, were — 1st. A means for exposing the fistula to view and manipulation ; 2d. A suture which would remain in place without causing inflamma- tion ; 3d. A means of disposing of the urine during the process of cure. From the time that Pare suggested a plan of treatment, it will be no- ticed that surgeons brought these three means of cure to their aid. But they employed them separately, some using one of them, some another, and others still combining two. It was not, however, till the time of Gos- set, in 1831, that the three were combined by the same operator. In 1570, Ambrose Pare proposed the closure of vesico- vaginal fistulas by a retinaculum. In 16G0, Roonhuysen, of Amsterdam, used a speculum, through which he pared the edges of fi^^tula^ and united them by a needle. In 1720, Voelter, of Wurtemberg, advised a needle, needle-holder, suture by silk or hemp, and a catheter. In 1792, Fatio, of Basle, operated by twisted suture, placing his patients in the lithotomy position. In 1804, Dessault used a vaginal plug and catheter in the bladder. In 1812, Naegele, of Wurtemberg, scarified the edges by scissors, used needles to approximate them, and employed the interrupted suture. In 1817, Schre- ger, of Germany, placed the patient on the abdomen, scarified the edges, and used interrupted suture. In 1825, Lallemand, of France, applied nitrate of silver to the edges of the fistula, and approximated them by a " sonde erigne" passed through the bladder, and, of fifteen cases, cured four. In 1829, Roux, of France, tried twisted suture with metallic bars and ordinary thread. In 1834, Gosset, of London, combined the knee- elbow position, levator perinei speculum, metallic sutures, and catheter URINARY FISTULA HISTORY. 241 permanently kept in tlie bladder. In 183G, Beaumont^ employed the quilled or clamp suture. In 1837, Jobert de Lamballe resorted to auto- plasty, transplanting a piece from the labia, buttocks, or thighs. In 1838, Wutzer, of Bonn, placed his patients on the abdomen, pared the edges of the fistula, and approximated them by insect needles and figure-of-8 suture. To expose the fistula the perineum was held up by a hook and the labia drawn aside by assistants. In 1839 and 1840, Hayward, of Boston, U. S., reported three cases cured by vivifying the edges and closing with silk suture. This surgeon introduced a notable improvement, and aided in the final success by vivifying not only the borders of the fistula but the neighboring vaginal surfaces. In 1844, Chelius^ placed his patients in the knee-elbow position. In 1846, Metzler,' of Prague, employed the levator perinei speculum, perforated balls the size of shot, the knee-elbow position, gilded needles, and a permanent catheter. In 1847, Mettauer, of Vir- ginia, employed the catheter and leaden sutures with such success that he was led to make the following statement : " I am decidedly of the opinion that every case of vesico-vaginal fistula can be cured, and my success jus- tifies the opinion." In 1852, Jobert de Lamballe adopted his method, styled " reunion autoplastique par glissement," which consisted in giving sufficient vaginal tissue for union, by cutting transversely through the vagina, at its junction with the uterus, in a line with the fistula. In 1852, Marion Sims,* of the United States, combined the three essentials for suc- cess; the speculum, the suture, and the catheter, and placed the operation at the disposal of the profession. The discoveries to which he laid special claim were these : — 1st. A method by which the vagina could be distended and explored ; 2d. A suture not liable to excite inflammation or ulceration ; 3d. A method of keeping the bladder empty during the process of cure. Entering the field almost as early as Sims, Simon, of Germany, greatly aided in systematizing the operation, and has been second to no one else in improving it. From a study of the literature of this subject it is made as evident as written testimony can make any history of the past, that not only did several investigators combine two of these elements of success in their operations, but that two, Gosset, in England, and twelve years afterwards Metzler, in Germany, absolutely combined all three. It is also made equally evident that they either failed to recognize the importance of what they had attained, or did not impress its value upon others so that humanity could profit by it. Dr. Gosset's procedure is thus described in his ov/n words in the first volume of the London Lancet, page 346. " Having placed the patient resting upon her knees and elbows, upon ' Med. Gaz., Dec. 3d, 1836, p. 355. 2 Agnew, op. cit., p. 15. 3 Schiippert on Ves.-Vag. Fistula, p. 41. •» Amer. Journ. Med. Sci., 1852. 16 242 FISTUL^E OF THE FEMALE GENITAL ORGANS. a firm table of convenient height covei-ed with a folded blanket, the ex- ternal parts were separated as much as possible by a couple of assistants, so as to bring the fistula, which was immediately above the neck of the bladder, into view. I seized with a hook the upper part of the thickened edo-e of the bladder which surrounded the opening, and proceeded with a spear-shaped knife to remove an elliptical portion, which included the whole of the callous lip surrounding the fistula, the long angle of the ellipsis being transversely. This was readily effected ; but, in conse- quence of the very contracted state of the parts, the next steps of the operation were with difficulty executed ; and I should not have succeeded in passing the sutures, had I not used needles very much curved, and a needle-holder which I could disengage at pleasure, the needles being with- drawn with a pair of dissecting forceps after the holder was removed. In this way three sutures were passed ; and afterwards, by twisting the wire, the incised edges were brought into contact and retained in complete apposition until they had firmly united. One of the sutures was removed at the end of the ninth day, the second at the end of the twelfth day, and the third was allowed to remain until three weeks had elapsed. After the operation the patient was put to bed and desired to lie on her face, an elastic gum catheter, having a bladder secured to its extremity for the reception of the urine, having been introduced and retained by means of tapes. She had not the slightest discharge of urine through the vagina after the operation, which completely succeeded in restoring the healthy functions of the part. The advantages of the gilt wire suture are these : it excites but little irritation, and does not appear to induce ulceration with the same rapidity as silk or any other material with which I am acquainted; indeed, it produces scarcely any such effect, except when the parts brought together are much stretched. You can, therefore, keep the edges of a wound in close contact for an indefinite length of time, by which the chances of union are greatly increased. I have used it now in very many operations, as after extirpation of the breasts, tumors of various kinds, and for bringing the lips together after the removal of a cancerous growth, in all of which cases it answered extremely well." The method of Metzler was published in the Prague Viertel Jahresschrift for 1846, under the title of " Pathology and Treatment of Urinary and Vesico- Vaginal Fistulas, with a method of treatment easily executed and completely successful." I transcribe his article from the brochure of Dr. Schuppert already alluded to. " To perfoi-m the operation successfully, it is of much importance to have — 1st, a speculum, serving as a dilator of the vagina. Such an in- strument consists of a grooved conical blade, five and a half inches long, three inches wide at the anterior part, one-half an inch wide at the posterior. The end of the speculum is bent under at a right angle, and protected with wood for the handle. The instrument is best when made URINARY FISTULiE HISTORY, 24-3 of silver, and polished to reflect tlie light on the parts to be operated upon. 2d, an apparatus consisting of perforated clamps, gilded needles, and an instrument called ' Rosenkranzwerkzeug,' consisting of perforated balls of the size of large shot, by which the clamps are held in contact. After the patient is placed on her knees and elbows, the dilator is introduced into the vagina and given to an assistant, who in holding it presses it against the rectum. The edges of the fistula are then pared off, which may be accomplished with curved scissors. One line and a half from the mucous membrane of the vagina and half a line from the edge of the bladder have to be cut off; the needles are then applied, and the wound held in coaptation by the clamps; a female catheter is introduced into the bladder by the urethra, and tlie catheter fastened by a T bandage." From what has been said thus far it would appear that Dr. Sims was forestalled in all the details of the discovery by which he has rendered vaginal fistulae curable. To a certain extent this is unquestionably true, but only as regards the theory of the matter. Before his publications the unfortunate women, whose lives were rendered miserable by fistulae through the vaginal wall, were virtually almost as hopelessly affected as they were before Gosset and Metzler appeared in the field. Velpeau,^ in 1839, thus speaks of cure of these fistute: "To abrade the borders of an opening, when we do not know where to grasp them; to shut it up by means of needles or thread, when we have no point appa- rently to secure them; to act upon a movable partition placed between two cavities, hidden from our sight, and upon which we can scarcely find any purchase, seems to be calculated to have no other result than to cause unnecessary suffering to the patient." Vidal de Cassis'' says: "I do not believe that there exists in the science of surgery a well-authenticated, complete cure of vesico- vaginal fistula." Malgaigne,^ in 18o4, says: "But the truly rational method, that which at present offers the greatest facility and efficacy, and the only one which should be applied in all cases of fistula of large size, is the suture by the procedure of Jobert." Wutzer reported the following as the statistics which he had collected:* " 20 cases of vesico- vaginal fistula were subjected to 48 operations — among which were elytroplastie, episioraphie, cauterization, sutures, interrupted or twisted, and both — and only two cured!" This was the real state of science with reference to this opprobrium chirurgice when Marion Sims, by combining and utilizing the three essen- tials for success, gained it, and rendered the operation practicable for all surgeons. It must not be supposed that he availed himself of the results obtained by his predecessors. All that he attained was arrived at by hard and original labor. Indeed, no one can read his address upon " Silver ' Operative Surgery. ^ Patliologie Externe. 3 Manuel de Med. Op^rat. * Med. Record, vol. i. p. 322. 244 FISTULA OF THE FEMALE GENITAL ORGANS. Sutures in Surgery," delivered before the New York Academy of Medi- cine, in 1857, without being struck by his want of familiiirity with the antecedent literature of the subject of his discourse. I would not be understood as claiming for America in this matter more than she really deserves — the establishment of the method of cure upon a firm and certain basis. To claim more than this would be to ignore the plain teaching of history. To France belongs the inception ; to England the glory of having absolutely made the discovery, although she did not appreciate the fact ; to Germany, next to America, the credit of having specially advanced and perfected reliable operative procedures. In that country to-day, by the method of Simon, success even in the gravest cases has become the rule and failure the rare exception. Since the first publication of Sims's method, numerous modifications of it have been put into practice both in this country and Europe, and Dr. Sims himself has altered his plan of operating very much. The principle which he demonstrated is, however, the same, and the modifications of the operation all act in developing it. In this country, the operation is commonly performed, not by specialists alone, but by practitioners in every walk of the profession, and, thanks to the extreme simplicity of Sims's procedure, it is no longer looked upon as a difficult undertaking, requiring special skill and experience. It is at the present day certainly very difficult to appreciate the statement of a physician^ of Ireland, that "he unfortunately had the opportunity of seeing a great number of fistulas, and a great number of oi)erations, and his experience had been that the vast majority of them {)roved unsuccessful." Means for Ohtaining a Natural Cure. — Within /i few days after de- livery the obstetrician is generally made aware of the existence of vesico- vaginal fistula by a steady and involuntary dripping of urine. As soon as this is evident a Sims's stationary catheter should be placed in the bladder, the vagina frequently syringed out with warm water to lessen inflammatory action, and the patient kept in the abdominal decubitus, in order that a repair of the injury may be accomplished by the efforts of nature. This is all that can be done at this time, for it is too early to resort to suture, and the lochial discharge would be interfered with by a tampon intended to aid in the cure. The operation by suture should not be undertaken before the immediate results of parturition have passed off" and the fistula has assumed a permanent size and character. ' Remarks by Dr. Crouyn before the Surgical Society of Ireland, March 15, 1872. URINARY FISTULA TREATMENT. 245 Treatment. The methods at our command for curing, or, where cure is impossible, obviating the inconveniences due to fistulse of the female urinary apparatus, are — 1st. Cauterization ; 2d. Suture ; 3d. Elytroplasty ; 4th. Occkision of the vagina or uterus. Cauterization. This once favorite method of treating all varieties of these fistulte has now very deservedly fallen into disuse under the influence of improved methods by suture. Malgaigne probably gives this means its proper place when he declares that it should be employed only in those cases where the fistula is scarcely perceptible. Even in such cases Sims's operation is far preferable, and cauterization should be employed only where some special circumstance, such as want of skill or of the proper instruments, forces the operator to resort to it. The performance of it is very simple. Sims's s[)eculum being passed so as to expose the fistulous spot, its borders should be thoroughly touched with a pointed stick of nitrate of silver or the actual cautery. This should not be repeated before the slough created has separated, and an opportunity been allowed for granulation to fill up the opening. To cheek the flow of urine through the fistulous orifice and support tlie vaginal and vesical walls during the process of granulation, a small tampon of cotton, a Gariel's air pessary, or a glass vaginal plug should be kept in the vagina, and, to prevent distention of the bladder, a sigmoid catheter should be permanently retained. Suture. Preparation of the Patient. — No operation in surgery more urgently demands a good constitutional condition, as an element of success, than this. Should the patient's health not be good, and her blood-state be abnormal, a visit to the country, exercise, and fresh air, with vegetable and mineral tonics, will do a great deal towards avoidance of failure. At the same time the vagina should be regularly syringed with warn, water to overcome local inflammation, and insure cleanliness. Should the disorder which caused the destruction of the vaginal wall have pro- duced as a complication cicatricial bands in the canal, these should be cut, from lime to time, and allowed to heal over a glass vaginal plug, and if contraction have taken place in the urethra, it should be overcome by bougies. Before the time of the operation the bowels should be thoroughly evacuated by a cathartic, and on the day of its performance very little 24(3 FISTULA OF THE FEMALE GENITAL ORGANS, food should be taken, for fear that the long-continued use of an anaesthetic might produce vomiting, which would tear out the sutures. Sims's Operation This operation may be divided into three parts: — 1st. Paring the edges of the fistula ; 2d. Passing sutures through them ; .'}(1. Approximating them and securing the sutures. The patient, being placed upon a table two and a half by four feet, which is covered by folded blankets, is brought under the influence of an anaesthetic, and placed in the following position. She is made to lie on the left side, with the thighs bent at about right angles with the pelvis, the right a little more flexed than the left. The left arm is placed behind her back, and the chest brought flat down upon the table so that the sternum may touch it. The assistant who is to hold the speculum, which is then introduced, does so with the right hand, while with the left he elevates the right side of the nates. The table should be so arranged that a bright and steady light may fall into the vagina, which being then fully distended, will be seen throughout its extent, except where it is obscured by the speculum. The operator, having near him all the instruments, etc., which he will require, places his assistants thus: one holds the speculum, another ad- ministers the anaesthetic, and a third stands ready at his right hand to remove the blood accumulating in the vagina, by means of sponges, in the sponge-holders. Fig. 91, which are rajjidly washed in a basin of water that stands by his side, to be used again. A i'ourth assistant, if attainable, may be well employed in handing the instruments as they are required. All being ready, he proceeds with the first step of the operation. Paring of the Edges of the Fistula. — The edge of the fistula, at the point which is deemed most difficult of access and manipulation, is caught by the tenaculum, or with what 1 much prefer, the tooth forceps, shown I Curved scissors. Fig. Bistoury for paring edges of fistula. in Fig. 59, and held up. Then with a pair of long-handled scissors, Fig. 87, or a knife, Fig. 88, a strip is cut, extending from the mucous mem- URINARY FISTULiE TREATMENT, 247 brane of the bladder to that of the vagina, care being taken not to wound the former. Fig. 89. Fio. 90. rmeminiiiiii/iw^ Showing bevelling of edges, a, vesical border ; b, vaginal border ; c c, incision. Paving the edge.=!. (Wieland and Dubrisay.) Fic!. 91. Sims's spouge-holder vcith handle nine iuches long. Another portion of the edge is then seized, and removed like the first. The wound t!iu.s left should be one bevelled from the vesical surface out- 248 FISTULiE OF THE FEMALE GENITAL ORGANS. wards, and great care should be observed to remove the entire border, for upon this success depends. It is of great moment that sufficient tissue should be removed, and that the amount taken on the vaginal surface should be greater than that near the vesical. Prof. Simpson^ makes this point very clear by the following language: "Enter the point of your knife into the vaginal mucous mem- brane at some distance from the fistula; then transfix with your knife the edge of the fistula to the extent you intend to remove it, and bringing it out at the vesical border, carry it right and left fairly round the opening, so as, if possible, to bring out a complete circle of tissue." The abraded surface, from the edge of the fistula to the point of vaginal section, should measure at least four lines, one-third of an inch, while above, it should just touch the vesical border, not invading its mucous membrane. This is made evident by Fig. 90. During this part of the operation the sponges, held in long-handled sponge-holders, will have to be freely resorted to, but the bleeding generally soon ceases, and the operator may proceed to the second step. Passing the Sutures The sutures are passed by means of slightly curved needles held in a pair of strong forceps. Fig. 92, made for the pur- pose. In some cases the metallic thread, made of annealed silver, which is employed, may be passed at once, but usually silk threads are first passed, and the silver sutures are attached and drawn through. Dr. E. Cutter recommends a very ingenious method for avoiding the necessity of threading the needle, and thus having a piece of silver wire folded over so as to interfere with its passage through the tissues. He Avelds the wire firmly to the needle so that no obstruction exists at the point of union. A number thus prepared are in readiness for each operation. The needles which we employ in the "Woman's Hospital are about three-quarters of an inch long, round, slightly curved, and without cutting edo-es anywhere. Dr. John T. Hodgen, of St. Louis, has invented a needle which serves an excellent purpose. It is a very small, straight, short needle, with a point like that of a trocar. This passes readily through the tissues, and to it is attached a delicate silk thread which car- ries the silver wire, the bent end of which is rubbed down very small by sand-paper. The needle, held in the grasp of the needle-holder, should be passed at the angle of the wound which is most difficult of access, half an inch from the edge of the incision, and brought out at the vesical surface, but not involving its mucous lining. Fig. 93 represents the point of entrance and exit of the needle. The point of the needle having passed out, it is engaged by tlie small, olunt hook Fig. 98, until it can be seized and drawn through by the 1 Diseases of Women. 1 URINARY FISTULyE — TREATMENT. 249 needle forceps. Then it is plunged into the other lip and drawn out half an inch from the edge of the incision. The ends of the silk suture are Course of the needle, a, vesical border ; 6, vagi- oial border ; c, point of entrance of needle ; d, point of exit of needle. Fig. 94. 1 • 1 pose the fistula above, and In case the fistulous orifice be so high as to be sutures are passed. 2P)2 FISTUL/E OF THE FEMALE GENITAL ORGANS. considered beyond reach, the only remaining resource is to close the os uteri externum by suture, and allow menstruation to occur through the bladder. Vesico-vtero-vaginal Fistula. For these the plan of vivifying the anterior lip of the os, and thus making the uterine tissue subservient to closure of the fistula, is peculiarly ' Fig. 107. Fig. 108. Anterior lip of fistula united to anterior lip of corvix. (Simon.) applicable. The operation, represented at Fig. 107, is similar to that for ordinary vesico-vaginal fistula, the only difference being that one lip of the fistula is made of the vivified cervix uteri. In case the anterior lip of the uterine neck be so completely destroyed that it cannot furnish the requisite tissue for this purpose, the vagina may be united to the posterior lip so as to throw the cervix into the bladder. Menstruation will after- wards occur into that viscus, and the blood thus accumulating be discharged with the urine. Fistiilce with Extensive Destruction of the Base of the Bladder. It has already been mentioned that elytroplasty and kolpokleisis offer resources in these cases. To Dr. Bozeman, however, we are indebted for still another procedure, interior lip of fistula nnitpd to posterior lip of ,, ^ c ^ ■ ^ • • cervix (Simon.) ^"^ "^St Step CI Whlch COUSlStS ID URETERO-UTERINE AND URETERO- V A GIN AL FISTULA. 263 dragging tlie uterus down daily for weeks before tlie operation by means of a pair of forceps by which the neck is seized. In this way the uterus is made to approximate the vulva. Then one lip of the cervix, beino- vivified, is brought into contact with the extremity of the remains of the vesico-vaginal septum, and firmly united with it by suture. To facilitate this procedure, the cervix may with great advantage be slit to the vaginal junction, drawn forward and made to fill the space left vacant by the sloughing of the vagina. Uretero-uterine and Uretero-vaginal Fistulae. In addition to the varieties of urinary fistulte mentioned here, certain rare instances of union between the ureters and vagina or uterus have been recorded. A striking example of uretero-uterine fistula may be found detailed in the Dictionnaire de Medecine, vol. xxx., by M. Berard. It is not only interesting in itself, but as displaying the method by which the diagnosis may be arrived at is worthy of special mention. Regarding it at first as a vesico-uterine fistula, from the fact that urine was dis- charged from the uterus, he arrived at a different diagnosis from these facts : — 1st. The urine flowed steadily from the cervix when tlie bladder was empty. 2d. The urine thus flowing was limpid, unlike that from the bladder. 3d. The patient being kept seated over a vessel for two hours so as to preserve all the urine flowing per vaginam, a catheter was passed into the bladder and the amount removed exactly equalled that which liad escaped vicariously. 4tli. Injecting the bladder with fluid colored by indigo, the urine pass- ing per vaginam remained limpid. oth. A sound being passed into the uterus and anotlier into the bladder, their points could not be brought into contact. Uretero-uterine fistula is by no means common ; only one instance is mentioned by Dr. Emmet in his recent work as having occurred in his extensive experience. Dr. W. H. Baker, ^ of Boston, lias recently pub- lished an interesting case, which was cured by dissecting up the ureter which ended at a point near the meatus urinarius, making an opening near the neck of the bladder, turning the ureter into this, and then closing tlie vaginal wound. Dr. Henry F. Campbell,^ of Georgia, reports an interesting case oi' uretero-vaginal fistula which he cured by this simple procedure: passing a small bistoury up the ureter, he slit its anterior wall, the knife passing ' N. Y. Med. Journal, Dec. 1S7S. 2 Amer. Journ. Med. Sciences, Jan. 1880. 264 FISTUL.E OF THE FEMALE GENITAL ORGANS. into the bladder. He then closed the vaginal surlace of the cut thus made with silver suture. The patient rapidly and entirely recovered. An exceedingly interesting instance of this variety of fistula is men- tioned by Zweifel, of Erlangen, in which he removed the kidney of the diseased side with a successful result. The right kidney wliich was left proved quite sufficient for the wants of the economy. There are eccentric and rare forms of fistula which I have not men tioned in my enumeration. For example, I have met with a case of vesico-abdominal fistula. Eight days after the operation of ovariotomy, about one pint of urine began to pass daily through the abdominal open- ing, the lower angle of which had been kept open for washing out the peritoneum. That the fistula was vesical and not ureteral was proved by the escape of colored fluid through the abdominal wound when injected into the bladder. Tins patient entirely recovered, and the fistula healed of itself. Where a larger extent of denuded surface is required than can be ob- tained by paring the edges of fistuljB, Langenbeck and CoUes have resorted to the following plan. Splitting the edges of the fistula, they have sepa- rated the two flaps thus produced, and bringing the opposing raw surfaces together, have secured them by suture. Treatment of Long, Tortuous, Capillary Sinuses remaining after Operation by Suture. Sometimes fistul^e situated near and involving the neck of the uterus will be cured in great part by suture, and yet, at one or both extremities of the original opening, long, capillary sinuses will remain, which, running a tortuous course, reach the bladder and render the operation a failure. Under these circumstances it is almost impossible to pare the edges of these tracts by knife or scissors, and the cautery which has been generally used for them commonly fails to cure them. For these I have adopted with the most satisfactory results the following plan. Having a dentist's burr made with cutting flanges, instead of dull ones, such as are usually employed, it is fitted to the ordinary dentist's treadle ; as the burr is made to revolve rapidly by the action of an assistant's foot, it is passed up and down the sinus to be closed several times until the operator feels that the entire canal is thoroughly denuded. Then by curved needles, deep sutures are passed ai)proximating its vivified walls. By this means I have cured several fistulae situated just in contact with the cervix uteri, which would have been exceedingly difficult of cure by any other method. It lias the advantage of being very expeditious, and I would urge its claims in this class of cases. FECAL FISTULA. 265 CHAPTER XVI. FECAL FISTULA. Definition — These, which are much less frequently met with than urinary fistulae, consist in communications established between the vagina or vulva and some part of the intestinal tract. Varieties They may be recto-vaginal, entero-vaginal, or recto-labial ; the first being the most common, and the second the rarest of the varieties. Causes. — The causes which produce them are almost identical with those which result in urinary fistulfe, viz. : — Prolonged pressure ; Direct injury ; Ulceration or abscess. The first of these may produce them, as it does those occurring on the anterior vaginal wall, by creating an intense inflammation which results in sloughing, or the intensity of the pressure may be so great as rapidly to destroy the vitality of the part. Such pressure is most frequently the result of difficult parturition, but in rare cases it may arise from badly- fitting pessaries or scybalous masses in the rectum. Direct injury by instruments used in delivery, or others employed for removal of impacted feces, may evidently produce them. Ulceration or abscess much more frequently produces fecal than urinary fistulfe. For the recto-vaginal variety stricture of the rectum is a fruitful source, the stricture producing a retention of fecal matters which excites ulceration that may extend to the vaginal canal. An abscess between the vagina and rectum may cause a communication between the two, or bur- rowing towards one labium may open tliere and connect this part by a tract with the rectum. In the same manner a purulent collection has been known to make a junction between the caput coli and vagina. Lastly, syphilitic and cancerous ulceration may open a channel between the intestinal and vaginal canals. Symptoms — The most prominent, often the only symptom which will attract the patient's attention, will be a discharge of offensive gas or fecal matter by the vagina. The amount which escapes will of course be governed by the size of the fistula, but the annoyance dependent upon the accident will not be so, for even the smallest quantity will be sufficient to render the patient utterly wretclied by the offensive odor to which it gives rise. 26G FECAL FISTULA. Physical Signs The patient being placed upon the back, touch should be practised upon all the surface of the vagina. If the fistula be one of any magnitude, this will at once discover it. If not, careful exploration by the speculum will almost always do so. Sims's speculum should be introduced under the symphysis so as to lift the anterior wall of the vagina while the lateral walls are held aside by spatula?. Should visual explora- tion not reveal the opening, the rectum may be filled Avith tepid water colored with cochineal or indigo, and its escape carefully watched for. Prognosis Fecal fistulas are more likely to be spontaneously recovered from than those of urinary character, from the fact that they give passage to gaseous and semi-fluid excretions, and not to an irritating fluid which is constantly dribbling away and keeping the fistulous walls from uniting. But even these are rarely recovered from unless surgical aid be brought to their relief. Fig. 109. Examination for fecal fistula. Treatment. — Recto- vaginal and recto-labial fistulce should always be treated by suture. This is practised upon the same plan as that which is followed in vesico-vaginal fistulte, with these exceptions, that the patient is placed in the position adopted in operating for stone, and that the speculum is so inserted as to elevate the anterior instead of the posterior vaginal wall. Before operation, the sphincter ani muscle should always be paralyzed by thorough stretching by the fingers, and after it a rectal tube should be retained, unless very annoying to the patient. After the operation, too, the rectum, which should have been thoroughly emptied by enema before it, should be kept perfectly quiet by opiates for ten or twelve days. When SIMPLE VAGINAL FISTULA, 267 evacuations are first permitterl, laxatives should be employed in order to avoid tenesmus, which might destroy the union of the lips of the fistula. In one case of recto-vaginal fistula I have introduced the speculum into the rectum, and closed the fistula on the rectal surface. The facility with which the operation was performed was surprising. Should the fistula exist only a short distance above the sphincter ani, the best method of treatment is to cut completely through the perineal body, vivify carefully, and close the wound. Entero-Vaginal Fistulae. Entero- Vaginal Fistula, which consists in a fistulous tract between some part of the intestinal canal above the rectum, and the vagina, is rare, and when existing should be looked upon as an artificial anus, the closure of which would be attended by danger. If the opening be direct and there be no tract leading from one canal to the other, this would not be the case, but if a tract exist, the closure of its vaginal extremity would probably result in abscess excited by fecal matters passing out of the intestine. Simple Vaginal Fistulae. Definition Under tins head are grouped those forms of fistulous con- nection Avith the vagina which do not act as vicarious outlets for any neio-h- boring organ, as, for example, peritoneo-vaginal, perineo-vaginal, and blind fistulas. Peritoneo-vaginal Fistula has been rarely met with. When it does occur it is attended by danger of descent of the intestine into the vao'ina, and entrance of fluids and air into the peritoneal cavity. One reason for its rarity is probably the fact, that, no excrementitious substance passing through it, it very generally disappears without becoming chronic. Should it not do so, no annoyance would arise from its existence, and it would be susceptible of immediate cure by suture. Perineo-vaginal Fistula may result from partial closure of a ruptured perineum leaving a small orifice near the sphincter ani, or from penetra- tion of the presenting part of the foetus through the perineum. It may be readily cured by incision, ligature, cauterization, or injection, after the plan just pointed out in connection with fecal fistulae. Blind vaginal Fistulce are those which lead to a purulent collection in some part of the pelvis. They will be fully treated of when considering pelvic abscesses, and nothing need be said of them here further than to mention the principles upon which their treatment rests : 1st, dilatation of the fistulous tract by tents or incision ; 2d, exerting an alterative action on the walls of the abscess by iodine, iron, nitrate of silver, water, etc. etc. 268 ACUTE ENDOMETRITIS, CHAPTER XVII. ACUTE ENDOMETRITIS. I FREELY confess that the arrangement of no subject treated of in this work has caused me more perplexity, and is offered to the reader with greater hesitancy, than that which relates to the divisions of endometritis. Having personally no theory to sustain in reference to the matter, my sole desire is to present the subject in the manner which will best aid in its comprehension, assist the practitioner at the bedside, and favor a future advance in its pathology. Throughout the literature of gynecology admissions will everywhere be found of the fact that endometric inflammation limits itself to the neck, the body, or even, according to one authority,^ to the fundus of the uterus, and yet the two varieties of the affection are treated of as one, and one author^ even goes so far as to assert that " the facility for locating its limit exclusively to cervix, body, or fundus rests only in the brain of the theorist." Barnes treats of the whole subject as " endometritis," yet, with characteristic candor, he says, " it appears to me that attention has been too strictly fixed upon the visible changes in the cervix and os uteri ; and that, thus engrossed, the mind has been closed against the less telling evidence of changes in the body of the uterus." All things being carefully considered, I have thought it best to adhere to the arrangement which follows, guarding the reader against the idea that any facility of differentiation, any dogmatic certainty of conclusion is claimed in reference to the matter. The arrangement simply seems to me, for many reasons, that which best meets the requirements of the present and favors the prospects of the pathology of the future. The varieties of inflammation of the lining membrane of the uterus may be clearly expressed in the following manner : — / General. Acute < Cervical. ( Corporeal. Endometi'itis < f General. Chronic ■ Cervical. ( Corporeal. ' Dr. RoTith's article on "Fundamental Endometritis." 2 Dr. T. A. Emmet, op. cit. CAUSES. 2G9 Synonyms. — Acute endometritis has been treated of under the names of acute uterine leucorrhoea, acute uterine catarrh, acute internal metritis. Frequency Acute intiammation of the lining membrane of tlie uterus is a condition which occurs quite frequently. Often running a rapid course, however, and ending in recovery or in chronic disease, it passes unrecognized in many cases. In this way I would explain many of the cases of suppressio mensium and congestive dysmenorrhoea, which we so often find ending in chronic disease. And thus also would I account for the profuse and painful attacks of leucorrhoea occurring with exanthema- tous fevers, and lasting for a length of time after they have passed off. It is very generally stated that acute metritis is seldom met with except as a sequel of parturition, and I agree in the statement as applying to parenchymatous inflammation, but it does not apply to endometritis, which often proves the source of sudden menstrual disorder and the cause of violent leucorrhcea. Varieties The morbid process may affect the lining membrane of the cervix or of the body alone, or it may attack the whole uterine mucous tract, its selection of site being governed by its cause. Thus, that form which immediately follows parturition or abortion, or results from gonor- hoea, is likely either to affect the whole mucous tract or the cervical canal alone ; while that which is due to sudden checking of the menstrual flow is more likely to be confined to the body. Causes The causes of acute endometritis are the following : — Direct injury ; Cold from exposure during menstruation ; Constitutional disease of septic or asthenic character; Vaginitis, specific or simple ; Excessive venery; Suppression of menstruation. Examples of direct injuries which may produce acute endometritis are the introduction of the uterine sound or the intra- uterine pessary, the em- ployment of tents or the application of chemical irritants, surgical opera- tions, and intemperate coitus. It is, probably, in some instances, through the instrumentality of this disease that those cases of fatal peritonitis which result from tents, sounds, and intra-uterine pessaries occur. Inflammatory action is first set up in the lining membrane of the uterus, and thence swiftly passes through the Fallopian tubes to the peritoneum. Specific vaginitis or gonorrhoea will sometimes pass up into the cervix and body of the uterus, and out through the Fallopian tubes, creating pel- vic peritonitis of most violent character. Even simple vaginitis, when of very severe form, may produce endometritis, though this is by no means common. The peculiar blood state, attending upon and forming an element of 270 ACUTE ENDOMETRITIS. measles, scarlatina, variola, and roseola, and exert ing^ its influence on all the mucous linings of the body, will sometimes result in general endometritis, and the hemic condition resulting from phthisis not rarely does so. Kiwisch has styled this, -'metastatic constitutional catarrh." Exposure to cold and moisture, great mental anxiety, or any other in- fluence which suddenly checks the menstrual flow, not infrequently pro- duces this disease. At the moment of exposure suppressio mensium, or cono-estive dysmenorrhoea, may take place, and from that time endometritis may exist. When we consider that such a sudden check of menstruation will sometimes result in hematocele of fatal cliaracter, it is certainly not to be wondered at that it may likewise produce the disease of which we are speaking. Excessive venery, even where no violence is done to the uterus, may produce it by the prolongation of intense congestion of the organ kept up by this act. Symptoms The disease demonstrates its presence in the non-puerperal uterus without any very violent symptoms. Ordinarily the patient complains of pain, weight, and dragging in the pelvis; pain in the back, groins, and thighs; burning and pricking in the vagina, and vesical and rectal tenesmus. After four or five days there is usually a discharge of a viscid liquid, which in eight or ten days becomes creamy, purulent, and perhaps bloody ; tympanites and sensitiveness upon pressure, and uterine tenesmus or "bearing-down pains," show themselves in severe cases, and at times, though rarely, there is active diarrhoea due to reflex irritation of the rectal nerves. Should the fluid discharged from the vagina be allowed to come in contact with the skin of the vulva, abdo- men, or thighs, an intense cutaneous irritation is established, which may go on to excoriation and the development of pruritus of aggravated char- acter. In two cases I have seen prurigo thus excited which spread over the entire body. If the reaction of this purulent discharge be examined into, it wall sometimes be found to be acid and at other times alkaline. The explanation of the fact is this : the discharge from the uterus is alka- line and that from the vagina acid. If the irritating uterine fluid liave established, as it very generally does, vaginitis, the acid secretion from this source overcomes the alkalinity of that from the other. If, on the other hand, no severe vaginitis exist, the discharge from the uterus pre- sents its ordinary alkaline features. Physical Signs Upon examination by touch the os uteri is found gaping, the cervix swollen and very sensitive to pressure, the body slightly enlarf-ed, and the whole organ lower than normal in the pelvis. Through the speculum the cervix is found to look swollen, oidematous, and red, and from the pouting os pours forth either a clear, albuminous-looking fluid, muco-pus, or long tenacious shreds of cervical mucus. All explora- tions of the uterus should, as a rule, be avoided. The probe, if used at DIFFERENTIATION PATHOLOGY. 271 all, should be employed with the greatest caution, and never unless passed through the speculum. The sound as ordinarily used should not be thought of. Probing will discover great sensitiveness throughout the uterine cavity, and the slightest touch upon the fundus will cause the discharge of a few drops of blood. Indeed, so great is the engorgement that even the introduction of the speculum will often cause blood to flow from the cervix. Bimanual examination will discover the uterine body enlarged, and tender upon pressure, so that one who judged hastily, and without suffi- cient knowledge of the subject, would be very apt to diagnosticate with great positiveness acute parenchymatous metritis. There can be no doubt that many of the reported cases of that affection have been nothing more than instances of this form of endometritis. Differentiation. — The only diseases with which this would with any probability be confounded are, periuterine cellulitis, pelvic peritonitis, and acute vaginitis. In the first two of these, constitutional disturbance is generally more marked and excessive than in this ; they are often pre- ceded by chill, and usually by more intense febrile action, and greater elevation of temperatui'e. This, however, is not universally true. Tlie last is very generally attended by a lesser degree of general disturbance. No positive conclusion can usually be arrived at without physical explo- ration, which in pelvic inflammation will discover fixation of the uterus, hardening of periuterine tissue, and excessive tenderness when parts other than the uterus are compressed by conjoined manipulation. It will generally be noticed that in cellulitis and peritonitis there is no great increase of uterine or vaginal discharge. Pathology — In its first stage acute endometritis consists in an intense and active hyperasmia of the mucous lining of the uterus, which is red, swollen, (Edematous, and softened. Its surface is spotted, Scanzoni de- clares, from congestion of the capillary network around the mouths of the utricular follicles. When the second stage has set in, the cavity of the uterus is found to contain an excess of mucus or creamy-looking pus, which maybe more or less mingled with blood. If the cervix be involved in this inflammatory engorgement, the mucous membrane of its vai^inal portion participates markedly, as an examination by the speculum will prove. In the mucus just mentioned the microscope reveals the presence of thousands of cells and sometimes entire casts of the utricular follicles. " Ordinarily," says Scanzoni,^ " acute catarrh of the mucous membrane of the uterus is accompanied by a congestive swelling of the muscular substance of the womb, and most generally it is possible, particularly in the most internal layers of the organ, to see with the naked eye, that the ' Diseases of Females, American ed., p. 193. 272 ACUTE ENDOMETRITIS. vessels are gorged with blood. There ordinarily result from it an infiltra- tion and a softening, which are much greater in the layers of the paren- chyma of the uterus nearest to the mucous membrane. Hence, these alterations of tissue which are characteristic of acute parenchymatous metritis ordinarily accompany catarrh of the mucous membrane, when this has attained a high degree of intensity." " The whole substance of the uterus," says Klob,^ " generally appears to be increased, and its tissue more vascular and succulent, especially in the layers nearest the mucous membrane." Acute endometritis very rarely shows itself before puberty. Complications. — Its complications are acute metritis, urethritis, vagi- nitis, vulvitis, cystitis, salpingitis, pelvic peritonitis, and various eruptive disorders, the results of scratching excited by pruritus vulvee. The first of these complicating conditions is of so much moment as to require special consideration. The time has, I think, arrived when, with our present light upon the subject, acute parenchymatous metritis should be given a subordinate place in pathology instead of the prominent one which it formerly occu- pied. With reference to its frequency as a primary aficction, many con- flicting statements will be found. This arises partly from tlie fact that some have written of it without making any distinction between the forms occurring in the puerperal and non-puerperal states, while others have confined their remarks, as is here done, to the disease in the latter condi- tion ; partly from endometritis, active congestion from suppressio mensium, and peritonitis and cellulitis having been mistaken for metritis ; and in great part from the difficulty of gaining post-mortem evidence, the disease generally being recovered from. As a complication of inflammation of the internal mucous or external serous covering of the uterus, parenchy- matous inflammation is universally admitted. As a pathological entity, however, I question whether any well-authenticated case of this affection is on record. The descriptions of the disease which are given in recent works, such, for example, as those of Courty, Gallard, and Scanzoni, each of Avhom devotes considerable space to it, appear to me to have come down to us as a matter of literary tradition rather than of clinical research. While searching for a case of pure uncomplicated metritis, I have seen numbers of cases which were regarded by others as of this character, and quite a number which I viewed as such until enlightened by post-mortem or other evidence. Rokitansky^ declares that, " in acute inflammation of tliis organ, generally the lining membrane of the uterus is afi^ected pri- marily, and that this is scarcely ever the case with the uterine tissue, as ' Path. Anat- Female Sec. Organs, American ed., p. 231. ^ Pathology Anat. TREATMENT. 273 far as can be demonstrated by the pathological anatomist, with the ex- ception of the reaction following traumatic influences, especially of the vaginal portion." In liis recent work Klob^ takes still stronger ground as to the existence of uncomplicated metritis, and asserts that never having met with an instance of the disease, he is forced to describe it upon the authority of others. Some practitioners are prone to regard every case of inflammatory action in the pelvis, accompanied by great tenderness over the uterus, as metritis. Such cases are much more frequently due to pelvic cellulitis or peritonitis, which are by no means rare affections, or to active congestion, caused by suppression of the menses or excessive coition. After parturi- tion, either at term or premature, true metritis does occur not unfrequently, but this variety does not concern our present investigation. As regards that form which we are considering, I feel convinced that, if the expe- rienced practitioner will put aside his preconceived views and interrogate the results of his observation, he will find, if he has his attention aroused to the frequency of the diseases which simulate it, that he has met with this affection very rarely. Course, Duration, and Termination. — Acute endometritis, when oc- curring in the non-puerperal state, may, without treatment even, go on to recovery, generally lasting from a month to six weeks, and perhaps pass- ing through its whole course without its existence having been diagnosti- cated. It sometimes ends in the chronic form of mucous inflammation, or even in slight hyperplasia, the superficial, subjacent, connective tissue be- coming affected. It is doubtful whether any severe case of endometritis runs its course without being to a greater or less extent complicated by a slight degree of parencliymatous disorder. As already stated, the disease may end in chronic endometritis or in recovery. It may, likewise, end in death ; inflammatory action spreading along the Fallopian tubes and causing salpingitis, which, by resulting in free purulent discharge into the peritoneum, may establish inflammation tliere. Prognosis — In spite of all these possibilities the prognosis is always favorable if the patient take ordinary care of herself and yield to a judi- cious plan of treatment. Treatment — The diagnosis having been clearly made, treatment should be at once established. Complete rest of mind and body should be re- garded as essential points. In severe cases, the patient should be kept perfectly quiet upon her back in bed, and not allowed to leave it or to assume the sitting posture even to satisfy the calls of nature. Opium should be freely given by mouth or rectum for the production of perfect nervous quiescence and for the relief of pain. In severe cases one grain ' Path. Anat. Female Sex. Orgaus, American ed., p. 231. 18 274 ACUTE ENDOMETRITIS. of powdered opium or its equivalent of morphia should be administered every third hour. This drug, I feel sure, not only acts as a sedative to the nervous system, and a quieter of pain ; it absolutely modifies the in- flammatory process by its influence upon the nerves. The bowels, unless constipation exists, should not be acted upon by cathartics, and ordinarily no other medicine than opium should be administered. Over the hypo- gastrium a soft, warm poultice of powdered linseed should be placed and covered by oiled silk. This need not be renewed oftener than once in twelve hours, for the oiled silk will preserve its warmth. The patient should not be annoyed by leeches or cups. Even if high febrile action show itself, this can be readily controlled by appropriate administration of tincture of veratrum viride. The diet should be very simple, and should consist of fluid food chiefly, as milk, beef-tea, etc. A condition of intestinal quietude should be encouraged, and therefore such food as involves the elimination of a small amount of excrementitious matter should be allowed. By these means motion in the abdominal cavity may be lessened, and rest be assured to the diseased part. As soon as free secretion of muco-pus begins to show itself, the vagina should be gently syringed out three times daily with copious injections of very warm water. For the proper accomplishment of this the patient should turn so as to lie across the bed, in the French obstetric position, on the back, with the buttocks over the edge of the bed, which has been protected by India- rubber cloth, each foot being supported by a chair. A nurse, then i^lacing between the thighs a tub containing three or four gallons of water, should pass the nozzle of a Davidson's syringe up to the cervix, and for fifteen minutes project against it a steady stream. All examination by speculum, probe, and, after a diagnosis has been made, even -by the finger, should be avoided unless some special indication demand it. Astringent injec- tions and all vaginal applications should be avoided. The affection which we are treating is located in the uterus, not in the vagina, and such appli- cations merely annoy the patient and aggravate the disease. The warm injections which have been advised act as poultices or fomentations to the whole internal surface of the pelvis, at the same time that they insure cleanliness to the vagina and remove from it a fluid which, if left there, might excite vaginitis. Under this plan of treatment the patient should be kept until recovery, or until we are admonished by time that the dis- ease has passed into its chronic form and requires different remedies. To one accustomed to the advice to apply leeches to the cervix or peri- neum, pass the speculum, and apply solid nitrate of silver to the cervical canal, inject the vagina with solutions of persulphate of iron, keep the bowels constantly active by saline cathartics, etc., this plan may appear too inefficient to be relied upon. Of any one entertaining this doubt 1 would ask a trial and comparison of the two methods before he arrives at a decision which will guide his future practice. If his experience agree with mine, I do not doubt the resulting verdict. CHRONIC CERVICAL ENDOMETRITIS. 275 CHAPTER XVIII. CHRONIC CERVICAL ENDOMETRITIS. When inflammation of acute character affects the uterus, it has a marked tendency to invade the entire organ, and to involve both cervix and body but with chronic inflammation this is not the case. Being of a lower grade of intensity, it more strictly confines itself to the mucous mem- brane and limits itself to the body or cervix. Such limitation is, how- ever, neither universal nor absolute, sometimes subjacent parts being more or less implicated, and at others the mucous membrane of the entire organ being simultaneously and equally involved. Definition — By the term chronic cervical endometritis is meant chronic inflammation of the mucous membrane, extending from the os internum to the OS externum, as represented by the dots in Fig. 110. Fig. 110. The dots represent the site of chronic cervical endometritis. Frequency. — Of all diseases of the genital system of the female this is without doubt the most frequent, and, although not in itself a malady of dangerous character, may prove the starting point for some of the most serious and rebellious of uterine disorders. Exposed as the cervix uteri 276 CHRONIC CERVICAL ENDOMETRITIS, is to injury during coition, laceration from parturition, and irritation from walking, riding, and lifting, it is not surprising that its complicated in- vestment should frequently become the seat of disease. This aifection too is a frequent source of menstrual disorders, and very commonly produces sterility. Synonyms It has been described under the names of cervical catarrh, cervical leucorrhoea, and endo-cervicitis. Anatomy of the Cervical Mucovs Membrane The cavity of the cervix uteri is a fusiform canal, measuring about one inch and a quarter, begin- ning at the OS internum above and ending at the os externum below. On the anterior and posterior walls of the cervix are ridges, from which folds are given off which are arranged with regularity, and run obliquely up- wards and outwards, to end in other indistinct lines on the sides of the canal. This arrangement of mucous membrane has received the name ot arbor vitaj. Between these folds numerous mucous glands are seen, which are called by some the glands of Naboth.^ Dr. Tyler Smith^ estimates that a well- FlG. 111. Villi of canal of the cervix uteri, covered by cylindrical epitbelium aud containing looped bloodvessels. One hundred diameters. (T. Smith.) developed virgin cervix probably contains at least ten thousand of these follicles. The mucous membrane forming these folds or rugSE is covered ' A great deal of curio.sity attaches to the nature and function of these glands. Some regard the Nabothian glands as identical with the mucii>arous follicles, others look upon them as occluded glands distended by their retained secretion. 2 On Leucorrhoea, Am. ed., p. 38. PREDISPOSING CAUSES. 277 over by cylindrical and ciliated epithelium and studded by villi, which are found in considerable numbers upon the larger rugae and other parts of the mucous membrane. (Fig. 111.) The natural secretion of the cervical canal has been shown by M. Donne to be alkaline, unlike that of the vagina, which is acid. Pathology Cervical endometritis consists in inflammation of all this structure and consequent alteration of its condition. The mucous glands are especially involved in the morbid action, the disease chiefly consisting in glandular inflammation. The glairy mucus which is secreted in large amount as one of its symptoms is the characteristic discharge of these struc- tures. Looked at with a strong glass in post-mortem examinations of this disease, they are seen enlarged and elevated, and, according to Aran,^ their mouths may be seen very much dilated. In some cases it becomes com- plicated by granular degeneration. The villi or papillae, especially those on the vaginal face of the cervix, become diseased. At first there is a loss of the normal supply of epithelium, which produces a slight and very superficial abrasion. This becomes in time more distinct and mai-ked, from destruction of the villi themselves over spaces of greater or less ex- tent. If this process of destruction should go on and affect the deeper tis- sues, a true ulcer would be formed, and no one Avould ever have denied the name of ulceration to the existing condition, but it does not thus progress. In time an hypertrophy occurs in the villi, which increase in size, project like so many hairs from the surface, and give to the os and cervix an ap- ['carance which has caused the term granular degeneration to be applied f.0 it. This state affects the vaginal portion of the cervix chiefly, but may jxtend up the canal. Another pathological state, which is occasionally met with as a compli- cation of cervical endometritis, is an eversion of the os and lower portion of the canal to such an extent as to keep up inflammation there by the friction of the membrane, thus exposed, against the floor of the pelvis. Some very obstinate cases are due to this condition. The diseased mucous membrane pours forth with great activity large amounts of thick, tenacious mucus, which is loaded with epithelium and sometimes tinged with blood. Predisposing Causes — It is a matter of some moment that the etiology of this affection should be studied under two heads — predisposing and ex- citing. The former includes : — Natural feebleness of constitution ; The existence of a cachexia, as tuberculosis or scrofula ; Impoverishment of the blood from chlorosis or other cause ; Prolonged mental depression ; Insufficient nutriment ; « Mai. de I'Uterus, p. 423. 278 CHRONIC CERVICAL ENDOMETRITIS. Excessive lactation ; Frequent parturition ; Subinvolution ; Styles of dress which depress the uterus; Want of exercise and fresh air. These influences either act injuriously upon the nervous system, and thus interfere with the circulation and nutrition of the lining membrane of the cervix ; or by directly disordering the vessels and nerves of the uterus render it ready for the establishment of disease by some cause which would have exerted no baneful effect upon a woman in perfect health. It may naturally be asked why some of these influences should especially produce this disease. My answer is, that they do not do so. Sometimes they cause chronic pneumonia ; at other times granular eyelids ; at others follicular faucitis ; and again at others chronic cervical endometritis. Exciting Causes Chief among these may be enumerated : — Displacements of the uterus, especially flexions ; Excessive or intemperate coition ; The use of intra-uterine pessaries ; Puerperal endometritis ; Acute non-puerperal endometritis ; Exposure or fatigue affecting a subinvoluted uterus ; Efforts at production of abortion and prevention of conception ; Vaginitis, specific or simple ; Obstructive dysmenorrhea ; Cervical polypi ; Laceration of the cervix. Many other causes might be enumerated ; but these will suffice to shovr the nature of those influences which act as excitants of the disease. Many of those mentioned would fail to produce it in a uterus which had not been prepared for their action by depreciating constitutional condi- tions. When treatment is established for the cure of the disease, if it be inaugurated and pursued without regard to the predisposing causes, it will often prove inefficient or futile in cases which would yield to a plan that showed a recognition of their importance. Appreciating highly, as I do, the value of local treatment in uterine affections, were I in the manage- ment of the disease limited entirely to one kind — local or general — I do not hesitate to say tha-t I would infinitely prefer the latter. A removal from a city to the country, the use of mineral and vegetable tonics, plenty of good, nutritious food, the observance of regular hours, the systematic practice of exercise in the fresh air, and the pleasures of cheerful society, will, I feel confident, do far more for the patient than a weekly visit to the office of a physician and the reception of the most appropriate local treatment which science can afford. But better than either plan is the judicious combination of the two. They should go hand in hand. My PHYSICAL SIGNS. 279 wish is to keep prominent the fact, that of the two the general treatment is the more important in the disease which now concerns us, as it is in many others which we shall come to consider. Symptoms Cervical endometritis may exist for a length of time with- out presenting any symptoms of sufficient gravity to warn the patient of its presence. Even a leucorrhcea, which is somewhat abundant, often fails to attract her attention. The answer to a question as to its existence will often be a negative one in cases in which the practitioner will, by the speculum, discover a considerable amount in the vagina. In the great majority of cases l,he disease will soon announce its existence by some or all of the following signs. The first symptom which will attract attention will probably be dragging sensations about the pelvis. These will soon be followed by pain in the back and loins, which will be very much increased by exercise or muscular efforts. Tlien a more or less pro-" fuse leucorrhcea will be noticed, the discharge as it issues from the vulva resembling boiled starch or thick gum-water, and often irritating the vulva and vagina to such an extent as to produce inflammation in them. Menstrual disorders may now show themselves. The discharge may be either too scanty or too profuse, too frequent or too infrequent, and to a certain extent painful ; sometimes, though not often, decided dysmenor- rhoea will exist. Usually before the disease has existed for a long period, the constitution of the patient will show signs of becoming implicated. She will become nervous, irascible, moody, and often hysterical. Her appetite will dimin- ish and digestion grow feeble, so that impoverished blood will soon be observed as a result of impaired nutrition. With some or all of these signs of the existing disorder, the patient may continue for a length of time without suffering from others of more annoying or graver character. Complications may, however, rapidly develop themselves; cystitis, cervi- cal hyperplasia, and vaginitis coming on and proving exceedingly trouble- some. At times pain during sexual intercourse constitutes a prominent sign of cervical disease, but it belongs rather to cervical hyperplasia than to endometritis, the former having added itself as a complication to the latter, and thus produced the symptom. Sometimes nausea, and even vomiting, present themselves as symptoms, and these, togetlier with the digestive disorder before mentioned, produce a deterioration in the nutri- tion of the patient. Although these symptoms are enough to make us confident of the ex- istence of uterine disorder, they by no means furnish reliable grounds for a positive diagnosis. This can be arrived at oily by physical exploration. Physical Signs. — The patient being placed upon her back, and the finger of the examiner introduced into the vagina, the os uteri will pro- bably be found in its usual position in the pelvis, for the weight of the uterus is not increased, the connective tissue not being involved. The os 280 CHRONIC CERVICAL ENDOMETRITIS. may be somewhat enlarged and its lips slightly puffed, or it may be roughened on account of granular degeneration. Sometimes, however, severe cervical endometritis may exist without any enlargement of the os, or any trace of abrasion or granular degeneration. If the finger be placed under the cervix and that part raised by it, pain will be complained of, though not to any great extent. This will be most marked opposite the OS internum. No other affirmative sign can be elicited by this means, and the speculum should then be used. By this the os will be seen to be in the condition just described, and from it will be found to exude a long string of tough, tenacious mucus which will closely resemble the white of egg. If entangled by a small mass of cotton attached to the end of a whalebone rod, it will be found to be so viscid and resisting that it cannot be drawn from the canal. It will resist even a stream of water thrown with some force upon it, and very often is removed only after several efforts by this or other means. The cei-vix will usually be found to be somewhat enlarged. Its tissue may present a swollen, puffed appearance, or be intensely red as if in a state of granular degeneration, which will upon close inspection be found to be due to removal of its investing epithe- lium and the occurrence of hypertrophy of the villi. Should this condi- tion exist, it will afford relief to the mind of the inexperienced gynecolo- gist, for the diagnosis of the case will be clear. But another state of things may be discovered which will leave him in doubt. Upon removing the plug of obstructing mucus, he may discover no evidence of disease. The OS is no larger than it should be, its tissue is not reddened, no degene- ration exists, in fact nothing is found explaining the backache, nervous- ness, impaired nutrition, and profuse leucorrhoea which led him to advise and urge the examination. The case is simply one of cervical endome- tritis which affects the glands of the canal without having produced granu- lar degeneration. It is often a matter of great difficulty to decide w'hether endometritis is confined to the neck or extends through this part into the body. In many cases a certain conclusion is impossible. The evidences by which it may be usually arrived at are these : in the former case the neck alone is found enlarged and tender to touch, conjoined manipulation, and the probe ; in the latter, the body also shows these signs of implication of its tissues in the morbid action. The discharge resulting in the former is more thick, tenacious, and difficult of removal than in the latter variety. Lastly, the constitutional symptoms attending the latter are ordinarily graver than those created by the former. Course, Duration, and Termination Cervical endometritis is not u self-limiting disease, and consequently its duration will depend upon circum- stances which control its progress. It may unquestionably disappear with- out medical aid. Any alterative influence which exerts a complete change in the economy, as, for instance, parturition, entire alteration of the habitf? TREATMENT. 281 of life, or some change equally decided, sometimes results in a cure. But it is certainly safe to say that, unchecked, it frequently passes, in multi- parous women, into cervical hyperplasia, which would probably draw in its train displacement, and all the long list of ailments which make the lives of women sutiering from uterine disease so burdensome. Prognosis. — The prognosis of this affection will depend upon the degree of glandular disease accompanying it. If the mucus which marks inflam- mation of the glands be slight in amount, and not very tenacious in cha- racter, whatever be the extent of coincident granular degeneration, the prognosis is favorable. When, on the other hand, there is little granular disease, and a large amount of thick, resisting mucus hangs from the cer- vical canal, the prognosis, according to my experience, is very doubtful, and sometimes hopeless, unless very radical measures be adopted. If every practitioner will look back into his experience, he will see that in all severe cases he has either been forced to resort, for their cure, to measures which absolutely destroy the diseased glands, or that the patients in time, wearied of his insuccess, have gone for treatment elsewhere. Let it be remembered that I allude now only to very severe cases where the glands are profoundly involved. In regard to such, I feel sure that the experience of others must agree with mine. Even in minor cases great caution should be observed as to fixing the time at which recovery will take place. Even in the mildest case which has lasted for some time, from four to six months will probably elapse before perfect cure can be accomplished, and even after this a relapse will be very likely to occur unless preventive measures be adopted and strictly adhered to. Treatment — The disease consisting in cervical endometritis, the efforts of the practitioner should be directed to producing an alterative influence upon a mucous membrane which is in a condition of chronic inflammation, and the avoidance of all influences which may cause it to spread to adja- cent tissues. These ends will be best accomplished by the following means : — General regimen ; Emollient applications; Alterative applications; Ablation or destruction of the diseased glands. General Regimen — " The first care of the practitioner," 5ays Sir Charles Clarke, "should be to remove, if possible, the causes of the disease. . . Women who live in a moist atmosphere, who keep bad hours, who spend much of their time in bed, or who inhabit hot rooms (being generally weak women, and having a relaxed vagina), will be apt to be affected by the complaint." All such unfavorable circumstances should be modified. If any depressing influence, sucli as lactation, any habitual discharge, or 282 CHRONIC CERVICAL ENDOMETRITIS. any cause for mental anxiety, be discovered, it should be carefully removed, and the patient, unless absolutely plethoric, be put upon the use of vege- table tonics, the mineral acids, and preparations of iron. The functions of the alimentary canal should be constantly supervised. The diet should be mild and unstimulating, but most nutritious. No system of starvation should be entered upon, for the tendency of the disease is to the produc- tion of spanaemia, and this we should combat. A course of full diet is, on the contrary, often decidedly indicated; for, as I have elsewhere remarked, women commonly depreciate the vital forces by an unintentional starva;- tion. Under these circumstances I am often in the habit of prescribing the following course: the patient is directed to eat fresh animal food, eggs, butter, wheat, etc., three times a day at regular meal times. Then between breakfast and the midday meal to take either a tumbler of fresh milk, half a tumbler of cream, or a teaciipful of beef- tea, and to repeat this fluid but highly nutritious repast between the midday and evening meal, and again when retiring at night. It is surprising to see how often pa- tients will rapidly improve in all their functions under this course. The digestion will improve and constipation disappear or become greatly ameliorated, and under the improvement in the tone of the nervous system sleep will become more profound and refreshing. All spices and stimu- lating condiments should be avoided. Every day, unless some special con- traindication exist, the patient should take fresh air and exercise, by carriage or on foot for a time, which should be limited by the circum- stances of the particular case. If she should be unable to do this from any cause, she should be thoroughly protected, and pure air, even in win- ter, be allowed to circulate freely in her chamber, all the doors and win- dows of which should be opened for two or three hours daily. This plan, which is suggested by Prof. Byford, of Chicago, I have found a most ex- cellent one. The bowels should be kept regular by saline cathartics, and the skin in proper state by occasional baths. Care must be observed not to depreciate the strength by catharsis, and, to prevent this, a ferruginous tonic may be advantageously combined with a cathartic, as in the fol- lowing mixtures : — I^. Magnesise sulphatis, ^ij- Ferri sulphatis, gr. xvj. Acidi sulphurici dil. 31- Aquae, Oj. — M. One ounce (two tablespoonfuls) in a tumbler of iced water every morning upon rising. I^. Sodse et potass, tart. §ij. Vini ferri amari (U. S. D.), §ij. Acidi tartaric!, SiU* Aquae, ^xiv. — M. One ounce in a tumbler of iced water ever morning upon rising. EMOLLIENT APPLICATIONS. 283 Should one draught not be sufficient, two or even three may be taken daily, for the result will prove tonic and reparative as well as cathartic. If much disturbance of the nervous system should exist, the bromide of potassium in doses of five to ten grains, three times a day, will be found very useful. The appetite and digestion are so often impaired that special attention will generally have to be directed to alleviation of that collection of symp- toms which are grouped under the head of dyspepsia. The stomach sym- pathizing with the uterus does not perform its functions with vigor; the gastric juices appear to be wanting or inefficient, and fermentation of the food often takes the place of digestion. Under these circumstances I can recommend from lengthy experience with it the following digestive tonic : — ^. One rennet, washed and chopped. Sherry wine, Oj. Macerate for twelve days, then decant, filter, and add — Dilute nitro-muriatic acid, 5ij' Tinct. of nux vomica, 5ij' Subnitrate of bismuth, 3ij' One tablespoonful in a qnarter of a tumbler of water before each meal. This prescription combines the tonic properties of nux vomica and the peculiar alterative influences of bismuth, with a fluid which resembles the gastric juice. In many cases of habitual indigestion I have obtained from it the best results. Emollient Applications — The cervix should be irrigated every night and morning, by warm water thrown against it. To the water may be added chloride of sodium, glycerine, boiled starch, infusion of linseed, slippery elm, or tincture of opium. The irrigation should be so planned as to last for ten or fifteen minutes without fatiguing the patient or proving a source of annoyance to her. The methods for doing this are so fully described elsewhere that they need not be repeated here. In many cases of this affection of not very aggravated character, and which have not advanced to the production of granular degeneration or hyper[)lasia, if this plan of general tonic treatment and soothing injections be faithfully carried out, all complaints will cease on the part of the patient, and a cure be gradually effected. Should this result not be attained, or should the disease be discovered at the first examination to have pro- foundly involved the cervical glands, resort must be had to applications to the diseased surface through the speculum. In cases in which the lining membrane of the cervix is in a condition of granular degeneration, and the mucous glands are very little affected, cure can be almost as readily accomplished as where the same granular disease exists on the vaginal face of this part. But such cases will be treated of under the caption of " Granular, Degeneration of the Cervix ;" 284 CHRONIC CERVICAL ENDOMETRITIS, they do not properly come under consideration at tlie same time with the more obstinate disease of the glands. To make this statement more clear; cervical endometritis consists of glandular inflammation, which is some- times complicated by granular degeneration. In some cases the glands are very slightly diseased, while the villi of the canal are decidedly so ; these come under consideration rather as " Granular Degeneration," which will be treated of elsewhere, than as true endometritis. Alterative Applications — It will be found that cervical endometritis, existing in a canal the os externum of which is contracted, will always prove much more difficult of cure than in one where this part is dilated. The degree of dilatation will generally be found to exert a marked influ- ence over the tractability of the case. When then it is discovered that the disorder does not disappear under the influence of time, and the sim- ple measures already mentioned, as one of ordinary catarrh, it is always advisable to dilate this part before proceeding with more decided measures. If this be neglected, and the practitioner satisfy himself with passing through the constricted orifice, nitrate of silver, iodine, pencils of zinc, alum, iron, etc., once or twice a week, no good whatever will result. After months or even years of treatment, he will discover that the mild means which he has adopted have left the disease uncontrolled ; or that the severe ones have increased contraction of the os, which renders men- struation difficult and painful. The best and simplest method for overcoming the difficulty is to snip the external fibres of the os by scissors for an eighth of an inch, touch the raw surfaces thus made with nitrate of silver or solution of persulphate of iron to prevent union, and keep plugs of carbolized cotton in the canal for a week. Should there be any objections to this procedure, which is pain- less, free from danger, and efl^ectual, the same thing may be imperfectly accomplished by repeated dilatation by metallic sounds, or by tlie use of a tent of sea-tangle or sponge. The use of a tent which dilates the os externum, not passing within the os internum, is to a great extent free from the dangers attaching to those which invade the body. The os ex- FiG. 112. Syringe for removing cervical mucus. ternum having been dilated by one of these methods, the first if there be no special objection to it, so that free escape of the secretion of the muci- parous glands may occur, the canal must be thoroughly cleansed. Unless this be systematically done it will be imperfectly accomplished, and the ALTERATIVE APPLICATIONS. 285 thick, tenacious material will completely shield the diseased glands and neutralize any chemical agent before it can reach them. The most etfi- cient means for removing tliis plug is the syringe represented in Fig. 112. It is a syi-inge of hard rubber, two inches in circumference, holding an ounce, and so arranged as to be worked with one hand, the index and middle lingers surrounding the neck, and the thumb retracting the piston. Upon the extremity of its long pipe is slipped a bit of gutta-percha tubing, the free portion of which projects half an inch. This free portion readily enters the cervix, and goes up to the os internum. When introduced, the piston is powerfully retracted, the mucous plug is sucked in, and the cer- vix is left entirely clean. Where the material which covers the os is purulent or starchy, and not tenacious, a stream of water may be projected from this syringe against the cervix, and the whole be removed by suction ; or this may be done by a small pledget of carbolized cotton wrapped around a staff of whalebone, hickory, or bamboo, eight inches long, as thick as a pipe-stem, and taper- ing toward its extremity. Should the first pledget become saturated, it can readily be slipped from the staff and another wrapped in its place, or several rods may be prepared and kept ready for use. Fig. 113. Kod eight or nine inches long, wrapped with cotton. When the characteristic plug of tenacious mucus is present, there are but two methods which entirely remove it : one is the exhausting syringe ; the other the use of a dry sponge as large as a raspberry fixed in a long- handled sponge holder, or held in long dressing forceps such as those shown in F'ig. 2, and passed into the cervical canal and rotated so as to entangle the thick mucus. The sponge should be thrown away afterwards, for the repetition of its use might convey disease from one patient to another. A supply of such small pieces of sponge should be kept at hand, in order that a new one may be used for each patient. After having been cleansed by one of these methods, the cervical mucous membrane is exposed, and applications can be made to it with some prospect of their coming in contact with the diseased glands embedded in the jungle of convolutions which constitute the arbor vitfe. A neglect of the syste- matic removal of this material, I believe often prevents cure, and lience I am so minute in reference to what may appear an insignificant point. It is a fact, universally admitted in every department of therapeutics, that certain substances of greater or less strength as escharotics have the property, when applied to inflamed mucous surfaces, of so modifying the morbid action existing in them as to diminish its intensity and in time to check its progress. It is upon this principle that chronic inflammations 286 CHRONIC CERVICAL ENDOMETRITIS. of the fauces, urethra, bladder, and many other mucous surfaces are treated, and it is equally applicable to the part which we are considering. Alterative and escharotic substances may be applied to the lining mem- brane of the cervix uteri in the following ways : by painting solutions over the canal by a brush or dossil of lint, by touching the whole diseased area with drugs in solid form, or by leaving them for varying lengths of time in contact with the walls of the canal in a solid form, or upon cotton which has been saturated with solutions of them. Should the case be one of short standing and of no great degree of severity, the cervical canal should be thoroughly painted over with the compound tincture of iodine, a strong solution of nitrate of silver, glycerine saturated with tannin, or a saturated solution of carbolic acid. This may be done by using a brush of pig's bristles, which is far superior to one of camel's hair ; or, by wrapping cotton around a delicate probe of silver or whalebone and saturating this with the solution. Emmet's silver or Budd's vulcanite probe answers an excellent purpose. Fig. 114. Budd's elastic probe. ^^ Should the practitioner prefer to use a solid caustic, the nitrate of silver may, with great advantage, be employed, though the means generally adopted for applying this substance are inefficient. If a straight stick of lunar caustic be fixed in a quill or held in the grasp of a pair of forceps and passed into the os, by no possibility can the procedure accomplish what is desired. It may cauterize, and will probably do so with objec- tionable thoroughness, a quarter or half an inch of the lower portion of the canal ; but how can it be expected to go upwards for an inch and a quarter and come in contact with the whole surface inflamed, a surface remarkable for its inequalities and convolutions? Sir Benjamin Brodie many years ago, according to Dr. Barnes, of London, advised fusing nitrate of silver and allowing it to cool upon the tip of a probe for cauter- izing sinuous tracts ; and Chassaignac, of Paris, applied the same sub- stance to the cavity of the womb by coating platinum wires with it. Dr. F. D. Lente, of Cold Spring, N. Y., has experimented extensively in reference to this subject, and the result of his investigations has been to furnish the profession with the best and most reliable of all the means at our command for applying solid lunar caustic to the mucous lining of the uterus. Other methods which have been suggested and employed are these : the use of Lallemand's porte-caustique ; leaving a pellet of nitrate of silver in the uterine cavity to dissolve ; carrying up a small piece held in a delicate wire casing, etc. ; but none of these compare with Dr. Lente's, ALTERATIVE APPLICATIONS. 287 which is thus practised. A probe, somewhat similar to the ordinary uterine probe, is warmed and then dipped in a little platinum cup that contains nitrate of silver which has been fused over a spirit-lamp. Removing the probe after dipping it, and waving it for a few seconds, a film of the nitrate will be found to have covered its tip. It may then be again dipped, and the process repeated until a sufficiently large pellet is made to cover the end of the instrument. Figs. 115 and 116 represent the probe and cup. Fig. 115. Lente's silver caustic probe. Fig. 116. =c Lente's cup for fusing nitrate of silver. The cervical canal having been cleansed of mucus, and its direction learned by the ordinary probe, Lente's probe is passed up and rubbed against every part of its investing membrane, and dipped as carefully as possible into its convolutions before removal. After such an application, a stream of water should be projected against the cervix, and a pledget of cotton, which has been freely saturated with glycerine, with a bit of thread attached, should be placed against it. By means of the thread this may be removed by the patient in twelve hours. Tlie walls of the cervical canal may also be thoroughly cauterized by the introduction and retention of Braxton Hicks's crayons of sulphate of cojjper, iron, zinc, or alum cast in a mould of the length and size of the canal. The gelatine crayons of Chamberlain also answer very well. They are introduced into the cervical canal and kept i« situ by a roll of cotton. The zinc points may be allowed to dissolve, as they give no pain in doing so. Those of iron, alum, and copper should have a thread attached by which the patient may remove them when they cause discomfort. Alteratives in combination with cocoa-butter may be made into sup- positories two inches in length, and left in the cervical canal. Into these cervical suppositories may be introduced zinc, copper, iron, lead, or bis- muth, with opium, conium, or hyoscyamus. Fig. 117 repi'esents an instrument, originated by Dr. Sims, which con- sists of a silver probe surmounted by a slide, by means of which a roll of cotton soaked in any medicated solution may be left within the cervical canal. Two inches of the probe are wrapped with cotton which is soaked with 288 CHRONIC CERVICAL ENDOMETRITIS. the solution selected, and then passed into the cervical canal so as to be en Op. cit., p. 75. SYMPTOMS. 295 Uterine congestion with greater or less intensity. Dr. Tilt' remarks with reference to it : " It is useless to disguise the fact, connection has a down- right poisonous influence on the generative organs of some women." I cannot believe that the Almighty has ordained a function as essential to the perpetuation of our species which has a downright poisonous influ- ence on the generative organs of a healthy woman. And yet, to a certain extent, the statement is correct, for upon a Avoman who has enfeebled her system by habits of indolence and luxury, pressed her uterus entirely out of its normal place, and perhaps goes to the nuptial bed with some lurking uterine disorder, the result of imprudence at menstrual epochs, sexual intercourse has indeed such an influence. The taking of food into the stomach exerts no injurious influence on the digestive system, but the taking of food by a dyspeptic who has abused and injured the organ may do so. Injuries from sounds, etc., act so evidently in exciting inflammation as to need only mention. Certain conditions of the blood sometimes produce acute corporeal en- dometritis, which, as already stated, may pass into the form under con- sideration. As a complication of the exanthematous diseases, endometri- tis is well known, and its occurrence with phthisis has been noted by Dr. Gardner in the American edition of Scanzoni. Every practitioner must have noticed it in connection with that affection. Tumors in the cavity or walls of the uterus very generally produce this disease in consequence of the congestion of the mucous membrane which they cause. Vaginitis of non-specific character may, and of specific form often does, pass by continuity of structure into the neck and body of the uterus. The latter has in these cases in my experience not only affected the body, but the Fallopian tubes, resulting in peritonitis. Symptoms. — The symptomatology of corporeal endometritis constitutes one of the most unsatisfactory and obscure subjects in the entire field of gynecology. At times its symptoms are so slight and at others so masked and obscure, that the disease often runs a lengthy course without exciting the suspicions of either physician or patient. Its efil;cts upon the consti- tution also diifer most unaccountably in different cases. Sometimes the disease will continue for ten, fifteen, or twenty years, producing profuse leucorrhoea, menstrual disorders, and nervous derangement, and yet result in no annoyance so grave as to cause the patient to seek medical aid. At others it accompanies or excites areolar hyperplasia, which induces displacement and causes pain on locomotion, sexual intercourse, and the passage of feces through t-he rectum ; or results in an ichorous discharge, which creates the annoying symptoms of vaginitis, cystitis, or pruritus ' Op. cit., p. 234. 296 CHRONIC CORPOREAL ENDOMETRITIS. vulvae. The chief symptoms which usually present themselves in a case of mucous inflammation of the uterine body are — Leucorrhcea ; Menstrual disorders ; Pain in the back, groins, and hypogastrium ; Nervous disorders ; Tympanites ; Symptoms of pregnancy ; Sterility. Profuse leucorrhcea of glairy character is one of the chief signs of the affection. This when very tenacious and thick is the product of the cer- vical glands, but the lining membrane of the uterus likewise secretes a similar fluid, differing from it chiefly in possessing the qualities mentioned in a very much less marked degree. But uterine leucorrhcea differs from cervical in other particulars ; it is often more or less mixed with blood so as to have a rust-colored appearance, especially for a fortnight after men- struation. This, Dr. Bennet^ looks upon as being " as characteristic of internal metritis as the rust-colored expectoration is of pneumonia." It is a reliable and valuable, though by no means a universal, sign. Some- times the menstrual discharge is regarded by the patient as greatly pro- longed, when in reality it is this blood-stained leucorrhcea which follows the process of menstruation, that gives rise to the belief. In some in- stances the discharge is milky, and at others, and these are the most rebellious cases, perfectly purulent. There is a variety of corporeal endo- metritis which occurs in old women who have long ceased to menstruate, in which a watery or creamy pus is secreted. These cases are often accompanied by the most wearing and harassing pruritus vulvte. Menstrual disorders are rarely absent. The discharge is sometimes too profuse, even lasting throughout the month and constituting menorrhagia, or it is very scanty, and shows a marked tendency to cessation. Where the connective tissue is entirely unaffected, menorrhagia may occur without pain, but this is not common, for that tissue is often simul- taneously involved and dysmenorrhcea coexists. Sometimes in these cases, an exfoliation of the entire lining membrane of the cavity of the uterine body occurs at the menstrual periods. This has received the name of the dysmenorrhoeal membrane, and is by some regarded as an evidence of chronic corporeal endometritis. Pain in the back, groins, and hypogastrium is generally present, and at times a burning sensation over the symphysis pubis proves a source of great discomfort. Nervous symptoms of greater or less severity generally show themselves before the disease has lasted long. Tlie patient complains of neuralgic ' Op, cit., p. 76. COURSE, DURATION, AND TERMINATION. 297 headache, especially over the crown, hysterical symptoms, with sadness, tendency to weep, and a feeling of intense isolation and incapacity for any mental effort. Meteorism is a very common symptom, the connection of which with inflammation of the uterine mucous membrane is not, at first glance, clear. It is probably due to disorder of the nervous influences governing peris- talsis and giving tone to the intestinal muscular tissue, which proceeds to such an extent as to result in accumulation of gases in the canal. In the same way this affection may induce constipation, which is often one of its most obstinate accompaniments. Symptoms of pregnancy often exist in connection with the disease, and sometimes mislead the physician. Nausea and vomiting are by no means invariably present, but are valuable signs. They appear to result from this disease as they do from occupation of the uterine cavity by the pro- duct of conception. Sometimes, in addition to these, there are darkening of the areolae of the breasts, and enlargement and sensitiveness of the mammary glands. When to these are added abdominal enlargement, from tympanites and irregularity of menstruation, it will be perceived how easily an error might be made. Sterility is so commonly a result of endometritis that it should be con- sidered as one of its signs. Very often it has been the only symptom that has led to an investigation of the state of the uterus which has determined the existence of the disease. The affection does not, however, preclude the possibility of conception ; it only diminishes the probability. Physical Signs The physical signs are neither numerous nor reliable. Those of real value only will be mentioned. The uterine probe passed into the cavity will often show the length of the uterus to be greater than it would be in health, and create more discomfort than in a healthy uterus. Upon conjoined manipulation, two fingers being placed in the fornix vaginae, and the fingers of the other hand made to depress the anterior wall of the abdomen, sensitiveness will usually be found in the body of the organ. The recognition of the absence of cervical disease, while at the same time there are profuse uterine leucorrhoea and the other symp- toms recorded, will lead us strongly to suspect corporeal endometritis. Lastly, dilatation of the os internum may be taken as a corroborative sign. Course^ Duration, and Termination This disorder often lasts for years ; in the case of a nulliparous woman confining itself to the mucous mem- brane; in that of a woman who has borne children gradually exciting congestion and exuberant growth in the subjacent parenchyma. This is the most frequent result exerted upon the parenchyma, but it may be affected in two ways: 1st, a hyperplasia, or excess of nutrition, may occur; 2d, an aplasia, or want of nutrition, may take place, and dilatation and distention eventuate. 298 CHRONIC CORPOREAL ENDOMETRITIS. Complications — The most ordinary complications met with are dis- placement, vaginitis, granular degeneration of the cervix^ and pruritus vulv£B. Treatment Special attention should be given to sustaining and im- proving the general health of the patient, which will often show a marked tendency to depreciation. Good diet, fresh air, systematic exercise, and avoidance of all circumstances calculated to depress the spirits or harass the mind, should he recommended. If practicable, change of air and scene should be brought to our aid, and the patient be sent occasionally to some suitable watering-place or country resort. The healthy condition of the nervous and sanguineous systems will be fostered by these measures, and should medicinal tonics be required, iron, the mineral acids, quinine, the bromide of potassium, or nux vomica may be administered. All rich and highly spiced food should be avoided, and the patient should be guarded against habits of indolence and luxury which tend to exhaust the nervous strength. The uterus should be placed at rest by removal of pressure upon the fundus by clothing, limitation of marital intercourse, avoidance of violent and intemperate exercise, and if necessary, by a sustaining pessary. Should absolute displacement exist, it should be carefully rectified ; should laceration of the cervix exist, it should be repaired; and in case uterine enlargement or subinvolution be present, ergot in small doses should be systematically administered. Applications to the Uterine Cavity Upon theoretical grounds direct applications to the diseased endometrium would hold out a brighter prom- ise of cure in these cases than any other plan of treatment, and during the past quarter of a century it has become the conventipnal habit to recom- mend them. In this habit I have shared until closer observation and enlarging experience during the past five years have led me to become sceptical as to the utility of the course. Observation and experience have so changed my own practice that I find myself very rarely resorting at present to applications above the os internum uteri. That they may become necessary in certain cases I do not at all deny; but I maintain that they should not be habitually resorted to : 1st, because they very generally fail in curing the disease ; and, 2d, because they are by no means void of danger. That a certain number of cases of pelvic peritonitis and cellulitis are created by these applications all must admit. In spite of this fact their use would be decidedly indicated were their results very promising. But in my experience their results are not promising, and for this reason I have given up their general use. I shall nevertheless describe the methods 'by which such applications should be made as fully as possible. Recamier was the first who had the boldness to cauterize the cavity of the uterus, which he did by means of nitrate of silver in an ordinary TREATiMENT. 299 Fig. 120. porte-caustiqiie. The practice thus introduced was continued and spreiad abroad by Robert, Richet, Trousseau, Maisonneuve, and others, and to-day is still commonly resorted to. Tiiere are four methods by which it may be practised : 1st, by the use of sohitions painted over the surface ; 2d, by ointments left to melt in utero; 3d, by injections of fluid into the cavity of the body; 4th, by solid caustics. In commencing treatment the practitioner should see that the cervi- cal canal is well opened, in order to admit the free escape of fluids from the cavity above, and the ap- plication of substances through it from below. This perviousness, if it do not exist, should be secured by the use of dilators before the local treatment is proceeded with. If the uterus be found sensitive to vaginal and rectal touch, the patient should remain in bed for some days before the first application is made, the bowels be kept active by mild saline {Turgatives, and warm baths or hip-baths Avith co- pious vaginal injections employed. If the operator use the ordinary long, cylindrical speculum, he will in the majority of cases fail to accomplish the end in view, reaching the fundus uteri, for through such an instrument, it is always difficult to penetrate so high into the cavity. If, however, he uses the Sims speculum, or one of its modifications, or a short, cylindrical instrument, he will succeed with- out effort or delay. The instrument being intro- duced and the cervix cleansed by the speculum syringe, the operator very gently passes through the cervical canal a small and delicate cervical speculum. That shown in Fig. 120 is one of the best of its kind. Having previously wrapped the silver or hard rubber probe with a film of cotton, he now passes this up to the fundus. This removes a good deal of mucus i'rom the cavity which would otherwise have neutralized the caustic introduced. Removing the cotton from the probe, he wraps another piece around it, or, as is better, uses another probe al- ready wrapped, and, dipping this into the fluid caustic which he has determined to use, he passes it directly to the fundus and gently moves it over the surface. This should not be repeated, for the astringent action of the caustic makes repetitioh difficult, and if properly done the first time it will be unnecessary. After Wylies's cervical specu- lum, with probe passing through it. BOO CHRONIC CORPOREAL ENDOMETRITIS. this the patient should go to bed and remain perfectly quiet, until the next day at least, and if any discomfort exist, for several days. In place of the cotton-wrapped probe, the painting of the uterine surface may be very thoroughly accomplished by the use of a small brush of pig's- bristles dipped in the solution, and passed through the cervical speculum. The alteratives which may be thus employed are : — Solution of chromic acid 3J to §j water j Solution of nitrate of silver ^j or 3ss to ^j of water ; Compound tincture of iodine §ss to §ss of glycerine. Saturated solution of sulphate of zinc ; Saturated solution of sulphate ot copper ; U. S. D. solution persulphate or perchloride of iron with equal parts of glycerine. Solution of chloride of zino 5j to §j water ; U. S. D. muriate tincture of iron ^ij to §j water ; Saturated solution of carbolic acid. Use of Ointments. — The application of ointments to the lining mem- brane of the uterus is so inconvenient and disagreeable a process that I cannot recommend it. It possesses no special advantages. It is proceeded with in much the same manner as that of fluids, except that a different insti-ument is, of course, necessary for their introduction. One which answers the purpose very well is the invention of Dr. F. D. Lente. It consists of a syringe with a silver tube attached. The ointment to be employed is put into the syringe by a spatula, and, the tube being intro- duced into the uterine cavity, the piston is pushed forward and the oint- ment is forced out. The following are the ointments which are generally thus employed, though any others — as lead, bismuth, calomel, iodine, etc. — might be substituted : — ^. Argenti nitratis, ^ij ; Belladonnje ext. 3j ; Ungt. spermaceti, Qij. — M, 'Sf.. Pliuubi acet. 5ij' Morph. sulphat. gr. iv ; Butyr. cacao, §ss ; 01. olivje, q. s. — M. The Application of Alteratives of Solid Character to the Endometrium. — Substances of solid character which will melt under the influence of the heat of the body may be introduced into the uterine cavity in the form of suppositories or pencils. The pencils of zinc, copper, alum, or iron men- tioned in the last chapter may be thus employed, or suppositories made with cocoa-butter, or according to Becquerel's formula, may be used in- stead. Becquerel's formula is the following : — I^. Tannin, 4 parts ; Gum tragacanth, 1 part; Bread crumb, q. s. One to be gently pushed into the uterine cavity and allowed to melt, every four days. INJECTIONS INTO THE UTERINE CAVITY. 301 Upon first trying an intra-uterine suppository or pencil of a certain strength, I should advise that a thread be always attached to it in order that it may be removed by the patient in case ot" pain. After testing in this way, the thread may be dispensed with, but, as a preliminary precau- tion, its necessity is great. Cases are met with in which a few drops of water in the cavity of the uterus will cause pain, and I have seen the cau- tious introduction of the uterine sound cause violent epileptiform convul- sions. Should such a result follow the introduction of a medicated pencil which has slipped out of reach, the position of the introducer would be an unfortunate one. Injections into the Uterine Cavity — The subject of intra-uterine injec- tion has often come very prominently before the profession, and been fully and ably discussed. Many eminent authorities have pronounced in its favor, and reported hundreds of cases in which they have employed it with impunity and benefit. In the practices of many it is, indeed, a routine method of treating corporeal endometritis. While the evidence which has been adduced proves that with proper precautions this means of medica- tion is robbed of its chief dangers, it likewise makes it evident that in careless, inexperienced, or unskilful hands it carries with it manifold and serious perils. This method of treatment is not a new one, as many have appeared to think, but one of the oldest on record. It is certainly a suspicious cir- cumstance that, employed, as it has been at various periods, during 2000 years, it should have, even at our day, as many opponents as it now numbers arrayed against it. It may be suggested that the necessity for allowing escape of the injected fluid has been only recently recognized, and that therefore the safety of tlie method lias been only of late secured ; but this is not so, for in 1833, Melier, of France, employed a double canula constructed on the same principle as that of some to which I shall soon make allusion. In this connection it may not be unprofitable to take a rapid survey of the history of the subject. For most of my facts I am indebted to an exhaustive article by Dr. J. Cohnheim/ of Berlin, and translated by the late Dr. Kammerer,^ of this city. Intra-uterine injec- tions were employed and advised by Hippocrates, B. C. 400, for the purposes of washing out bits of retained placenta and medicating the surface affected by catarrh. They are likewise advised by Paulus -3^gi- neta, and, as we come down to later times, by Sylvius, Montanus, Am- brose Pare, Bottoni, Roderic a Castro, Mercurialis, Ludovic Mercatus, and Astruc. Otto, a translator of Astruc into German, in a note ex- presses the opinion that the fluid does not ordinarily penetrate into the uterine cavity, being prevented by the os internum, and says that " he ' Beitrage zur Therapie der Chronischen Metritis. Berlin, 1868. 2 Amer. Journ. Obstet., vol. i. p. 377. 302 CHRONIC CORPOREAL ENDOMETRITIS. knows of cases in which the use of the above 'beautiful remedies' was followed by attacks of severe uterine colic." Tiie method was again advised by Wenceslaus, Collingwood, Berends, and Steinburger, and op- posed with apparently equal warmth by Frank and Hourmann. The latter author drew attention to the dangers of the method by reporting a case of severe metroperitonitis, which resulted from a simple injection given for leucorrhoea; and immediately following his case three fatal ones were reported, two in Bretonneau's wards and one in Nelaton's. At a still later period they have been recommended by Recamier, Velpeau, Ricord, Kennedy, Retzius, Routh, Sigmund, Matthews Duncan, Tilt, Braun, Martin, Courty, Nott, Kammerer, and others, and been opposed by Oldham, Mayer, Bessems, H. Bennet, Gosselin, Depaul, and others. Cases of violent uterine colic, accompanied by great prostration, feeble and rapid pulse, faintness and coldness of extremities, are repeatedly re- corded even by the advocates of the method ; and peritonitis, ovaritis, and salpingitis, which have been recovered from, have been met with as results of the practice by Hourmann, Leroy d'Etiolles, Landsberg, Old- ham, Pedelaborde, Retzius, Becquerel, Noeggerath, myself, and others. Fatal cases of peritonitis have occurred to Bretonneau, Nelaton, Gubiau, Noeggerath, Von Haselberg,' Jobert,'^ and others. A case of sudden death from entrance of air into the veins has been met with by Bessems,* who, in post-mortem examinations, "found air-bubbles in the vena cava and heart." Another case ending thus suddenly is reported by Dr. Warner,* of Boston, as occurring at the Charity Hospital of St. Louis, where " a small quantity of water injected into the uterus occasioned im- mediately death. This result was evidently from shock." I do not find any statistical records from Dr. Simpson upon the subject, but the general impression left upon his mind concerning the method is thus plainly stated :^ " But, mark you, never think or dream of throwing liquids into the interior of the uterus by means of any injecting apparatus, for severe and fatal inflammations are very likely to ensue. Such a result may perhaps be caused by the fluid running along one or other patent Fallopian tube, and escaping into the peritoneum ; more probably it may be due to laceration of the mucous membrane and entrance of the fluid into one of tlie uterine veins ; but however it may be produced, the consequences of injecting fluid ^o the cavity of the w^omb are so often dangerous and deadly, that tli^^ractice has now been given up, I believe, by all accou- cheurs." In t|^ passage he alludes to injections into the non-puerperal uterus for dysiwhiorrhoea. BecquereP reports the practise as applied to ' Ainer. Journ. Med. Sci., April, 1870, p. 566. 2 Bennet on the Uterus, p. 287. 3 N. Y. Journ. Obstet., vol. i. p. 394. * Boston Gynecological Journal, vol. ii. p. 286. 6 Dis. of Women, ^. ed., p. 110. 6 Mai. de I'Ut^rus. INJECTIONS INTO THE UTERINE CAVITY. 303 six cases of uterine catarrh. " In one case only, the catarrh was dimin- ished; of tlie remaining five, three could be saved onlj' by energetic antiphlogistic treatment, the effects of the injection being exceedingly severe." Noeggerath reports four cases treated by injections ; in the first case, cure was happily effected ; in the second, cure was accomplished, but serious and protracted symptoms followed ; in the third case, metro- peritonitis was set up, but controlled ; and in the fourth case the patient died. There are two considerations in connection with this subject which must not be lost sight of. One of them is thus stated by Dr. Henry Bennet : " This accident" [fatal peritonitis, due, as he thought, to pas- sage of fluid through the Fallopian tubes] "would probably have occurred mucli oftener than it has done in the hands of French practitioners, were it not that the natural coarctation of the os internum must have generally prevented the fluid injected from penetrating into the uterine catnty." The other is this, that many cases of peritonitis, some fatal and others not so, which have been due to it have not been reported. One of the former and two of tlie latter have come to my own knowledge. The explanation formerly given of the accidents which may follow this procedure, was very naturally the penetration of fluid througli the Fallo- pian tubes into the peritoneum. But, although this does occasionally occur (see Von Haselberg's case as an example), it has been proved by experiment upon the dead body, as well as by observation of the practice upon the living, that there is a resistance on the part of the tubes which ordinarily prevents it. Experiments to test this matter have been care- fully conducted by Vidal, Klemm, and Hennig, and all with the same result. It is probable that entrance is resisted successfully by tubes whicli are healthy, but that dilatation and atony from salpingitis would render the patient liable to the accident. The deduction which the evidence elicited forces upon us is self-evident, namely, that at the same time that this method of treatment systemati- cally and carefully resorted to is a valuable resource in endometritis, it is attended by many and great dangers. While it is proved that with cer- tain precautions, and in the hands of one skilled in manipulations of this character, intra-uterine injections may usually be employed with safety, and profit, it is equally manifest that a certain number of deaths have been due to them, and that they are frequently followed by excessive pain and grave constitutional symptoms when the essential precautions are neglected. I should strongly recommend the general practitioner who is unfamiliar with the treatment of uterine disorders to avoid their use entirely, except in cases of uncontrollable hemorrhage, in which the cervix is well dilated and no flexure of the uterus exists. When he is induced to essay this plan in the treatment of corporeal endometritis, let him bear 304 CHRONIC CORPOREAL ENDOMETRITIS. in mind that the possibility of easy escape of the fluid injected is not an advantage merely, but an essential for safety. One very recent advocate of intra-uterine injections with a great deal of naivete makes the following statement : — ' " Though most frequently women do not sutler any pain when injections, even of a strong solution of caustic, are made into the womb, yet it some- times happens that symptoms which give great alarm to inexperienced persons do occur. The patient suddenly cries out, complains of violent colics, of pain in the womb like that of labor ; the abdomen becomes swollen, the face becomes pale, the extx-emities cold, the pulse small, and the patient is thrown into a state of great depression. These symptoms are sometimes accompanied with great trembling of the limbs and vomiting. "1 have related a case of this kind at the end of this memoir. Such a train of symptoms is undoubtedly alavuiiug in appearance, but is not fol- lowed by any fatal result." I confess to sharing the feelings of those inexperienced persons who are greatly alarmed at the development of " such a train of symptoms," for that it is alarming not only in appearance, has been more than abundantly proved by the occurrence of death in a number of cases. The experiments of Vidal, Hennig, ami Klemm force us to admit that passage of fluid through the Fallopian tubes is not as likely an occurrence from intra-uterine injections as one would suppose it would be from theo- retical reasoning. Cohnheirti, to whose admirable resume of this subject 1 am so much indebted, appears to regard them as conclusive. To my mind they are very far from being so. It is important to note that ex- periments performed on the cadaver are usually applied to healthy uteri and undilated tubes, while the gynecologist employs these injections in cases where the endometrial mucous membrane is inflamed, and the Fal- lopian tubes very often dilated in consequence. Is it not likely that a disease which overcomes the sphincteric action of the os internum uteri would likewise have a similar effect upon that of the metro-salpingian orifices? Post-mortem examination proves this to be the case. Then there are a number of cases on record in which such immediate inflamma- tory results followed in the peritoneum, that there can be little doubt as to the occasional relation as cause and eflfect. Take for example the report of a case by Pedelaborde, in L'Union Medicale for 1850, in which, " three min- utes after an injection of a decoction of walnut leaves, severe uterine pains ensued, and in a few hours were followed by acute peritonitis." A similar instance occurred to myself from injection of solution of persulphate of iron. Lastly, in a fatal case occurring to Von Haselberg, the metal iron was detected by chemical tests in one lube. If in a uterus free from dis- ease, whether in the cadaver or the living subject, a syringe be carried up ■ Gantillon on Uterine Catarrh, pamphlet, 1871. INJECTIONS INTO THE UTERINE CAVITY. 305 to, but not through, the os internum, and an injection made, the fluid will not enter the cavity of the body — and why ? Because corporeal en- dometritis lias not destroyed sphincteric action at the os internum. But in cases of t^ndometritis, where that action is destroyed, a paralyzation having been eflTected there by disease, how different is the case! Under such circumstances patients are often unable to use vaginal injections, for the reason that the fluid at once passes into the cavity of the body, and produces violent uterine colic. These cases are, I claim, precisely parallel, and ignoring the fact upon which I have here laid so much stress is not only invalidating experiments made to throvv light on a point of clinical importance ; it is absolutely perverting them to the production of evil. The medicinal substances which have been thus employed have varied very much with the views of different practitioners. Velpeau employed concentrated solutions of nitrate of silver; Ricord from two to three parts of tincture of iodine to one hundnxl parts of water; Evory Kennedy twenty to thirty drops of nitrate of mercury ; while Sigmund resorts to solutions consisting of half a drachm of nitrate of silver, one drachm of sul- phate of copper, one drachm of iodide of potassium with nine grains of iodine, two drachms of chloride of zinc, or three drachms of perchloride of iron, to three ounces of water. Hennig employs pure warm water for a time, then water slightly tinctured with iodine, and lastly, pure tincture of iodine or solutions of silver; Fiirst, one drachm of nitrate of silver to two of water ; Martin, of Berlin, five grains of aluminate or sulphate of copper to six ounces of distilled water; and Kammerer used ten to twenty drops of concentrated solution of chromic acid ; Lugol's solution of iodine and iodide of potassium, or pyroligneous acid, in weak solution ; or ten grains of sulphate of zinc to one ounce of water. Before leaving this subject I will embody in a series of propositions the most important facts connected with it. 1. Intra-uterine injections may produce death even when simple and unirritating fluids are employed, by peritonitis due to absorption of the fluid and subsequent phlebitis ; passage of fluid into the peritoneum ; en- dometritis (?) ; or by sudden entrance of air into a vein. 2. Even v/hen no such dire result takes place, they may set up severe uterine colic, with tendency to collapse, from hysterical neuralgia, violent uterine contractions like "after-pains," or intense irritation of uterine and tubal mucous membrane. 3. These dangers may be to a great extent avoided by attention to certain rules, which here follow : — «. Never inject the uterine cavity except with the certainty that the injected fluid can rapidly escape. Therefore always, unless the os inter- num be very much dilated, precede the injection by use of a tent, and always use a syringe insuring immediate reflux. The method for employ- 20 306 CHRONIC CORPOREAL ENDOMETRITIS. ing uterine injections is very simple, but should always be practised with great system and caution. A single tube of silver or elastic material like a catheter, with eyes at the side, may be used, provided the little syringe which projects the fluid be immediately removable so that the means of ingress may at once become the means of egress. We may, however, still more certainly insure egress by another instrument. The necessity for return of the injected fluid is so great that canulae with double canals or a canal and gutter have been constructed with especial reference to this. One of the most effectual and safest of these is the instrument shown in Fig. 121. Fig. 121. Molesworth's double canula and bulb syringe for injecting the uterine cavity. "When the India-rubber bulb is squeezed, the fluid which it contains escapes from holes in the end of the canula, and at once returns through another tube which lies alongside of it. Then, as the compression of the bulb ceases, a vacuum is created which sucks back every superfluous drop. b. The best substances for injection are tincture of iodine, nitrate of silver, sulphate of soda, pyroligneous acid, carbolic acid, and sulphates of zinc, copper, or iron in weak solution. It is best always to begin with the use of weak alkaline injections of warm water, not only to see how tolerant the uterus will prove to the process, but because in the experi- ments of Klemm on the cadaver, in three out of eighteen cases, blue ink injected through a narrow os with moderate force penetrated the venous system of the uterus and broad ligaments without apparent laceration. After tolerance has been tested, stronger solutions may be used. c. Always use solutions at a temperature of at least 85° to 90°. d. Wash out the cavity with warm fluid before using the stronger ap- plication; and in injecting always be sure that there is no air in the syringe, and never eject the fluid which it contains with force. e. Never employ this method in a sharply flexed uterus before replace- ment, never just before or after a menstrual period, and never when pelvic peritonitis or periuterine cellulitis has recently existed. /. After the use of this plan let the patient lie down until all sense of discomfort has passed, and confine her to bed and give opium freely on the first appearance of pain. 4. In uterine colic the most certain and immediate relief will follow the use of morphia by the hypodermic syringe. Astruc advised the addi- tion of narcotics to injected solutions for the prevention of the accident. AREOLAR HYPERPLASIA OR CHRONIC METRITIS. 307 o. Lastly, although this plan of treatment, robbed of many of its dan- gers by the precautionary measures here advised, may be comparatively safe in the hands of specialists skilled in uterine manipulations, it will always remain a hazardous method for the general practitioner who lacks such skill and who employs instruments not entirely suited to the [)urpose. It may now be asked, since I oppose the habitual practice of carrying applications above the os internum uteri as well as that of injecting the uterine cavity, what course I do advise and adopt in the management of this atfection. As I have already stated, I would recommend careful attention to the general state, removal of displacements, cure of lacera- tion of the cervix, extirpation if possible of any existing neoplasm, and, if uterine enlargement exist, the free use of ergot. To favor the free escape of mucus from the uterine cavity I would see that the cervical canal be dilated. And now if improvement did not occur I would apply the dull wire curette freely over the whole surface. In speaking of the pathology of corporeal endometritis, it was stated that the diseased mem- brane in time develops upon its surface fungoid granulations, mucous cysts, and mucous polypi. These secondary conditions often result in metrorrhagia or menorrhagia. Not only does the gentle application of the little wire curette without cutting edge accomplish the removal of these, it produces, when thoroughly applied, an altered state in the entire en- dometrial membrane, breaks distended bloodvessels, and often accomplishes a great deal for the relief of the disease. In cases of endometritis engrafted upon subinvolution and accompanied by hemorrhage, it is especially ap- nlicable. But its beneficial results depend, I feel sure, upon the fracture of tortuous and distended bloodvessels, and it is chiefly for this purpose tliat I use it. The use of the dull wire curette does a greater amount of good in these cases at the expense of less risk than the applications just mentioned, and 1 infinitely prefer it. CHAPTER XX. AREOLAR HYPERPLASIA OF THE UTERUS— THE SO-CALLED CHRONIC PARENCHYMATOUS METRITIS. Definition and Nomenclature. — One of the most common pathological combinations which confronts the gynecologist is that which I here en- deavor in as concise a manner as possible to picture. A patient calls upon 308 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. him for relief of backache ; pelvic pains ; dragging sensation about the loins; "bearing-down pains;" leucorrhoea ; menstrual disorder, tending chiefly to excessive flow ; throbbing sensation about the uterus ; general feeling of despondency ; malaise and weakness ; and irritability about the bladder and rectum. All these rational signs pointing to the uterus as the probably delinquent organ, a physical exploration is made, and furnishes the following results : the uterus is usually discovered to be in the condition of descent, retroflexion, or anteflexion; it is voluminous, tender to the touch, and evidently engorged with blood; from the cervical canal a leucorrhoeal matter pours ; the probe carried to the fundus finds it tender, and creates the flow of a little blood ; the cervix is often in a condition of granular or cystic degeneration ; and a low grade of vaginitis exists. To this pathological combination the more superficial diagnostician will often apply a name which announces one only of the existing conditions, as, for example, uterine catarrh, ulceration of the cervix, or retroversion or prolapse. The more reflective and intelligent examiner will ordinarily group the coincident morbid states together under the name of " chronic metritis." The latter would be fully sustained in his position by authority as abun- dant as it is orthodox, for by systematic writers, since the days of Reca- mier, this uterine state has been described as one of " chronic parenchy- matous metritis." Only within a very recent period have the pathologists of the German school begun to question the validity of this conclusion, which, taking its origin in France, was spread through England and America chiefly by the writings of Dr. Henry Bennet. According to this view the following pathological changes were believed to be those resulting in the condition just described. In the first stage the parenchyma was regarded as gorored with blood, a state of active congestion existing. This was supposed soon to pass into the second stage, consisting in an effusion of lymph, when, unlike a similar process in other parts, the morbid action ceased, or rather did not advance, and unless relieved by treatment, con- tinued stationaiy for a length of time. The third stage of inflammation in other parts, that of suppuration, was admitted to occur rarely here, or in the parenchyma of the body, but in time all inflammatory action ceas- ing, the cervix remained large and indurated without sensitiveness, or the effused lymph might be absorbed, and great diminution in size occur with! induration. Were this really the case the condition would constitute onei of inflammation, even if we restricted ourselves in the use of that ambigu- ous term to the narrow and precise limits prescribed by Dr. J. Hughes 1 Bennett, when he says, " It should be applied only to that perverted alte- ration of the vascular tissues, which })roduces an exudation of the liquor j sanguinis ; it is this exudation alone which can be held to unequivocally characterize an inflammation." AREOLAR HYPERPLASIA OR CHRONIC METRITIS. 309 Examined more recently, however, by the more certain and less theo- retical processes of modern science, all this has come to be looked upon as erroneous. Cases which were formerly regarded as instances of inflam- mation on account of the existence of enlargement, congestion, and tender- ness upon pressure, the microscope now proves to have been instances of excessive growth of the connective tissue of the uterus, with congestion, and resulting hyperaesthesia of its nerves. It may result from three entirely different pathological states : first, from interference with retrograde metamorphosis of the puerperal uterus from any cause; second, from congestion long kept up by mechanical causes, such as displacement ; third, from a formative irritation or state of hyper- nutrition excited by endometritis, or the existence of fibrous tumors. Whatever be the originating pathological condition, that which results and which we are now' considering consists in hyperplasia of connective tissue as its most marked feature, and of congestion and nervous hyperaesthesia as important accompaniments. It is true that some progressive writers still cling to the name chronic inflammation, and apply it to hyperaemia resulting in hypergenesis or hy- pertrophy of connective tissue, but this is by no means the signification which is ordinarily given to the term. Indeed, with reference to the ute- rus, so vague and unsatisfactory is the appellation chronic metritis, that there is no knowing what idea one who uses it really intends to convey. He who has in the library and at the bedside been perplexed and dis- heartened by the constantly recurring uncertainty which it has induced, will have learned to appreciate the feeling which prompted two eminent pathologists, Andral and J. Hughes Bennett, to propose that the vague term " inflammation" should be expunged from our nomenclature. To quote the words of an accomplished writer of this city: — " The entity inflammation, fallen from its high and palmy state, is hanging by its eyelids as a pathogenic factor in most of the organs of the body ; its last resting place seems to be the womb, and here still it has a good foothold. Why should uterine pathology alone be cumbered by an outworn theory?" It is not an entirely correct statement that this pathological doctrine originated in France. Upon the revival of gynecology in that country by the labors of Recamier, it likewise revived and assumed important pro- portions. But the theory of parenchymatous inflammation as explaining this condition is as old as the science of medicine itself, and it certainly is a peculiar commentary upon it, that now, in the most advanced period that the science has ever known, the retention of it not only results in doubt, uncertainty, and scepticism, but absolutely creates controversial discussion, and forms sects and factions, where all should be united for the common good. " All must mourn," remarked the late Professor Hodge, " over a discrepancy of opinion which bears so directly on the treatment 310 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. of such painful and distressing maladies." " We cannot but believe," says Meredith Clymer, " that the time is not far off when this vexed but important question will be re-opened, and examined in a fair-judging, and not peremptory and dogmatic spirit, uninfluenced by prejudice, prescrip- tion, or tradition ; and that, measured by a new standard, and settled by the I'equirements of a more enlightened knowledge of the laws of life, present differences will be reconciled, hostile opinions conciliated, and the angry voice of adverse factions be heard ' not any more forever.' " Everywhere throughout the recent and progressive literature of gyne- cology, the foreshadowing of the advancing change in views with regard to this subject will be recognized. The pendulum, swung too far by the hand of Dr. Henry Bennet, is making its inevitable return. That it may stop on safe middle ground must be the hope of all. " The determi- nation of blood to a part here noticed, characterized by dilatation of the arteries, with increased flow of blood through the capillaries, must be dis- tinguished from the congestion of inflammation, characterized by the accumulation and stagnation of red and white corpuscles in the vessels, tending to be abnormally adherent to each other and to the vessels," says Dr. H. G. Wright,^ quoting from Dr. Aitken. "Tested by this standard," that of Dr. J. Hughes Bennett, already quoted, says Dr. Graily Hewitt,^ "the uterus is certainly very little liable to ' inflammation ;' exudation, and transformations of such exudations, purulent and otherwise, similar to what may be witnessed in other organs of tlie body, being very rarely witnessed in the parenchyma of the uterus. The morbid processes with which we are familiar as affecting the tissues of the uterus are for the most part alterations of growth, irregularities in growth, slight modifications, in fact, of the processes which follow each other in due succession in the natural condition of things. The word ' inflamination,' used in Dr. J. Hughes Bennett's sense of the word, certainly fails to convey an adequate idea of tlie modifications observed under such circumstances." " Diffuse growth of connective tissue," says Klob,^ " constitutes the so-called indu- ration, hitherto considei-ed as a result of parenchymatous inflammation of the uterus. . . . For reasons mentioned, I would also advise a disuse of the term ' chronic inflammation.' " In a discussion* upon chronic metritis before the New York Academy of Medicine, Dr. Noeggerath limited the disease to " growth of the cellular tissue both of the body and neck, occurring only during the puerperal state." Dr. Peaslee preferred " to call the disease under consideration congestion, rather than inflamma- tion, because it has none of the events of inflammation ;" and Dr. Kam- merer expressed the view that " chronic inflammation of the substance of the non-puerperal uterus is never met with ; what has been described as 1 Uterine Disorders, p. 218. « Dis. of Women, p. 363. 8 Op. cit., p. 129. * Med. Record, No. 92, p. 475. AREOLAR HVPERPLASIA OR CHRONIC METRITIS. 311 such is hypertrophy of connective tissue, resulting from long-continued hypertemia." These views, which among men who are in the advance in gynecology are rapidly gaining ground, are not sustained by analogical reasoning, but by anatomical proof. I know of nothing which will more surely convince the reader of the necessity for an alteration in our nomenclature concern- ing tliis condition, than a perusal of Scanzoni's^ article upon it. This author, after heading his chapter, " Chronic Parenchymatous Inflammation of the Womb," goes on to say : " The nature of the disease would then be, in an anatomical point of view, an hypertrophy of the cellular tissue." Certainly the " anatomical point of view" is an important one, and it is supported by what we observe from a clinical stand-point. So much evil has arisen for pathology and treatment from the use of the term chronic metritis, and so clear a demonstration has been made that the condition so called is not one of true inflammation, that some other ap- pellation is not only desirable, but has become absolutely essential. It is incontestable that there is a peculiar condition that affects the uterus which is characterized by distention of bloodvessels from vital or mecha- nical cause ; effusion of the serum of the blood ; and hypergenesis of con- nective tissue. To denote this state, gynecologists have long required a name, for medical nomenclature is as necessary as it is faulty. Lisfranc felt this need when he styled it " engorgement ;" Hodge when he entitled it " irritable uterus ;" Bennet when he called it " metritis ;" and others also have acknowledged the necessity, Klob, for example, in " habitual hypera?mia" and "diffuse proliferation of connective tissue," and Kiwisch in " infarctus." The appelhitions infarctus, engorgement, and hyperaemia only convey a partial idea of tlie truth ; they only announce one element of the con- dition— congestion ; while that of irritable uterus ignores all structural change in announcing another element — nervous hyperaesthesia. At the same time that the phrase " diffuse proliferation of connective tissue due to hypera?mia," which is emi)loyed by Klob, clearly defines the pathological condition, it is too long and burdensome to answer the purpose of a name to be conventionally employed. If there be a term now in existence which does really convey the idea truly and completely, it should surely, in the interests of pathology and treatment, as well as out of consideration for the overburdened student of medical nomenclature, be employed in prefer- ence to the adoption of a new one. Enlargement of an organ due to for- mation of new cells similar to those of the tissue in which they are de- veloped, has been styled by Virchow, hyperplasia, in contradistinction to hypertrophy, which consists in increase of size from distention of cells already existing. As the condition of the uterus now under consideration • Dis. of Females, Am. ed., p. 181. 312 AREOLAR HYPERPLASIA OR CHRONIC METRITIS, is one arising from over-excitation of the vaso-motor and excito-nutritive nerves, a " formative irritation," as Klob styles it, and resulting in a numerical hypertrophy, it appears to me that the term areolar hyperplasia would more correctly designate it than any other with which I am ac- quainted. With a sincere desire to lessen and not to increase the labors of the student and the perplexities of tlie gynecologist, I shall therefore replace the confusing term chronic metritis, by that of areolar hyperplasia of the uterus. Tliat the term is faultless, I do not claim. To one unaccustomed to it, it must even appear peculiar. I have merely to ask for it a favorable consideration on the grounds that it is faithfully descriptive of the condi- tion to which it is applied, and that a decided necessity for some such term exists. In a very fair, critical review^ of the third edition of this work, the reviewer remarks that this name " involves the notion that the connective- tissue elements alone hypertrophy, and disowns the muscular element as the one most readily provoked to increase. We do not deny that, in the disease in question, there is hyperplasia of connective tissue, or, at any rate, of non-muscular elements ; but we must aver our belief that concomi- tantly there is increase in the muscular elements also." At first glance, this appears to be a very strong point of objection ; but I think that even the writer himself will, upon more careful examination of the views of pathologists, agree that they look upon the proliferation of areolar tissue as ahvays the characteristic or highly predominant feature of the condition, and regard muscular growth as an insignificant accompaniment only. For obvious reasons it is impossible for me to quote largely to sustain this position, and I confine myself to the statement of Professor Klob,^ who, in speaking of this condition, expresses himself in the following terms : " The whole uterine connective tissue sometimes proliferates either with- out accompanying increase of the muscular substance, or, if this does occur, the connective tissue predominates to such an extent that the mus- cular substance is comparatively of not much account." It is true, that, while most who have investigated this subject have found, like Klob and Scanzoni, a great preponderance of connective tissue, and an insignificant increase of muscular elements, some have declared that the muscular structure is greatly hypertrophied. One reason for this variance of opinion is this : the most prolific source of areolar hyperplasia, the so-called chi-onic metritis, is interference with involution of the par- turient uterus. What begins as subinvolution ends, in time, in a condi- tion ordinarily styled chronic metritis. He who examines early will • Brit, and Foreign Medlco-Chirurgical Rev., Jan. 1873. * lu the American translation of Klob the rendering is not this ; but Dr. Kammerer. the translator, informed me that that passage is not correct, but that this is. PATHOLOGY OF AREOLAR HYPERPLASIA. 313 probably find a greater amount of muscular elements than he who does so later ; and let it be remembered that by continental writers, with one ex- ception,^ no recognition is made of subinvolution as a disease distinct from what Chomel styled it, post-puerperal metritis. In this way I reconcile the researches of Klob, whose statement I have quoted, with those ol' Finn,^ who reports the following observations, made at the Institute of Pathological Anatomy in St. Petersburg : — " 1. The normal disposition of the single muscular fibre, as well as of the muscular bundle, remains unchanged. " 2. The muscular fibres do not change in quality, neither is their fatty degeneration a pathognomonic sign of this disease. "3. The muscular fibres are always extended in both their length and breadth above their normal standard, but more so in the former direction. '•4. The number of fibres is always largely increased. "5. The amount of connective tissue in the latter stage of the disease is always relatively diminished, but absolutely enlarged, so that the in- crease of bulk of the uterus is mainly caused by the h3'perplasia of the muscular fibres, the augmentation of the connective tissue iufiuenciug it buthttle." If the disease really consists in a proliferation or hypertrophy of the areolar or connective tissue of the uterus, and not in chronic inflammation, it would certainly be advantageous to apply to it some name which would signify that fact. "•Areolar hyperplasia"^ expresses this fact concisely, and hence I have employed it. Pathology of Areolar Hyperplasia. — The vast majority of cases are due to interference with that retrograde metamorphosis occurring in the puer- peral uterus, styled involution. To comprehend the pathology of cases thus arising, it will be necessary to consider the physiology of that process as well as the pathological conditions which may affect it. It is only within the last quarter of a century that we have understood the process by which the uterus, an organ measuring three inches, in the short space of nine months enlarges so as to contain a child or even /wo or three children, and then within two months after delivery, undergoes so rapid an absorption as to return to its original size. The credit of elucidating the subject belongs chiefly to Germany, for it is to Virchow, Franz Kilian, Heschl, Kolliker, and Retzius that we are most indebted. The important pathological fact that arrest in or disturbance of this process constitutes a condition of disease emanated from Sir James Simp- son, who, in 1852, published the first article which drew especial attention to it. His article was entitled, " Morbid Deficiency and Morbid Excess ' M. Courty. 2 Am. Journ. Obstet., vol. i. p. 264. 3 Hypertrophy signifies excessive growth of the elements of a tissue already existing ; hyperplasia signifies the development of new tissue. 314 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. in the Involution of the Uterus after Delivery." Since that time, the condition which now engages us has become generally recognized as a uterine state of great frequency and moment. To fully compreliend this part of our subject it is necessary to bear in mind the component parts of the healthy uterine parenciiyma. It con- sists of five elements : 1st. Fusiform fibre cells, or, as they are termed, the smooth muscular fibres ; 2d. Round and oval nuclei, which are sup- posed to be elementary fusiform fibre cells ; 3d. Amorphous or homoge- neous connective tissue, which permeates the parenchyma and binds together the fibre cells and nuclei ; 4th. Fibrillated connective tissue or white fibrous tissue ; and 5th. Elastic fibrous tissue. These elements, together with nerves, bloodvessels, and lymphatics, make up the tissue of the uterus, which is covered by a serous membrane externally and a mu- cous membi'ane within. No sooner does this structure feel the stimulus of conception than it develops rapidly, partly by growth of already existing structures and partly by new formations. Tlie round or oval nuclei rapidly develop into fusiform cells, and these as rapidly grow into colossal cells which grow longer and more powerful as pregnancy advances. "A new formation of muscular fibre also takes place, "^ the connective tissue elements grow proportionately, and tlie bloodvessels enlarge. Parturition occurs, and almost immediately a retrograde evolution begins to restore the uterus to its original constituency. The fully de- veloped fibres undergo a fatty degeneration ; the fat thus formed is absorbed, and the organ rapidly diminishes in size and weight. This fatty degen- eration affects the organ after the fourth day subsequent to delivery, and, according to Heschl, the commencement of a new formation of muscular fibres is recognized in the fourth week after labor, in the form of nuclei and caudate cells. At the end of the eighth week tlie uterus has returned to its normal state. Certain untoward influences may retard or check this process, and the uterus remain flabby and large, when it is said to be in a state of subin- volution, or arrested retrograde evolution. Thus far we have been dealing with facts thoroughly ascertained by histological investigations and fully established by evidence yielded by the microscope. But from this point the pathology of subinvolution is not so satisfactorily settled. Prof. Simpson declared that the disease was due to the fact that " this retrograde metamorphosis of the uterus has not taken place during the puerperal month, or has taken place only to such an imperfect degree that the uterus is of the size we usually see it have at the end of the first week or so after delivery;" but he entered, if I may judge from the posthumous volume of his work upon Diseases of Women, ' Arthur Farre, Cyc. Anat. and Phys., article Uterus. PATHOLOGY OF AREOLAR HYPERPLASIA. 315 upon no detailed account of the existing pathological defect in the organ. Since his writing, it appears to have been agreed upon that this consists of persistence of the muscular fibres, characterizing pregnancy, in a state of fatty degeneration. TliQs Dr. Wright^ says, " Pathologically it closely corresponds with that state of tlie heart structure so admirably described by Dr. Richard Quain, and commonly known as fatty degeneration." Dr. West^ expresses himself thus : " Though fatty degeneration of the tissues takes place, yet the removal of the useless material is but imper- fectly accomplished, while the elements of the new uterus are themselves, as soon as produced, subjected to the same alteration." I search in vain the literature of the pathology of this subject for a basis for these hypo- theses. That literature is scanty in the extreme as yet, and the subject awaits extended researches before we can speak intelligently' of it. The day has passed, however, when we can let probabilities in pathology pass current for facts. The best, indeed I may say the only detailed account of this condition studied by the microscope, which I have been able to obtain, is one by Dr. Snow Beck,^ of London. "The enlargement of the uterus did not depend so much upon an increase in the size of the contractile fibre-cells, as upon an increased amount of round and oval globules, with amorphous tissue in the uterine walls. . . . The essential condition of the organ consisted in the elements of the different tissues retaining a portion of the natural enlargement consequent upon impregnation. But this enlarge- ment was more due to the increased size and amount of the soft tissue present in the walls of the uterus, as well as at the internal surface, than to the increased size of the contractile fibre-cells." Marked congestion existed, the bloodvessels being large and forming a complete and continuous system with the capillary network on the inner surface of the uterus. No allusion to preponderance of muscular fibres is anywhere made, and no mention of fatty degeneration occurs. The condition of the uterine cavity is important. It is always increased in size, the glands of the cervix are usually enlarged, and upon the lining membrane of the cavity fungoid growths are commonly developed. This is all that can with positiveness be said of the pathology of the early periods of subinvolution in the present undeveloped state of the subject. The uterus, the study of the tissues of which gave Dr. Beck's results, measured 3^ inches in length, 2^ inches across the fundus, the walls were If inches thick, and the uterine canal was 3 inches deep. As time passes the uterine walls diminish in size, their tissue grows less ' Uterine Disorders, p. 221. 2 Dis. of Women, 3d Eng. ed., p. 89. 3 London Obstetrical Trans., vol. siii. p. 239. 316 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. vascular, the bloodvessels become smaller, and the uterine cavity assumes smaller dimensions. But the organ does not assume its original size; it remains large, dense, tirni, and sensitive ; for years presenting the charac- teristic appearances of the so-called chronic parenchymatous metritis. Although taking an entirely different view of the pathology of chronic metritis. Dr. West' signalizes almost the same fact in the following words : " It must, however, be at once apparent, that after inflammation has passed away, its effects may remain in the larger size and altered structure of the womb, and that the very nature of these changes will be such as to render the repair of the damaged organ both unlikely to occur, and slow to be ac- complished, and must leave it in a condition peculiarly liable to be aggra- vated during the fluctuation of circulation, and alternations of activity and repose, to which the female sexual system is liable." This is just the state to which I allude at the commencement of this chapter, as one exist- ing years after labor, and which, attended by congestion, displacement, catarrh, and granular degeneration, is styled chronic metritis. It is, I think, this state which most frequently furnishes instances of areolar hyperplasia to the microscope. Let any one faithfully and patiently watch a case of subinvolution for a year or two with reference to this point as I have repeatedly done, and I cannot doubt that he will have the same evidence which makes me so strong in my present belief. Lastly, let it be remembered, that by the French school no condition of arrest of development is recognized as ac- counting for it; these are cases of "post-puerperal metritis," metritis, according to M. Gallard,^ without symptoms, ''chronique d'emblee." Does any one claim that between this condition and chronic metritis a difference should be made? Let him tell me by what means he can at the bedside distinguish one from the other, and I may agree with him. There are no means for such differentiation. If the uterus be very large and the patient recently delivered, the case is termed subinvolution by English writers; if its dimensions have diminished, years have elapsed since par- turition, and the almost universal accompaniments of the condition, leu- corrhoea, granular degeneration, and displacement, be present, it is styled chronic metritis. Arrest of involution of the puerperal uterus is an occurrence of very great frequency. It constitutes the chief cause of all chronic uterine dis- orders, and for this reason its importance cannot be overestimated. Until this subject receives the attention which it deserves, the present confusion as to the causes, pathology, and general features of chronic metritis, which helps to weaken uterine pathology, must continue. As a very general rule, areolar hyperplasia, the so-called chronic metri- tis, is a consequence of subinvolution. This constitutes the explanation ! Op. cit., p. 89. 2 Op. cit., p. 372. PATHOLOGY OF AREOLAR HYPERPLASIA. 317 of the fact that so large a number of women with uterine affections refer their illnesses to child-bearing, and that so many who are well until that process remain invalids afterwards. Go back to the commencement of all cases of uterine disease, and a very large proportion will date from parturition. These hyperplastic or subinvoluted uteri were those which chiefly furnished Lisfranc's cases of " engorgement," which Jobert " melted down" with the actual cautery, and which hundreds to-day are treating by powerful caustics as parenchymatous metritis. The question may be asked, do 1 myself not blister, apply leeches, and even amputate the cervix in these cases? The element which sustains the disease is an excessive supply of blood ; to diminish this is to strike at the root of the evil. In areolar hyperplasia I blister lightly, to exert an alterative in- fluence upon the nerves ; for the relief of coincident congestion, I leech occasionally, as I would for hyperaemia elsewhere ; and I amputate, as I would do the enlarged tonsils ; but nowhere would I treat the condition as inflammation. The only apology which I offer for enlarging still further upon this part of my subject, is contained in the fact that I regard it as one of the most important points in the whole of uterine pathology. Even by Parisian writers, who above all others have been wedded to the theory of chronic inflammation, the dependence of a peculiar form of so-called chronic me- tritis upon disordered involution has been recognized. " The commence- ment of chronic metritis," says Gallard,^ " is so insidious, that it is often difficult to determine its date in each particular case. So rare are cases of true acute metritis which, in perpetuating themselves, become chronic, that it is generally admitted that the disease is, to a certain extent, chronic from its commencement. Nevertheless, I consider this passing of acute into chronic metritis as much more frequent than most authors think . . . Aran, after having contested this, was forced to recognize, as the origin of the greatest number of cases of chronic metritis, acute metritis follow- ing parturition. This acute stage often passes unnoticed among the sequelas of labor, scarcely disturbed by slight febrile movements, which excite no suspicion of uterine inflammation so long as they do not present them- selves with the alarming symptoms so characteristic of puerperal metritis. Here we see arise a condition which Chomel with his eminently judicious and practical mind was obliged to distinguish from this serious disease by giving it a particular name, that of post-puerperal metritis." .... " This inflammation, which surprises the uterus before it has finished the work of involution which would reduce it to its normal size, finds in the histological features of this organ circumstances most favorable as well for its development as its perpetuation and its passage into the chronic stage." If this passage be read with the key which I here offer, it becomes * Le(;ons Cliniques sur les Mai. des Femmes, p. 372, 318 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. plain how a condition arises insidiously after labor without the symptoms of inflammation, and yet ends in what is generally called chronic meti'itis ; how a state due to parturition differs so widely from ordinary puerperal metritis, that a new distinctive appellation is required for it ; how metritis appears to commence in chronic form ; how Aran found this latent, un- demonstrative, acute disorder the " source of the majority of cases of chronic metritis;" and how, in spite of the obscurity of early symptoms, M. Gallard is forced to believe that the chronic disease does follow an acute puerperal metritis, the development of which is obscured by the sequelai of labor. The supposed acute metritis, without symptoms to announce it, which is conjured up to sustain an untenable theory, was really an arrest of retrograde metamorphosis ; the chronic metritis, which was afterwards found to exist in full development, with a commencement so obscure that it must have been "chronique d'emblee,"* was this same condition passing or having passed into areolar hyperplasia. At this time its slowly retrograding muscular fibres have, to a great extent, passed away, but its connective tissue continues exuberant, and the uterus re- mains large, swollen, tender, and heavy. Compared with interference with in\-olution, all other pathological influ- ences become comparatively insignificant as causes of this condition ; nevertheless they must receive due w^eight. The tissue of the virgin uterus presents a structure unfavorable to this disorder. That of a uterus once aflfected by gestation offers a more propitious field for its development. Displacement of the uterus at first results in passive congestion, this being kept up, hypergenesis of connective tissue takes place. Fibroids, whether they be submucous, subserous, or mural, keep up a constant nervous irritation that induces hyperemia, which proves the first step towards this affection. In a very important essay, Rouget* proves the uterus to be an erectile organ, as richly supplied with a network of vessels as such organs always are, and very subject to active physiological con- gestion. It is certain that such a kind of hyperaemia attends ovulation, and it is highly probable that sexual congress has a similar result. From this it will appear how prolongation of the molimen menstruationis, and excessive indulgence in sexual intercourse, especially near menstrual epochs, may produce evil consequences.^ As cardiac diseases and abdominal tumors, which interfere with venous return through the vena cava, produce blood stasis and oedema of the feet, of the labia majora, and of the parts about the vagina, so do they result in the same way in the uterus. Klob declares that this purely passive con- ' Gallard, op. cit. ^ Rouget — R6cherches sur les Organes firectiles de la Femme. 8 Scanzoni calls attention to the fact that it is met with in prostitutes. I PATHOLOGY OF AREOLAR HYPERPLASIA. 319 gestioii is capable of inducing liypernutrition and hypertrophy of the con- nective tissue.^ It has been already said that in acute endometritis the hyperi^mia attending the disease ordinarily extends to the parenchymatous layers immediately adjacent to the diseased mucous membrane, and that in chronic endometritis there is often in the submucous connective tissue an absolute hypertrophy. In some cases the process passes into a diffuse proliferation of the connective tissue of the entire uterine wall. Thus as a result of cervical endometritis we sometimes find cervical hyperplasia resulting, and so with the disease in the cavity of the body. As I have already stated, where the uterine parenchyma has never undergone that physiological hypertrophy and retrograde metamorphosis attendant upon utero-gestation, endometritis will continue for a long period without ex- citing hyperplasia; but where such changes have occurred, the more loose and permeable texture offers itself as an easier prey to the morbid process. Thus cervical endometritis will continue for years in a virgin without any apparent enlargement of the structure of the neck, while such a result soon follows in a woman who has borne children. This fact has not attracted special attention, and yet it is a point which every practi- tioner must recognize, when it is brought to his attention, as one which is familiar. Under these circumstances the enlargement is not due to any- thing absolutely connected with parturition. Parturition has been the predisposing cause; endometritis the exciting. A very striking illustration of this affection due to non-puer[)cral causes is related by Dr. West, whose observation seems to have led liim to very similar conclusions with mine. "Some years ago," says he, "I saw a lady, aged forty-three, who, during thirteen years of married life, had never been pregnant. She had always menstruated painfully, and rather profusely ; and both these ailments had by degrees grown worse, and this especially during the last few months. She complained of a sense of weight and dragging immediately on making any attempt to walk, and induced even by remaining long in the sitting posture. . . . i\Ien- struation was very profuse, accompanied by discharge of coagula, while at uncertain intervals during its continuance most violent paroxysms of uterine pain came on. On examination the enlarged uterus was distinctld felt above the symphysis pubis, as large as the doubled fist, and i)er vaginam the whole organ was found much enlarged, and much heavier than natural; the cervix large and thick, but not indurated; the os uteri small and circular; and the hymen was entire." He goes on to say: " Whenever the uterus is exposed to unusual irritation, it increases in size; not necessarily, nor I believe generally, as the result of inflamma- ' Klob, op. cit., p. 130. 320 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. tion, but because the organ is composed of formative material, which excitement of any kind will call into active development." In the first stage of the disease, the hypertrophied areolar tissue is con- gested, containing absolutely more blood than normal, and the whole of the affected part, neck, body, or entire uterus, is greatly increased in size and weight. As time passes, the second stage of the disorder supervenes, and an opposite state of things is set up. Klob describes it in these words: "The parenchyma on section appears white or of a whitish-red color, deficient in bloodvessels, from compression of the capillaries by the contraction of the newly formed connective tissue, or from partial destruc- tion or obliteration of vessels during the growth of tissue; the firmness of the uterine substance is also increased, simulating the hardness of carti- lage, and creaking under the knife." This constitutes a true sclerosis^ of the uterus. Every practitioner must have met with cases in which a large, red, engorged, and soft uterus, examined after an interval of several years, has been found, to his surprise, to have become small, densely hard, white, and anasmic, and its cavity diminished in size. Such an organ removed from the body cuts like fibrous tissue, and appears when cut almost as dense and bloodless. In leaving this important and interesting part of my subject, let me sum up what has been said, in a few words : — 1st. The condition ordinarily styled chronic metritis consists in an en- largement due to hypergenesis of its tissues, especially of its connective tissue, which induces nervous irritability, and is accompanied by con- gestion. 2d. Decidedly the most frequent source of this state is interference with involution of the puerperal uterus. A very large proportion of the cases of so-called . chronic parenchymatous metritis are really later stages of subinvolution. 3d. Areolar hyperplasia is often induced in a uterus which has once undergone the development of pregnancy, by displacement, endometritis, and other conditions inducing persistent hyperemia. 4th. The same influences may possibly produce it in the nulliparous uterus, most frequently they do so in the neck, but such a result is ex- ceedingly infrequent. oth. However produced, the condition is one of vice of nutrition engen- dering hyperplasia of connective tissue as its most striking feature, and, although attended by many of the signs and symptoms of inflammation, it in no way partakes of the character of that process. It has been maintained by some that acute puerperal metritis extends ' The term sclerosis was, I believe, first applied to this condi-tion by Skene, of Brooklyn. Subsequently Gallard likewise employed it. COURSE AND TERMINATION. 821 itself into the chronic metritis of the non-puerperal state, and this form of the affection has been differentiated from subinvolution. I have seen no evidence of the correctness of this view, nor do I believe that any such distinction can be made at the bedside. Coxirse and Termination. — The length of time which this condition may last is very uncertain. After the connective tissue once becomes thor- oughly affected by the disease, it rarely returns to its original condition, but so complete is the relief which may be afforded the patient by removal of those concomitant conditions that attend upon it and increase the dis- comforts which are due to it, that she will often for years imagine herself well. Very suddenly, however, imprudence during menstruation, the act of parturition, over-exertion, or some other influence creating congestion, will produce a relapse which will convince her of her error. It is aston- ishing to what an extent enlargement of the cervix as a result of areolar hyperplasia will go. Sometimes this part will equal in size a very small orange, and, filling the vagina, w^ill compress the rectum to such an extent as to interfere with its functions. Uninterfered with by art the disease has no fixed limits. The increase of uterine weight which it induces usually results in displacement. This increases already existing conges- tion, and the patient suffers, until the menopause at least, from endome- tritis, granular cervix, and the ordinary symptoms of displacement. Fio. 122. Frn. 123. The dots represeut the site of cervical hyperplasia. The dots represeut the site of corporeal hyperplasia. Tn some cases contraction of the exuberant tissue occurs, and uterine atrophy with its accompanying symptoms takes place. Varieties — Whatever be its cause, areolar hyperplasia may affect the 21 322 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. entire uterus ; it may limit itself to the neck, extending from the os exter- num to the OS internum ; or it may affect the body from the os internum to the fundus. The habitat of hyperplasia limited to the cervix is repre- sented by Fig. 122, while Fig. 123 represents that of the corporeal variety. Whether arising from imperfect involution or from non-puerperal causes, this limitation to cervix or body will be frequently observed. Dr. West^ alludes to the cervical variety as " one in which the enlargement is limited to the neck of the womb, and sometimes even involves only one lip, gene- rally the anterior. In the latter case it is usually consequent on child- bearing, and perhaps is, strictly speaking, rather the result of a partial deficiency of involution of the uterus than the effect of a generic hyper- trophy of the part." This fact was first announced in Great Britain by Dr. Evory Kennedy. Frequency This affection is one of great frequency, and as it was formerly universally regarded as chronic parenchymatous metritis, this is one great reason why inflammation of the structure of the uterus was tliought to be so common. This fact makes its careful study a matter of great moment to the gynecologist. I do not hesitate to declare that he who fully masters it and thoroughly appreciates its frequency and influ- ence will possess a key to the management of numerous cases which would in vain be sought for elsewhere. As I have before remarked, interference with that retrograde metamor- phosis of the puerperal uterus which is now styled involution is in the great majority of cases its cause. Surprise may for this reason be excited by the assertion that of all forms of the affection, the cervical variety is tlie most frequent. The reason for this is to be found in the facts that cer- vical endometritis, which in multiparous women proves a not infrequent source of the disorder, is more common than the kindred affection of the body ; that the cervix is peculiaily exposed to mechanical injury from coition, friction against the vaginal walls, and laceration, occurring during parturient distention ; that after childbearing the connective tissue at this point is looser and more permeable than that of the body ; and that when involution is retarded for some months and then is accomplished, it some- times takes place in the body, but fails to do so in the neck from that expo- sure to injurious influences which has just been alluded to. The body of the uterus is so completely removed from contact with mechanical agencies outside of the abdomen that this part of the organ, as ah-eady stated, is not so frequently affected by hyperplasia as the corre- sponding tissue of the cervix. Still it is by no means unfrequently diseased. A large number of cases of obstinate uterine disorders occurring as a re- mote result of parturition are really of this nature, and the displacements, rebellious leucorrhoea, and other concomitant evils which characterize them, » Op. cit., p. 93. I PREDISPOSING CAUSES. 323 are merely symptoms of this affection or of some of its resulting complica- tions. An important fact connected with this state is that where hyper- trophy of the connective tissue exists, transient attacks of active congestion frequently occur and excite acute symptoms. These pass away, leaving the basis of the affection in its original state, again to return with all the signs of relapse. And thus a series of short but severe exacerbations go on developing themselves in the ordinary course of an attack of the dis- order. Predisposing Causes These may be enumerated as — A depreciation of tlie vital forces from any cause ; Constitutional tendency to tubercle, scrofula, or spanaemia ; Parturition, especially when repeated often and with short intervals ; Prolonged nervous depression ; A torpid condition of the intestines and liver. Nulliparity secures, to a very great extent, an immunity from the dis- ease, and multiparity constitutes a most important predisposing cause. This fact arises not merely from its being, as it often is, an immediate consequence of the parturient act, but from the peculiar tissue changes of utero-gestation rendering the uterus prone to its development. " Fre- quently," says Klob, " this proliferation of connective tissue is developed after repeated deliveries in rapid succession without any previous or exist- ing inflammation, .... and sometimes is developed in consequence of the puerperal condition." Its " causes must be sought for in habitual hypersemia;" consequently whatever state gives a tendency to tliis must be regarded as a pi'edisposing cause, while one which induces and perpetuates it must be looked upon as exciting. The woman who has never been pregnant is much less liable to areolar hyperplasia than she whose uterus has undergone the tissue changes of utero-gestation. Nevertheless, in very rare and exceptional cases, I think that she may suffer from it. In the whole of my experience I have seen but two or three cases, and the diagnosis in these is based upon clinical evidence alone. Here let me guard the reader against a fallacious argument which is often used in reference to this matter. As areolar hyperplasia is rarely seen except in women who have borne children, it is said that it is always the result of interference with involution. This is incorrect. A woman bears a child, has no post-partum trouble, and goes through uterine invo- lution perfectly. A year or two afterwards she has endometritis. This in time produces areolar hyperplasia with its usual symptoms and physical signs. The same kind and degree of endometritis in a nulliparous woman would have lasted for years without parenchymatous complication. In the former case the endometric disease existed on ground favorable to hy[)erplasia, because an important predisposing cause existed. In the latter such predisposition was wanting. 324 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. The exciting causes are the following : — Over-exertion after delivery ; Puerperal pelvic inflammation ; Laceration of the cervix uteri ; Displacements ; Endometritis ; Neoplasms ; Cardiac disease ; Abdominal tumors pressing on the vena cava ; Excessive sexual intercourse. After delivery many of both these sets of causes are developed by the pernicious system of management which nurses frequently adopt. The nerve and blood states of the woman are depreciated by starvation, impure air, and disturbance of sleep by attention to the wants of a child, while the enlarged uterus is forced into retroversion and the congestion which it induces, by a very tight bandage, rendered still more hurtful by a thick compress over the uterus. The practitioner who regards delivery of the placenta as the end of the third stage of labor furnishes a marked predispos- ing cause. The third stage of labor consists in complete and permanent contraction of the uterus, and may not be accomplished for hours after the expulsion of the placenta. No obstetrician has done his duty who leaves his patient before its accomplishment. Symptoms It is impossible to present the symptoms of this condition entirely separated from those of complications which very commonly at- tend it, such, for example, as displacement, laceration of the cervix, ovarian congestion, granular cervix, etc. These states of course produce symptoms of their own which mingle with those of the main disorder. The symptoms then, which are due to areolar hyperplasia and its almost inevitable complications, are the following. If the cervix alone be affected there are — Pain in back and loins ; Pressure on bladder or rectum ; Disordered menstruation; Difficulty of locomotion ; Nervous disorder ; Pain on sexual intercourse ; Dyspepsia, headache, and languor ; Leucorrhoea. If the affection be general or corporeal, graver symptoms manifest them- selves.^ Chief among these are — ' It must not be supposed that all these symptoms occur in all or even in the maiority of cases. In many cases few, and in some almost none of them will be recoornized. PHYSICAL SIGNS. 325 A dull, heavy, dragging pain through the pelvis, mucli increased by- locomotion ; Pain on defecation and coition ; Dull pain beginning several days before menstruation, and lasting dur- ing that process ; Pain in the mam nice, before and during menstruation ; Darkening of the areolte of the breasts ; Nausea and vomiting ; Great nervous disturbance ; Pressure on the rectum with tenesmus and hemorrhoids ; Pressure on the bladder with vesical tenesmus ; Sterility. Physical Signs of Cervical Hyperplasia — Vaginal touch will gene- rally discover that the uterus has descended in the pelvis so that the cer- vix will rest upon its floor. The cervix will be found to be large, swollen, and painful, and the os may admit the tip of the finger. If the finger be placed under the cervix and it be lifted up, pain will usually be complained of, and if it be introduced into the rectum so as to press upon the cervix as high as the os internum, it will often reveal a great degree of sensitive- ness. Under these circumstances the direction of the uterine axis will generally be found to be abnormal. The cervix will in some cases have moved forwards and the body backwards, or the opposite change of place may have occurred. Pltysical Signs of Corporeal Hyperplasia If two fingers be carried into the vagina and placed in front of the cervix so as to lift the bhulder and press against the uterus, while the tips of the fingers of the other hand be made to depress the abdominal walls, the body of the uterus will, unless the woman be very fat, be distinctly felt, should the organ be ante- flexed. Should it not be detected, let the two fingers in the vagina be now carried behind the cervix into the fornix vaginie, and the eflTort re- peated ; if the uterus be retroflexed or retroverted, or even in its normal place, it will be detected at once. By these means we may not only learn the size and shape of the organ, but its degree of sensitiveness. This may likewise be accomplished to a certain extent by rectal touch. The ute- rine probe may then be introduced, the cavity measured, and the sensi- tiveness of the walls carefully ascertained. A point which should be settled before the diagnosis can be considered complete will be, whether the cervix alone is atfected, or whether its en- largement is only a part of a general uterine development. To determine this question, two means are at command: first, the examiner, introducing one or two fingers under the body of the uterus, and depressing the abdo- minal walls by the other hand, so as to clasp the fundus, ascertains whether it is larger than it should be, or of normal size and free from sensitiveness- 326 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. Pie then passes the uterine probe into the cavity of the body, and meas- ures it. If the uterine cavity be increased in size, the evidence is in favor of the disease having extended to the tissue of the body. Sliould its size be normal, this is probably not the case. This sign is not, how- ever, to be entirely relied upon. Differentiation When the whole uterus is affected, or the body of the organ alone is enlarged, the diseases with which areolar hyperplasia may be confounded in its first stage, are : — Pregnancy ; Neoplasms ; Periuterine inflammations. From these a careful differentiation should be made; for if in error, the practitioner would not only fail in giving relief, but, in some cases, might do great injury. For example, an examination by the probe might pro- duce abortion, or so aggravate periuterine inflammation, as to cause seri- ous and alarming consequences. The introduction of the probe or sound should, for this reason, be practised with great caution, and only when good reason exists for supposing pregnancy and periuterine inflammation absent. Between pregnancy and endometritis with corporeal hyperplasia,' there is a chance of error in diagnosis ; for in both there are enlargement of the breasts, darkening of the areola3, enlargement of the uterus, derangement of the nervous system, and nausea and vomiting. In the one, however, menstruation does not cease, there is no kiesteine in the urine, there is great sensitiveness of the body of the uterus, and an abundant leucorrhoea. Dr. Tilt has drawn especial attention to this important fact, in connection with endometritis: " When most of the symptoms of early pregnancy are present," says he, " without menstruation being suspended, in compara- tively young women, internal metritis may be suspected." Fibrous growths in the uterine walls will sometimes, from the peculiar symmetry of their development, completely mislead us, giving uterine enlargement, leucorrh'jea of bloody character, etc. 1 have now in my possession a uterus in the anterior wall of which a fibrous tumor, equal in size to a goose's egg, gives upon superficial examination all the appear- ances of engorgement and hypertrophy of uterine tissue with anteflexion and endometritis. In the same manner polypoid growths or submucous fibi'oids might give trouble in diagnosis. Under such circumstances reliance would have to be placed upon the use of the sound, conjoined manipulation, and tents, together with the rational signs. Periuterine inflammations fix the uterus, create hardness and swellings in the iliac fossae and pouch of Douglas, and sometimes produce purulent discharges. Sometimes, suspicion of scirrhous cancer in an early period being enter- tained, it becomes necessary to decide between its existence and that of PROGNOSIS COMPLICATIONS. 327 the second stage of areolar hyperplasia or sclerosis. Scanzoni doubts the possibility of deciding, but it appears to me that the investigator will usually succeed in doing so, by the following comparison of signs and symptoms : — In Cervical Sclerosis. In Scirrhous Cancer. The patient shows no cachexia. She often does. There is tendency to amenorrhoea. There is tendency to hemorrhage; The history usually points to parturition. It does not. It has been preceded by symptoms of uterine It has not. enlargement. The cervix feels like dense fibrous tissue. It feels almost like cartilage. The body is perhaps implicated. It is very rarely so. A sponge-tent softens the tissue.' It leaves it hard and dense. Prognosis — The prognosis in hyperplasia of the entire uterus or of the body alone is unfavorable with regard to complete cure, though highly favorable with reference to great relief of symptoms and to danger to life. Should the patient be approaching the menopause, it is possible that, after the functions of the uterus cease, atrophy may occur and relief be ob- tained. But one cannot be sure even of this, for the monthly discharge may give place to metrorrhagia, or all the symptoms may continue in spite of the menstrual cessation. Under a course of local treatment, com- bined with one conducted with special reference to the general system, hope may always be held out that, although restoration of the uterus to its normal condition may not be effected, the evils resulting from the complications of this disease can be so fully controlled that comfort will be obtained. When the neck of the uterus alone is affected, a favorable prognosis may always be made, for here there are fewer grave complica- tions to be encountered ; such, for example, as corporeal endometritis, menorrhagia, etc. The diseased part is likewise more accessible to local treatment, and is also a much less sensitive and important part of the organism ; 1 might indeed almost say a less important organ, so distinct are the uterine body and neck physiologically and pathologically. As I have elsewhere stated, the prognosis will depend in a great degree upon the patient. If she be unwilling to sacrifice her inclinations and pleasures, but half fulfil the directions of the attending physician, and clandestinely expose herself to prejudicial influences, the treatment will accomplish nothing. In the case of a reasonable patient, who appreciates what is at stake, and is anxious to regain her health, it may be regarded as favorable. Complications — Areolar hyperplasia may give rise to many and serious complications, as, for example, displacements, cystitis, rectitis, cellulitis, endometritis, menstrual disorders, hysteria, dyspepsia, ovarian disorders, etc. ' This test originated with Spiegelberg. 328 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. The question has been raised by Dr. Noeggeralh as to the causative influence of this disease in the production of cancroid affections. In an essay read before the New York Academy of Medicine in 1869, he reported six cases which he regarded as due to the " transformation of the tissue affected with chronic metritis into epithelioma or cauliflower ex- crescence." The object of the essay was " to prove that the tissue of the uterus affected with chronic metritis is apt to be transformed into papillary epithelioma." My experience has never furnished me with a case illus- trative of the correctness of Dr. Noeggerath's opinion. It certainly can- not be an ordinary sequence of events, for the subject long ago attracted attention, and I know of no recent author who takes similar ground. Klob's' opinion is expressed in these words : " What has been said by various authors on the relations of diffuse growth of connective tissue to the development of carcinoma must be considered as a mei'e hypothesis." Treatment Let me urge upon the practitioner, as a rule to be observed in every case, before treatment is adopted for this disorder, to examine for and remove, if discovered, the five following complications which very often accompany areolar hyperplasia, and establish symptoms which greatly increase the evils attending it. So important do I consider them, that I give them decided prominence. 1st. Laceration of the cervix uteri, which creates intense nervous irri- tation, both immediate and reflex, and consequent uterine congestion and neuralgia. 2d. Displacement of the uterus, which results in vascular engorgement, dragging upon uterine ligaments, mechanical interference with surround- ing parts, and difficulty in locomotion. 3d. Fungoid degeneration of the endometrium, which results in profuse leucorrhoeal and bloody discharges. 4th. Granular and cystic degeneration of the cervix, which produce nervous and vascular derangement of the uterus, leucorrhcea, and menor- rhagia. 5th. Vaginitis, which is excited by the discharge dependent upon en- gorgement of the endometrium. He will be most successful in the treatment of areolar hyperplasia who most assiduously searches for and cures these complicating conditions be- fore addressing remedies to the main affection. Laceration o{ the cervix, and exposure of the delicate walls of the cer- vical canal to friction against the vagina, is so frequently not only a con- comitant circumstance but, I think, a cause of this condition, by interfering with involution, that it should always be looked for. Let it not be sup- posed that a mere visual inspection will reveal its existence. It will often • It must be noted that Klob alludes to carcinoma, while Noeggerath limits his statement to epithelioma. TREATMENT. 329 fail to do so while the red aoid excoriated cervical walls are being for long periods treated for so-called ulceration by caustics and alteratives. To test the question, a tenaculum should be fixed in each labium cervicis, and these should be approximated so as to pi-esent to the eyes of the examiner the perfect cervix as it existed before the accident. Once discovered, the inner surfaces of the torn lips should be thoroughly pared and brought to- gether by suture. Such an operation will often have a most happy effect upon the uterine disorder ; nervous irritability will disappear, and nutri- tion become greatly improved by removal of this focus of irritation. If displacement exist, great benefit will be obtained from support ren- dered by means of a light and well-fitting pessary, the elastic ring of Meigs if there be merely direct descent ; Hodge's double lever or one of its varie- ties if there be retroversion; or an anteversion pessary if the uterus have fallen forwards. In some cases the benefit derived from these instruments will be the chief, perhaps the only relief which we can bestow, and even where we cannot cure the disease we may by their use render life much more agreeable by the alleviation of discomfort. If evidences of fungoid growths on the endometrium exist, the whole cavity should be gently scraped by the wire-loop curette, and this source of leucorrhoea, metrorrhagia, and uterine congestion taken away. At the same time that I have elsewhere urged that too great importance should not be given to granular and cystic degeneration of tlie cervix, I would not ignore the fact that, once established, they become a source of irritation, and thus of uterine engorgement. They should by all means be treated and removed. Vaginitis is secondary to uterine catarrh, which is a very common ac- companiment of hyperplasia. It should be treated by the ordinary means elsewhere indicated, and a recurrence prevented by relief of the endome- trial disease. The subject carefully analyzed presents itself in this way. If the ab- normal condition, which has created areolar hyperplasia, has passed away, this condition is not in itself the source 0*1 many disagreeable symptoms. No woman thus affected feels perfectly well, but she is often sufficiently comfortable to be able to perform all her duties in life. But the uterus thus diseased is peculiarly liable to certain complicating conditions which have just been mentioned, and these create a great deal of discomfort by production of pains in the back and loins, nervousness, leucorHuea, and menstrual disorders. These symptoms are then in a great degree, as I stated in giving the symptomatology of hyperplasia, due to the complica- tions of the disorder, and not to the disorder itself. In other words, sus- tain a hyperplastic uterus, keep it free from displacement, granular and cystic disease of the cervix, and uterine catarrh, and the patient will be so comfortable as, in most instances, to feel satisfied witli her condition. Sometimes this is all that we can accomplish. Tlie mere fact of accom- 330 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. plishing these results will, however, do much for the cure of the disease itself. Relief of displacement favors free venous return and prevents con- gestion which feeds and perpetuates hyperplasia. Cure of uterine catarrh and of granular and cystic degeneration of the cervix removes two great causes for hypera^mia of mucous and submucous tissues. The means em- ployed for the relief of these symptoms even do more, they tend by their own direct influence to alter the morbid state of the nerves of the part, to diminish the calibre of bloodvessels under their control, and thus to check excessive nutrition and secretion. All complications being removed, the practitioner has now to deal with a large, heavy uterus, the tissue of whieb is exuberant, the bloodvessels enlarged, and the nerves in a condition of hypersesthesia. Let me enumerate the indications to be met by a few leading proposi- tions. 1st. Everything possible should be done to prevent congestion, and remove that already existing. 2d. Every attention should be given to the restoration of the general system, especially the blood and nerve states. 3d. All weight should be taken from the large and heavy uterus. 4th. Nervous hyperaesthesia should be relieved by every means in our power. The means for furthering these ends may thus be presented : — Rest ; General treatment ; Depletion ; Emollient vaginal injections ; Alteratives. Jlest The patient should be instructed to take much less exercise than usual, to lie upon her bed or lounge for an hour every day about mid-day, and to be especially quiet during menstrual pei-iods. It is as a general rule highly improper to confine her to bed, for many women become restive under the confinement, and suffer both in mind and body, the sanguineous and nervous systems being impaired by want of fresh air. If the connective tissue be so much affected that the cervix is very painful upon pressure, absolute rest upon the back may become necessary, but my impression is that deprivation of fresh air and exercise ordinarily does more harm than is compensated for by the advantages arising from quietude. Every day she should go, unless deterred by some special cause, into the open air, and a limited amount of exercise should be incul- cated as a means of keeping up the general health. Within a few years Dr. "Weir Mitchell has introduced a plan for treat- ing eases of neurasthenia which consists of complete rest. The patient is for a period varying from six weeks to tlu'ee months kept as quiet, upon TREATMENT. 331 her buck in bed, as if she were a marble statue ; or rather, I should say, as far as voluntary motion is concerned. She is fed by an attendant who is constantly by her side, and is not allowed even to lift her arms from the bed. Meantime she is very thoroughly nourished by milk, animal broths, malt, cod-liver oil, eggs, and other nutritious substances, every two or three hours ; while cutaneous action is excited, peripheral circula- tion kept at a maximum of activity, metamorphosis and elimination in- creased, and muscular strength fostered, by manipulation, passive exercise, electricity, and kneading. The moral faculties are likewise supervised ; hysterical symptoms are controlled by moral suasion, judicious neglect, and an earnest appeal to the reason of the patient ; and the mind is made to feel the influence of alienation from home influences by entire seclusion from friends and relatives. I can of course only allude to this plan, which observation leads me to set a very high estimate upon in the treatment of special cases, and would refer the reader for further details concerning it to the writings of Dr. Mitchell,' and to an excellent article by Dr. William Goodell.'^ Tlie uterus should be placed at rest as much as possible. Its natural tendency under these circumstances is to fall from its position ; consequently all pressure should be removed from its fundus by wearing the clothing loose, sustaining the weight of the skirts by attaching them to the upper garments, so as to have the shoulders bear the burden, and uncompromis- ingly abolishing the corset. At the same time a system of exercises should be practised by the pa- tient calculated to develop the power of the abdominal and thoracic mus- cles and thus restore or increase the retentive power of the abdomen. These will be alluded to in detail under the head of displacements of the uterus. Abdominal bandages are very unpopular with many practitioners, who believe that they absolutely do harm. I believe otherwise, and regard them as great adjuvants, not in keeping up the uterus, but in supporting the super-imposed viscera, which, pressed downwards by tight clothing, and badly supported on account of the relaxation of the abdominal walls, fall directly upon tiie fundus. Tiiere is a great variety of abdominal sup- porters. I have no favorite, for one will accomplish the end in a woman of a certain figure which would be inappropriate for another. That one should be selected which absolutely accomplishes the end in view, namely, sustaining the viscera and supplementing the weakened muscles of the abdomen. Sexual intercourse often produces bad results in an organ which is so prone to congestion, and great infrequency and caution should be enjoined with reference to it. • Fat and Blood, and how to make them. 2 Nerve tire and woiub ills, Lessons in Gynecology. 332 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. By combining all these means we do all in onr jjower to place the hyperplastic nterus at rest as we would a fractured bone or enlarged testicle. General Treatment The diet should be plain and unstimulating, but at the same time nutritious, and in every way calculated to maintain the normal state of the blood. Should spancemia exist, ferruginous tonics, alone or combined with vegetable tonics, should be administered. The bowels should be kept in a perfectly normal state, and the skin active. Specific remedies have been, and are still, employed by some practitioners for diminishing the size of the uterus. Of most of these 1 doubt the effi- cacy. During the state of enlargement, that is, before contraction of the exuberant tissue has occurred, ergot, kept up for a considerable time, pro- duces good results. By its power of exciting contraction of the uterine tissue it diminishes hyperoemia, and lessens the bulk of the uterus. European writers speak in liigh terms of the alterative influences of the various watering-places and baths of the Continent, as those of Marienbad, Schwalbach, Briicknau, and Kissingen, in Germany, and of Saint Sauveur, Barreges, etc., in France. None of these equal in reputation the waters of Kreuznach in Germany, the curative property of which is supposed to depend upon the bromide of magnesium which they contain. It is very probable that the hygienic and social influences which surround these places and render them attractive, are to be credited with most of the good that they do. Aran, after admitting that the water of Vichy may exert some influence, thus pointedly expresses himself with reference to the others: "Whatever be their composition, in whatever countries they may be found, I know of no work in which we can find an approximation to a demonstration in their favor." No other general means compares in result with a change of abode and corresponding change of air, habits, and associations. A removal, for example, to the seaside, where bathing can be enjoyed, a sea voyage, or a residence at an agreeable watering place, may accomplish much good. Mental depression predisposes to and aggravates this disease most markedly. Aran goes so far as to say that he has almost invariably found it present as an exciting cause. However this be, cheerful and congenial company certainly proves one of the best nervous tonics in a therapeutic point of view, and should always be sought for. A stay in a well regulated hydro- pathic establishment, where the patient can have pure air, plain and nutritious food, and agreeable society, together with the strict attention to the general rules of hygiene which characterizes those institutions, will often produce the best effects. Depletion. — If vaginal touch and conjoined manipulation discover the fact that the uterus is tender, the occasional abstraction of small amounts of blood by puncture or scarification Avill be beneficial. Not more than an ounce or two should be taken at once, unless ameuorrhoea be a sym])- DEPLETION. 333 torn. In case this be so, a more copious abstraction by leeches, during the menstrual epoch, will often give great relief. At times leeches then applied to the cervix will give great pain by their bites. This is some- times so severe as to lead to the apprehension that one has escaped into the cavity; hence it is important that they should be counted before being placed in the speculum, and on their removal from it. The three methods by which local depletion of the cervix can be best practised are leeching, scarification, and cupping. Three or four large leeches, or a sufficient number of small ones, to take from three to five ounces of blood, may be applied in the following manner: A cylindrical speculum, of sufficient size to contain the entire vaginal portion of the cervix, being passed and the part thoroughly cleansed, a small pledget of cotton, to which a thread has been attached for removal, should be placed within the os, so as to prevent the entrance of the leeches to the cavity above. A few slight punctures, sufficient to cause a flow of blood, sliould then be made in the cervix, and all the leeches to be employed thrown in, and the speculum filled at its extremity by a dossil of cotton pushed towards the bleeding surface. The speculum should be watched until they cease sucking, for if left for a very short time, even with the mouth of the instrument filled with cotton, they will escape. After their removal all clots of blood should be removed by a sponge or a rod wrapped with cotton, the speculum withdrawn, a large sponge squeezed out of warm water placed over the vulva, and the patient directed to remain perfectly quiet. Should scarification be employed, a very sharp and narrow bis- toury or tenotomy knife may be introduced within the os, and drawn out- ward towards the vaginal edges of the cervix so as to sever all the super- ficial vessels over which it passes. I would recommend, in preference to this plan, acupuncture, which may be performed by an ordinary three-sided surgical needle held in the grasp of a pair of forceps, or, still better, by a little spear, the invention of Dr. Buttles, of this city. Fig. 124. Buttles's spear-pointed scarificator. This little instrument, when plunged about one-sixteenth of an inch into the cervix and given a rapid half turn before removal, causes a very free flow of blood should congestion exist. If a sufficient flow does not occur from three or four of its punctures, this can be caused by dry cup- ping the cervix by a very simple instrument, made of \'ulcanite, which is introduced through the speculum, the medium size of the cylindrical variety being large enough to admit it. Being passed up to the cervix, the piston is retracted, and so perfect is the working of tliese instruments, when constructed of vulcanite, that a complete vacuum is produced. By 334 AREOLAR HYPERPLASIA OR CHRONIC METRITIS. using this for a few minutes, and then puncturing, with Buttles's spear, from two to four ounces of blood may readily be drawn. The exhaustei: should not be used after puncturing, but before it. All that will be neces- sary afterwards will be to pass a moist sponge, attached to a sponge- holder, over the punctured surface so as to prevent clotting in the mouths of the bleeding vessels. Dr. John Byrne, of Brooklyn, has drawn especial attention to still another method, which in some cases answers an excellent purpose. It consists in passing a long, delicate blade up the os internum, and cutting through the mucous membrane, its bloodvessels, and the super- ficial layer of muscular tissue, as it is withdrawn through the os externum. Local depletion by one of these methods should be practised cautiously, the patient for twenty-lour hours after its adoption being kept perfectly quiet in bed. Fig. 125. Hard rubber cylinder fur dry cupping tlie cervix uteri. It is surprising to observe how steadily depletion by all these means has been, during the last ten years, going out of vogue in New York. Many gynecologists with large practices have entirely given it up, and in the Woman's Hospital it has almost completely passed out of use. It must be remembered, however, that the same statement Avould hold good in refer- ence to abstraction of blood in every other department of medicine. Vayinal Injections. — A great deal of advantage accrues in these cases, fi'om the systematic use of very copious vaginal injections of water as hot as the patient can bear them. They should be employed for from fifteen to twenty minutes at a time and once in every twelve hours. Their use quiets pain, improves the pelvic circulation, removes irritating secretions, and unquestionably stimulates the absorption of effused material. Local Alteratives. — The best local alterative is the compound tincture of iodine, which, by means of a brush of pig's bristles, should be carried up to the OS internum or even to the fundus, should endometritis exist, and over the whole cervix ; then, waiting for complete drying, this process should be repeated. After these applications a wad of cotton, to which a string has been attached in such a way as to leave its surface flat, should be saturated with glycerine and laid against the cervix. This acts as a local hydragogue, and disgorges the tissues. These local applications should be repeated once a week, but others should be made oftener by the patient herself by means of vaginal injections, by which the drugs just mentioned may be brought in contact with the cervix. Should it appear to the practitioner that persistent liypera3mia requires more energetic means than those mentioned, resort may be had to counter- LOCAL ALTERATIVES. 335 irritants which vesicate and destroy the mucous membrane of the vaginal cervix, and thus cause a free tiow of serum. Such cases grow smaller and smaller in my practice as I grow older in experience, and although I admit the occasional necessity of these means, 1 caution the reader against a constant or too early resort to their use. They cannot diminish the absolute size of the enlarged organ, and should not be used with any such view. They can remove congestion and nervous exaltation, and in cer- tain exceptional cases may be employed for these purposes. One of the best methods for practising counter-irritation upon the cer- vix uteri is by blistering, a means for which we are indebted, I believe, to Aran, of Paris. To blister the cervix, a large cylindrical speculum should be used which will take the whole part into its field. The cervix having been cleansed and dried by a soft sponge or dossil of cotton, a camel's- hair brush is dipped into vesicating collodion, which consists of ordinary collodion, commonly known as liquid cuticle in this country, containing in suspension cantharides, and painted over the whole vaginal cervix, no effort being made to avoid the os. There are two preparations of vesi- cating collodion, one made with ether, the other with acetic acid. The second is the more powerful and the less likely to affect the vagina. In a few seconds after it is painted on the cervix, it forms a hard, insoluble covering, upon which two or three other coats maybe at once applied. The whole is then exposed to the air by keeping the speculum in place for a few minutes, a stream of cold water projected upon it, to prevent any escape into tlie vagina, and the process is finished. In from eight to twelve hours the epithelial covering of the cervix is entirely removed by this, and a free flow of serum takes place as from a blister elsewhere ap- plied. After this the patient should be kept perfectly quiet for several days, cleansing the vagina by warm injections, and as soon as the dis- charge shows a tendency to cessation, the blistering should be repeated. The only objections to this method of counter-irritation are the liability to vaginitis and cystitis from escape of tlie blistering fluid into the vagina and mouth of the urethra, which can readily be avoided, and the pain which is experienced in some cases while vesication is taking place. After blistering, pledgets of cotton saturat(3d with glycerine should be applied for the hydragogue effects of that drug. Vesication may be easily produced by still another method which is both effectual and simple. By means of a solid stick of nitrate of silver, which is rubbed gently over the whole vaginal portion of the cervix, its epithelial covering is destroyed, soon sloughs off, and leaves a granulating surface, which may be dressed with any of the alterative substances mentioned above, or with glycerine. Mild and lacking in vigor as this course may appear, let any one test it side by side with the plan of using the acid nitrate of mercury, potassa fusa, and potassa cum calcc, and the actual cauteiy ; of swabbing out the 336 GRANULAR AND CYSTIC Uterine cavity with chemically pure nitric acid, or of leaving a piece of solid nitrate of silver to melt within it; and, unless his experience greatly differ from mine, he will feel tliat in the former he has reached a resting place for his faith in the treatment of the most important of all the forms of uterine disease. He will see proof daily spring up before him that his capacity for benefiting his patients has greatly increased, while his liability to injuring them has as markedly diminished. Dr. August Martin, of Berlin, advocates amputation of one lip of the cervix for the induction of a species of involution in cases of areolar hy[)er- plasia. Some time ago he reported seventy-two such operations, in only seven of which did any inflammatory symptoms sliow themselves, and which were invariably followed by a diminution in the capacity of the uterus of from two to three centimetres. In a discussion which followed a paper by Martin, Kelu'cr, Schrceder, and Olshausen agreed with it. This method possesses none of the advantages of ti-achelorrhaphy, to which it is infei-ior jn every respect. Both operations are usually employed where lacej'ation of the cervix exists as a cause of the hyperplasia. CHAPTER XXI. GRANULAR AND CYSTIC DEGENERATION OF THE CERVIX UTERI. No subject in connection with gynecology has attracted more attention ivithin the past fifty years than inflammatory ulceration of the cervix uteri. Until a comparatively late period it was fully believed in, but, as more careful observation has been practised, the fact has been recognized that unless affected by direct pressure or friction from some solid body the cer- vix uteri is little prone to simple ulceration. It is, of course, everywhere admitted tliat cancerous and syphilitic ulcerations may affect tliis part, but no one would propose to style these inflammatory ulcers. It is like- wise admitted, that in a prolapsed uterus, friction against a pessary or the clothing, commonly produces true inflammatory ulceration. But these admissions do not touch the point at issue, and it is fully agreed to-day tliat the condition lately styled inflannnatory ulceration, by Dr. Henry Bennet and his school, was not one of ulceration at all, but one of exube- rant growth of the tissues of the cervix with or without laceration of this part, which is nuich more correctly described under the names which head this chapter. It not unfrequently happens that one symptom of a disease will so dis- tress and harass a jtatient that nnnedial measures must be entirely directed to it, although the practitioner be aware of the fact that it depends on dis- DEGENERATION OF TUE CERVIX UTERI. 337 eases elsewhere located. An example of tliis is frequently presented in the morbid state under consideration, which, in itself, proves so annoying by its profuse discharge, and interference with the functions of the uterus and with locomotion, as to call for prompt relief. The vaginal surface of the cervix uteri is covered by a smooth mucous membrane, which is continuous below with that of the vagina, and extend- ing through tlie cervical canal joins that of the body, which differs widely from it, at the os internum. This membrane is covered over by numerous papilla? which become visible when a sulficiently strong glass is used. One or more slender bloodvessels pass into each and form at their extremities vascular loo[)S, then return, and at their bases pass into adjoining ones. They are comidetely covered by pavement epithelium and basement mem- brane. Throughout tlie cervical canal mucous crypts or follicles exist, which are likewise found scattered over the vaginal portion of the cervix, and even within the cavity of the uterus itself. Tlie diseases of two of these elements of cervical mucous membrane are now to engage our attention. Granular Degeneration of the Cervix. Definitiuii — Tills condition, which has been described under the names of erosion of the cervix, granular ulcer, and epithelial abrasion, ^^.loists, as its nan.e implies, in the development of a surface of granular character on tlie smooth faoe of the cervix and just within the os. Frequency — It is an affection of great frequency, attending all the dis- eases of the uterus which result in leucorrhiea, and being commonly a con- comitant of most of the diseased conditions of the parenchyma and linin"' membrane. Very often it exists for a length of time without any suspicion of its presence arising in tli(; mind of patient or physician, ancl sometimes without causing symptoms which prove in any great degree annoying. At others, grave constitutional signs may be traced to it and entirely re- moved by its cure. Causes The predisposing causes are: — Enfeebled general health ; Spanajmia ; The scrofulous diathesis; The syphilitic diathesis. Those which are exciting are the existence of — Displacements; Endometritis; Laceration of cervix; Areolar hyperplasia ; Abuse of sexual intercourse; Vaginal leucorrhoja; Pessaries which touch the vaginal face of the cervix. 22 338 GRANULAR AND CYSTIC From this array of causes it will appear that it is rarely a disease which stands alone, but that it is usually engrafted upon some other affection of greater moment. Although this is true, it will not do in practice to carry the view too far. At the same time that it must be admitted that granu- lar degeneration, even of aggravated character and considerable propor- tions, affecting the vaginal face of the cervix, and the distal extremity of the cervical canal, is commonly a consequence of some pre-existing dis- ease, the fact must not be lost sight of, that this affection of itself keeps up a hyperfemia in the subjacent and neighboring parts of the uterus, and even extends a reflex influence to the ovaries. By almost all writers upon this subject since Recamier's time, too much stress has been laid upon the theory that it depends upon an "indurated and hy[)ertrophied condition of the parenchyma of the cervix." That it results from tliis no one would deny, but it is equally true that it often arises from other causes, and itself induces this one. In general terms we may say that it is usually produced by, 1st, any disorder which keeps the mucous membrane of the cervix constantly bathed with ichorous fluids for a length of time ; 2d, by anything which keeps up friction against the cer- vix; 3d, by any influence producing and perpetuating congestion of the uterus. Let the reader turn to the list of predisposing causes and he will see that they are just such as to favor these morbid influences, and that the exciting ones are those which absolutely produce them. For example, displacements keep up congestion of parenchyma and mucous membrane, and produce uterine leucorrhcea, and cause friction between the cervix, thus engorged and excoriated, and the vaginal surface. Hyperplasia pro- duces displacement with all its results, furnishing in advance a tissue peculiarly prone to hyperaemia, and already abnormal in character. Lacera- tion of the cervix is a fruitful source of cervical hyperplasia, and the ever- sion of mucous membrane which attends it establishes friction which results in leucorrhcea and increase of hypera?niia. But it is unnecessary to ap|)ly remarks which are so obvious to each of the causes mentioned. Before Emmet pointed out the pathological bearing of laceration of the cervix, a great many cases of that accident were regarded as granular degeneration. A careful differentiation must be practised with reference to the two affections, while at the same time a proper degree of weight should be given to the fact that granular degeneration often occurs in vir- gins and involves the whole vaginal face of the cervix. Symptoms. — Should granular degeneration exist with but trivial disor- der of the uterus of any other kind, very few symptoms may be present. Indeed, profuse leucorrhcea is sometimes the only one of which the patient will complain. The fact that other and more serious symptoms generally show themselves, is a corroboration of the statement, that graver disease of the uterus constitutes an important element in such cases. Ordinarily, DEGENERATION OF THE CERVIX UTERI. 339 these are the sym[)tom8 which will be noticed in a case of the more serious kind: — Profuse bloody and purulent leucorrhoea; Pain and hemorrhage after intercoui'se ; Menorrhagia or metrorrhagia; Pain on locomotion ; Fixed pain in back and loins; Tendency to spantemia; Nervous disorders and perhaps hysteria. Physical Signs — Vaginal touch alone might serve as a diagnostic means, for by it the cervix is felt to be covered by a velvety or granular surface, which, to the practised finger, is at once recognizable. But the speculum offers the fullest corroboration or corrects any error committed by this means. By it, the cei-vix, more especially near the os, is seen to be covered by a mass of pus, which being removed lays bare an intensely red, granular, hemorrhagic-looking space of greater or less extent, closely resembling the inner surface of the eyelids when affected by granular degeneration. The diseased surface does not appear depressed below, but is sometimes even elevated above the surrounding mucous membrane. Course and Duration The disease is unlimited. If the general health inaprove, it is possible that nature may effect a cure without the aid of local treatment, but such a result should not be anticipated. The degene- rated surface may go on for an unlimited time pouring out pus, and thus greatly impoverish the blood and cause grave constitutional results. Pathology. — According to Ruge and Veit, the maceration of the cervi- cal mucous membrane in ichorous fluids results in the desquamation of epithelium to such an extent that only one layer of cells exists, through the diaphanous structure of which the red colored tissue beneath is visible, with its exaggerated vascular supidy. Very soon from the epithelial layer prolongations project inwards, dividing the subjacent tissue into villi or processes, such as are formed in the vesi- cal and uterine mucous membrane. These villous projections are new formations, not hypertrophied papilla?. They are covered with epithelium, richly supplied with superficial bloodvessels, and liable to increase to large masses. To these the names of varicose and bleeding ulcer and cock's- comb o-ranulation have been given. Prognosis — The prognosis in this affection is always good, though it may require a great deal of time to effect a cure, for this will not be per- manent unless that of the coexisting disease be accomplished. Treatment Before treatment for this condition is commenced, let me urge the practitioner to examine carefully as to whether he is really deal- ing with a case of granular degeneration or with one of cervical laceration. The two conditions closely resemble each other ; the former often com- 340 GRANULAR AND CYSTIC plicates the latter ; and a treatment which is appropriate to the one is utterly insufficient for tlie other. Granular degeneration being generally a secondary disorder engrafted upon a pre-existing one, before treatment is adopted, the primary disease should be sought for, and both should be treated simultaneously. Should displacement, endometritis, vaginitis, or areolar hyperplasia exist, attention should be directed to their relief at the same time that this one of their results is treated. It may be asked, if this be true, how- ls it that the mere application of caustics to the diseased surface will so often effect a recovery without regard to other disease ? An influence which commonly induces granular degeneration is congestion of the mucous and submucous tissues at the vaginal extremity of the cervix. The sohi- tion of continuity to which the caustics are ap[)lied, acts, after their application, as an issue, and they by derivative and alterative influence effect good. It is pi-ecisely in accordance with this principle that the practitioner, if called to treat a very obstinate case of cervical hyper- plasia, which is unattended by such solution of continuity, creates it by abrading the surface by a blister, and then cures the issue thus caused by such caustics as the nitrate of silver or chromic acid. It is common to hear physicians remark that they are more successful in treating cases of cervical enlargement accompanied by granular degeneration, than those which are free from it. The key to the explanation is, I think, the one here given. Having presented these remarks and sufficiently insisted upon their importance, I now proceed to the consideration of the special treatment of the condition itself. Before commencing treatment, the general health should receive especial attention ; those tonics a-nd hygienic directions which appear best suited to the particular case being given. These indi- cations should from the commencement be as far as possible fulfilled : 1st, the granular surface should be put beyond the influence of friction ; 2il, it should be protected from contact with ichrous discharges ; 3d, a steady alterative influence should be exerted upon it by local applications ; and 4th, congestion of the uterus and of the especial part diseased should be prevented. To accomplish the first indication the uterus, if displaced, should be put and kept in position by a well-fitting pessary. Even if its axis be normal, it is often excellent practice to lift it out of the pelvis by an elastic ring. At the same time such support prevents a tendency to congestion of the organ, and may be rendered more effectual by careful removal of all weight from the abdomen, by tightly fitting or heavy clothing. Let no one who has not tried this as an adjuvant, undervalue it, for there can be no question of its great utility. Free use of copious vaginal injections should be practised twice daily, to remove all leucorrhoeal discharge, and should this arise from endome- DEGENERATION OF THE CERVIX UTERI. 341 tritis, that condition should be treated. Tliis indication may further be accomplished by the ap[)lication of the styptic colloid of Richardson, wliich consists of a strong solution of tannin in gun-cotton collodion. I know of no means better calculated than this to accomplish all four of the indications enumerated. It appears to act not only as a direct alterative, but, forming a protective crust over the surface, constitutes for it a shield against friction and uterine discharges, while at the same time, by its compression of the excoriated villi, permeated by their loops of vessels, and of the submucous tissue with its increased vascular supply, it dimin- ishes local congestion. The nerves governing nutrition and circulation in the part should be impressed witii a new influence by direct alterative applications. The best solid ones are the stick of nitrate of silver or sulphate of copper ; and the most effectual fluid applications, saturated solution of carbolic acid ; chromic acid sss to water 3J ; compound tincture of iodine ; equal parts of tannin and glycerine, left in contact with the part on pledgets of lint or cotton ; iodoform ; and saturated solution of persulphate of iron, pure or diluted with equal parts of glycerine. It is a good routine plan to begin with a thorough application of solid nitrate of silver, and follow tiiis immediately by a protective coating of styptic colloid. When an exuberant development of villi, called by Evory Kennedy, I think, cock's-comb granulation, exists, it is well to snip the growths as close as possible to the mucous membrane by a pair of long-handled scis- sors, or even to scrape the surface until it is smooth, by means of the steel curette, before applying the caustic. After this the same substances may be used as for ordinary degeneration. Should simple eversion of the cervix exist, the hemorrhoidal mucous membrane should be at once removed by the scissors or destroyed by fuming nitric acid. When this is excessive, and due to laceration of the canal by parturition, the condition may be cured by an operation which consists in paring with long scissors the edges of the cervical fissure, and passing deep sutures of silver wire so as to approximate them thoroughly. By this means the os is restored to its integrity, and the everted mucous surfaces being placed face to face, friction against them is prevented. The last indication in enumeration, but not in importance, is the pre- vention of congestion, local and general. To a certain extent this is accomplished, locally, by all the alterative and astringent applications alluded to, and the same thing may be furthered by vaginal suppositories and injections. Should any case prove very obstinate, this end may be more decidedly attained by taking a sharp-pointed, curved bistoury, and beginning as high up the cervix as the disease extends, cutting through the mucous membrane and submucous tissue, extending the incision out- side the OS as far as the surface is affected. Five or six such superficial 342 GRANULAR AND CYSTIC and painless incisions sever the network of little vessels in the submucous tissue, and, for the time at- least, interfere with the circulation. Congestion of the whole uterus is greatly relieved by removal of weight from it by abdominal and skirt supporters ; avoidance of muscular efforts ; the use of a pessary ; careful regulation of tlie bowels ; rest, especially during menstruation ; and the use of copious warm vaginal injections. Applications should be made not only by the physician, who will pro- bably use the speculum not oftener than once a week, but also by the patient, who should make them daily by injections and suppositories. Tiie former should be thus employed : every night and morning a gallon of warm water, containing one ounce of glycerine and one drachm of sulpliate of zinc, or two of sulphate of alum, acetate of lead, or tannin, should be injected for a period varying from ten to twenty minutes. Or if it be found necessary to employ a stronger astringent solution, a gallon of pure water may be used first, for the time mentioned, and then a medi- cated solution, one quart in amount, be used for a short time afterwards. Vaginal suppositories are by some practitioners employed under these circumstances. A suppository may be made to contain three grains of oxide of zinc, or of sulphate of alum ; ten grains of mercurial ointment ; five grains of iodide of lead ; or two grains of tannin. To any one of these, should an anodyne be needed, one grain of the extract of belladonna, or of opium, -may be added. These substances may be made into a mass with powdered gum tragacanth, starch, or slippery elm, and glycerine, and the whole covered with cocoa butter. They may be introduced by the fiuo-er, but by the use of the vaginal suppository tube, elsewhere mentioned, there is much greater certainty of their coming in contact with the dis- eased surface. Suppositories may be employed once or twice a day. Surprise may be felt at the small amount of medicinal substance which I propose to add to each suppository. A great deal of discomfort often arises from larger doses than I have mentioned. I have repeatedly seen patients for whom two grains of tannin thus administered was too large a dose, and who had in consequence to cut each suppository in half before employing it. Cystic or Follicular Degeneration of the Cervix. Definition This form of disease, though not so frequent as tliat last mentioned, is by no means rare. It consists in an inflammation of mucous follicles, which resemble those of the cervical canal, and which are scat- tered over the vaginal face of the cervix, and exist even in the cavity of the womb. "The cervical mucous cysts," says P'arre, "are lined by epithelium and basement-membrane. They contain a small quantity of mucus together with granule-cells. Those upon or near the margin of the OS uteri may be sometimes observed to contain short papillse within their DEGENERATION OF THE CERVIX UTERI. 34? Fm. 12n. Cystic degeueration of tlio cervix. margin." A recollection of these facts is essential to a full understanding of the stages of this form of degeneration. Pathology. — Follicular disease of the cervix shows three entirely dif- ferent phases : 1st. A number of vesicles, equal in size to a millet seed and filled with a fluid like honey, is noticed covering the part. These are due to repletion from retention of the secretion of tiie follicles. 2d. These cysts are seen open, i. e., they have burst, and a depression marks tlie former site of each, 3d. The papillee which they contain undergo hypertrophy and cause the appearance of red, elevated, hemorrhagic-looking tubercles in place ol the depressions just mentioned. For the thorough knowledge of this subject we are indebted, as for so much else relating to the anatomy and pathology of the uterus, to Dr. Arthur Farre. Usually the cervix is seen studded over by little globular bodies about as large as a hemp seed, with here and there a depression, and here and there a promi- nence of red and irritable looking character. Synonyms It will now be readily appreciated why a variety of names should have been applied to this disease when examined at different stages. Follicular disease is supposed to be the source of the eruptive affections described by authors as acne, herpes, and aphtha? of the uterus. Causes Anything which keeps up congestion in the cervical mucous membrane may give rise to this affection of the mucous glands of the vaginal cervix. Among the chief are : — Cervical endometritis ; Granular degeneration ; Cervical hyj)erplasia ; Laceration of the cervix. Prognosis. — If a few scattered cysts appear, the prognosis is decidedly favorable ; but in certain rare cases, where the whole of the extremity of the cervix is filled by them, nothing but amputation of the part containing them accomplishes cure. Treatment. — The contents of all the cysts should be evacuated by a bistoury, and their cavities thoroughly cauterized by a sharp point of nitrate of silver, chromic acid, or the acid nitrate of mercury. Sliould the second or third stage exist, the diseased surface sliould be treated upon very much the same plan as that advised for granular degeneration. Sliould a great amount of cystic degeneration exist, and cure not follow evacuation and cauterization of the cysts, the vaginal face of the cervix should be removed by the galvano-caustic wire, or by bistoury or scissors. Here, as in cervical endometritis of cystic character, the rule of surgery which inculcates the ablation of a part which is the habitat of a disease which proves incurable by minor means, should be followed. 344 SYPHILITIC ULCER OF THE CERVIX UTERI. CHAPTER XXII. SYPHILITIC ULCER OF THE CERVIX UTERI. Frequency Syphilis may affect tlie cervix uteri either as a primary or secondary disorder, though in neither form is it by any means common. It is now a settled fact that true chancre may locate itself upon the cervix, but not the less certain is it that it rarely does so. I liave seen but one case which I felt satisfied was of this character. This was proved by inoculation, the most certain way in which a strictly reliable conclusion can be arrived at, and by corroborative evidence existing in the presence of syphilitic roseola without primary disease elsewhere. Dr. Bennet^ states that in his own practice it has been very rarely met with, and quotes in confirmation of his own experience that of Ricord, Cullerier, Gibert, Duparcque, and others. M. Bernutz, who has made, according to Becquerel,^ a special study of this subject in the hospitals of Paris, describes chancres of the os minutely, dividing them into Hiinterian, diphtheritic, and ulcerous, which resemble phagedenic very closely. With regard to secondary affections on the cervix, there has been considerable discussion, some regarding them as quite common, others as very rare. Becquerel, after careful research in I'Ourcine Hospital at Paris, was con- vinced of their occurrence, and Bernutz describes mucous patches, vege- tations, erosions, tubercles, and gummy tumors. I know of no more significant evidence of the rarity of these affections upon the cervix than the fact, that in a recent work upon syphilis, a work remarkable for tlie thorough and comprehensive style with which it deals with all relating to that subject, almost no mention is made of syphilitic affections of the cervix. I allude to the work of the late Prof. Bumstead.^ The author investi- gates the character of syphilis when affecting all parts of the body, even the lachrymal sacs, the membrana tympani, etc., but nowhere is any mention made of the disease appearing on the cervix, except a cursory statement, that at Bellevue Hospital he had seen some remarkable in- stances of mucous patches thus located. The sign of the secondary dis- order which we would most naturally expect to find in this site would be the mucous patch, as it is one of the most frequent of all the manifesta- tions of that stage ; but we are informed by MM. Davasse and Deville,* » Bennet ou the Uterus, p. 350. 2 MaL de I'Uterus, vol. i. p. 169. 3 Bumstead on Venereal Diseases. * Davasse and Deville, Des Plaques Muqueuses : Arch. Gen. de Med., 1845, t. ix. et X. SYPHILITIC ULCER OF THE CERVIX UTERI. 345 that of one hundred and eighty-six women affected by sypliilis, and ex- amined in reference to the location of its lesions, they were found on the cervix uteri but once. Course and Termination The primary affection being located on the cervix, the general system becomes affected as from a chancre on any other part, and, as M. Gosselin has pointed out, instead of passing off rapidly, as it sometimes does, it may assume the fungous type. During its course the cervical chancre lias a marked tendency to become covered by false membrane, which Robert^ first noted, and Bernutz subsequently corrobo- rated. Unless a fact corroborated by Forster^ be carefully borne in mind by the diagnostician, a grievous error may occur in the differentiation of this form of ulcer from malignant disease. He declares that syphilitic ulcers sometimes destroy tissue so freely as to penetrate into the bladder or rectum. Differentiation — For evident reasons this is a matter of great import- ance, not only as regards therapeutics, but because it may involve a deli- cate legal question affecting the chastity of the woman. Tliese are the means of diagnosis in cases of chancre : — Border of ulcer precipitous ; Surface of ulcer depressed ; Great tendency to bleed ; Great tendency to false membranous .covering ; Rapid development of constitutional symptoms ; Early a|)j)ea ranee of roseola ; Transmission by inoculation. All of these signs are of value, but the only ones upon which a positive opinion could be based are the last tiiree. Secondary eruptions, as for example, mucous patches, vegetations, etc., which appear here will be known by Their ra[)id development ; Their connection with constitutional signs ; Simultaneous affection of the vagina; Absence of chronic cervical inflammation ; The peculiar appearance of secondary eruptions. Treatment — This will consist in cases of chancre of the ordinary treat- ment adopted when such an ulcer affects any other part. In cases of secondary affections the patient should be put upon a mercurial course, the surface cauterized, and subsequent dressings made of mercurial pre- parations, of which the black or yellow wash, mercurial ointment, and calomel, are the best. > Aran, Mai. de 1' Uterus, p. 524. - ^^ Klob, op. cit., p. 243. 846 UTERINE FUNGOSITIES. CHAPTER XXIII. UTERINE FUNGOSITIES. History The fact that the lining membrane of the uterus becomes covered over to a greater or less degree with fungous masses, which have a marked tendency to bleed, was announced by Recamier, who not only- described them, but gave us the best method yet devised for their re- lief. After attention was called to the subject by him, theses were written upon it in Paris and Strasbourg, by Rouyer and Goldschmidt, and the subject attracted a great deal of notice in France, and received the attention of such men as Marjolin, Robert, Trousseau, Nelaton, Maison- neuve and Nonat, who not only adopted Recamier's pathological views but endorsed and practised his method of treatment. After many yeais of trial this contribution of the great French gynecologist may be regarded as by no means the least valuable of the many which he has made to this department. For a long time kept sub judice, it has of late years found its way into the text-books. Definition Uterine fungosities may be defined as fungous projections from the endometrium, the result of prolonged congestion from any cause, or of the organization of portions of placenta remaining attached to the surface. Under this head, of course, carcinoma and sarcoma of the endo- metrium might through an error in diagnosis be brought, but the nature of those grave disorders being once recognized, no one would think of classifying them under it. Upon theoretical grounds objection might be raised to classifying under the same head hyperplasia of the lining mem- brane of the uterus and remains of the placenta, but as the symptoms and treatment of the two conditions are identical, and there is no means of differentiating one from the other, it seems better for practical purposes to consider them together. Frequency Fungoid degeneration of the endometrium is an affection of great frequency ; one which plays the part of an important factor in men- orrhagia and metrorrhagia, and which often saps the health of [latients in whom its existence remains for years unsuspected. The practitioner who recognizes the important bearing of this subject will find himself prepared to cope with many cases of chronic endometritis, menorrhagia, metror- rhagia, and uterine enlargement which before proved entirely rebellious to treatment. Synonyms The disorder is sometimes described as granular hyper- SYMPTOMS. 847 plastic, or polypoid endometritis, or, as Slavjanky styles it, " internal villous metritis." Pathology. — Uterine fungosities will usually be found to exist as a con- sequence of uterine engorgement, however kept up ; or of abortion or labor. I have also repeatedly seen them in young women at the age when menstruation is establishing itself, and found them under those circum- stances produce a most excessive and dangerous degree of hemorrhage. In the first condition mentioned, prolonged congestion creates a hyper- genesis of tissue which results in hyperplastic growths upon the endome- trium. In tike second, if a large portion of placenta remained attached in utero, what is sometimes styled a placental polypus would be created, but small portions only being here and there attached, these little fungosities are the result. In the third condition, the great impetus given by puberty to sexual growth in the developing girl seems to affect the uterine lining so as to produce localized hypertrophies upon its surface. Under the microscope these growths if the result of hyperplasia and not of retention of small portions of placenta are found to consist, accord- ing to Dr. F. Delaiield, who has repeatedly examined them tor me, of hypertrophied elements of the mucous membrane, dilated follicles, enlarged bloodvessels, and exaggerated cell growth. Sometimes the amount of material removed at one time will amount to one, two, or three drachms, and its appearance will make one instinctively dread the existence of a malignant basis ; but the microscope will commonly even in such cases convey the comforting assurance to the contrary. Causes. — The causes may be enumerated as follows : — Abortion or labor at full term ; Endometritis; Subinvolution; Laceration of the cervix ; Uterine displacement of any variety ; Fibromata, submucous or interstitial. All these, except the first, seem to produce the condition by exaggerating formative development, or by keeping up engorgement of the uterine lining membrane. Symptoms — There is but one symptom which has any significance, that is uterine hemorrhage. This may consist only in a great exaggeration of the menstrual flow, or in profuse metrorrhagia. Whenever either or both of these is present, without other assignable cause, these growths should be suspected. For example, a patient has lost a great deal of blood from the uterus, and an abnormal condition is strongly suspected as the cause ot the excessive flow ; no solution of continuity is found to exist, no neoplasm ot any kind is discovered, and no large portion of placenta is supposed to be in utero ; under these circumstances fungosities should always be sus- pected, and their existence determined by physical examination. The 348 UTERINE FUNGOSITIES. method of deciding the question is so simple that it shouhl, under these circumstances, be unhesitatingly employed. Physical Signs — Fungosities being suspected to exist, the patient should be examined with Sims's speculum. Aftei" its introduction, the cervix should be held by the tenaculum, and if" the os externum or cervical canal be very small, it should be gently opened by the introduction of two or three graduated uterine dilators until it will admit the little wire curette to be shown further on in this chapter. An ordinary looped wire answers very well, and I have often made a loop of a lady's hairpin, bound it with waxed thread in the bite of the forceps, and employed that. All being now prepared, the loop of the wire curette, or the loop of wire, is passed in and drawn gently down the anterior face of the uterine cavity, then of the posterior, and then of each horn. As it is withdrawn after making each exploration, it is examined to see if it has dislodged a fun- gosity. If there be any within the cavity, and the instrument be not held in very unskilful hands, one or more will be looped off. These may, for greater certainty of diagnosis, be put under the microscope. In some cases a mamilloid process of mucous membrane will be found covered over with epithelium, placed edgewise upon it with great regularity ; in others, a piece of placenta will be seen ; while in a few cases the tale will be told of commencing cancer or sarcoma, which will yield to no treatment whatever. It has been said that the curette gently passed over the endometrial surface will reveal little irregularities, even if it do not remove tliem ; and in very marked cases this is true, but he who relies upon this as a crucial test will pass over many minor cases requiring diagnosis and treat- ment scarcely less than they. The wire hook should be regarded as a valuable diagnostic resource in all endometrial outgrowths. Employed as such, as freely as I make use of it, I have yet to see an accident follow its introduction if applied with caution. I have seen the uterine sound excite peritonitis, but never the wire loop used gently for the purpose merely of diagnosis. By its instrumentality the powerful aid of the mici'oscope is put at our service, and many an obscure case will be made clear, many a doubtful one set at rest by the combination. Course, Duration, and Termination These growths may last, produ- cing their evil results for years ; not increasing at all, but not diminishing. If the patient become pregnant, the changes of parturition seem in some cases to destroy their activity, but even this they at times resist, and after delivery the case goes on as befoi-e. Sometimes the little growths will be cast off and appear in the menstrual discharge. But this casting out does not go on to cure. If not interfered with, they will commonly annoy and weaken the patient until the meno- pause, when, notwithstanding their presence, the uterine flow will usually cease. I say usually, for the reason that in some cases it will obstinately continue at irregular intervals for years after its occurrence. PROGNOSIS. 349 The remedy to wliicli I Imve made allusion as having been introduced by Kecamier, is the use of the curette, which meets the requirements ot the condition perfectly. It must not, however, be supposed that one, or even several applications of the curette, will uniformly cure these cases ; many of them will [)rove very obstinate, rebellious, and perplexing. Some years ago, I attended, with Dr. Fessenden, of Brooklyn, a young lady of sixteen, who, ever since the establishment of menstruation, had lost blood so freely at her periods as to be alarmingly exsanguinated. I em- ployed the wire curette, and removed a great number of large growths, and she got up apparently well. In three months, however, her dangerous symptoms returned, and the operation Avas repeated and followed by in- jection of compound tincture of iodine into the uterine cavity. Again she got better, and again had a relapse after a few months. Sims's cutting curette was then employed, and after its use nitric acid was applied by Lombe Athill's method. After this Dr. Fessenden occasionally made an application of iodine to the uterine cavity, and she idtimately recovered. In another case which I attended with Dr. L. M. Yale, of New York, the curette was, during the course of three years, used ten times, very large quantities of fungous growths being each time removed; and the application of the instrument, Sims's being sometimes employed, and at other times mine, followed by free a|)plications of iodine or nitric acid. After a time we felt sure that sarcoma or can(;er must be the basis of the affection, but Dr. Delafield cheered us with the assurance that this was not so, and the justice of his statements was verified by the entire recovery ot our patient. In a great many cases I have had to repeat the operation of scraping about once a year for a long time, so that now I always guard my patients against this possibility for fear of their being disappointed at the result. Another curious fact connected with this operation, which I am at a loss to account for, is the irregularity in menstruation which occasionally follows it. The period next succeeding the operation will possibly be as profuse as those before it, but after this the patient may menstruate very irregularly. Results Directly : — Menorrhagia ; Metrorrhagia ; Leucorrhoea. Indirectly : — Spantemia ; Sterility; Constitutional feebleness. Prognosis — This will depend in great degree upon the treatment adopted. If the practitioner be one of those who abhor a resort to even 350 UTERINE FUNGOSITIES. the simplest surgical procedures, and who rely upon constitutional treat- ment in all these affections, the prospects of the patient tor recovery are poor. If, on the other hand, the procedure about to be described here be resorted to, recovery is as certain as the method is simple and safe. Treatment — Recamier advised the introduction into the uterus of a small scoop called the curette, by which these growths could be gently scraped off. His advice, although followed by some able men, was not generally accepted, and his method excited a great deal of hostility which even now has not passed away. The reason for this was, I think, the fact tliat the instrument employed for the procedure was so rough and hai-sh. At a later period.Sims introduced the steel curette shown in Fig. 128. This was an advance over Recamier's method in the superiority of the means for attaining the end. But even the use of Sims's cutting steel instrument was too dangerous, and the operation remained imperfect. For a number of years I have employed the instrument" shown in Fig. 129. Fig. 127. Fig. 128. Fig. 129. r Kfecamier's curette. Sims's steel curette. Thomas's wire curette. It consists of a copper wire with a small loop at its extremity. The loop is slightly flattened at its edges, but still it is not a cutting instru- ment. Even if applied with force, it can do no serious damage. It removes the growths by looping them off', not by cutting or tearing the endometrium, I employ it very largely in practice, and never yet have I had any accident follow its use in several hundred cases. Of course, as DANGERS OF THE CURETTE, 351 there are instances in which the passage of a uterine sound will cause peritonitis, so there are those in which this operation may end fatally, but I have never met with one, and no one could use it more freely than I do. In a very few rare cases in which the wire curette fails to effect a cure, I employ Sims's more powerful instrument, but never do I do this without good reason. After the operation the patient should be kept perfectly quiet in bed for three or four days, and any tendency to inflammation at once met by the treatment appropriate to peritonitis. Dangers of the Curette The dangers which attend upon the use of the curette are : — Peritonitis. Cellulitis. Atresia of the cervical canal. Hemorrhage some hours after operation. I have seen the first follow the use of the steel curette, never of the wire. It should be guarded against by care after operation, perfect rest for several days, and the free use of opium in case of pain. Tiie second is likely to occur in cases in which cellulitis has existed in chronic form before resort to the curette. The third I have seen in one case after the whole corporeal and cervical lining was thoroughly scraped by the cutting curette. The fourth, which I have once met with, may readily be pre- vented by the use of a vaginal tampon. Fio. 130. Emmet's ciiretto forceps. Emmet, in the hope of avoiding these dangers, recommends in place of the curette, the use of a pair of forceps with cutting edges shown in Fig. 130. By these the fungoid growths are seized and removed by alternate sepa- ration and approximation of their blades. 352 LACERATION OF THE CERVIX UTERI. CHAPTER XXIV. LACERATION OF THE CERVIX UTERI. Definition — This consists in the tearing of the wall of the cervix uteri during labor either partly or entirely tlirough the tissue which com- poses it. History. — It has long been known that during the last part of the first stage of labor, as the presenting part of the child escapes from the uterus and enters the vagina, the circular fibres of the os externum and of the vaginal portion of the cervix not infrequently give Avay under the exces- sive distention which occurs, and lacerations in one, two, or more direc- tions take place. In 1851 Sir James Simpson^ drew attention very fully to this subject, pointing out the facts that lacerations of the cervix uteri are of very frequent occurrence, that tliey are not the result of misman- agement, that they are so common after first labors as to be regarded as reliable signs of labor having occurred, and that they may be complete or may involve only the mucous and middle coats of the cervix. Some of the evil results of the condition too were recognized, as will be seen by reference to Dr. Gardner's work upon sterility, where it is credited with the causation of hypertrophy of the cervix, ulceration, cervical catarrh, sterility, and abortion. But the important pathological bearings of this accident upon disorders of the uterus, has been ai)preciated only of late years. Tlie credit of having recognized the significance of the lesion, and of liaving furnished us witli a safe and efficient means of cure, belongs to Dr. T. A. Emmet, The future of his operation for its relief will unquestionably be a long and brilliant one, and its results will effect a great deal of good for uterine pathology. Dr. Emmet, after having performed the operation for seven years, published his first paper upon it in 18G9. It was not, however, until a second paper by him in 1874 that the importance of his discovery was fully appreciated. Since that period it has gradually risen in favor, althouofh even now its great merits are not generally recognized. It is surely not too much to say of it that it constitutes one of the most im[)ort- ant contributions to gynecology which has ever been made. Frequency No reliable statistics are at our disposal upon this subject, for the reason that lacerations of the cervix exist under two forms with ' Edinburgh Jouri;. of Med. Science, p. 488, and works of Sir J. Simpson, Am. <3d. p. 152. PATHOLOGY. 353 reference to pathology : first, they may be important factors ; and second, their existence is recognized by inspection, but they produce no evil re- sults whatsoever. The question is not therefore merely how often the cer- vix is to a greater or less degree lacerated during parturition, but how often such laceration is productive of results which have an important bear- ing on uterine pathology. Simpson^ declared that evidence of a certain degree of laceration is given by " almost every careful autopsy of women after delivery, whether assisted or not assisted during their labor." Em- met^ says, " at least one half of the ailments among those who have borne children are to be attributed to lacerations of the cervix." GoodelP esti- mates " that about one out of every six women suffering from uterine trouble has an ununited laceration of the cervix." It may be taken for granted, first, that a certain degree of laceration of the vaginal extremity of the cervix uteri is the rule in first labors ; second, that a certain number of these are entirely recovered from or exist with cicatrized surfaces with- out pi'oducing pathological consequences ; and third, that in a large pro- portion they prove important factors of uterine disease. Tlie great reason for the varying results of laceration is this : if it inter- fere with involution of the body or cervix of the uterus, hyperplasia either local or general will result, with accompanying cystic degeneration, catar- rhal inflammation, eversion, and congestion ; if, in spite of it, involution goes on to a successful issue, tlie parts give evidence of the accident only by physical examination, not by pathological results. Upon the recogni- tion of this fact should rest tlie necessity for operative interference. If it become the rule of practice that all cervical lacerations should be closed without reference to their pathological influences, many women will be exposed to operation without cause and without compensation. Synonyms — Lesser degrees of laceration are described as fissures, and cases attended by eversion of the cervical endometrium as ectropion. Varieties — Laceration may be partial, where the mucous or middle coats of the cervix are torn through, the external being intact ; and com- plete where the whole texture of the canal is involved in tlie rupture. It may likewise be bilateral, unilateral, or stellate. Anatomy — It must be remembered that this accident involves the lining membrane of the cervical canal, with its reticulated mucous membrane and immense number of Nabothian glands. Should it produce pathological results, they will primarily affect these parts, secondarily those which are more remote. Pathology — Laceration of the cervix, occurring as it does during partu- rition, is very apt to interfere with involution of the cervix, of the body, or of the whole uterus. This interference may be very slight or very marked, ' Op. cit., p. 152. 2 oij. cit., p. 480. 3 Lesson in Gynecology, p. 169. 23 354 LACERATION OF THE CERVIX UTERI. the degree generally depending upon the extent of the injury inflicted. As a result of the accident, the cervix or whole uterus remrJns enlarged ; cystic hyperplasia affects the cervical endometrium, rich in glands; hyper- secretion at once takes place very markedly ; and granular degeneration with eversion of the lining membrane occurs. This combination makes up the condition formerly characterized as inflammatory ulceration of the cervix and ti-eated by depletion and caustics. I would not be understood as maintaining that unless laceration of the cervix produces subinvolution it therefore does no harm, but merely as asserting that it usually and chiefly effects its results in that manner. This is the explanation of the fact that section of the non-parous cervix for removal of tumors or for the cure of sterility or dysmenorrhoea very rarely results in any of the evils ordinarily attendant upon laceration, such as eversion, endometritis, or areolar or cystic hypei'plasia. It is not to be denied, however, that laceration of the parous uterine neck, unattended by subinvolution, and section of the non-parous, sometimes, by slight ever- sion of the mucous membrane and tlie influence of friction from the vagi- nal walls, eventuate in areolar or cystic hyperplasia with endometritis and granular degeneration. The last is not a necessary result of laceration, but is produced indirectly by the ichorous mucus which is secreted by the inflamed endometrium. Causes Every patient, when informed as to the existence and origin of this condition, instinctively turns in a direction to which the mind of woman has a natural proclivity, that of censuring the medical attendant for the unfortunate result. It becomes the bounden duty, at the present day, for the gynecologist to remove fully and completely all such disj:)0si- tion on the part of the patient, not as a matter of professional courtesy, but of simple justice. Let a patient be ever so well attended, this acci- dent may, as Prof. Simpson pointed out, occur even after a short and natural delivery. It will be noticed that I say that, "at the present day," no blame should be allowed to attach to the attending obstetrician. I feel sure that this will not be so in the future. It is true that even then prevention will prove impossible ; but not so, early recognition. Six weeks or two months after delivery every parturient woman should, with our present lights, be examined as to the condition of the perineum and cervix uteri. It is an entirely fallacious position to assume that an ex- amination just after labor rev^eals the real state of these parts. No one could then thoroughly inform himself, except by an exploration the ex- posure attendant upon which would defeat its practice. As far as the cervical injury is concerned, too, even if discovered just after labor, it could not then be operated on, and by the end of the period of involution it might have entirely disappeared. An examination at the time when a parturient woman should be discharged from the obstetrician's observation, the end of the period of involution, and not the ninth day, as is now gene- PHYSICAL SIGNS. 355 rally done, would reveal tlie true condition of things, and in a great many cases avoid for women lives of suffering and invalidism. A laceration of the cervix being discovered, it would not follow that operation Avould be inevitable, but the obstetrician, being now forewarned, would be prepared to act for the best interests of his patient. The chief causes of laceration of the cervix may thus be stated : — Precipitate labor ; Manual delivery ; Instrumental delivery ; Labor with rigidity of os ; Cicatricial material in tissue of cervix ; Cancerous degeneration of cervix ; Section of cervix during labor ; Too early evacuation of the liquor amnii ; Abortion. In my own experience I have met with every cause here stated as pro- ductive of this accident, the first three recorded being infinitely the most frequent. Head last labors, calling as they do for the very rapid passage through a badly dilated os of an uncompressed head, often induce it, but these I consider in the category of " manual delivery." Emmet considers criminal abortion a particularly frequent cause, though it is difficult to see why it should be more so than that from accidental causes. Symptoms The rational signs of this condition are, as a rule, nume- rous and important : — Pain in back and loins ; Sense of " bearing down ;" Leucorrhica ; Increase or diminution in menstruation ; Sometimes hemorrhage after coition ; Neuralgia of cervix ; Sometimes sterility ; Discomfort in locomotion ; Dyspareunia. All these, of course, do not occur in any one case. Some cases present some of them, and some others. Physical Signs — The examination for this lesion should always be made with Sims's speculum or one of its modifications. By the cylin- drical speculum, or by those valvular ones which distend the vagina slightly, it is often not recognizable, and always imperfectly appreciated. This furnishes a good illustration of the truth of the position elsewhere assumed in this work, that the gynecologist who habitually employs Sims's method of examination stands upon a vantage ground unattainable by one who does not do so. r The cervix, being exposed to view, will be seen to present somewhat the appearance shown in Figs. 131 and 132. 356 LACERATION OF THE CERVIX UTERI, Fig. 131. Bilateral laceration to vaginal junction. A, A, lips of the severed os externum. B, OS internum. Fig. 132. I i i Bilateral laceration to vaginal junction, with liyperplasia of cervical walls. A, A, lips of severed OS externum. B, os intPininu. PHYSICAL SIGNS. 357 In both these diagrams the round spots on the cervical walls represent enlarged Nabothian follicles; in the second the dotted lines must receive no attention, as they refer to something to come hereafter. But these d'iai^rams, although conveying correct ideas of the general nature of cervi- cal lacerations, do not sufficiently portray the many variations which this interesting and important lesion may assume. Fig. 133 represents the Fig. 133. Double tenaculum scparatiug tin; flaps of a [unilateral] laceration. (Emmet.) more detailed outline of a unilateral laceration, the rent being posterior, and Fig. 134 of a multiple or stellate rupture. Fig. 134. Multiple or stellate laceration of the cervix. (Emmet.) Many cases of the varieties of cervical laceration which I have men- tioned, unilateral, bilateral, and multiple, wliether these be complete or partial, are obscured by hyperplasia and eversion of the endometrium, 858 LACERATION OF THE CERVIX UTERI. with its glands in a, condition of cystic degeneration ; by areolar hyper- plasia of one or both lips of the tear; and by granular degeneration going on to development of extensive exuberant growths. These can only be recognized by careful and attentive examination. For excellent delinea- tions of these and life-like representations of them, I would refer the reader to some colored lithographs by Dr. P. F. Munde.' The parts being exposed to view by the speculum, a tenaculum should be fixed in each extremity of the severed cervix and its divided walls drawn together. As they come into contact, the normal shape of this part will present itself to view and at once be recognized unless, as in Fig. 134, so much hypertro[)hy has occurred on the inner walls of the two sides as to render tliis impossible. Even then, however, an approxima- tion to the truth may always be arrived at. Differentiation The conditions from which laceration of the cervix will generally have to be ditferentiated are these: — Granular degeneration ; Cystic degeneration ; Simple hyperplasia or hypertrophy; Malignant disease. It will often prove by no means easy to arrive at certainty until the case has been kept for some time under observation. From cancerous exuberation from the endometrium the microscope will sometimes prove the only certain method of differentiation. Results Nothing more triumphantly displays the value of Emmet's contribution to gynecology in connection with cervical lacerations than a full exhibit of tlie evils which result from that condition. Its ordinary consequences are — Chronic peri-uterine cellulitis ; Epithelioma ; Subinvolution of a part or the whole of the uterus; Sterility ; Menstrual disorders ; Cervical endometritis ; Granular and cystic degeneration ; Fungosities of corporeal endometrium ; Neuralgia of cervix ; Dyspai'eunia ; Tendency to abortion ; Uterine displacements. There can be, on the part of those who have been properly impressed with the importance of this lesion, no question as to the truth that all the conditions mentioned may originate from this accident. ' Am. Journ. Obstet. and Dis. of Women and Children, Jan. 1879, p. 134. TREATMENT. 359 No part of the body of a woman is so liable to the development of cancer as the uterus ; no part of the uterus so liable to it as the neck ; and no tissue of the neck so liable to it as the glandular lining membrane. Exposure of this by eversion, the result of laceration, would, theoretically, be supposed to be a fruitful exciting cause of that affection, and practical observation abundantly supports theory in reference to the matter. My own observation has for several years made me feel sure of this, and that of Breiskey, Emmet, and Veit is recorded to the same effect. This alone offers a valid indication for the closure of lacerations attended by local engorgements and irritation. Prognosis As time passes, the raw surfaces of the lacerated cervix may gradually become cicatrized, its evil results diminish, hyperplasia disappear, and the patient enjoy very good health, in spite of the fact that the condition still exists. Tiiis may occur without treatment, though the application of alteratives, escharotics, and astringents, as iodine, nitrate of silver, cantharides, tannin, alum, zinc, etc., unquestionably hastens and secures the result. Ordinarily the patient remains to a certain extent an invalid until the menopause, when the occurrence of atrophy of the internal genitalia effects a removal of the consequences of the laceration. Treatment — This maybe palliative or curative, the former being appro- priate to cases in which from any cause the operation of trachelorrhaphy cannot be performed. Palliative treatment consists in the use of copious hot water vaginal injections, evacuation of cervical cysts by puncture, application of alteratives, such as iodine, nitrate of silver, glycerole of tannin, removal of all superincumbent weight, and direct support of the uterus by a pessary. Curative treatment consists in repair of the laceration by trachelor- rhaphy, after the patient's general condition has been rendered good and the affected parts have been properly prepared for operation by the pallia- tive course just mentioned. I will describe the operation as applied to a case of bilateral laceration. The patient being anaesthetized and placed upon a table before a window, in Sims's position, his speculum should be introduced, and two tenacula fixed, one in each flap of the laceration, and they should be approximated. If this can be effected, the operator determines exactly where his denuda- tion is to be made ; if it be found to be impossible, he recognizes the fact that the case will require a special plan of treatment, which is soon to be described. Having decided where the denudation is to be made, the operator catches the lower side of one flap, and, by scissors, cuts away the mucous membrane and a small portion of the parenchyma as far as the angle made by the junction of the two flaps. Then seizing the other flap he treats it in the same way, the strip of separated tissue being now completely removed. The same process is gone through with on the other side, the resultant of both being two long raw surfaces, one on each side 860 LACERATION OF THE CERVIX UTERI. ))f the laceration, with a strip of undenudecl tissue extending upwards to or towards the os internum. Fig. 135 will siiow this. Fig. 135. Lacerated cervix denuded, and strip of undenuded surface left to act as a cervical canal. The flow of blood is now stanched, if necessary, by a tampon of linen or cotton left in place for five or ten minutes. The operator, again fixing the tenacula, ascertains by approximation of the opposing denudations thai they will after passage of the sutures lie in contact with each other, and proceeds to the second step of the operation. Fixing the tenaculum in the cervix near the upper angle of the lacera- tion, he now passes through one flap a sharp-pointed, short needle, held in the needle forceps. The needle is introduced about a quarter of an inch from the edge of the denudation, passed through, and in the same way carried through the opposite lip. This needle is armed with a loop of silk by means of which a silver wire is drawn into place, the ends of which are placed under the finger of the person holding the speculum. One after the other wire sutures are passed from above downwards, about a third of an inch apart, until the lower extremity of the laceration is reached. Then the other side is treated, if it be a bilateral laceration, in the same manner. The sutures are now twisted one by one, the upper ones being first dealt with, until all are twisted, when each one is bent downwards so as TREATMENT, Fig. 136. 361 Sutures passed after denudation of cervix. to lie flat against the wall of the cervix. The conclusion of this procedure is shown in Fig. 137. In case the laceration is multiple or stellate like that shown in Fig. 134, it is not proper to close each little fissure separately, but cutting up on each side to the vaginal junction so as to make the laceration one of bilateral variety, denuding still more so as to narrow the cervical canal- and then closing by suture as already described. Still another class of cases must be mentioned. Sometimes hyperplasia of the inner walls of the cervix has occurred to such an extent as to pre- vent easy approximation of the opposing flaps, as shown in Fig. 132. Here it is necessary to cut away the hypertrophied tissue below the dotted lines, and then the cervical walls will readily come into apposition. The patient, after the operation, should be confined to bed and kept upon low diet. The bowels may be moved every day, and the urine 362 LACERATION OF THE CERVIX UTERI. evacuated upon the bed-pan. Twice a day the vagina should be cleansed by a warm, carbolized injection, and on the eighth or ninth day the sutures should be very cautiously removed beginning with those above. If union have not occurred or seem very weak, the lower ones may be left for a fortnight. Fig. 137. Sutures twisted and beut downwards against the wall of the cervix. The operation sometimes, though very i-arely, results in cellulitis or peritonitis, and considering the good which it accomplishes is remarkably free from risk. The use of a pessary to sustain the heavy uterus is often advisable for two or three moiitlis after recovery. DISPLACEMENTS OF THE UTERUS. 363 CHAPTER XXV. GENERAL CONSIDERATIONS UPON DISPLACEMENTS OF THE UTERUS, History. — That the earliest practitioners of medicine were familiar witii this subject is abundantly attested by the writings of the Greek and Roman schools. It is distinctly mentioned by Hippocrates, and more clearly and exactly still by Galen and Moschion about the second century of the Christian era. This remark applies not only to prolapse, but also to versions, whicli were evidently understood. Hippocrates and Moschion even described latero-version, a variety which has not been much noticed by modern writers, and Aetius^ in the sixth century indicates the method for reduction and retention in place of the retroverted womb. Although certain passages in the works of these old writers seem obscurely to refer to bending of the uterus upon itself, such for example as one in which Hippocrates speaks of cases in which " utcroruia os conclasum, ant con- tort um fiierit," there is no satisfactory evidence that they understood the ditierence between versions and flexions. Passing over many centuries, at the middle of the eighteenth we find gynecologists paying attention to versions, and even to flexions, of the pregnant uterus, but losing sight of these displacements in the non-preg- nant organ. Versions were at that period described by Gartshore, W. Hunter, Jahn, and Desgranges ; and flexions by Saxtorph, Wltczek, Baudelocque, and Boer. Gartshore describes a case of retroflexion com- plicated by retroversion, but the flexion appears to have made little im- pression upon him. In 1775 Saxtor[)h wrote an essay entitled " De Is- churia ex utero retroflexo," describing a case with autopsy, but the words *' orificium alte supra pubem reperi," show that it was not a true case. About the same time Wltczek published an unquestionable case " de utero retroflexo," but it occurred during utero-gestation, and hence does not concern our inquiry. Both in England and France the subject of dis- placements attracted great attention at this period. " At this time Cho- part upon his return from England, where he became well acquainted with AV. Hunter, informed the Academy of Surgery what progress was being made in a subject which had attracted attention in France thirty years before."^ ' Tetrabiblos, ch. Ixxvii. 2 Cusco, "These de PAntedexion et de la Retroflexion de PUterus," Paris, 1853. 364 DISPLACEMENTS OF THE UTERUS. Denman was the first writer who described flexion of the non-pregnant uterus, which he did in reference to a case of retroflexion, about the year 1800. The wanting link, the description of anterior flexure, was not supplied until M. Ameline, of France, described anteflexions in 1827. After this many others added to the knowledge of the subject, which soon assumed its place in systematic medical literature. A great deal was done for it by the introduction of the uterine sound as a means of diagnosis and of reposition. In carefully perusing more modern literature with reference to its con- tributions to uterine flexions, I am impressed with the belief that we are indebted to none more fully than to Cusco, whose very valuable thesis I have alluded to, and Graily Hewitt, whose views are familiar to all. In this country the profession is generally indebted for correct views upon the subject to Dewees, Meigs, and Hodge. More especially has the last of these identified his name with it by important contributions to pathology and treatment. Pathological Significance of Versions and Flexions — The ancients ascribed to these displacements many constitutional evils, as paralysis, hysteria, etc., and even until a very recent period they were credited with a great deal of pelvic pain and functional uterine disturbance, wliich it was supposed almost universally attended them. Until 1854 this belief pre- vailed very generally, having the powerful support and endorsement of such men as Velpeau, Simpson, and Valleix. It is true that it was con- tested by Cruveilhier and Dubois,^ before the period mentioned ; but at that time a spirited discussion arose concerning it in the Academy of Medicine of Paris, which not only threw much doubt upon it, but gave rise to a powerful opposition, in the ranks of which appeared Depaul, H. Bennet, Aran, Becquerel, and others equally eminent. They maintained that these displacements of the womb, if unaccompanied by textural lesion, produced no constitutional disturbance ; created, as a rule, no dis- comfort; and did not deserve the attention in treatment which had been bestowed upon them. They did not believe that the dislocation was the cause of suffering when this existed alone, but looked upon it, in such cases, as an epiphenomenon engrafted upon some important lesion. Con- sequently they were opposed to reliance being placed upon support by pessaries as one of the essentials of treatment, as had been done by the other school. When views supposed to be false are repudiated, those adopting new ones are always apt to run too far into an opposite extreme, and in this instance many have done so. Scanzoni'^ sounds the keynote of this extreme party when he states, that "flexions of the womb do not acquire any impor- 1 Goupil, B. & G., op. cit., p. 459. « Op. cit., Amer. ed., p. 112. VERSIONS AND FLEXIONS, 365 tance, nor are followed by any serious dangers, save when they are com- plicated with an alteration in the texture of the organ." The following propositions present the views upon this subject whicli I think will be found to bear the test of experience : — 1st. Versions and flexions of the womb may, but very rarely do, exist without causing any symptoms, for in themselves they do not constitute disease. Thus it is that in rare cases we see the uterus forced completely out of its place, without the production of morbid signs. 2d. By interfering with escape of menstrual blood, by disordering ute- rine circulation, and keeping up hyperaemia, by causing pressure and friction from contact with surrounding parts, and by creating a barrier to the entrance of seminal fluid, they become, as a general rule, of great importance and require special attention. 3d. Often being the results, as they are sometimes the causes, of uterine and periuterine diseases, their treatment should be combined with efforts at the alleviation of these states. 4th. Treatment by pessaries, combined with means which remove the weight of the superincumbent intestines, is of great value. By it, even although the primary disease is not affected, we may relieve one of its most troublesome symptoms, which often reacts for evil in aggravating and prolonging the affection which caused it. When the displacement has resulted from relaxation of the uterine ligaments, in consequence of increased weight or pressure from the abdominal viscera, pessaries prove a most useful and efficient means of treatment. 5th. One reason for the great prejudice existing against the use of pessaries in the minds of many is to be found in the fact that most of tiie enlargements of the uterus were attributed unhesitatingly to parenchyma- tous inflammation. Mechanically lifting an inflamed organ appeared repulsive to reason. 8o long as the existing inflammation was uncured, efforts appeared to be directed to a side issue, a result and not the root of the disorder. Since it is now known that what was supposed to be chronic metritis is really a vice of nutrition resulting in new formation of connec- tive tissue, this theoretical objection falls to the ground. Gth. Another reason is this : it requires skill, and ingenuity, the result of practice, not only to do good with pessaries, but to apply them without doing absolute harm. In the hands of a physician who has made no special, or at least careful, study of their use, and who habitually applies only a half-dozen in the course of every year, pessaries are elements of absolute danger. It would be as unreasonable to expect an untauglit experimenter to fit the foot comfortably with a shoe, as to hope for effi- ciency, comfort, and safety from a pessary applied by ignorant hands. 7th. The gynecologist who to-day assumes the position that pessaries are useless or worse, and treats uterine displacements without their aid, 366 DISPLACEMENTS OF THE UTERUS. will fail, bv reason of the absence of other means to accomplish the existing indications, to meet the requirements of his cases. Definition and Synonyms The term displacement is applied by British and American writers to any decided removal of the uterus from its normal position, without reference to the direction in which it has been moved ; while French writers apply the term displacement only to ascent and descent of the uterus, reserving that of deviations for versions and flexions. Anatomy.. — One of the salient points in the comprehension of this most important subject consists in a clear understanding of the natural position of the healthy uterus. But unfortunately, owing to the fact that the position of this organ varies constantly with insi)iration and expiration, with muscular effort and quietude, and with fulness and emptiness of the bladder and rectum, it is difficult to arrive at common ground with refer- ence to a point apparently so easy of settlement. As this chapter pro- gresses, I pro[)ose to put before the reader a diagram of the normal posi- tion of the uterus when not influenced by any decided disturbing cause. It is the result of long and careful investigation, and represents the truth, I think, more accurately than any other with which I am acquainted. Let any one examine a healthy uterus by means of Sims's speculum, and he will recognize that it is delicately and perfectly poised near the middle of the pelvic cavity by such supporting influences that it is never, even for a few seconds, perfectly at rest. It ascends with expiration and descends with inspiration with such regularity and distinctness, that one operating upon the pelvic viscera can, by this up-and-down movement, recognize at once when an anossthetic is affecting respiration badly. Under the influence of more decided factors, such as pregnancy, repletion of blad- der or rectum, or violent muscular efforts, still more marked changes of position occur to it. Nevertheless we must agree upon a medium position as the normal one for a healthy uterus. The mechanical influences which sustain the uterus and preserve its pelvic equipoise are five in number. These are — 1st. The retentive power of the abdominal cavity. 2d. The attachments to the areolar tissue of the pelvis. 3d. The juxtaposition of the other organs. 4th. The vaginal promontory upon which the neck rests. 5th. The following ligaments : — a. Tlie round ligaments, continuations of uterine tissue, extending from uterine horns to labia majora; b. The utero-vesical ligaments, bands of pelvic fascia, and uterine muscular tissue passing between the bladder and the cervico-cor[)oreal junc- tion, where they attach themselves, and prevent retreat of cervix : c. The utero-sacral ligaments, formed of hypogastric fascia, and the uterine and vaginal tissue, extending from posterior surface of cervix, passing backwards to be attached to sacrum, and prevent- ing passage of cervix forwards ; ANATOMY ?>67 d. The broad ligaments, folds of peritoneum inclosing areolar tissue, ovarian and round ligaments, and ovaries ; preventing lateral, anterior, and posterior displacements. None of these means of suspension are concerned in flexions and inver- sion, which are combated by forces of entirely different nature. The tissue of the normal, unimpregnated uterus is of such strong, resisting character in the adult female, as to prevent too great a curvature of the body upon the neck either anteriorly, laterally, or posteriorly. It is to this peculiarity of structure that immunity from these conditions is due. When stimulated by pregnancy, the uterine tissue develops rapidly into muscular structure. This keeps the cavity of the organ closed by tonic contraction, and removes the possibility of inversion unless it be accom- plished by absolute violence. But when from any cause this contractile power is destroyed and the condition of tone is replaced by one of atony, flexion or inversion may occur. Fig. 138. 1i„uf I 'n I The regions of the ahdomen and their contents. Edge of costal cartilages in dotted outlines. (Gray.) The retentive power of the abdomen is one of the most important influ- ences for the support of the uterus, and one of the most neglected in con- sideration of this subject. Fig. 138 represents the abdominal viscera in 368 DISPLACEMENTS OF THE UTERUS, their normal condition and place. The diaphragm, one of the muscles most essential to respiration, is located nearly midway in the trunk, across which it extends like a concavo-convex curtain. " Its action exactly re- sembles that of a piston in the cylinder of a pump.'" As it contracts it forces the abdominal viscera downwards directly upon those of the pelvis, and as it relaxes, and expiration occurs, the depressed abdominal viscera rise to their former place, drawing the pelvic viscera upwards. This up-and-down movement not only keeps the uterus in place, but it exerts a powerful stimulating influence upon its circulation, and prevents that tendency to sluggishness which perfect quietude so markedly favors. Dr. Matthews Duncan^ has very ably treated of this important subject, and done a great deal of good with reference to it ; an excellent contribution has been made to it by Dr. Busey,^ of Washington ; and a remarkable work has been written upon it in its various aspects by Dr. Geo. H. Taylor,*of New Fig. 139. Normal position of tlie uterus. York. In my mind its importance cannot be over estimated, for I believe that more valuable contributions to the etiology of uterine displacements in the future will come from investigations in this direction than any other. ' Course of Lectures on Physiology, by Prof. Kuss, of University of Strasbourg, p. 294. 2 Researches in Obstetrics. 3 Amer. Jouru. Obstet., February, 1872, p. 585. * Diseases of Women, 1871. ANATOMY. 369 Fig. 139 represents the results of my researches as to the normal posi- tion of the uterus, the bladder and rectum not being entirely empty. I shall allude in detail here to only one other factor in uterine support. The cervix will be observed to impinge slightly upon the anterior rectal wall, and to depress it a little. This a rectal examination will usually reveal as the rule. The perineal body being normal, the posterior vaginal wall will from this point be found, upon careful vaginal touch, to rise up below the cervix, which will thus rest in a very shallow well or depression, the anterior cervical wall being supported as if by a shelf, by the anterior projection of this. This anterior projection of the posterior vaginal wall is what I have styled the vaginal promontory in the enumeration of the influences supporting the uterus. Like the third factor mentioned, it is not powerful, but, like it, it is too important to be overlooked. It must be borne in mind that the support of the uterus is not accomplished by one or two powerful factors alone, but by a combination of several, each work- ing towards a common end. This very fact makes it manifest that a number of mechanical influ- ences may force an organ thus sustained upwards, downwards, laterally, or even bend it upon itself or turn it completely inside out, and that the direction of the impelling force or nature of the loss of support will deter- mine the character of the displacement. The displacements which may thus result have received the following appellations : — Ascent ; Descent or prolapsus ; Anteversion ; Anteflexion ; Retroversion ; Retroflexion ; Lateroversion ; Lateroflexion ; Inversion. These varieties should not be memorized by the student, for such an effort would be uncalled for. Let him suppose any pear-shaped bag, one of gutta-percha for instance, suspended by yielding supports in a cavity, and it must be evident that these and only these changes of position could be impressed upon it. Having said this much in a general way as to displacements, let me say a few words with special reference to uterine flexions. Version, or turning of the uterus, signifies the fact that its long axis has changed its normal direction in the pelvis. Flexion signifies the bend- ing of the uterus upon itself, so that a decided angle is created in its long axis. One condition is a displacement ; the other a deformity in the organ. One may be likened to a dislocation of one of the long bones ; the other to a fracture with angular union of the broken extremities. The 24 B70 DISPLACEMENTS OF THE UTERUS. treatment of one involves merely restoration of a dislocated organ ; that of the other, rectification of a deformity which may have lasted for years or may even have been congenital. Frequency — Flexions of the utei'us, that is, displacements, anteriorly, posteriorly, or laterally, in which the decidedly predominating feature is flexion and not version, are very common. In 339 displacements Noiiat . fouud (J7 flexions. " 84 " Meadows " 54 As to the relative frequency of anterior and posterior flexions, the evi- dence is decidedly in favor of the former. In 67 cases of flexion Nonati found 33 anteflexions and 14 retroflexions. " 54 " " Meadows2 " 20 " and 34 " " 54 " " Scanzom^ " 46 " and 8 " " 23 " " Valleix^ " 11 " and 12 " "296 " " Hewitts " 184 " and 112 " Out of 1670 cases of flexion collected by Ludwig Joseph,^ of Breslau. 1100 were anterior and 570 posterior. Out of 345 cases of flexion, Emmet^ found 273 to be anteflexion, 29 to be retroflexion, and 43 to be lateroflexion. Although the results are somewhat conflicting, the preponderance of evidence very decidedly favors anteflexion over retroflexion. One reason why we should anticipate that retroflexion would be less frequent than anteflexion, is that the natural anterior obliquity of the uterus favors the latter and opposes the former displacement. Another is the fact that the former is more thoroughly guarded against by ligamentous support ; the round ligaments, running as they do from the horns of the uterus to the vulva, decidedly tending to prevent its occurrence. Iv'ot only do they do this ; the uterus, being kept by them in anterior inclina- tion, should softening of its structure occur, or any direct force be exerted upon it, naturally bends forwards. If this be so, it may be asked why areolar hyperplasia so frequently results in retroflexion as well as in anteflexion. One reason is because the first effect of the increased uterine weight attending that disease is descent of the uterus. This relaxes the round ligaments, tends to bring the uterine axis in coincidence with that of the middle of the pelvis, and favors retroflexion. For a time the tendency is to descent and coincident retroversion. This continues until the progress of the cervix is checked ' Mai. de ITterus, \>. 416. « Am. Journ. Obstet., 1st vol. p. 175. 8 Klob, op. cit., p. 69. * Cusco, Th6se, p. 35. 5 Dis. of Women, 2d Am. ed., p. 213. Hewitt includes versions with flexions. The otlier statistics refer to pure flexion. 6 Berlin Beitrage zur Geburtsliulfe und Gyuiikologie, vol. ii. part 2, 1873. » Priu. and Prac. of Gynecology. ANATOMY. 371 by the utero-sacral ligaments. Then the heavy body bends, the weak- ened tissue yielding at the os internum, and retroflexion results. Another reason is that flexion commonly follows parturition, at which time, attack- ing an organ with weakened tissues and relaxed ligaments, it meets with an efficient ally in the nurse, who favors retroflexion at the expense of anteflexion by zealously forcing the fundus backwards by a tight obstetric bandage. Thanks to the researches of Coste, Pouchet, Bischoff, and others, we are to-day well informed concerning the development of the uterus. Pearly in embryonic life a little duct shoots out from the external surface of each Wolffian body. These pass downwards to unite and make a common canal, which becomes in time separated into uterus and vagina. Very soon a constriction appears, the neck of the uterus is formed, and becomes well developed, wliile a very small spot marks the point where the body is to show itself. Tiie original canals become Fallopian tubes, and at the time of birth these, as well as the neck and body of the uterus, vagina, and other organs, have arrived at maturity. But it must not be supposed tliat the proportions of the adult uterus exist in that of infancy. The neck forms three-quarters of the organ, and the body, represented by a soft movable membrane, has no fixed position, but follows the bladder, if upon opening tiie abdomen it is drawn forwards, or the rectum, if that viscus is pushed backwards. Later in the life of the girl, even after she has reached puberty and menstruation has occurred, the uterus is curved forwards; and this anterior inflexion lasts through life, if a normal state continue, though it is generally diminished and sometimes overcome by puberty and utero-gestation. In 1849, Velpeau, whose insiglit into gynecology was certainly remark- able, in a discussion before the Academy of Medicine of Paris, declared that he had so often found an anterior inflexion of the uterus in healthy women, that he was inclined to look upon it as normal. Upon this hint two of his pupils, Boullard (1852), and Piachaud (1853), with great assiduity, investigated the subject, and determined that it is so in the child and virgin; the latter basing his deductions upon 107 cases. Boul- lard found it to exist in 80 female foetuses, and in 27 adult females. Ver- neuil and Follin subsequently confirmed these observations. That this is the normal condition up to puberty is unquestionable; nor can it be denied that to a limited degree it is so even afterwards in the unmarried female. But, as Cusco has pointed out, it greatly diminislies at puberty, unless abnormal flexion is developed. Up to this time tlie neck of the uterus represents three-quarters of its entire bulk, and the whole organ is an insignificant element of the human body. At this time, however, it becomes an important organ. The body develops ; its walls become thick, dense, and strong; "and," says Cusco, "this is an import- ant point, if the development is regular its walls establish an equilibrium ; 372 DISPLACEiMENTS OF THE UTERUS. the uterus straightens itself; its anterior concavity disappears; and there remains only a slight depression corresponding to the bladder." Up to this period of life curvature is unquestionably due to the want of tone and power which characterizes undeveloped uterine tissue, for even when ante- flexion does not exist, the organ is generally otherwise displaced. Thus, M. Soudry,' in 71 post-mortem examinations of infants, found the uterus anteflexed 41 times, anteverted 11 times, retroverted 15 times, retroflexed twice, and retroverted with anteflexion twice. We may then conclude from the evidence at present upon record — 1st, That anteflexion is the rule during early childhood; 2d. That it is quite frequent, in slight degree, in nulliparous women, without constituting disease. For the prevention of versions certain pelvic ligaments are very effectual, but they have no power to prevent bending of the uterus upon itself. This is accomplished by the inherent strength and resistance of the proper tissue of the organ. Remove a normal uterus from the cadaver, balance it upon the cervix, and it will sustain itself perfectly ; press it down by applying force to the fundus, and its own resiliency will cause it to erect itself im- mediately. Suppose a uterus to be composed of gutta-percha instead ot living tissue ; the material forming the walls of the neck will support the fundus when the pear-sliaped bag is held by the stem or narrow part. To carry the simile further, so long as the proper tissue of the stem or neck remains normally strong, flexion will be impossible unless its resistance be overcome by direct physical force exerted by pressure or traction. But if some influence be brouglit to bear locally, so as to soften the part sustain- ing the fundus, it is evident that, as the gutta-percha walls grow weak, there may be a flexion of the fundus from its own weight. It will be said that these views represent the uterus as supported by the vagina, and leave out of consideration the broad ligaments which sustain the fundus. If these ligaments were tightly drawn cords, I could admit their action, but as they are merely lax folds which are not made tense by the bending of the uterus upon itself, I do not do so. A corroboration of this view is found in the frequency of flexions in the uteri of the aged which have lost tone and strength. " In aged women," says Klob,^ " with exceedingly relaxed uteri, the pressure of the intestines upon the posterior surface of the organ is sufficient to cause anteflexion." Pathology Flexions may be congenital or accidental. As the oppo- site walls develop, an excess of nutrition may be appropriated by one, which grows rapidly, while the other developing more slowly arrests the erection of the uterus, and, giving it an inflexion, creates a concavity on one side and a convexity on the other. If the posterior wall develop most decidedly, an anteflexion results ; if, as was the case in nineteen out of M. ' Aran, op. cit., p. 981. 2 Op. cit., p. 61. ANATOMY. 373 Soudry's seventy-one autopsies of infants, posterior displacement exist, and the anterior wall receive the chief amount of nutrition, a retroflexion is the consequence. But not only does the excessive growth of one wall create an inflexion on the opposite side ; the side which is bent undergoes to a certain extent atrophy, and this increases the already growing dispro- portion. This, in all probability, is the source of congenital flexion, a condition always exceedingly diificult of cure, but fortunately one which does not create as much corporeal congestion and constitutional disturbance as the more remediable form which is accidental. In the supplement to the second volume of Herbert Spencer's work upon Biology, appear some remarks upon the influence of prevailing winds upon the growth of trees, which are interesting in this connection. The tree, says he, being habitually bent in one direction, its nutrition is, on the concave surface, impaired, the ligneous material upon the convex portion is deposited in excess, and in consequence the heart of the tree is not cen- tral, but considerably nearer to the concave than to the convex surface. Upon experimenting upon growing twigs by bending them to one or the other side, he found that he could uniformly produce the same result. When the laterus is flexed, a similar change will be found to occur from a like cause. Congenital anteflexion is much more common than congenital retro- flexion. Cases of the latter are, however, by no means unknown. Boivin and Duges' report two cases, Dubois one, Deville one, and Bell one in a very young girl. I have several times met with it. Any influence which weakens the tissue constituting the uterine walls, creates flexion. If the posterior wall be chiefly aflTected, the body falls backwards; if the anterior, it inclines forwards; if both, the direction of inclination is decided by extraneous forces. Rokitansky has proved that such weakening is accomplished by endometritis, which creates an inward growth of tlie utricular glands into the submucous connective tissue, near the OS internum, which in consequence undergoes atrophy and enfeeble- ment ; or by cystic degeneration in the cervical glands, "which, from their increased size and subsequent pressure, cause the submucous stratum to become atrophied, and which ultimately bursting, thereby cause a col- lapse of tissue in the formerly dense framework of the uterus, leaving in its place a flaccid net-like areolar tissue incapable of sustaining the organ in its normal position." Both these occurrences, says Klob, take place quite frequently. Rokitansky says that in the anterior semicircle of the uterine tissue around the os internum of women who have borne manj children, a large transverse vein is found, which, by its removal of tissue, weakens the wall. But there are other influences which may accomplish this result. ' Cusco, op. cit., p. 34. 1 374 DISPLACEMENTS OF THE UTERUS. abscess of the uterine tissue ; development of fibroids which disorder the bloodvessels ; varicose degeneration of the veins and sponginess of tissue engendered by i)rolonged traction upon the neck ; disturbance of nutri- tion by flexure created suddenly by a blow or fall, or gradually by traction from false membranes ; subinvolution, or areolar hyperplasia, which ac- complishes, on a large scale, the substitution " for the dense framework of the uterus of a flaccid, net-like areolar tissue, incapable of sustaining the organ," which Rokitansky declares occurs at the os internum in cystic degeneration. This loss of power in one or both walls of the uterus is frequently, though not universally, the cause of flexions of accidental character. They are sometimes due to force sufliciently strong to overcome the resist- ing power of the uterine tissue, either suddenly or by slow degrees. Once flexed, one wall soon undergoes degeneration, and thus two causes for a continuation of the condition are combined. The point of greatest weakness is the point at which flexion occurs, and this is usually opposite the os internum. In anteflexion it may occur below this point, when the neck only is flexed, from prolonged and habitual constipation. In both retroflexions and anteflexions I have known it to occur at the middle of the body, and escape superficial examination, or induce a belief in the existence of fibrous tumor. Klob has noticed this but once, and has failed to find an analogous instance. Cusco^ records one case in his own experience where the body was equally divided by a flexion, and quotes Ashwell and Bell for others of similar character. These are the influences under which flexion is induced. No sooner does it occur, than a marked change takes place in the uterine circulation. The uterine bloodvessels arise from the arteria uterina hypogastrica, the arteria uterina aortica, and from the arteria spermatica externa.^ The veins make up by their union two plexuses, the uterine and pampiniform. All these vessels go to and come from the uterus at its sides. A flexion of this organ to a certain extent ligates these vessels, as Hewitt expresses it, and interferes with circulation directly and immediately. The incom- pressible arteries still carry blood to the body, but the compressible veins fail to return it to the general circulation, and the consequences are con- gestion, oedema, and, in time, hypergenesis of tissue. This important fact Hewitt, in his recent admirable edition of his work upon Diseases of Women, lays so much stress upon, as to make it the pivotal point of his pathological creed. There can be no question of the truth of this view, nor of its extremely important pathological bearing. In bringing it prominently forward, and insisting upon its frequent and striking effects as a factor in uterine disorders, Hewitt has, in my judgment, done a great deal of good. He is in error, however, in supposing that it had ' Op. cit., p. 37. * Strieker's Manual of Histology. RESULTS AND COMPLICATIONS. 3T5 previously been unrecognized, as the following passage from his work announces : " It is somewhat snrprising that the occurrence of mechanical congestion of the body of the uterus, arising from mere change of shape of the organ, as above pointed out, should not have attracted the atten- tion of uterine pathologists." Since the appearance of Klob's work on Pathological Anatomy, published in 1868,' it had especially attracted my attention, and had constituted a prominent feature in my teachings. Klob^ declares that "a further consequence of venous hyperaemia, arising from hindered reflux of blood at the point of flexion, is oedema with tumefac- tion and genuine hypertrophy of the body of the uterus. The reflux of blood from the uterine to the hypogastric veins is interrupted, and in con- sequence of the collateral hyperoemia, frequently a very considerable dila- tation of the plexus pam[)iniformis takes place, because the blood can now only flow through the spermatic vein." Under this mechanical influence both neck and body become tumid, tender, and painful ; the mucous lining is so congested as to give forth excessive amounts of mucus and blood; and the tissues of the organ, excited to excessive growth by prolonged blood stasis, undergo in time marked hypergenesis. At the point of flexion the cervical canal is always more or less closed by apposition of its walls. From this cause the ingress of fluids is pre- vented, and sterility commonly results, and the egress is interfered with to such an extent that dysmenorrhoea, hematometra, hydrometra, and accumulations of mucus take place. Of course such accumulations cannot occur with impunity; they result in the production of endometritis and 0ven in hematocele by regurgitation. In congenital flexion the circulation of the uterus is so gradually inter- fered with that marked congestion is not so likely to occur as it is when the organ is suddenly bent upon itself, nor is occlusion of the cervix ordi- narily so complete. Results and Complications Already the reader can enumerate for himself many of the consequences arising from flexion of tlie uterus; and a list of them placed before him will need little further explanation as to the mode of their production. They are the following: — Congestion ; Hypergenesis of tissue ; Sterility ; Dysmenorrhoea ; Menorrhagia ; Endometritis ; Tendency to abortion ; ' Hewitt's views were first published in an article read before the British Medical Association at Leeds in 1870. 2 Op. cit., p. 60. 376 DISPLACEMENTS OF THE UTERUS. • Hematocele ; Ovaritis and Salpingitis ; Pelvic peritonitis ; Fluid accumulations in utero ;^ Uterine neuralgia ; Cystitis and Rectitis ; Granular degeneration. When it is remembered that each of these aiFections sets up symptoms and complications of its own, it will be appreciated that flexion of the uterus is a disorder which, apparently insignificant in itself, is the source of many grave results. Deranged uterine circulation produces menstrual disorder. Usually this consists in excessive flow, but sometimes the opposite condition exists. Ovarian congestion, neuralgia, and enlargements, as, likewise, catarrh of the Fallopian tubes, are probably due to a reflex influence transmitted through the intimate and sensitive nervous connections between the uterus and these organs. Rigby attributed them to pressure, but this does not appear to account for those conditions. Peritonitis results from pressure and friction by the displaced fundus, and, in some cases, from reflux through the tubes of imprisoned fluids. It is by no means rare ; so common is it, indeed, that Virchow regards traction by false membranes as the chief cause of anteflexions. That this pathologist is in error upon this point is the belief of all others with whose views 1 am familiar. Etiology of Uterine Displacements Both in didactic and clinical teach- ing I have for many years grouped the causes of uterine displacement in the manner about to be described. Enlarged experience with the method leads me to regard it with increased favor, and I would urge its claims to adoption, by teachers and students. By it no influence producing displace- ment escapes classification, and it induces him who employs it to arrange the subject systematically in his mind. The general causes of uterine displacement may thus be tabulated: — 1st. Any influence which increases the weight of the uterus ; 2d. Any influence which enfeebles the supports of the uterus ; 3d. Any influence which displaces the uterus by pressure ; 4th. Any influence which displaces the uterus by traction. To state this more fully in other words: — 1st. The uterine supports are equal to sustaining the organ when of normal weight ; but when its weight is increased they naturally fail in their task. 2d. Even if the uterus be no heavier than it should be, it may become * Kiwisch reports a case of hydrometra. CAUSES. 377 displaced from depreciation of that support to which it is entitled, and which was made to sustain it. 3d. If both the uterus and its sustaining powers be perfectly normal, it is evident that direct or powerful pressure may overcome the latter, and force the organ from its place. 4th. It is equally evident, that, as, by a tenaculum fastened in the uterus of the cadaver, w^e may drag it from its position, so may contracting lymph or a prolapsed vagina effect this in a living body. All these facts having been premised, a concise view of the special causes of displacements may be thus presented. 1. Influences increasing weight of uterus. Congestion ; Tumors in the walls or cavity ; Pregnancy ; Excessive growth of any of its component parts ; Subinvolution ; Fluid retained in cavity ; Masses of cancer or tubercle. 2. Influences weakening uterine supports. Rupture of the perineum ; Weakening of vaginal walls ;' Stretching of uterine ligaments ; Want of tone in uterine tissue; Degeneration of uterine tissue ; Abnormally large pelvis ; Any influence impairing sustaining power of abdomen. 3. Influences pressing the uterus out oj place. Tight clothing; Heavy clothing supported on the abdomen ; Muscular efforts ; Ascites ; Abdominal tumors ; Abscesses or masses of lymph. Repletion of the bladder. ' 4o Influences exerting traction on the uterus. Lymph deposited in pelvic areolar tissue ; Lymph deposited on peritoneum of pelvic viscera; Cicatrices in vaginal walls ; Shortening of uterine ligaments ; Natural shortness of vagina ; Prolapse of vagina, bladder, or rectum. • Such weakening from subinvolution or any other cause destroys the support- ing power of the vaginal promontory. 378 DISPLACEMENTS OF THE UTERUS. The mode of action of each of these causes is so evident as to require no special mention at this time, but they will be particularly alluded to hereafter. No circumstance combines so many of these causes of displacement as utero-gestation and parturition. Should involution follow these without interruption, no tendency to displacement results. But the process of in- volution is frequently interfered with. Then, as consequences of the arrest of retrograde metamorphosis, the uterus remains large and heavy ; the vagina voluminous and feeble ; and the uterine ligaments, which owe their strength chiefly to the uterine tissue which they contain, lax and weak. As a result of parturition, too, the perineum is often enfeebled, which allows of prolapse of the vagina, which produces traction upon the uterus. These remarks apply to true displacements of the uterus. To flexions or deformities of the organ itself, they do not so sufficiently apply as to render uncalled for some special remarks, which I now proceed to offer. Predisposing Causes of Uterine Flexions — Any cause which predis- poses to enfeeblement of uterine tone, to the development of a force wliich overcomes this even when unimpaired, or still more one wliich combines the two evil influences, prepares the way for flexure of the uterus under the impulse given by a sudden or persistent exciting cause. Tiiey may be thus enumerated : — Parturition ; Impoverishment of the blood ; Enfeebled nerve state ; Extreme youth or age ; Laborious occupation ; Relaxation of abdominal walls ; . Influences altering pelvic axes. Exciting Causes. — One of the functions of the cervix uteri is to support the body, and for the performance of this it is abundantly competent, un- less its powers be impaired by one of the following influences : — Influences weakening uterine support. Endometritis ; Cystic degeneration near os internum ; Pregnancy ; Fatty degeneration ; Areolar hyperplasia ; Vascular degeneration in uterine walls. Influences increasing the weight of the fundus. Enlargement of the body ; Pregnancy ; Tumors ; Accumulation of fluid in utero. CAUSES. 379 Influences pushing the fundus or cervix forwards or backwards. Abdominal or pelvic tumors ; Ascites ; Fecal accumulation ; Tight clothing ; Muscular efforts. Influences exerting traction forwards or backwards. False membranes from pelvic peritonitis. Of the first class of causes, inflammation affecting the mucous membrane of the neck and creating areolar hyperplasia in the parenchyma is, accord- ing to my experience, one of the most frequent. The hyperplasia thus arising results in atrophy of the muscular and submucous fibrous structures of the uterus and their replacement by hypertrophied areolar tissue, and produces a marked tendency to tliis deviation by thus substituting a lax and feeble for a dense and powerful substance. Klob declares that this replacement of strong tissue by that which is weaker occurs more especially near the OS internum. Virchow denies the agency of tliis condition as a causative influence, as he likewise does that of fatty degeneration, observed by Scanzoni, at the point of flexure. The influence of parturition, abortion, and pregnancy has been admitted by all authorities. The varieties coming under the head of the second set of causes are all universally admitted, as are also those belonging to the third. Fecal im- paction may possibly produce flexion of the body, and frequently causes tlie cervix to bend sharply forwards. The fourth set of causes is put beyond question, by the fact that in autopsies the uterus is often found thus bound in a state of flexion. The etiology of cervical flexion is somewhat different from that of cor- poreal. It is, I feel satisfied, generally induced by pressure directly ex- erted upon the uterus by tight clothing, which forces it against the concave surface of the vagina. This surface gives the impinging part a slant for- wards, and keeps it thus bent. Habitual constipation increases this vicious curve, and the two causes combined often result in this unmanageable form of the affection. This explains the fact, which all must have noticed, that in pure corporeal flexion the uterus is often high up in the pelvis, while in that of cervical form it is almost invariably low down. It likewise ex- plains what my observation leads me to regard as a fact, that in nuUipa- rous women the cervical and cervico-corporeal varieties preponderate in frequency over the corporeal form, which is generally met with in multi- parous women. There is still another pathological element which enters into the eti- ology of cervical flexions, and explains the phenomena with regard to them which I have just mentioned. The uterus being forced downwards by influences exerting themselves upon the abdomen, if the utero-vesical ligaments be lax and yielding, corporeal flexion will occur, the cervix 880 DISPLACEMENTS OF THE UTERUS. retreating under pressure. If, however, these ligaments keep the cervix in close contact with the bladder, cervico-corporeal or pure cervical flexion will be developed. Parturition does more to stretch these ligaments than anything else, and thus cervical flexion is not so generally met with in women who have gone through that process as in those who have not. Corporeal flexion is the variety seen after parturition ; the cervical and cervico-corporeal forms, those which we see in nulliparous women. Not only is this fact interesting in reference to pathology ; it has an impor- tant bearing upon the treatment of cervical flexions. He who would treat these cases successfully must systematically stretch the ligaments which keep the cervix in an anterior position, and by this means strive to change the form of displatiement to that of corporeal flexion, or of anteversion. Retroflexion is most frequently the result of some influence which weakens the tone of the uterine walls, but, even when this is normal, any force dii-ectly applied may displace it and produce a flexure, whether such force is developed suddenly or gradually. We have now pursued the study of flexions, as a whole, as far as it is profitable to do so ; and from this point, they shall be considered under separate heads. The uterus may be flexed upon itself anteriorly, posteriorly, or laterally, giving rise to the disorders known as — Anteflexion ; Retroflexion ; Latero-flexion. The fundus in falling forwards or backwards does not always preserve the median line, but commonly falls obliquely to the right or left. This obliquity is frequently created, even where the medijin line was orignally preserved, by the use of a pessary, and constitutes so prominent a difficulty in these cases that I employ a special instrument for its treatment. Thus we may find a uterus flexed forwards and laterally; backwards and forwards ; backwards and laterally, etc. These varieties are known as— Retro-anteflexion ; Retro-lateroflexion ; Ante-retroflexion ; Latero-anteflexion, etc. The student need not memorize tliese, but, merely keeping in mind the fact tliat such combinations are possible, he will readily recognize them at the bedside if he have mastered the three chief forms. This is all that need be said upon the subject of uterine displacements in general. I shall now proceed to complete the outline here sketched, and to go into the details connected with each variety of the affection^- ASCENT AND DESCENT OF THE UTERUS. 381 CHAPTER XXVI. ASCENT AND DESCENT OF THE UTERUS. Ascent of the Uterus. In its normal condition the uterus descends into the pelvic cavity so as to assume a position about two inches from the vulva. If its weight be augmented, it comes much lower than this, and continues to do so as its vohime increases, until its development becomes so great that it cannot be accommodated by the pelvis. Then it escapes from the cavity by ascend- ing to a more capacious space above the superior strait. Tliis change occurs in every normal pregnancy. During the first three months the uterus falls in the pelvis, being in a state of prolapse. As the fourth month approaches its volume becomes so great that it can no longer be retained in the pelvic cavity, and then it escapes above the superior strait where sufficient space is affi^rded for it to undergo full development. This is not only so in pregnancy ; the uterus is similarly affected by morbid growths. When, under these circumstances, it leaves the pelvis, the fact is expressed by the term ascent. Ascent of tlie uterus is never an original disease, but the result of some important change connected with that organ, and requires merely a men- tion. It may occur whenever a tumor is developed in connection with the va"-ina, rectum, or recto-vaginal cul-de-sac, wlien there exists a growth in the walls or cavity of the uterus which renders it too large for accommo- dation in the pelvis, or, when an abdominal tumor draws up the uterus. It never requires treatment, and is of importance only as exciting suspi- cion of pregnancy, or as an evidence of morbid growth in some way con- nected with the organs of generation. Descent or Prolapsus of the Uterus. Definition, Synonyms, and Frequency — The name of this disorder defines its character with sufficient clearness. It is of frequent occurrence, and under the name of Falling of the Womb is well known to women, and constitutes for them an object of especial dread. As almost all women, after the period of fruitfulness has passed, have an intuitive fear of cancer of the uterus, so do a large number before that time manifest an appre- hension of prolapsus. In the one case the anxiety is for life, in the other for usefulness and comfort. Unfortunately for the student of this subject, its nomenclature has been 382 ASCENT AND DESCENT OF THE UTERUS. rendered somewhat obscure. By some, all cases of prolapsus in which the uterus does not escape from the vagina are termed incomplete, while those in which it does are styled complete. By others, complete protru- sion is denominated procidentia; and, by others still, a very slight descent without alteration of direction of axis has been designated by the very old name of squatting uterus. ] have striven to simplify the matter by apply- ing the name prolapsus to all, and marking the degrees of descent by the terms 1st, 2d, and 3d. Anatomy Those uterine supports which are especially active in pre- venting uterine descent are the surrounding areolar tissue, which binds it to the bladder, the rectum, and the pelvic walls; the utero-vesical and utero-sacral ligaments ; and the retentive power of the abdomen. About the sustaining influence of the vagina there is much difference of opinion ; some, like Savage, denying it ; while others, like Bennet, West, and Kiwisch, maintain it. My opinion is, that the promontory formed by the vagina in front of the cervix certainly effects something in the way of support, although observation has led me to modify very much the belief which I once had in the general sustaining influence of the canal. Loss of tone in it, resulting in prolapsus vaginas, is commonly attended by a similar prolapse in the uterus, but it does not follow that the uterus falls from want of support ; it is more probably dragged down by the heavy vagina. This view may be sustained by so many strong arguments that it need not invoke weak ones. A good deal of stress has been laid upon an experiment for which Aran credits Stoltz ; that of cutting the vagina away without noting any descent of the uterus. A little reflection must show that this proves almost nothing. It merely demonstrates the fact that, without the vagina, other supports are sufficient to sustain the uterus. No one has ever maintained that the vagina was the only support which keeps the uterus up, nor that others were insufficient without it. A great deal of support is unquestionably derived from the connective areolar tissue, wdiich so closely unites the uterus with the rectum, bladder, and pelvic walls, as to involve displacement of these viscera in its descent. Dr. Savage, dragging the uterus of a cadaver forcibly downwards by means of a vulsellum attached to the neck, found that after cutting its important ligaments, and overcoming by force the action of the vagina, it still would not advance. '' The obstruction was found to be due to the subperitoneal pelvic cellular tissue, particularly where it surrounds and accompanies the uterine bloodvessels." The most important factors in the prevention of prolapse are the utero- sacral ligaments, which Aran considered the only real ligaments of the uterus. Arising from the point of junction of neck and body, they usually embrace the rectum in their bifurcation posteriorly, and, diverging on each side of it, terminate in the subperitoneal cellular tissue, as high up as the second lumbar vertebra. They are exceptionally inserted into the rec- CAUSES OF PROLAPSUS UTERI. 383 turn. It was the recognition of this anatomical arrangement of these im- portant ligaments which led Huguier to suggest that they be called utero- lumbar, instead of utero-sacral. They consist of the following elements : peritoneum, pelvic connective tissue, uterine cortex, and vaginal muscular fibre. Their influence, as likewise to a much less degree that of two similar bands connecting the cervix in front with the bladder, cannot be doubted. These are probably all the factors which unite in the prevention of pro- lapsus in the first and second degrees. When they are entirely overcome and the descent has become complete, the round and broad or lateral liga- ments come into action, but not until that has occurred. Varieties. — This displacement may occur very suddenly and unexpect- edly, or gradually and by successive steps. As the symptoms of the two varieties differ only in the rapidity and severity of their development, and the second is much the more ^^'^- l^^. frequent, I shall direct my remarks chiefly to it, and describe the first in a few words in an appro- priate place. Prolapsus may exist either in the first, second, or third degree, the direction of the uterine axis in each of which is exhibited in Fig. 140. In the first the uterine axis is bent forwards, the organ being somewhat anteverted and sunk in the Diagram representing the 11111 uterine axis in the three pelvis. In the second the body lias gone towards degrees of prolapsus, the sacrum, the cervix having come down to the ostium vaginte. In the third the last barrier has been overcome, and either a part or the whole of the uterus hangs between the thighs. Causes — The causes which predispose to this accident are — Child bearing ; Laborious occupations; Advanced age ; Habitual constipation. I know of no way in which I can give so concise a summary of the ex- citing causes of prolapsus as by a reference to the classification to which I have already referred under general considerations upon displacements ; for the exciting causes will be found to belong in every case to one of four classes : those increasing uterine weight ; those enfeebling uterine sup- ports ; those forcing the uterus down by power applied above ; and those drawing it down by traction from below. a. Examples of causes connected with increased uterine weight : — Tumors, submucous, subserous, or mural ; Pregnancy, (rare, but sometimes met with) ; Hypertrophy or hyperplasia ; Retained fluid. 384 ASCENT AND DESCENT OF THE UTERUS. h. Examples of causes connected with enfeeblement of uterine sup- ports : — Abnormally capacious pelvis ; Destruction of power of the perineum ; Loss of tone in vaginal walls ; Loss of tone in uterine ligaments ; Absorption of fat from pelvic areolar tissue; Atony of abdominal muscles ; Diminution of power of respiratory muscles. c. Examples of influences forcing the uterus downwards : — Violent coughing ; Tumors in abdomen ; Ascites ; Violent muscular efforts ; Tight and heavy clotliing ; Straining at stool. d. Examples of influences dragging the uterus down : — Congenital or acquired shortness of the vagina ; Prolapse of vagina, bladder, or rectum ; Uterine prolapsus. I have already stated that these evil influences are most completely combined in the condition existing after parturition, when the uterus is heavier than normal, the recently distended vagina relaxed and feeble, the uterine ligaments very much stretched, and the sphincteric muscles of the vagina weakened. When, as so often happens, rupture of the perineum and of the cervix uteri occur, and are followed by subinvolution of vagina, uterus, and uterine ligaments, we have in perfection all the conditions which give rise to this displacement. Of all the causes of prolapsus this combination is the most frequent, and hence the difficulties attending cure. It is for this reason that prolapse is found to be rare in women who have never borne children, less rare in those who have borne one only, and appears to increase in frequency in proportion to the frequency of the parturient process. Scanzoni reports that in 114 cases of prolapsus 99 occurred in women who had borne children. Even the most complete prolapse, however, will sometimes be met with in young and unmarried women. Within the past five years I have met with three such cases, one in a virgin of nineteen, one in an old maid of about sixty, and the third in a healthy, laboring woman at the menopause. Next in order of frequency will be found a condition which occurs in old women, a loss of vaginal power from atrophy of the vagina, and ab- sorption of the padding of fat which normally occupies parts of the pelvis, and helps to aid that canal in sustaining the uterus. This condition has been specially mentioned by some of the German pathologists, and atten- tion has been called to its importance by Dr. Barnes, of London. Here, PATHOLOGY OF PROLAPSUS UTERI. 385 although the uterus is atrophied, it descends in spite of its lightness, partly from loss of support from the vaginal promontory and partly from traction exerted upon it by the prolapsing vaginal walls. An important position as a pathological lactor is assumed by loss of the retentive power of the abdomen. Want of exercise except in walking in- duces in women very commonly an atonic condition of the thoracic and abdominal muscles ; and the respiratory act therefore becomes inellicient, and the piston function of the diaphragm feeble and imperfect. As a consequence of this failure, the uterus rises in the pelvis at each expira- tion less perfectly than it ought ; its circulation, lacking the stimulus of the abdominal rise and fall, becomes sluggish ; gradually it settles lower and lower in the pelvis, and becomes a readier prey to the action of other ma- lign influences. Relaxation of the abdominal walls probably also favors displacement by eiJecting an alteration of the direction of pressure transmitted to the uterus, bladder, and superior vaginal wall, and by permitting the free en- trance of intestines into the anterior peritoneal prolongation or anterior uterine excavation. Increased uterine weight and pressure from above are so plainly active in creating prolapsus, that no one will doubt their causative influence. By its instrumentality we see complete prolapsus occur with ovarian tumors, ascites, etc. Pathology There is no variety of displacement about the pathology and mechanism of which gynecologists are more at variance than this, and yet none to which a greater amount of honest, scientific labor has been applied for the elucidation of these very points. As examples, I may cite the experimental researches of Aran,^ Legendre,^ Huguier,^ Savage,* and Taylor,* to which the seeker after more elaborate data is referred. My limited space will not permit me to go fully into the views of these investigators, and I shall confine myself chiefly to a rather dogmatic state- ment of my own opinions, at the same time acknowledging that they are, in great extent, founded upon the investigations alluded to. It matters not whether the original cause of the displacement be in- crease of uterine weight, depreciation of sustaining power, or direct force exerted upon the organ from above or below ; an invariable result of its existence is diminution of the power of the uterine supports. The liga- ments are stretched, the vagina distended and doubled upon itself or everted, and the contractile power of the sphincteric muscles impaired. • Etudes Anatomiqties et Anatomo-pathologique sur la Statique de I'Uterus, Paris, 1858, Arcliiv. Gen. de Med. 2 De la Chute de I'Uterus, Paris, 1860. ' Les AUongements Hypertrophiques du Col de I'Uterus, Paris, 1859. * Female Pelvic Organs, London, 2d ed., 1870. 5 On Amputation of the Cervix Uteri, etc., New York, 1869. 25 386 ASCENT AND DESCENT OF THE UTERUS. The displaced organ is generally affected by congestion and inflammation of the mucous lining, its cavity is much enlarged, and solutions of con- tinuity occur upon the cervix. The vaginal rugae are effaced, and the lining of the canal, exposed to atmospheric influences and friction, looks like the cicatrized surface of scalded ekin rather than mucous membrane. " The tension of the aponeurotic flbres of the broad ligaments," says Legendre, " during uterine prolapse, results in compression of the hypo- gastric veins, as compression of the veins of the neck occurs, from tension of the cervical fascia, when the head is forcibly thrown backward. In this way congestion of the uterus and other pelvic organs is kept up." Pro- lapsus, from its influence in thus producing hypersemia, is usually attended by hyperplasia of the areolar tissue of the uterus. This organ undergoes an absolute increase in size, and the tissue of the cervix is especially altered. Simultaneously with hyperplasia, there is varicose degeneration of the bloodvessels of the cervix and absorption of its proper tissue. This increases the natural ductility of the part, and upon any traction being applied it stretches so as to produce the phenomenon of variation in the length of the uterus, mentioned under the head of physical signs. The walls of the vagina are found much thickened by proliferation of epithelium and hypertrophy of the submucous layers of areolar tissue. Thus it be- comes not only more capacious, but heavier and more voluminous than normal, and even if its increase in volume and weight are consequences of uterine displacement, it drags upon the uterus and increases its tendency to descend. The uterus may descend from its normal place in the pelvis under any one of the four influences which have been mentioned. It must not, how- ever, be supposed that one only is usually active. On the contrary, two, three, and even four are often combined in furthering the result. For thoroughness of study they are examined apart, that course being also chosen from the fact that even if several causes are combined, one is usu- ally especially prominent as a factor. If a careful clinical study be made of this interesting subject, the ute- rus will be found to descend in one of these ways : — 1st. A woman who has previously been in good health begins to com- plain of dragging about the loins, backache, and sense of fatigue about the pelvis. An examination is made, and the uterus is found resting upon the floor of the pelvis, its axis little altered. There is no rupture of perineum, no redundancy of vagina, and the habits of life of the patient preclude the possibility of muscular efforts or tight clothing being agents in the condition. A careful examination of the displaced uterus shows it to be large and heavy from subinvolution, or discovei's a fibrous tumor in its structure. The natural supports have been perfect, but they have been overtaxed and have yielded. Increased uterine weight is the prime mover in the disorder. PATHOLOGY OF PROLAPSUS UTERI. 887 But keep this case under observation. Tiie descent already effected has drawn down the bladder, caused pressure upon the rectum, established a hyperjemia in the tissues of" the vagina, and begun already to rob the uterine ligaments of their power by stretching them. Pressure on the rectum and dragging upon the bladder create irritation, the patient "bears down" in evacuating these viscera, and a new influence is developed : force from above. Very soon congestion of the vagina results in exces- sive areolar growth, this canal falls into its own distended channel, and another evil influence is the result : ti'action upon the uterus from below. The uterus has now descended so that its os projects between the labia majora ; if its ligaments were stretched before, how much more so must they be now ! 2d. A uterus is found in the first degree of prola|)Sus. It is a healthy uterus, normal in size, weight, and consistency. Its supports appear per- fect, and no influence exerts traction upon it from below. Everything is normal, but one — the uterus has descended. Examination proves that this woman has labored hard, lifting heavy weights, and placing herself in a constrained attitude to do so ; or she has for weeks suffered from a spas- modic, violent cough ; or from obstinate constipation which has caused tenesmus. The cause of the prolapse is evidently force applied to the uterus from above. But this remains the sole cause for a sliort time only. Very soon increased weight of the uterus from congestion, enfeeblement of uterine supports from prolonged tension, and traction by falling of the hypertropliied vagina and prolapsed bladder complete the vicious circle. 3d. An examination of the uterus in a case exactly similar as to symp- toms, demonstrates no increase of uterine weight, no force applied from above. The woman is found to have a justo-major pelvis, which has always resulted in precipitate labors ; or she is past sixty, and a senile atrophy is developing; or the perineum is ruptured, and the anterior and posterior vaginal walls are protruding in egg-like pouches at the vulva, not sufficiently to drag upon the uterus, but enough to shorten the vagina by allowing its distal end to protrude, and thus the vaginal promontory is removed. The mischievous factor is loss of uterine support. The uterus is normal in weight and exposed to no evil influences from pressure or traction, but its feeble supports even then are unfit for their functions, and the uterus falls. It descends to the second degree, and, dragging upon the broad ligaments, their aponeurotic expansions compress the hypogastric veins, great congestion results, and at once a new influence develops — increased uterine weight. Now rectal and vesical tenesmus and pi*essure by the displaced abdominal viscera add another untoward element — force applied from above. And as the descending uterus everts still further the congested, voluminous, and heavy vagina, it drags the offending organ still more rapidly down. 4th. The reader wearied by repetition may crave a respite here, but he 888 ASCENT AND DESCENT OF THE UTERUS. asks it just where it cannot be granted, for we come to the consideration of the most frequent and consequently most important of all the influ- ences resulting in prolapsus uteri. Prolapse of the uterus is sometimes a primary affection, but in the great majority of cases it is secondary, pro- duced by prolapse of the vagina, which literally drags it from its position. There are two methods in which this occurs : 1st. The perineum is rup- tured, and by this the vaginal walls lose the buttress against which they rest, and the power of the pubo-coccygeus muscle is diminished. 2d. A vagina developed by utero-gestation does not undergo involution, but remains a large, voluminous, and heavy bag, the redundant walls of which overcome the resistance of the perineal body and prolapse, dragging the uterus down, either before or simultaneously with their escape from the vulva. Dr. Duncan, in an essay read before the Edinburgh Obstetrical Society,^ in 1871, maintained that the perineum had nothing to do with the support of the uterus, and that, therefore, laceration of this part is not a cause of prolapsus. I do not believe that the perineum supports the uterus directly, nor that upon the cadaver its section would result in prolapsus ; but I believe that destruction of the perineal body which acts as a support to the vagina results in loss of support to both its posterior and anterior walls. These prolapse, their tissue becomes hypertrophied, and they drag down the bladder and then the uterus. Look at Fig. 5G and see how much support vagina and bladder obtain from the perineal body, and the results of its rupture may be better appreciated. So long as the vagina is normal in volume and weight, and remains within the pelvis with its walls in apposition, it constitutes, by its ante-cervical projection, I think, a uterine support. So soon as it falls from the^ pelvic cavity, becomes hypertrophied, and has its walls separated, it not only loses this power, but degenerates into a uterine tractor. The same autliority points to the fact that many cases of complete perineal laceration do not produce prolapsus uteri. This is true. Such laceration is usually the result of parturition, and is, I am satisfied, often a cause of subinvolution of the vagina. If this condition has resulted, the laceration is very generally followed by prolapsus vaginas, and tlius by descent of the uterus. If vaginal involution have not been interfered with, it is usually not so. Aran points out the fact, that removal of the vagina from the cadaver does not produce uterine prolapse, and Dr. Duncan declares, "I have no doubt that, if, by way of experiment, the perineum was cut through in a healthy woman, no tendency to prolapsus would be thereby produced." I freely accept both experiment and proposition, but I cannot agree in the deductions based upon them. When the uterine ligaments are strong, the uterus does not readily leave its position. Sometimes traction steadily ■ Transactions, vol. ii. p. 269. PATHOLOGY OF PROLAPSUS UTERI. 389 exerted upon the cervix fails to draw down the body, but stretches the neck so that the uterus measures by the sound between :ix and seven inches. Klob^ decla''es, that "relaxation of the uterine tissue is notice- able in the region of the external orifice, and consequently in what was previously the vaginal portion and lower segment of the cervix, which part often assumes a spongy softness. This relaxation must be attributed to the varicose condition of the bloodvessels, and absorption of the cervi- cal tissue." This, and not hypertrophy, is probably the condition of this distended part. . In many cases, before prolapse occurs, the uterus is affected by areolar hyperplasia, or the local atrophic state engendered by flexion, which last Dr. Hewitt regards as a frequent source of it, and when thus weakened it readily yields to traction. When the tractile force is checked by reposition of the uterus, the neck instantly contracts, and the length of the whole organ greatly diminishes. May this fact not explain the experience of Huguier, who found only two cases of true prolapse in sixty reported cases, and of Routh, who in a large experience met Avith only three? It seems to me highly probable that these investigators, making their measurements while the uterus was prolapsed to the third degree, concluded that hypertrophic elongation of the supra-vaginal portion existed, when in reality this peculiarly elastic tissue, which was the consequence and not the cause of the descent, was the true pathological condition. Certainly some such explanation must account for the remarkable discrepancy which exists between the results of these two eminent gynecologists and the great majority, whose experi- ence is opposed to theirs. In these cases the force of traction appears to expend itself upon the most powerful uterine ligaments, those inserted at the axis of rotation, the cervico- corporeal junction. They yield, and the cervix advances towards the vulva, but the uterus, supported though it is by fJactors of less power, resists steady traction, and remains in place. Legendre attached to the cervix uteri of a cadaver, a weight of fifteen kilogrammes, which was gradually increased to fifty during the period of an hour, then diminished to thirty, and kept up traction by that for two hours. At the commence- ment, the uterine canal measured by the sound five centimetres, and at its conclusion nine, the lengthening being chiefly in the cervix. In other experiments, a less weight kept in action for several days, caused complete prolapse with elongation of the cervix uteri. Since the appearance of Huguier's essay u[)on supra- and infra-vaginal elongation of the cervix as conditions commonly mistaken for prolapsus, writers have commonly considered hypertrophic elongation of the cervix below the vaginal junction under this head. I shall not do so, because the propriety of such a course seems to me to be sustained neither bjf ' Op. cit., p. 88. 390 ASCENT AiND DESCENT OF THE UTERUS, clinical observation nor pathological investigation, and because true cer- vical hypertrophy will be elsewhere treated of. That there is a form of hypertrophic elongation of the cervix uteri, which occurs below the cervico-vaginal junction, and appears upon very superficial examination to resemble prolapsus, or even produces that con- dition by traction, I, of course, admit. But it appears to me erroneous to reo-ard supra-vaginal elongation, which is marked by an attenuation of the tissues of the heck and "a spongy softness," according to Klob attributable to a " varicose condition of the bloodvessels and absorption of the cervical tissues," as true hypertrophy. It is highly probable that this condition, the result of traction, may occur during pregnancy, and exist as a source of great annoyance after it. The following deductions by M. Gueniot^ substantiate this view : — " 1. In certain women there exists during pregnancy, and occasionally at the time of parturition, a special affection of the neck of the womb, which generally passes unrecognized, and has not hitherto been the subject of any description. " 2. This affection may be designated under the name of (Edematous Elongation with Prolapse of the Neck, which indicates the principal con- stituent traits. Hyperfemia and turgescence of the organ, the arrange- ment of its cavity, which is transformed into a long and freely patent canal ; the rapidity with which these symptoms may disappear, and the great facility with which they may be reproduced under certain circum- stances, are all so many fundamental characters of the affection. ■ Ulcera- tion of the OS tineas, occlusion of the vagina, a thin and flaccid condition of the uterine walls, are also almost constant symptoms ; as are also cir- cumpelvic pains, a feeling of general debility, and variable disturbances in micturition. " 3. The causes of this change in the neck of the uterus are complex ; they are derived from two sources : certain anatomical dispositions of the organ, and various circumstances exerting upon it a prolonged mechanical action. " 4. Although very rare, oedematous elongation with prolapse of the neck is, without doubt, a less exceptional affection than one would be in- clined to imagine. Many observers have erroneously assimilated it to hypertrophic elongation, or to simple prolapsus, to which affections, in truth, it presents a great analogy, but from which it is essentially distin- guished by proper and very important characters." Cojurse, Duration, and Termination — Prolapsus uteri is unlimited in its duration, and, unless relieved by art, will continue indefinitely. It impairs the patient's comfort and capacity for exertion, but rarely has a fatal termination, unless by exciting peritoneal inflammation, or pelvic « Archives G6ii. tie Med., Juillet, 1872. SYMPTOMS OF PROLAPSUS. 391 cellulitis, as I have seen it do in several cases. Even in the chronic form of the disease, death has in very rare cases occurred from urinaamia, the result of interference with the ureters. The trigone of the bladder be- coming displaced to such an extent that the orifices of the ureters are pressed firmly against the symphysis pubis by the mass behind it, they become obstructed and distended, and in time hydronephrosis may result. Virchow^ and Kivvisch^ both announce this fact. An interesting instance of death thus produced may be found in the twelfth volume of the Trans- actions of the London Obstetrical Society, reported by Dr. Phillips. In a case of incarcerated uterus occurring in my own experience, and which will receive further mention elsewhere in this article, T was compelled to resort to a degree of force in returning the displaced organ, which at the time of application I regarded as attended by extreme danger. Had my efforts not succeeded, death would, I feel sure, have resulted; for the uterus and surrounding parts appeared to be about passing into a state of gangrene. This case before I saw it had resisted all the efforts which were applied by three competent physicians. After forcible replacement, the entire lining membrane of the vagina sloughed, and the patient narrowly escaped death from peritonitis, which was excited and ran a violent course. Forcible taxis was resorted to, with a conviction on the part of tiie attend- ing physicians and myself, that the issue involved either restitution of the uterus or d(?ath. Symptoms The symptoms of prolapsus are dependent upon two re- sults growing out of the displacement : the mechanical interference of the womb with surrounding parts, and alteration induced in its circulation and tissue by reason of its abnormal position. The uterus may remain even in the third degree of descent without any marked symptoms, but generally congestion, areolar hyperplasia, and granular degeneration occur, which render it sensitive and intolei'ant of pressure or friction. At the same time, by dragging upon the bladder, rectum, and all the pelvic areolar tissue and fascite, and by protruding between the labia, it produces discomfort and often impedes locomotion to a great extent. The most prominent of the symptoms thus created are the following: — Sensation of dragging and weight in the pelvis ; Rectal and vesical irritation ; Pain in back and loins ; Great fatigue from walking; Inability to lift weights ; Leucorrha?a and other signs of congestion. It is a very singular and striking fact, that in prolapsus, even of the third degree, there is very commonly no menstrual disorder, and equally remarkable that sterility does not ordinai-ily exist. These immunities » Trans. Obstet. Soc. of Berlin, 1847. 2 Clinical Lectures. 392 ASCENT AND DESCENT OF THE UTERUS. are probably dependent upon the facts that the uterine catarrh which usually exists is rather the result of a passive congestion of the endome- trium than of true inflammation, and that the axis of the organ, although altered in direction, is not bent upon itself so that an obstruction in it is created. Physical Signs. — All the symptoms detailed will only excite suspicion and prompt an examination which will fully elucidate the case. Should the affection exist only in the first degree, the finger passed up the vagina will meet with the os low down in the pelvis and pressing upon its floor. As it is slid upward in front of the cervix and along the base of the bladder, the I'esisting anterior wall of the uterus will be clearly distinguished, and it may be found that anteversion or anteflexion exists, complicating pro- lapsus. If the second degree have been reached, the os will be found at the ostium vaginae, prevented from escaping only by the resistance of the sphincteric muscles, and the body, instead of lying forwards, will be to some extent retroverted. To determine the degree of prolapsus, more especially in this stage, the patient should be examined standing. Sight and touch will combine in making a diagnosis in the third degree of prolapse rapid and easy, but even here I have known very grievous mistakes committed. The apparent ease of the diagnosis sometimes causes error by inducing neglect of that caution and watchfulness which, even in the simplest cases of disease, constitute the only safeguard of tlie phy- sician. One very curious phenomenon which in the physical investigation of these cases must have struck every practitioner is this : the uterus being procident and a sound introduced, it passes up for the distance of five or six inches. The organ now being replaced, and again examined by the sound, it is found to measure only three or four, and this experiment may be repeated any number of times with the same result. The explanation of this fact is given in connection with the subject of pathology. Differentiation. — In any of its varieties prolapsus uteri n)ay be con- founded with fibrous polypus, inversion of the uterus, and hypertrophic elongation of the neck, from all of which, however, it is readily distin- guished if the practitioner be awake to the possibility of error. From the first it is known by the presence of the os and cervix, and the general shape of the mass. From the second, by the presence of the os and cervix, and absence of the signs of inversion. The third will readily be recognized by the great length of the cervix, the impossibility of replacing the supposed prolapsed organ, and the great depth of the uterus discovered by the uterine probe, after it has been restored to the pelvis. Prorjnosis — In most cases a great deal of relief cati be eflected by medical and minor surgical means. In a few in which the displacement is secondary to the existence of a large abdominal or perhaps uterine tumor, COMPLICATIONS OF PROLAPSUS. 393 nothing can be done either for relief or cure. In many in which descent of the uterus is secondary, due to traction upon it by the prolapsed vagina, bladder, and rectum, cure can be effected, even where the third degree has been reached, by surgical procedures appropriate to the cure of the primary displacements which produce traction upon the uterus. In cases existing only in the fii'st and even the second degree cure may, in favorable cases, be accomplished by mere removal of the causes which are gradually depressing the uterus. Complications. — Prolapsus of the uterus in its first and second degrees, and still more frequently in its third, produces the following complications : — Congestion of the uterus and its appendages ; Endometritis and Fallopian salpingitis ; Hyperplasia of uterus ; Hypertrophic elongation of the cervix ; Cystocele ; Rectocele. As soon as the uterus descends into complete prolapse, and to a less extent when it has reached only the first and second degrees, its tissue becomes congested, and appears swollen, (Edematous, soft, and relaxed. In time this passive hypersemia induces hyperplasia, which especially affects the connective tissue. As a consequence the uterus is enlarged, and increased in weight and capacity. Not only do congestion and hyper- plasia affect the parenchyma of the uterus ; the mucous membrane and submucous tissue are likewise disordered, and endometritis is an almost invariable consequence of prolapse. It has been already stated that pecu- liar changes occur in the cervix. This part becomes particularly soft and relaxed ; its vessels become varicose, and the muscular tissue is often absorbed in great degree. In consequence of these secondary morbid states we generally have as concomitant symptoms, leucorrhoea, dilatation and eversion of the cervix, disorders of the bladder and rectum, and sometimes cystitis. Eversion of the cervix is too important a feature of the condition to be passed by with- out special mention. As the uterus descends it inverts the vagina. This, by its cervical attachment, which now becomes depressed to a point far below its upper portion, makes constant traction upon the os externum; the principle being the same as that by which the colpeurynter is made to dilate this part for the establishing or expediting the first stage of labor. As this action is prolonged and increased by furtlier descent of the uterus and inversion of the vagina, the cervical canal is rolled out, so as to be- come completely everted, and the os internum becomes literally tlie ex- ternal and only os uteri, the real os externum having disappeared by expansion. Dislocation of the bladder is accomplished by uterine descent to such an extent that if a catheter be introduced it will pass downwards and 394 ASCENT AND DESCENT OF THE UTERUS. backwards. Tliis complication is important, for not only do traction and dislocation tend to the production of cystitis ; it is further induced by reflex irritation and by decomposition of urine occurring from retention, after urination, in the pocket formed by the inverted wall of the bladder. By a similar process prolapse of the anterior wall of the rectum occurs, and results in fecal impaction at this point. Sudden or Acute Prolapsus may come on from any great effort, a fall, or violent contraction of the abdominal muscles, acting upon a uterus which is enlarged by liyperplasia, subinvolution, pregnancy, or tumors. It may even occur to a uterus normal in size and consistency. In an instant the patient feels that something has given way within her, becomes pros- trate and much alarmed, and suffers pain of an expulsive character, as if desirous of forcing something from the pelvis. I have twice seen it occur within a fortnight after delivery from sudden and violent muscular effort: and once in a nuUiparous girl of nineteen years, in consequence of a violent muscular effort made to lift a heavy weight, the cervix was driven out of the vulva, the body being arrested by the sphincter vaginae and perineal septum. The last patient I saw a year after the accident. She had suffered intensely from the displacement, but from false modesty had never told of it. I discovered distinct traces of the hymen, which I had every reason, both physical and moral, to believe had not been ruj)tured by sexual congress. In such a case as this it appears to me highly probable that the utero- sacral ligaments are ruptured. This supposition, the difficulty of proving which by necropsy is apparent, may have attracted attention, but the only allusion to it which I have met with is the following from Courty, who, in speaking of the utero-sacral ligaments, says, " if they are stretched or broken, the entire organ falls." In acute prolapsus, should reduction not be affected at once, violent pain will be felt over the sacrum and groins, and the degree of traction exerted upon the pelvic peritoneum may result in dangerous inflammation. Treatment The first indication as to treatment is to return the dis- placed organ to its normal position ; the second, to keep it there. Methods of Replacing the Uterus In general no difficulty will attend the performance of the first indication, but in some cases careful and intelligent taxis Avill be necessary. The best method for applying this is the following ; the patient, after thorough evacuation of the bladder and rectum, if this be possible, should be placed in the genu-pectoral position, in order to cause gravitation of the pelvic and abdominal viscera towards the diaphragm. She should not kneel upon a soft or yielding bed, into which the knees would sink, but upon the floor or a table, for the object of the posture is to elevate the buttocks and depress the thorax as much as pos- sible. Ten or fifteen minutes should then be allowed to elapse before any efforts are made at reduction. In this time the intense congestion which METHODS OF SUSTAINING THE UTERUS. 395 exists in the pelvic viscera will greatly diminish. Tlie operator then taking the cervix into the grasp of his index, middle, and ring fingers, pushes the uterus firmly and forcibly upwards in coincidence with the axis of the inferior strait. While the right hand is thus employed, the left rests upon the back of the patient and steadies her body. No sudden or violent force is exerted, but by steady pressure, kept up, if necessary, for fifteen, twenty, or thirty minutes, the uterus is restored to its place. Few cases will resist tliis kind of effort at reduction, although some may do so. For example, I have already referred to a case in which an in- carcerated uterus, which appeared upon the point of becoming gangrenous, could not be reduced by the method described, and in which, as no time wns to be lost, I produced complete anaesthesia, and then, taking tlie organ firmly in the extremities of the thumb and three fingers, I carried it by main ibrce into position. Methods of Sustaining the Uterus. — Before pursuing any special course of treatment for this end, the practitioner should endeavor to discover the cause of the descent. If it be due to increase in the weight of the uterus, or to pressure exerted upon it from above, it is evident that the indication will be very different from what it would be if the cause were traction by a prolapsed vagina. Unfortunately, however, after the disease has existed for some time, it is often impossible to fix definitely upon tlie cause ; for even if it were originally increase of uterine weight, the lengthy inversion of the vagina, and stretching of the uterine ligaments involved in its descent, will have destroyed all power in these parts. As far as possible, however, the original cause should be ascertained, and if it be properly sought for it will, in a number of cases, be discovered. For example, suppose that there be no excessive enlargement or prolapse of the vagina, no evidence of excessive downward pressure, and yet the uterus lies upon the pelvic floor. Strength should be given to its normal supports. Suppose, on the other hand, that the vagina be found to be in its normal state, and the prolapsed uterus to be very lieavy, weighing, perhaps, three times what it should. This increase of weight should receive especial attention. If, again, the insignificant, atrophied uterus of an old woman of seventy be prolapsed into a large, flabby, non-contractile vagina, traction by this vagina may safely be accredited with the uterine displacement. Lastly, if the common coincidence of rupture of the perineum, with subinvolution, and prolapse of the vagina and uterus be encountered, it may be assumed that increase of uterine weight, loss of support, and trac- tion, have all combined to bring about the issue. It should be the care of the physician to keep every one of the indica- tions suggested by these factors in mind ; and in every case attend first to 396 ASCENT AND DESCENT OF THE UTERUS. that which concerns the primary and most important ; afterwards, to those which are secondary and created by the displacement itself. A very important question otfers itself for consideration here : Is it pos- sible to give relief in an aggravated case of prolapse in the third degree without resort to operative procedure? The position has of late been taken by high authority that surgery must always be invoked as our final resort in such cases, and that less radical treatment should be looked upon as palliative and in great degree preparatory. This I regard as a doc- trine calculated to do great harm, and one which entirely misrepresents the true requirements of the subject. I should state the matter thus : In a very large majority of cases of prolapse of the uterus, whether in the first, the second, or the third degree, relief may be obtained without resort to operation ; in a certain number of cases where traction by the prolapsed vagina, I'ectum, or bladder is the cause of the uterine displacement, it should be our chief resource. Now it may be said in reply to this that even if such traction was not a primary factor in the displacement, it is always a secondary one, and, like a great many theoretical observations, this will carry weight. But it is not really a valid argument at the bed- side for him who studies these cases from a scientific standpoint, however powerful it may be in the mind of the empirical gynecologist. If the perineum have lost all power, and a loose, flabby condition exist in the vagina from subinvolution or hyperplasia the consequence of prolonged congestion, and the resulting vaginal, vesical, and rectal prolapse has dragged the uterus down, operation merely fulfils the important indication of removing the cause of the trouble, and logically presents itself as an important resource. If, on the other hand, a heavy uterus presses down of its own weight, or a normal one is forced down by pressure from above, closing the perineum, or contracting the vagina by colporrhaphy, is illogi- cal, unnecessary, and empirical. I would conclude this part of the subject by repeating, that operative procedure for uterine prolapse should be only exceptionally resorted to, and then to fulfil an indication, not to comply with a dogmatic pule. I have at this moment under observation a number of cases in which entire I'elief to complete prolapse has been afforded by means which will soon be mentioned here. So complete is this that the patients thus relieved would not listen to the proposal of operation. It is true, that complete cure has not been effected, but complete relief has. If the operative pro- cedures for such cases were simple, entirely free from danger, and certain as to result, a imiversal resort to them would be indicated ; but they are not so. I would not willingly appear to oppose operation in these cases, for I favor it and constantly practise it. I merely urge the api)lication to them of the ordinary rules which govern the scientific surgeon elsewhere. 1 will now consider in order the methods most appropriate for resisting each of the pathological conditions which result in uterine prolapse. METHODS OF SUSTAINING THE UTERUS, 397 The means adapted to prevention of pressure from above are — Removing weight of clothing by use of skirt-supporters ; Removing weight of intestines by prohibition of tight clothing, use of an abdominal supporter, and avoidance of injurious muscular efforts ; Preventing accumulation of urine and feces. The skirt-supporter is merely a pair of suspenders that may be contrived by any woman of ordinary ingenuity, and which enables the patient to carry the wliole weight of the under-garments upon the shoulders. A representation of a very good one will be found in Fig. 141. Or the skirts may be affixed to a waist, which replaces the corset, by buttons, as shown in Fig. 142. ' Fig. 141. Fig. 142. Skirt-supporter. Waist witli buttons for support of skirts. There are many varieties of the abdominal supporter, some of which, unfortunately, are so constructed as to do absolute harm. Should com- pression be exerted by them upon the abdomen above the navel, it will tend to increase pressure upon the uterus, or at least to annul all the benefit of that exerted below this point. The principle upon which these supporters should act is this — they should do just what the patient's hands do when she places them above the pubes, and lifts the abdominal viscera. Some of them are composed simply of bands of thick cloth, others are pads or disks of horn or metal, with encircling bands like those of the hernial truss. The physician may choose intelligently, if he only bears in mind what it is that he desires to accomplish by them. During the continuance of treatment the patient should be limited as to exercise and confined to bed during menstrual epochs, when the uterus is known to be heavier than at other times. Should the accident have immediately followed parturition, she should be kept in the recumbent posture to favor the accomplishment of involution. 398 ASCENT AND DESCENT OF THE UTERUS. Means adapted to diminution of uterine weight are — Removing polypi, tumors, etc., by operation ; Removing uterine inflammation, hypertrophy, and congestion, by appro- priate treatment ; Amputation of the neck of the womb ; Repairing laceration of the neck. Sometimes, by applying appropriate treatment to an enlarged cervix, the uterus is in time so much lightened by cure of attendant hyperaemia that relief is effected, but in other cases the hyperaemia is so persistent and rebellious that these means fail, and resort must be had to more powerful ones. A lacerated cervix will often prove a focus of irritation, and thus a cause of uterine congestion and hyperplasia, which may result in descent of the uterus. Under these circumstances closure of the lacera- tion will often effect a complete cure, and it should without delay be per- formed. In some cases, even when parturition has never occurred, hypertrophy of the cervix occurs and proves a cause of prolapsus. For this, resort has been had to amputation of the neck. M. Huguier, of Paris, was, in 1848, the first to perform this operation for prolapsus, though it has long been resorted to for cancer. Since that time it has been performed by many others, after methods which will be described in a chapter devoted to the operation. It must not be supposed that the mere removal of superabun- dant tissue is relied upon for the diminution of uterine weight. It is rather the derivative and alterative influences set up by amputation of which the surgeon endeavors to avail himself. Means for strengthening or sup-plementing uterine supports: — The recumbent posture ; Local astringents and tonics ; General tonics ; Exercising the retentive powers of the abdomen ; Pessaries. The recumbent posture, persistently persevered in, accomplishes a great deal of good in cases of prolapsus in the first, and sometimes even in the second degree. The buttocks being elevated, the uterus retreats from the pelvis, and its supports are left entirely at rest. Opportunity is thus afforded the weakened tissues to contract, to gain tone and strength, and in time to resume their functions. The results of posture may be mate- rially increased by simultaneous employment of the following agents. Astringents and Tonics. — By these means the pelvic tissues may be made to sustain the uterus for a time, and thus by keeping it out of dan- ger of congestion from interference with circulation, opportunity is given for removal of engorgement or slight hypertrophy. The astringents most commonly employed are tannin, alum, persulphate ASTRINGENTS AND TONICS. 399 of iron, and the bark of the white oak. They may be injected into the vagina in solution or infusion, by means of the ordinary syringe. A very excellent astringent under these circumstances is the infusion of the sumach berry, which grows commonly by our roadsides throughout the country. Tonics may be locally applied by the use of cold hip-baths, douches, sea-baths, and by copious vaginal injections of cold water, salt and water, or sea-water. General tonics, mineral and vegetable, should be employed. Among tliese, ergot, strychnia, and iron may be specially mentioned. Sea-bathing is peculiarly beneticial for this purpose, for it not only acts locally, but improves the tone of the whole system. In speaking generally of the influences which sustain the uterus, the peculiar retentive power of the abdomen has been mentioned very fully. Habits of life, with reference to exercise, dress, etc., exert a marked influence over this power. The woman who rarely exercises so as to call for full expansion of the lungs, gradually diminishes her breathing power, and in the end suffers from atony of the thoracic muscles. This renders diaphragmatic action feeble; the alternate rise and fall of the abdominal viscera is lessened ; they settle down upon the pelvic viscera; and the abdominal muscles lose their power and activity. This result is produced not only by a life of inactivity, which enfeebles the muscles which accomplish thoracic and abdominal respiration by want of use, and thus indirectly lessens diaphragmatic action ; any influence which directly interferes with the piston-like action of the diaphragm, or indirectly enfeebles by prolonged pressure the thoracic and abdominal muscles, tends to overcome this important function of the abdomen in supporting and keeping the uterus in good circulatory condition. Should any" one doubt this, let him examine with Sims's speculum several tightly-laced women, who, since childhood, have done all that art could do to annihilate this sustaining power of the abdomen ; and then the same number of women undeformed by the pernicious habit. Let him even examine the same woman with and then without corsets, and he cannot fail to recognize the slight uterine movement in the one case, and the active, vigorous rise and fall in the other. The influence of constriction at the waist will be readily appreciated by reference to Figs. 143 and 144. As the retentive power of the abdomen is destroyed by pernicious habits, it may with perseverance and judicious efforts be restored, and the import- ance of striving to accomplish its restoration in all cases of uterine dis- placement cannot be too strongly insisted on. This should be done first by freeing the trunk from all constriction and weight ; second, by causing free action of the diai)hragm by general exercises which cause this muscle to work vigorously ; and, third, by the practice of special exercises adapted 400 ASCENT AND DESCENT OF THE UTERUS. to development of the thoracic and abdominal muscles. As excellent general exercises may be instanced, rowing in a light boat or upon a rowing machine,' practising the " lift cure," the use of Goodyear's " par- lor gymnasium," or calisthenics. Walking and riding, either in a vehicle Fig. 143. Fig. 144. O The action of the diaphragm, the parts in normal condition. The action of the diaphragm, the parts deformed by tight and heavy clothing. or on horseback, are excellent in their results upon the general health, but they fail uttei'ly in fulfilling the special indication required. They improve nutrition and strengthen the muscles of the lower extremities, but not those of the upper portion of the trunk. Their substitution therefore for those just mentioned is an error. They may add to the general good accomplished, but do not develop either the lost function or the muscles which should perform it. There are also particular exercises adapted to the especial develop- ment of the abdominal muscles, at the same time that they excite an ex- aggerated action on the part of the diaphragm, and tend by that and by gravitation to raise the pelvic viscera. For a full exposition of this subject I would refer the reader to a work by Dr. George H. Tayloi-.^ His directions for the special fulfilment of this indication I give in his own words. "The patient lies back downward on a horizontal couch, with the hands strongly clasped over the head and pressing on its crown ; the feet drawn up so that the heels are in close contact with the trunk, the soles of the feet resting on the couch, the knees and thighs being strongly flexed. By a moderate effort the patient raises the hips as high ' Implements for these exercises are on .sale in all our large cities. 2 Dis. of Women, Maclean, N. Y., 1871. PESSARIES. 401 as she can, or till the thighs and trunk form a straight line, the shoulders and the feet only resting on the couch ; in this position the trunk must for a few moments be sustained. The hips and trunk are now allowed slowly to fall back to the commencing position on the couch. This action may be repeated a dozen or more times, a few moments of rest inter- vening." Another exercise is this: "The invalid lies on a horizontal couch with face downward, the elbows resting firmly on the couch, the arms perpen- dicular and supporting the upper portion of the trunk, the ankles strongly flexed, the toes, like the elbows, resting firmly on the couch. By a strong effort all the muscles of the anterior portion, that is, the under side of the body, are caused to contract, the knees are straightened, the hips and whole body raised from the couch, and made to form a horizontal line, touching the couch at no point but the elbows and toes." Still another is the following : " Two stools or chairs are placed so far asunder that the patient, in lying face downward across them, will be sup- ported by the chest resting upon one and the legs upon the other. While thus lying the abdomen is unsupported and consequently gravitates towards the ground, causing retraction of the generative intestine. In this posi- tion, the patient must endeavor to maintain her body in a straight line, in opposition to the tbi'ce of gravity acting on its central portion." Pessaries — The plan of supporting the prolapsed uterus, vagina, bladder, and rectum by mechanical contrivances which supplement the enfeebled natural supports constitutes a method of great value, and one which should never be cast aside. In a great many cases, objections, or advanced age on the part of the patient, want of skill on that of the physician, and the uncertainty as to result which attaches to all surgical procedures for the cure of prolapse, render a resort to a method whicl) relieves very greatly, during even a long lifetime, one which is dictated by prudence and good sense. To support ibur organs, the vagina, uterus, bladder, and rectum, which are, and have been for a long time, i)rolapsed, by an artificial me- chanical means, frequently taxes the skill of the ablest gynecologist, and sometimes utterly defeats his best attempts. Let the general practitioner bear this undeniable fact in mind, and not become discouraged by diffi- culties, nor disheai-tened by repeated fruitless efforts. Let such a one who reads this believe too the assertion which I here make, that I advise no instrument merely because it has been generally accepted, and that I limit myself to the mention of those only which I daily employ in practice with good results. In employing pessaries for all the varieties of prolapsus of the pelvic organs, the desideratum is an instrument which will not distend the vagina, at the same time that it will support the uterus. Such instru- ments as sustain the vagina without distending it, and thus allow it to regain something of its former tone and elasticity, are those which should 26 402 ASCENT AND DESCENT OF THE UTERUS. be, as far as possible, selected. The great functions which, in the majority of cases, are required of a pessary in prolapsus are these : first, to supple- ment the action of the utero-sacral ligaments, the chief factors in sustain- ing the uterus ; second, to keep the vagina, bladder, and rectum in place, so as to prevent them from perpetuating the uterine displacement by traction. I have already- said, that he who treats this condition, in any of its varieties, by replacement and support by a pessary, must frequently meet with insuccess. Is it not illogical to suppose that by any mechanical contrivance, heavy, congested, and prolapsed organs, often four in number, very generally three, can be, without preparation or the use of allied means, kept at once in normal position? Yet such a result is often anticipated. Before resorting to a pessary at all, it is a good plan to keep the patient in the recumbent posture for a few days, or, if possible, a week, with the foot of the bedstead elevated twelve inches, for the purpose of allowing con- gestion to pass off. During this time mild cathartics should be given to further this end by removal of fecal matter and stimulation of hepatic circulation, and the vagina should be systematically and copiously irrigated with astringent fluids to harden its tissues in preparation for a pessary, to effect support of the uterus, bladder, and rectum by a re-establishment of its sustaining power, and to cause contraction in its distended superficial bloodvessels. This time is not wasted, for the case is sure to be a lengthy one, and at the end of it, the patient is much better able to begin treat- ment of a mechanical kind without meeting with mishaps, which, in the commencement, dishearten and discourage her. Nowhere is the state- ment more true than here, that a good beginning advances us half way to success. The patient having risen, all of these means, except recumbency, should be continued throughout treatment, and others which are adjuvants to the pessary should be adopted, as, for example, removal of weight of clothing ; avoidance of deleterious muscular efforts, long standing, and constrained postures ; diminution of weight of uterus ; development of retentive power of the abdomen ; and others which have been already enumerated. Having attended to all these points, the pessary presents itself as a valuable re- source by which to complete and effect restoration of the [)arts : without attention to them it is, as a rule, too feeble to accomplish, unaided, the desired result. Let us suppose that we are dealing with a case of prolapse in the first or second degree, what pessary should we choose ? This will depend upon the amount of weight to be sustained. If this be great, subinvolution of the uterus existing, and depressing the organ, very possibly no internal pessary will succeed ; if it be moderate, almost any one of this list will do so Meigs's elastic ring, Hodge's, Smith's, Plewitt's, or Thomas's pessa- ries, all of which are shown by diagrams in connection with retroversion. PESSARIES, 403 None should be used wliich distends the vagina, and that employed should be worn without any sense of discomfort; should be kept clean by irriga- tion with astringent fluid every night, or night and morning ; and should be examined, at intervals, by the physician, to make sure that it is not injuring the tissues. If the great weight of the uterus render these pessaries, which pass en- tirely into the vagina, inetfectual, or should the case be one of prolapse in the third degree, others, which are in part external and in part internal, should be employed. I very rarely attempt to sustain a completely prolapsed uterus by an internal pessary, because I usually despair of success, and because I have known such evil consequences result from them in such cases, that I am unwilling to let the patient pass out of my sight with one in place. It is safer, more effectual, and more comfortable for both phy- sician and patient that she should wear an instrument which she can remove at will, allow the parts to rest during the hours of recumbency, and replace upon rising. There are three methods by which such support may be furnished, by a stem curling over the perineum, by one passing out of the vagina over the symphysis pubis, and by one end- ing at the middle of the vulvar open- ing, and resting upon a bandage passing beneatli it. Of these plans, the best is the first, and the next, in merit, the second. The third is ob- jectionable on account of the want of some point of support against which to fix the distal extremity of the stem, and to prevent motion in it. Fin. 146. Cutter's prolapsus pessary in position. Fig. 147. Cutter's prolapsus pessary. Tliumas'.s modification. 404 ASCENT AND DESCENT OF THE UTERUS. 1^0 pessary with which I am acquainted, so universally answers the indications of supplementing the action of the utero-sacral ligaments and sustaining the prolapsed vagina, rectum, and bladder as Cutter's admirable pessary, shown in Figs. 145 and 146. The cup at its upper extremity receives the cervix uteri, and the simplicity of the instrument enables the patient to remove and I'eplace it with perfect facility. This should be done in the recumbent posture upon retiring at night and rising in the morning. Means for preventing traction by the vagina: — Perineal support ; Perineorrhaphy ; Colporrhaphy. Perineal Support. — I have already pointed out the important function of the perineal body in closing the mouth of the vagina and offering a but- tress for the support of its walls. When rupture of the perineum occurs, its sphincteric powers are destroyed, and the result is sagging of one or both columns of the vagina and coincident descent of the uterus. By firm pressure at the weak spot, by means of a pad or cushion filled with hair, cotton, or air, and combined with an abdominal supporter, to which it may be attached, partial relief is sometimes obtained. Perineorrhaphy. — Much more complete and permanent support may be given to the vagina, and prolapse of its walls be much more certainly ob- viated, by restoration of the perineal body by the operation of perineor- rhaphy. If the uterus be not very heavy, this operation often proves a very excellent means of relief, for it removes the tractile power, which pulls down this organ, and thus the cause of the accident is taken away. But this operation, although efficient in these cases, is not likely to prove so where so heavy a weight, as a much enlarged uterus, requii'es support. It must not be supposed that, in cases of prolapsed vagina, perineor- rhaphy is limited to instances in which the perineal body is rujitured. It is equally applicable to those in which it has lost its power from any of those influences which are mentioned in the chapter upon the perineum ; such as subinvolution, etc. etc. In all cases, to be eflfectual, perineorrhaphy must restore the lost organ, the perineal body, and not simply shut the evil from sight by drawing be fore it a thin and useless curtain, which extends from the fourchette to the anus. Should this operation not be sufficient to remove traction, colpo-perine- orrhaphy, or anterior or posterior colporrhaphy, or a combination of these may be practised. For these procedures the reader is referred to chapters which have gone iDefore. By the:e means traction is taken away from the uterus, and if this was ANTEVERSrON OF THE UTERUS. 405 the cause of its prolapse relief will probably follow, but it is never safe to promise a good and permanent result from any of the operations of colpor- rhaphy. If in a case of laceration of the cervix, relaxation of the vagina, and complete distention or rupture of the perineum, the patient is willing to submit to three operations — operation upon the cervix, colporrhaphy u[X)n anterior wall, and closure of the perineum — cure will often be com- plete and permanent. This is a trying ordeal, both mentally and physi- cally ; nevertheless, most women affected by prolapsus in the third degree would unhesitatingly accept one of even greater severity with the prospect of cure. Besides the operations here mentioned as practised upon the vaginal walls, Episiori'haphy, which has been already described, has at various times been resorted to as a curative or palliative process for the affection of which we are treating. This, too, has been variously combined and modified, as, for example, under the names of Inferior Elytrorrhaphy, Elytro-episiorrhaphy, Episio-perineorrhaphy, etc. For fear of confusing the subject by the introduction of details which, although highly interest- ing, are of no great practical value, I shall not describe these modified procedures, but pass them by with this mention. Not only have efforts of this kind been made for narrowing the vagina and creating an artihcial cicatricial anterior or posterior column for the support of the uterus ; the actual cautery, mineral acids, escharotics, ulce- ration created by galvanic pessaries, and sloughing produced by pressure by forceps, have all been tried for the accomplishment of the much-desired end. I shall not go into the detail of describing these procedures, but refer the reader, who desires further information upon them, to Scanzoni's work upon the Diseases of Females. All these methods have the disad- vantages of proving excessively painful, after anresthetic influence has passed off, and of being more unmanageable and less certain in their results than those here described. CHAPTER XXVII. ^ ANTERIOR DISPLACEMENTS OF THE UTERUS. Anteversion. Definition and Frequency This disorder of position consists in an anterior inclination of the uterus, so that the fundus approximates the symphysis pubis and the cervix retreats into the hollow of the sacrum. Although not so frequent as its kindred condition, anteflexion, it is by no means of rare occurrence. At times it presents itself as an annoying 406 ANTERIOR DISPLACEMENTS OF THE UTERUS. com])lication of areolar hyperplasia or fibroid growths, while at others it is produced witliout any alteration existing in the uterine parenchyma. Dr. ChurchilP opens his chapter upon this subject with these words : " It may be thought somewhat out of place to treat of some of these dis- placements here, as they are so intimately connected with pregnancy and parturition ; but as they do occur independently, it appears to me prefera- ble to travel so far. out of the way in order to complete the subject, rather than give a partial view, or omit it altogether." My own experience leads me to an entirely different conclusion from that here recorded by the emi- nent Irish obstetrician. I meet with versions very commonly in the non- puerperal state, although it must at the same time be admitted that anterior displacements generally assume the character of flexions. To give some idea of the relative frequency of the various anterior and posterior dis- placements, I present the following tables. The first table is one con- structed from a valuable statistical i*eport by Dr. Meadows: — . 84 Number of cases of displacement examined " " posterior displacement 52 } *' " anterior displacement 32 < ' Antevers oflexion overs ion xion sion 34 18 20 12 It is impossible to reconcile the discrepancy of the results obtained liy statistical evidence accumulated by diflferent observers. Thus, for example, out of 339 cases of displacement recorded by M. Nonat,^ the following were the number of anterior and posterior inclinations : — Anteversion ....... 135 Anteflexion . . • . . . . .'33 Retroversion ....... 67 Retroflexion ....... 14 " Anteversion," says Klob,^ ''in general is a rare form of displacement, and occurs much less frequently than retroversion." Emmet, out of ooo cases of version, found 236 to be anteversion and 295 retroversion. Subjects of this character belong to that class upon which reasoning and theorizing accomplish no good, but rather the contrary. The only way in which they can be settled is by carefully collected statistics, and one would suppose that this method would be conclusive. Yet we see in the present case how far this is from being the fact. Dr. Meadows's most frequent displacement is M. Nonat's and Scanzoni's least frequent.' Kothin"^ but discrepancy and doubt result from the comparison of the fio-ures of these three conscientious observers. "Tliere is nothing," said ' Diseases of Women, Am. ed. ^ Mai. de I'Uterus, p. 416. 3 Klob, Patholog. Anat., p. 68. ANTEVERSION OF THE UTERUS. 407 Sydney Smith, " so unreliable as figures, except facts." After such a comparison of statistical evidence one feels inclined to agree with him. The normal position of the uterus is one of slight anteversion, the axis of the body corresponding with that of the superior strait, which is a line running from the umbilicus, or a little above it, to the coccyx. The degree of this forward inclination may be so increased by slight causes as to constitute a morbid state. As to the line which separates what is normal fromjWhat is abnormal, it is impossible to lay down any exact rule ; experience must be our guide. In general terms we may say, that when the long axis of the uterus is found lying across the pelvis, the fundus near the symphysis pubis, and the neck in the hollow of the sacrum, anteversion exists. Predisposing Causes. — The predisposing causes of this affection are parturition, enfeebled muscular condition, habits of indolence and inac- tivity, and loss of tone in the abdominal walls. The exciting causes may thus be presented. Influences increasing the weight of the uterus. Congestion ; Hypertrophy or hyperplasia ; Subinvolution ; Fibroids ; Pregnancy ; Laceration of the cervix. Influences forcing the fundus directly forwards. Violent efforts ; Abdominal effusions ; Abdominal tumors ; Tight clothing. Influences enfeebling uterine supports. Ruptured perineum ; Relaxation of ligaments ; Destruction of the retentive power of the abdomen. Cysto- cele. Influences dragging the fundus directly forwards. False membranes ; Prolapsus vagina3 ; Cystocele ; Shortness of the round ligament; (?) Anteflexion. A large number of cases will be found due to areolar hyperplasia, a number by no means inconsiderable to fibrous tumors, some of the most irremediable cases to false membranes, many to cystocele which takes away support at the same time that it produces traction, while a few will exist witiiout other ai)parent cause than direct pressure from some power 408 ANTERIOR DISPLACEMENTS OF THE UTERUS. which forces clown the abdominal viscera upon the fundus. The last cause is much aided by laxity of the abdominal v/alls, which robs the viscera of support. One fruitful source of the condition is unquestionably the gradual de- struction of the retentive power of the abdomen by habits which engender atony of the thoracic and abdominal respiratory tnuscles and enfeeblement of the action of the diaphragm. Symptoms In a certain number of cases anteversion will be found to exist without creating any disturbance either constitutional or local. This, however, is a rare exception to a general rule. By pressure of the OS against the posterior vaginal wall, anteversion commonly induces dysmenorrhoea and sterility, and by pressure of the fundus against the bladder, and the cervix against the rectum, these viscera are irritated and interfered with in their functions. The bladder more especially suffers, sometimes a state bordering upon cystitis being engendered. Pressure upon the rectum more rarely produces tenesmus and a painful, irritable state. In exceptional cases it is surprising to see to how great an extent loco- motion is affected by this condition. My experience furnishes me with four cases in which patients were for long periods confined to bed or the lounge on this account. In one of these the patient had not left the house for four years ; in another she had scarcely assumed the upright posture for eight months ; the third was the counterpart of the second ; while in the fourth the patient for twelve years had never walked over a quarter of a mile without serious inconvenience. In each of these cases positive proof was afforded me of the agency of anteversion in producing the disability which existed, by its removal when the uterus was properly sustained by an anteversion pessary, and by relapse at once recurring when without her knowledge she was left without it. Not one of these women was suffer- ing from that hysterical condition which so often misleads the physician as to the results of remedies. Course, Duration, and Termination Even if the exciting cause of the condition be removed, it will usually continue, for the broad and utero- vesical ligaments have by long distention become stretched and enfeebled, while there has been simultaneous contraction in the utero-sacral liga- ments from long disuse. The first fail to aid the fallen organ ; the last help to keep it out of position by lifting the cervix up against the rectum. Sometimes cure is affected by pregnancy, the displacement disappearing as involution is accomplished. Usually, however, unless the exciting cause of the condition be removed, and the organ be kept in proper position for a year or more, the displacement will continue unabated. Varieties -Anteversion may be complete or partial. While there are three degrees of retroversion and of prolapse, there are but two of this displacement, for the axis of the uterine body is naturally inclined so much ANTEVERSION OF THE UTERUS. 409 forwards as to prevent us from including slight increase of inclination under the head of disease. Fi"-. 148 will show the varieties referred to ; an inclination of 45° re- presenting the first degree, or partial anteversion, and that of 90° the second degree, or complete anteversion. Fig. 148. The degrees of anteversion. Diagnosis. — When in a case of this displacement vaginal touch is prac- tised, the patient lying on the back, the index finger passed into the fornix vaginae discovers that the cervix is absent. A rapid investigation will prove that it is not to be found in the pubic or lateral regions of the pelvis, and deep exploration with two fingers will discover it high up in the hol- low of the sacrum. The finger being then passed towards the pubes will come in contact with a hard ridge, whicii will run towards the symphysis. Conjoined manipulation will prove this to be the body of the uterus, and complete the diagnosis. Should further evidence be required, the uterine probe, very much curved, may be passed into the cavity, though this is rarely necessary and always ditficult. Differentiation. — Capuron tells us that Levret mistook the first case he saw for stone in the bladder, operated for this, and sacrificed the life of the patient. In spite of such a grave mistake at the liands of so great an authority, it may be stated that there is no diseased condition with which this should be confounded. The disease inducing the displacement may not be recognized, or some serious error may be made as to its nature, 410 ANTERIOR DISPLACEMENTS OF THE UTERUS. but tliat does not concern the present subject. The recognition of the mere fact of the anteversion is never difficult, if proper diagnostic means are brought to its elucidation. Prognosis The prognosis as to any serious injury which will arise from the displacement is decidedly good, although there are many incon- veniences and discomforts connected with it, sucii, for example, as vesical and I'ectal irritation, neuralgia in consequence of compression of the nerves, and difficulty in locomotion ; none of these, however, go on to a dangerous degree of development. If the condition be not treated by mechanical means, it will prove entirely incurable ; but by these the prospect of great improvement and even of complete cure is very good. Important and early evidences of improvement resulting from mechanical treatment are frequently obtained in disappearance of dysmenorrhcea and sterility. It is often difficult to remove the exciting cause of anteversion, and even should this be accomj)lished, the uterus is so prone to retain the abnormal position in which it has long been kept, that great difficulty attends its retention in normal position. One of the reasons tor this is the fact, already stated, that the uterine ligaments readily alter their proportions under certain influences. Thus during pregnancy they are all elongated ; in posterior displacements the utero-sacral ligaments are stretched,-^ and in anterior inclination the utero-vesical ligaments are similarly affected. As the antithesis of this fact, prolonged absence of function causes con- traction in these structures ; thus in anteversion the utero-sacral ligaments are generally shortened, and there is no doubt that the round ligaments are similarly altered. . Anteflexion. Definition. — This, which is one of the most frequent of all uterine dis- placements, consists in a bending of the organ so that the fundus, the cervix, or both, are bent more or less sharply forwards. Vai-ieties There are three forms of anteflexion: first, corporeal flexion ; second, cervical flexion ; third, cervico-corporeal flexion. 1st. The cervix being normal in position the body is flexed ; 2d. The body being normal in position the cervix is flexed ; 3d, Both are flexed forwards. The lines represented in Fig. 150 will serve to show the deviations which may affect the axes of both body and cervix. These varieties are neither arbitrary nor unnecessary. The existence of each may readily be verified at the bedside, and treatment should always be materially modified by the peculiarity of the deviation. It appears to me that a neglect of them and the fixation of attention upon flexure of the body alone has seriously retarded progress in treatment. No one can intelligently treat anteflexion without regard being had to ANTEFLEXION OF THE UTERUS. 411 the variety of the disorder to which lie is called upon to adapt his mechanical appliances. Fig. 149. I Anteflexion. In addition to these there is a rare form in which the cervix is flexed forwards and the body backwards, but it is difficult to represent the axes of this variety in a diagram. Fig. 150. / <- L Normal axes. First variety of flexion. Second variety of flexion. Tliird variety of flexion. Symptoms A certain degree of this displacement may exist for years without the development of symptoms. Very generally, however, obstruc- tion to venous return at the point of flexure produces congestion which increases the displacement, disturbs the nervous system, and disorders uterine functions. Then the following symptoms develop themselves : — Pain over hypogastrium and in groins and back; Irritable bladder; Leucorrhoea ; 412 ANTERIOR DISPLACEMENTS OP THE UTERUS. Dysmenorrhoea ; Sterility ; Nervous disturbance and despondency; Pain on locomotion ; Menorrhagia ; Tendency to abortion ; Pain on sexual intercourse ; Pelvic neuralgia; Sense of depression at the epigastrium. In some cases there is a morbid and invincible aversion to walking, partly arising from physical and partly from mental causes. I have, in several cases, seen women who had been liedridden for three and four years rapidly restored to their powers of locomotion by restoration of the uterus to position, and its retention by an efficient pessary. Dr. Hewitt mentions the retention of secundines after abortion in cases of anteflexion, and their putrefaction in utero, and advises as treatment restoring the organ to place, when expulsion at once occurs. Physical Signs — As the finger passes into the vagina and touches the cervix, nothing abnormal will usually be discovered. But as it sweeps aloncr the anterior wall of the uterus, about the os internum a protuberance will be met with which presses upon the bladder. The finger which has thus far explored being kept in contact with this mass, the disengaged hand should then be laid upon the abdomen and made to depress the anterior abdominal wall so as to approximate the finger in the vagina. By this means the shape, size, and sensitiveness of the body may be ascer- tained. The diagnostician is, however, still in doubt whether the enlarge- ment may not be one due to fibrous tumor or cellulitis. This point he settles by placing the patient on the side, introducing Sims's speculum, and gently probing the uterus to the fundus. Giving to the probe the curve which by vaginal touch he has been informed is that of the uterus, he carefully passes it in. Should it not proceed without obstruction, he with- draws it, alters the curve, and tries again. Having succeeded in intro- ducing it, he learns the course of the uterine canal, its length, and the sensitiveness of its walls. Should the probe have entered the mass felt through the vagina, that mass is the uterine body. Should it go in the normal axis or backwards, it is not the uterine body, but some growth in contact with it. In pure cervical flexion the neck will be felt sharply bent forwards and in the double form both neck and body will be found flexed. Prognosis. — The prognosis as to cure will depend upon certain circum- stances which I will proceed to enumerate. (o) It is better in multiparous than in nnlliparous women, because the vagina in the former more readily admits of tlie use of mechanical supports, and because it is acquired and not congenital. TREATMENT OF ANTERIOR DISPLACEMENTS. 413 (b) It is better in pure corporeal anteflexion than in those varieties in •which the cervix is affected. (c) Where the cervix is thrown far back and lifted high in the pelvis, the prognosis is decidedly unfavorable, and more especially if there exist only a scanty vaginal pouch anterior to the neck. (c?) If the flexion be of reducible kind, prognosis is favorable; if tlie contrary, it is by no means so. (e) The prognosis of congenital flexion is almost a hopeless one, unless the knife be resorted to. ( /") Of all the cases except the last the prognosis is most unfavorable in those in which the vagina joins the cervix very low down, near the os externum, and where the uterus is held high in the pelvis. The shibboleth of the subject of prognosis as to cure is, however, this : if the flexion be entirely reducible, the case may be cured ; if it be not so, it will in all probability prove incurable. As regards the general health of the patient, the prognosis is not usually bad, but enlargement of the uterine body may result from anteflexion, and its consequences are commonly sterility, vesical irritability, dysmenorrhcea, and leucorrhoea. Treatment of Anterior Displacements The first point Avhich the prac- titioner should settle before commencing treatment, is whether the dis- placement is the main source of existing morbid phenomena, or whether these are due to some disease which underlies that condition. If he be led to regard it as merely a coincident or resulting condition which is producing no annoyance, of course the primary disorder must take pre- cedence of it in treatment. It is, however, futile to assume the position that not the displacement, but its cause, must be the main object of atten- tion ; that, if endometritis, subinvolution, or a fibroid be its cause, they, and not it, must be treated. Nothing so surely prevents success in the management of such cases as the carrying into practice of the theoretical view that support must be confined to cases of pure, uncomplicated dis- placement. It is very often required where this is a result or complication of other disease. We are called upon to alleviate one of the most annoy- ing symptoms of disease here, as we are in so many other instances. Pes- saries are frequently required by the uterus as splints are by a fractured bone, not absolutely as a means of cure, but as adjuvants in treatment, by which rest and freedom from pain caii be procured while the healing pro- cess advances. Means for Reduction — In the restoration of an anteverted uterus to its place, difficulty will rarely be experienced, for, unlike retroversion, the displacement does not often become complete. Even when it does so, reduction may be easily accomplished. Wlien it proves difficult, the bladder having been emptied by the catheter, the patient should be placed upon her back on a hard bed or table, and all tight clothing removed 414 ANTERIOR DISPLACEMENTS OF THE UTERUS. from the abdomen. The operator having oiled two fingers should then pass them into the vagina, and press their tips against the body of the uterus, which will have forced the walls of the bladder down before it. The fingers of the left hand being thus employed, the right should be laid upon the abdomen, so as to push up the abdominal viscera and uterus when reduction is attempted. The patient is now directed to fill the lungs with air, and then to expel it gently by a prolonged expiratory act. As this expiration is being finished, the operator presses up the body of the uterus by the fingers in the vagina, and the abdominal viscera and fundus by the hand on the abdomen.' He will generally succeed at once in replacing the organ. Should he not do so, he should repeat the process as above described, until the end is attained. Of course where the dislo- cation is partial, restoration may be much more easily effected ; but in this case it accomplishes nothing, for no sooner does the force applied cease, than the organ again falls out of place. As the fundus is lifted by bimanual manipulation, the hand on the abdomen keeping it up, the finger in the vagina should be placed behind the cervix, and this part be pulled forwards towards the symphysis. Some practitioners rely lor cui-e upon the daily restoration of an anle- verted or retroverted uterus, but hopes thus based will usually prove delusive. Where the version is complete and sudden, a return to the normal position may be final ; but rarely have I seen it so result where the displacement was incomplete and chronic. The method just described is, unless the uterus be bound down by false membranes, very generally successful in anteversion. In anteflexion also, where the displacement is one of reducible character, it is often all that is required. But in cases of anteflexion irreducible in character or difficult of reduction, more efficient means must be resorted to. These may be enumerated as the uterine sound, Elliott's repositor, Jennison's sound, and Wallace's spring tent, or laminaria tents. Of course such restoration is only temporary, but even that benefits utei-ine circulation and improves the nutrition of the enfeebled concave wall. I have elsewhere likened the flexed uterus to a bent twig. The replacement of the former may be compared with the straightening of such a twig by the forester, and the use of a pessary to the employment of the supporting splint which he binds to the growing tree and by which he strengthens its weak side. The uterine sound being introduced to the fundus, not much curved, but as straight as it can be made to pass, the handle being held in one hand, the tips of the fingers of the other should be pressed against the shaft of the sound near the middle, and they being made a fulcrum, the handle ' The operator should be very sure that tlie anteverted uterus is not boninl down by false membranes before applying force for its replacement. MEANS FOR REDUCTION. 415 should be carried to the symphysis. By this manoeuvre the flexed fundus is elevated, and at the same time carried towards the hollow of the sacrum. This point being reached, the sound should be very gently rotated, and complete retroversion with partial retroflexion of the uterus accomplished. This should be done with the utmost gentleness, and as I have described, not by a sudden rotation of the flexed organ, which forcibly sweeps the fundus around the superior strait of the pelvis. Sims's speculum being introduced and the cervix caught by a tenacu- lum, Elliott's sound, shown in Fig. 151, may be carried quite curved Fig. 151. Elliott's uterine repositor. into the flexed uterus and straightened by the action of the screw at its lower end. A method of reposition wliicli I prefer to these in anteflexion is that by the use of Jennison's sound, Fig. 152. Fig. 152. Jennison's sound. Pressure upon the lower extremity of this causes the upper to bend sharply so that it readily enters a flexed uterus. Then reversal of this pressure lifts the flexed body, and not only straightens the uterine axis but creates retroflexion. Every succeeding exercise of the uterus in this straightening process renders reposition easier, improves the nutrition of the flexed wall, and benefits the circulation in the organ. After this has been done four or 416 ANTERIOR DISPLACEMENTS OF THE UTERUS. five times the second indication should be attempted, keeping the uterine body in position. In a large number of cases of anteflexion, however, even these means of replacement prove unavailing, and the deformity of the uterus is sus- ceptible of relief by two plans of treatment only : that which, by uterine tents and the intra-uterine stem, forcibly straightens the bent organ ; and that which, by the knife or scissors, renders the canal straight witliout reference to the relations of neck and body. Such cases being commonly congenital, one wall is well developed by excessive growth, while the other is dense, rigid, atrophic, and unyielding. They may, however, result from prolonged accidental flexion, with development of slight attacks of peritoni- tis; even without the last, indeed, for cicatricial retraction of the atrophied section of connective tissue has been found by Klob under these circum- stances. One of the most effectual means of meeting the difficulties of irreducible flexioE is the use of the spring tent of Dr. Ellerslie Wallace, of Philadel- phia. He passes through a canal made in a piece of carbolized sponge a small piece of watchspring and compresses the sponge so as to make the tent curved as represented in Fig. 153. Fig. 153. Ellerslie Wallace's spiins.' tent. In this condition it is passed into the flexed uterus, and as the sponge softens, the spring erects itself and straightens the uterus. All the dan- gers attending the use of sponge tents attend the use of this, but no more. It may be practised once a week until three or four tents are used, or it may be used once and be followed by the intra-uterine stem. The same end may be obtained by moistening in hot water a laminaria tent up to the point of bending, and passing this into the uterus, and keep- ing it there until it fully expands. One very important fact, however, which should be constantly borne in mind in connection with anteflexion is, that there is a class of cases of irredu- MEANS OF RETENTION. 417 cible flexions wliich is incurable. The practitioner, unwilling to admit this to himself, or not appreciating the fact, begins treatment from a conventional idea that such is his duty. But the case proves tar too obstinate for the ordinary local treatment; tents will not cure it, and trachelotomy, not fully meeting the mechanical indications, fails likewise. If the patient passes the ordeal without being attacked with peritonitis or cellulitis, she in time gives up all efforts at cure, or seeks the advice of another physician. Means of Retention in Position of a Uterus Anteriorly Displaced These should be based, like those adopted in all other uterine displacements, as far as possible upon antagonizing the influences which produce and per- petuate the aberration from the normal position. The repetition of this fact, and of the means for developing the principle in connection with the various displacements, may prove tedious, but I otFer no apology for this, for the great advantage which will result to the student from following this course will abundantly justify me. It will be said too, by tlie many who prefer empirical to scientific methods, that the plan pursued is based upon theory which is not applicable at the bedside. Let this question be put to the test of experience, and the student will find that the mere direction of the mind into proper channels of thought and investigation will give the plan value and induce him to adopt it. In every case of anterior displacement let the practitioner endeavor to find out which is the main element concerned in its production, but at the same time let him remember that this one has almost surely developed others which are scarcely less important as factors. In most cases, there- fore, he will be called upon to direct his attention to all forms of the patho- logical influence about to be mentioned. All increased weight of the uterus should be treated by appropriate means ; inflammation and its results by methods already mentioned, hyper- j)lasia and hypertrophy by means adapted to their management, and lace- ration of the cervix by ti-achelorrhaphy, etc. The fulfilment of this indication alone will sometimes effect a complete cure of anteversion. Whether it does so or not, the next should always receive attention. Pressure from above should be removed by carrying the weight of the clothing upon the shoulders, by skirt-supporters; pressure of the intestines, by proliibition of tight clothing, the use of an abdominal supporter, and the avoidance of injurious muscular effort. The dorsal decubitus in cases occurring suddenly, as, for example, during pregnancy or after labor, is of great value, and even in chronic cases is an important adjuvant to tx-eatment by pessaries. In the commencement of such ti-eatment at least, it should be always adopted, for two or three hours every day, at mid-day, for the purpose of affording a temporary rest to tlie parts. In proportion to the disadvantages resulting from corsetting the upper segment of the trunk, are the advantages to be derived, in these cases, 27 418 ANTERIOR DISPLACEMENTS OF THE UTERUS, from thus acting upon the lower. When the abdominal walls are lax and yielding, and do not properly sustain the viscera, they fall upon the fun- dus uteri, and tend to produce and keep up anterior obliquity. No one can deny that by a w^ell-fitting abdominal supporter, tone is given to the lax walls, and that the intestines, not the uterus, are sus- tained. I have already stated that many are prejudiced against this means and decry it as absolutely injurious ; but I see it too plainly and certainly productive of good results in daily practice to admit of any doubt in my mind concerning it. Dr. J. C. Nott offered a very plausible explanation of the fact that in some women benefit follows the use of abdominal sup- porters, while in others absolute injury results from their employment. " If the patient be emaciated," said he, " and the abdominal walls retracted or even flattened, the supporter will depress and not sustain the uterus. On the other hand, if the woman be corpulent, the greatest support will be yielded by its application." I have employed for tliis purpose with very great advantage an abdominal pad or truss, which is at the same Fig. 154. Abdominal pad of wood or cork. time simple, inexpensive, and efficient. It consists of iin ovoid block of cedar, pine, or cork, five inches long by four inches wide. This is con- vex upon the surface to be placed next the body, and flat on the opposite side, and is held in place by an elastic band or slender strip of steel covered Fig. 155. Abdouiiual supporter. with leather, like an ordinary male truss. The pressure made resembles that of the hand, and, as soon as patients become accustomed to it, which it should be borne in mind may take a little time, gives great com- fort. Another very efficient one is shown in Fig. 155. MEANS OF RETENTION 419 Traction upon tJie uterus from beloiv, if found to exist, should be re- moved by perineorrhaphy alone or combined with colporrhaphy, or it may be obviated by the use of a pessary which sustains vagina, uterus, aiul bladder. Fig. 156 shows how loss of power in the perineum will result in pro- lapse of the anterior vaginal wall, how the bladder will in consequence prolapse, and how the upper portions of the uterus will follow it, ante- version resulting, and how perfect repair of the perineum will remove all traction from the uterus, and allow it to resume its place in the pelvis. The perineal body destroyed, both rectal and vesical walls descend Loss of the normal supports of the uterus should be overcome by the use of general and local tonics, developing the retentive powers of the abdomen, and by the use of pessaries. Astringent vaginal injections, sea- bathing, and the internal use of vegetable and mineral tonics are unques- tionably of value. By the development of the retentive power of the abdomen, a great deal can be done for replacement and support of an anteverted uterus. Every morning and evening the patient should place herself flat upon the back upon her bed, with the hands clasped over the head and the heels touching the buttocks. Then she should raise the pelvis as liigh as possi- ble, and sustain it for a few moments, the shoulders and soles of the feet alone touching the bed. Letting the pelvis slowly descend, she is to re- peat this a half dozen times. The movement too for strengthening tli":- 420 ANTERIOR DISPLACEMENTS OF THE UTERT^S. abdominal muscles mentioned under treatment of pi-olapse should be prac- tised here, as well as the general exercises indicated there for the full development of the thoracic and dorsal muscles. Pessaries. — What is desired of a pessary in sustaining the anteflexed or anteverted uterus is this : to make gentle pressure on the base of the bladder above the cervico-corporeal junction, and as near to the fundus as possible, to supplement the vesico-uterine ligaments, and at the same time not to injure the vagina by excessive pressure at this point. It is by no means easy to make an instrument answer these i-equirements; it may either keep the uterus in place at the expense of a degree of force which will create a solution of continuity in the vagina, or it may, when pos- sessed of too little power, allow the fundus in spite of it to fall forwards. The use of pessaries for this displacement requires a vast deal more skill, mechanical ingenuity, and patience than is necessary in those of posterior variety. Even with every precaution, cases will commonly occur in which the parts will be injured by pressure; and without precautions the means is one which is attended by absolute danger, in cases in which pelvic peritonitis has preceded the displacement, the danger is so marked that treatment by pessaries, either should not be adopted at all, or, if attempt- ed, should be limited to the most cautious trials. The diagnosis having been made, and it having been decided that retention of the uterus in position is not attended by danger on account of former pelvic peritonitis, and that the displacement results from no condi- tion removable by operation, the treatment should be commenced in this way. The intestines should be evacuated by a cathartic, all weiglit removed from the fundus by abdominal and skirt supporters, and the pa- tient enjoined to take veiy moderate exercise and to avoid all violent efforts. Every night and morning she should use the w^arm vaginal douche, not only at first, but throughout the duration of treatment, to prevent irritation from it. Before tiie introduction of a pessary, the uterus should have been several times replaced by conjomed manipulation and held in position for two or three minutes at a time. At the end of this period, if the displacement is readily reducible, and it requires no great force to sustain the uterus, the anteversion pessary represented in Fig. 157 may be introduced, and the patient allowed to walk about. Should it give no pain, she may wear it home, even if going to a distance from the practitioner's residence, for she can herself remove it on the first menace of injury. In three or four days the instrument should be ex- amined. If it have given pain or have left its mark upon the vaginal walls, it should be changed at once; if not, it may be left for a week; then for two weeks ; then for a month ; and afterwards for a still longer time, two months, for example, without examination. The pessary here advised is represented oi)en for withdrawal by the dotted lines, and closed PESSARIES, 421 as it should be in the vagina in introduction. The piece which sustains the fundus is large and smooth, so as not to injure the vaginal wall. When the pessary is drawn upon by means of its lower branch, this piece falls back of itself, and thus the instrument is susceptible of removal. The Fig. 157. Cn >I.REYNDERS-CO.NEVv"y-.."'::. Thomas's anteversion and anteflexion pessary. possibility of removal by the patient is an important element in an ante- version pessary, for she may go away after its introduction and suffer agony in a few hours, and, should she be unable to remove it, inflamma- tion might result. Even if she obtain medical aid, it is often very diffi- cult lor a physician ignorant of the peculiar construction of one of these instruments to remove it. I never consent to a patient who is wearing one leaving my office to go out of the city without first making myself sure of her ability to remove it herself. The pessary here represented is inti'oduced closed and carried to and behind the cervix just as one for retroversion is. As the piece intended to support the fundus is resisted by the pubes, the perineum is depressed and it is carried under it. The instrument is opened as shown in the diagram, not for its insertion, but for its withdrawal. The anterior, projecting piece may be made longer or shorter as greater or less elevation of the uterus becomes necessary. Fig. 158 repre- sents this instrument modified so as to con- sist of a permanent and immovable projec- tion on the anterior face of a Hodge or Smith pessary. In the case of a virgin it is often difficult to withdraw and introduce these, but in a married woman, and espe- cially in a parous one, it is easy of applica- tion. Another instrument which I employ very commonly, both in antever- sion and anteflexion, is tliat shown in Figs. 159, 160, and 161. The instrument is here presented closed. It is introduced open. Upon pulling upon the bow which presents at the mouth of the vagina, the piece which sustains the uterus falls back, and it can readily be with- drawn by patient or physician. Fig. 158. Thomas's anteversion pessary, with fixed projection. 422 ANTERIOR DISPLACEMENTS OF THE UTERUS. Fig. Ifi2 represents a modification of the two instruments which [(re- cede it. Fig. 159. Fig. 160. Fig. 161. Thomas's anteversioa pessary as it appears iu the vagina. The same instrument in position. The same instrument as it appears on removal. Fig. 163 represents an elastic pessary for anterior displacements, made of spiral wire and strips of whalebone covered with gutta-percha, by Otto and Sons, of this city. The whole pessary is so pliable that it can be in- troduced and withdrawn with perfect ease. Fic. 1()2. Fig. 163. Thomas's anteversiou aud auteflexion pessary. Thomas's elastic pessary for anterior displacements. If the attending physician possess only little skill in the use of pessa- ries, or if the uterus be replaced with difficulty, and sustaining it appear to require force, he had better not employ an internal pessary, but limit himself to one connecting externally with a band. Support may be given to such a pessary by a stem arching over the perineum, as shown in Fig. 164. This displays in position a modification of Cutter's retroversion pessary. The upper extremity of this form of Cutter's pessary has a bulb attached to it, and is so bent forwards as to strike the base of the bladder, anterior PESSARIES, 423 to the cervix. This is introduced by the practitioner, and its method of introduction and removal fully explained to the patient. She is instructed how to remove it upon retiring every night, and to replace it before rising in the morning. By it the cervix is pulled forwards, the utero-sacral liga- FiG. 164. Anteversiou pessary supporting uterus. ments stretched, a tolerance of a foreign body established, and a pouch or pocket created anterior to the cervix, which will accommodate in time the pessaries already depicted, if tlie practitioner desires to try them. The bulb pessary with external attachment may in any case be used as pre- paratory to an internal instrument. After the foi-mer has been used for a Fig- 165. Fig. 166. Cutter's T pessary for anterior displacements ililicatiou of Cutter's pessary. month or so, the latter will generally be applicable. One having experi- ence with these two instruments can almost always tell witliout experi- mentation which will be appropriate. If there be a pouch anterior to the cervix when the base of the bladder is pressed up by the finger, the in- 424 ANTERIOR DISPLACEMENTS OF THE UTERUS, ternal pessary will be tolerated. If there be none, and the tissue resist pressure by the finger, it cannot be employed until space has been created by the other instrument. To facilitate the proper introduction of this instrument, and to prevent the supporting portion from being placed behind the uterus instead of in front of it. Dr. Cutter has devised the instrument shown in Fig. 165, and I have modified it as shown in Fig. 166. Even if the patient made an effort to place these instruments incorrectly, it would be accomplished with difficulty. Their beneficial results in these cases are unquestionable except by those whose prejudices or incapacity have defeated them. Cases will occasionally be met with in which the parts are so sensitive that the hard bulb of these pessaries cannot be borne. Under these cir- cumstances, they can be with great advantage replaced by soft balls of very fine sponge, until the reposition of the uterus and removal of conges- tion which is thus effected render solid bulbs tolerable. Fig. 167. Graily Hewitt's auteversion pessary. Fig. 167 represents the very excellent pessary of Dr. Graily Hewitt. I have employed it very extensively, and esteem it highly. I have also in some cases found the pessaries of Guerung and Fowler answer very well in anterior displacements. The latter of these is shown in Fis. 168. PESSARIES. 425 He wlio expects from these methods extraordinary results will surely be disappointed. In a certain number of cases failure Avill attend all means tlius far devised, not excepting surgi- cal procedures. My experience, however, ^'^' ^"°' warrants me in saying that a persevering re- - '''~° sort to the treatment here advised will reward /tT^^ the gynecologist by success in many cases. After overcoming this form of flexion, a Meigs's ring pessary should be worn for a long time to prevent relapse. After over- .1 . 1 11 ii c c a • • i. Fowler's pessary for anterior commjj this, and all other forms ot flexion, it ^ i . " ' ' displacemeuts. is well to dilate the cervical canal by means of graduated sounds, as there is generally more or less contraction of it. I would especially impress the importance of not relying exclusively upon any one of these pessaries or internal supporters. Their use should be combined with external means calculated to remove pressure from the fundus. By this combination the happiest results may be confidently anticipated from eflfbrts at relief of this often distressing accident. Before concluding, let me recapitulate (he most important of the maxims embodied in this chapter. 1st. Never begin treating an anteverted uterus mechanically until satis- fied that no periuterine inflammation exists ; that bad symptoms present are due to the displacement ; and that no condition susceptible of removal by medical or surgical means requires earlier and more prominent atten- tion than retention of the uterus in position. 2d. Before using a i)essary, act thoroughly on the intestinal canal, use warm vaginal injections freely, and replace the uterus repeatedly. 3d. Do not rely upon vaginal support alone, but aid it by avoidance of all pressure from above, and by using an abdominal pad. 4th. Pessaries are of the greatest value in treating anteversion, but require much more skill, are attended by greater danger, and are more apt to need frequent alteration than Avhen used in posterior disi)lacements. There is no comparison in the relative amount of difficulty in applying this means to the two varieties of displacement. 5th. Never use an anteversion pessary which the patient cannot remove, unless she keep within reach of your aid ; always examine frequently to see if injury is being done to the vaginal walls, and never let a patient wearing one pass entirely out of observation. 6th. If no sufficient pouch exist anterior to the cervix for the accommo- dation of an internal pessary, create one by use of the external bulb pessary. At the same time that I speak so strongly of the difficulties surrounding the treatment of these cases, and so repeatedly point out the dangers attending it, I must make this statement for those who have been dis- 426 ANTERIOR DISPLACEMENTS OF THE UTERUS. couraged by repeated failures : were I asked from the treatment of what class of uterine diseases I experienced the greatest satisfaction, and felt that I had accomplished most good for my patients, I should unhesitatingly reply — anterior displacements of the uterus. In many cases of this variety of displacement, a great deaf of relief may be obtained from merely lifting up the displaced organ in the pelvis without rectifying, the anterior displacement, and for one who is not familiar with the use of anteversion pessaries, or has not at his command facilities for procuring good instruments, I really think that this, in the commencement of treatment, if not throughout its entire course, is the safer and better plan. Lifting the uterus may be accomplished by the ordinary ring pessary or Gariel's air pessary, and the simultaneous use of the abdominal pad of wood or cork. If the pad be used alone, and when the fundus uteri is behind the symphysis pubis, no good will result from it ; but if the uterus be lifted so that the fundus becomes amenable to direct pi'essure, the benefit felt will be often very great. As I have elsewhere stated, furnishing support to a uterus anteriorly displaced is much more difficult than to one which inclines posteriorly. As there are, therefore, men who to-day doubt the efficacy of support for the latter forms of displacement, there must be many more who entirely oppose that for the former. To both classes of objectors I would say, with a confidence resulting from a large daily experience, that the hostility to mechanical support in both varieties of displacement arises partly from prejudice and partly from want of skill on the part of the practitioner, who charges to the mechanical process shortcomings which really lie at his own door. On more than one occasion I have heard the most unmeasured denun- ciations against anteflexion pessaries u[)on the part of men who I found had been persistently using them upside down. Failing to give relief by instruments thus used, the illogical experimenters have been too willing to attribute to a method what was really due to an ignorant abuse of it. In certain cases of anteflexion, notably those requring the energetic means recently mentioned for their reduction, pessaries resting in the vagina fail to accomplish the required purpose, and the use of more power- ful means of support are resorted to. Recognizing our poverty of resources in such cases M. Velpeau,' be- tween thirty and forty years ago, conceived the very plausible idea of restoring the uterine axis to its normal direction, by introducing a stem to the fundus, and retaining it there. After experiment he abandoned it, and subsequently Amussat followed in his steps, both in essaying and cast- ing it aside. In 1848, Prof. Simpson again brought it into notice in versions and flexions, and met with a warm ally in M. Valleix, of Paris. • Discussion in Acad, de Mud., reported in Charleston Med. Journ. 1853. PESSARIES. 427 The instrument known as the intra-uteVine or stem pessaiy, unquestion- ably counteracts directly and immediately all flexions of the uterus. But it was found to cause peritonitis and death in a number of instances, and in consequence it was, for a time, almost entirely abandoned. So de- cidedly did experience appear to weigh against it that it became difficult to ex[)lain the encomiums once showered upon it by its advocates, and the remarkable cures reported from its use. Nonat declared that, carried away by enthusiasm, " ils se sont laisses aller trop facilement sur le terrain glissant des illusions." Nevertheless, the method was never entirely cast a?ide, for none could hesitate to indorse the sentiment expressed by Mal- gaigne, in the discussion upon the«subject in the Academy of Medicine in Paris, in 1852, that, " a treatment which Amussat, Velpeau, Simpson, Huguier, and Valleix had tried, cannot, should not, be considered as repugnant to common sense." During the last ten years there has been evidenced, however, a gi'owing inclination to return to this plan, and the last five have brought forth a number of reports favorable to it. At a medical convention held in Innsbruch, Germany, in September, 1869, this subject received some attention. Spaeth, of Vienna, expressed his belief in the disadvantages of the intrauterine treatment of flexions, ahhough he has found in some cases a total insensibility and an absence of reaction from the wearing of intrauterine instruments. Hugenberger, of St. Petersburg, advocated the use of Simpson's pessary in flexions, and declared his experience to be, that it was not only tolerated, but did great good whep properly applied and retained for a sufficiently long time. More recently. Prof. Schultze, of Jena, advised the use of the intraute- rine stem in certain obstinate cases, but, in a review of his publication, by Dr. Munde, in the American Journal of Obstetrics, it evidently appears that he does so with caution and reserve. Prof. Olshausen, of Halle, likewise published his experience with the method. Of its character the reader can judge for himself, for the pro- fessor gives accurate data. Out of 297 cases of versions and flexions, 81 were treated by the stem and ') were so treated for other conditions than displacement. Periuterine inflammation resulted in 7 cases ; treatment was stopped on account of hemorrhage or pain 10 times; the stem could not be kept in place 3 times. Of 66 cases in which they did well, in 15 the results appeared to be permanent; in IS improvement was great and lasted a long time ; and in 17" doubtful [jermanent results were obtained." In 11 sterility was cured. The stems were worn for periods varying from a i'ew weeks to 22L months. Drs. Savage and Chambers have both reported very favorably upon this plan in the Obstetrical Journal of Great Britain and Ireland, to which the reader is referred for their interestino; articles. I would likewise refer to 428 ANTERIOR DISPLACEMENTS OF THE UTERUS. excellent essays by Dr. Routh\ of London, and Dr. Van De Warker,^ of Syracuse. Before tlie use of this method careful examination should be made as to the previous existence of periuterine inflammation. If any be found existing the uterine stem sliould be avoided. A great variety of instruments have been employed for keeping the stem in place. Some are complicated, others stiff and unyielding, while most are not susceptible of removal by the patient, and are therefore wanting in the main element of safety. I would recommend the instru- ment which I employ for this purpose as not subject to any of these objec- tions. It consists of two parts, a stem of solid glass, two to two and a half inches long, and ending below in a round bulb as represented in F'ig. 169. This being introduced into the uterus, it is supported by the ante- flexion pessary shown in Fig. 169, or, if difficulty be found in using this^ by an ordinary Hodge pessary, between the branches of which a cup has been placed, as shown in Fig. 197, or by a disk of vulcanite shaped like the Hodge or Smith pessary, as shown in Fig. 170. Fig. 169. Fig. 170. Anteflexion pessary supporting intra-uterine stem. Glass stem suppovteil by disc pessary. The stem ending in a round bulb rests upon the surface of the pessary, and changes position with every movement of the uterus. It must be re- membered that it is not used for anteversion but for anteflexion, and that stability of the base of the stem is not desirable. Just above the shoulder a small hole may be made through the stem through which a silk thread is passed wdiich hangs from the vulva. Upon the first evidence of trouble the patient draws out the loosely fitting pessary, then making traction upon the thread removes the stem. Before introduction of the stem, the cervix, if found to be too contracted for it to pass, should be dilated by one or more tents, whicli for the time straighten the uterus and dilate the cervical canal. After introduction the patient should be kept in bed for three or four days, and, upon leaving it, snould be careful in her movements for a week or two. She should be London Obstet. Trans. 2 Amer. Gynecolog. Trans. TREATMENT. 429 directed to remove the tent upon the occurrence of pain, chilliness, or feel- ing of general languor or discomfort. Even the most ardent advocates of stem pessaries will admit the propriety of these jjrecautions, and even tlieir bitterest opponents must allow that with them as a safeguard, in certain cases they should be resorted to. To cast them entirely aside when such high authority recommends them, would be irrational and unjustifiable. To use them freely in the face of such evidence as we possess would be reckless and unwarrantable. It requires skill in introducing the pessary after introduction of the stem before the latter falls from its place. A Sims's speculum is a sine qua non ; the stem should be held in place by Sims's depressor, and the pessary be slid into place upon this. In this way the manoeuvre is easy. I am opposed to the exhibition of instruments which I have not myself fully tried, but the stem pessary of Dr. H. F. Campbell impresses me so favorably that I depart from my rule and present it here. Fig. 171. Canijibeirs soft-rubber spriog-stem pessary. A. The soft-rubber stem and sprinij jn-epared for iutroductiou B. Shows the spriug separately. C The rubber cap or hood. It will be seen that this consists of a soft-rubber tube and watch-spring. It is introduced bent upon itself by means of a sound, and this being with- drawn it straightens itself under the influence of the protected spring. But in a certain number of cases even the intra-uterine stem fails. Then the gynecological surgeon, following the example of the general surgeon, gives up striving after an end unattainable by minor means, and resorts to tlie knife for relief. Should the patient not tolerate the intra-uterine pessary with comfort, should the flexion not yield to the treatment by it, or should the practi- tioner prefer to adopt operative procedures, an operation devised by Sims is at. his disposal not intended to cure the displacement, but to remedy its resulting cervical obstruction, leaving the disorder of position unchanged. Operation for Irreducible Cervical, Corporeal, or Cervico-Corporeal Flexion — If a piece of stiff tubing be bent, the calibre of its canal will be obliterated at the point of flexure in proportion to the acuteness of the angle created. In the same manner is the uterine canal affected by the lesion under consideration. The obstruction created in this way prevents the free escape of menstrual blood, which distends the cavity of the uterus and forms clots within it, and these at each menstrual period are expelled 430 ANTERIOR DISPLACEMENTS OF THE UTERUS. by uterine tenesmus. In consequence of tbis, inflammation of the mucous lining of the uterus arises, that in time may [)roduce areolar hyperplasia, which favors further displacement by the inci-ease of uterine weight attend- ing it. The effort required for expelling clotted menstrual blood creates painful menstruation, and the same obstruction which retards egress of fluids interferes with ingress and prevents conception. Having been forced to accept the displacement as an irremediable evil, we now endeavor to strike at one of the sources of the pathological series which residts from it by overcoming obstruction at the point of flexure ; in other words, by substituting a sti'aight for a crooked canal. This can be accomplished by cutting through one ^""■- l''^^* wall of the cervix. Having thus over- ^-''' ~"""~^ come cervical obstruction and consequent /'' \ accumulation of fluids in utero, do we at / \ / u \ the same time remove the tendency to i' \\ \ mechanical congestion of the body of the \ \\ \ uterus ? Not entirely, but if we secure \^ \\ \ the results of cervical section as we may X^ \\ \ ordinarily do by subsequent use of tlie ^x^ \ \ ' intra-uterine stem, we accomplish to a '\ \\ I certain extent both results. \ \\ / If the posterior uterine wall, bent for- ,, '' \\ ^ / ward as shown by the line c h, Fig. 172, (' ^/''^^^^^^\ ^" ^ '^^^^^ *-*'^ anteflexion, be cut towards ^"---^^;^!^-'^^ ^V'{ the vaginal junction so that a probe will / ^,-'''' \\ pass into the uterus in, the direction of "-— '' \ \ the line a d, the obstruction resulting \ \ from the existence of an angle will be "^ removed, and thus fluids would have Iree Schematic diagram, showing the area- . „ . ^ c . tionof neNY uterine axis. « 6 represents entrance ami exit, for instead ot turning the axis of the body; i c represents the {jjy an Cyc. Anat. and Phys., Sup., p. 631. ^ Becquerel, p. 441, vol. i. 3 Aran, Mai. de I'Uterus, p. 675. 478 . PERIUTERINE CELLULITIS. guinis is efFiised, which creates hardness and tension, and lastly suppuration occurs, and ends the morbid process, unless one of two other terminations takes place. Resolution may occur, or, in place of suppuration, the areolar tissue involved may be destroyed, as it so generally is in anthrax and phlegmonous erysipelas, and come forth as a sloughing mass. The term phlegmon, now almost obsolete with us, but still in use on the continent of Europe, signifying inflammation of areolar tissue, is strictly applicable to this affection. Its source is similar to that of areolar inflam- mations in other parts of the body, and its three stages are identical with theirs. The most common seat of periuterine cellulitis is the areolar tissue of the broad ligaments, and generally that of one side only is affected. In a certain number of cases where no affection of the areolar tissue of the broad ligaments exists, circumscribed tumors, in immediate contact with the womb, have long been noticed. Lisfranc supposed them to be due to partial parenchymatous metritis, " engorgements," which had resulted in enlargements of one part of the organ ; and no one contradicted him until M. Nonat,^ about the year 1849, described them as being due to phlegmonous inflammation in the areolar tissue immediately around the uterus, i. e., between the cervix and rectum, the cervix and bladder, and immediately by the side of the neck. The existence of this variety of cellulitis has been denied by M. Beruutz, who sustains his position by abundant argument. In reference to it, I will merely say here, that there are, so far as my knowledge extends, only two cases of such limited cellu- litis substantiated by autopsic evidence, one reported by M. Demarquay,^ the other by M. Simon.^ Nevertheless, judging from clinical observation, one is inclined to side with the view of Nonat rather than with that of Bernutz. There are many cases in which abscesses in the broad liga- ments point and discharge anteriorly or posteriorly to the cervix, but these come within a different category. The broad ligaments and their entire contents, cellular tissue, ovaries, and Fallopian tubes, are more fre- quently affected than any other parts, and M. Aran goes so far as to say that the collections of pus occurring in periuterine cellulitis " belong more particularly to the ovaries and tubes." In post-mortem examinations these parts are often found imbedded in a mass of effused material, the ovaries, one or both, in a state of suppuration, and the tubes inflamed and filled with pus, or constricted at both uterine and ovarian extremities and dilated by sero-purulent material so as to constitute tubal dropsy. I have examined the post-mortem reports of cases by a number of authorities with reference to this jwint, and, rejecting only those in which the exami- nation was made in too careless a manner to allow of their admission, I present them in the following table : — • Op. cit., p. 237. 2 Gazette des Hdpitaux, April 17, 1858. 3 Bull, de la Sac. Anat. de Paris. COMPLICATIONS, 479 2. M. Nonat. 3. M. Nonat. 4. M. Nonat. 5. 6. Dr. West. Dr. West. 7. 8. 9. Dr. West. Dr. McClintock. M. Demarquay. 10. M. Simon. No. of Case. Authority. Seat of Purulent Collection. 1. M. Nonat. Behind the uterus connecting with suppurating cyst in left ovary ; small abscess in right ovary. Behind uterus and rectum extending into broad ligaments of both sides. On left side extending from uterus to ilium. Behind uterus and vagina extending into left broad ligament ; another the size of a hen's egg just behind the uterus, opening into a third, very large, extending to sigmoid flex- ure and into broad ligament. Left broad ligament. Opposite right sacro-iliac synchondrosis under psoas muscle, another to the left of and behind the rectum. Left broad ligament. Left broad ligament. In cellular tissue between uterus and rectum and also in recto-uterine pouch of peritoneum. Size of a small orange, between the bladder and uterus, sending conoidal prolongation into left broad ligament. Its limits were as follows : base of bladder in front ; neck and body of uterus behind ; peritoneum above ; vagina below ; at the sides it ran off into the broad ligaments. Left broad ligament. Left ovary, right tube, with pelvic adhesions throughout. Size of an apple in left broad ligament. At side of uterus and in the left broad ligament. It will thus be seen that of this number, which is large when it is re- membered that the disease rarely ends in death, but two cases present instances of cellulitis, uncomplicated by disease of" the cellular tissue of the broad ligaments, ovaries, or tubes. One of these, Ihat of Simon, is conclusive of the possibility of such disease ; that of Demarquay is doubt- ful, for with the abscess in the cellular tissue, there was also one in the cul-de-sac of Douglas. The purulent collections in this disease may be results of morbid action in the cellular tissue, the ovaries, or the Fallopian tubes. In other words, with the disease known as cellulitis we often, indeed generally, have other affections, some of them, in the present state of our knowledge, not separable from it, which attend upon it as compli- cations. Complications The complications of periuterine cellulitis are — Pelvic peritonitis ; Ovaritis; 11. M. Aran. 12. M. Aran. 13. M. Bourdon, 14. M. Aran. 480 PERIUTERINE CELLULITIS. Fallopian salpingitis;^ Endometritis; Uterine displacement. The occurrence of these complications with cellulitis is so frequent that they may, at least the first three, almost be regarded as elements of it, when it exists in severity. They are, indeed, universally present where the tissue of the broad ligaments is seriously involved, as will be seen by reference to autopsic evidence contained in any of the works upon the subject. The fact of the frequent coexistence of endometritis should be especially noted, for great injury may be done by local treatment of it, under the supposition that it is the cause of symptoms which in reality are the results of cellulitis. Course, Duration, and Termination It is necessary that 1 should here inform the reader that the account which I shall give of this part of our subject will difier essentially from that generally found in systematic works, for the reason that, regarding pelvic cellulitis and pelvic peritonitis, which are usually treated of synonymously, as different affections, I shall attempt to describe them separately. Cellulitis proper, that is, uncompli- cated by other diseases, rarely passes into a chronic state, but usually in the course of two or three weeks passes off by resolution or ends in suppu- ration, the former being much the more frequent termination. Any one of its usual complications, however — peritonitis, endometritis, ovaritis, or salpingitis — may become chronic, and thus leave the impression upon the mind of the observer that the original affection has done so. Or one or more abscesses may discharge themselves by long sinuses which fail to allow of their complete evacuation, and may continue to, pour out pus for months or even years. In saying that cellulitis rarely becomes chronic, I look upon chronic pelvic abscess rather as one of its results than one of its stages. If the case be of acute character and occur as a sequel of partu- rition, suppuration may take place in a few days, but ordinarily, even under these circumstances, it does not occur for two or three weeks. In a chronic case the effused matter may remain hard, resisting, and ligneous for months without showing signs of softening, but such instances are ex- ceptions to the rule. After suppuration has occurred the disease may follow one of three courses : — 1st. The accumulated pus may discharge itself and the abscess gradu- ally dry up and disappear. 2d. The empty sac, lined by pyogenic membrane, may for an unlimited time go on pouring out pus. 3d. Small abscesses may form and discliarge in one part, then otliers may do so in another, until the whole pelvic areolar tissue is perforated by them and by fistulous tracts connecting them. ' a-a'K'^iy^, " a tube." PROGNOSIS — CAUSES. 481 There are various outlets for the imprisoned purulent accumulation : — 1st. Through the abdominal walls or saphenous openings ; 2d. Through the pelvic viscera, bladder, rectum, vagina, urethra, or uterus ; 3d. Through the floor of the pelvis near the anus ; 4th. Through the pelvic foramina, obturator, or sacro-ischiatic ; 5th. Through the pelvic roof into the peritoneal cavity. Sometimes the purulent collection burrows into the surrounding tissues and evacuates itself at a distance. In one case which I saw with Dr. Echeverria, it passed through the sciatic foramen, and, burrowing upwards and forwards, came forth near the great trochanter. It may thus take so eccentric a course as to mislead the practitioner as to the seat of the abscess. The most frequent channels of evacuation are tlie vagina and rectum, in the non-puerperal form, and probably the abdominal walls in the puer- peral, or at least the results of Dr. McClintock's* carefully noted cases would lead us to believe so. In 37 puerperal cases treated by him which ended in suppuration, 20 abscesses discharged in the iliac reo^ions, 2 above the pubes, 1 in the inguinal region, and 1 beside the anus. Of the remaining ]3, 6 were discharged per vaginam, 5 per annm, and 2 burst into the bladder. In the non-puerperal variety it is extremely rare for the abscess to discharge externally, and fortunately in both forms it is rare for it to burst into the perineum. Prognosis — A guarded prognosis should always be made as to the time of recovery, lor no amount of experience can foresee the course of the affection; whether the effused liquor sanguinis will disappear by absorp- tion in three weeks ; whether the discharge of one abscess will end the {)atient's suffering ; or whether a chronic induration will exist for a great length of time. But fortunately it may be stated, that the prospects as to life are decidedly favorable, though in cases occurring just after parturi- tion, there is always some danger from general peritonitis. Causes — The disease usually occurs as a result of one of the following causes : — Parturition or abortion ; Inflammation of uterus or ovaries ; Direct injury from coition, caustics, pessaries, operations, or blows. Parturition or abortion produces, according to statistics, from one-half to two-thirds of all the cases. Even this large proportion I believe to fall short of the truth, from the fact that those collecting the statistics from which the deductions were drawn made no distinction between this disease and pelvic peritonitis. Cellulitis will very rarely be met with, except after the parturient process. It is true that, when the puerperal state ' Op. cit. 31 482 PERIUTERINE CELLULITIS. exists as a predisposing cause, exposure to cold, fatigue, over-exertion, etc., will excite it ; but under these circumstances they are merely imme- diate and exciting influences. Inflammation of the Ovaries or Uterus. It is rare to meet with the affection in a non-puerperal patient, as the result of exposure, unless she be suffering from disease of these organs. Aran believes disease in the ovaries to be "almost always the cause." It is certain that these organs are generally diseased where the affection exists, but it is difficult to de- termine whether as a complication, or as the first link in the chain. In the histories of fourteen autopsies which I have collected, the state of the ovaries is mentioned in ten. Out of these they were affected by inflam- mation in seven. In some of the seven cases, abscesses existed ; in others their tissue was in part destroyed, and in others they had entirely disap- peared. Any chronic or acute disease of either the uterine parencliyuia or mucous lining, may also result in it, and I have more than once seen it follow applications of mild character to the cavity of the uterus. Direct injury is by no means a rare cause in non-puerperal cases, though it generally proves active in those suffering from previous uterine or ovarian disorders. Thus it may follow operations upon the neck or body of the uterus, slitting the neck for flexion or contraction, for example, or simple dilatation by a tent. It may result from efforts at removal of intra-uterine growths, and one fatal case that I have met followed the ligation of haemor- rhoids. The important fact, that this disease is usually not an idiopathic affec- tion, but one symptomatic of uterine or ovarian inflammation, has been especially insisted on by Dr. Matthews Duncan, who- first drew attention to it as early as 1853. Symptoms — The acute form, and more especially that occurring after parturition, is usually ushered in by very decided symptoms, of which the most constant are the following : — Chill ; Increased thermometric range ; Pain ; Fever ; Dysuria; Metrorrhagia. The chill, though sometimes absent, is a very general symptom. No sooner does it pass off than the pulse rises to 110 or 120, increased heat is felt in the hypogastric region, and pain, which for a number of hours or perhaps days before was just perceptible, comes on with considerable violence. The thermometer shows marked increase of animal heat, the mercury rising to 103° or 104°, and, in severe cases, even higher. With these general symptoms there will be others pointing to the rectum and bladder, and should the affection exist in a menstruating woman the flow PHYSICAL SIGNS. 483 may be much increased. Even when the patient is not menstruating, uterine hemorrhage sometimes, though not frequently, comes on. But he who awaits these symptoms for diagnosis will be led into many errors of omission, for subacute cases very generally, and acute cases sometimes, fully develop themselves without them. All cases may be brought under three heads as to severity of symp- toms : — 1st. Cases accompanied by chill, fever, pain, and ordinary signs of inflammation ; 2d. Those accompanied by pain without chill or fever; 3d. Those marked by scarcely any symptoms except extreme feeble- ness and some sense of pulsation and weight about the pelvis, with hectic fever towards evening. Cases which have assumed the chronic form will present themselves witli such a history as this : a patient who was delivered one, two, or three months ago has not recovered her strength, but is very feeble, has no appetite, and feels nervous, depressed, and feverish towards evening. She has no absolute pains, but fears that something is wrong about the womb, for now and then she feels a sensation of throbbing, tension, and weight about that organ, which is increased by defecation, urination, and walking. This prompts to physical exploration, which establishes the diagnosis. Physical Signs Physical exploration is the means on which we must rely for a rapid and certain determination of the character of these cases. Should the finger be introduced into the vagina during the first stage, the parts will be found to be very warm, and perhaps a swollen and oedema- tous spot may be detected. Upon pressing in different directions great sensitiveness will be observed, and by conjoined manipulation a particu- larly sensitive point will be detected, usually on one side of the uterus. As the second stage, or stage of effusion, advances, induration occurs in the areolar tissue affected, and then, by careful vaginal touch combined with external manipulation, a tumor as large as a walnut, a goose's egg, or an orange, may be detected in one of the broad ligaments, or in the tissue around the cervix. But the examiner must not suppose that the mere introduction of the finger into the vagina will accomplish a discovery which often requires the greatest care and most thoughtful attention in examination. The finger being passed up to the cervix, and the other hand placed upon the hypogastrium so as to make counter-pressure, it should be carefully pressed against Douglas's cul-de-sac and all around the cervix over the base of the bladder and as far as possible towards the fundus. Then it should be made in a similarly careful manner to traverse the sides of the pelvis where tne broad ligaments are placed, and last of all, those parts below the pelvic roof. For one sufficiently practised in this kind of examination 484 PERIUTERINE CELLULITIS. this procedure will generally be sufficient to determine the existence of even a very small point of induration on the sides or in front of the uterus. Sometimes, where it is posterior to that organ, a rectal exploration will throw much additional light upon the case. Should the disease have advanced to its third stage, in addition to the signs already noted, the uterus, which, as already mentioned, is generally displaced, is now pushed from its normal position, in a direction opposite to the accumulated pus. Sometimes it lies upon the floor of the pelvis, at others it is in a state of anteversion, retroversion, or lateroversion, and, more rarely, sharply flexed, the body having remained movable after the cervix has become flxed. Into whatever malposition it has been forced it remains to a certain extent immovable, from fixation by adhesive lymph. But this fixation is by no means so complete, so universal, as in pelvic peritonitis. I feel satisfied that I have seen two unquestionable cases in which no fixation of the uterus existed at all. This, however, is very rare. Nonat has even gone so far as to declare that the phlegmonous mass itself may be movable, and Dr. Duncan reports one case which appears to vei'ify this statement. I have never seen an instance in which this mass was not firmly fixed. Differentiation — The diseases with which it may be confounded are — Fibrous tumors ; Hematocele ; Pelvic peritonitis ; Early pregnancy. Fibrous tumors are painless, free from tenderness, and movable in the pelvis. They are unaccompanied by chill, fever, and other signs of inflammation, and are closely attached to the uterus, so as to form part of it. The tumors resulting from cellulitis are the contrary of all this, and appear firmly attached, like bony growths, to the walls of the pelvis. Hematocele occurs suddenly with uterine hemorrhage, and is marked by prostration, coldness, and other symptoms of loss of blood. The tumor created is soft in the beginning and grows hard ; that of cellulitis is hard in the beginning and tends to softening. Pelvic peritonitis shows the ordinary signs of peritoneal inflammation, great tendency to relapse at menstrual periods, excessive pain and tender- ness, and produces no distinct tumor in the beginning, but hardening of the whole pelvic roof. Later, a small tumor may be discovered, but it is usually posterior to the uterus and not on one side of it. The uterus is less movable than in cellulitis, and when the body is fixed the cervix sometimes moves under pressure. Dr. Geo. Engelman* has drawn attention to a rare class of cases in which early pregnancy simulates this disorder very closely. ' St. Louis Med. and Sui-lt. .lournaL TREATMENT. 485 Consequences of Cellulitis. — The remote results of tliis affection arc po grave, that even if there were no dangers immediately connected with it, they would stamp its occurrence as a great disaster. The ovaries are at times destroyed by supi)urative action; at others they undergo an atrophy, the result of inflammation, and the Fallopian tubes are often left imper- vious. The uterus is often permanently displaced in consequence of strong adhesions which bind it in a bad position. From this results the fact that, although the disease be cured, the patient is often left incapaci- cated for some of the most important physiological functions. Sterility, amenorrhoea, dysmenorrhoea, menorrhagia, tubal dropsy,' and displace- ment may remain to attest the gravity of the original disease, and continue for an unlimited time a source of sufiering for the patient and discourage- ment for the physician. Treatment Should the practitioner be called in the acute stage of cel- lulitis, the patient sliould be at once completely quieted by opium. If pain be violent, the hypodermic method should be employed in its admin- istration; if not, it should be given by mouth or rectum. This drug throughout the acute stage of the affection should be steadily kept u\). It accomplishes these results: it relieves pain, diminishes the severity of the inflammatory process, keeps the bowels constipated, produces sleep, and creates general nervous quietude. If when first seen the patient be suffer- ing very severely, ten dro[)S of Magendie's solution of morphia may be injected by the hypodermic syringe into the cellular tissue of the arm. Absolute rest should be enjoined, the patient not being allowed to sit up in bed for a moment, u|)on any pretext whatever. Were I limited to one remedial resource in this affection, I sliould choose rest in j)reference to all otliers, but to accomplish anything it must be absolutely enforced. The diet of the patient should be mild and unstimulating, consisting of milk with farinaceous substances, and tea or coffee. If the case be seen very early, before the stage of eflTusion has occurred, a bladder of crushed ice should be laid over the hypogastrium in the hope of arresting the advance of the disease. But if the disease has advanced beyond the point where this seems possible, warm poultices of powdered linseed should be applied every third or fourth hour over the hypogastrium, the bowels be kept constipated, and febrile action, sliould it exist, be quieted by refrigerants and direct sedatives, as tincture of veiatrum viride, tinc- ture of aconite, or tincture of gelseminum. As soon as the acute symptoms have passed, and vaginal touch informs us that the effused material is becoming thoroughly organized, a furtiier effort should be made to break up the morbid train before it passes on to suppuration or into chronic induration, by the application of a blister, six by eight inches, over the hypogastrium. This sliould not be applied be- * Aran, op. cit., p. 638. 486 PERIUTERINE CELLULITIS. fore febrile action and the most acute symptoms have disappeared. Some excellent authorities, among others Sir James Simpson, object to blistering for fear of strangury resulting. I have never had to do otherwise than congratulate myself on its employment. Should the case tend to an acute course, and suppuration be impending, this should be encouraged by con- stant poulticing. As soon as the acuteness of the attack has passed, until which time attention should be turned to quieting the general symptoms of inflamma- tion, it is advised by the best authorities that the iodide or bromide of potassium should be administered, the former in five-grain doses repeated every third or fourth hour, or the latter in doses of ten, fifteen, or even twenty grains, at the same intervals. At the same time that I am not prepared to deny the utility of these drugs, I confess that I have never been able to persuade myself that they really accomplish any good result. There is no more certain method of disgorging the veins of the pelvis and lower bowel than by acting upon the liver, which governs the outlet of the portal system, with which they are connected, and this can most readily be done by mercurial cathartics. Thus occasionally used, the mercurials prove of great benefit in relieving congestion, which is a lead- ing element of the disease. But in doing this we are not developing the specific action of these medicines, wliich here act as a subordinate, and not the chief element of treatment. The production of ptyalism should be avoided, since it is by no means certain that it is of any benefit, and by impoverishing the blood at the commencement of what may become an exhausting disease it may do absolute injury. As the acuteness of the affection subsides the bowels should be kept free by laxative medicines, and the occasional use of a mercurial in this ca[)acity is indicated. It may be necessary to repeat the application of the blister before the case ends in suppuration or passes into the chronic stage. While the patient remains in bed, warm poultices, or towels wrung out of warm water and covered by oil silk, should be worn over the hypogas- trium. An additional emollient remedy of great value is the persevering use of the warm douche for fifteen or twenty minutes, night and morning, after Emmet's method, already described. The fluid used should be as warm as the patient can bear it, and may be slightly medicated in the later stages by the addition of chloride of sodium, tincture of iodine, or iodide of potassium. The injections stimulate the absorbents, and, at the same time, quiet inflammatory action, in the performance of which func- tions they are invaluable in these cases. As the third stage of the disease, or the stage of suppuration, merges into pelvic abscess, it will be best to postpone the consideration of its management to the chapter in which that subject is treated. I will merely state here that after an abscess has formed and evacuated itself, great care PELVIC PERITONITIS. 487 should be taken not to allow the patient to exert herself for several weeks, for fear of a relapse, and even after she has left the house and begun to exercise regularly, during two or three menstrual periods she should con- fine herself to bed. CHAPTER XXXI. PELVIC PERITONITIS. Definition Inflammation involving the peritoneum covering the female pelvic viscera, and limited to it, receives the name of pelvic peritonitis. It must not be supposed that by this definition is meant simply that form of peritoneal inflammation arising in the pelvis and spreading into general peritonitis, which has long been described as metro-peritonitis. The disease that we are now considering is one usually strictly limited to the pelvis, presenting symptoms peculiar to itself, and rarely passing into the general form of the same disorder. History Long before pelvic cellulitis was known, peritonitis, limited to the serous covering of the pelvic organs, had attracted attention, and its clinical resemblance to cellulitis, as subsequently described, fully noted. Thus Morgagni^ relates a case in which, thirty days after delivery, the right ovary and tube were adherent to the colon and almost destroyed by an abscess. Nauche, in his work on Diseases of the Uterus, published at Paris in 1816, described inflammation of the uterus as aftecting, first, the mucous membrane ; second, the parenchyma; and, third, the serous cover- ing. In 1828, Mad. Boivin credited the adhesions resulting from this affection and binding the uterus down with a large number of abortions attributed to other causes; and, in 1833, she described immobility of tiie uterus, for which she gave as causes, peritonitis, metro-peritonitis, and pelvic abscess. In 1839, GrisoUe* distinctly stated, that " there are cases of circumscribed peritonitis which, producing a tumor appreciable to sight and to touch, may lead to the belief in the existence of plilegmon," ^. e., a tumor the result of inflammation of areolar tissue. Lisfranc,^ writing ten years after Boivin and Duges, copies their description very closely in his article on " Fixite de la Matrice," without referring to them, and like them attributes it to peritonitis or metro-peritonitis. Although these facts were known and universally admitted, they • Artie. 22, epist. 46. Nonat, op. cit., p. 234. 2 Bernutz and Goupil, op. cit., p. 398. 8 Clin. Med., vol. iii. p. 514. 488 PELVIC PERITONITIS, attracted little notice, and after the description of pelvic cellulitis by Doherty and Marchal de Calvi, pelvic peritonitis was almost entirely lost sight of. This was due to the fact that the enthusiasm created by the description of a long-forgotten affection caused observers to look upon the results of peritonitis as those of cellulitis, and to describe them as such. Thus the matter rested until 1857, when M. Bernutz, in a treatise written in concert with M. Goupil, not only drew especial notice to it, but took the position that inflammation of the cellular tissue immediately around the uterus, described by Nonat as " phlegmon periuterin," or what would strictly be termed, in our nomenclature, " periuterine cellulitis," did not exist as a pathological reality, but that the lesions ascribed to it were absolutely due to pelvic peritonitis. These views, published at first in the " Archiv. Gen. de Med.,"* are fully elaborated in the admirable work^ of these observers more recently brought forth. They do not touch the general subject of periuterine cellu- litis as it exists in the broad ligaments, subperitoneal tissue, and around the rectum, but only that variety supposed to have its seat in the areolar tissue between the uterus and peritoneum. It has been already stated that M. Bernutz was incited to his investi- gations by certain views advanced by M. Nonat as to the pathology of periuterine induration, which sometimes goes on to suppuration. But his researches served not merely to settle this comparatively unimportant point, they proved the fact, for which the investigator appears to have been himself entirely unprepared in the beginning, that many of those cases regarded as instances of non-puerperal cellulitis are in reality not phlegmonous but peritoneal inflammations. Since the publication of these views I have directed my attention particularly to this point, and from careful observation, both clinical and post-mortem, feel warranted in recording the conclusions at which I have arrived in the following propo- sitions : — 1st. Periuterine cellulitis is rare in the non-parous woman, while pelvic peritonitis is exceedingly common ; 2d. A very large proportion of the cases now regarded as instances of cellulitis are really those of pelvic peritonitis ; 3d, The two affections are entirely distinct from each other, and should not be confounded simply because they often complicate each other. They may be compared to serous and parenchymatous inflammation of the lungs, — pleurisy and pneumonia. Like them they are separate and distinct, like them affect different kinds of structure, and like them generally com- plicate each other. 4th. They may usually be differentiated from each other, and a neglect » Arcliiv. Gen., 1857. ^ Clin. Med. des Femmes, 1862. HISTORY. 489 of the effort at such thorough, diagnosis is as reprehensible as a similar want ol' care in determining between pericarditis and endocarditis. M. Bernutz cites the results of five autopsies^ by himself, and between twenty and thirty by others which presented all the signs of pelvic perito- nitis and none of cellulitis, although during life the symptoms and signs generally attributed to the latter disease were present. As an example conveying some idea of the close clinical resemblance between his cases found in autopsy to be peritonitis and those ordinarily regarded as cellulitis, I quote the salient points in his sixth observation. Patient 33, lymphatic temperament, entered hospital November 24th for feebleness, pain in the back, emaciation, and dysmenorrhoen. After a while loss of appetite, increase of pain, and chills appeared. By touch the uterus was found completely fixed, low down in the pelvis and inclined to the right side, and attached to it a very sensitive tumor the size of a hen's egg, extending behind the womb. On the loth of December this tumor was as large as a turkey's egg. February 1st : tumor only the size of a pigeon's egg ; a circumscribed tumor on the left attached to uterus and to the walls of the pelvis. Marcli 23d, uterus movable and tumor reduced to the size of a little nut. April 4th, she died; and autopsy showed tubercular pelvic peritonitis, evidenced by tubercular deposit, lymph, pus, fii'm old adhesions, ovaries imbedded in false membrane and nearly de- stroyed. I had often been struck by the great similarity between peritonitis and many of the cases of what, until enlightened by M. Bernutz, I had re- garded as cellulitis, and by the fact that they occasionally ran into general peritonitis without any apparent emptying of purulent collections into the peritoneal sac, but I never had an opportunity of examining such a case post mortem until the following presented itself: — Mrs. M., aged 35, married, but never pregnant, had been under my care, during the winter, at the Woman's Hospital, for anteflexion of the uterus, the result, as I supposed, of periuterine cellulitis. August 6th, I was called to see her in consultation with Dr. Roth, her family physician, and found her suflfering from severe pelvic pain, constant vomiting, and fever. Upon vaginal touch I found the uterus immovably fixed and the pelvic roof as hard as a board. The pelvic tissue was everywhere hard and resisting, and the physical signs of what I had habitually styled cellulitis were present. About a week afterwards the patient died suddenly and unexpectedly, and I made an autopsy in presence of Drs. Roth and J. C. Smith. No general peritonitis existed ; the left ovary presented a sac the size of a hen's egg, filled with pus ; the pelvic peritoneum was intensely inflamed and the uterus bound down by old false membranes, bands of ' I have rejected a number of the cases reported, because not sufficiently con- clusive. 490 PELVIC PERITONITIS. which matted all the parts together. The vermiform appendage Avas bound to the right ovary and the caput coli lay just below the uterus. No trace of inflammation could be discovered in the pelvic cellular tissue except, of course, that in immediate contact with the ovary. The fixation of the uterus, observed during life, was due to lymph effused upon the pelvic peritoneum, and no trace of inflammatory action in the pelvic areolar tissue could be discovered as accounting for it. It is true that the left ovary, enveloped by the layers of the broad ligament, was inflamed, and that a certain amount of inflammation existed in the cellu- lar tissue immediately surrounding it, but this did not extend. Frequency. — A reference to the autopsic notes of cases of cellulitis, for example those recorded by West, Nonat, Aran, and McClintock, will give abundant evidence of the almost universal attendance of this complication upon it. But, even without the existence of that disease, Aran found it in greater or less degree in fifty-five per cent, of cadavers of women ex- amined in his service. This proves that peritonitis, limited to the pelvic viscera, is a common affection, and one which is very generally overlooked. It is probably to its occurrence that are due so many of those attacks of violent hypogastric pain occurring with menstruation, or just after it, accompanied by vomiting and slight febrile action, and which are generally treated by domestic remedies and viewed as cramps or uterine colic. Pathology The disease runs its course here, as peritoneal inflamma- tion does elsewhere, in three stages. In the first there are simple engorge- ment and turgescence of the vessels, producing redness, dryness, and pain. Fig. 208. The straight line represents approximately the roof of the pelvis ; the dotted line represents it more exactly. In the second stage an entirely different state of things will be found to exist, to comprehend which fully, the reader must bear in mind what is meant by the " roof of the pelvis." If a plane De passed backwards from CAUSES. 491 a point just under the pubic arch, through the cervix uteri at the attach- ment of the vagina, to the sacrum at the attachment of the utero-sacral ligaments, it will correctly represent this roof, which is thus formed by the vesico-vaginal septum, the lower extremity of the uterus, which projects, as it were, through a hole in the roof, the upper part of the fornix vaginte, and the utero-sacral ligaments. Above the plane, the organs of reproduc- tion float, as Nonat expresses it, " in an atmosphere of cellular tissue." Let the reader suppose that instead of this yielding, springy tissue, these organs were fixed in their places by having a fluid mixture of plaster of Paris poured around, among, and over them, which had afterwards be- come solid, and lie may form a correct idea of what vaginal exploration will yield to the sense of touch in the second stage. The roof of the pelvis is hard, ligneous, and as if composed of a " deal board," to which Prof. Doherty likens it. The uterus, which is generally much displaced, is immovable, and all its apjiendages appear fixed by some solid surround- ing element. This, the second, stage consists in a collection of plastic lymph on the surface of the peritoneum, and of serous, purulent, or sero-purulent fluid in its most dependent parts. In the third stage the fluid, if serous, is absorbed ; if purulent, dis- charged, and the exuded lymph undergoes organization and subsequently contraction. This binds the uterus, its appendages, and some of the intes- tines together in a mass, which yields all the physical signs of a tumor. Causes. — Its causes are the following : — Periuterine cellulitis ; Parturition or abortion ; Gonorrhoea ; Endometritis, ovaritis, or salpingitis ; Escape of fluids into the peritoneum; Traumatic influences ; Imprudence during menstruation ; Tuberculous or cancerous deposit ; Uterine displacement. Its frequent dependence on the first needs no further mention. As a result of parturition or abortion, it is so well known as to make the exhibition of proof here almost unnecessary. Reference may be made, however, to 53 autopsies by Aran,' in which, out of 38 women who had borne children, 24 presented evidences of its previous existence, while out of 15 who were nulliparous, only 5 did so. Gonorrhoea, by passing into the uterus and through the Fallopian tubes, is a fruitful source of the affection. According to M. Bernutz, 28 out of 99 of his casee Iiad this origin. I have seen a number of severe cases due • Op. cit., 718. 492 PELVIC PERITONITIS. to it, and the great importance attached to this cause by Noeggerath is elsewhere fully stated. It would be strange if ovaritis and endometritis did not, at times, cause pelvic peritonitis. That they frequently do so, is abundantly demonstrated by autopsies made after their existence both in the puerperal and non- puerperal states. Salpingitis causes it not only by the extension of inflammation along the mucous, into the serous membrane which is continuous with it, but by emptying its accumulated pus into the peritoneal cavity. Escape of fluid into the peritoneum is an undisputed cause of this, as of general peritonitis. I myself produced a well-marked case, which almost terminated fatally, by injecting a solution of [)ersulphate of iron into the uterine cavity. The passage of the fluid through the tubes could not be questioned, for agonizing pain came on in less than three minutes, and continued up to the development of inflammation. This danger has caused the almost entire abandonment of intra-uterine injections on the part of the majority of practitioners, unless the cervix be previously dilated by tents.. But many other sources from which fluid may enter the peritoneum exist ; as, for example, rupture of an ovarian cyst, discharge of tubal dropsy, or of a pelvic abscess, intra-peritoneal hemorrhage, regurgitation of obstructed menstrual blood, etc. Traumatic agencies, as blows, falls, injury during labor, punctures, etc., may result in partial, as they do in general, inflammation of the perito- neum. During the performance of menstruation, a physiological function which involves ovarian rupture and produces hemorrhage, which must pass to the uterus by a narrow tube not permanently in immediate contact with the ovary, any degree of exposure must evidently tend to inflammation in the investing peritoneum. Of M. Bernutz's 99 cases, 20 were thus pro- duced. Tubercles deposited in the part, either on the peritoneum or in the tissue of the tubes or uterus, may, as they do elsewhere, result in secondary inflammation ; and cancerous or cancroid degeneration would be still more likely to produce the same result. In certain peculiar states of the system this affection is excited by the most trivial circumstances, and very commonly the physician is held to a severe account for the fatal issue of an aflTection which he as little expected to arise from his interference as the friends of the patient did. I have seen it excited by the passage of the uterine sound, the use of a small sponge tent, and, in one case, from the passage of water, used by vaginal injection, into the uterus. Dr. Barnes, in his late excellent work on the "Diseases of Women," says, "I have seen fatal peritonitis fol'ow the simple application of nitrate of silver to the cervix uteri." It should be the duty of every physician to shield an unfortunate brother practitioner VARIETIES — SYMPTOMS. 493 by the protection which these facts legitimately afford hirn ; but it should equally be the duty of each to remember this paragraph, the whole of which is italicized in Dr. Savage's work upon the Female Sexual Organs — " No surgical proceeding whatever, touching any part of the uterine system, should be unattended by the [)recautions observed in operations of a grave character there or elsewhere ; in certain states of the general system, unforeshadowed by any recognizable peculiarity, the most trivial operation has been speedily followed by fatal peritonitis." Varieties This afliection may assume either an acute or chronic form, though when it constitutes the principal disease it generally, in the begin- ning, presents the features of the former. When it occurs as a complica- tion of tuberculosis or uterine disease, it often assumes from the beKinnino: the chronic type. Besides these varieties there are two others which can- not be passed without notice — menstrual pelvic peritonitis which becomes aggravated at periods of ovulation, and recurrent peritonitis which lasts for many years, giving, however, immunity for long periods, and then recurring with great violence from a trivial cause. I have had several such cases, one of which lasted ten and another eight years. For eight, ten, or twelve months these patients enjoy an almost absolute immunity from the disorder : then, excited by some apparently insigniticant cause, a severe and excessively painful attack comes on. Sometimes these attacks are complicated by cellulitis, and a purulent accumulation fre- quently discharges itself through the pelvis as a consequence of them. Symptoms — The acute form shows itself by — Pelvic pain and tenderness ; Sometimes great vesical irritation ; Usually increased thermometric range ; Nausea and vomiting ; Anxious facies ; Mental disturbance; Tympanites. When a severe acute attack sets in, it may cause either a chill, or a sensation of coldness so slight that the patient will not recall its occurrence unless her attention be especially directed to it ; or pain and fever may show themselves without this symptom. Pain is at times only moderate, but at others most severe. It may occur in paroxysms, which ci'eate the greatest agony and prostrate the patient by their severity. I have seen it amount to agony equal to that arising from the passage of a biliary calculus, causing the patient to roll in bed, seize the bedclothes in the teeth, and cry aloud most piteously. As a rule, it is not so violent as this. Pain may show itself quite early in the disease, or may be preceded for several days by pelvic uneasiness and weight. Tenderness over the whole hypogastrium accompanies it to such a de- 494 PELVIC PERITONITIS. gree, that even the weight of the bedclothes is intolerable, and the patient, to relieve it, lies upon the back with the legs flexed in order to relax the abdominal muscles. The pulse shows in slight cases very little, and in severe cases a con- siderable amount of febrile action. It is small and wiry, and increases in rapidity to 110 or 120 to the minute. The thermometric range is likewise variable. In the beginning of an attack, which may become a severe one, the range may be normal, or even below the normal standard. " Sub-normal temperatures are espe- cially common in peritonitis," says Wunderlich, "and always sus|)icions ; death may follow them closely. High and rising temperatures do not add, per se, arguments for an unfavorable termination, althougli adding another dangerous element to the ca;n," says he, "several cases of death where no puncture has been made — some of them very painful cases — when I had urged puncture and was overruled." As a rule he punctures per vaginam. Prof Brickell, of New Orleans, has recently taken strong ground in fiivor of the early evacuation of pelvic accumulations, and, as I especially desire to lay before the reader an unbiassed view of the present state of professional opinion upon this important subject, I give his conclusions in full :— "1. I have no doubt at all that there are two distinct forms of pelvic inflammation — serous and phlegmonous, or suppurative. An attack of 506 PELVIC ABSCESS. either may be abortive — tliat is, may fail to result in formation of pus or effusion of serum. But, should either pus or serum be deposited, then, 2. I am sure that evacuation is the proper practice; and, 3. Either should be evacuated 2)er vagmam. 4. The presence of pus in any portion of the body is not to be tolerated by the surgeon. I contend that the presence of effused serum in the ])e\- vis is not to be tolerated either. As long as it is present, in addition to the pain and prostration present, there is the abiding stimulus to repeated inflammations, and the pelvis can and will be ravaged. 5. Topical applications and internal remedies have no influence on pelvic and serous effusions, according to my observation." For my part, I feel very sure that this subject is one upon which no fixed rule can be given. The surgeon must weigh the dangers of opera- tion with those of delay, and decide by the indications presenting in each individual case. Were the determination of the existence and locality of purulent accumulation really as easy at the bedside as one might be led to regard it from the literature of the subject, I should strongly advocate a uniform resort to evacuation. But this not being by any means the case, I am induced to do otherwise. Nor must it be imagined that seek- ing for pus hidden away in the pelvic areolar tissue is an entirely safe procedure. The following fatal case, due in all probability to an entrance of air into the veins, will prove interesting in this connection: — " In the case reported,' aspiration some three months before, for the removal of a quantity of pus from the pelvis, had been followed by much relief. The symptoms having returned, the needle was again introduced through the vagina to the left of the uterus, a distance of three-fourths of an inch. As soon as the pumping was commenced the patient manifested pain, became convulsed, and grew purple. Congestion of all the superfi- cial veins followed, though the needle was immediately withdrawn as soon as the symptoms began, when no more than four or five strokes had been made. In three minutes the patient was comatose, and in ten minutes the heart ceased to pulsate. "The autopsy revealed a small punctured wound on the left side of the vagina, one and a half inches before its juncture with the uterus. The probe passed upward and to the lett three-fourths of an inch in the direc- tion of a soft tumor in the uterus. Around the track followed by the probe was no more than a teaspoonful of clotted blood. A close network of small veins was traversed by the puncture just outside of the vagina, but after the most diligent search it was seen that no important bloodvessel had been touched. The areolar tissue about the uterus contained air. The left lung was much congested. The right chambers of the heart were filled with air, and contained no blood. The left chambers were ' Boston Med. and Surg. Jouru., vol. uii. No. 17. TREATMENT. 507 empty. The valves were normal. The veins of the stomach were dis- tended with air, presenting tlie appearance of pale round worms." The Best Point for Evacuation To whatever surface the point of the abscess is nearest, that will, as a general rule, be the best for its evacua- tion. If there be a choice, the locations at which it will most likely point should be chosen in this order: 1st, the vagina; 2d, the rectum; 3d, the abdominal walls. Dr. Savage reports the points of opening, artificial or spontaneous, in 19 cases,- they were as follows: — 1 above pubes at median line. 1 midway between navel and pubes. 1 outside left saphenous opening. 2 by rectum ; 1 fatal. 1 by rectum and side of anus. 1 by colon ; 1 fatal. 4 by vagina. 2 by bladder. 1 by iliac region. 3 into peritoneiim ; 3 fatal. 1 by rectum and internal abdominal ring. 1 by vagina, bladder, rectum, and inguinal region. It will be seen that out of 19 cases 5 proved fatal- — 3 by emptying into the peritoneum, and 2 by causing colitis and rectitis. Methods of Operating — The propriety of opening the abscess having been determined upon, the operator, if he intend reaching it through the vagina or rectum, should carefully investigate, by touch, as to the pres- ence upon their walls of large bloodvessels, the opening of which might prove a source of serious hemorrhage. The patient being placed on the left side and Sims's speculum introduced, if there exist the slightest doubt as to the contents of the sac the needle of a hypodermic syringe should be plunged into it and the point decided. If this be not done, an ordinary exploi'ing needle should be passed into the tissues until pus is seen to flow along its groove. Then the operator, feeling sure of his ability to reach pus, holds the needle in one hand, while with the other he slides the point of a bistoury along its gutter and passes it to the place of accumulation. This is a method at once safe, certain, and effectual, and I sliould recommend it in preference to any other except that which comes next to be consid- ered. The aspirator affords an easy and effectual means of emptying these accumulations, and at the same time one that is to a great extent free from danger. After it has removed all the fluid which will flow, its action may be reversed, the sac filled with warm carbolized water, and this at once drawn off again. Should reaccumulation take place, the situation and certainty of the purulent collection being established, it may be evacuated by a bistoury. If the opening made be large enough to admit the finger, it should be passed in, and by it any tract leading into 508 PELVIC ABSCESS. an adjoining abscess sliould be enlarged, and any sloughing tissue met, removed. After this, should there be any fear of closure of the canal just opened, its walls may be touched by nitrate of silver, or painted with solution of persulphate of iron, or a piece of gum-elastic catheter or rubber tubing may be left in it. If it be thought best to select the abdominal surface as the point of evacuation, all danger of escape of pus into the peritoneum may be avoided by following the suggestion of Recamier with reference to hepatic cysts, namely, causing adhesions of the layers of the serous membrane by a nitric acid issue over the point of selection. A trocar, the needle of the aspirator, or a bistoury guided by an exploring needle, may be plunged through the centre of the issue without the danger just mentioned. Means for Causing Closure of the Sac Sometimes, after the evacua- tion of these abscesses, their sacs will not close, but, remaining open for months and even years, go on pouring out large quantities of pus. The causes of their not closing are these: the existence of sinuses, which will not allow their complete evacuation ; a peculiar condition of their walls from the existence of a membrane, called by Delpech pyogenic, which tends to prolong suppuration ; or the passage into the sac of air or feces from the intestines, or urine from the bladder. Of these the first is decidedly the most frequent, and should be met by dilatation of the tract leading to the abscess, by tents of laminaria, or enlargement by the knife. Should the abscess have a short and free outlet, the sac should be injected two or three times a week with tincture of iodine, at first in solution, afterwards pure ; or by solution of carbolic acid. In case of entrance of feces, air, or urine into the diseased part, a counter-opening should be made which will allow their free escape, and the part kept as clean as possible by injection of tepid water. Then the fecal or urinary fistula allowing the vicarious discharge should be cured by appropriate means. Before practising any opei'ation for evacuation of pelvic abscesses an anaesthetic should always be administered, as perfect quietude is essential to safety. PELVIC HEMATOCELE. 509 CHAPTER XXXIII. PELVIC HEMATOCELE. Definition and Synonyms — Under this and tlie synonymous titles of retro-uterine hematocele, periuterine hematoma, and bloody tumor of the pelvis, has been described an accumulation of blood in the pelvic cavity either above or below tlie peritoneum. History. — Although an attempt has been made to prove that the ancients were cognizant of this affection, the proof of such a fact is not satisfactory. The earliest allusion made to it is contained in the works of Ruysch, of Amsterdam, who wrote in 1737. After this, little attention was paid to it until the time of Recamier, althougli mention of it was made by Frank, Deneux, and some others. In 1831, Recamier, under the impression that he was opening an ab- scess, cut into a tumor behind the uterus and gave exit to a large amount of black, grumous blood, and about ten years afterwards Bourdon, one of his pupils, published another case occurring in his practice. A tabular view of the names of those who have been chiefly instru- mental in elucidating the subject and sytematizing our knowledge upon it is here presented : — . Recamier, 1831, " Lancette Frangaise ;" Velpeaii, 1843, " Recherches sur les Cavites Closes ;" Bernutz, 1848, " Archives de Medeciiie ;" Vigues, 1850, " Des Tumeurs Sanguines de PEscav. Pelvienue ;" Nelaton, 1851, "Gazette des Hopiteaux ;" Nonat, 1851, " These de Cestaii, Gallardo, et Frost ;" Huguier, 1851, Lecture before Surgical Society of Paris ; Gallard, 1855, "Uniou Medicale ;" Voisiu, 1858, " De I'Hematocele Retro-Uterine." I have not endeavored to record the names of all who have made valu- able contributions in France, for had I done so, the list would have been a long one. Those only are referred to who have been foremost in ad- vancing our knowledge. It will thus lie seen that we are indebted to France for the early litera- ture of pelvic hematocele. Germany has of later years contributed a great deal towards it through the labors of Olshausen, Crede, Braun, Hegar, Virchow, Schroeder, Seiffert, and others; and England through those of Madge, McClintock, and Tuckwell. In America, Prof. Gunning S. Bed- ford reported the first case which I can find recorded. More recently, we were indebted to Dr. Byrne, of Brooklyn, for a faithful report of several 510 PELVIC HEMATOCELE. cases. Prior to the year 1851, although it had attracted some attention, it was not well understood even in France, for, in 1850, we find Malgaigne cutting into a hematocele under the impression that he was enucleating a fibrous tumor, and losing his patient from hemorrhage. Frequency This subject is not fully settled, a good deal of discrepancy of opinion existing concerning it. Prof. Olshausen, of Halle, declares tliat in 1145 gynecological cases he saw 34 hematoceles, and SeifFert, of Prague, reports 66 seen in 1272 cases of pelvic female diseases. In ten years Dr. Barnes has met with 53 cases, and in twenty years Dr. Tilt has seen but 12. I do not regard the disease as being, by any means, very rare, but my experience assures me that many cases of cellulitis and a certain number of uterine and periuterine tumors are reported as those of hematocele. Pathology The definition of hematocele has no relation whatever to the cause of the hemorrhage which gives material for the bloody tumor. The disease consists in the collection of a mass of blood in the pelvis, either above or below its roof. Whatever be its source, such a collection constitutes the affection which engages us. Ordinarily, we find that the flow giving rise to it takes its origin from one of the three following sources : — 1st. Direct escape of blood from vessels in or near the pelvis ; 2d. Reflux of blood from the uterus or pubes ; 3d. Transudation of blood in consequence of dyscrasia or peritonitis. It is evident that hematocele is not a disease, but a symptom of a num- ber of pathological conditions. As, however, the source of the hemor- rhage which results in the bloody tumor very often cannot be ascertained, we are forced to deal with its most prominent and significant sign, taking this as an exponent of a state which is beyond the possibility of diagnosis. In works upon practice written twenty years ago, we find dropsy treated of as a disease. In those of to-day it is regarded only as a legitimate re- sult of renal, cardiac, or hepatic disease. Obstetric writers, even as late as ten years ago, described puerperal convulsions as a disease incident to parturition. Those writing ten years hence will probably regard them, as many do to-day, as one of the numerous consequences of renal disease. We may with good reason hope that the time will come when a similar improvement in description, based upon an advance in our knowledge of pathology, may connect itself with hematocele, but at present the dis- covery of the source of the hemorrhage is usually impossible. The special sources of the hemorrhage inducing the aflPection, which have been revealed by post-mortem examinations, may thus be presented at a glance : — 1. Rupture of bloodvessels in the pelvis. Utero-ovarian ; Varicose veins of broad ligaments ; PATHOLOGY. 511 Aneurism of artery ; Vessels of extra-uterine ovisac. 2. Rupture of pelvic viscera. Ovaries ; Fallopian tubes ; Uterus. 3. Reflux of blood from the uterus. Reflux of menstrual blood. 4. Transudation from bloodvessels. Purpura ; Scorbutus ; Chlorosis ; Hemorrhagic peritonitis. All of these causes have been proved by post-mortem research to have resulted in hematocele, but it cannot be questioned that rupture of any bloodvessel which empties its contents into the peritoneum might also do so. Blood poured 4nto the peritoneum from rupture of the spleen, for ex- ample, would gravitate towards Douglas's cul-de-sac, because it is the most dependent portion of that membrane, and coagulating would give all the signs of a bloody tumor in that locality. At times the affection is in- dicative of serious internal lesion, rupture of the ovary or tube ; at others it results merely from imperviousness of the cervical or tubal canal, which prevents the advance of menstrual blood and causes it to regurgitate into the peritoneum ; while in still a third class of cases, it is created by pour- ing out of blood from the vessels of the peritoneum. The last condition has been described as hemorrhagic peritonitis, and especially pointed out by Virchow. Scliroeder believes that peritonitis always precedes the oc- currence of hemal.ocele. Tliat it usually accompanies it is unquestionable, but if it be a precursor of this affection, which suddenly bursts forth upon a patient apparently in good health, it tells badly for our means of diag- nosis of pelvic peritonitis. It is undeniable, however, that in some cases hematocele does follow and not precede the peritonitis. Whatever be the source of the blood, it collects either in the most de- pendent part of the peritoneum, or in the pelvic areolar tissue beneath it. Here it remains for a time fluid, then undergoes partial coagulation, be- coming a grumous mass like currant jelly, and lastly, all the fluid being absorbed, a hard, resisting tumor composed of fibrinous material remains. Should the collection have occurred in the peritoneum, its boundaries will be the walls of that cavity laterally and below, while a localized perito- nitis forms for it a roof of effused lymph. If it collect in the areolar tissue of the pelvis, the effused blood will make its own nidus by perco- lating the loose structure and mechanically creating a space in it. In either of these positions it is entirely absorbed and reduced to a hard, firm tumor, which remains for a long time, or is discharged by the vagina 512 PELVIC HEMATOCELE. or rectum, or into the peritoneum. The last point of evacuation is fortu- nately rare. Konat^ quotes Dupuytren for the following very ingenious and plausible explanation of the method of such absorption, which he likens to the process of digestion. The vessels of the cyst which are in contact with the mass remove its fluid portion, and thus its hard surface comes in apposition with the sac. This excites effusion of serum, which softens the fibrinous wall and renders it susceptible of absorption, which soon occurs. Then again contact excites a flow of fluid, and again this is removed, until the whole mass is diminished or completely absorbed. Causes — A glance at the recognized causes of the disease will make it evident that congestion of the pelvic organs must, in an eminent degree, predispose to it. This explains the fact that it has been found to have occurred most frequently during the period of ovarian activity and espe- cially during a menstrual epoch. The predisposing causes are — The period of ovarian activity, 15 to 45 ; Disordered blood state, plethora or anaemia ; The menstrual epoch ; Chronic uterine or ovarian disease ; The hemorrhagic diathesis. The exciting causes are — Sudden checking of menstrual flow ; Blows or falls ; Excessive or intemperate coition ; Obstruction of cervical canal ; Obstruction of Fallopian tubes ; Violent efforts. Varieties — There are two forms of the affection, subperitoneal and peritoneal. In the latter the blood tumor forms within the peritoneum, where it in time becomes encysted unless death occur at an early period. In the former, it occurs in the areolar tissue of the pelvis, under the peritoneum. The propriety of the consideration of the former under the same head as the latter has been contested by Aran, Bernutz, and Voisin, but from a clinical standpoint it appeal's to be quite valid. Not only have dis- tinct instances of subperitoneal hematocele been recorded by such ob- servers as Simpson, Olshausen, Tuckwell, and Barnes ; cases have, likewise, pi-esented themselves, which commencing as subperitoneal ones have ruptured the peritoneal covering of the pelvis, and thus broken down the theoretical barrier which pathologists have been inclined to establish between the two varieties. Of the two varieties, the peritoneal is much the more frequent, at the > Op. cit., p. 344. VARIETIES. Fig. 209. 518 Peritoneal hematocele. (Barnes.) Fig. 210. Subperitoneal hematocele. (Eimnet.) uZr'TT!. V' "T ""^^ ^'■«™- I" « -'OP-^ Tuckwell found .he ZZ^^r t '" "■'"■^-'"'>'- In « -- wl,ich I .aw with Dr. Z2\ZZ , T ' '" ™''* " '''•"="""^'' of « '"">- which lay ob- a It of . "'""" '" <"'-"7-f"".- Lours the patient fell into su..e of collapse, and as we saw her thus, the nature of the tumor, which 514 PELVIC HEMATOCELE. we were doubtful about on the previous day, became evident. Upon a post-mortem examination an ante-uterine hematocele as large as a goose's egg V?as found under the peritoneum, through which it had broken, dis- charged a portion of its contents into the peritoneum, and caused collapse and death. This is the only ante-uterine, but not the only subperitoneal, hematocele with which I have met. Symptoms The absolute occurrence of hemorrhage is generally pre- ceded by symptoms which are premonitory, as fixed, dull pain over the ovaries, derangement of menstruation, metrorrhagia, or prolongation of the menstrual discharge. The symptoms of the actual escape of blood will depend in great degree upon the nature and gravity of the accident which has given rise to it. Sometimes the affection occurs without any violent symptoms and almost without warning. It will be appreciated that this would be so if it were due to gradual reflux of blood on account of constricted cervix, or transudation, the result of purpura. Frequently a sudden manifestation of symptoms occurs, and the accident is announced as rapidly as is cere- bral apoplexy. It is evident, then, that the symptoms must differ widely in cases marked by very great and sudden loss of blood, and those accompanied by very little. In the first there are evidences of profuse abstraction of vital fluid, great peritoneal shock, and excessive prostration. In the second these may all be so slight as to escape the notice of non-observant patients. The best course which can be pursued in reference to the matter is, I think, to take, as an example, a case of moderate severity, and guard the reader against supposing that all attacks give the same degree of in- tensity of symptoms. Most prominent among the symptoms are — Severe pain in the j^elvis ; Pallor, faintness, and coldness of extremities; Sense of exhaustion ; Nausea and vomiting; Metrorrhagia; Uterine tenesmus; Tympanites; Interference with bladder and rectum; Small and rapid pulse; Depressed thermometric range. The patient feels as if a large and heavy body exists in the pelvis, and instinctively strives to expel it by the vagina. At times the pain com- plained of is very acute; at others, it is a dull and heavy aching. After a variable time, generally within forty-eight hours, a reaction from this state of prostration occurs. Sometimes this is slight ; at others decided. It is dependent chiefly upon the degree of inflammation set up DIFFERENTIATION. 515 by the sanguineous accumulation acting as a foreign body. This is usually marked by the following symptoms : — Tendency to chilliness ; Constipation ; Suppression of urine ; Great tympanites ; •' . Heat of skin ; High thermometric range ; Rapid pulse ; Tenderness over abdomen. All these symptoms point to two facts : 1st, sudden and excessive loss of blood ; 2d, the existence of some substance in the pelvis which mechan- ically interferes with its viscera. A part of them might be produced by menorrhagia, a part by sudden retroversion ; but a union of the whole will strongly excite suspicion of hematocele, and call for a physical ex- ploration. Physical Signs Vaginal touch reveals a tumor usually posterior to uterus and vagina, and generally partially closing the latter. The mass thus felt, if the examination be made very soon after its formation, will be found to be soft, smooth, and obscurely fluctuating. If a number of days have elapsed before it be touched, it will give the impression of a smooth, dense, solid body. The uterus will be found pressed out of its position, generally upwards and forwards, so that the cervix will be above the sym- physis. Sometimes, though rarely, it is forced out of the median line to one side. Nonat* dogmatically announces that the uterus is never found between the tumor and the rectum, that is to say, behind the mass of blood; but Chassaignac^ reports a case in which the sanguineous collection existed entirely between the bladder and uterus, and consequently must have forced that organ backwards ; and similar cases are recorded by G. Braun, Olshausen, Barnes, Emmet, myself, and others. Rectal touch will show that the bowel is partially closed by pressure from the tumor. Abdominal palpation will reveal the presence of a hard mass which may extend only up to the superior strait, or as high as the navel. In cases where a small quantity of blood has been effused, and more especially where this has collected under and not in the peritoneum, an abdominal tumor may not be discovered. By the aid of conjoined manipulation the shape, extent, and character of the mass may be further ascertained. Differ e7itiation The diseases with which hematocele may be con- founded are — 1 Op. cit., p. 342. 2 Courty, Mai. de I'Uterus, p. ftl2. 516 PELA^C HEMATOCELE. Pelvic cellulitis or abscess ; Retroversion ; Extra-uteriue pregnancy ; Fibrous tumor ; Dislocated ovarian cyst. The mass created by cellulitis and abscess is usually found at the side of the uterus, and not posterior to that organ ; it develops less suddenly than hematocele ; is hard at first, and gradually softens ; is exquisitely painful to touch ; does not lift the uterus and ])ress it forwards ; and is not usually accompanied by metrorrhagia. Retroversion may present the signs due to the mechanical results of hematocele, but not those due to loss of blood. If pregnancy coexist, conjoined manipulation will usually suffice for diagnosis. If it should not, the uterine probe will elucidate the case. Extra-uterine pregnancy does not develop suddenly, but slowly, and is characterized by many of the signs of pregnancy. In place of metror- rhagia there is usually, though not always, ameuorrhoea. Fibrous tumors grow slowly, are painless, and move with the uterus. They are irregular and hard, and do not usually push the uterus so far forwards and upwards. Displaced ovarian cysts are painless, show no signs of hemorrhage, and cause no constitutional disturbance or metrorrliagia. Course, Duration, and Termination — Hemorrhage from the sources enunciated as those of hematocele may be so great as to destroy life im- mediately. Five such instances are recorded by Voisin, and OUivier d'Ano-ers^ mentions two in which death occurred in half an liour from rupture of a varicose utero-ovarian vein. Such a termination is, however, decidedly exceptional. The tumor generally disappears by absorption, is discharged by the rectum or vagina, or remains a hard, indurated mass long afterwards. Discharge is most frequently followed by recovery, but sometimes putrefaction occurs in the walls of the sac, septicaemia takes place, and death ensues. The process of absorption may be accom[)lished in three weeks, or six months may elapse before it is complete. In some cases a slow and steady hemorrhage appears to go on for weeks, and render the bloody tumor gradually larger. In others hemorrhages subsequent to the first take place after this has become encapsulated. After subsidence of the symptoms of reaction, chill, fever, and sweating often come on late, marking suppuration in the mass, and slight septic absorption. Prognosis — The prognosis of hematocele must be governed in great degree by the amount of blood lost, the degree of constitutional shock resulting, and the intensity of I'eaction excited. As a rule it is favorable ; 1 Noeggerath, Bui. N. Y. Acad. Med., vol. i. p. 577. TREATMENT. 517 especially so, I slioukl say, when treated upon the expectant plan, and not by immediate surgical interference. In cases of peritoneal form a graver prognosis is called for than in the subperitoneal, for evident reasons ; and where a great deal of blood has been lost the dangers are greater than where the amount has been more limited. This is true not only from the fact that an excessive flow might cause death from exhaustion, but because the removal of so large an amount of coagulum, whether by absorption or discharge, must necessarily expose the patient to great dangers. When death occurs it is usually a consequence of loss of blood, shock from sudden invasion of the peritoneum, peritonitis, rupture of the encap- sulated mass into the peritoneum, or septicaemia. Treatment. — The physician will rarely be called upon to resort to treat- ment before the amount of blood which is destined to be lost has collected in the pelvis. He will, however, often be present to witness the great constitutional disturbance and excessive prostration and pain which imme- diately follow the hemorrliage. The diagnosis being made, the indica- tions for treatment will be simple enough : — 1st. To check tendency to further loss ; 2d. To prevent death from prostration ; 3d. To relieve pain. These indications should, as far as possible, be met simultaneously, for the dangers to be combated all occur at one and the same moment. The patient should at once, without the delay attendant upon changing the clothing, etc., be put in a condition of perfect rest, and a full dose of morphia be administei'ed hypodermically. A bladder of crushed ice or cloths wrung out of iced water should be laid over the hypogastrium, and bottles of hot water or warm bricks wrapped in flannel should be put to the soles of the feet. Should the stomach not be very irritable, brandy and water or iced champagne should be given freely by the mouth. If prostration be so alarming as to threaten collapse, and the stomach be intolerant of ingesta, brandy or sulphuric ether in doses, the former oi two drachms, and the latter of half a drachm, should be injected subcuta- neously by the hy[)odermic syringe. Reaction having taken place, the most perfect quietude should be ob- served, pain should be relieved and nervous shock prevented by the free use of opium or one of its salts, and the diet should consist of milk, animal broths, and gruels of farina, sago, or Indian meal. . And now will arise the important question, whether the accumulated blood should be left for removal by nature, or should be evacuated by surgical means. Recamier, in introducing tlie subject to the profession, inaugurated the practice of evacuating such tumors, and Nelaton indorsed and popularized it. But experience taught Nelaton that the procedure was not judicious, and " to-day he proscribes it in an almost absolute 518 PELVIC HEMATOCELE. manner.'" Immediate surgical interference presses its claims in consider- ation of tlie facts that — 1st. It is capable of cutting short a lengthy and dangerous disorder; 2d. It may save the patient from the dangers incident to absorption as well as discharge. 3d. It removes from the peritoneum or pelvic cellular tissue a foreign body, which, undisturbed, would prove the focus of inflammation. It is not surprising that it was the favorite plan in the infancy of the subject. AVhen, however, pathologists had had an opportunity of study- ing the natural history of the affection, it was as naturally abandoned, for the following reasons : — 1st. It was discovered that, when not interfered with, hematocele very generally passes away rapidly. 2d. It was discovered that the dangers of puncture were greater than those of the tumor left undisturbed ; 3d. Medical means were found to exert a marked controlling influence over its complications. With the light which experience has thrown upon this point, it appears to me that, without being dogmatic, we may safely adopt this rule. The mere presence of a large amount of blood in the peritoneum does not warrant evacuation. If, as time. passes, suppuration within the sac, which has then pretty certainly become encapsulated, and septic absorption are manifested by chills, febrile action, and profuse sweating, the softening mass sliould be discharged by incision. In other words, so long as the accumu- lated blood appears to be doing no decided harm and nature seems to be causing its absorption, it should be left alone. But go soon as evidences of septicaemia are observed, it should be evacuated. Under these circum- stances, a neglect of surgical interference would be culpable. Without such indications it should be avoided, and reliance placed upon medical resources, for it should be borne in mind that the collection of blood is usually in the peritoneum, and that incision of this membrane, in addition to its own inherent dangers, would always expose to those arising from admission of air. Methods of Operating — The patient being placed upon the back, as if for lithotomy, a trocar and canula may be held in the right hand, guided to the most fluctuating and dependent part of the mass, and plunged in. Or, the patient lying on the left side, the perineum and posterior vaginal wall may be lifted by Sims's speculum, and an incision made into the wall of the tumor by a tenotomy knife or small bistoury. Tiirough the open- ing thus made, one or two fingers should be introduced and the clots re- moved. After evacuation by either method, the nozzle of a syringe should be introduced into the sac, and a stream of tepid water, or of this with a ' Nouat, op. oit FIBROID TUMORS OF THE UTERUS. 519 very small amount of carbolic acid, should be very gently and cautiously made to wash out the cavity remaining. This should be repeated once or twice in twenty-four hours, for prevention of septicEemia. All this should, as far as possible, be done under the antiseptic method. After the abatement of acute symptoms, a blister, four by six inches, should, unless some contra-indication exists, be applied over the hypo- gastrium, and this may with advantage be repeated every ten or twelve days. Its results will often be very marked, and, although apparently harsh practice, it prevents much suffering, while it causes but little. As time passes and pain is relieved, quinine, alone or combined with sulphuric acid, in full doses will prove a valuable remedy, and should be kept up perseveringly. CHAPTER XXXIV. MYO-FIBROMATA OR FIBROID TUMORS OF THE UTERUS. Definition and Synonyms Tlie parenchyma of the uterus is liable to undergo a localized hypertrophy, which results in the production ot two varieties of tumors ; the fibrous and the fibro-cystic. The first, which is one of the most frequent pathological conditions to which this organ is subject, will now receive attention, while the second and much rarer form will be treated of in a separate section. By the older writers fibrous tumors were styled tubercula, steatomata, sarcomata, etc. Since their true nature has been more carefully studied by aid of the microscope and been understood, they have been described under the names of fibrous tumors, uterine fibroids, fibroma, and more recently, by Virchow, myoma. I have adopted the terms which head this chapter, following the example of Billroth for the first, and of Klob for the second, for the reason that neither that of fibroma nor myoma alone expresses the existing pathological condition. Billroth* rejects the latter name, which signifies that these growths consist in hypertrophy of muscular substance ; and at the same time he refuses to admit the former, as that conveys the equally incorrect idea that they are constructed of connective tissue. Fibroid {fibrosiis and tiSoj), resembling fibrous tissue, is at least not calculated to mislead, while mvo-fibroma expresses the exact truth. History.— \]\\i\\ the time of Dr. William Hunter, who wrote towards the close of the eighteenth century, the true nature of uterine fibroids was ' Surg. Pathol., p. 583. 520 FIBROID TUMORS OF THE UTERUS. not appreciated. They were confounded with malignant growths, of which they were regarded as a variety. He described them under the name of fleshy tubercle, and contributed greatly to the knowledge of their patho- logy; but it was not until the writings of Chambon,^ Baillie, Bayle, and others that the subject was fully elucidated. Sir Charles Clark, in 1814, wrote an excellent chapter upon them, which would almost answer the requirements of our day. Pathology — Surprise that any confusion should have existed between these tumors and cancerous growths, will cease when we consider that their identity is boldly assumed by so careful an observer as Dr. Ashwell, as late as 1844. He gives five reasons for his belief, which he declares appear to him " conclusive." His reasoning has failed to convince others, no writer since his time having adopted the view which Dr. Hunter suc- ceeded in abolishing, and no fact in gynecology is now more fully settled than that of the non-malignancy of these tumors. Until recently the question has not been settled as to the possibility of their undergoing cancerous degeneration. Bayle and Lobstein have de- clared that they never do so, and the researches of Cruveilhier and Lebert tend to support the view ; while Kiwisch, Dupuytren, Atlee,'^and Simpson believe that malignant degeneration occurs in rare cases. The weighty authority of Virchow^ is cast into the scale favoring the possibility of both carcinomatous and sarcomatous degeneration, and Klob agrees iu this assertion. "In 1862," says the latter author, "a singular specimen was added to the Salzburg Museum. From a fibroid tumor the size of a child's head, situated in the posterior walls of the uterus, carcinoma had un- doubtedly been developed without any other portion, of the body being affected, and I am therefore constrained to allow the possibility of such a transition, although I cannot recall a second case of this kind either in the literature of the subject or in my rather extensive experience." Although this case seems to settle the matter of possibility, at least, it must not be forgotten that beyond doubt such a change of type is exceed- ingly rare. It is in this connection a fact worthy of note that in the ne- gress, in whom fibroid tumors are so common as to be regarded by some as almost universally met with after the thirtieth year, carcinomatous affections of the uterus are very rarely seen. I have met with two cases in which uterine fibroids which had been known to exist for eight and ten years, and had behaved like benign growths, suddenly took upon themselves the aspect of sarcoma, and led to a fatal termination. In one case the tumor was removed post-mortem, and in the other ante-mortem with great relief to symptoms. ' Mai. do rUterus. ^ McClintock, Diseases of Women. 3 Pathologie des Tumeurs, Paris, 1871. PATHOLOGY. 521 Uterine fibroids may develop singly, when ordinarily they do not attain to a very great size. Sometimes, however, they exist in great numbers, and grow to a very large size. Courty reports one weighing fifty pounds, and I have removed one, with uterus and both ovaries, of the same weight. Some years ago I exhibited to the New York Patliological Society, the uterus of a negress which contained thirty -five tumors of every size between tiiat of a foetal head and that of a marble. Fibroids may develop in any part of the uterus; but the usual site is in the body or fundus. Mr. S. Lee examined seventy-four preparations in the London museums, and found that the rarest of all locations for them is the cervix. A very interesting instance of a large tumor developed below the OS internum is reported by Dr. Murray, in the sixth volume of the London Obstetrical Transactions. I have myself removed several of this character from the parenchyma of the cervix, the body of the uterus being in no wise involved. Their structure varies very greatly, not only from their original develop- ment being different, but from their being susceptible of several diseased states, which will very soon be mentioned, and which produce their cha- racteristic alterations. The typical form is that of hard, resisting fibrous tissue, which creaks under the knife. Under the microscope this is found to consist of long, fine fibres, generally united in bundles ; of fusiform fibre-cells analogous to fibro-plastic elements ; and of round or elliptic granules of small size ; the whole being bound together by fine intercellular substance. Tiiey consist of the hypertrophied elements of the uterus, to which organ they are strictly homologous. In the majority of cases, it is de- clared by recent pathological investigators, that connective tissue pre- ponderates in their construction, but there is always a certain degree of muscular hypertrophy concerned in their development ; hence Billroth's objection to the terms fibroma and myoma. In some cases the amount of muscular exceeds that of connective tissue in their construction. This, which may be styled the normal type of the uterine fibroid, is departed from by formation of cysts in the midst of the fibrous tissue, which consti- tutes the tumor one of fibro-cystic character. Uterine fibroids are liable to a variety of diseases, among which the most frequent are oedema ; inflammation ; gangrene ; fatty, colloid, and calcareous degeneration ; and apoplexy. The last consists in rupture of small bloodvessels within the mass, and consequent accumulation of blood. Very rarely the whole mass becomes a ball of calcareous matter, which, projecting in utero and becoming detached, is sometimes discharged per vaginam. This is the disease which was described by old writers as ute- rine calculus. The uterine attachment of fibroids of compound character is sometimes the seat of a si)ecies of varicose degeneration of the small 522 FIBROID TUMORS OF THE UTERUS. vessels, which causes the structure to resemble erectile tissue. Tumors thus affected have been styled by Virchow, telangiectatic tumors. This vas- cular structui'e readily bleeds, and in one case I saw it the cause of a small Fig. 211. uterine fibroma. Oblique longitudinal section of muscular cell-bundles. (Billroth.) hematocele. But large vessels are likewise discovered in the pedicles of fibroids ; Caillard reporting one the size of the radial artery. Klob has met with but one such vessel, which was the size of the uterine artery. Varieties Klob divides these growths into two classes — simple and compound. The first consists of one tumor, w hich is generally spherical, and which is connected by loose connective tissue with the uterus. The second is a compound tumor, made up of a number of small fibroids, con- nected by loose connective tissue. The second variety is more vascular than the first, and its surface is nodulated and not smooth. Both these classes present themselves clinically in three varieties, which are created by the locality of the growths in the walls of the uterus. If they lie under the mucous membrane projecting into the uterus, they are called submucous ; if under the peritoneum, subserous ; if in the wall of the uterus, interstitial. If a tumor be situated in the wall of the uterus, it may remain there until it assumes large dimensions. Should it be near the mucous or serous lining, it is subjected to contractile efforts on the part of the surrounding parenchyma, which are excited by its presence, and which often in time force it towards the uterine or abdominal cavity. Sometimes its connec- CAUSES COMPLICATIONS. 523 tion with the mother tissue is kept up by a broad base ; sometimes it is limited to a long, slender pedicle, which, in the case of the subperitoneal varieties, allows of great mobility. Should the mass be forced into the uterine cavity, and gradually assume a slender, pedunclated attachment, it receives the name of fibrous polypus, which is therefore a variety of submucous fibroid. These neoplasms often affect the uterus very curiously. The interstitial varieties produce every form of displacement ; the sub-mucous sometimes produce complete inversion of uterus and vagina ; and the sub-peritoneal, Virchow declares, by dragging the fundus upwards not only draw out the cervix so as to make it resemble the urethra, but absolutely cause " the spontaneous separation of the neck from the body of the uterus." The last variety, too, sometimes shows most singular migrations. The pedicle being broken, they have at times been found rolling about freely in the peritoneum, and at others, having set up adhesive inflammation, they have been found detached from the uterus, and attached to some other abdominal viscus. Causes The predisposing causes, or rather those generally regarded as such, are — Race, tlie African being peculiarly liable ; Age, from thirty to forty-five ; Nulliparity ; Menstrual disorders of long standing. Concerning the exciting causes, one writing in the year 1874 may, unfortunately, quote the words of Sir Charles Clarke, recorded in 1814: " Nothing is known respecting the cause of this disease." vSixty years of research have thrown no light upon its etiology. Complications The most frequent of the complications which show themselves in the course of the disease are — Endometritis ; Displacement ; Cystitis ; Obstruction of the rectum ; Hemorrhoids ; Pelvic peritonitis ; Areolar hyperplasia ; Atrophy of uterine walls ; Grave menstrual disorders. Every one who has made autopsies upon cases, in which uterine fibroids have existed, must have been struck by the fact of the varied appearance of the walls of the uterus. Where several tumors exist the uterine cavity- is sometimes so perverted and rendered so tortuous that it cannot be traced, while in cases where a large number of tumors are formed, the 524 FIBROID TUMORS OF THE UTERUS. whole uterus seems to have disappeared, its place being usurped by tumors. In the case already cited, in which I counted thirty-five tumors, no trace of the uterus could be discovered by the naked eye, above the os internum. In some cases the vice of nutrition set up by the presence of these growths results in thickening of the uterine walls by the establishment of inter- stitial hypertrophy, in others localized points of thickening exist, while in others still the wall of the uterus may become so attenuated by distention and atrophy as to leave only a thin film to represent it. This distended and attenuated organ is that which Walter has styled the " membranous uterus." Symptoms. — The enumeration of complications just given is a sufficient explanation of the great number of rational signs which present them- selves, for not only do we meet with the symptoms of fibroid tumors, but with those of a variety of disorders which they excite. Most prominent among the symptoms are — Menorrhagia or metrorrhagia ; Irritability of bladder and rectum ; Pain throughout the pelvis ; Uterine tenesmus ; Profuse leucorrhoea ; Dysmenorrhcea ; Signs of pressure on crural nerves and vessels ; Watery discharge from uterus. These symptoms are not equally common to the three varieties of the affection. Subperitoneal tumors often, and interstitial tumors sometimes, are accompanied by none, or at least by very few. of them. It is the submucous variety which most constantly and prominently develops them. The immediate effects of uterine fibroids are exerted upon the system thi'ough the following means : — 1st. They produce excessive menstrual discharge and profuse leucor- rhoea, which impoverish the blood. 2d. They press upon and derange the innervation of neighboring parts. 3d. They, in some way, interfere with hematosis and tlie functions of the ganglionic nervous system. 4th. They disorder the mind by creation of depression of spirits, from the fact that the patient recurs with gloomy apprehension to their exist- ence almost constantly. Physical Siffns Although the rational signs are so numerous and striking, they can never do more than excite a suspicion, wliich leads to investigation by physical means. In the case of a large tumor no difficulty in diagnosis will present itself; for the results of vaginal touch, abdominal palpation, and conjoined ma- nipulation will be so decided as to settle the character of the case defini- DIFFERENTIATION. 525 tively. When, however, a growth of siiiall size exists, great difficulties will often attend diagnosis, which may be delayed until the case has been under observation for a long time. A thorough examination involves full and careful exploration, by touch, of the anterior and posterior surfaces of the uterus, as well as of its cavity to the fundus. To examine the external surfaces of the uterus, the patient should lie upon the back with the thighs flexed. All constriction should be removed from the waist, and the bladder and rectum emptied. The examiner then, depressing the uterus by the right hand placed over the hypogastrium, should sweep the index finger of the other as high up as possible over the posterior wall, first by vaginal and then by rectal touch. While the finger in the vagina or rectum lifts the uterus, the tips of the fingers placed on the abdomen should be forced behind the fundus, and downwards over the posterior uterine wall so as to approach the finger within the pelvis. By these means the posterior wall will be superficially examined in women with tense abdominal muscles, thoroughly in those in whom they are thin and relaxed. The finger in the vagina now drawing the cervix forwards, the fingers of the hand on the abdomen should be made to depress its walls so as to sweep from the fundus over the anterior surface down to the cervix. The finger under the cervix lifting it up will offer itself as an opposing force to the hand on the abdomen. This manoeuvre will tully expose to examina- tion the anterior surface of the uterus, unless the patient be very lat. Should she be so, a tenaculum may be fastened in the cervix, and the ute- rus drawn down by it, so that the posterior wall will be better within reach of rectal touch, and the anterior wall within that of vaginal exploration when the finger is pressed firmly against the base of the bladder. When, in a case in which it is of importance that a certain diagnosis should be arrived at, it proves impossible to do so by use of the means thus far mentioned, the modification of Simon's method, mentioned in the chapter upon Diagnosis, may be resorted to with great confidence as to the results which it will yield. For investigating the interior surface of the uterus, the neck should be fully dilated by tents, and immediately upon their removal, tlie uterus being depressed as for examination of the outer surface, the finger should be carried into the cavity of the body. Differentiation — The diseases which may be confounded with fibrous tumors are — Pregnancy ; Periuterine cellulitis or abscess ; Pelvic hematocele ; Anteflexion or retrofiexionj Ovarian tumors ; Fecal impaction. 526 FIBROID TUMORS OF THE UTERUS. In pregnancy, amenorrhoea and other signs of ntero-gestation exist,, while in uterine fibroids tliere is usually a tendency to menorrhagia. In pregnancy the uterus is symmetrical, in fibroids usually asymmetrical. The tumor found in pregnancy is generally softer than in fibroids, and more uniformly median in position. In a doubtful case time, with its develop- ment of foetal movements, will always settle the point. The tumor created by cellulitis is usually immovable, very sensitive, accompanied by fever, comes on suddenly, and fixes the uterus. A fibroid tumor is the opposite of this in every respect. Hematocele generally occurs suddenly and with violent symptoms. The tumor is sensitive and immovable, at first semi-fluid, and accompanied by tympanites and constitutional disturbance. Fibroid tumors show no such symptoms. Flexion may be determined by the uterine probe, and differentiation established between it and fibroids by conjoined manipulation and rectal touch. Ovarian tumors of solid form are the only ones wliich usually give diffi- culty in diagnosis, and these are rare. They are unaccompanied by me- norrhagia, can be pushed from side to side without affecting the position of the uterus as ascertained by vaginal touch, and are less affected by movement of the uterus by means of tiie uterine sound. In cases where an ovarian tumor is firmly attached to the uterus, differentiation is not only difficult, but often impossible. Fecal impaction presents a tumor which can often be indented by pres- sure, is generally in the caput coli, does not move with the uterus, gives severe intestinal pain and disorder, and exerts little influence on the func- tions of the uterus. From this rapid disposal of the subject of differentiation it must not be supposed that it is always an easy matter. In, many cases only careful watching will enable the diagnostician to arrive at a certain conclusion. Prognosis The practitioner cannot be too cautious or display too much reticence in pronouncing the prognosis of uterine fibx'oids. There are few diseases in which the young physician will be led into greater error or be made to regret more decidedly an over-confident prediction. Fibroid tumors, unless of great size, rarely end fatally, however gloomy the pros- pect may appear when they are first discovered. And yet death from them is not so infrequent as to warrant an entirely favorable prognosis. Frequency These statements are to a certain degree corroborated by an examination into their frequency. Were they as dangerous as is some- times supposed, a large number of deaths would be annually produced by them, for, to use the words of McClintock, '' without question the most frequent organic disease of the uterus, if we except inflammation and its effiicts, is fibrous tumor." Bayle estimated that of all women dying be- COURSE, DURATION, AND TERMINATION. 527 yond thirty-five years of age, twenty per cent, were thus affected. Even supposing tiiat this assumption was an exaggerated one, an idea of the frecjuency of the affection may be gathered from the fact of his venturing upon it, and surprise at it will be modified when the following extract is read from Klob.^ In speaking of their frequency, he says, "At the cli- macteric period, it is such that undoubtedly 40 per cent, of the uteri of females, who die after the fiftieth year, contain fibroid tumors." Let the diagnostician who has discovered a uterine fibroid, and feels prompted to give a grave prognosis concerning it, bear these facts in mind, and he may be prevented from injuring his patient's comfort and his own reputation by so doing. Course, Duration, and Termination — As already stated, these growths may attain the enormous weight of fifty pounds. Fortunately they very rarely reach such dimensions, but even when they do not, they sometimes exhaust the patient by metrorrhagia, leucorrhoea, hydrorrhoca, and a low grade of constitutional irritation, often attended by hectic fever. But this termination, like the pi*eceding, is exceptional. Having attained a mode- rate size they generally remain stationary, or increase slowly until the menopause, creating considerable inconvenience and depreciating the patient's strength by hemorrhage. Then undergoing a certain degree of atrophy with the cessation of uterine and ovarian functions, they cease to be, to any degree, a source of annoyance, or at least of danger. Even during the age of uterine activity, natux-e may, unaided, effect a cure by the following means : — Absorption or atrophy ; Direct expulsion by rupture of attachment ; Sloughing, from deprivation of nutrition, or inflammation ; Calcareous degeneration ; Gangrene. The tumor is sometimes deprived of nutrition by inflammatory action occurring in the vascular structure of the uterine attachment, which has already been described, collections of pus being sometimes discovered in it. Throughout their existence these tumors sympathize in the uterine changes which attend upon these three conditions: menstruation, utero- gestation, and the menopause. With the occurrence of menstruation they, like the tissue of the uterus, become congested, enlarged, and sensitive. During pregnancy their component muscular fibres grow, and probably undergo retrograde metamorphosis after delivery. As senile atrophy suc- ceeds the menopause, their nutrition is impaired', and fatty and calcareous degeneration sometimes occur. Sometimes fluid collections take place within these masses, some morbid process destroying their tissue as if by liquefaction. The fluid thus col- ' Op. cit., p. 177. 528 FIBROID TUMORS OF THE UTERUS. lecting may be purulent, wtitery, or sanguineous. In some cases a colloid degeneration is said by pathologists to occur in or near the centre of the mass, which softens down and liquefies the fibroid tissue. In others, an apoplexy takes place, which creates the initial cavity, and this is subsequently found filled with the debris of the clot and with turbid serum. Palliative Treatment In the vast majority of cases of interstitial and subserous fibroids, the efforts of the practitioner sliould be limited to pallia- tion of the evils resulting from these growtlis. These evils will generally be due to either one or all of the three following conditions which result from them : displacement of the uterus ; pressure on surrounding organs and parts ; and menorrhagia or metrorrhagia. The first will often be greatly relieved by restitution of the displaced organ, and its retention at, or even above, the superior strait. This may be accomplished by the ordinary means of replacement, and the use of the bulb pessary (Fig. 192), in difficult cases, or of one of the varieties of intra-vaginal anteversion or retroversion pessaries, in less obstinate ones. By a properly adjusted pessary, aided by complete removal of weight and constriction from the abdomen, and the use of an eflftcient abdominal pad, the second set of evils may be ameliorated. Relief of hemorrhage generally proves difficult, and not rarely impossible. The presence of the fibroid in utero keeps up congestion of the endometrium, and this results in leucorrhoea, hydrorrlioea, and menorrhagia. Fortunately, good can generally be, to a limited extent, at least, effected by rest in the recumbent posture during the menstrual periods ; the use of hemostatic agents, as elixir of vitriol, ergot, viscum album, cannabis indica, gallic acid, etc. ; and the use of the tampon after a sufficient loss has occurred to meet the demands of ovulation. The practice of applying a tampon of carbolized cotton impregnated with solu- tion of alum after a menorrhagic flow has, under these circumstances, lasted for four or five days, I often resort to, and never with any but good results. Without some such controlling influence, the patient will commonly become greatly exsanguinated. While these means are being adopted the bowels should be kept regular, and the functions of the skin and liver carefully supervised. In some cases the engorged condition of the mucous membrane lining the uterus causes it to become covered by little fungoid growths, which keep up and greatly increase the amount of hemorrhage. Under these cir- cumstances, the application of the wire curette is of great service. Even if there should be an error in diagnosis, this treatment will accomplish good by severing the distended vessels of the mucous membrane, and relieving congestion. Should it be found that by this means even, hemorrhage is not suffi- ciently controlled, resort should be promptly had to palliative resources of a more decidedly surgical character. These may prove efficient as CURATIVE MEDICINAL MEANS. 529 hemostatics, while at the same time they prepare the way for curative means, if they should be in time deemed necessary. It has been found that hemorrhage due to uterine fibroids is often greatly diminished by section of the uterine neck, a practice which was first inaugurated by Amussat, and imitated by Nelaton, Brown, and Mc- Clintock. In some not very explicable manner, cutting, through the cervical canal by deep incisions on its sides exerts a good influence in controlling this form of hemorrhage. A still more powerful effect will follow incision directly through the investing coat of the tumor itself, so as to cut its capsule, its superficial layer of fibres, and its superficial blood- vessels, and thus diminish its vascular supply. When, however, the tumor becomes so accessible as to render this possible, complete removal becomes so likewise, and should be preferred. Curative Medicinal Means Whether absorption of these neoplasms can be excited by any of those medicines styled absorbents, is not cer- tainly ascertained. Tumors have in some instances been known to dis- appear while such drugs have been employed, and perhaps they did so in consequence of their use. But no such eftect can be looked for with any confidence. Indeed, with our present experience, such a result must be regarded as decidedly exceptional. Scanzoni, after advising those medi- cines which are most popular as stimulants of absorption, says, "We do not remember a single case in which, with the means indicated, or with others, we have obtained the complete cure of a fibrous body." If such drugs be tried for this purpose, they should be continued for many months, and even a year or two, before the trial can be considered fairly made, for their action is never immediate. Those in greatest esteem are iodine, the iodide and bromide of potassium ; that class of drugs supposed to possess the power of inducing fatty degeneration, as arsenic, phosphorus, and lead, " steatogenic" drugs, as they have been styled; preparations of lime ; and the waters of certain mineral springs, as Kreuznach, Kissingen, Krankenlieil, etc. Some of these waters may be employed externally in the form of baths as well as internally. About eight years ago, a series of eight cases of uterine fibroids was published by Hildebrandt,^ of Konigsberg, in which the only treatment adopted consisted in the subcutaneous injection of ergot. In seven, an extraordinary improvement took place. The theory of the plan is this : compression of the tumor by ergotic contraction of uterine fibre interferes with nutrition ; fatty degeneration in consequence occurs ; and the tumor is thus rendered susceptible of absorption. The results obtained by Hilde- brandt were so favorable, that even the most sanguine were led to fear that future experience might not prove as successful. His method has, how- • Berlin Klin. Wochenschrift. Amer. Journ. Obstet., Nov. 1872. 34 530 FIBROID TUMORS OF THE UTERUS. ever, been so far tested by others that it must be conceded that it promises better results than any other which has been employed. The following is a condensed synopsis of some of Hildebrandt's cases: — Case 1. Patient eet. 31 ; tumor for three years ; uterus as large as at seventh month of pregnancy ; hemorrhages frequent and copious. Injec- tions of ergotine practised daily for six weeks, when menses became regular and painless. Injections continued daily for fifteen weeks more, when tumor, which had been growing smaller from week to week, was found to have disappeared. Case 2. Under use of injections uterus "diminished in volume by ab- sorption of the intrauterine tumor ; menstruation became regular ; and pain and leucorrhoea disappeared." Case 3. Patient vet. 30 ; profuse sanguineous discharges, sometimes lasting from six to eight months, since the age of sixteen. Anaemia and emaciation extreme ; fundus of uterus nearly midway between pubis and umbilicus ; by touch, tumor distinguished in the anterior -wall of uterus. Subcutaneous injections daily from January 17th to March 5th, when the patient was discharged ; menses regular ; general condition improved; and uterus notably diminished in size, the vaginal jDortion having in great part returned to its iiormal volume. Case 6. Patient tet. 45 ; uterus reached to umbilicus ; anteverted ; large fibroid in anterior wall ; hemorrhage ; and irregular menses. After resort to injections, improvement was well marked ; fundus descending to a point midway between umbilicus and pubes. The solution used by the hypodermic syringe consisted of three parts of the aqueous extract of ergot to seven and a half of glycerine and the same of water. The point of puncture was the hypogastric region. At each injection three grains of the extract were used. In some cases this treatment produces severe ergotism at so early a period that it has to be desisted from, while at others it residts in the production of small abscesses of painful character. Hildebrandt declares that the introduction of the needle straight down into the subcutaneous areolar tissue obviates the occurrence of abscesses. Should (he subcuta- neous method disagree with the patient, as it did in two out of Hilde- brandt's nine cases, ergot may be given by mouth or rectum, with the prospect of exciting tonic uterine contraction, diminishing vascularity, and lessening sanguineous and mucous discharges, and subsequent growth of the tumor. Although the experience of others with this practice has not been so good as that of Prof. Hiklebrandt, all who have tested it must admit that his method possesses great merit, and fills a place in treatment which has heretofore been unoccupied. Ergot not only acts by exciting uterine action and thus interfering with the growth and retention of the neoplasm, but it likewise causes contraction of the bloodvessels themselveS; and thus impairs nutrition and limits development. Its advantages as a palliative CURATIVE MEDICINAL MEANS. 531 means have been already mentioned ; in that capacity it also acts in the two ways, of constrictor of uterine fibre and of arterial muscle. This explains its results in hemoptysis and other varieties of hemorrhage. Prof. Hildebrandt, in the American Journal of Obstetrics, gives an account of 19 cases, and in the Berlin Klin. Wochenschrift of 8 cases, in which he has treated fibrous tumors of the uterus by hypodermic injections of ergotine. Out of the number 3 were cured; 11 were diminished in size, and the metrorrhagia and leucorrha3a cured ; 4 showed no effect from the treatment; and in 9 the tumor was not affected, although the hemor- rhage was relieved. One tumor of very large size extending above the umbilicus entirely disappeared. He considers the treatment most likely to result favorably — 1st. When the tumor is submucous; 2d. AVhen the tumor is richly provided with muscular tissue, and pos- sesses the consistence and feel of a tense, elastic cyst ; 3d. When the walls of the uterus are sound and capable of vigorous contraction ; 4th. When the chronic metritis or parametritis has been removed by proper treatment; 5th. When the tumor has collected no capsule. Byford has collected 101 cases from various sources ; of these he reports — Cured 22 Benefited by relief of liemorrhage and leucorrlicea . . .19 Tumors diminished in size and liemorrhage removed . . 39 Resisted treatment ......... 21 The best preparations for hypodermic injection that 1 know of are Squibb's ergotine dissolved in glycerine and water, Merck's ergotine, and Bartholovv's solution. Tiiese should be used fresh, the needle should be previously washed in carbolized water, the fluid thrown well down into the subcutaneous cellu- lar tissue, and the part gently rubbed with the palm of the hand after injection until all tumefaction disappears. The injections should be given irom three to seven times a week. Subperitoneal tumors are not nearly so favorably affected by this method as interstitial and submucous growths. In the last variety the danger of the creation of" sloughing at a time when the rigidly contracted state of the OS prevents resort to surgical procedure for immediate removal should not be overlooked. I have seen quite a number of fatal cases from this cause. Hildebrandt's method is a very trying one for the patient. Many suffer from abscesses, some from severe uterine pains, while others positively object to the pain and annoyance of repeated punctures to such an extent as to cause the physician to desist from treatment. 632 FIBROID TUMORS OF THE UTERUS. Dr. Eplu-aim Cutter, of Boston, has obtained excellent results in these cases from a strictly animal diet of the most nutritious character, and the passage of the galvanic current through the tumor by puncture on each side of the abdomen by strong steel electrodes. He declares that very little constitutional disturbance follows these punctures, and that great diminution of size commonly results, with occasional complete cures. In April, 1880, Dr. Cutter reported to the Boston Gynecological Society the following results : — No. of cases treated by electrolysis 50 No. in which growth was arrested ...... 32 No. in which growth was not arrested ..... 7 No. which ended fatally 4 No. which were cured 4 No. whicli were relieved merely ...... 3 Before taking up the consideration of the surgical resources applicable to uterine fibroids, I would sum up the general management of their varieties in the following manner : — 1st. With the means at presen-t at our command, all t^he varieties of fibroids, the subserous, the submucous, and the interstitial, are amenable to extirpation ; but the danger of removing t«he first by laparotomy is so great that this should not be resorted to unless life be threatened by the non-removal of the tumor. 2d. If an interstitial fibroid be readily accessible by cutting through its investing tissues, it should be removed. 3d. Submucous fibroids divide themselves into two classes, thus : if the OS internum be obliterated, and the tumor present at or within the os externum, the case is most favorable for removal ; if the os internum be unyielding, and the cervical canal undilated, danger will always attend dilatation preliminary to removal of the growth. 4th. In cases unfavorable for removal it is best to resort to good diet, tonics, ergot, and means calculated to palliate symptoms, and await an alteration in existing circumstances which may prove more favorable to a resort to radical treatment. Curative Surgical Procedures — The gynecologist of to-day in recog- nizing the important advances in his department, signalized by the dis- covery of ovariotomy, the cure of vesico-vaginal fistula and reparative operations upon the perineum, the uterus, and the vaginal walls, often forgets how much has been done in reference to the extirpation of uterine fibroids of all three varieties. Prior to the present century, and even during the first half of it, the operation of laparotomy for subperitoneal tumors of this class was unknown ; interstitial tumors were uninterfered with ; and he who studies the methods of those who attacked submucous growths by the constricting ligature, will at once appreciate how hazard- 'ous, difficult, and uncertain were the means at the disposal of the surgeon of the olden time for dealing with them. CURATIVE SURGICAL PROCEDURES. 533 The key-note to the modern advance in this subject was struck by the late Dr. W. L. Atlee, of Philadelphia, when in the year 1853 he presented to the American Medical Association an essay entitled, " The Surgical Treatment of Certain Fibrous Tumors of the Uterus heretofore considered beyond the Resources of Art." This essay received the prize of the asso- ciation, and to-day stands as the pioneer article in the surgical literature of these grave and otherwise irremediable cases. Both in this country and in Europe the lead of this bold surgeon has been followed, and the methods which he advocated a quarter of a century ago, and which slowly battled with a pretty decided opposition, ha%'e come to be recognized as legitimate surgical resources. The views of Atlee, as published in 1853, may be epitomized in these three propositions :- — First — If a non-pediculated tumor cannot, from the nature of its attach- ment and envelopes, be expelled or drawn by mechanical means through a dilated os uteri, it is advisable to make by the knife a means of escape for it into the uterine cavity, through its capsule or enveloping tissues. Second — If the tumor thus offered an outlet cannot be removed, it should be forced into and out of the uterine cavity by cutting the cervix, and persistently using ergot. Third — The tumor, once coming within reach, it should as soon as practicable be enucleated or detached, and removed by the surgeon. That this method of treating such cases is attended by the great dan- gers of septicaemia, peritonitis, hemorrhage, and exhaustion, is not to be denied. But it must be borne in mind that while heroic interference is environed by risks, a Fabian course, a policy of watching, waiting, and inactivity, is by no means always a safe one. The growing tumor creates exhausting hemorrhages, dangerous mental depression and anxiety, and disturbance of the functions of nutrition and excretion, which slowly drag the patient down to death. Tlie dangers attending strangulation of a uterine tumor by a constricting ligature are now recognized as of so grave a character as to render every cautious surgeon averse to the employment of this method, and although the boldness of the plans recommended by Atlee may appal the timid prac- titioner, it is now pretty generally appreciated that in apparent temerity there is a degree of safety not to be found iu measures which are osten- sibl}' milder and safer. The plans now usually adopted for the extirpation of submucous and interstitial fibroids may thus be summarized : — Excision ; Ecrasement ; Avulsion ; Enucleation ; The production of sloughing. 534 FIBROID TUMORS OF THE UTERUS. The two elements which govern success in the removal of these growths by the surgical processes which now come to be considered are these : 1st, the degree of projection of the tumor into the uterine cavity ; 2d, the de- gree of dilatation of the cervical canal. I do not say that they de(nde the propriety of operation. Removal may be practised where the tumor is to a great extent interstitial, only causing slight protrusion inwards of the mucous membrane, and where the cervical canal is completely contracted. But in such cases it is more difficult of accomplishment, and much more dangerous to the life of the patient. An interstitial fibroid excites uterine contractions, which in time usually extrude it, making it either subserous or submucous. In both cases it carries with it a covering of uterine tissue, which when it enters the uterine cavity is one of the influences which prevent its expulsion into the vagina ; the closure of the cervix being another. In some cases nature unaided overcomes these obstacles. When they are too powerful for her, art comes to her aid and removes them. If the cervical canal be sufficiently dilated to allow of immediate access to the tumor, much danger, delay, and trouble are avoided by that condition. If it be deemed best to force open the way to the neoplasm, the cervical canal may be distended by cutting through it up to the vaginal junction, and giving ergot to expand it ; by dilating it gradually by tents ; and by forcibly dilating it by water bags, or by graduated dilators. Hydrostatic dilatation is applicable only when the part is dilatable, and offiirs little resistance. The ordinary water bags known as Barnes's dilators are not powerful enough for the expansion of the cervix of the non-puerpei'al uterus, and besides this they dilate irregularly. Molesworth's dilators, shown in Fig. 212, are by far more efficient in these cases. This instrument consists of Fig. 212. Molesworth's cervical dilators. a series of long bags of pure rubber, constructed in such a manner as to secure lateral expansion without elongation, and a nickel-plated force- pump, worked by screw power, by which water or air can be forced into the bag, to dilate it as rapidly or as slowly as desired. Each instrument EXCISION. 535 has a small stopcock, enabling the operator, Fig. 213. if he desire, to remove the pump, leave the bag in position, and thus continue dilatation for any length of time. Each instrument has several bags, the smallest of which is one-eighth of an inch in diameter, and capable of being dilated to from one-half to three-fourths of an inch. The largest bag is one-fourth of an inch, and can be dilated to from one to one and a half inches. The method which I have found safest and most certain for preparatory dilatation of the cervix is that of cutting through its walls laterally by Paquelin's'thermo-cautery in the direction shown by the dotted lines in Fig. 213, and then keeping the patient under the hypodermic use of ergot. Excision Should a small submucous tibroid project into the uterine cavity, it may be removed by the severance of its attachment by means of the knife, scissors, or other cutting instrument. If it be within reach of the knife or scissors, it may be removed by them. In case it be attached higher in the uterine cavity, the polyptome of Aveling may be made to answer a good purpose (Fig. 214). Incision of cervix by Paqut'lin's knife for the accomplishment of dila- tation. Fig. 214. Aveling's polyptome. Removal may likewise be accomplished by the forceps of Nelaton, represented in Fig. 215, or by long-handled, curved scissors, by which as Fig. 215. N61aton's forceps. much as can be got within their blades should be cut away. In this way, piece by piece, a large portion or the whole of the growth may be excised. 636 FIBROID TUMORS OF THE UTERUS. Ecrasement In many cases in which excision may be practised, ecrase- ment becomes possible and should be preferred. The operation consists in cuttino- off the mass, as near its attachment as possible, by the ecraseiir. This instrument, the invention of M. Chassaignac, of Paris, consists of a Fig. 216. The 6craseur, straight and curved. Fig. 217. flattened tube of steel which has two rods of the same metal passing through it to its upper extremity (Fig. 216). To the end of each of these the extremity of a chain is attached. This is passed around the part to be cut off, and the rods are retracted by a ratchet movement at the other extrem- ity. Steadily and slowly the chain tightens around the mass and cuts its way through it. The ecraseur not only presents the great advantage of prevent- ing hemorrhage, but experience proves that after its use inflammatory action is much less likely to occur than after that of cutting instruments. Should the tumor be small and have passed out of the uterus into the vagina, the chain of the ecraseur may be passed over it as a noose, by the fingers. If it be small and inside the uterus, or if the tumor be of great size, whether in the vagina or uterus, it may be necessary first to pass a cord around it by means of canulaj, and in this way to draw in place the chain, which may be subsequently attached to the ecraseur. In many case the use of the ecraseur is so difficult that it becomes inef- fectual. Under these circumstances the wire rope ecraseur of Dr. Brax- ton Hicks answers a most excellent purpose. Its constricting wire is stiff', The ecraseur at work. AVULSION — ENUCLEATION. 637 small, and manageable, and thus we may be able to ensnare a tumor which was unattainable by Chassaignac's instrument. Should the tumor be very large and fill the vagina completely, there are two methods by which it may be entirely removed : 1st, it may be drawn down by obstetric forceps and delivered ; 2d, it may be cut away, piece by piece, until its base be reached. By the first plan the uterus is Temporarily inverted, the morbid growth removed by the knife, scissors, galvauo-cautery, or ecraseur, and the uterus replaced, after the stump, should it bleed, has been seared by the red-hot iron. Of these I greatly prefer the second, which I have oi'ten practised, and never with hemor- rhage as a result. Avulsion The cervix being dilated, the tumor is seized by vulsellum forceps and firm traction, with slight rotatory movement, made upon it. Under this tractile force its uterine attachments may be ruptured and the tumor come away. If it do not do so, the operator passes one hand into the vagina and two fingers into the uterus, by which he ruptures the attachments of the growth and thus frees it. Meantime the hand of an assistant is placed over the hypogastrium to steady and depress the uterus. Dr. West,^ writing in 18G4, says, "The forcible avulsion of polypi is a rough and hazardous proceeding, a relic of barbarous surgery." Enucleation Where the attachments of the tumor are so extensive, or where it is so much embedded in the uterine parenchyma, as to render it impossible to practise upon it any of the procedures already described, the operation of enucleation offers itself as a most efficient and valuable resource. It has been stated that the attaclmient of submucous and even interstitial fibroids to the uterine wall is not firm, they being surrounded by a layer of loose cellular tissue. This fact suggested many years ago, to the mind of Velpeau, the possibility of enucleating them, and in 1840 M. Amussat put the theory into practice. At the same time that it must be regarded as a valuable resource in many difficult cases, it cannot be denied that it is one attended by great hazard, as it may be destructive to life by inducing exhaustion, hemorrhage, perforation of the uterus, pyaemia, or inflammation of the pelvic viscera. Dr. West reports twenty-eight cases in which it was performed, fourteen of which proved fatal. "Peritonitis, phlebitis, and pyaemia," says Dr. West,' in estimating the prospects of success held out by enucleation, " the consequences of vio- lence done to the uterus of women exhausted by large and frequently repeated floodings, are dangers from which but few have altogether escaped; under which I fear that correct statistics will show that most have suc- cumbed." The dangers attending its performance should not deter the surgeon from resort to it in suitable cases which absolutely require aid. They should merely induce him to exhaust all palliative means before resorting to this. > Op. cit., Eug. ed., p. 305. 638 FIBROID TUMORS OF THE UTERUS. Enucleation may be practised by two methods: immediate, in which the fingers of the operator at one sitting accomplish the removal of the tumor; and gradual, in which the fingers of the operator merely inaugu- rate the process which contractions of the uterus are excited to com- plete. If the first plan is to be pursued, the patient, after previous complete dilatation of the cervical canal, is placed upon her back upon a strong table, the legs being held by assistants. An assistant firmly depresses the uterus by pressure on the abdomen, and the operator, by means of a pair of scissors, guided by two fingers, cuts into the capsule. Into this opening he passes the index finger and fixes the tumor. By means of scissors or a probe-pointed bistoui-y a crucial incision is then made through the cap- sule as freely as circumstances will admit. Passing one hand cautiously into the vagina, and forcing the uterus towards the vulva by his otlier hand and that of an assistant, he now proceeds to peel back the capsule and gradually to enucleate the mass. Usually the desired result will be accomplished, and an artificial os thus oftered for escajje of the tumor from its capsule. If the vagina be not very dilatable, it had better be prepared for these manipulations by copious warm vaginal injections and gradual distention by water bags. If the second plan^ is decided upon, the os being dilated or incised, a long crucial incision is made over the presenting part of the tumor, the lips of the capsule separated by the finger, and the patient put upon the steady and systematic use of ergot, in the hope that the body of the tumor may present through this species of os, and be expelled by uterine efforts. Production of Sloughing Baker Brown and others adopted for the removal of these growths plans for mutilating them, and thus'establishing the process of sloughing by which, a partial liquefaction of their tissue being effected, they could be more readily discharged by uterine efforts or removed manually. I mention the plan only to inveigh against it in the strongest terms. It should be cast aside for the reasons that it is attended by very great dangers, and that much better ones are at our disposal. Although these metliods are, as I have stated, far in advance of strangu- lation by ligature, to all of them serious objections and deficiencies attach. Excision, from the fact that it is, except in the case of pediculated growths, difficult to reach the point of uterine attachment by knife, scissors, or polyptome, is often impracticable. Torsion can be applied only to pedicu- lated tumors. Avulsion and enucleation are difficult of accomplishment, slow of performance, and so exhausting to the patient that she is in dan- ' An excellent resume of this subject, including both the immediate and gradual forms of enucleation, will be found in the Med. Times and Gaz., Aug. 1857, by Mr. J. Hutchinson. I mention this particularly because some more recent writers appear to regard this mode of dealing with fibroids as entirely new. EXCISION WITH SPOON-SAW. 539 ger of sinking in consequence. Ecrasement frequently fails to remove the entire growth, and leaves the uterine attachment to decompose and cause septicaemia. And the removal of uterine tumors by the establishment of the process of sloughing, insures so certainly, as has just been stated, the great dangers of septic poisoning, that this method should, in view of the fact that much safer ones are at our disposal, be now regarded as unwar- rantable. Instead of the occurrence of sloughing being courted by the surgeon, it should in these cases be feared, and avoided by all the means by which he can oppose its develojiment. One of the great objections to the use of ergot as a means of causing the enucleation or expulsion of large submucous growths is the tendency of the compressing influence of the uterine fibres to impair the nutrition of the neoplasm so completely as to produce its death and decomposition. Dr. Emmet advocates very strongly the removal of fibroids projecting into the uterine cavity by firm traction, which he thinks causes the uterine parenchyma to expel the tumor in imitation of a natural process, and then cutting off" the most prominent part attainable in the vagina by curved scissors. In this way he reports the successful removal of a number of large fibroids. I now proceed to lay before the reader a plan which experience leads me to regard as superior to any of these, and which I believe will super- sede them with all who are willing to give it a fair trial. This method consists in seizing the tumor at Fjg. 218. its most dependent and accessible point with strong vulsellum forceps, passing up along its sides the spoon-saw or serrated scoop depicted in Fig. 218, and by a gentle, pendulum motion from side to side sawing through the attachments of the tumor and free- ing it entirely from its connections with the uterus. Tliis instrument consists of a steel spoon with a strong handle, twelve or thirteen inches long. The spoon itself is slightly convex upon its outer, and concave upon its inner surface, while its borders are serrated. The saw teeth are blunt and not slanted in either direction, but perpendicular. The outer convex surface protects the uterine wall entirely, while the inner and concave causes the instrument to hug the tumor and run along its surface as it cuts its way laterally and upwards. The advantages wliich experience teaches me at- tach to this instrument are the following: 1st, the attachments of the tumor are separated by a saw, which greatly limits hemorrhage; 2d, the shape of the spoon, convex without and concave within, The spoon-saw. 540 FIBROID TUMORS OF THE UTERUS. causes it to follow of itself the contour of the tumor unless this be very lobulated, and protect the enveloping uterine tissues from injury ; 3d, rhe highest points of attachment of the tumor are as readily reached as the lowest, the freed growth descending under traction as the saw severs its adhesions in successive sweeps around it; 4th, the saw action gives to the process of separation, whether the growth be interstitial or submucous, sessile or pediculated, rapidity and certainty ; and 5th and last, though by no means least, the nature of the spoon-saw secures separation of a growth at the highest point of its attachment, leaving no peduncle to decompose. Before endeavoring to remove a sessile uterine fibroid, it is always ad- vantageous to learn as much as possible about the degree of its attachment. Not that even universal attachment should prevent the removal of the neoplasm by means of the spoon-saw, but because here as elsewhere " knowledge gives power," and creates confidence. I have, after trying various methods of doing this, settled upon the use of the flat, elastic whalebone sound, which is represented in Fig. 219. Fig. 219. Elastic flat whalebone probe. The manner in which I came to employ this was the following: Going to the country to remove a submucous fibroid, I endeavored by means of Simpson's sound, Sims's probe, and my own round, elastic whalebone sound to discover the extent of attachment of the growth, but for some reason could not succeed. Taking then a flat piece of whalebone about six inches long, which one of the ladies present removed on the instant from her dress, I put a knob upon it by touching it repeatedly with melted sealing-wax, and I em[)loyed this with perfect success. This improvised sound I took away with me, and for a year or more employed it on simi- lar occasions. After that I had one made artistically, which is represented in Fig. 219. This sound is used in this way: The index finger of the left hand is placed on the most accessible part of the tumor; then the sound, held in the right hand, is slid up on one side between the tumor and the uterine wall until arrested, when the index of the left hand is placed upon its shaft at the os externum uteri. The sound being then withdrawn, and the finger kept upon it, it is laid upon a sheet of paper or against a black- board, and being curved, a line is drawn from its tip to the indicating EXCISION WITH SPOON-SAW. 641 finger. Then the sound is passed on the other side, and a similar trans- fer of its course is made to the sheet or board. In this way it is possible not only to approximate the truth, but to be \yonderfully exact as to it. I have repeatedly demonstrated the efficiency of this sound to classes of students and to medical men, and I feel sure that it leaves nothing to be desired in reference to the determination of the degree of attachment of any uterine fibroid which can he fully touched by the Jinyer. Without this possibility the method is unreliable. There is no method by which I could so surely lay the claims of this instrument before the reader, and at the same time demonstrate its appli- cation, as that of reciting two average cases in which I have employed it; one a case of submucous and one of interstitial fibroid : — Case I — In June, 1876, I was called by Dr. John Burke, of this city, to see with him Mrs. A., a lady forty-seven years of age, who had been for four years suffering from a very profuse menorrhagia and metrorrhagia. To such an extent had she been reduced by loss of blood that she was generally confined to her chamber, and suffered from oedema pedum, palpitation of the heart and dyspnoea upon the slightest exertion. Ilor appearance was that of one suffering from an exaggerated degree oi' anaemia, which was rapidly being aggravated by repeated and seveie hemorrhages. The liver was found to be very much enlarged, -as was likewise the spleen ; the former, as we supposed, from fatty degeneration, the latter from malarial poisoning. Mrs. A. had been examined repeatedly as to the uterine condition during this period, and twelve months before I saw her Dr. Burke had discovered the existence of a submucolis uterine fibroid, supposed to be as large as the egg of a goose. At no time up to June, 187G, did he con- sider her in a condition fit to admit of an efllbrt at the removal of this, but at that time he called me to decide whether it would not then be pos- sible. When I first saw her I found the uterus, by conjoined manipulation, as large as it would be in pregnancy at the fourth montli, admitting a sound to a distance of five inches, and the ti[) of the index finger, when force was used, so that a hard, pyriform tumor could be touched in the uterine cavity. The patient was so much exsanguinated, so much exhausted, and her nervous system so profoundly depressed, that I decided against operation, and she was fully sustained by diet and fresli air, in the hope that a few months would so improve her state as to render operation possible. I saw her several times after this with Dr. Burke, but instead of getting better, she steadily grew worse, and in September general dropsy set in, afiecting the peritoneum and the cellular tissue of the body. We now thought the case decided, and gave up all hope of removal of the uterine growth. In time, however, all the effused fiuid disappeared, and about 542 FIBROID TUMORS OF THE UTERUS, Fig. 220. the beginning of January she was so far restored that the question of operation was again agitated. On tlie 15th interference was decided upon, and on the 28lh the tumor was detached and removed. The following diagram represents the attachments of this tumor : — It was free upon one wall only; attached throughout the other to within an inch of the os internum. At midday, on the 28th of January, detachment and extraction were practised in the presence and with the assistance of Drs. Burke, Walker, and Jones. The patient, being etherized, was placed in Sims's position, and his speculum was introduced. The cervix being then caught with the tenaculum, its lips were severed on each side, so as to open the way to the tumor, which could by the finger be felt above before this was done, but now could be quite freely manipulated. A powerful vulsellum forceps was then firmly fixed in the growth, and se- curely locked. Then, with the spoon-saw, the uterine attachments were rapidly and very easily severed. I was equally surprised and pleased, as were also my assistants, at the rapidity, ease, and certainty with which the sawing motion given to this instrument by the right hand separated the tumor from the uterus, even at the fundus. In a very few minutes I had succeeded in de- <.aching and delivering a tumor which by methods which 1 have heretofore adopted would have taken, I think, at least a half hour. Indeed I must say that I believe that in the enfeebled state of the patient by no other method could it have been removed without great risk of fatal exhaustion. The tumor weighed seven and a half ounces, and measured, in its long diameter, four inches, and in its short, three. It resembled in shape and size a large goose-egg, and was composed of the ordinary tissue which characterizes these myomata. The patient entirely recovered, and is now enjoying good health. Cask II — Georgiana P., a't. thirty-six years, who has been married fourteen years, and had one child twelve years ago, since which time con- ception has not occurred, was admitted to my service in the Woman's Hospital, Dec. 20, 1879. The patient was perfectly well until April, 1879, when, just after a menstrual period, she was suddenly seized with profuse uterine hemorrhage, accompanied by severe uterine tenesmus. This lasted only twenty-four hours, but it exhausted her very much indeed. At every menstrual epoch which has occurred since that time she has had profuse hemorrhage, with what she styles " bearing-down pains." This has lasted Attachment of fibroid in Mrs. A.'s case. EXCISION WITH SPOON-SAW. 543 Fig. 221. usually about nine days. During the months of July and August she suffered very much from dysuria and rectal tenesmus. For the last four or five months before admission she had been almost entirely unable to walk, because locomotion created the " bearing-down pains" already alluded to. She declared that up to April, 1879, she was in excellent health. She was aneemic, very pale, and extremely weak. During the month of October, hemorrhage was so severe that a vaginal tampon had to be applied repeatedly to check the excessive discharge of blood. Upon physical examination the uterus was found very large, the fundus extending up to a point midway between the umbilicus and ensiform car- tilage. The cervical canal was distended so as to admit the tip of the index finger freely. The posterior uterine wall, including the cervix, was immensely hypertrophied, and out of all proportion to the anterior. The uterine cavity, measured by an elastic sound, was found to have a depth of nine and a half inches, the sound passing upwards and then inclining somewhat backwards towards the spinal column. The following diagram will convey a more correct idea to the mind of the reader than a much more lengthy description in words would accomplish. The patient, with her husband, had come from Colorado Springs, and was exceedingly desirous to have some curative treatment adopted, ibr experience had taught her the inutility of the treatment by ergot, preparations of lime, and the various other thera- peutical resources which are ordinarily adopted in cases such as hers. Accordingly she was seen with me in consultation by a number of ray colleagues of the hospital staff, before whose consideration I laid the operation which I shall now describe; and I was thoroughly sustained in the resort to it. The propriety of the opera- tion and the urgent demand for prompt action in this case were from the first quite clear to my mind, and at no time did any doubts as to the justice of this conclusion present themselves. The reasons for my convictions were the following: — 1st. My experience with the spoon-saw in a large number of cases made me feel confident that success would crown ray efforts as to the mere sur- gical part of the work. Diagram representing the tumor imbedded in the posterior wall of the uterus. 1 shows the projecting posterior wall; 2, the uterine cavity; 3. the tumor; 4, anterior uterine wall at the point of attachment of the anterior vaginal wall. 544 FIBROID TUMORS OF THE UTERUS. 2(1. The tumor, already large, was growing fast, and, in a few months, the abdomen would have had to be opened to give exit to it. 3d. The patient was losing large amounts of blood, and growing, of course, steadily weaker, and progressively more despondent. 4th. She lived- in Colorado, far away from any surgical centre, and, if she were sent away now, it was highly improbable that, weakened by hemorrhage, discouraged by failure to obtain relief from surgery, and alarmed by the great and increasing size of the abdomen, she would ever again make an attempt to save her life. In the present I saw a courage- ous and comparatively strong and healthy woman, with a fairly good blood state, unimpaired nerve condition, efficient digestive function, and a tumor weighing two pounds, not willing merely, but eager for operation. In the future I foresaw an anaemic, feeble, and despoi dent one with impaired digestion, an exhausted nervous system, and a tumor weighing eight or ten pounds, still willing to submit to operation perhaps, but doing so with diminished hope and lessened enthusiasm. On the 5th of January I proceeded to remove the tumor in tlie following manner, and in the pi-esence of Prof. Alfred C. Post, and Drs. Emmet, C. C. Lee, J. B. Hunter, C. S. Ward, H. D. Nicoll, S. B. Jones, and the house staff of the hospital. The patient, having been etheriz(;(l, was placed in Sims's position upon a strong table before a windov; admitting a good light. During the steps of the operation I was ably assisted by the assistant surgeons in my department, Drs. Ward and Nicoll. Sims's largest speculum having been introduced, and the perineum and posterior wall of the vagina lifted by it, I caught the uterine wall at the point marked by the figure 1 (Fig. 221), and, by means of a pair of long-handled scissors, snipped a piece out of it, extending deeply into its structure. Upon this a very free flow of blood occurred, but I disregarded it, and as I proceeded with the operation it very soon ceased. Keeping a strong tenaculum fixed in the uterine tissue between the figure 1 and the poste- rior vaginal walls, I now passed my right index finger into the opening which I had made, and in this way enlarged it somewhat. Then taking a very strong and large grooved director, I forced it upwards towards the figure 2, and vsliding a knife in its groove, I slit the enveloping uterine wall high up into the uterine cavity. By the finger I now enlarged the opening thus made, and was at once gratified by the sight of the wliite fibrous structure of the tumor of which I was in search. Into this I at once fixed a powerful pair of vulsellum forceps, and taking the spoon-saw swept it around, and detached the tumor from its uterine bed for about an inch and a half or two inches all around. I now made traction upon it with the vulsellum, but found that the tumor was too large to be dragged down into the pelvis. Taking, tiien, a pair of long-handled scissors, I cut out the portion of tlie tumor within the bite of the forceps, removing a piece about as large as a hen's egg. LAPAROTOMY. 545 Then seizing anotlier portion of the tumor, I cut it out, and continuing in this way I remov< d, piecemeal, all that portion which I had detached by the spoon-saw. I now seized the tumor again with the vulsellum forceps, and detach- ing, by means of the spoon-saw, about an inch and a half more of it, I removed it piecemeal by the scissors as already described. This process I repeated till about one-third of the tumor only remained, when 1 de- tached the entire mass with the spoon-saw, and drew it away. The operation lasted one hour and twenty minutes. After the first inci- sion it was accompanied by almost no hemorrhage, and the patient bore it remarkably well. At its conclusion the large cavity left by the re- moval of the tumor was syringed out with strongly carbolized water, and stuffed to its full capacity with carbolized cotton. The patient was put to bed; given a full dose of morphia hypodermically ; kept very warm by the a|)plication of artificial heat; as soon as she could swallow, given brandy and water in small amounts at short intervals, and kept upon the general regimen usually adopted as preventive of shock. I shall not weary the reader with a detailed account of the progress of the case ; suffice it to say, that no bad symptoms developed themselves, and that just one month after the performance of the operation, the patient left the hospital for her home. The tumor weighed exactly two j)ounds, and was a good example of the ordinary myo-fibroma. It must be remembered that its duration is un- known. True, it was discovered in April, 1879, but it is highly probable that it had existed long before that time. At the conclusion of the operation, an eminent surgeon who was present remarked that he was surprised that I had depended so little upon the spoon-saw in its performance. My own feeling in regard to the matter is this : without the spoon-saw nothing would have induced me to touch this case; with it at my disposal, I would willingly undertake to cope with any number of similar ones. After having detached segment after seg- ment of the lower portion of the tumor, dismemberment and removal of parts of it were easy. An attempt to excise and remove the growth before detachment would, I think, have very soon been followed by the filling of the vaginal canal with intestines. I have now operated more than twenty times with the spoon-saw, and its efficiency becomes more and more apparent with increasing experience. At present I resort to no other means for removal of intra-uterine growths which are firm and large enough to admit of traction by the vulsellum forceps. Laparotomy — One of the great questions of the future in gynecology is to be not the propriety but the proper limitation of the operation of lapa- rotomy for the removal of uterine fibroids, involving, as it very commonly does, the ablation of a part or the whole of the uterus. Indeed, no ope- rator should undertake gastrotomy for a uterine fibroid without being pre- 35 546 FIBROID TUMORS OF THE UTERUS. pared, if necessary, to remove the uterus with the tumor, for the connec- tion is often so intimate that a determination of the attachments of the tumor is out of the power of the most skilful diagnostician. Indeed, even after removal of the mass from the body, its relations to the uterus are often discovered only after patient and intelligent search. Dr. Farre tells of a specimen preserved in one of the London museums as a solid ovarian tumor which, upon careful examination, he proved to be uterine by tracing the Fallopian tubes into it. It was also in this way that the nature of a tumor removed by Dr. Storer was identified ; Prof. Ellis, after a very minute examination, distinctly discovering the entrance of the tubes into the cavity of the body, and thus settling the matter. I have said that the future would concern " not the propriety" of the operation of uterine extirpation for fibroids, for, although all conservative men must condemn the reckless resort to the operation, which is sometimes practised at present, all progressive men should, I think, be agreed that under certain circumstances it is not only an admissible but a necessary procedure. The point of difference should be, to-day, not the legitimacy but the indications for the operation. "Seeing the results of the operation in this country," says Emmet, "no surgeon is justified in attempting to remove the uterus for the growth of a fibrous tumor except as a forlorn hope." " At present," says Barnes, " there is little ground for enthusiastic advocacy of the practice. The case may best be summed up by stating that the question is ad hoc sub jiidice." These two eminent gynecologists may be said to reflect the general con- servative sentiment of the profession. And yet this adverse inclination in the professional mind is no more marked than it was a, quarter of a cen- tury ago with reference to ovariotomy, the crowning glory of gynecological surgery. It must be remembered, on the one hand, that many cases in which removal of a large fibroid, which has involved the ablation of the whole uterus, have recovered, and it must be appreciated, on the other, that the surgeon who refuses the chances of operation to one who is failing from the existence of a uterine fibroid, should pause when he reflects that a tumor, the removal of which appears to be exceedingly difficult, may prove upon experiment to be extremely easy. Two cases of my own will illustrate this remark. Fifteen years ago Prof. F. N. Otis brought to me for con- sulfation a patient who had a very large uterine fibroid, and I decided against the advisability of operation. In time the patient died, and a colossal tumor was found unattached in the abdomen, connected with the uterus by a small pedicle, which could easily have been severed. Five months ago a Swedish woman presented herself in my service in the Woman's Hospital with an abdominal tumor, weighing about fifty pounds, which had undoubtedly existed for twenty-three years. Of this fact we had positive proof, apart from her own statement. I felt inclined to regard the tumor as a uterine libro-cyst, and operated with the belief that I should Pozzi2 119 Boinet 46 A. Leblond^ 12 Storer* . 24 Thomas^ 12 Schroeder^ 108 STATISTICS OF LAPAROTOMY. 547 have to remove tlie whole uterus. The tumor proved to be ovarian, and the patient rapidly recovered. The warmest advocate of uterine ablation for fibroids has been M. Pean, the celebrated surgeon of Paris. In 1873 he published statistics, which will soon be cited, and made the following declarations : "Amputation of the supra-vaginal portion of the uterus is not an operation of much graver character than extirpation of ovarian cysts complicated by adhe- sions." .... "Ablation of the uterus is a perfectly justifiable ope- ration, which the surgeon is as much warranted in undertaking under certain circumstances as ovariotomy." At that time he reported nine operations, with seven recoveries, and yet during the past seven years no further report has emanated from him. Statistics — No reliable statistical report on the subject exists, so far as my knowledge goes, so that I shall have to content myself with fragmen- tary evidence. P6an' collected 44 cases, of which 14 recovered and 30 died. 42 " " 77 " " 12 " " 34 " " 8 " "4 " 6 " " 18 " 1 " " 11 " 30 " " 78 " Of Schroeder's cases, 73 with removal of the uterus gave 55 deaths and 18 recoveries (24j^q^q^ per cent.) ; while 35 operations, without removal of the uterus, gave 23 deaths and 12 recoveries (34 j^^ per cent.) It would not be safe to generalize from all these cases, for without doubt many of the same cases have entered into the calculations of several authorities. Having at hand no better material, I present this in its crude state. Let us remember that antiseptic surgery has just dawned upon science, and let us hope that the statistics of the future will show a great advance over those of the past. Supported by such statistical evidence, it is certainly not venturing too much to say, that, if a fibroid be pedunculated and unattached, its re- moval is not much more dangerous than the ordinary operation of ovari- otomy was a few years ago ; that, if it be completely ajiialgamated with tiie uterus, or so bound to neighboring parts that removal proves very difiScult, the operation may be abandoned, the patient having, without great risk, availed herself of the only chance of cure ; and that, even if tlie removal of the tumor involve that of the uterus and ovaries, we may ' Hysterotomie, par J. Pean et L. Urdy, Paris, 1873. 2 Pozzi, These d'agr^gation, 1875. 3 Traitg Elem. de Chirurg. Gynecol., Paris, 1878. * Successful Removal of Womb and both Ovaries, 1866. ^ Dis. of Women, 1874. f- Dis. of Female Sexual Organs. 548 FIBROID TUMORS OF THE UTERUS. Still indulge in a fair hope of saving our patient. Surely, when ablation of the entire uterus, as an addendum to the Ca3sarean section and as a remedy ibr cancer, is winning the position of a warranta^ble procedure by reason of the success attending it, he who allows death to occur from uterine fibroids without offering his patient the chance of safety possible from gastrotomy, is assuming a responsibility far greater than that which would attend an honest and well directed effort to save life. The same arguments which can be urged in favor of ovariotomy do not, however, apply to tliis procedure. Ovarian tumors almost always run a rapid course toward death ; fibroid tumors do so only exceptionally. The former are not ameliorated by the menopause ; the latter are usually greatly benefited by it. The accidents which have generally produced a fatal termination in cases of gastrotomy are as follows : — 1st. Primary or secondary shock or collapse ; 2d. Remorrliage ; 3d. Peritonitis ; 4th. Septicaemia. We are now possessed of means for limiting the first ; the improved methods of hemostasis at our command diminish the danger of the second ; and the knowledge of the fact that antiseptic surgery markedly diminishes the probability of the occurrence of the third and fourth, will in future aid in avoiding them. Methods of Removal I shall now proceed to describe three operative procedures, the first that of Pean ; the second that of Schroeder ; and the third my own. Peaii's Operation. — This is divided into three stages. The first one consists in making an abdominal incision through the median line, ex- tending downwards to one inch above the symphysis pubis, and upwards towards the umbilicus as short a distance as is compatible with exposure of the surface of the tumor. Second Stage If any fluid exist in the tumor it should be evacuated by puncture by a trocar or canula. If it be small enough, either before or after this, to be drawn through an abdoimnal opening of moderate size, this should be done, and the operator may at once proceed to the third stage. If it be solid and too large to be drawn out, it should be removed piecemeal in the following manner. By means of a long, curved needle, two cr three strong wires are carried deeply into the tumor and tightly twisted, so as to constrict the vessels, and the intervening mass is cut away. Then another portion is similarly treated until the tumor is small enough to be drawn out. Adhesions are then carefully tied and broken, and the tumor is delivered. Third Stage The tumor being held up by one assistant, while another closes the abdominal wound to prevent escape of the intestines ; the uterus METHODS OF REMOVAL. 549 is penetrated by tlie long, curved needle near the os internum, or even lower if the tumor extend downwards; wires are drawn into place; the two halves of the cervix are compressed by twisting them ; the tumor is cut off; and the pedicle thus formed is fixed in the wound. The wound is then closed, and the pedicle, which is kept in the abdomi- nal wound by means of the instruments by which the wires were twisted, is treated as after ovariotomy. Sckroeder's Operation.^ — The abdominal incision having been made in the m-jdian line, and the uterus and tumor exposed to view, a needle is passed at the os internum and strong ligatures applied. This cuts off the blood supply to the tumor, which is cut to pieces as we would cut a melon and removed. The incision by which the uterus is removed is wedge- shaped, and the edges of the wound are approximated by deep and arti- ficial sutures, so that the opposing edges of the peritoneum come into contact, and the stump thus arranged is dropped into the peritoneum. ISchroeder has operated for tumors of the uterus six times, with five recov- eries. German operators seem to be pretty uniformly agreed that return of the pedicle to the abdominal cavity and complete closure of this is an essen- tial to a successful system in this operation. The validity of this position is, however, by no means proved. Very surely, the external treatment of the pedicle does not invalidate the perfect practice of Lister's antiseptic methods where proper precautions are used in renewal of the dressings. Thomas's Operation The abdominal walls are incised as for ovari- otomy, and all cystic formations emptied by tlie trocar and canula. The lowest portion of the tumor is then manipulated so that a strong cord, a piece of cod line, for example, is passed under it. By this the pelvic extremity of the tumor is lifted so that one limb of the clamp, shown in Figs. 222 and 223, which measures nine and a half inches in length, can be passed under it. The second limb of the clamp is tlien screwed to the first, the tumor cut through, the severed end of it drawn down by vulsella, and, the entrance of blood to the peritoneal cavity being prevented by stuf- fing napkins under and around the bleeding surface, the mass is diminished in size by the knife, and removed as rapidly as possible. The pedicle is tlien examined, and, if it be found practicable, a second clamp is placed lower down, the first removed, and additional tissue cut away above the lower one. The clamp is kept in place during the progress of the case as after ovariotomy. Should this manoeuvre be found to be impossible from the great bulk of the lower segment of the tumor, the incision is prolonged to such an extent tliat the tumor can be delivered with a certain degree of force. Two assistants then lift it as higli in the air as possible, and the attachment of the bladder to the tumor being examined by a catheter, the former is detached from the latter if this be found necessary. As near to the vaginal ' Amer. Journ. Obstet., Jan. 1879. 550 FIBROID TUMORS OF THE UTERUS. junction as it can be placed, the large clamp is then applied and screwed so firmly as to control hemorrhage. Fig. 222. Thomas's clamp, open. Fia. 223. Thomas's clamp, closed. By this means the portion of the tumor which is to be used as a pedicle is compressed, and as far as possible diminished in bulk. The tumor and as much of the uterus as is above the clamp is now cut off. The clamp is thus far used as the main hemostatic agent ; but it is not to be thus employed permanently. Three or four steel knitting needles are now passed through the tissue just above the clamp, at right angles, so as to support the part after the clamp is loosened. Then by large cautery irons the tissue above clamp and needles is thoroughly charred. This is the permanent hemosta- tic power upon which dependence is placed, and to render it reliable the whole inch of pedicle above the clamp should be completely charred. The FIBRO-CYSTIC TUMORS OF THE UTERUS. 551 clamp is now loosened, tlie ordinary antiseptic dressing applied, and the patient put to bed and closely watched for evidences of hemorrhage or shock. The first should be met by tightening the screws of the clamp ; the second by hypodermic injections of morphia, brandy, and ether, and by warmth to the entire body, and especially to the soles of the feet and palms of the hands. I have now removed the uterus, in whole or in great part, on account of tumors seven times, with four recoveries and three deaths. In no case was the operation one of election ; in every case it was a matter of neces- sity, the patients in every instance having the choice between uterine extirpation and death. These operations, like all others in abdominal surgery, should, with the light which we at present have upon the subject, be performed under the antiseptic method. On the twelfth or fourteenth day the clamp may be cautiously removed. During the last two months I have twice removed the entire uterus by this method, with the recovery of both patients. Oophorectomy Extirpation of the ovaries, castration, Battey's opera- tion, has been now repeatedly performed for the premature induction of the menopause, for the control of the exhausting hemorrhage which so commonly marks these cases. The operation has been performed for the fulfilment of this indication, where uterine tumors have existed, as follows : — Hegar' has operated 12 times, with 9 recoveries and 3 deaths. Freund " 3 " 2 " " 1 " Goodell " 1 " 0 " " 1 " Mann " 1 " 0 " " 1 " Total number of cases, 17 " 11 " " 6 *' Hegar, whose experience with the operation is greater than that of any other authority, regards its efficacy in very large fibroids as doubtful. CHAPTER XXXV. CYSTO-FIBROMATA, OR FIBRO-CYSTIC TUMORS OF THE UTERUS. Definition, Syiionyms, and Frequency. — The form of compound uterine tumor which we are now considering has been described by different authors under the names of cysto-fibroma, cysto-sarcoma, cysto-myoma, cystoid and fibro-cystic tumor. • See, with reference to this subjeet, a paper by Dr. Mann, Areliiv of Med., vol. iv. No. 1, Feb. 1880. 552 FIBRO-CYSTIC TUMORS OF THE UTERUS. Our knowledge of these tumors is but recently acquired, and is even now exceedingly elementary. In two of its most important aspects, diagnosis and differentiation from other forms of abdominal tumor, we have been very deficient, and from this have resulted frequent and serious errors. Considerable attention is, however, being now directed to the subject, and already we are possessed of means which were wanting only a few years a^o for arriving at correct and certain conclusions concerning them. Cysts may develop in connection with the uterus in two entirely differ- ent ways: first, a cyst may grow and become very large, being enveloped by a layer of uterine tissue ; second, solid tumors of the uterus, whether benign or malignant, may undergo cystic degeneration, that is to say, within the structure of a solid tumor cysts may develop, which, distending the spaces in which they first form, gradually increase in size, and it may be in number, until what was formerly a solid growth becomes in certain parts filled with fluid. Thus we may have cysto-sarcoma, cysto-fibroma, cysto-chondroma, or cysto-carcinoma. It must not be supposed that this variety of tumor compares in fre- quency with the simple fibroid, or that cystic degeneration often affects that. It is not a matter of very common occurrence, but it is certainly sufficiently common to demand especial consideration at the hands of the gynecologist. As has been the ease too vyith many other affections, as soon as special attention has been directed to it, it has been found to be much more frequent in occurrence than was previously supposed. Up to the year 1869, Koeberle^ tells us that only fourteen cases had been recorded, of which two were discovered post mortem. Dr. C. C. Lee,^ however, in that year, collected the reports of nineteen cases, nine in this country, eight in England, and two in France. Dr. E. R. Peaslee,' writing in 1872, says, " I have myself met with ten cases in the last two years, and have seen not less than fifty since my first operation of ovariotomy in 1850." Pathology. — Pathologists describe a variety of methods by which spaces may be created within fibroid tumors, which, subsequently becoming lined by a fluid-secreting membrane, are filled with serous, sero-sanguiuolent, or colloid material. "Within some fibroid tumors," says Klob,* "cavities may be found, which may have occurred in several ways. They either result from a dropsical condition, or the connective tissue of the tumor undergoes colloid metamorphosis (mucous degeneration), commencing at the centre of the tumor, and in consequence of which its substance lique- fies into an albumino-serous fluid. Finally, hemorrhages into the substance of a tumor may lead to the formation of cavities similar to the so-called 'apoplectic cysts.'" In speaking of neoplastic cysts, Billroth^ says, "These 1 Gazette Hebdom., No. 16, 1869. ^ Remarks upon Diagnosis of Ovarian from Fibro-Cystic Tumors. 8 Ovarian Tumors, p. 107. * Op. cit. * Op. cit., p. 621. PATHOLOGY. 653 result mostly from softening of tissue previously diseased by cell-infiltra- tion, or a firm tumor substance. As soon as the new formation has sepa- rated into sac and fluid contents, in some cases a secretion from the inner wall of the sac begins, so that the softening cyst becomes a secretion or exudation cyst, and thus grows. Any tissue rich in cells may be trans- formed into a cyst by mucous metamorphosis of the protoplasm, or, as others express it, by separation of the mucous substance through cells without any connection with development of mucous glands." He then goes on to liken the process by which fluid spaces are created in chondro- mata and fibromata to the formation of the joints in the limbs of the foetus by mucous softening of the cartilage tissue, of which the bones of the limbs are formed. Furthermore he declai-es, that "the often slit-shaped, smooth-walled cysts with serous, or sero-mucous contents which occur in uterine myomata, are possibly enormously dilated lymph spaces," a view which was first advanced by Cruveilhier. It will be seen that the term cystic degeneration is rather loosely applied to this aflfection, for the fluid collections taking place are rather results of liquefaction than of true cyst development. Nevertheless I shall adhere to its use. Cystic degeneration affects submucous or interstitial fibroids much less frequently than those which are subserous. The following case reported by Dr. Sims, which he considers one of this degeneration in a submucous fibroid, is worthy of citation. It is described by him in these words : " I passed a trocar into it at its lowest point, and in the direction of its long axis, and there were discharged more than twenty ounces of a colored serum. The puncture was enlarged for two inches to prevent its closing. There was at once a sensible diminution in the size and tension of the abdomen. The discharge kept up for some time ; and this, together with occasional injections into the very fundus of the uterus, with the liquor ferri persulphatis, diluted with three or four parts of water, arrested very promptly the hemorrhages, and the patient was dismissed in two months in a very comfortable condition, and with strength enough to walk six or eight miles." As the records of cases of fibro-cystic tumors are not very commonly met with in the literature of this subject, I shall make reference to a few of them. Kiwisch^ described one which filled the whole pelvic cavity, and extended as high as the ensiform cartilage. It took its rise from the posterior uterine wall ; had as its base a fibroid tumor the size of the head, which was enveloped in uterine substance; and weighed forty-six pounds. Cruveilhier'^ mentions a similar one. Spencer Wells^ speaks of two cases. In one the tumor was connected with the right side of the fundus by a ' Quoted by Klob, op. cit., p. 182. « Klob, op. cit., p. 182. 2 Diseases of Ovaries, p. 354. 554 FIBRO-CYSTIC TUMORS OF THE UTERUS. broad band ; its solid portion weighed sixteen pounds ; its fluid portion twenty-six; and a semifluid material four pounds. The uterus was twice its natural size. In the other there were two tumors, both of which had a uterine attachment, and consisted of solid and fluid elements. A very striking instance of this aflfection I saw submitted to operation by Dr. James L. Little of this city. The tumor, which yielded very obscure fluctuation, fllled the entire abdominal cavity, and was composed of a net- Avork of fibrous tissue, constituting spaces varying in size from that of an apple to that of a cocoanut, which were filled with colloid material. This growth sprung from the neck of the uterus. It took its origin from the post-cervical wall, and the tumor growing from this pedicle filled the whole abdominal cavity, and was before operation regarded as ovarian. Symptoms Fibro-cystic tumors do not vary in symptoms from sub- peritoneal fibroid growths of equal size. Like them they produce — Displacements of the uterus ; Pressure on rectum and bladder ; Menorrhagia in some cases. Physical Signs The uterus is usually found to be enlarged from excess of nutrition resulting from the formative irritation due to the propinquity and connections of the tumor, and to be elevated and lie in front of it. Tlie sensation yielded by bimanual manipulation and by palpation is not that of a hard, solid, and resisting mass, but an obscurely fluctuating sen- sation is discovered. It is common in such cases to find a certain number of examiners inclining to the theory of fluidity, and others to that of solidity in the growth. If an explorative tapping be practised by the hypodermic syringe, a very small amount of fluid, which is usually viscid or turbid, will be withdrawn from some places, while no fluid whatever will appear from others, and if a trocar or a large needle of the aspirator be employed a quart or two of thick straw-colored fluid may be drawn ofi^', leaving, usually, solid elements remaining. In rare cases of large uterine cysts the sac may be entirely emptied, and even these signs be wanting. Differentiation Many competent authorities have declared that the diagnosis of this form of tumor and its differentiation from ovarian cyst is impossible. Koeberle says, " the diagnosis of fibro-cystic tumors has, up to the present time, been declared impossible by almost every author," and Baker Brown acknowledges that he knows of " no distinguishing marks between the two." Even after incision Spencer Wells declares that he knows of nothing but a darker hue of the sac-wall to put the operator on his guard. The result of this difficulty is illustrated by the fact that out of Lee's nineteen cases eighteen were operated on under a mistaken diagnosis of ovarian cyst. The conditions with which this form of tumor will most likely be con- founded are — DIFFERENTIATION. 555 Pregnancy; Fibroid tumor of the uterus ; Ovarian cyst. From the first it may be known by absence of the gastric and mammary symptoms of that condition, by menstruation not only continuing but per- haps showing a tendency to increase in amount and frequency, by absence of foetal movements and heart sounds, and by the duration of the tumor beyond nine months. From fibroid tumor it may be known by its yielding obscure fluctuation, its assuming usually larger proportions, its more rapid growth, and, be- yond everything else, by its yielding fluid to the exploring trocar. From ovarian cyst diagnosis is usually difficult and often impossible ; the chief grounds upon which it will always depend, and upon which it may sometimes be made, are the following: — Shape and density of the tumor ; Its connection with the uterus ; The depth of the uterus ; The rapidity of growth and effect on health ; The effects of tapping ; The characters of the fluid withdrawn ; The elevated position of the uterus in the pelvis. There are other differential signs, but these are the really reliable ones. A great array of symptoms often confuses rather than helps the inexpe- rienced diagnostician, and T wish to analyze the subject here as it should be analyzed at the bedside. When a differential diagnosis is arrived at, it is ordinarily done in the following way : — 1st. The examiner in palpating has been struck by the fact that the surface of the tumor which he supposes to be ovarian is peculiarly irregu- lar and resisting to the touch, and that fluctuation is obscurely yielded in certain places only. This renders him suspicious, and he determines to investigate fully before committing himself to the diagnosis of ovarian tumor which at first suggested itself. 2d. He now examines the uterus and finds that the sound proves it to be much deeper than normal ; that as he rotates this organ upon the sound it appears united to the tumor ; tliat posteriorly to the uterus the tumor seems to join it and grow from it ; and that as an assistant lifts, depresses, and rolls the tumor, the uterus moves distinctly. His suspi- cions are strengthened. 3d. He now questions the patient more closely, finds that she is over thirty, fibro-cystic tumors rarely appear before thirty, and that this tumor lias been slowly but steadily growing for four or five years without materially impairing her health. He feels the necessity for further infor- mation, and resorts to removal of the fluid by the aspirator or trocar. 556 FIBRO-CYSTTC TUMORS OF THE UTERUS, 4th. The fluid whicli pours away is transparent and straw-colored, and as it ceases to flow he discovers that the sac only in part collapses. Test- ing the matter, he finds that this is not due to the existence of other cysts, but that solid elements prevent collapse. 5th. He now examines the fluid withdrawn, and finds that it coagulates spontaneously as well as under heat. The whole contents of the tube give a large coagulum like that of the blood clot in consistence though not in color. Placed under the microscope, a peculiar fibre cell may be dis- covered which is characteristic, according to Dr. Atlee, of the fluid of fibro- cystic and not of ovarian tumors. It is a product derived from the tissue in which the cyst forms itself, the muscular tissue of the uterus. Fig. 224. The fibre cell (A) characteristic of fihro-cystic tumors. (Atlee.) 6th. Anxious now to test as completely as possible the relation of tumor and uterus, he practises the method of Hegar and Schultz. The patient is anaesthetized and laid upon the back ; one assistant pulls the cervix down by means of a tenaculum, and another seizes the tumor and alter- nately lifts and depresses it, while the examiner, by means of two fingers carried high up the rectum, seeks to find out how intimate is the relation of uterus and tumor. Even from this apparently copious supply of diagnostic means in many cases only a doubtful conclusion can be drawn, for every one of them is often fallacious in typical cases, and always so in large cysts unaccompa- nied by any fibrous structure except that constituting their walls. The tumor may not be irregular nor hard; it may develop with great rapidity ; the uterus may not increase in depth, may move independently of the tumor ; and tapping may empty it. On the other hand, cases of true ovarian tumor are not rarely met with in which the uterus is increased in depth, the tumor and uterus move synchronou.sly under slight impulse, tapping only partially empties the sac, leaving solid masses remaining, and TREATMENT. 657 the growth of the tumor is slow and has little influence upon the general health. The late Dr. W. L. Atlee' most truly remarked, that " no amount of experience will avail the surgeon in making a ditFerential diagnosis by the ordinary methods of examination." " But," said that eminent ova- riotomist in alluding to his past errors of diagnosis, " such errors need not be repeated." He believed that we had arrived at a period when, by means of the fibre cell, diagnosis becomes at once simple and positive. Should the diagnostic method which he has furnished us bear the test of experience, a most important result will indeed have been attained. Dr. Atlee relies upon the physical properties of the fluid withdrawn from these sacs for diagnosis of their origin, whether uterine, ovarian, or of the broad ligaments. The characters of fibro-cystic fluid are these. It is transpa- rent, of a deep amber color, and very thin when first drawn, but forms a hard and firm coagulum in a little while, which in a few hours shrinks and separates into a clot and a thin watery serum. It coagulates by heat, and resembles in every respect the liquor sanguinis. Under the microscope few cells appear in it. There are epithelium, oil globules, and a fibre cell, represented at A in Fig. 224. This is characteristic of the structure in which the cyst originated. Course, Duration, and Termination This form of tumor runs a very slow course. Much graver and more rapid in development than the pure fibroid, it develops more slowly than ovarian cyst. I had recently under observation two very large tumors supposed to be of this kind. One of them had existed for eleven years, and yet the patient still performed the functions of nurse in a hospital. It is true that her abdomen was im- mensely distended, and that she moved about with difficulty, but thus far she had not been completely incapacitated. In the second case the tumor had existed for about five years. It was quite large, when the patient, after an attack of illness which was supposed by her physician to be peri- tonitis, began to improve, and is now reported to me as being better than she has been for many years. Although this is the slow course of the affection in some cases, in others it exhausts the patient by constitutional irritation, the result of mechanical interference with other organs; menorrhagia; and deprivation of exercise and fresh air. Prognosis — The prognosis is unfavorable. Relief by medication is in the present state of therapeutics unattainable, and the operation of lapa- rotomy is much less promising when performed for uterine than for ova- rian tumors. Treatment. — Nothing more need be stated in reference to this subject than has been already said in connection with uterine fibroids, and will be said in speaking of ovariotomy. 1 Ovarian Tumors, p. 263. 558 UTERINE POLYPI. CHAPTER XXXVI. UTERINE POLYPI. Definition. — A uterine polypus is a tumor covered by the mucous mem- brane of the uterus, attached to that organ by a pedicle or stem, and originating in a hypertrophy or hyperplasia of some of its proper tissues. Portions of placenta, the fibrinous remains of blood clots, and parts of the foetal envelopes, sometimes remain in utero, and take upon themselves the shape and develop the symptoms of true polypi. They might, with justice, be described as pseudo-polypi, but the true polypus originates in morbid growth of the tissues of the oi-gan from which it springs, and it retards progress in pathology to confound these conditions with that to which this chapter is devoted. History While so many uterine disorders of great obscurity are de- scribed by the earliest medical writers, this, the diagnosis of which is often so self-evident and positive, attracted little attention. Hippocrates, Celsus, Galen, and even Aetius make no mention of it. By Moschion it was described in the third century, and called pulps or polypus, but it was certainly neither well understood nor treated in his time, and we get no clear accounts of it until the revival of this branch of learning by the French School in the seventeenth century. Then Guillemeau, and subse- quently Levret, threw much light upon it, and in the latter part of the eio-hteenth and bef^inning of the nineteenth centuries many others contri- buted to place our knowledge upon its present basis. Varieties. The student will meet with much difficulty in arriving at definite ideas concerning the varieties of uterine polypi. Almost all authors differ in their classification, and the number of names which have at various times been applied to them is too large even for repetition. Let it be borne in mind that, since these tumors are formed by excessive development of one of the tissues existing in the uterus, there are but three elements which can give rise to them : the muscular tissue ; the connective tissue ; or the glands of the organ. It is true that by some a species of vascular polypus formed from development of the bloodvessels, a species of telangiectasis, has been described, but it is probable that this is only a form of the cellular or mucous variety. All classifications of these growths are to a great extent arbitrary, and hence in the present state of pathology none can become universal. That which I shall adopt is this : — 1st. Cellular polypi ; 2d. Glandular " 3d. Fibrous " PATHOLOGICAL ANATOMY. 559 These varieties are subject to morbid changes which create other forms ; as, for example, fatty, calcareous, and malignant polypi. Colombat refers to a large, hollow polypus which, when removed, leads the operator at first to fear that he has mistaken an inverted uterus for a polypus. He states that Richerand and Jules Cloquet were once thus deceived, until the subsequent death of the patient enabled them to correct their error by post-mortem inspection. Mme. Boivin represents one of this character, in Plate 19 of her work. She calls it a hollow polypus ; declares that, before its removal by M. Dubois, it was F""- 22r.. regarded as inversion by several physicians, and ac counts for it by supposing that some plastic element had coated the uterus and been ripped off, except at its cervical attachment, and had become inverted by menstrual fluid collected above. Some years ago Dr. Henschel presented to the New York Obstetrical Society a hollow polypus which was attached to the cervix by three points. It was referred to Dr. Noeg- gerath for examination and report, and his method of accounting for it was similar to that of Mme. Boivin in the case just mentioned. Pathological Anatomy — The cellular polypus is a tumor, generally of pear sha})e, varying in size from a marble to a hen's egg. It is covered over by mucous membrane, and consists within of connective tissue in a state of hypertrophy or hypergenesis. Its attach- ment is generally, though not always, to one wall of the cervix, and in its structure there appears a certain amount of cervical fibrous tissue. Some- times the pedicle of this variety is very long and slender, so that it hangs outside of the vulva. The glandular polypus consists in hypertrophy of the Nabothian glands, or, according to Di*. Farre, of the u-tricular follicles. Several follicles are enlarged, and, being bound together by connective tissue, make up a tumor of pediculated form. It may arise either from the cervix or body, but very generally grows from the former, and is commonly gregarious, a large number of very small ones often studding the walls of the cervical (anal. The most remarkable instance of this variety with which I have ever met is that represented in Fig. 226. The whole growth measured in length 4^ inches, and in longest diameter 2| inches. It filled the vagina completely, grew from the inner wall and lip of the cervix, caused no symp- tom except leucorrhoea and pelvic neuralgia, and was not known to exist until difficulty in sexual intercourse caused the patient to apply for exami- nation. The mass was examined after removal by Dr. F. Delafield, and Ibund to consist of enlarged cervical follicles, the grape-like masses shown in the diagram, which was copied from nature by Dr. J, B. Hunter, bound Cellular polypus. 5G0 UTERINE POLYPI. together by connective tissue. I removed it with great ease by the ecra- The fibrous polypus is a submucous fibroid, resembling closely those which are subserous and interstitial. ^'^" ^^^" Slowly extruded from the uterine parenchyma by its contraction, the tumor gradually acquires a pedicle and becomes the form of polypus under consideration. Fibrous po- lypi usually arise from the body of the uterus, though they are some- times attached to the rim of the os. Causes. — Any chronic inflamma- tory action, any obstruction to escape of menstrual blood which causes uterine tenesmus, or any influence tending to keep up ute- rine congestion, will predispose to hypergenesis of the elements of the mucous membrane. But as for fibroids, so for fibrous polypi, no positive cause is known. Symptoms Polypi occasion two classes of symptoms ; one dependent upon the congestion which their presence excites, the other upon the mechanical obstruction which they offer to the escape of menstrual blood. These two influences result in the following signs: — Leucorrhoea ; Pain in back and loins ; Menorrhagia; Metrorrliagia ; Hydrorrhcea ; Dysmenorrhoea. The last of these is not a fre- quent sign, but sometimes presents itself prominently, as it did in the following case, which occurred be- fore we understood the use of tents as we do at present. A lady came „..,,. J 1, * , from a distance to put herself under A submucous nbroid being gradually trans- i formed into a fibrous polypus. Dr. Metcalfe's care for dysmenor- Glandular polypus. Fig. 227. DIFFERENTIATION. 561 1 rhcea, characterized by severe tenesmus and expulsion of clots. These symptoms had lasted for years, and had resulted in emaciation, and great nervousness and irritability. In time she came under my care, was treated by me for nearly a year, and went home unrelieved. At her next menstrual period she sent for the physician of the neighborhood, who examined by touch, detected in the vagina a small polypus which hung by a stem from the uterus, and twisted it off, to her complete and permanent relief. This had been at last expelled after having rested upon the os internum, and acted as a ball valve for years. The uterus had been repeatedly examined before, but nothing could be discovered. Physical Signs These will depend in great degree upon the size and location of the growth. Should it be in the cavity of the body, and small, no signs will be afforded by the touch or speculum, and the uterine sound will give no evidence of its presence. The cavity will be discovered to be much congested, and a copious flow of blood will often follow the with- drawal of the instrument. Should the tumor be large, the uterus will often be found to be displaced, and increased in size, and the cervix some- what dilated. Should the attachment of the tumor be cervical, it can often be felt hanging from the canal or in the os uteri. But no examina- tion for uterine polypi can be considered complete until the cervix has been fully dilated by tents, and careful exploration been made by touch. Even then small growths will sometimes escape research. By any other means than dilatation and touch it is often very difficult to determine whether a small neoplasm exist iri utero or not. This state- ment, the history of the following cases which have occurred in my prac- tice very recently, will illustrate : — Miss B., a spinster, aged tliirty-eight years, had suffered from profuse menorrhagia and metrorrhagia for three years, and u{)on examination I found the uterus enlarged and measuring internally four inches. I made the diagnosis of intra-uterine neoplasm, dilated with tupelo tents, and found only fungosities to exist. Mrs. M., aged thirty -seven years, married thirteen years, sterile, suffer- ing from marked dysuKmorrhoea, was submitted to the operation of bilateral tracheotomy, on account of constriction and tortuosity of the neck, which rendered the introduction of the sound almost impossible. On the tenth day after the operation hemorrhage occurred, and upon examination I found a hard, fibrous polypus as large as a pigeon's egg presenting at the os, which I very readily removed. Differentiation — Polypi must be differentiated from fibrous tumors even after the discovery of an intra-uterine growth has been made. The symp- toms to which these affections give rise are very similar, and it is by physical means alone that differentiation can be effected. These means are the use of tents, the sound, and touch. By them, the mobility of the 36 562 UTERINE POLYPI. tumor, the point of its attachment, and the breadth of its base, may usu- ally all be determined. Course and Termination Nature may cure a uterine polypus by eject- ing the mass with so much force as to fracture its attachment and discon- nect it from the uterus; or calcification, fatty degeneration, ulceration, or sloughing may occur. But none of these results can be looked for with any confidence. In the majority of instances, without surgical interference, steadily advancing anaemia ultimately destroys life. Prognosis The prognosis is generally good ; depending, of course, upon the possibility of removal. Complications — Polypi, if so small as not to greatly increase the weight of the uterus, create but two complications, leucorrhcea ?ind metrorrhagia, which may go on to the production of fatal antemia. If they be so large as to increase the size and weight of the uterus, displacements, with their attendant irritation of rectum and bladder, may show themselves, and even inversion has been known to occur. Treatment. — This may be either palliative or curative, and it is as neces- sary for the practitioner to familiarize himself with one as with the other plan. Many a patient suffering from intra-corporeal polypus has had life cut short by intemperate efforts at its removal, who by a systematic and patient course of palliative treatment might not only have lived for years but have ended lier disease by expelling the tumor into the vagina and rendering it accessible to safe removal. There are few men of large experience, who cannot recall such instances of the unfortunate results of injudicious prac- tice, either in their own experience or that of others. The dictum of Gooch that, " when hemorrhages from the uterus arise from a polypus, medicines are useless. The only efi^ectual way to cure the hemorrhages is to remove the polypus," is undeniably sound. Lives have, however, been sacrificed to just such a style of assertion both in this and other diseases. When the young practitioner reads the brilliant record of an os dilated, an instrument carried to the fundus, a tumor removed, and a case of metror- rhagia cured, he feels almost culpable if he have a case under treatment and do not follow a similar course, and as he sees his patient's pale face every day demanding a cure, he is often hurried into a resolve to run every risk to effect one. But he who is familiar with this kind of practice knows that it in reality involves many dangers, and that successful cases have a proneness for creeping into literature which does not characterize fatal issues. I would be distinctly understood, as not undervaluing the practice of dilating the cervix and removing intra-corporeal polypi by instruments carried to the fundus. I merely desire to insist upon the fact that such a course is necessarily dangerous ; that it should be undertaken only after careful consideration ; and that its proper performance requires skill and experience. TREATMENT. 563 Whenever it is practicable to do so, all manipulation should be delayed until expulsion of the tumor into the vagina is accomplished ; but, unfor- tunately, operative procedure is often called for before this can be effected. Then the operator has no choice. He is forced to proceed to removal of the growth even at a disadvantage and at a risk to his patient. If the os internum be fully dilated, the opening of the external os will not prove difficult of accomplishment. Slitting the neck or dilating it will usually be sufficient to bring the growth within reach of a tenaculum which will draw it forth. But where both are to be opened danger is involved in the process, for not only are we called upon to assume that connected with and dependent upon the use of tents : we have to do so in a pathological con- dition peculiarly liable to be complicated by endometritis and pelvic peri- tonitis. I have seen several deaths due to these efforts, and I always inaugurate them with a certain amount of anxiety. Palliative Treatment As I have said a great deal in connection with the treatment of submucous tibroids, which would have to be repeated here if I went into the detailed consideration of this subject, I shall limit my- self to a concise recapitulation. 1st. Replace the uterus if it be displaced, and keep it in position by means of an appropriate pessary, at the same time that all pressure is taken from the fundus by avoidance of tight clothing and all violent mus- cular efforts, and by the use of skirt and abdominal supporters. 2d. Keep the patient in bed at menstrual periods, urging her to avoid warm drinks, and to use cold and acid ones. Give viscum album, can- nabis indica, opium, gallic acid, ergot, or elixir of vitriol freely during the periods. After a menstrual epoch has lasted four or five days, use a tampon saturated with solution of alum or tannin, removing it immediately if there be any evidence of regurgitation through the tubes. 3d. Keep the bowels regular, and avoid fatigue and over-exertion at all times. 4th. Repair the damage done to the blood by nutritious food, and that done to the nervous system by bitter tonics and nervines, avoiding the use of iron and quinine, which increase the tendency to hemorrhage. 5th. During the inter-menstrual periods give ergot freely, to favor ex- trusion of the growth. Curative Treatment There are three positions in which a polypus may be found : above the contracted os internum, above the contracted os externum, or in the vagina. The first position presents the gravest diffi- culties in the management of these cases, the second presents much less serious difficulties, while the third may, with our present appliances, be almost said to present none. If it be discovered that the cervical canal has been dilated by the weight and wedge-like action of the polypus aided by uterine contraction,, the walls of the cervix may be slit on each side nearly to the vaginal 564 UTERINE POLYPI. junction, and a tenaculum or vulsellum fixed in the tumor by which it may be drawn out of the uterus. Or by means of tents the resisting os may be dilated so as to admit the smallest size of Molesworth's dilator, and by this further expansion may be effected. After this, if the tumor can be seized, it may be drawn out, or ergot in full doses may be given to cause its expulsion. If it be found necessary to seek the pedicle at or near the fundus, it may be severed by the same means which we adopt in case the tumor hang in the vagina, namely — Excision ; Torsion and traction ; Ecrasement ; The gal vano-cau Stic wire ; ^ The spoon-saw. Should the pedicle be within reach of knife or scissors, it may be divided; or if higher in the uterus, the polyptome (Fig. 228) may be em- ployed. Should the growths be so small as not to be susceptible of seiz- ure, they may be scraped from their attachment by a large steel curette ; and should they be small and possess slender pedicles, they may be seized with forceps and twisted off. Should they be so small and slippery as to defeat this plan, or should they be numerous, or return very soon after removal, the cervix should be slightly dilated, cleansed of mucus and blood, and thoroughly painted over by fuming nitric acid, as recommended by Dr. Lombe Athill in disease of the lining membrane. Fig. 228. Simpson's polyptome. The ligature, once so popular, should never be employed ; the tardiness of its action, and the fetid discharge which it excites, rendering it objec- tionable and dangerous. Ecrasement constitutes sometimes a safe and expeditious operation. Sometimes, however, great difficulty attends the encircling of the tumor by the chain of the instrument. To effect this, it is often necessary to encircle the mass first by means of a ligature passed by Gooch's canula?, and then to draw the chain into position by tying it to the end of this, as represented in the cha()ter on fibroids. Under these circumstances Hicks's wire rope ecraseur (Fig. 229) constitutes an excel- lent substitute. The polyptome of Simpson or that of Aveling often answers a good purpose in these cases. "When the polypus is of hard, fibrous character, and fills the uterus so completely that the pedicle cannot be reached, those portions Avliich are within reach may be cut away piecemeal by Nelaton's forceps, constructed TREATMENT. 565 for this purpose, or by ordinary curved scissors. Dr. Goocli long ago announced that when a ligature was applied around one of these growths, that part above as well as below its constriction often died. It is with a hope of such a result that we make use of this means. I have, however, Fig; 229. G.TIEMANN &.C0. Hicks's wire rope ecraseur. cut through the centre of a fibrous [)olypus and found the attached portion continue to flourish as before operation. When a large fibrous polypus presents its pedicle in such a way that it can be encircled by the galvano-caustic wire, this instrument may be em- ployed. It not only cuts without the application of force through the hardest tissue, but, being brought to a white heat by the electric current which passes, through it, it sears the open vessels, checks hemorrhage, and prevents septicaemia. I have deemed it my duty to place before the reader all the methods at our disposal for the removal of these neoplasms, that he may exercise his choice as to a selection. In my own practice I have given them all up for the spoon-saw, which is fully described under the head of uterine fibroids. A very small spoon-saw will readily pass through a partially dilated os internum and witliout difficulty slip up to the attachment of the polypus and sever it without the creation of hemorrhage, while it is kept in a state of tension by traction upon its most dependent part by the vul- sellum forceps. Should a very large fibrous polypus have escaped from the uterine cavity in whole or in part, the lowest portions should be cut away by scissors, and the tumor delivered piecemeal. In conclusion, I offer a resume of the methods of treatment recom- mended in this chaptei'. 1st. If a polypus exist in utero and the cervical canal be firmly closed, avoid immediate attempts at its removal unless the symptoms be so grave as to make that course advisable. Temporize by employing palliative means until dilatation of the cervix and perhaps expulsion of the growth into the vagina are effected. 2d. To facilitate expulsion, dilate by tents or incise the walls of the cervix laterally and use ergot steadily, either internally or hypodermically. 3d. If the OS internum be fully dilated, remove the polypus at once, for 566 SARCOMA AND ADENOMA OF THE UTERUS. the operation is one attended by little danger even if the cervix requires incision. 4th. If the cervix be dilated and the tumor be in utero, seize it with a vulsellum at its lowest extremity, and make a cautious but rapid attempt at its removal by torsion and traction. Lengthy manipulations carried on in utero are always very hazardous. 5th. If it cannot be removed in this way, slide up along the wall of the tumor, upon which steady traction is made, the spoon-saw, sever the stem, and deliver the growth. CHAPTER XXXVII. SARCOMA AND ADENOMA OF THE UTERUS. History Scattered through medical literature may be found descrip- tions of a tumor growing from the cavity of the uterus, which appears to occupy a middle ground between myo-fibroma on the one hand and true cancer on the other. Presenting in many respects the ordinary physical aspects of benign fibroid growths in their early periods, these tumors demonstrate a marked tendency to return after ablation. Even after repeated and thorough removal, they again and again recur, and in many cases their real character is in this way discovered. Another peculiar and dangerous characteristic, which marks their difference from benign fibroids, consists in their tendency to throw out fungoid growths, which show a marked tendency to undergo molecular death and disappear by ulceration, which process saps the vital forces of the patient by repeated and pro- longed hemorrhages, and by opening the mouths of absorbent vessels for the entrance of septic elements into the blood. The clinical features of such growths will be found recorded in English literature by Callender,^ Hutchinson,^ Oldham,^ and West,* to whose inte- resting accounts the reader is referred. Of course pathologists were struck by these two facts in connection with such tumoi's : first, their mai'ked tendency to return after ablation, and second, the absence of micrographic evidences of cancer in pathological developments showing many of the features of malignancy. Paget grouped them under three heads, malignant fibrous tumors, recurrent fibroids, and myeloid tumors, while Lebert described them under the name of fibro-plastic tumors, and Rokitansky under that of fasciculated cancer. Not until the time of • Pathological Transactions, vol. ix. 2 ibid., vol. viii. 3 Wilks, Pathological Anatomy, p. 404. ■» Op. cit., art. Recurrent Fibroid. PATHOLOGY. 567 Virchow were they described under the old and previously loosely applied term of sarcoma. This pathologist clearly defined the disease and placed it in a distinct class, apart from developments somewhat similar in clini- cal features, but some of which were entirely benign and other? truly cancerous. Definition, Frequency, and Synonyms " Sarcoma," says Virchow, " is for me a production easily definable. I mean by it a growth the tissue of which, following the general group, belongs to the connective tissue series, and which is distinguishable from marked varieties of the groups of connective tissues only by the predominant development of cellular elements."^ They possess, he declares, the characters of incomplete, rudi- mental, or embryonic development, and not those of perfect tissue. This peculiarity existing in the original tumor becomes more and more marked as recurrence takes place after successive removals. Were I to draw my deductions from my own experience, I would say that sarcoma of the uterus was not very rare. Many cases which have been regarded as cancer, and not a few of supposed fatal fibroid tumor or polypus, have been unquestionably of this affection. Virchow,- however, expresses a diflferent opinion. " The production of sarcoma on the mucous lining of the uterus," says he, "is often spoken of, and even in his first work Lebert describes a fibro-plastic polypus. Nevertheless, from my observation sarcoma is very rare at this point, and the majority of tumors described as such are of a simply hyperplastic nature. True sarcoma, however, does originate in the uterine mucous membrane in medullary form difficult of recognition, often very soft, and with round cells, some- times with all the characteristics of myo-sarcoma ; the tissue may become in places more compact, and may form larger masses, and attain a degree of firmness so great that I have seen the best diagnosticians deceived as to the nature of the affection, and take it for a fibroid." Before my atten- tion was especially called to this subject, I confounded such cases with medullary cancer. Since that time I have met with many cases which, both from clinical and microscopic evidence, I am forced to regard as sarcomatous developments. None were confounded with simple hyper- plastic growths, as Virchow suggests, for all ended fatally. Pathology — Pathologists have commonly confounded sarcoma of the uterus with cancer. The reasons for this are probably these : after the former begins to ulcerate, it resembles the latter in many clinical features, both have a marked tendency to return, and they sometimes unite in the same tumor. The time has certainly arrived, however, when they should be separated both clinically and pathologically. • Pathol, des Tumeurs, par R. Virchow, traduit par P. Aronsohn, vol. ii. p. 173. 2 Op. cit., vol. ii. p. 344. 568 SARCOMA AND ADENOMA OV THE UTERUS. Of late years uterine sarcoma, as a disease apart from cancer, has re- ceived careful study in Germany, excellent reports of cases being furnished by Ahlfield, Hegar, Winckel, Gusserow, Spiegelberg, and others. Unlike myo-fibromata, sarcomatous tumors have no capsules, but are immediately connected with the uterine connective tissue. Yirchow de- clares that, " in accordance with their density, sarcomata may be, like all morbid tissues, divided into two groups : soft and hard sarcomata." As the disease consists merely in a multiplication of normal cells, homolo- gous to the tissue in Avhich it develops, and subject to no other disorder than hypertrophy, it is characterized by one of the cells typical of the con- nective tissue group. Thus we may have spindle, round, and stellate celled sarcoma, the second being the most frequent, and the first the rarest in the uterus. In some cases the cells are so large as to cause the name "giant-celled" to be given to the growth. "We may," says Virchow, " divide all sarcomata, and not simply those rich in cells, into two groups : the one with large, and the other with small cells." These cells are merely exaggerated reproductions of those of the mother tissue, and "be- have like cells of parenchyma, not like surface cells (epithelium, cancer)," which are heteroplastic to .the mother tissue. Between these cells the intercellular substance is always preserved, while in cancer we find cells of epithelial type pressed closely together in alveoli formed of trabeculse created by connective tissue. Sarcoma, usually primary, is sometimes engrafted upon myo-fibroma by the process styled metaplasia, and a true sarcomatous tumor may itself be affected by cancer. Sarcomata into which a great deal of fibrous tissue enters are dense, like myo-fibroma, and Hegar^ admits a transition form, a fibro- and myo-sarcoma. Schroeder gives an illustration representing a sarcomatous polypus growing from a carcinomatous cervix. Virchow divides all sarcomata into hard and soft in a general way, and then gives a great many subdivisions, as fibro-sarcoma, myxo-sarcoma, glio-sarcoma, melano-sarcoma, chondro-sarcoma, and osteo-sarcoma. These growths are so rich in vessels that Virchow declares that this feature is characteristic of them. To this vascularity is due their tendency to give forth a watery flow, to bleed freely, and to absorb septic materials. Clinically, uterine sarcoma presents itself under two forms, which are often very distinct from each other, and yet between which in many cases an absolute line cannot be drawn. These are the hard and diffuse forms. In the one case a dense, solid, tense, and elastic tissue is presented to the touch, the chief anatomical character of which is the existence of fusiform cells. In the other a diffuse, a fungous-like structure is found, which is characterized by small round cells. When the parenchyma of the uterus is affected by the hard variety, pain, according to my experience, is very ' ArcLiv fur Gynsekologie, ii. 1871. PHYSICAL SIGNS. 56C> severe. When a purely diffuse, endometrial form of the disease exists, there is very often none. The second variety will sometimes till and dis- tend the uterus to a great degree. The growth being removed by the curette, the patient greatly improves, but very soon the uterus refills and operative procedure is again called for. I have known patients live very comfortably for years through the relief afforded by this course, ultimately dying, however, of the continually returning affection. Causes. — With reference especially to uterine sarcoma, little can with positiveness be said on this point. Virchow alludes, in speaking of sar- coma in general, to injuries, youth and old age, primitive debility in the part affected, inflammations, etc. ; but whether uterine sarcoma has ever been traced to these I do not know. Symptoms. — These may be thus presented : — Pain ; Menorrhagia or metrorrhagia ; Offensive mucous discharge ; * Pinkish watery discharge ; Discharge of shreds or portions of tlie tumor ; Pressure on rectum and bladder ; Uterine tenesmus ; Constitutional depreciation. Gusserow declares that pain is constant and early, but Hegar denies this. My experience would lead me to indorse the opinion of the latter, though I have seen it very severe. Physical Signs — These will depend to a certain degree upon the indi- vidual peculiarities of the case. Sarcoma usually develops in the cavity of the uterus. One case has been reported by Veit in which the cervix was primarily affected, two by Kunert, and I have now under my care an unquestionable case of fibro-sarcoma having this origin. The growth usually arises from the uterine wall by a broad base and projects into the cavity. In time, uterine contractions dilate the cervix, and a portion of the mass is forced through the os. In rare cases sarcoma assumes a polypoid form, and in others, coinci- dently with the uterine development, an extra-uterine growth projects into Douglas's pouch or one iliac fossa. Another way in which sarcoma affects the uterus is by diffuse infiltration into one or both walls. This may affect mucous or submucous tissues alone, or even the muscular struc- ture itself. This surface soon ulcerates and gives forth a fetid discharge. In some cases this diffuse infiltration may affect the whole uterus, giving it the appearance of symmetrical enlargement. If the tumor can be touched, it is usually found to be soft, spongy, and friable, though in some cases it is hard and firm like myo-fibroma. By conjoined manipulation the uterus is found to be large and usually irregu- lar in shape as if the seat of fibroid tumors. The uterine sound indicates 570 SARCOMA AND ADENOMA OP THE UTERUS. enlargement of tliis organ. It is very common for the cervix to be dilated and portions of the mass to be expelled. Differentiation — Although these symptoms and physical signs will strongly point to the existence of sarcoma, the microscope alone will dis- tinguish it from cancer, myo-fibroma, and simple hyperplastic growths. Course., Duration, and Termination It runs a much sloAver course than true cancer;" a much more serious one than fibroids and hyperplastic growths. In rai-e cases it terminates rapidly, but it has frequently been known to last for five or six years. The patient gradually sinks under the following morbid influences: hemorrhage, septicaemia, spread of the disease to neighboring abdominal viscera, disturbance of nutrition, or peritonitis. Prognosis. — This is invariably unfavorable ; a fatal issue is a question merely of time, whether the growth be removed or left uninterfered with. The microscope, to a certain extent, aids us in predicting the probable rapidity of the affection. The more nearly it approaches a hard growth, the preponderating element of which is fibrous tissue, the slower will be its course ; the more it partakes of a soft character and shows itself rich in cellular elements, the more rapid will be its progress in molecular death. Again, the small-celled varieties show a more marked tendency to rapidity of production than those which are characterized by large cells. Treatment If the cervix be dilated, and a sessile growth be discovered in the uterine cavity, it should be entirely removed by the spoon-saw, galvano-cautery, ecrasement, or the large curette, and the base of the growth thoroughly cauterized with chemically pure nitric acid. If the cervix be not dilated, this may be accomplished by the use of tents, and the disease attacked by the surgical means recommended. Should the disease affect the parenchyma, and not especially the endo- metrium, the propriety of uterine ablation should certainly be considered. The fact that this disease is much less liable to return after removal than cancer would recommend it more strongly than in that disorder; and if sarcoma were confined to the uterus, the prospect of success from operation would be far greater. Adenoma of the Uterus The lining membrane of the uterus, in addi- tion to sarcoma, cancer, benign fungosities, and polypoid tumors, is some- times the seat of adenoma, a disease consisting of hypertrophy of its glandular structure. This affection develops the same symptoms as the others just mentioned, chief among which is hemorrhage. The diagnosis is established by expo- sure of a portion of the diseased tissue, removed by the curette, to the microscope. The treatment of adenoma consists in entire removal by the curette, after dilatation of the cervical canal, and the application to the surface^ from which it has been scraped, of fuming nitric acid. CANCER OF THE UTERUS. 57l It has a marked tendency to return, though much less so than sarcoma and cancer. This fact should teach us, however, the lesson that in dealing with it the entire endometrium should be thoroughly scraped in order to prevent the rapid generation ot" some remaining portion of the growth. I have seen but one unquestionable case of this disease, and in this the curette during a period of four or five years was used very thoroughly four- teen times, compound tincture of iodine and nitric acid having been re- peatedly applied after its use. After that the patient entirely recovered, and has now remained well for a number of years. The growths removed in this case were examined repeatedly by Dr. F. Delafield, who for some time feared malignancy, but finally decided that they were of the character mentioned above. Very recently I have seen a case with Dr. MoUer, upon which, during seven years, he has repeatedly employed the curette for an abundant and steadily recurring growth. A portion of it, being examined by Di*. W. H. Welch, the pathologist of the Woman's Hospital, was pronounced to be a mixture of sarcoma and adenoma. CHAPTER XXXVIII. CANCER OF THE UTERUS. Definition — Between cancer of the uterus and the same affection in other parts of the system there are no marked differences. As in other organs, it may be defined as a disease which is characterized by great pro- liferation of connective tissue, excessive generation of cells of epithelial type, and marked tendency to extension to neighboring parts, to molecular death, and to return after removal. Waldeyer' concisely defines cancer as "an atypical epithelial neoplasm." History — M. Becquerel asserts that, " in spite of its great frequency, cancer of the uterus is not a disease of which the history has been long known." That it was not understood as we understand it to-day, is most true ; but the ancients surely had a certain degree of knowledge concern- ing its clinical features. Hippocrates — de Morbis Mulierum — describes it at length, declaring it to be incurable. Archigenes wrote a chapter upon it, describing the ulcerated and non-ulcerated forms and the peculiarities of the discharges. His article is preserved by Aetius, who entitles it, " De Cancris Uteri," and is copied verbatim by Paul of ^gina without the slightest acknowledgment. The Arabians likewise were familiar with ' Billroth, Surg. Pathol., Am. ed. 6T2 cancer of the uterus. it, Alsaharavius, Haly Abbas, and Rhazes all alluding to its prognosis and treatment in a manner which leads us to believe that they understood its true nature. Upon the revival of gynecology in France, the disease was confounded with fibrous tumors and areolar hyperplasia. Astruc described "scirrhus" as the result of abortion, in 1766, and the confusion which attached to his description extended long after him. It characterized the times of Reca- mier and Lisfranc, and even so late as our own period we see the view endorsed by Ashwell, Montgomery, Duparcque, and many others. Blatin and Nivet,^ in expressing their belief that scirrhus results from chronic inflammation of the parenchyma, append the following footnote : " Paul of ^gina, Galen, Andral, Broussais, Breschet and Ferrus, Piorry, Bouil- laud, etc., place scirrhus among the terminations of chronic inflammation; some of them, however, admit the existence of a predisposition." Although it was known to the physicians of the most ancient times, we are indebted to them for little in connection with it, except portions of the imperfect nomenclature which now attaches to it. It is beyond question that within the last half century much more has been accomplished for the thorough understanding of the subject than ever has been done at any former time, and yet, even now, much doubt and uncertainty exist as to its varieties, and its pathological characteristics. Pathology With regard to the pathology of cancer the views of patholo- gists have, of late, undergone considerable modification. Formerly, the prevailing opinion was that it was always the local manifestation of a general blood state. At present, opinion is divided ; many still adhering to the old view, while others are yielding to the cogent -reasoning of those who regard it as originally a local affection, one of the most striking fea- tures of which is a tendency rapidly to intoxicate the system. In an ex- ceedingly able and interesting discussion upon this subject before the London Pathological Society in March, 1874, the former of these views was maintained by Messrs. De Morgan, Hutchinson, Moxon, Arnott, and others ; the latter by Sir James Paget, Sir W. Jenner, Dr. Greenhow, and others. So equally was the society divided in opinion that a com- mentator remarks that " in point of numbers the constitutionalists almost equalled the localists." Whatever be the peculiar state which gives rise to cancerous deposit, it is certain that any form of the aff'ection may arise from one and the same disorder. This is proved by the facts that several deposits of different varieties may coincidently exist, that one form may change into another, and that one being remov(;d by surgical means a different one may re- place it. As there is doubt as to the origin of cancer, so is there as to the method ' Mai. des Femmes, Paris, 1842. VARIETIES. 573 in which the local deposit takes place. Certain pathologists, of whom M. Robin, of Paris, may be taken as a representative, believe that, under the influence of a constitutional vice, which exerts a baneful influence over nutrition and formation, a fluid blastema is transmitted from the blood into the connective tissue of the part. From this molecules arrange themselves and form the anatomical elements of cancer. Another party, of which Virchow was the founder, maintains that the proliferation of connective tissue and hypergenesis of cells both arise from repeated sub- division of connective tissue corpuscles. These go, some to creation of tissue, some to filling brood-spaces, and others to formation of epithelium. Still another party, headed by Remak and Waldeyer, hold that all cancer- ous disease in the uterus takes its origin from the epithelium lining glands which dip into the parenchyma. The cancer cells are due to perverted action of normal epithelial production, wdiile the stroma comes from pro' liferation of the interstitial substance or connective tissue of the part. "Only Thiersch, and recently Waldeyer," says Billroth, "maintain, as I do, the strict boundary between epithelial and connective tissue cells. . ... I only call those tumors true carcinomata which have a forma- tion similar to that of true epithelial glands (not the lymphatic glands), and whose cells are mostly actual derivatives from true epithelium." If the cervix uteri has been first affected, the disease spreads from this point, invades the whole neck, and sometimes the body of the uterus, the ovaries, vagina, bladder, and intermediate tissue. Even the bones of the pelvis may be attacked. For a varying length of time the deposition goes on, then without assignable cause the lowly organized mass begins to die, and ulceration or molecular death occurs. The detritus gives rise to a fetid, ichorous, and bloody discharge, which excoriates the vulva and thighs, and renders the patient disagreeable to herself and all around her. The disease extends to neighboring and distant organs by several methods : first, by continuous growth ; second, by absorption of conta- gious fluid or cell elements from tlie cancer by the lymphatics and trans- mission to the glands and other parts ; and third, by venous absorption. Varieties} — Cancer may attack the uterus in any one of the following forms : — 1st. Scirrhus ; fibrous, or chronic cancer; 2d. Encephaloid ; or acute cancer ; 3d. Epithelioma ; cancroid, or epithelial cancer. In addition to the varieties of cancer thus far recorded, a fourth- Ihe colloid, is often mentioned. It is now very generally regarded as incor- • Although to be systematic I have deemed it best to adopt these conventional terms, the student must not imagine that it is always an easy matter to classify a uterine cancer under one of tliem. Very commonly a growth will be met with, which occupies a middle ground between these varieties, and is neither pure scir- rhus, encephaloid, nor yet epithelioma. 574 CANCER OF THE UTERUS. rect to look upon this as a true variety of cancer, for it is ratlier a mucoid degeneration of one of the preceding varieties. The same kind of de- generation may affect other growths ; and, if the mere presence of colloi Op. cit., p. 473. 2 Op. cit., p. 242. s Op. cit., p. 254. 636 AMENORRHCEA. Frequency — It is an affection of great frequency among women who live luxurious and indolent lives, and disorder the nervous and sanguineous systems by neglect of those habits wiiich keep them in a state of health. Hence it is very frequently encountered among the members of the higher classes of civilized society all over the world. Varieties — If the habitual monthly discharge be suddenly checked, the disorder is styled suppressio-niensium ; and if the discharge have never appeared in a woman who ought to menstruate regularly, it is called emansio-mensium. Pathology — That the discharge of blood, which, occurring at monthly periods, constitutes menstruation, is a true hemorrhage dependent upon the process of ovulation, is now regarded as a settled fact by most physi- ologists. In accordance with a law of nature which we recognize in its effects but cannot explain, once in every twenty-eight days one or more ovules in each ovary burst their envelopes, and entering the Fallopian tubes pass downwards to the uterus. This eruption of ovules produces in the ovaries congestion and nervous exaltation, which continue until the process is completed. No sooner are these organs thus affected than, through the instrumen- tality of the ganglionic system of nerves connecting them with the uterus, that organ sympathetically undergoes congestion likewise. The whole uterus becomes heavy and descends perceptibly in the pelvis ; its mucous membrane is swollen and turgid, and the vessels which supply it dilate under an excessive hypera^mia, as do those of the conjunctiva in conjunc- tivitis ; then a rupture occurs and relief is obtained by hemorrhage. For the proper performance of the function three elements must exist in a perfect state of integrity: 1st, the uterus, ovaries, and vagina must be perfect in form and vigor; 2d, the blood must be in its normal state; and 3d, the nervous system governing the relations between the uterus and ovaries must be unimpaired in tone. Any influence disordering one or more of these may check ovulation, the great moving cause of the function ; prevent the degree of sympathetic congestion necessary for rupture of uterine vessels; or oppose the discharge of blood which has been effused. The non-performance of the function of menstruation was formerly, and even now is by some, regarded as productive of many constitutional evils, as, for example, chlorosis, phthisis, dropsical effusions, etc. It is highly probable that in tliese deductions the effect has been mistaken for the cause. The impoverished blood, and nervous derangement attendant upon these affections, result in failure of that function. No proof exists which can substantiate the view that amenorrhoea ever induces permanent lesion of any organ in the body. Causes. — After what has been already stated, the causes of the affection may be tabulated without fear of confusing the reader. CAUSES. 637 Amenorrlioeii may result from any of the following conditions: — Abnormal states of organs of generation. Absence of uterus or ovaries ; Rudimentary uterus or ovaries ; Occlusion of uterus or vagina ; Uterine atrophy ; Pelvic peritonitis ; Atrophy of both ovaries ; Cystic degeneration of both ovaries. Abnormal states of the blood. Chlorosis ; Plethora ; Blood state of phthisis ; " "of cirrhosis ; " "of Bright's disease, etc. Abnormal state of ganglionic nervous system. Atony from mental depression ; " " indolence and luxury ; " " want of fresh air and exercise ; " " constitutional diseases, as phthisis, etc. Complete absence of the internal organs of generation is very infrequent, though a rudimentary condition is less rare. With reference to absence of the uterus, Scanzoni remarks : " On carefully analyzing the reported cases of entire absence of the womb, we find that almost always some rudiments of this organ still exist, so that authenticated and unquestion- able instances of this anomaly are extremely rare." He further declares that he has never been able to authenticate a single case. I have seen one instance presented by Prof. I. E. Taylor to the Obstetrical Society of this city, in which no trace of the uterus could be detected upon the closest scrutiny of the parts removed post mortem. Absence of both ovaries is quite rare. They are most frequently found to be in a rudimentary condition resembling their fcctal state. The vagina may be occluded by an obturator hymen, contraction from inflammation and sloughing, or from congenital or acquired atresia. So likewise may the canal of the cervix uteri be congenitally or acci- dentally closed. What I have styled atony of the nervous system has been well described by Prof. Hodge, of Philadelphia, under the name of sedation. It consists in a decrease of the excitability, vigor, and activity of the nervous agency which controls the functions of different organs, and has for its cause phy- sical and moral influences, some of which have been enumerated. Some of the functions which are under the control of the ganglionic system are, the action of the heart, digestion, peristalsis, and regulation of animal heat. In one leading a natural and liealtliy life, in the country for ex- 638 AMENORRHCEA. ample, all these are likely to be normally performed ; but if the same individual remove to a crowded city, lead the life of a student, exhaust his nerve power by late hours, bad air, and mental efforts, all of them rapidly become deranged. He suffers from palpitation of the heart, dyspepsia, coldness of hands and feet, and constipation. This change usually occurs slowly, but sometimes it does so rapidly, as from a sea-voyage or any very violent mental strain. In a similar manner the processes of ovulation and menstruation are affected by it, in some cases gradually, in others with great rapidity. Differentiation Before treatment is instituted for this condition, it must be carefully differentiated from — Pregnancy ; The menopause ; Tardy iiaenstruation. The first will be readily recognized by its characteristic signs, if sus- picion be awakened, and they be investigated. Very often no such sus- picion arising, the criminal desires of some women are gratified, and the hopes of others blighted through the unintentional induction of abortion by the treatment adopted. The law with regard to the menopause is, that it should occur between the ages of forty and fifty, but it is sometimes delayed until sixty or seventy, and at others take place at a very early age. It may occur as early as the twenty-first year, and in twenty-seven put of forty-nine cases of early cessation collected by Dr. Tilt,' it took place from the twenty- seventh to the thirty-ninth year. The absence of sensations of discomfort at the periods when tlie menses should occur, will help to lead the practi- tioner to a correct conclusion as to the character of the case. Sometimes mothers will be much alarmed by absence of the function in girls at fifteen or sixteen years. It should be remembered that it is not very rare for it to be delayed until those ages. DiflTerentiation should be accomplished under these circumstances as under the last mentioned. Treatment From what has been already said, it is manifest that ame- norrhoea is not a disease, but a symptom of some local or general disorder, and it follows that all efforts directed simply to re-establishment of tlie absent function, must necessarily be empirical. The cause should be dis- covered, and, if possible, removed. Should it be susceptible of removal, the method appropriate for accomplishing this will be evident, while if it depend upon an incurable condition, great benefit will be gained by the avoidance of means previously practised in the vain hope of establishing the flow, and by our ability to place the mind of the patient beyond the harassing influence of suspense. If the uterus be found to be absent, all that can be done will be to ab ' On Uterine and Ovarian Inflammation, p. 54. TREATMENT. 039 stract a sufficient amount of blood from the arm by venesection, if neces- sary, to relieve the urgent symptoms attending each epoch. Occlusion of the vagina or cervix should be treated by surgical means, the barrier being overcome by the knife, scissors, or trocar. In case a rudimentary or atrophied uterus be discovered as the source of the affection, attempts should be made to develop it by local stimulation and distention. At short intervals it should be fully distended by a tent, in order that an increase of nutrition and consequent increase of volume and capacity may be excited. When this plan is not in operation, an intrauterine galvanic pessary may be kept in utero for the furtherance of the same end. It is astonishing how much development may be obtained by a persevering practice of this plan. In many instances it will restore the uterus to its original size, and cause a return of the menstrual flow. But it often requires considerable time to bring about so favorable a result ; even years may elapse before it is fully attained. If it be decided that the non-performance of the function is due to ple- thora, anaemia, or chlorosis, these states should be treated ; the first by venesection, strict diet, exercise, and a life in the open air; the second and third by change of air, rich food, exercise, and ferruginous tonics. In plethora. Prof. Bedford speaks highly of the abstraction of blood from the arm at intervals of a month, the abstraction being performed between the menstrual epochs. Should some grave constitutional condition like tuberculosis or the others mentioned, be found to be the main morbid state, it, and not its resulting symptom, should attract attention. An atonic state of the nervous system governing menstruation should be treated by a resort to a general tonic course. Among the means appli- cable to its removal may be especially mentioned, exercise on foot and horseback, rowing, calisthenics, sea-bathing, nutritious food, and nervous tonics of medical character, as nux vomica, strychnine, quinine, and the general use of electricity. It is in this class of cases that many drugs and prescriptions styled emmenagogue have often succeeded in restoring the function even when used empirically. A state of general nervous atony is frequently attended by chlorosis and always by constipation. The ner- vous disorder and two of its resulting symptoms may be favorably affected by the stereotyped combination of aloes, iron, and myrrh or nux vomica; and the sluggish nerve power may be temporarily excited to the perform- ance of its duties by the administration of tansy, rue, ergot, or savine. But it is not through desultory means of this character that a cure can be anticipated with any confidence. A more comprehensive plan directed to the improvement of the patient's constitution should be adopted and sys- tematically pursued. As general means those already mentioned will always be found highly useful. If the patient while at home cannot be prevailed upon to practise sufficient self-denial to avoid what is injurious, 640 AMENORRHEA. or be made to develop the energy necessary to follow a course which requires effort, she may, with great advantage, be placed for a time in a well-regulated hydropathic establishment, where the early hours of retiring, simple food, exercise, society, pure air, and bathing, will accomplish a roborant effect which wnll pi'ove of great value in the cure of the affection. But not merely should constitutional means be adopted. After the general condition has been improved, local stimuli may be resorted to with great benefit. Those which will be found to be most efficient are — Passage of the sound ; Tents ; Cupping ; Electricity ; Stimulating enemata ; Baths. In their action these means probably exert an influence not oidy on the uterus, but sometimes by their stimulating effects excite the process of ovulation. The sound should be passed up to the fundus once every day for three or four days before the expected flow ; or if the process of ovula- tion do not demonstrate its existence, it may be passed once a week throughout the month. At the same periods tents of tupelo or sea-tangle may be used, the dangers attending them being always borne in mind during their employment. The cervix uteri may, by the application of an exhauster or dry cup, have a marked hypersemia excited within it, which extends to the uterine body and replaces that which should have occurred from physiological causes. A very simple method for producing it is to enclose the cervix within the mouth of the cylinder of hard rubber represented in Fig. 246, and then exhaust the air by withdrawing the piston. Fig. 246. Syringo fur dry cupiiiug the cervix. Before the introduction of this instrument the uterus should be exposed by means of the speculum. In this way I have repeatedly drawn, with- out effort, one or two drachms of blood through the mucous lining of the neck. Electricity is a means of great value. One pole of a battery may be applied over the lower portion of the spine and the other passed over the hypogastrium, placed in contact with the cervix, or even carried, by means of a wire covered, except for its terminal three inches, with a gum- elastic catheter, up to the fundus of the uterus. For the purpose of keep- ing up a mild but steady current within the uterus. Prof. Simpson has TREATMENT. 641 advised a stem composed of copper for one half its length and zinc for the other half, which is passed up to the fundus. It has an ovoid disk at its lower extremity upon which the cervix rests. Dr. Noeggerath has made an improvement in this by having the stem composed of two parallel pieces of copper and zinc, instead of two short pieces of these metals united at the centre of the stem. As these instruments must be left in place while the patient walks about, there is always danger of their irri- tating the walls of the uterus to too great an extent. To avoid this I have employed a stem composed of alternate beads of copper and zinc, held together by a small wire rope, which passes tlirough the centre of each, and is secured to the uppermost and to the vaginal disk below. This may, by any movement of the uterus, be bent at the required angle, and consequently can do no injury. (Fig. 247.) The disk or bulb of this instrument should be made globular Fig. 247. so as to rest in the cup held between the branches of a Hodge or Smith pessary, as shown in Fig. 197. As an excitant of the menstrual flow, enemata of very warm water impregnated with chloride of sodium, aloes, or soap, constitute a valuable resource. Not only does the medicinal substance irritate the uterine nerves, the Galvanic pessary. warm fluid brought into close contact with the uterus also excites a flow of blood to it. Hip-baths and pediluvia have long been resorted to for the purpose of exciting menstruation. They should be prolonged, and as warm as the patient can bear them. In addition to these means, copious injections of warm water may with benefit be tl;rown into the vagina, one or two gallons being, by means of a proper syringe, projected against the os uteri. Reasoning from analogy and from our knowledge of the physiology of menstruation, we are unquestionably warranted in the deduction that in a certain number of cases amenorrhcea is due to non-performance of the function of ovulation. It is not possible to give clinical evidence of the fact, but it may be strongly surmised when none of the symptoms usually attendant upon this process present themselves at monthly periods. The means by which it should be treated are those already advised, for any of the causes mentioned may produce that variety of the affection which is due to non-performance of ovarian functions, in the same manner that they give rise to that form depending upon the incapacity of the uterus. In many cases where, in s])ite of well directed efforts, eight, ten, and twelve months will elapse without signs of menstruation, and this on re- peated occasions, it is useless to continue efforts such as those which have been mentioned. The case is often better left to nature. 41 642 LETJCORRHCBA. CHAPTER XLIII. LEUCORRHCEA. In my anxiety to impress the importance of regarding and treating this condition as a symptom of uterine or vaginal disease, and not as a primary affection, I have been in great doubt as to the propriety of devoting a separate chapter to it. In doing so I confess that I yield to a conven- tional practice which I do not fully indorse, and I offer this fact as an explanation of any supei'ficiality in the treatment of the subject which may strike the reader. I feel very sure that the writer of fifty years hence will omit the separate consideration of this symptom entirely. Definition This afi^ection, the name of which is derived from xsuxoj, "white," and ^jw, "I flow," consists in a whitish, yellowish, or greenish mucous discharge from the vagina. Synonyyns. — It has been, in modern times, described under the names of fluor albus, blennorrhoea, pertes blanches, fleurs blanches, and whites. In ancient literature the variety of names which was applied to it may be judged of when it is stated that over fifty appellations were at different times employed in designating it. Frequency No disease or symptom in the whole' list of female ills is so common. Probably no woman ever goes through life without at some period, and for a variable time, suffering from it. It is only when it becomes annoying by its constancy, abundance, or irritating properties that it attracts attention and causes the patient to seek assistance. Histoi'y In the earliest writings of the Greek school and throughout Roman and Arabian medical literature, abundant descriptions of this dis- order may be found. Hippocrates described it, pointing out as among its symptoms, puffiness of the face, paleness, and enlargement of the abdomen. He evinces a familiarity with its treatment by an admission of the difli- culty of curing it. Areteeus of Cappadocia, in the first century, mentioned the varieties of leucorrhcea, as to color, quantity, etc., and Aetius and Paul of ^gina speak of two forms of the affection, red and white flux. For the latter, Aetius recommends gestation, vociferation, walking, etc. The Arabians, Haly Abbas and Aisaharavius, wrote upon t)ie subject, but advanced nothing new. As in ancient times, so also in modern, it has attracted a great deal of attention, and until the establishment of the present school of gynecology by Recamier, was treated of as a disease rather than as a symptom. Even VARIETIES. 643 long after this period it was commonly regarded as a disease ; the result of constitutional debility, or the index of an impure blood state. For the views which are now entertained concerning it, we are indebted to no one so much as to Dr. J. H. Bennet, of London, who, by his forcible reason- ing, supported by clinical evidence, clearly demonstrated its ordinary de- pendence as a symptom upon some local lesion. Dr. Tyler Smith, in an elaborate essay upon the subject, has also done much to elucidate certain points in its pathology, which before his time had been undeveloped. Pathology As a discharge of mucus or muco-pus is a symptom of urethritis, bronchitis, nasal catarrh, and faucitis, so is it a symptom of inflammation of the vagina and lining membrane of the uterus and Fallo- pian tubes. Whatever influence is capable of ci'eating it elsewhere may give rise to it here, and in this position it is, as it is elsewhere, only an isolated sign of a pathological state. It is not by any means, however, always an evidence of inflammatory action. As many individuals upon exposure to cold will freely discharge mucus from the nostrils without any inflammation existing, so will many women suffer from leucorrhoea from any cause producing a temporary congestion of the mucous mem- brane. But in these cases the disease is temporary, following or pre- ceding the menstrual congestion, oi* arising from fatigue or exhaust ioa When it becomes permanent and the discharge grows profuse or acrid, its connection with a morbid state is rendered probable. At such times it is always a symptom of some abnormal condition of the uterus. Fallopian tubes, or vagina, and its presence should lead to an investigation of these organs. Any agency which moderately increases vascular activity in a secreting organ tends to augment the amount of its secretion. I say moderately increases, because an excessive turgescence, such as attends upon acute inflammation, checks secretion entirely. Such an influence being exerted upon any part of the mucous covering of the generative canal of the female, an excessive flow of plasma, together with a rapid exfoliation of epithelial cells and the formation of pus-corpuscles, results. Varieties — Leucorrhcea is divided into two vai'ieties, according to its origin — vaginal and uterine. Either of these may exist separately, or the two may coexist. If it be vaginal, it may continue as such for a length of time. If the inflammatory action producing the discharge be confined to the uterine mucous membrane, it may remain so without im- plicating the vagina, but that canal receiving the products of uterine secretion is generally excited into morbid action. A similar result may frequently be observed in nasal catarrh in children, the upper lip being bereft of its epithelial investment, and a papular or vesicular eruption excited over the neighboring parts of the face. Vaginal leucorrhoea consists of a w^hite, creamy, purulent looking fluid, 644 LEUCORRH(EA, ■which is composed, according to Dr. Tyler Smith, of the following elc ments : — Acid plasma ; Scaly epithelium ; Pus corpuscles ; Blood globules ; Fatty matter. Under the microscope it appears as represented in Fig. 248. Fig. 248. Vaginal leiicorrhoea under the microscope. (Smith.) That arising from the canal of the cervix is thick, tenacious, and ropy, like the white of an egg, and consists of — Alkaline plasma ; Mucous corpuscles ; Altered cylindrical epithelium ; Pus corpuscles ; Blood globules ; Fatty particles. Examined by the microscope it presents the appearance shown in Fig. 249. That arising from the body of the uterus resembles the cervical form, except that it is less gelatinous, less ropy, and more likely to be tinged with blood. Causes Any pathological state which keeps up in the uterus a con- dition of engorgement ending in inflammation, or simply in retarded and enfeebled circulation, may create leucorrhcea as a symptom. Prominent among these may be mentioned — Subinvolution of uterus ; Suppressed menstruation ; Fibroids, polypi, or fungous vegetations ; TREATMENT. 645 Prolonged lactation ; Gestation and parturition ; Excessive coition ; Ana3mia ; Uterine displacement ; Laceration and eversion of cervix ; Endometritis, corporeal or cervical ; Granular degeneration ; Syphilitic ulceration ; Vaginitis, specific or simple ; Habitual constipation ; Toxaemia from malaria, uraemia, or gout. Fig. 249. °-o/;^^' of„«^i^ p°9^^ ^'^^ Cervical leucorrhcea under the microscopo. (Smith.) It will thus be seen that the disorder may in some instances be a trivial matter, which, by a judicious combination of general and local means, will rapidly disappear, while in many others it is an attendant circumstance of some grave pathological state of the uterus ox vagina, and consequently difficult of cure. Prognosis. — This will depend in great degree upon the cause. If this can be readily removed, the prognosis will be favorable ; wliile if it be connected with some serious organic lesion, it will not be so. Results. — Uterine leucorrhcca may result in — Sterility ; Vaginitis ; Pruritus vulviB ; Vulvitis ; Salpingitis ; Granular degeneration. Treatment When a patient applies to a practitioner for the cure of leucorrhoea, it should be his first endeavor to discover the cause of the muco-purulent flow. A suspicion as to the source of the difficulty may 646 LEUCORRIKEA. ordinarily be based upon examination into the rational signs, but a diag- nosis of the condition which gives rise to the symptom which has excited anxiety in the mind of the patient can be more certainly arrived at by physical exploration. If upon this, disease of the uterus, vagina, or Fallopian tubes be discovered to exist, either in the form of inflammation or conges- tion, this affection should receive appropriate treatment. To recapitulate the plans which should be pursued would here be entirely out of place, for they are laid down in other parts of this work in connection with the special disorders of these parts. Suffice it here to say that the condition underlying the symptom leucorrhoea should receive treatment always. Sometimes the application of the curette, the operation of trachelotomy or of trachelorrhaphy, the replacement of a displaced uterus, or the removal of a submucous tumor will cut short a treatment which might otherwise be prolonged for years. As to general treatment, a course especially adapted to giving tone to the dilated bloodvessels of the mucous membrane, and overcoming the tendency to excessive creation of cells and exudation of blood plasma, should in addition be adopted. To begin with, the })atient should be put upon general tonic treatment, such as the use of quinine, Peruvian bark, strychnine, and iron ; sea-bathing ; change of air and scene ; and the substitution of quiet and cheerful social influences for those which are exciting or depressing. The diet should also be made nutritious and simple, and all stimulants, spices, and condiments be strictly avoided. When the vagina is affected, that canal, after having been carefully cleansed, should, by means of a rod wrapped with cotton, be thoroughly washed over with a solution of the nitrate of silver, one part to eight or ten of water. After this a tampon of cotton saturated with glycerine should be left in the canal for twenty-four hours and removed by the patient, a thread being attached to it for this purpose. Then copious astringent and soothing vaginal injections should be employed night and morning. The best astringents for this purpose are alum, tannin, infusion of oak bark, zinc, and lead. As examples of good combinations, I give the following : — I^. — Acidi tannici, ^iv. Glycerinse, ^xvj. — M. S. — A tablespoonful to a qiiart of tepid water, to be used as a vaginaf injection for five minutes every night and morning by means of one of tlie syringes recom- mended. I^. — Capri sulphat. 5Jss. Zinci sufphat. 5jss. Aluminis sufphat. 3Jss. Gfycerinse, §v.i. — M. Folfow same directions as tliose given above. One drachm of boracic acid to a pint of warm water, half a drachm of hydrate of chloral or i^alf an ounce of the fluid extract of pinus Canadensis to the same also answer an excellent purpose. TREATMENT. 647 Once a week the application of the solution of nitrate of silver, in diminishing strength, should be repeated and followed by the use of the tampon of cotton soaked in glycerine, or glycerine and tannin, until the leucorrhoea is cured. Cure will commonly be effected by these means, if no other disorder exist to reproduce a symptom which it has once proved itself efficient to establish. If such a condition exist and be overlooked by the practitioner, it will inevitably cause again what it did before. Neither plan should be despised — treatment of the causative disorder nor that of the resulting symptom ; and by a combination of the two plans better results will be obtained than could be accomplished by an exclusive adherence to either. In cases of chronic vaginitis, astringents sometimes appear to do harm, and infusions of flaxseed, slippery elm, and similar substances often prove beneficial. On the other hand, in the treatment of chronic endometritis, it will often be found of benefit to use astringent injections which act not only by securing cleanliness, but by hardening the vaginal mucous mem- brane and preventing the complication of vaginitis as a result of uterine catarrh. As a general outline, the following may be given as a phm of treat- ment : — 1st. Keep the uterus in perfect position by a pessary if it be decidedly displaced ; 2d. By appropriate cathartics, keep the portal circulation free and the rectum emptied of feces ; 3d. Cure laceration of the cervix if it exist, and remove polypi and fungosities ; 4th. Remove all weight from the uterus from above, and all traction from it from below ; 5th. Keep the cutaneous circulation active by baths, friction, exercise, and pure air ; 6th. Keep the blood and nerve states normal by tonics, exercise, etc. ; 7th. Counteract all toxfemic influences, such as malarial, (wliether palludal or from sewer emanations), ursemic, scorbutic, rheumatic, or arthritic ; 8th. Keep the menstrual function normal by careful supervision ; 9th. In case cardiac disease, aneurism, hepatic disease, pelvic peri- tonitis, or perimetric cellulitis are primary causes of it, recognize the futility of local treatment, and do not annoy the patient by a resort to it. To enter more minutely into the treatment of leucorrhcea would be to defeat the main object which I have had in view, that of subordinating the consideration of this disorder to that of the diseased states whic'- produce it. (548 STERILITY. CHAPTER XLIV. STERILITY. Definition and Synonyms This term, which is derived from orsptoj, "barren," and implies an incapacity for conception, is synonymously entitled barrenness and infecundity. History Throughout medical literature, from the earliest periods to the present, it has attracted special attention, and been the subject of dissertations by all authors who have touched upon the affections peculiar to females. The frequent reference made to it by Biblical writers as a reproach to women, is too well known to require special mention. Causes To comprehend the pathology of sterility, the physiology of conception must be clearly understood. In the act of coition the male organ, being introduced into the vagina, projects into and against the cervix a fluid, consisting of a thick, watery portion, holding in suspension large numbers of ciliated cells which have the power of moving by ciliary action. The bulk of this fluid pours down into the vagina, but many of the cells which it contains pass upwards into the body of the uterus, and through the Fallopian tubes as far as the ovaries. Should they come in contact with an ovule, impregnation may take place in the ovaries, Fallo- pian tubes, or uterus. When the impregnated ovule attaches itself to the uterus, the mucous membrane of this organ undergoes exuberant develop- ment, and throws around it an envelope called the decidua reflexa. Fur- ther than this, the process does not concern us, for conception has then followed impregnation, fixation of the impregnated ovum having occurred. These facts being kept in mind, it becomes evident that a variety of influences may interfere with the performance of this delicate and subtle process. For its accomplishment four things are necessary as far as the woman is concerned. 1st. The possibility of the entrance of seminal fluid into the uterus ; 2d. The possibility of the production of a healthy ovule ; 3d. The possibility of the entrance of an ovule into the uterus ; 4th. The absence of influences in utero destructive to the vitality of the eemen, and preventive of fixation of the ovum upon the uterine wall. Should these four conditions exist, no woman will be sterile. She may not bear children, but the incapacity may attach to the male and not to her ; or, having conceived, she may have suffered from consecutive abor- tions, which have been mistaken for attacks of menorrhagia. CAUSES. 649 The special causes of sterility, or those interfering with these condi- tions, may be thus presented : — 1st. Causes preventing entrance of semen into the uterus. Absence of the uterus or vagina ; Obturator hymen ; Vaginismus ; Atresia vaginas ; Occlusion of cervical canal ; Conical shape of cervix ; Cervical endometritis ; Polypi or fibroids ; Displacements ; Very small os internum or externum. 2d. Causes preventing the production of a healthy ovule. Chronic ovaritis ; Cystic disease of both ovaries ; Cellulitis or peritonitis ; Absence of ovaries. 3d. Causes preventing passage of ovule into uterus. Stricture or obliteration of Fallopian tubes ; Absence of Fallopian tubes ; Detachments and displacements of Fallopian tubes. 4th. Catises destroying vitality of semen or preventing fixation of im- pregnated ovum. Corporeal or cervical endometritis ; Membranous dysmenorrhoja ; Menorrhagia or metrorrhagia ; Abnormal growths ; Areolar hyperplasia. The mode of action of most of these causes is so self-evident as to make anything more than their mention unnecessary. Some of them, however, require special explanation. Vaginismus is an appellation which has been given of late years to a hyperossthetic state of the ostium vaginaj, which results in spasm of its sphincter. This interferes with the entrance of the male organ, and con- sequently of seminal fluid into the vaginal canal ; indeed, in aggravated cases, it entirely precludes sexual approaches. The affection is by no means rare, and is a fruitful source of sterility. An abnormal shape of the cervix has been pointed out by Dr. Sims as a frequent cause of infecundity. If this part be too long, so as to curl or bend upon itself, it is evident that it may not admit seminal fluid through its canal. But even a slighter degree of elongation, in which the cervix has a conical shape, has been observed to be frequently followed by that 650 STERILITY. Fig. 250. Conoidal cervix. (Sims.) condition. Fig. 250 represents the variety of conoidal cervix generally met with as productive of sterility. Endometritis, whether it be cervical or corporeal, fills the uterine canal with a thick, tenacious mucus, which often prevents the entrance of semi- nal fluid or destroys its vitality. Flexions of the uterus, by producing bending of the cervical canal, and versions, by pressing the os against one wall of the vagina, so as to close it as if by a valve, may entirely obstruct the passage to the uterus. Obliteration and displacement of the tubes frequently result from pelvic peritonitis, and thus that atfection olten entails sterility of the most irremediable character. The second stage of the disease consists in effusion of lymph, which in time undergoes contraction, and either closes these canals or draws them out of place. Membranous dysmenorrhoea, or rather the tendency to exfoliation of uterine mucous mem- brane which characterizes it, so alters the uterine surface as to render it inapt for the fixation of the ovum. Menorrhagia and metrorrhagia may result in the washing away of the ovum after impregnation and before fixation. The normal menstrual hemorrhage occurs before the entrance of the ovule into the uterus. If it be excessive and prolonged, it may remove the ovule entirely, and in the same way metrorrhagia may remove the impregnated ovum. An abortion does not occur under these circumstances, for although- impregnation may have taken place, conception has not done so. Abnormal growths of any form which fill the uterine cavity, as, for example, fibroids, polypi, hydatids, or moles, may so interfere with the attachment of the ovum to the uterus, as to prevent conception even when impregnation has occurred. Although it is impossible to give positive proof of the fact that serious chronic disease of the ovaries results in a blighting influence upon the ovule, such a conclusion is rendered highly probable by the results of ex- perience in such cases. Such a result is often found to attend chronic ovaritis, general pelvic peritonitis or cellulitis, and double cystic disease. Some of the causes here enumerated are much more frequent than others. I would enumerate the most common causes in the order of their frequency in the following sequence. First, glandular cervical endome- tritis ; second, areolar hyperplasia, the result of subinvolution of the ute- rus ; third, conoid cervix, with contracted os ; fourth, flexion and version of the uterus ; fifth, contraction of os externum ; sixth, fibroids, intersti- tial, or submucous; seventh, menorrhagia or metrorrhagia; and eighth, ovarian incapacity from -»iironic ovaritis or pelvic peritonitis. I do not TREATMENT. 651 state this sequence dogmatically, but merely to convey an idea of my im- pressions with reference to the matter. Differentiation — Before it is determined that a woman is sterile, the sexual capacity of the husbnnd should be ascertained. Men are averse to the confession of impotence, and will often allow the supposition of sterility on the part of their wives to be maintained rather than admit the truth. In two cases I have used an anaesthetic, ruptured the hymen, and distended the vagina, under the impression that sterility of several years' standing was due to the impossibility of the accomplishment of intercourse, and have subsequently discovered that the husbands of my patients were entirely impotent, and had been so before marriage. Prognosis. — In reference to a disorder which may be produced by such a variety of causes, no positive prognosis can be given, for its cure will entirely depend upon the removal of the agency which produces it. Much, too, will depend upon the thorough investigation of the causes by the physician, and a proper understanding, on his part, of the treatment. Un- questionably a large proportion of sterile women may, by appropriate treatment, be made fruitful. Results — No physical results are produced by sterility, but its existence "will frequently depress the spirits and sadden a disposition which, under other circumstances, would have been cheerful and equable. The married woman has always regarded and will forever view this incapacity as a reproach to her womanhood, and no amount of argument can make her accept it with resignation. Treatment — The treatment of sterility consists in the removal of its cause. Many of these causes are not susceptible of remedy, while the means of treating others are so evident that special mention may be confined to a few. Obturator hymen, vaginismus, atresia vaginae, and occlusion of the cervical canal should be treated by the surgical operations appropriate to each. In case the vaginal cervix should, to only a limited extent, be too pro- jecting or conical, the bilateral operation for its enlargement should be practised after the method elsewhere described. If a slight constriction of the cervical canal appear to be the cause of the condition, dilatation may be essayed in place of a surgical procedure. In an aggravated case, when the neck projects^markedly and is decidedly conoidal in shape, both these means are insufficient ; amputation then becomes necessary. After this has been recovered from, the bilateral operation for cervical hyste- rotomy is often necessary before cure is effected. In this connection the chapters upon dysmenorrhoea and amputation of the cervix should be referred to. Endometritis should be appropriately treated, and abnormal growths should be dealt with as if sterility did not exist. If a displacement be discovered and replacement and retention be pos- sible, they should be practised. But if in case of flexion this be impos- 652 AMPUTATION OF THE NECK OP THE UTERUS. sible, the uterine canal should be rendered as straight as is practicable, by the cervical incision recommended by Dr. Sims for dysmenorrhoea. Men- orrhagia and metrorrhagia should be treated upon the plan recommended in the chapter upon those subjects, and the patient be advised to keep very quiet and to avoid warm and stimulating beverages during menstrual epochs. A remark made in connection with the treatment of leucorrhoea may with propriety be repeated here, namely, that to enter moi-e minutely into the study of special remedial measures would tend to divert the mind of the reader from a point which I regard as of paramount importance ; that this affection is commonly only a symptom which should be reached through the malady which induces it. As I have elsewhere stated, glandular endometritis and tortuosities of the uterine neck are among the most frequent of the causes of sterility. The first of these is a disorder which is often incurable, and the surgical operations practised for the latter very commonly fail of result. And so with regard to other conditions resulting in sterility. If at the end of a large experience every one would compare the number of his failures in treating sterility with that of his successes, his results would not be regarded as very satisfactory. Unfortunately, the unsuccessful cases soon sink beneath the mental horizon, while the successful ones stand out promi- nently, and thus many a practitioner, by his evidence, unintentionally misleads others and produces disappointment. CHAPTER XLV. AMPUTATION OF THE NECK OF THE UTERUS. Although the recognition of the important role played by laceration of the cervix in uterine pathology will certainly circumscribe very much the field of this operation, there are nevertheless conditions which will still call for a resort to it as the most effective surgical resource. As a full description of the operation has not yet been elicited by previous chapters of this work, it will be well to consider it here before leaving the con- sideration of uterine and taking up that of ovarian diseases. History Ambrose Pare' was the first surgeon who advised amputation of the cervix. He recommended it in malignant growths of the part, to which, he says, *' we may apply the speculum matricis, in order to see more easily." It is reported, upon insufficient authority, to have been performed as early as 1652, by Tulpius, of Amsterdam, and in 176G, by ' ffiuvres d'Ambroise Pare, lib. xxiv. p. 1012. CONDITIONS DEMANDING AMPUTATION. 653 La Peyronie. Daniel Turner,' of London, in 1736, reported an instance in wliich the neck of a prolapsed uterus was amputated by means of a razor in the hands of the patient herself, who was insane. The recovery of the woman was evidently regarded as a wonderful circumstance. In 1802, the operation was systematized by Osiander, who performed it twenty-three times, and after this it was resorted to by Dupuytren, Eeca- mier, Hervez de Chegoin, and others. It was, however, in the hands of Lisfranc that it attracted special attention, and in consequence of his en- thusiasm it was for a time regarded as a means which was destined to accomplish a vast deal of good. His reports of its results were most favorable, and he described its dangers as slight. But soon after his pub- lications upon it there appeared a counter-report from the young physician^ who took charge of many of his cases and was familiar with all, which cast discredit upon all the master's statements. By Pauly, the truth was, as Becquerel expresses it, " brutally revealed," and it was entirely at va- riance with the representations of Lisfranc. Since that time the operation has to a certain extent fallen into disrepute, but is still resorted to in appro- priate cases. Dangers. — The dangers of the procedure are the following : — Primary hemorrhage ; Secondary hemorrhage ; Peritonitis ; Cellulitis ; Tetanus. The statistics of the operation have not as yet been carefully collected. Lisfranc reported 99 operations and only two deaths, but these statements Pauly renders more than doubtful. Huguier reports 13 operations and no deaths ; Sims over 50 operations and one death ; and Simpson 8 opera- tions and one death. Even these reports, favorable as they are, refer to the results of ampu- tation by the knife. By galvano-cautery much better results are obtained. It is really surprising to see how little constitutional disturbance follows this operation. Out of the large experience of Dr. Byrne, of Brooklyn, with it, no fatal case is reported ; and only one bad result has occurred in my own practice in over fifty amputations of the whole cervix. Conditions demanding Amputation The conditions which ordinarily tail for removal of the cervix are the following: — Malignant disease ; Great enlargement from cervical hyperplasia ; Longitudinal cervical hypertrophy ; Conical and projecting cervix ; Granular or cystic degeneration of intractable character. • New York Med. Journ., vol. v. No. 5. 2 Pauly, Maladies de I'Uterus, Paris, 1836. 654 AMPUTATION OF THE NECK OF THE UTERUS. One of these conditions, longitudinal cervical hypertrophy, not having previously received special mention, requires it here. The cervix may be congenitally very much elongated below the vaginal junction. Generally it undergoes hypertrophic elongation from a simple formative irritation, a low grade of cervical endometritis, congestion long kept up, or prolapsus in the third degree. Under these circumstances the neck grows very long, so as to rest between the labia or even to project ibr a number of inches from the body, and it has in some instances been mistaken for the penis. By means of the touch, conjoined manipulation, the speculum, and the probe, a diao-nosis can readily be made. M. Huguier, some years ago, maintained that this condition often deceived practitioners into the belief in prolapsus uteri. . Varieties of the Operation In some cases, as in cancer, for example, it is necessary to remove the entire cervix and even as much tissue as possible from that portion of the organ above the vaginal attachment. In others, only half of the vaginal portion requires ablation, while in still another set of cases, only the removal of a thin section of the hypertro- phied lips is called for. Methods of Performance The operation may be performed by the following methods : — By the bistoury or scissors ; By the ecraseur ; By the galvano-caiistic battery. Operation by Bistoury or Scissors — When performed by the first method, the patient should be placed upon the left side and Sims's specu- lum employed. The cervix being slit bilalerally, one lip is seized and cut off as near the vaginal junction as is deemed advisable, and then the other is removeil in a similar manner. Formerly the operation was completed at this point, but Dr. Sims lias introduced the practice of di-awing down the mucous membrane and stitching it, with silver sutures, so as to cover the stump, as that of the arm or thigh is covered by skin after amputation of those parts. When the stump is covered by mucous membrane, after tliis plan, recovery is much more rapid than when granulation is allowed to accomplish the cure. This operation is often a bloody one. Operation hy the JCcrasenr. — In operating by this method, if the uterus be prolapsed, if the degree of longitudinal hypertrophy be so excessive as to cause full protrusion of the cervix, or if such protrusion be attain- able by moderate traction, the patient may be placed on the back. If the uterus be high up in the pelvis and strong traction be necessary to depress it, the best position will be found to be that advised when scissors or the bistoury are employed, the speculum being used. Tlie passage of the chain will be found to be very simple, and tlie part should be slowly cut through. In using the ecraseur for this purpose, great care should be observed METHODS OF PERFORMANCE. 655 not to allow of too great dragging of the chain upon the neck without cutting. If attention be not given to this point, the peritoneum may be opened or the bladder involved. I describe the operation by the ecraseur, although I regard it as inferior in merit to both the other methods mentioned, I do this because the ope- ration is often called for far from surgical centres, where it is very difficult to procure a battery, and where no operator of sufficient skill can be found to perform amputation by cutting instruments. Operation by Galvano-cautery The galvano-caustic apparatus consists simply of an instrument which enables the operator to engage any part in a loop of wire which, being connected with a powerful galvanic battery, becomes red hot and cuts its way tlirough. The instruments generally Fig. 251. Byrne's g-alvano-caastic battery.i employed here are a German battery, Middledorpf 's ; or Grennett's, a verj compact instrument made in London ; and one constructed by W. F. Ford, ' For details concerning this instrument I refer the reader to Dr. Byrne's inter- esting brochure entitled Electro-cautery in Uterine Surgery, Wm. Wood & Co. 656 DISEASES OF THE OVARIES. 9f New York, after a method suggested by Dr. John Byrne. , It would be out of place here to give details concerning these instruments ; all of them answer the purpose in view very well. That of Dr. Byrne is, for an American, most attainable, and is certainly a very efficient and reliable apparatus. It is shown in Fig. 251. In amputating the neck in this way, the patient may be placed upon the back, and the uterus drawn down between the labia ; or, if this de- pression of it be difficult, she may be placed upon the side, and Sims's speculum employed. By one of these procedures the part to be ampu- tated is fairly exposed to view and manipulation. The wire loop of the galvano-cautery is passed around the neck as high up as is deemed safe, and tightened until it is fixed in the tissues so as not to slip. Then the current of electricity is made to pass through it, and the loop being slowly tightened by the turning of a screw by the operator the cervix is ampu- tated. Sometimes the removal of the portion of the cervix desired is difficult of attainment, a scalping process being substituted for a complete amputation. To accomplish the operation completely, I have devised the forceps shown in Fig. 235. By the long, sliding screw between the blades, the cervix is drawn into their grasp and fixed by closing them. Tlien the screw is withdrawn, and the cold wire slid over the projecting portions and tight- ened, and, the electric current passing, a red, and not a white, heat being established, the cervix is completely removed. By this method immediate hemorrhage is usually controlled, but not so remote hemorrhage. Sometimes on the fifth, sixth, or even the tenth day a most active ilow takes place in spite of every precaution. For this reason the tampon should be used after such an amputation, and the patient's convalescence be carefully watched. CHAPTER XLVI. DISEASES OF THE OVARIES. History Ancient literature is singularly barren upon the subject of ovarian diseases. That the functions of these organs were known to early anatomists, there is no doubt, for as early as 200 B. C. the operation of castration of female animals is alluded to by Aristotle, and in the second- century A. C. they were described by Galen under the name of "testes muliebres." As to the influence exerted by them upon menstruation, they were not informed, for they attributed tliat process, according to Aristotle, to a superfluity in the blood, an opinion which was entertained HISTORY. 657 even by Hippocrates. The works of Aetius make no mention whatever of ovarian disorders, and those of Paul of ^gina are equally silent. When it is borne in mind that the ovular theory of menstruation dates back for its origin to the labors of i^segrier, Gendrin, BischotF, Pouchet, and others of our own time, and that the operation of ovariotomy was never systemati- cally performed before the year 1809, it will be appreciated how recently the profession even in modern times has fully grappled with the subject. During the past twenty years full amends have been made for this delay in progress, for in that time no portion of the field of gynecology has received more attention or been more thoroughly investigated than that which now engages us. Not only have most of the diseased condi- tions of the ovaries been satisfactorily investigated, and the diagnosis of them reduced to a scientific system ; for the most frequent and important of them surgical means have been instituted with such success as to have given procedures of the most appalling character and undoubted dangers the position of legitimate and justifiable operations. The recent literature of ovarian pathology and surgery is now enriched by the contributions of so many capable observers, that it is almost invidious to particularize the most prominent. Unfortunately there is one set of ovarian affections with reference to which these statements are not true ; those of inflammatory character. Our means of diagnosis of ovaritis, both acute and chronic, is, in spite of all the advances alluded to, so elementary and unreliable that the result is discordance of views, and uncertainty as to patholof'y and therapeutics. It was probably the contemplation of this fact which, led Scanzoni to open his article u[)on diseases of the ovaries with the followino- sentence: "If we felicitate ourselves upon the progress which has been made during the last few years, in the diagnosis and treatment of the diseases of the uterus, we should, on the other hand, remember that the labors of gynecologists in respect to the diseases of the ovaries have been almost fruitless in practical results." In illustration of the difficulties attending the diagnosis of ovarian diseases, I introduce a table which I have constructed from Hennio-V report of one hundred post-mortem examinations made by him, with spe- cial reference to this point. "If we now turn our attention," says he, "to the diseases of the ovaries, it is a fact of great value, in reference to diagnosis, that in ten out of one hundred cases, the diseased state of the ovary was, or might have been, recognized during life — more frequently by rectal exploration than by vaginal or abdominal." On the other hand, out of 81 bodies, a diseased condition of the ovaries was found in 53, a proof of how frequently disease of the ovaries cannot be recognized during life. The diseased condition was more frequent in one ovary alone than in both ; this being found in three-fourths of the cases. ' Catarrh of fcjexual Organs of the Female. By Carl Hennig. 42 668 DISEASES OF THE OVARIES, Out of eighty-one cases 5=^ U C3 d o t3 p gj o d o -3 o3 S 2 ^ ■^ a p. a 3 >■ ©■a X >>==! t^e « o ^ o o HI W Pm 53 30 5 1 6 9 Anatomy of the Ovaries The ovaries are two follicular glands about the shape and size of small almonds, situated one on each side of the uterus. So dependent are they upon the position of the uterus and sur- rounding viscera that they have really no fixed place. They are usually found in the lateral and posterior parts of the true pelvis, about an inch from the uterus, and just below the point where the Fallopian tubes enter that organ, the left being in close proximity with the rectum. Each ovary is attached to the peritoneum, which connects it with adjacent structures, and is firmly united with the uterus by means of a fibrous cord arising from the horn of each side. The Fallopian tube of each side is connected w'ith the ovary by one fimbria, and acts at periods of ovulation as its excretory duct. The sur- face of the ovary is not covered by peritoneum, for, arrived at the circum- ference of these organs, this membrane loses its characteristic appearances, and the only trace of it which is discoverable is a layer of basement- epithelium.^ Around the circumference of the ovaries a cortical portion exists, whose duty it is to generate the Graafian follicles. "Within this is a fibrous structure, composed of muscular fibres, cellular tissue, vessels, and nerves, which receives the name of stroma. Removed from the stroma and examined with care by the microscope, each of the Graafian vesicles is found to consist of a sac, called the tunic, which is filled with fluid, the liquor folliculi, in which is contained the ovum or egg which is the female contribution to conception. It is now accepted as a fact by most physiologists, although still con- tested by some, that the periodical discharge of blood from the uterus, which is called menstruation, is merely a uterine symptom of the discharge of one of the ova from the ovary by rupture of a follicle. After the period of puberty has arrived, one or more of the follicles of each ovary burst every month by the follow'ing process : a congestion or hyperasmia occur- ' For details with regard to these curious and recently discovered facts, the reader is referred to essays by Otto Schrone, Henle, and Sappey. ANATOMY OF THE OVARIES. 659 ring in the ovary for some reason beyond our comprehension, causes an excessive secretion by the walls of the follicle, in which a miniatui'e dropsy takes place. This goes on to rupture, and escape of the liquor folliculi, blood, granular cells lining the ovisac, and the ovum. The nerve supply to both uterus and ovaries is excited by this process, and one of the results of such excitement is contraction of the delicate middle layer of uterine fibres which surround the network of minute vessels en- < veloping and penetrating the uterine structure. This throws the vascular apparatus into a state of erection. Great engorgement occurs on the sur- face of the uterine mucous membrane, and probably on that lining the Fallopian tubes; they rupture, and a flow of blood takes place. Three elements are concerned in this discharge: 1st, ovarian irritation excited by ovulation and transmitted to the nerves governing the muscles consti- tuting the middle coat of uterine fibres ; 2d, erection of the uterine vascu- lar system ; 3d, consequent rupture of the bloodvessels of the mucous membrane of the uterus and escape of blood. The ovisac being thus emptied, a clot of blood soon forms within it, then an hypertrophy of the cells lining it occurs, and the corpus luteum is formed. If the examiner hold up one of the broad ligaments between himself and the light, a small plexus of white, crooked tubes will be seen forming a cone, the apex of which is directed towards the hilus of the ovary. It measures about an inch in breadth, and consists of about twenty tubes which are filled with a clear fluid. This is the organ of Rosenmiiller, which has recently been minutely described by Kobelt under the name of the par-ovarium, and is supposed by him to be an exaggeration of tlie Wolffian body. The exact location of the par-ovaria is this : they lie be- neath the ovaries and between the ultimate folds of the peritoneum cover- ing the fimbriated extremities of the Fallopian tubes, which have received the name of the alae vespertilionum. Tiie ovaries are supplied with blood through the spermatic arteries, which, upon arriving at the margin of the pelvis, pass inwards between the layers of the broad ligaments, and thus reach their lower border. Their nervous supply is not extensive, and is derived from the renal plexus. The ovary presents its most perfect type in the yoimg virgin, when its dimensions are greatest and its surface undeformed by the numerous cica- trices which appear at a later period. The dimensions of this organ are greater than they are during early virgin life only during and for six weeks after the process of utero-gestation. Henni^, who has made a spe- cial and exceedingly minute study of this point, declares that pregnancy increases the length but not the breadth nor the thickness of the organ. Utero-gestation, which leaves the uterus larger than it was before, has the contrary effect upon the ovaries, which after its accomplishment diminish in size, never again to attain their former dimensions while in a state of health. 660 DISEASES OF THE OVARIES. Varieties of Ovarian Disease. — Any one or all of the tissues which have been mentioned may be affected by disease, or the position of tlie ovary may be altered to such an extent as to constitute a morbid stale. The following table presents a list of the disorders of these glands which will now receive special attention : — Absence ; Imperfect development ; Atrophy ; Inflammation ; Neoplasms. Absence. One or both of the ovaries may be congenitally absent, but such a con- dition is very rare. When it does exist, it is generally only a part of a complete w^ant of genital development which is manifested not only by these organs but by the parts making up the vulva, the vagina, and the uterus. Kiwisch declares that it has been most frequently observed in the bodies of newly -born infants who were not viable on account of compli- cated deformities. Where there is congenital absence of the ovaries the woman is generally small in stature, her figure undeveloped, as if the period of girlhood were abnormally prolonged, and the genital system im- perfect, as already mentioned. In some cases the mind is very deficient, a condition bordering upon idiocy sometimes existing. In others this' is not the case, but the patient suffers from depression of spirits, and appears to lack vigor both of mind and body. Development into womanhood has never arrived for her, and she remains a child without the vivacity and cheerfulness of childhood. Although certainty can only be arrived at post mortem, a diagnosis may be made during life by the use of Simon's method, which may guide us in prognosis and treatment. Indeed, one of the greatest benefits which can accrue from a correct conclusion will consist in the avoidance of all efforts which, being vainly addressed to exciting the performance of the functions of the ovaries, deteriorate the state of the patient. Should the general condition of the patient, the undeveloped state of the vulva, vagina, and uterus, and the entire absence of the menstrual crisis combine as evidences of the condition, a diagnosis is admissible. Imperfect Development. This condition, which consists in persistence of the foetal state of these organs after the period of puberty when rapid development should have occurred, is by no means so rare as that just mentioned. It may exist on one side only, tliough it generally affects both. As in the case of absence of the ovaries, a certain conclusion is not easy, and as in that case, also, we draw a presumptive conclusion from want of development in the other IMPERFECT DEVELOPMENT. G61 organs of generation, absence of the usual signs of the mensti-ual crisis, and lack of general constitutional vigor and development. As examples of cases susceptible of such an explanation, I record the histories of two with which I have recently met. The first is that of Miss F., referred to me by Dr. Rodenstein, of Manhattanville. She is twenty-four years of age, and yet has the appearance of a girl of thirteen. Indeed, it is difficult to believe the statement that she is more than that age. The features, limbs, mode of expression, and general deportment are those of a child. She has never menstruated nor shown any evidences of a tendency to do so. Physical exploration shows the vulva in the state of early girlhood, the mons veneris destitute of hair, the labia thin, and the vagina so small and narrow that the little finger only can be in- troduced, and that causes great suffering. The canal being short as well as narrow, the uterus can be touched, and is found like a little nut in the vagina, so light that its weight is scarcely perceptible. The second case is one which I saw with Prof. W. H. Thompson. The patient is eighteen years old, and has never menstruated. Previous to the treatment established by Dr. Thompson, she suffered greatly from epileptic seizures, which have evidently impaired the force of her intellect, but during the two months before I saw her she had been free from them. The girl is slow in her movements, childish in manner, and stupid in reply- ing to questions. L [)on physical exploration, the vulva, vagina, and uterus are found fully and perfectly developed, the latter giving by measurement, with the uterine probe, two and a half inches. Nothing can be elicited with reference to the ovaries by physical means, but the rational signs mentioned, together with the fact that all the appearances of girlhood are combined with entire absence of any apparent effort at ovulation, render the supposition that the ovaries are undeveloped, or foetal, highly probable. Sometimes cfises will be met with in which masculine development, emansio-mensium, and sterility will lead to a diagnosis of absence of the ovaries, but which will subsequently undergo a change and give all the evidences of the presence and efficiency of these organs. One such case, which occurred in tlie practice of Dr. Metcalfe and myself, is worthy of record. Mrs. B., a large, muscular, and liandsome woman, had men- struated very irregularly and scantily for ten or fifteen years. Sometimes the menstrual discharge would be entirely absent for months, then it would at long and irregular intervals show itself for a day. Her health was not affected by this in any way. She presented, however, many signs of masculinity ; the voice was harsh, the breasts flat, and the chin covered with a sparse beard. After having been married for years she became pregnant, and in due time bore a child, subsequent to which she men- struated more regularly and plentifully, and has since borne two children. Treatment. — Should the ovaries be congenitally absent, it is evident that art can do nothing to remedy the evil. Should they exist in an 662 DISEASES OF THE OVARIES. undeveloped or foetal state, it is possible that, by a proper stimulus applied to them by the most direct means in our power, growth and maturity may be fostered, unless the condition be one of aggravated arrest of develop- ment. The means which are most likely to accomplish this are — General tonics ; Uterine irritation ; Electricity ; Marriage. The sanguineous and nervous systems should both be brought into as perfect a state of health as possible by ferruginous and bitter tonics, fresh air, exercise, change of scene, and a general observance of the laws of hygiene. The most direct method for irritating the ovaries is through the uterus, with which so close a sympathy exists. For tliis purpose tents may be occasionally resorted to, as often, for instance, as once or twice a month. This not only prepares the uterus for its part of the process of menstrua- tion, but causes a hypersemia in the ovaries, which we know to be the physiological forerunner of ovulation. Electricity may be employed by placing one pole of a battery over the spine and one over the ovaries, or, more effectually, by carrying one pole, protected where it touches the vagina, to the cervix uteri, connecting this with a battery, and passing the other pole over the ovaries. An intra- uterine galvanic pessary may likewise answer a good purpose, when worn steadily and persistently. The ovarian irritation and congestion incident to the marital act will sometimes excite ovulation, not at the moment of coition, as was formerly supposed, but remotely. Atrophy of the Ovaries. At a period, varying from the fortieth to the fiftieth year, the ovaries are destined to undergo atrophy. They diminish in volume, become wrinkled, the Graafian follicles disappear, and the stroma becomes dense and non-vascular. This is a physiological process, and marks what is termed the menopause, or period of menstrual cessation. Sometimes this process sets in at a very early period, owing to some abnormal condition which has excited it, and produces the same results as those following it when it takes place at the normal time. Causes. — With regard to the special causes of this occurrence very little is absolutely known, further than the fact that it sometimes occurs from pelvic inflammations. It is probable that acute ovaritis may produce it, and it is certain that, at times, it results from pelvic peritonitis and cellu- litis. The following case which presented itself at my clinique some time ago is illustrative of this fact. Mary G., a healthy young Irish womari, aged OVARIAN APOPLEXY. 663 24 years, stated that she had a miscarriage at the third menstrual period, five years before, in Albany. Three days after the product of conception had been cast otF, she was taken with a chill, with violent pain over the abdomen, and was declared by her physician to have inflammation of the bowels. Of this attack she nearly died, but after a confinement to bed for six weeks grew better. For two years after this she had irregular, pain- ful, and profuse menstruation. As she expressed it, whenever she became fatigued or excited, flooding would come on. After this time the men- strual periods disappeared, and she now applied for relief on account of amenorrhoea of three years' standing. Physical exploration revealed the uterus in normal position, though diminished in size to about two inches. Nothing could be ascertained about the ovaries. The view which I took of the case was that pelvic peritonitis and acute ovaritis originally existed ; these left the parts in such a state that for two years metrorrhagia and menorrhagia occurred ; then subsequent contrac- tion occurring in the effused lymph in and around the ovaries, atrophy resulted with its usual consequence, amenorrhoea. The peculiarly destructive influence exerted upon the ovaries by pelvic peritonitis will be impressed upon any one who makes an autopsy in a patient who has died of that affection, or who reads the reports of others. Very often the ovaries cannot be discovered in tlie mass of " putrilage" which occupies their site. Treatment — An attempt may be made, by the means recommended in the treatment of undeveloped ovaries, to excite ovulation in any part of the glands which may still be capable of performing the function. But it should not be persisted in if not at once attended by good results, for in- flammatory action may be excited by it. When these means are essayed, great caution should be observed and tlieir influence developed only to a limited degree. Ovarian Apoplexy. Definition — The word apoplexy is very loosely employed in reference to sanguineous effusions in all the organs of the body, some signifying by it sudden vascular rupture, while others apply it to interstitial hemorrhage occurring even very slowly. This has created confusion of description, and certainly added difficulty to the clear comprehension of the pathologi- cal states to which it has been synonymously applied. Thus, in describing ovarian apoplexy, Kiwisch^ divides it into primary and secondary, con- sidering as examples of the latter, hemorrhage frOm the walls of a cyst which fills it slowly with blood, or hemorrhage the result of tapping. The two conditions should be regarded as essentially different, and I would offer this as the proper definition of our subject. Apoplexy of the ovary ' Op. cit., p. 232. 664 DISEASES OF THE OVARIES. consists in a rapid effusion into its tissue of blood, which results from rup- ture of one or more of its larger vessels. The ovaries present the only example in the animal economy of apoplexy occurring as a physiological act. At each menstrual period, as an ovule leaves its nidus, an apoplexy from the vessels of the tunic of the ovisac occurs as a necessary consequence. It is this which, upon subsequent alteration, constitutes the corpus luteum. Generally these hemorrhages are self-limiting, and their effects rapidly disappear ; in some cases, how- ever, the bleeding continues too long or returns after cessation, and then the collection of blood sometimes reaches the size of a man's fist or of a child's head.^ In some instances the tunica albuginea of the ovary is completely ruptured, when the effused blood pours into the most depend- ent portion of the pelvic cavity, constituting pelvic hematocele. Symptoms The occurrence of apoplexy is often ascertained only in autopsy, no signs existing during life by which it can be positively diag- nosticated. The symptoms which w^ill usually point to its existence are sudden and violent pain over the region of one ovary, with sense of great exhaustion, nausea, and vomiting. These symptoms, if combined with enlargement and tenderness of one ovary, as ascertained by conjoined manipulation, will be sufficient to render a diagnosis warrantable if the patient's health has previously been good. Prognosis The great danger from the accident is peritonitis, arising either from implication of the peritoneal fold which makes the broad liga- ment, or from rupture of the cortical portion of the ovary and occurrence of hematocele. Treatment. — Should there be symptoms of peritonitis, the treatment elsewhere recommended should be adopted. Beyond this, all that can be done is to keep the patient quiet in the recumbent posture, and prevent all muscular effort until absorption occurs. Displacement of the Ovaries. The extreme mobility of these glands and the laxity of their supports have already been remarked upon. Any influence which increases their weight, draws upon them directly, or acts upon them by traction through a neighboring organ, may cause them to leave their position, and even in rare cases to pass out of tiie pelvis in the form of hernia. For example, they may be displaced by inflammation, hypertrophy, ovarian foetation, etc., which cause increase of weight ; or they may be acted upon by con- tractions of effused lymph, resulting from pelvic peritonitis ; contraction of the ovarian ligaments, etc., drawing them out of place ; or they may be affected by displacement of the uterus, pregnancy, or hernia of any ' Kiwisch, op, cit., p. 232. OVARITIS. 665 of the abdominal viscera acting upon them by means of traction. A hernia of the ovary alone is very rare ; it is almost always attended by hernia of the Fallopian tube, or some portion of the intestines or omentum. The ovaries often fall, when their weight is increased, into the cul-de-sac of Douglas. More rarely they pass into the inguinal canals, or through them into the dartoid sacs of the labia majora. Here they show a monthly intumescence, which creates great local disturbance, and keeps the part swollen, heated, and tender, until ovulation is passed. Deneux^ declares that they may enter the femoral, umbilical, and ischiatic openings, or form a part of ventral hernia, and Kiwisch has reported a case in which one entered the foramen ovale. The accident is rarely important in its results except in reference to excluding the suspicion of other forms of tumor, and avoiding the danger of surgical interference under a mistaken diag- nosis. Treatment — The treatment consists in returning the displaced part by taxis, and keeping it in situ by a properly constructed truss, pessary, or bandage. Should the gland be bound in its false position by strong mem- branes, the propriety of its removal might be considered, in case serious inconvenience resulted from the displacement. Ovaritis. Definition By this term is meant an inflammation of the tissue com- prising the ovaries, which has been described by some authors under the name of Oophoritis. A dogmatic treatise upon ovaritis in the non-puer- peral woman is, in the present state of science, impossible. So much con- cerning the disease is unsettled, and such utterly discordant views are entertained upon it Ijy the most reliable authorities, that too great caution cannot be observed in treating of the subject, lest theories constructed upon analogical reasoning be made to pass current in the mind of the reader for facts faithfully observed at the bedside and in the dead-house. No writer should attempt its description without determining as Aran did, when he penned the following sentence : " I leave out of considera- tion all the fantastic descriptions of ovaritis Avhich have been constructed in the library by physicians who were more remarkable for brilliancy of imagination than knowledge of tlie disease." Our knowledge of the subject is at least so far advanced as to make a theoretical essay upon it entirely inadmissible. Varieties Ovaritis may be either puerperal or -non- puerperal. The first does not concern our present investigation, and we put it out of con- sideration. The non-puerperal form of the disease has been divided into acute and chronic, which will now engage us in order. ' R6clierches sur la Heriiie de I'Ovaire. 666 DISEASES OF THE OVARIES. Acute Ovaritis. This affection, though very common as a result of parturition or abor- tion, is, except as a complication of pelvic peritonitis or cellulitis, quite rare in the non-puerperal woman. Mme. Boivin' even goes so far as to say that, " it would be diificult to point to a single well-authenticated case out of the condition of pregnancy." Dr. West^ remarks that, " acute in- flammation of the substance of the unimpregnated ovary is of such rare occurrence that no case has come under my own care, and but one has presented itself to my observation." Prof. Fordyce Barker^ says, " I doubt very much if I have ever seen a clear, well-marked case, and I have been for years looking for its existence in the dead-house." There can be no question of the truth of these statements as regards pure uncom- plicated inflammation of tlie ovary, but ovaritis of acute character going on to suppuration or production of a diffluent state of the stroma, is by no means rare as a complication of pelvic cellulitis or peritonitis. One of the greatest dangers to be feared from these diseases is injury or destruc- tion of the ovaries, and it is probable that few cases of cellulitis and none of peritonitis run their course without involving them to a greater or less extent. It is likewise probable that pelvic peritonitis is frequently excited by some trouble originating in the ovari Op. cit., p. 205. COLLOID DEGENERATION OP THE OVARY. 681 consideration of the facts leads to the conclusion that the affection is not cancer at all." M. BecquereP seems to have placed the question in its proper light when he says, "Several diseases have been confounded under the indefinite name of colloid cysts ; it is therefore essential, before ad- vancing, to distinguish these different varieties. We shall now endeavor to do this after them (Virchow and Scanzoni), previously remarking that under the name of colloid matter some have not at all intended to signify a cancerous product, while others have assigned it such an origin." Vir- chow^ strongly expresses himself upon this point. In speaking of the difference between the form and nature of growths, he says, "You may therefore say, colloid cancer, colloid sarcoma, colloid fibroma. Here colloid means nothing more than jelly-like." He then goes on to remark that no confusion should exist between such growths as colloid cancer and eolloid degeneration of the thyroid gland as to pathological significance. His description of the so-called alveolar cancer is thus quoted by Bec- querel: "Small pouches, which are filled with gelatinous matter and whose walls are lined by a layer of epithelium, are found in the paren- chyma of the ovary. These vesicles develop in every direction, but more especially at the periphery of the ovaries, where they form masses of irregular shape. Some of them are isolated, while others are grouped together in the following manner. The walls of these vesicles disappear by atrophy of cellular tissue, when they are only formed by their epithelial lining. This becomes infiltrated with fat, and the walls forming the connection are easily ruptured. Those of the. large cyst remain intact and become hypertrophied In other cases the vesicles rupture by over-distention ; from this results hemorrhage, and blood is found in the vesicles." Kiwisch describes it as a breaking up of the stroma of the ovaries into cellular cavities, alveoli, closely aggregated together and inclosing a jelly-like, semifluid mass. By others it has been likened to a sponge or a honeycomb. It is safe to conclude, from the present aspect of the subject, that, while colloid deposit may coexist in the ovary with true cancer, the peculiar breaking up of the stroma into alveoli which we have just described is not in itself a malignant affection, but one which seems to constitute a con- necting link between cancer and the benign degenerations. It frequently complicates cancer, sarcoma, and fluid tumors. " We have observed," says Kiwisch, " alveolar degeneration of considerable extent remain in the system for a long series of years, without any remarkably bad effects." Should a large cyst be discovered anywhere, and the size of the tumor require diminution on account of interference with surrounding parts, paracentesis may be practised ; but in a pure alveolar tumor, such an accu- » Op. cit., p. 226. 2 Cellular PathoL, p. 512. 682 OVARIAN CYSTS. mulation is not common. lender these circumstances, if the disease stead- ily advance and the constitution suffer in consequence, we should be encouraged by recognition of its non-malignant nature to perform ova- riotomy. CHAPTER XLVIII. OVARIAN CYSTS AND CYSTOMATA. This disease consists in the development of cysts within the ovary with- out coincident growth of solid elements, such as fibroma or carcinoma. Of all the varieties of ovarian tumor it is the most commonly met with, and hence for the practitioner it is the most important. It is fortunately, too, that which above all others is most susceptible of relief by surgery. Pathologists are still at variance with reference to the origin of ovarian cysts. While some with Wilson Fox' agree, that " all the forms of cysts met with in the ovary oi'iginated from the Graafian follicles, and that the multilocular forms are not the results of any special degeneration of the stroma ;" others, like Wedl, doubt their follicular origin entirely ; and others still, with Rindfleisch, admit two different sources of cystic forma- tion— one, the follicles, the other, the interstices of the stroma. " In many cases," says Rokitansky,^ " they are undoubtedly formed from the Graafian follicles, and it appears that an inflammatory process is particularly liable to give the first impulse to this metamorphosis. They ai-e probably, however, as often new formations from the beginning." " It was formerly very generally supposed," says Wedl," " that the cysts in the parenchyma of the ovary originated iu the Gi'aafian follicles, but no direct proof of this was ever given." Liicke,* one of the latest and most reliable authorities, takes even stronger ground against it than Wedl did. After quoting Rokitansky's views he goes on to say : " But we have already stated that cysts can only form in the connective tissue, and only after a long continued irritation ; and that it does not look at all probable that such cysts should form by spontaneous exudation. As tar as the cystoids of the ovary are concerned, theory certainly is not admissible. These tumors are essentially cysts from broken down tissue." ; While experimental pathologists are testing this question, we may for > Med, Chirurg. Trans., 1864. ' " Op. cit., p. 249. 3 Wedl's Path. Histol., p. 462. ^ Chapter on Tumors in Billroth and Pitha's Manual of General and Special Surgery. OVARIAN CYSTS. 683 the time assume that there are two entirely different pathological processes by which true ovarian cysts are generated : — 1st. The follicles of De Graaf become filled with a colloid material, due to abnormal secretion from their walls, and, according to Rokitansky and Rindfleisch,^ probably the result of inflammatory disease of the wall of the follicle. This is not the insignificant hydrops folliculorum which creates small cysts, but a true colloid degeneration of the follicle of much more serious import. 2d. A development of cysts may occur in the stroma of the ovary with- out connection with the follicles. In this case, according to Wedl, " the cyst consists in an excessive augmentation of volume of the areolae of the areolar tissue and of the papillary new formations composed of connective tissue." In this view Waldeyer coincides in his excellent treatise upon ovarian tumors.'- Liicke makes Rokitansky's view as to the mode of formation of these cysts in the stroma so clear that I use his words instead of quoting the original : " Cysts may also be generated by exudation into new formed connective tissue — the fiuid distending the different bundles, and as they intersect in all directions, the globular form is the result ; thus numerous small spaces communicate with each other, from their walls new cysts start, and thus very complex tumors can be formed." Rindfleisch^ accepts both of these sources of ovarian cystoma in the following words : " An exact investigation also proves that at least the majority of all ovarian cysts proceeds from Graafian follicles ; while, upon the other hand, until further information, a different mode of origin must be accepted for a group of cysts, although not so large, yet, at the least, just as important." The development of a substance resembling the glandular element of the ovaries, and constituting the nidus of cysts, has recently attracted considerable attention. In 18G2 Mr. Spencer Wells proposed for this the name of " adenoma" or "adenoid tumor." Further investigations appear to have satisfied pathologists that a degree of adenoid development occurs in every true ovarian cystoma. Mr. AVells himself, in his recent work on Diseases of the Ovaries, considers under the head of adenoid tumors all simple, multiple, and proliferous cysts ; and Delafield* declares, that " in the ovaries most of the compound cysts are adenomata, with dilatation of the follicles." Klebs strongly advocates this view. As adenoma is then a frequent element of ovarian cystomata, it requires no separate and spe- cial consideration. Until a recent period considerable attention has been paid to the char- acter of ovarian cysts, based upon the existence of a few and of many cysts. Pathologists are beginning to lay less stress upon this feature than ' Op. cit., p. 515. 2 Waldeyer, Eierstock unci Ei., Leipzig, 1870. ^ Op. cit., p. 515. ■» Post-mortem Examinations and Morbid Anatomy. nS4 OVARIAN CYSTS. they formerly did. Kindfleiscli declares that all are multilocular in the beginning, and that they become paucilocular, and, even in rare cases, unilocular, by fusion of adjacent cysts by breaking down of dividing septa. It must be admitted, however, that there is one class of tumors, the distinguishing characteristic of which is the existence of a few cysts only, one or two of which are usually very large, and another which is specially marked by numerous small cysts. The first constitutes the olygocystic tumor of Peaslee ; the latter the polycystic tumor ; or, as they are likewise styled, paucilocular and multilocular. P^ach class has usually certain well-marked features, the recognition of which is of value in a practical point of view. The first is thus described by Kindfieisch : " Multilocular tumors up to the size of a man's head, or unilocular cysts up to two feet in diameter, with smooth, but little ad- hering surface, and comparatively thick, fibrinous walls, Avhich are very commonly covered at their inner side with caulifiower-like or more tul)erous papillary excrescences." This is the form of tumor which he regards as due to colloid degeneration of the Graafian follicles. The second variety he describes in these words : " At the place of one ovary (the other, as a rule, is healthy, while in the first form the disease is often of both sides) there lies a tiunor, not infrequently far above the size of a man's head, which is composed of several large, and very many smaller, and even the smallest cysts. The larger cysts are often con- stricted, and exhibit, at these places, the remains of former partition walls in the form of fenestrated membranes, or ramified vascular strands, which evidently succumb to a gradual maceration. The surface of the tumor is probably always connected with the peritoneum by a large number of in- fiammatory adhesions, upon which larger venous vessels run to and fro. The walls of the cysts are comparatively thin, and easily torn," These tumors he regards as due to colloid degeneration of the stroma. While the statement of Rindfleisch that no " fundamental significance" can be attributed to the unilocular or multilocular character of these tumors is correct from an anatomical point of view, it is not the less co that the practitioner is greatly aided in prognosis and treatment by a recog- nition of the difference between the two forms of tumors just described ; and also of that which exists between them and another, which, being composed of both cystic and solid elements, receives the name of compound. We, therefore, proceed to consider the varieties of these growths in refer^ ence to the points mentioned, and to recapitulate succinctly what has been already said. Ovarian cysts are characterized by three marked features : first, cysts with one or very few large compartments ; second, cysts with a great many small compartments divided by thin cyst walls or thick trabecular ; and third, cysts which are composed of solid and fluid elements in varying OVARIAN CYSTS. 685 proportions. The first constitute the class styled the monocystic, unilocu- lar, paucilocular, or olygocystic tumor ; the second, that known as the multilocular or polycystic tumor ; and the third that which is commonly styled the compound ovarian tumor, " All cystoids are multilocular at the commencement," says Rindfleisch, but unilocularization he declares is especially frequent in those tumors arising from colloid degeneration of the Graafian vesicles. A true monocyst is rare, though it may grow to the size of the uterus in the ninth month of pregnancy. Kiwisch* has met with one whose contents weighed over forty pounds. In the com- pound tumor, cysts having formed in the solid tissue, the presence of solid and fluid elements is detected by examination. These cysts result chiefly from softening of tissue, or, as it is expressed, by liquefaction. " As soon," says Billroth, " as the new formation has separated into sac and fluid con- tents, in some cases a secretion from the inner wall of the sac begins, so that the cyst from liquefaction becomes a secretion or exudation cyst and thus grows." Dr. Noeggerath has been led to assume, by his microscopical investiga- tions, that " the proliferating cystoma, or adenoma-cylindro-cellulare, the origin of which is at the present time generally associated with the for- mation of Pfliiger's ducts, is to a large extent the result of a degeneration of ovarian bloodvessels. These alterations consist — 1st. Of a hyaline degeneration of arteries and veins. 2d. Of a cell proliferation and secondary softening of the media of arteries. 3d, Of an endarteritis destruens. 4th. Of an alteration of all the elements constituting the large arterial sinuses, and secondary enlargement of the same. 5th. Of a metamorphosis of capillaries into epithelial tubes." The walls of ovarian cysts consist of a covering of peritoneum, the proper tunic, tunica albuginea, of the ovary, and an epithelial layer. The peritoneum sometimes undergoes great hypertrophy, in rare cases being half an inch thick. The size to which ovarian cysts will grow is truly wonderful. It has been already stated that unilocular or monocystic tumors are rarely seen of very great size, but instances are on record of multilocular tumors con- taining over one hundred pounds of fluid, and Dr. Co]iland, in the Diet, of Pract. Med. tells of an instance in which five hundred pints of fluid were drawn off by repeated tappings, in twelve months. On(i or both of the ovaries may be affected, the right being that most frequently selected by the disease. The comparative frequency with « Op. cit., p. 102. 686 OVARIAN CYSTS. which the right and left ovary are affected is shown by the following table : — Authority. Safford Lee Chereau . Scanzoni . No. of cases. 93 215 41 Right side afl'ected. 50 109 14 Left side atfected. Both sides. 35 78 13 8 28 14 Contents of Ovarian Cysts This subject has been exhaustively inves- tigated by Scherer and Eischwald.^ By the latter it has been so minutely dealt with that little is left to be desired as to the chemistry of such fluids. These contents vary very much, between a clear, albuminous, serous fluid and a thick, gelatinous material which will flow through no canula, and has to be manually removed. The speciflc gravity may be as low as 1007, though usually it is 1018 or 1020. The most imi)ortant chemical constituent is an albuminate, termed colloid, which is usually more dense in polycystic than olygocystic tumors, and denser in small olygocysts than in the same after having assumed a large size. Tapping appears to increase the density of this fluid in olygocysts. According to Eischwald, two chemical transformations go on in the fluids of cysts simultaneously. Colloid material changes into muco-pep- tone, while the albuminates transuding from the blood are converted into albumino-peptone. A species of digestion of the raw material goes on under the heat of the body, as Rindfleisch expresses it, and consequently the larger and older the tumor the more fluid are the contents likely to be. Eischwald found tliese fluids chemically to consist of the following ele- ments : — Of the mucous ordei* — Substance of colloid particles ; Mucin ; Colloid substance ; Muco-peptone. Of the albuminous order — Albumen (and librin) ; Paralbumen ; Metalbumen ; Albumino-peptone (and fibro-peptone). As an example of the quantitative analysis, the following from one of Eischwald's cases will serve. 1 Wurzburger Medizinische Zeitschrift, 1864. CONTENTS OF OVARIAN CYSTS. 687 The debris (8.27) contained— Salts soluble in water 7.53 Potas. sulpb 0.08 " chlor 0.59 Sodse nat 6.29 " phosph 0.16 " carb 0.38 Loss 0.03 Salts insoluble in water ....... 0.74 8.27 Test for Paralhumen — Leave the fluid at rest in a cool place, filter or decant, and thus separate sediment from supernatant fluid. Pass a stream of carbonic acid gas through this fluid, and instantly a precipitate of fine flocculi of pai'albumen will occur. Test for Metalbumen Digest another part of this fluid with absolute alcohol for three days. Filter off the precipitate, and heat with distilled water. Filter again, and metalbumen may be precipitated by sulphate of magnesia. Paralbumen is precipitated from this fluid by a few drops of dilute acetic acid and redissolved by an excess. To the naked eye the fluids of ovarian cysts present various appearances, as they are tinged with blood or pus from hemorrhage or suppuration of the cyst walls. The varieties generally met with are the following : a light colored fluid like barley water ; a light brown fluid like infusion of linseed ; a dark red, bloody looking fluid ; a greenish-yellow, semi-solid gelatine; a purulent fluid of very oflTensive character closely resembling pea-soup in appearance ; very rarely an intensely black fluid ; and in der- moid cysts a grumous, gruel-like mass. Does a true ovarian cyst large enough to call for surgical interference, that is to say, larger than the size of a child's head to which hydrops fol- liculorum sometimes attains, ever contain fluid free from albumen? This is evidently a question of a great deal of importance. Wells^ and Barnes make three groups of ovarian fluid, the first of which they declare are de- void of fat and albumen. " Heat and nitric acid," says the former, "will neither coagulate nor precipitate them." W. L. Atlee relied upon absence of albumen as a sign that a cyst is not ovarian, and the following interest- ing case reported by J. L. Atlee^ will show the estimation in which this point is held by him. "I operated upon Mrs. M., aged over fifty years, in October, 1870. She had labored under abdominal enlargement from the presence of a fluid for several years, and had been tapped about twenty-seven times, filling rapidly after each operation. After the last two or three tappings a small tumor remained in the right iliac and pelvic regions ; but at no time could albu- ' Dis. of Ovaries, Am. ed., p. 92. * Essay by Dr. Drysdale, Trans. Amer. Med. Asso. 688 OVARIAN CYSTS. men be detected in the fluid by the ordinary tests of heat and nitric acid ; hence I diagnosed the case to be one of serous cyst attached to the broad ligament. The presence of the tumor, as large as a turl^ey's egg, in the right ihac region, an unusual thing in serous cysts, cast a doubt as to its true character ; but the inabilit}' to detect albumen by the above tests de- cided me against the operation, and the patient was sent home. Under these circumstances, a portion of the fluid obtained from the last tapjiing was sent to Dr. Drysdale, who gave a very decided opinion that the fluid was from an ovarian cyst. Upon the strength of this opinion I told the friends of the patient that I would operate if she filled again. "Accordingly, on the 14th of October, 1870, I removed a cyst weighing, with the contained fluid, fifteen pounds, and of an unusual character. The upper half of the cyst was very thin and of a serous nature. Below the umbilicus the cyst was much thicker, and, descending to the pelvis, proved to be the right ovarium, having one large cyst filling the abdomen above, with an aggregation of very small gysts constituting tlie iliac and pelvic tumor. "The peculiarity of this case consisted in the rupture, probably at an early period of the disease, and before I saw her, of the tunica propria, or albugineous coat of the ovar}^, leaving the peritoneal covering intact, and of sufficient strength to retain, not only the small portion of the ovarian secretion, but of the serum secreted by the peritoneal coat. This also ac- counted, in some measure, for the very rapid filling after each tapping." The correctness of the explanation given by Dr. Atlee is open to doubt, but his reliance upon presence of albumen as a sign of ovarian cyst is fully shown. Peaslee* expresses himself in these words, " the fluid of an ova- rian cystoma will probably always be found to contain albumen if it be limpid enough to flow tlirough the fine tube of the exploring trocar." I can safely say that I have never met with a true ovarian fluid which did not contain albumen. The solid elements of the fluid of ovarian cysts consist of the results of hemorrhage, and desquamation and fatty degeneration of epithelial struc- tures. In them are found cholesterine, fat globules, blood corpuscles, and pigment cells. Microscopical Appearance of Ovarian Fluids — The thinner, serous fluids present in comparison with those of colloid character few cellular elements. In the latter, under a power of from 300 to 550 I-^ischwald^ found such an amount of morphological elements that the fluid had to be diluted with water before it could be examined. He then found fatty ele- ments of various size ; round cells, some serrated ; large, colloid cells ; round cells similar to the pyoid bodies of Lebert, or the exudative cor- puscles of Henle ; globular aggregations varying in size ; scales of horny epithelium ; crystals of cholesterine ; dark brown pigment ; etc. "On placing a drop of the fluid removed from an ovarian C3^st under the microscope," says Drysdale,* " we usually liiid a number of granular cells, > Op. cit., p. IIU. - Op. cit. 3 Op. cit. CONTENTS OF OVARIAN CYSTS, 680 E, some free granular matter, c, and small oil globules, b ; and frequently, in addition to these, epithelial cells of various forms. A, and crystals of cho- lesterine, d. These, together with blood-corpuscles, F, the intlainmatory globules of Gluge, i, the pus cells, G H, and disintegrated blood and other cells, may all be sometimes seen tloatiug in either a clear or a turbid fluid." Fig. 252 E I ^ Jlicroscopic appearance of ovarian fluid. (I)rysilale.) For the microscopist and pathologist all these are of interest. For the ovariotomist this is the chief point of importance : is there any character- istic, pathognomonic cell or element upon the presence of which a positive diagnosis of ovarian cyst may be based ? When this question can be un- reservedly answered in the affirmative, a great advance will have been made in this important matter. Spiegelberg, in an interesting lecture upon the diagnosis of ovarian tumors, enumerates cylindrical epithelium, colloid cells, cholesterine, etc., and appears to rely upon the character of cells furnished by the part from which the material was secreted rather than upon any particular cell. Long ago, Nunn pointed out the existence of the " gorged granule," though not as a diagnostic point, and Paget, Bennett, Gluge, and others speak of the "granular corpuscle," the " compound granular cell," and the "inflammation globules." In an essay, already referred to. Dr. T. M. Drysdale, of Philadelphia, has recently described a cell which he calls "the ovarian granular cell," which, when found in pelvic tumors, he U 690 OVARIAN CYSTS. regards as pathognomonic of ovarian disease, and, as such, he looks upon its diagnostic value as very great. This matter is of so great importance, that I prefer to describe this cell in Dr. Drysdale's words. In referring to the cells shown in Fig. 252 he says : — "To find them all present in one specimen, however, is rare; more commonly we can discover but three or four of them in the fluid. But no matter what other cells may he present or absent, the cell which is almost inva- riably found in these fluids is the granular cell. "This granular cell, E, in ovarian fluid, is generally round, but sometimes a little oval in form, is very delicate, transparent, and contains a number of fine granules, but no nucleus. The granules have a clear, well-defined outline. These cells differ greatly in size, but the structure is always the same. They may be seen as small as the one five-thousandth of an inch in diameter, and from this to the one two-thousandth of an inch. In some instances I have found them much larger, but the size most commonly met with is about that of a pus cell. "The addition of acetic acid causes the granules to become more distinct, while the cell becomes more transparent. When ether is added the gran- ules become nearly transparent, but the appearance of the cell is not changed. "This granular cell may be distinguished from the pus cell, lymph cor- puscle, white blood cell, and other cells which resemble them, both by the appearance of the cell and by its behavior wath acetic acid. "The pus and other cells, G, which have just been named, have often a distinctly granular appearance ; but the granules are not so clearly defined as in the granular cell found in ovarian disease, owing to the partial opacity of these cells ; and when the granular cell of ovarian disease and the pus cell are placed together under the microscope, this difference is very apparent. In addition to the opacity of these cells, we frequently find their cell wall appearing Avrinkled rather than granular ; and further, in the fresh state, they are often seen to contain a body resembling a nucleus. "But, if there is doubt as to the nature of the cell, the addition of acetic acid dispels it ; for, if it is a pus cell, or any of the cells named above, it will, on adding this acid, be seen to increase in size, become very trans- parent, and nuclei, varying in number from one to four, will become visible. (See G, pus cell before adding acid ; and H, pus cell after adding acid.) Should the cell, however, be an ovarian granular cell, the addition of this acid will merely increase its transparency and show the granules more distinctly, "The compound granular cell, i, the granule cell of Paget and others, or inflammation corpuscle of Gluge, is also occasionally present in these fluids, and might possibly be mistaken for the ovarian granular cell ; but it is not difficult to distinguish them from each other. Gluge's cell is usually much larger and more opaque than the ovarian cell, and has the appearance of an aggregation of minute oil globules, sometimes inclosed in a cell wall, and at others deflcient in this respect. The granules are coarser, and vary in size, while the granules of the ovarian cell are more CAUSES. 691 uniform and very small. By comparing them in the drawing these differ- ences will be apparent. Again, the behavior of these cells on the addition of ether will at once decide the question ; for, while the ov^irian cell re- mains nearly unaffected by it, or, at most, has its granules made paler, the cell of Gluge loses its granular appearance, and sometimes entirely dis- appears through the solution of its contents by the ether. "That the discovery of a granular cell in ovarian fluid is new, I do not assert, as J. Hughes Bennett and other writers have described granular cells which they have seen in these fluids ; but, with one exception, their description does not correspond with the ovarian granular cell. Bennett,' for instance, states that the granular cell which he saw exhibited a distinct nucleus on the addition of acetic acid, which is not the case with this. Other writers have described the cells which they found as pus and pyoid cells ; and yet others confound them with the compound granular cell, or inflammation globules. The exception referred to above is found in Beale's description of the microscopic appearance of ovarian fluid. "^ The description given by Beale he declares to correspond closely to that of his "ovarian granular cell, but it is incomplete, and no test is given by which to distinguish it from other granular cells." Dr. Drys- dale, therefore, claims to have been the first to describe a cell which has never been accurately described before, and to have given the tests by which it may be distinguished from others, such as the pus cell, the white blood corpuscle, and the compound granule cell, which closely resembles it. He sums up in these words: — " I claim, then, that a granular cell has been discovered by me in ovarian fluid, which differs in its behavior with acetic acid and ether from any other known granular cell found in the abdominal cavity, and which, by means of these reagents, can be readily recognized as the cell which has been described ; and, further, that by the use of the microscope, assisted by these tests, we may distinguish the fluid x-emoved from ovarian cysts from all other abdominal dropsical fluids."^ Microscopists are by no means agreed as to the validity of Drysdale's corpuscles as pathognomonic of ovarian cyst. Indeed I may say that, so far as my knowledge goes, a very general scepticism with regard to it prevails. Time will soon .settle this matter, which as yet cannot be re- garded as at rest, for the subject is now receiving the attention which it long ago deserved. Causes — Very little is positively known upon this subject. The pre- disposing causes which are generally admitted are the following : — 1 Ed. Med. and Surg. Journ., vol. Ixv. p. 280, 1846. 2 The Microscope in its Application to Practical Medicine. By Lionel S. Beale, M.B., F.R.S., etc. 3d edit., p. 179. 3 The views of Dr. Drysdale are not yet veritied. The matter is at present sub fudice. Med. Press and Circular, March 26, 1873. NATURAL HISTORY. 693 Natural History of Ovarian Cysts Ovarian cystic tumors develop either by one or by a number of cysts. In the first case the cyst may become fully distended by fluid, reach a point where its growth ceases and remain qui- escent, only annoying the patient by the mechanical results of its presence and the appehension that it may increase and create trouble. There are no grounds for doubting the evidence that such tumors may remain with- out increase for even forty or fifty years, but such cases are rare exceptions to a general rule. " Much mischief has resulted, however," says Hewitt, *' from looking on such cases as the typical ones, while the large majority of the cases, the end of which is naturally death in a much shorter time, have been considered as the exceptional ones." We now and then meet with pulmonary tuberculosis which goes on to formation of a large cavity, and then for some unaccountable reason ceases to advance. The cavity, which is distinctly discernible, remains quies- cent, and the patient may live for years. As this is an exception to a rule in the natural history of phthisis, so is the tardy course of ovarian dropsy just alluded to an exception to the usual course of that affection. The olygocystic tumor grows much more slowly than the polycystic, and this is the more marked as it approaches the monocystic type. I removed one which had been under my own observation for nine years, and only at the end of this time did its existence affect the constitution. If its type be multilocular, the tumor advances more rapidly, cei'tainly, and uncontrollably, than in the case just mentioned. The prognosis of ovarian dropsy not interfered with by art, and by this we mean surgical art, as medicine has no controlling or curative power in the disease, is always unfavorable. The average duration of the cases of both types is supposed by the best modern authorities to be about three years of life after the inception of the affection. Mr. SafTord Lee has collected statistics as to the duration of the disease in 123 cases, not subjected to any curative surgical treatment. 1 year. 2 years. 3 " 4 " 5 " 6 " 7 " 8 " 9 to 50 " From this it will be seen that out of 123 cases 80 terminated within three, and 94 within five years. At the same time that the fact must not be lost sight of that 17 out of 123 cases lasted over nine years, and that some, the number of which is not stated, terminated at the end of fifty, it must not be accepted as certain that these were cases of true ovarian [n38 the d aration was " 25 " " 17 " " 10 " " 4 " 5 II " 4 " " 3 " " 17 " 694 OVARIAN CYSTS. cystoma. Experience in this affection leads to the suspicion that these were instances of dermoid cysts, or of" some variety of abdominal tumor which, while it closely simulates ovarian cystoma, runs a much more benign course. I have removed an undoubted mutilocular ovarian cyst which had lasted, the evidence in favor of duration being medical and perfectly reliable, for twenty-three years ; another for twelve and a half years ; another for ten, and another for nine yeai's. Spontaneoiis Cures of Ovarian Cysts — Sometimes nature effects a cure in one of the following ways. The cyst may discharge into the peritoneum, and absorption occur. Of this accident Dr. Tilt has collected 71 cases, of which 30 recovered, 19 were improved, and 21 died. I have met with four instances of such rupture, two of which proved fatal by peritonitis. The cyst walls may undergo calcareous degeneration, which checks ad- vance. The cyst may discharge externally by the abdominal or dorsal surfaces, or into the rectum, bladder, vagina, or uterus by means of the Fallopian tubes. Instances of the last occurrence are mentioned by Mor- gagni, Frank, Follin, and Boivin, and Richard records five cases. With reference to nature's power alone, or aided by absorbents, to re- move the accumulated fluid, Kivvisch declares, "We must express our dis- sent from the opinion of those practitioners who assume that an ovarian cyst can be completely removed by simple absorption. So far as we know, this process has not been satisfactorily demonstrated by a single case." It is the opinion of many that absorption of the contents of these cysts does occur, and numerous instances are cited in proof; but, in these cases, the doubt arises whether a true cystoma ovarii existed, or, one of the periute- rine cysts which so closely resemble it. Diseased Conditions affecting Ovarian Cysts — I have already alluded to suppurative inflammation of the cyst walls, which may occur in conse- quence of tapping, or without operative interference. The pulse and temperature become elevated, the patient restless and depressed, profuse perspirations occur, diarrhoea sets in, and, unless relieved, the patient dies with hectic symptoms. In a number of instances ovariotomy has been successfully performed under these circumstances. One such case is re- corded by Keith, the suppurative action occurring seven days after tap- ping ; three by Wells ; one by Peaslee ; and one by Teale.' I have seve- ral times operated upon cases in which ovariotomy was undertaken only as a last resort, where the contents of the cysts were excessively fetid, and the patient very ill at the time of the operation, and which have nevertheless done well. Twisting of the pedicle is another accident which sometimes takes place. Gallez,^ in referring to this, says, "This very curious and happy 1 London Lancot, Am. reprint, Sept. 1873. 2 L. Gallez, Histoire des Kystes de I'Ovaire, Bruxelles, 1873, p. 150, METHODS IN WHICH DEATH IS PRODUCED. 696 termination of ovarian cysts is unfortunately very rare, and likewise very difficult of artificial accomplishment ; its eflect is to produce strangulation of the tumor." Where the interference thus established in the vascular supply of the tumor goes just far enough to produce gradual atrophy, cure may be effected, and post-mortem evidence of such an occasional occur- rence exists. Ordinarily strangulation and death of the tumor occur, which destroy life unless ovariotomy should intervene. In 1865 Roki- tansky published an essay upon this subject, and since that time it has attracted considerable attention. He cited the details of thirteen cases, and Spencer Wells mentions two deaths thus caused before operation, and twelve cases discovered by him upon performance of ovariotomy. Klob reports an instance in which a tumor turned upon its pedicle five times; and in a case of fatal hemorrhage into the cyst Patruban found in autopsy torsion of the pedicle creating venous stenosis and rupture.' Crane^ and Tait* record cases in which small cysts were thus rendered gangrenous, in consequence of which the patients died of septicjemia. Sometimes an ovarian cyst increases very suddenly in dimensions, great pain from distention occurs, and symptoms of loss of blood develop them- selves. This is due to hemorrhage from the cyst wall. In two cases in my experience it has occurred; in one ovariotomy demonstrated the source of the difficulty; and in the other aspiration, adopted on account of the severe suffiiring from distention, did so. Parry* records a case which almost proved fatal froni this cause, and Patruban^ one which did so. In the latter case torsion of the pedicle seemed to have produced the rupture of vessels. Wonder at such an occurrence will cease when it is remem- bered that veins^ as large as the little finger have been found between the outer and middle layer of cysts. Conditions likely to complicate Ovarian Cysts They may be compli- cated by pregnancy; ascites ; fecal impaction ; Bright's disease; pleuritic effusion ; peritonitis with adhesions ; a low type of gastritis marked by intensely red tongue, constant vomiting, and tenderness of the stomach ; a low grade of septicaemia ; diarrhoea ; inguinal, umbilical, and crural hernia, etc. Methods in lohich Death is produced There are several modes in which ovarian dropsy produces its usual fatal results when uninterfered with by surgical means. 1st. A cyst may rupture and produce peritonitis, either before or after suppurative inflammation of its walls. 2d. Inflammation of the cyst wall may result in the filling of the cyst with pus, which produces hectic and in time exhaustion and death. ' London Lancet, Am. reprint, Sept. 1873. 2 Amer. Med. Monthly, April, 1861. » Edin. Med. Journal, 1861. * Am. Journ. Obstet., Nov. 1871. ^ Gallez, op. cit., p. 150. 6 T. S. Lee. 696 OVARIAN CYSTS. 3d. Fatal hemorrhage may occur into the cyst. 4th. Prolonged interference with the functions of nutrition and respira- tion may sap the powers of life. oth. Death of the cyst may occur from twisting or rupture of the pedi- cle and cause septicaemia. 6th. A low grade of gastritis, pleuritis,* or enteritis may produce ex- haustion. 7th. Finally, from the combined depreciating influences of this condi- tion, gradual or sudden prostration of strength may close the scene by death. Every one having charge of a case of ovarian tumor should recollect that often the only hope of saving life, threatened by the accidents here recorded, consists in an immediate resort to ovariotomy. Even acute peritonitis has been thus cut short, and patients with a temperature of 105° from suppuration of the sac have been saved. Spencer Wells arrived just too late to save two cases in which death resulted from hemorrhage into the sac, and Wiltshire in time to save one, and I operated with a successful result in a patient nearly completely collapsed from sudden rupture of a large cyst. AVe now approach the important subject of symptomatology of ovarian cysts and their differentiation from other morbid conditions met with in the abdomen. As the study of that subject will frequently involve allu- sion to pelvic cysts closely resembling ovarian but yet entirely distinct from the ovaries, I deem it best to take a rapid survey of them here. Cysts of the Broad Ligaments ^Cysts of considerable size sometimes form between the layers of peritoneum making up the envelopes of the broad ligaments. They are supposed to arise from the collection of fluid in the meshes of areolar tissue of the ligaments, or from the parovaria or bodies of Rosenmiiller. Within the external margin of the broad liga- ment, where the two walls of the peritoneum pass from the fimbriae of the tube to the ovary, exists the body of Rosenmiiller, parovarium, or Wolflian body, to which allusion has already been made as consisting of a number of little, tortuous cords, some of which are perforated by canals. The slight secretion occurring from the walls of these tubes sometimes becomes greatly increas(,'d, and the containing walls becoming proportionately dis- tended, a tumor is created. These cysts may attain a large size, though they do not generally do so. One of the most interesting cases of cyst of the broad ligament which I have seen in practice was in a lady from INIobile, upon whom ovariotomy was successfully performed by the late Dr. Nott, of this city. He had tapped her, and drawn off a large amount of limpid fluid four years before ' I have seen two cases in which liydrotliorax proved a great source of prostra- tiou. TUBAL DROPSY. 697 the operation, and the cyst had for about three years appeared to have closed. After that time, however, it had refilled, and was, when I first saw her in consultation with Dr. Nott, quite tense, and the abdomen ap- peared of about the size of that of a woman in the seventh month of preg- nancy. Operation was determined upon, but delayed for three months in consequence of the heat of the weather. When it was performed, both ovaries were found to be perfect in size and shape, and the cyst' was found to occupy the left broad ligament, the peritoneal walls of which were im- mensely distended over its surface. The peculiar features which have been found to characterize cysts of the broad ligaments are the following : They contain a clear, limpid, very slightly albuminous liquid, which takes on a purplish tinge when exposed to the rays of the sun ; tapping generally, though not always, cures them ; after tapping no cyst can be felt ; they are always unilocular ; and they have been found to contain in their walls nonstriated muscular fibre, which the walls of ovarian cysts never contain. Parasitic or Hydatid Cysts — Although cases of these cysts, developed in consequence of the presence of the echinococcus hominis and cysticercus cellulosae, are reported as having occurred in the ovaries, it is doubtful whether such reports are authentic. These parasites may, however, de- velop in the mesentery, the omentum majus, and even in the cellular tis- sue ; the vesicle of which the parasite consists becoming surrounded by a neoplastic sac. " I have seen," says Billroth, " cysticercus vesicles re- moved from the tongue and nose, echinococcus vesicles removed fi'om the back and thigh." Spiegelberg reports a case of retro-uterine, left sided parasitic cyst, simulating ovarian cyst, in which he cut down and removed some of the characteristic contents. This procedure and tapi)ing or aspi- ration are the only means of diagnosis which are at all reliable. Tubal Dropsy — This condition, which is described under the names of hydrops tuba3, salpingian dropsy, and hydrosalpinx, consists in the disten- tion of the Fallopian tubes by muco-serous fluid It arises in this manner: some influence, for example, acute or chronic salpingitis, pelvic peritonitis, or cellulitis, occludes both extremities of the tube. The inflammation of the mucous membrane of the tube creating a muco-serous fluid, the canal is distended by this, generally irregularly, to the size of the finger or small intestine. Thus far the aflfection does not concern our present investiga- tion, for there is no probability that such a growth would resemble ovarian tumor so closely as to lead to an error in diagnosis. But as this distention goes on, the raucous lining of the tube takes on the anatomical and phy- siological characters of a serous membrane, and secretes plentifully a serous, straw-colored, and slightly flocculent fluid. At times the distention of ■ This cyst is now in my possession. Dried and stuffed with cotton, it measures 26 inches iu circumference. 698 OVARIAN CYvSTS. the walls of the tube proceeds so far that the fluctuating tumor which results gives all the physical signs of ovarian dropsy. The testimony of authorities is almost unanimous that between this con- dition and ovarian dropsy there are no means of diagnosis without with- drawal of some of the fluid. M. Aran sounds the key-note to the general belief when he declares that,' " the tube distended by liquid, I am per- fectly assured, does not give a sufficiently clear sensation to allow us to diagnosticate its existence." Prof. Simpson, however, assumes a different position.^ He declares that, although "■ in practice this form of tumor is usually altogether overlooked or is mistaken for some other kind of tumor," it is really diagnosticable by the following means : " 1st, its free and inde- pendent mobility ; 2d, its elongated form; and 3d, its wavy outline." Let any one examine the shape of a large tubal dropsy, like that represented at Fig. 253, for instance, and he will see that both the shape and wavy Fig. 253. Tubal dropsy. (Hooper.) outline will fail him. When it is remembered that the afi'ection frequently results from pelvic peritonitis, it will be apparent that the freedom of mo- tion will be often delusive. " The diseased tube," says Courty,^ " is rarely free and without alteration at its periphery: generally it bears signs of old inflammation, which is adhesive, and this fixes it to the neighboring parts." I have met with the affection four or five times in autopsies, and this statement has always been sustained. The means of diagnosis just mentioned would be applicable to slight tubal distention, which is rarely productive of symptoms calling for ex- amination. Few instances of diagnosis are on record, and even in cases where tapping has been supposed to substantiate it, it is by no means sure that such a disease existed. Prof. Simpson reports but one case in his extensive experience in which he was able to come to a conclusion. He denies the possibility of great enlargement of these tumors, declaring that they rarely grow larger than a foetal head, and that we may justly be allowed to be sceptical as to cases reported as being much larger. Dr. » Op. cit., p. 633. 2 Op. cit., p. 432. » Op. cit., p. 987. SYMPTOMS. 699 Arthur Farre,' however, willingly admits the well-known cases of Bonnet and De Haen ; the first of which contained thirteen pounds of fluid and the second thirty-two pounds. Scanzoni circumstantially reports an in- stance in which the sac attained the size of the head of a child of ten years of age. Subperitoneal Cysts — Cystic degeneration is much more likely to occur in those organs which have, as component parts of their structure, minute cavities lined by epithelium. Thus, the kidneys and ovaries are pecu- liarly liable to be affected in this way. Cysts thus formed have been styled by Virchow cysts by retention. But cystic degeneration is by no means limited to such structures. It may occur in areolar tissue any- where, and those organs which, like the thyroid and mammary glands, are prone to production of new growths having areolar tissue as their basis, are likewise especially liable to it. It is believed by pathologists that under these circumstances the cyst is merely an expansion of the areolae of the areolar tissue. In various parts of the abdominal cavity such cysts are found under the peritoneum and classed under tlie head of subperitoneal cysts. Mr. SafFord Lee reports one case of a tumor which filled the abdomen, and destroyed life, after having lasted for twenty-five years. On post-mortem inspection a large cyst was found behind the peritoneum, which had originated under the pancreas. He reports another which began on the right side of the abdomen, was tapped forty-eight times, and was found by autopsy to be omental. Cysts connected with the Spinal Cord In November, 1870, a woman aged 36 years entered the Woman's Hospital in this city, and came under the care of Dr. Emmet.^ He found a large cyst filling the hollow of the sacrum and there "firmly fixed. To aid in diagnosis, an ounce of fluid was drawn off by aspiration. This was clear and limpid, free from albumen, and revealed under the microscope only a few oil globules. The patient died, and Dr. F. Delafield on making an autopsy found a cyst, which contained some three quarts of fluid, filling completely the pelvic cavity and extending up to a level with the second lumbar vertebra. This com- municated with the spinal cord by a funnel-shaped passage, which had as its lower outlet an oval opening extending from the upper margin of the second sacral foramen on the right to the position of the coccyx, which was wanting. Over the surface of tlie sac was a network of nerve tissue, extending posteriorly and to the right side. The sac was supposed to be one of spina bifida or hydrorachis. Symptoms. — During the earlier periods of the development of ovarian cysts, very few symptoms ordinarily show themselves. As enlargement ' Supplement Cyc. Anat. and Pliys., p. 619. 2 This case is described in the Amer. Journal of Obstetrics, Feb. 1871- 700 OVARIAN CYSTS. goes on the patient becomes struck by the fact that her abdomen has in- creased in size, and, if both ovaries be affected, menstruation sometimes ceases, and she may imagine she has become pregnant. Pressure of the small but increasing tumor will sometimes create dragging sensations about the pelvis, irritability of the bladder, and, if the growth occupy the retro-uterine space, as it often does, pain in the back. This is, however, by no means all the inconvenience which may be experienced. A small, movable cyst, which may be pushed about in the abdomen, will sometimes cause severe pain. In one such case which I saw with Dr. Noeggerath, the account of which is published in Dr. Atlee's work on the Ovaries, ovariotomy was necessitated, when the cyst was no larger than a cocoanut, by excessive pain. As the tumor grows and fills the abdomen, rising above the navel, a sense of distention is complained of, dyspnoea begins to show itself upon exertion, the patient feels more feeble than usual, and slight emaciation is observed. As it increases and begins to press upon the large viscera beneath tlie diaphragm, these symptoms increase, and the patient's face wears a peculiar expression, which has been styled by Mr. Wells, the "facies ovariana.'' This is created by an absorption of adipose tissue, an exaggeration of the natural furrows of the face, and an expression of anxiety and apprehension. To one who has studied this expression, an imperfect description such as this will recall it; but to one who has not become clinically familiar with it, it is impossible to convey a clear con- ception of it. To these symptoms the mammary and gastric symptoms of pregnancy sometimes, though rarely, add themselves. Pressure upon the kidneys creates congestion of these organs, and scanty secretion is a common result. Occasional attacks of localized peri- tonitis are by no means rare, and hence, in many cases, ascites becomes a complication of the affection. As the decadence of strength, the emaciation, and the impoverishment of the blood incident to this grave disorder increase with time, digestive and intestinal disorders show themselves, oedema of the feet and legs occurs, great feebleness appears, and the patient dies from progressive exhaustion. A summary of the rational signs which may arise in consequence of ovarian cysts from the commencement of their growth to full development may thus be given ; in-itability of the bladder, dysmenorrhcea, constipa- tion, hemorrhoids, pelvic pains of neuralgic character, symptoms of preg- nancy, scanty urinary secretion, intestinal and digestive disorder, deranged respiratory function, peculiar facies, emaciation, oedema, venous distention on surface, ascites, vomiting, diarrhoea, cardiac irregularity, aphthous stomatitis, and hectic. In cases advanced in the last stage, all the last of these may show themselves, and in early cases, all the first mentioned ; PHYSICAL SIGNS. 701 but, in many instances, some of the most prominent of these signs are entirely wanting. Physical Signs — The symptoms thus far enumerated are never suffi- cient for diagnosis. They are usually only sufficient to suggest physical examination, by which reliable signs will probably be discovered, and the diagnosis be made complete. The physical signs of ovarian cysts are, therefore, of the greatest importance, and the full capacity of physical exploration should in every case be developed, for to it we must look for answers to the following questions : — 1st. Does a tumor exist? 2d, If so, is it ovarian ? Does a tumor exist ? — To decide this question, the patient should be placed upon her back upon a flat, resisting surface, the abdomen uncovered, all constriction removed from the waist, and the knees drawn up so as to relax the abdominal muscles. It is of primary importance that she should be calm, and give herself up to the examination in the full desire of aid- ing the physician in arriving at a diagnosis. In some cases the patient, from nervousness, in some from pain created by pressure, and in others from a desire to mislead and deceive, will not be able or willing to do this, but, by suddenly contracting the abdominal walls, will place a serious, perhaps insurmountable, obstacle in liis way. Under such circumstances ether should be employed as an angesthetic, and full investigation made. The abdominal muscles being entirely relaxed, careful pali)ation and deep, steady, and prolonged pressure should be made by both hands over the whole abdomen, downwards towards the spine, and especially over the pel- vic region. By this means a more or less resisting mass may be discov- ered, which produces an abdominal enlargement visible upon inspection. Thus far very little has been learned ; merely that an abnormal enlarge- ment exists in the abdomen. It may not deserve the significant name of tumor, but be due to one of these states : — 1st. Abnormal thickness of abdominal walls ; 2d. Tonic spasm of abdominal muscles; 3d. Intestinal distention ; 4th. Distention of urinary bladder ; 5th. Pregnancy. With care and caution each of these conditions may usually be elimi- nated by means which we shall soon consider. A neglect of such means has often resulted in great and needless alarm to patients, and a painfully humiliating and often ludicrous exposure of the practitioner. It having been now decided that the patient has an abdominal tumor, or, in other words, an abdominal swelling due to a moi'bific cause of serious nature, it next becomes iijiportaut to decide whether it be ovarian or not. 702 OVARIAN CYSTS. Is the tumor ovarian ? — It has been already stated that any abdominal tumor may, unless careful means of differentiation are adopted, be con- founded with ovarian growths. The truth of this will be appreciated by reference to the valuable tables of Dr. John Clay, the translator of Kiwisch on the Ovaries. He has collected twenty-three cases of attempted ovari- otomy in which the operation was abandoned because the tumor proved not to be ovarian. Tlie tumors were of the following characters: — 12 were uterine ; 2 " omental ; 2 " results of cliroiiic peritonitis ; 2 " not discoverable ; 1 was tubal pregnancy ; 1 "• obesity; 1 " mesenteric ; 1 " splenic ; 1 " not stated. So great did the difficulties of diagnosis for a long time prove, that they were urged by the opponents of the operation as a valid objection to it as a surgical procedure. At the same time that they are still acknowledged, and that it is admitted that the most cautious and skilful diagnostician may be defeated by them, it can be conlidently asserted that every year's experience greatly diminishes them, and that with the improved means now at command, an experienced examiner will rarely be misled. Let me, however, again insist upon the fact that immunity from oft repeated errors can be obtained, even by such an one, only by strict adherence to a conscientious and exhaustive examination of every dase, a resort to all the known means of diagnosis, and a methodical exclusion of all condi- tions calculated to mislead. It is a fact which I daily see demonstrated that an inexperienced diag- nostician usually arrives at a conclusion by the application of a much smaller number of tests than a veteran examiner would dare to do. The latter has been so often deceived that he knows his weakness; the former has yet to learn. The means of physical exploration wliic'. are at our disposal are the following : — Inspection and manipulation ; Mensuration ; Palpation ; Percussion ; Ausculation ; Vaginal touch ; i Rectal touch ; The uterine sound ; Aspiration or paracentesis ; PHYSICAL SIGNS. 703 Chemical and microscopical examination of fluids of tlie tumor ; Explorative incision. Solid ovarian tumors are rare and seldom assume very large propor- tions, and although ovariotomy is sometimes demanded for their removal, the operation is specially adapted to cystic tumors. We therefore pass to the more careful consideration of the diagnosis of these, and their differen- tiation from other abdominal enlargements. An ovarian cyst usually develops markedly on one side of the abdomen, and if multilocular the abdominal distention is not symmetrical even in advanced periods. As it increases, the cyst pushes the intestines aside into the hypochondriac regions. The ascending and transverse colon alone approximate their normal positions, and the omentum majus is usually pushed up over the front of the tumor. While the cyst is in the pelvis, the uterus usually lies in front of it, but as increase of growth occurs it is ordinarily pushed behind it. There are, however, exceptions to both these statements. In rare cases, fortunately for the ovariotomist, a por- tion of intestine runs across the face of the tumor, being fixed there by adhesion. Tlie uterus, even late in the development of a large cyst, may be found in front of it or latero-flexed, latero-verted, or even drawn com- pletely above the pelvic brim. Curious as it may appear, great diversity of statement exists concerning the relation of cyst and uterus among writers on this subject. " Simpson's remark," says Peaslee,^ " that, ' if the sound show a tumor in front of the uterus, the disease is certainly not ovarian,' is incorrect. The uterus is in iront of an ovarian tumor only in exceptional cases ; but is often so in cases of uterine fibroma and fibro-cyst. Boinet mentions the fact as a remarkable one that Cruveilhier found the uterus behind an ovarian cyst in three instances." My observation cer- tainly agrees with that of Dr. Atlee,'-^ that " the uterus may be dragged up, or tilted up out of the pelvic cavity by the tumor ; or, through these influences, it may be found on either side, or disi)laced forward or back- ward within the pelvis. It may also be crowded downward against the perineum, or entirely extruded through the vulvar orifice. So that there is no general rule as regards the position of the uterus in ovarian tumors." When the tumor has ascended above the umbilicus, as the patient lies upon the back, the abdomen will appear rotund, a decided protuberance existing, and very little flattening out by sagging of fluid to the flanks occurring. As the hands are laid upon the surface, and manipulation is practised, a firm, dense mass will be felt, which, yields fluctuation, not usually of a superficial character like ascites, but less superficial and per- ceptible. Percussion will yield dulness all over the surface of the tumor and in one flank, but in the other resonance Avill generally exist. The surface of the tumor will often feel irregular and lobulated, and in multi- » Op. cit., p. 115. 2 Op. cit., p. 4(5. 704 OVARIAN CYSTS. locular tumors be more voluminous on one side than the other. If pres- sure be made upon the tumor, as the patient lies upon the back, it will resist like a full sac, and not yield, and the pulsations of the aorta may be felt obscurely through it. By vaginal and rectal touch the lower surface of the tumor may be felt and obscure fluctuation elicited. Mensuration practised from the umbilicus to the sternum, and the umbilicus to the anterior superior spinous processes of the ileum, will generally show a marked difference between the two sides in polycysts and less difference in monocysts. In ascites the two sides are symmetrical. Auscultation serves to exclude pregnancy. By vaginal touch the posi- tion of the uterus as well as its mobility is ascertained, and when com- bined with conjoined manipulation the solid or cystic character of a small or even a large tumor may be determined by it. Should the tumor be found low in the pelvis in the later periods of growth, it is probable that a short pedicle exists, and also probably adhesions. Should it have risen out of the pelvis the pedicle is probably, but by no means certainly, a long one. The uterine sound informs us as to the capacity, the mobility, and the sensitiveness of the uterus, as well as, to a limited degree, its relations to the tumor. Simon's method of rectal exploration, modified by the introduction of the hand without the tliumb into the bowel, constitutes one of the most valuable means of diagnosis and differentiation at our command. By it the point of origin of the tumor, as well as its general characters, may be very accurately ascertained. Emptying the cysts of the tumor of fluid by aspiration or tapping is likewise a most useful means of gaining information ; and of great moment is the careful and intelligent examination of the fluids removed. Of late it has been proposed to determine as to the nature of such fluid by the discovery in it of "luteine," a yellow substance found in the blood, the egg, and the fluid contents of ovarian tumors. As yet, this test has been too little investigated to enable us to decide what weight is to be given to it. Lastly, we reach the crucial test of explorative incision, the value of which cannot be exaggerated, but which is attended by considerable danger. These are the means by which the positive signs of ovarian cystoma may be elicited, but, before a diagnosis is arrived at by deductions based upon them, many other abdominal enlargements must be carefully con- sidered and excluded. If this be necessary merely in arriving at a correct diagnosis where no operation is to be practised, how mucli more so is it in view of the grave procedure of ovariotomy. Any one of tlie following conditions may mislead the investigator, and each of them must l)e in turn considered by him who desires to do his full duty to his patient and himself. PHYSICAL SIGNS, 705 Abnormal thickness or ten- sion of abdominal walls Distention of abdominal vis- cera Excessive development or dis- placement of other viscera of the abdomen Fluid accumulation within the peritoneum Cystic disease of other parts in the abdomen Pregnancy Diseased states of pelvic walls and areolar tissue [ Obesity ; J CEdema ; I Elephantiasis ; [ Tonic spasm. Tympanites ; Fecal tumor ; Dilatation of stomach ;* Distended bladder ; Hematometra ; Physometra ; Cystic chorion ; Hydrosalpinx. Ascites ; Encysted dropsy ; Hematocele ; Colloid accumulation. Cyst of broad ligament ; Renal cyst ; Splenic cyst ; Hepatic cyst ; Parasitic cyst ; Subperitoneal cyst ; Uterine cyst ; Uterine cysto-fibroma. Uterine fibroma ; Enlarged spleen ; Enlarged liver ; Fibro-plastic tumor of peritoneum J Sarcoma of abdominal glands ; Malignant disease ; Omental tumor ; Displaced kidney ; Displaced liver. Normal ; f Ventral ; Extra-uterine - Tubal ; ( Interstitial ; With amniotic dropsy ; With ovarian dropsy ; With dead child. [ Enchondroma ; .' Encephaloid of bones ; Pelvic abscess. ' A most remarkable and interestiug instance of this is recorded by Dr. Reeves Jackson, of Chicago, 45 706 OVARIAN CYSTS. Abnormal Thickness or Tension of Abdominal Walls — Obesity will be recognized by obscure resonance on percussion over the whole abdomen ; V)y absence of a defined, resisting outline to the supposed tumor ; by the possibility of catching the fatty walls between the two hands, lifting them, and rolling them over the muscular floor beneath ; by the deep depression which can be made when the patient is anaasthetized ; and by the pendu- lous folds created by assumption of the sitting posture. It would be inexcusable in an expert to mistake this condition for ovarian tumor, but for an inexperienced examiner not at all so. I see numerous cases every year in which such an error is committed by very competent practitioners. Oedema will be known by pitting upon pressure ; by the existence of the same condition in the areolar tissue of the feet or face ; and by its generally attending uraemia, chlorosis, or cardiac disease. Elephantiasis, of which Dr. Atlee records a remarkable case, would be recognized by the peculiar structural alterations of the skin which charac- terize it. Tonic s{)asm of the abdominal muscles has more than once led, as has indeed obesity, to abdominal section for removal of a tumor. It often oc- curs under the name of " phantom tumor" in very hysterical women, and is not rare as a reflex result of caries of the vertebrce. It may be diagnos- ticated by resonance on percussion ; absence of fluctuation ; and absence of all signs of tumor under anaesthesia. In case of doubt, anaesthesia should always be resorted to. In addition to these signs, the unaltered position of the uterus constitutes an important one. Distention of Abdominal Viscera — Even without abdominal spasm a large amount of air sometimes accumulates in the intestines from liysteria, digestive disorder, or great obstruction in the canal. It may be known by resonance on percussion ; absence of fluctuation ; absence of all signs of tumor upon examination under anaesthesia ; and the normal position of the uterus. By firm, steady pressure downwards towards the spine, kept up and increased after each expiration, resistance will be overcome, and deep exploration prove the absence of a tumor. This method was systematized by Roederer, Fecal tumor will be marked by absence of fluctuation ; a [leculiar ''doughy" sensation upon manipulation; pain upon pressure; constipa- tion ; violent colic ; and, most valuable sign of all, the creation of a dis- tinct pit or depression when steady pressure is made at one point, the patient being anaesthetized. The action of catliartics and enemata is often entirely delusive as a test of fecal tumor. Dr. Atlee relates a case of distention of the stomach in a man, in which that organ filled the entire abdominal cavity, and covered, like an apron, all the other abdominal organs. " Had the patient been a female," says he, " I should at once have pronounced it an ovarian cyst." Explorative incision would alone have accomplished diagnosis. FLUID PERITONEAL ACCUMULATIONS. 707 It may be thought unlikely that a distended bladder could be mistaken for an ovarian cyst, but it often gives the appearance of one. In one case in which this difficulty had existed for three weeks, I found the bladder distended so as to reach above the umbilicus, its neck being compressed by the neck of a retroverted pregnant uterus. Suspicion as to the nature of the tumor will be excited by interference with urination, constant in- voluntary discharge of urine taking place, and the very frequent concur- rence, according to my experience, of retroversion of the pregnant uterus. Should aspiration be practised, the physical and chemical features of the tu'ine will suggest a resort to the catheter, which will settle the question of diagnosis. In considering the differentiation of hematometra, physometra, and cystic degeneration of the chorion, little reliance should be placed upon rational signs in comparison with physical. Cessation of menstruation and many of the other signs of pregnancy will be discovered in most cases, and, in physometra and cystic chorion, characteristic discharges will usu- ally attend — air in the former, and bloody serum in the latter. The en- larged uterus will be recognized as the tumor in question by conjoined manipulation and Simon's method; but the decisive test of these condi- tions consists in the passage of the uterine sound, or of a silver catheter to the fundus, in order to allow of escape of imprisoned material, which, being collected, may be submitted to chemical and microscopical exami- nation. Hydrosalpinx sometimes develops into a large tumor. De Haen de- scribes one which weighed seven pounds. To differentiate such a con- dition from ovarian cyst, but two methods can be relied upon : first, the removal of fluid, and examination by chemical means and the microscope; and second, explorative incision. Fluid Peritoneal Accuinvlations — It is often exceedingly difficult to differentiate between ascites and ovarian dropsy. The means which ordi- narily enable us to do so are here stated. It must, however, be borne in mind that there are cases in which even the most important may be trans- posed. For example, an ovarian cyst sometimes establishes communica- tion with the intestines, and becomes resonant ; while, in ascites, where the amount of fluid is excessive and the mesentery short, dulness exists over the front of the abdomen. The rule is here adhered to, but the ex- ceptions must not be lost sight of. In Ovarian Dropsy. In Ascites. 1st. A small, round tumor will often have shown itself in the beginning in one iliac fossa ; 2d. In supine posture a rotundity is observed in the abdomen ; 1st. The enlargement will have shown no small tumor at any point ; 2d. In supine posture the fluid gravi- tates to sides of abdomen, and the ab- dominal surface is flattened ; T08 OVARIAN CYSTS, In Ovarian Dropsy. 3d. Percussion made in supine posture gives dulness over surface of abdomen ; 4th. Change of posture alters area of dulness but little ; 5th. No evidences of cardiac, renal, or hepatic disease exist as a rule ; 6th. Skin is normal as to color, mois- ture, etc. ; 7th. (Edema of the feet is absent until a late period, when the patient has be- come exhausted ; 8th. Health fails slowly ; 9th. Sitting posture atfects shape of abdomen but little ; 10th. Fluctuation ordinarily not so superficial, level fixed to great extent, ceases where intestinal resonance begins; 11th. Aortic pulsation transmitted ; 12th. Fluid usually amber colored and tenacious, often like syrup, of various hues in polycysts, not spontaneously co- agulable, always sticky when rubbed between fingers. Shows cylindrical epi- thelium, granular cells and matter, oil globules, and cholesterine, and contains paralbumen and metalbumen. The gra- nular cell is distinguishable from other cells by its merely becoming transpa- rent by acetic acid ; others increase in size ;' Specific gravity, 1.018 to 1.024. In Ascites. 3d. Percussion gives resonance over abdominal surface because the intestines float on the fluid ; 4th. Change of posture alters area of dulness markedly ; 5th. Evidences of cardiac, renal, or hepatic disease almost always exist ; 6th. Skin, in majority of cases, gives evidences of cirrhosis by its parchment feel and jaundiced hue ; 7th. OEdema of the feet exists as an early sign ; 8th. Health fails early and rapidly ; 9th. Produces bulging often in Doug- las's pouch and through navel ; 10th. More superficial, level changes with change of posture, perceived even where intestinal resonance exists. 11th. Not so. 12th. Fluidof light straw-color ; spon- taneously coagulable from containing fibrin ; without sediment usually; shows to microscope squamous epithelial cells, oil globules, pus cells, and amoeboid bodies ; does not contain paralbumen, metalbumen, or cholesterine ; Specific gravity, 1.010 to 1.015. Sometimes, however, peritoneal accumulations are sacculated by en- compassing lymph in one portion of the peritoneum ; among the intestines matted together by effused lymph ; or, as in a case recorded by West, enveloped by the omentum. " Between four and five quarts," says he, " of a dark fluid were found collected between the folds of the peritoneum." The amount of fluid thus imprisoned is often very large, and hence the difficulties of diagnosis which have led Mr. Wells^ to assert, " I am aware of no means by which such cases ore to be distinguished from ovarian dropsy." McDowell himself once 0[)ened an abdomen in such a case under the belief that an ovarian tumor existed. The intestines do not rise above the fluid as in simple ascites, but there is less rotundity to the mass, and less interference with respiration than are found to exist with ovarian cyst. ' Drvsdale. 2 Dis. of Ovaries, p. 134. CYSTIC DISEASE OF OTHER PARTS IN ABDOMEN. 709 Diagnosis in these difficult cases must depend upon the results of aspira- tion, examination of contained fluids, Simon's method, and explorative incision. The sudden appearance of hematocele, the immediate and often urgent symptoms which it excites, and the removal of a little fluid by aspiration will settle the question of diagnosis. Colloid disease sometimes affects the whole peritoneal cavity. In some cases it appears to escape into it from a ruptured ovarian cyst ; in others it originates there. Removal of a small amount of the characteristic material by tapping is the only means of diagnosis. Cystic Disease of other Parts in the Abdomen Cysts of the broad ligament so closely resemble unilocular ovarian cysts as to be diagnostic- able only by explorative incision or aspiration. Their character might be suspected from superficiality of fluctuation, slight implication of general health, absence of emaciation, and slowness of growth ; but the chemical and microscopical features of the contained fluid would alone decide posi- tively. This fluid is as clear and jDure in appearance as distilled water, showing when boiled after addition of acetic acid only a trace of albumen as an albuminate ; is loaded with chloride of sodium ; and contains only a few fat and blood globules. After evacuation the cyst walls cannot be felt, and tapping often proves curative. Spiegelberg removed such a cyst in 1869, the walls of which, unlike those of ovarian tumors, contained muscular fibres, and the fluid of which contained albumen. Renal cysts have several times deceived the most skilful diagnosticians. Their characteristics are these : they ordinarily push the intestines for- wards and not backwards ; pus, blood, and albumen usually occur in the urine ; these tumors grow from above downwards ; they are rare and grow slowly ; may be pushed up so that resonance occurs between tumor and pelvis ; and the fluid contained shows none of the microscopical features of ovarian cyst, while it shows the chemical and microscopical elements of urine. Sometimes echinococci, which are frequent in renal cysts and unknown in ovarian, are found. The tumor is apt to be crossed by the descending colon or to lie outside of the ascending colon ; it is usually marked by renal and not by menstrual derangement ; and is usually uni- lateral. Sometimes, however, a renal cyst occupies a median position ; extends like an ovarian tumor into the pelvis ; is attached to the pelvic organs ; pushes the intestines aside like an ovarian cyst ; contains fluid free from elements of urine ; and even presents cholesterine and paralbumen. In such cases the determination of the point of attachment by Simon's method constitutes a most valuable resource. Splenic and hepatic cysts are rare, grow from above downwards, give an area of dulness between tumor and pelvis, and in the fluid of the latter 710 OVARIAN CYSTS. the echinococcus is often discovered. In both Simon's method is of great value as a means of differentiation. Parasitic cysts, the result of the presence of the echinococcus, may ^ develop in any of the organs or tissues of the abdomen. Should the posi- tion of the tumor be such as to lead to doubt as to differentiation between it and ovarian cyst, diagnosis would be attainable only by aspiration and examination by the microscope and chemical means. The former would show the presence of the parasite. Subperitoneal cysts are distinguishable from ovarian only by physical features of contained fluid and explorative incision. Cysts growing from the uterus itself are not common. They may be recognized by Simon's method, by the chemical examination of tlieir contents, and by the curative effects of tapping. Atlee reports three cases thus cured. Furthermore, the fluid which they contain separates into a coagulum and a pinkish or bright red portion which does not coagulate, and the peculiar cells of ovarian fluid do not appear in it. Ovarian fluid never spontaneously coagulates. Fibro-cystic tumors are difiicult of differentiation from ovarian cystomata, but when we compare our present position with reference to this subject with what it was only a few years ago we have great cause for congratula- tion. I here give only the most prominent differences between the two diseases, and hence those upon which reliance can really be placed. To many of these even, however, there are exceptions ; to several there are none. Uterine Fibro-cyst. Grows slowly and occurs usually after thirty years of age. Uterine cavity generally enlarged. Connection of tumor and uterus usu- ally, though not always, intimate. Fluid spontaneously and quickly co- I Never does so agulates. Uterus sometimes lifted above pubes and out of pelvis, often in front of tumor. Health remains good for years. Microscope shows fibre cell (Drysdale). Ovarian Cyst. Grows more rapidly and is less gov- erned by age. Uterine cavity not usually enlarged. Uterus more independent of tumor. Uterus generally behind tumor. Generally fails within three years. Shows the peculiar granular and epi- tbelial cells of ovarian cyst. Although these signs are all of some value, those which should be re- garded as most i-eliable are the following : spontaneous coagulability of contained fluid ; presence of the fibre cell ; increased capacity of tlie uterus; and the determination of its connection with the tumor by means of Simon's method of rectal exploration. Ex^dorative incision sliould not rank high as a diagnostic method, for simple section of the abdominal walls is not enough, and the exploration which is further required to decide the point exposes the patient to great danger. NORMAL AND ABNORMAL PREGNANCY. 711 Excessife Det>eIopment or Displacement of other Viscera. — If ascites do not attend hepatic and splenic enlargement, tliere will never be any great difficulty in distinguishing them from ovarian cystoma. Should it do so, tapping should be resorted to. Uterine fibroma may be recognized by its peculiar hardness, slowness of growth, absence of fluctuation, continuance of good health and absence of emaciation, tendency to increased menstrual flow, irregular surface, intimate connection with uterus, increase in capacity of this organ, and absence of fluid upon aspiration or tapping. It must not be forgotten, however, that the uterus may be normal in size, and the tumor entirely independent of it. " The symptoms caused by the growth of large, fatty, and fibro-plastic tumors from various parts of the peritoneum or mesentery," says Spencer Wells, ^ "so much resemble those of true ovarian disease, that their real nature can only be determined in some cases by an exploratory incision or tapping." Should fluid be removed from them it would lack the pecu- liar ovarian cellular elements, and would spontaneously coagulate, and Simon's method would in some cases demonstrate the fact that the point of origin is not the ovary. A movable or floating kidney might be mistaken for an ovarian cyst, but for so small a one that the question of ovariotomy would not arise in connection with it. Time would prove that it was not a growing ovarian cyst. Dr. J. K. Dale,'' of Little Rock, Arkansas, reports an interesting case of tumor supposed to be ovarian, but which upon explorative incision was found to be the liver, which was " free and movable, very much enlarged, occupying the right half of the pelvis, encroaching upon the bladder and rectum, and interfering very materially with the due performance of their respective functions." I had myself precisely the same experience in a case in which I made an explorative incision in New Haven, in presence of Drs. Whittemore, Jewett, and others. Pregnancy — The ordinary signs of utero-gestation, both rational and physical, should be carefully considered in eliminating normal and inter- stitial pregnancy. More than one woman has died from the passage of a trocar and canula into the pregnant uterus after abdominal incision, an accident certainly scarcely more deplorable for the patient than for the unfortunate practitioner whose carelessness causes it. I say carelessness, for the reason that the passage of the uterine sound as a means of differen- tiation would always prevent error. True, this would result in pi-emature labor in normal pregnancy, but how much better this, even at the sacri- fice of the child's life, than the terrible mishap just alluded to. During the past eighteen months three cases of pregnancy at full term • Op. cit,, p. 146. * Richmond and Louisville Med. Journ., April, 1874 71^ OVARIAN CYSTS. have been referred to me as ovarian cysts, and this not by ignorant men but by very capable practitioners. Two out of the three pregnancies were illegitimate, and the examiners were misled by relying upon rational in- stead of physical signs. Reliance should be placed especially upon dis- covery of the fa3tal body and movements by careful palpation ; upon bal- lottement between the fifth and seventh months ; upon recognition, by vaginal touch, of the movable presenting part after that time ; and upon the foetal heart sounds and placental bruit. The gastric, mammary, and nervous symptoms of pregnancy sometimes result from ovarian disease. Should the child be dead many of these symptoms will be absent, and if it be retained in utero, as it sometimes is, for many years, diagnosis must depend upon the history of the case, Simon's method, the uterine sound, and dilatation of the cervix so as to admit of digital exploration. In tubal or ventral pregnancy diagnosis would prove more difficult, but the same means will aid in making it, for even when the foetus is developed out of the uterus that organ enlarges decidedly. Not only should a differential diagnosis be made between pregnancy and ovarian tumor ; even after recognition of the latter, the former should always be eliminated as a coincident condition. Dropsy of the amnion gives very superficial fluctuation, and might de- ceive one not careful in diagnosis. A patient investigation of the case, and consideration of its history would ordinarily remove all doubt. The fibres of the cervix uteri are usually expanded, the cervix moves as the tumor is rolled in the abdomen, and the uterine sound passes far up into the cavity above. Should aspiration have been resorted to, the fluid re- moved will be found to present the following features. It is alkaline, with specific gravity 1005 to 1010, contains albumen but no fibrin, and presents to the microscope epithelial cells and oil globules. Meconium and blood alter these features. Diseased States of Pelvic Walls and Areolar Tissue Enchondroma or encephaloid disease of the pelvic walls is hard, free from fluctuation, and firmly fixed and united to the part from which it grows. Rectal exploration and abdominal palpation will prove these facts, and if aspira- tion be attempted the absence of fluid will be evidenced. Pelvic abscess usually results from cellulitis, which presents marked symptoms. It rarely extends to the umbilicus, hardness will be felt in one or other iliac fossa, it is fixed in tlie pelvis, and aspiration gives evi- dence of pus. Excessive pain attends it, with throbbing and pain down one thigh, and the outline of the mass is obscure and unsatisfactory. There is often a tendency to point, there is pain upon pressure, and there are generally chills and fever. In the early days of ovariotomy, when adhesions were regarded as a bar to extirpation of these tumors, the question of the existence of adhe- sions possessed important bearings. Now, however, when even the firmest FLUID TUMORS. 713 attachments are broken not only with impunity, but with results which are often better than those which follow the removal of a tumor from a healthy peritoneum, it sinks into comparative insignificance. This is a most fortunate fact, for the reason that the determination of the existence of adhesions is little more than guess-work. Beyond a few very general facts by which we may venture to form a surmise, all is empirical predic- tion with reference to the matter. If the case have developed very rapidly and be believed to be unilocular, there are probably no adhesions. If there have been symptoms of peritonitis, there are probably adhe- sions. If the case have been painless, there ai'e probably none. Should the abdominal walls roll freely over the tumor, the patient lying upon her back, and should the tumor fall low in the abdomen as she sud- denly sits up, there are probably no anterior adhesions. But posterior ones may exist, and not be suspected from this examination. If, upon vaginal examination, the uterus and base of the tumor exhibit immobility such as is found in pelvic peritonitis, and if, upon change of posture from erect to supine, these parts do not retreat from the finger in the vagina, there are in all probability strong pelvic adhesions. All these signs are unreliable, and disappointment will surely follow any great degree of confidence which is reposed in them, but a compensa- tion is to be found in the fact already stated that even firm adhesions do not contraindicate removal. It is always desirable to know the length of the pedicle. This point can be approximatively settled, in a certain number of cases, by the means recommended by Tixier,^ of Strasbourg. He says : — "Practice and observation have enabled us to diagnose, in certain cases, the probable length and variety of the pedicle. Certain objective and sub- jective signs may guide the practitioner and facilitate his diagnosis ; a very important matter, since on the length of the pedicle often depends the success of the operation. " We have hitherto been able to diagnose with almost perfect certainty three varieties : the long, short, and twisted pedicle. "T/ie long pedide. — The form of the abdomen lias a peculiar aspect ; this is the form en hesace. The hypogastric portion of the abdominal wall is applied to the internal surfaces of the thighs, and the ovarian tumor, forcibly projected forwards, seems to be removed from the superior entrance of the pelvis. A vaginal examination reveals an elevation of the cervix uteri, and the index finger passed into the pelvic excavation does not meet with the tumor at any point. The womb is, very movable and can be readily displaced. The collection of these symptoms induces one to pre- sume that there is an elongated condition of the broad ligament and of the ' Le Pedicule et son Traitement apres I'Operation de I'Ovariotomie, Strasbourg. 1869 ; Archives Gen^rales de Medecine, Juillet, 1870. 714 OVARIAN CYSTS. Fallopian tube, a condition favorable for forcing the pedicle without the abdominal wound. ^ ''The short jjedide. — The existence of the short pedicle may be assumed in the presence of the following symptoms : in the first place, the form of the abdomen diflers from that described above ; one may observe a lateral extension without pronounced prominence of the median portion. In at- tempting to introduce the tip of the finger between the tumor and the pubes, one feels through the skin that the growth passes into the pelvic excavation ; its base seems to be seated over the pelvic opening. The vaginal touch denotes a sinking of the cervix uteri, and a more or less pro- nounced innnobility of the womb. If the pelvic excavation be then ex- plored with the finger, one feels that it is not free, and that certain parts of the tumor are contained within it. In the presence of these facts tlie surgeon may assume that there is a greater or less degi-ee of shortening of the pedicle. '■'■The twisted ■pedicle. — At first sight this torsion seems difficult to deter- mine. It may, however, under certain conditions, be diagnosed with greater certainty than the two preceding varieties. Its existence may be conckuled whenever the following symptoms have been observed : — "The patients experience at intervals very acute pains radiating down- wards along the vein corresponding to the affected ovary, and upwards to the lumbar region on the same side. These pains are excited by work and fatigue. They break out also when the patient is in bed, and wlien she wishes to change her position. One hears also from these patients of very strong uterine cramps analogous to those occasioned by deligation of the pedicle. The cystic fluid is more or less deep in color, presenting a hemor- rhagic appearance. The touch in these cases gives no precise indication. One can only acquire the idea of the existence of an habitually long and thin pedicle in cases of this kind." Although I have not been able to draw as positive and certain conclu- sions in reference to the determination of the length and character of the pedicle, by aid of these means, as M. Tixier has, I nevertheless regard ins suggestions as valuable, and well worthy of application to every case in which ovariotomy is contemplated. One rule which I have found very reliable is this — if the tumor be found far up, out of the pelvis, upon vagi- nal examination, the pedicle cannot be very short. If a tumor which is not very large be fixed in the pelvis so that it cannot be pushed out, the pedicle is probably a short one. The value of this sign may be increased by examining in the knee-elbow position. When doubts exist upon any of the points here stated, which cannot be removed by those means of investigation which are. limited by the abdo- minal walls and pelvic roof; which, in other Avords, extend to, but not beyond, the peritoneum in their immediate application, there exist three methods of exploration which bring the explorer into direct contact with the interior of the abdomen and of the tumor. Those positive and reliable FLUID TUMORS. 715 means, which may justly be styled the crucial tests of abdominal tumors, are the following : — Aspiration ; Tapping ; Explorative incision. To these a certain amount of danger undoubtedly attaches ; but when compared with the great danger arising from operation upon an uncertain diagnosis, it becomes trivial. Many an inappro[)riate case has been sub- mitted to the operation of ovariotomy which would have been spared it, with the promise of a prolongation of life, had one of these methods been previously employed. They are of course not to be confined to the deter- mination of the character of a tumor alone, but that of the origin, attach- ments, and complications of any abdominal growth. Aspiration. — The introduction of aspiration into use for the diagnosis of ovarian tumors constitutes a decided advance. The instnmient gene- rally employed in this country is that of Dieulafoy, shown in Fig. 28. By this a delicate, hollow needle is passed into the tumor, and powerful suction applied through an India-rubber tube connected with a strong syringe, in which a vacuum is created by an upward movement of the piston. Through the most delicate needle clear fluids will pass, and through the largest, which is very small when compared with an ordinary trocar and canula, very tenacious colloid material may be drawn. By this beautiful instru- ment a large polycystic tumor filled with tenacious, syrupy fluid may be readily emptied by turning the needle into new cysts as those first punc- tured are evacuated. And when complete evacuation is not desired, it furnishes a supply of fluid for chemical and microscopical examination. It greatly diminishes the dangers of such evacuation as comj^ared with those resulting from tapping. The dangers attending that operation are the fol- lowing: 1st, hemorrhage from a bloodvessel in the abdominal or cyst wall; 2d, admission of air to the cavity of the sac and decomposition of fluid, which may create inflammation of the cyst wall and septicaemia ; 3d, sub- sequent escape of the contents of the tumor into the peritoneum ; and 4th, fatal injury from wounding of an intestine or solid organ. Spencer Wells mentions a case in which an acquaintance of his tapped a patient who died soon after. Upon autopsy two and a half quarts of blood, which had escaped from a wounded varicose vein, were found in the peritoneal cavity. All these dangers are considerable from ordinary tapping ; decidedly less so from aspiration. It may then safely be said that aspiration accomplishes all that tapping does, at infinitely less risk, and that the former should, when practicable, always be preferred to the latter procedure. Unfortunately the cost of the aspirator is large, and it may not be attainable, or the fluid may be too thick to flow through it. When it is desired merely to obtain a small amount of fluid for examination, the hypodermic syringe may be employed, 716 OVARIAN CYSTS. even in preference to the aspirator. Tlie use of this instrument, which was suggested by Dr. H. F. Walker and practised by myself before our knowledge of that just described, consists simply in plunging the needle with syringe attached through the abdominal walls at different points, drawing out as much fluid as possible, and expelling this into a test-tube for examination. This method serves to determine the following points : 1st, whether a tumor is fluid or solid ; 2d, whether it contains clear, slightly albuminous fluid or ichorous and irritating material ; 3d, by means of several punctures whether it be multilocular or not. In 1875, Dr. Peas- lee declared that he did not regard the aspirator as safer than the trocar. Surely an instrument with which we venture to tap the distended intes- tines, the pericardium, and the bladder, must be safer than one which leaves so large a hole as the trocar. Although it has been stated that aspiration is much less dangerous than tapping, it must not be regarded as free from danger. Death has repeat- edly resulted from it, and it should be regarded as an axiom that all abstraction of fluid from an ovarian cyst, by whatever means it is accom- plished, is attended by danger. The smaller the puncture made, however, the less the danger, I think. Cases of peritonitis, some of them fatal, after aspiration, are recorded by Atlee, Little, Lusk, Munde, Gillette, and Jenks ; cases of decomposition of sac contents and septic fever are reported from the same cause by Goodell, Perujji, Schnetter, Skene, and myself; and a case of peritonitis and adhesions after diagnostic puncture by a hy- podermic needle by Fauntleroy of Virginia. Tapping Tapping is a means of great value in the diagnosis of ovarian cyst, and, where the aspirator is not attainable, should never be lightly disregarded. Atlee, Wells, Peaslee, Spiegelberg, and many other leading ovariotomists of our day place great stress upon its value, and although some, like Stilling, have entitled it, in the warmth of deprecation, " a crime," it may safely be said to have overcome the greater part of the objections once urged against it, and to have fully establislied its claim to consideration as a valuable diagnostic and palliative measure. WeMttAas proved that it does not considerably increase the mortality of ovariotMiy. It is often even an excellent preparation for that operation, and, when practised with proper precautions, its dangers are greatly diminished. It must not be forgotten, however, that it is attended by dangers, which are not matters of speculation, but of fact established by statistical evidence. Of 130 instances of first tappings analyzed by Kiwisch, 17 per cent, of the cases died within a few hours or days after the operation.^ This is certainly a mortality to be greatly dreaded, especially when the operative procedure which induces it is not curative, but one resorted to merely for palliation or the accomplishment of diagnosis. » Op. cit., p. 275. 2 Hewitt, op. cit., p. 637. TAPPING. 717 The operation of paracentesis, or tapping, consists of the introduction of a trocar and canula through the walls of a sac containing fluid, and allowing this to flow away. Of all the operations for relief of ovarian dropsy this is the oldest, and the one which has been most frequently performed. The advantages which it offers are facility of performance, quickness of relief, and immunity, to a certain extent, from the dangers which attend more radical procedures adopted in these cases. Although, in a limited number of cases, it has been declared to have proved curative, it should never be practised with any reliance upon its doing so, for doubt exists as to the authenticity of the facts. Furthermore, it is attended by the immediate dangers recently mentioned, and by the more remote one of exhausting discharge from the sac, which may con- tinue so long as to wear out the patient's strength. M. Courty collates one hundred and thirty cases treated in this way by Kiwisch, Lee, and Southam, of which these are the results : — 46 died after the 1st tapping. 10 " " 2d 26 " " 3d to 6th tapping. 15 " " 7th to 12th " 13 " " 12th tapping. Of 21 of these cases treated by Mr. Southam, 4 died within a few hours after the operation, 3 within the first month, and 14 within nine months. Kiwisch lost 9 out of 64 within twenty-four hours after the first tapping. Dr. Fock,' of Berlin, gives the following table, displaying the dates at which death occurred after first operations in 132 patients : — 25 died within a few days. 24 " " 6 months. 22 " " 12 " 21 " " 24 " 11 " " 36 " 29 only were alive at end of last date. 132 li'will thus be seen that reliable statistical evidence places this pro- cedui-e in the position of a palliative measure which is generally followed by advance of the disease, and not rarely by immediate evil results. Still it must not be lost sight of that death may be warded off by the operation, many existing evils alleviated through the course of a period varying from ten to twenty-five years, and that, in a few ca^es, complete cure may have been effected. Dr. Ramsbotham records an instance in which one hundred and twenty-nine tappings were performed in eight years, and four hundred and sixty-one gallons of fluid removed ; and Dr. Martineau another, in which eighty operations evacuated in twenty.-five years seven ' Simpson, op. cit., p. 347. jf 718 OVARIAN CYSTS. hundred and twenty-nine gallons. I had recently undei' my care a patient who for five years has had a large cyst which has been tapped forty-five times. I have stated that a considerable number of cases are on record in wiiich it is asserted that simple tapping has cured ovarian cystoma. It is a matter of great doubt whether the cases thus cured were true ovarian cysts, or cysts of the broad ligament, which are often thus cured. Know- ing of no well-authenticated case in which ovarian cyst has been thus permanently cured, we are not warranted in regarding this measure as anything more than a valuable diagnostic means and a palliative resource, which often saves life when it is threatened by one of the consequences of the cystic disease. In case the contents of the cyst do not appear to be those of true ovarian cystoma, but present the characters of the fluid of cyst of the broad liga- ment, tapping may be practised with a reasonable hope of curative results. The circumstances which ordinarily indicate the propriety of paracen- tesis as a palliative measure are, rapid accumulation wliich interferes with some important function; coexistence of ovarian disease with pregnancy; solitary character of the cyst ; firm adhesions which bind the tumor down so as to prohibit a more radical procedure ; great doubt as to diagnosis ; or constitutional debility, which prevents the tolerance of a more serious operation. The operation may be performed through the abdominal, vagi- nal, or rectal wall. Topping through the Abdominal Wall — The patieilt being placed upon the side, a many-tailed bandage, such as is employed in paracentesis ab- dominis, is passed around the body. Its ends being held by assistants, traction upon them makes firm pressure, evacuates the tumor, and pre- vents syncope. A fold of skin being now pinched up between two fingers, it is penetrated by a lancet or bistoury upon the linea alba, midway be- tween the symphysis pubis and umbilicus. The trocar and canula are then plunged through the two layers of peritoneum and the wall of the cyst. Through the canula thus introduced a flow of fluid will take place, which, if such an instrument as that represented in Fig. 254 be employed, will be conducted by an India-rubber tube attached to the canula into a tub placed by the side of the bed upon which the patient lies. The free extremity of this tube is kept carefully immersed in water in the tub, to prevent entrance of air into the sac. Should other cysts be felt through the abdominal wall after emptying the main one, the canula may be made to empty them, by pressing it firmly against them. The following rules should be observed in abdominal tapping of ovarian cysts, for it is highly probable that a strict adherence to them would very favorably affect the statistics of the operation. TAPPING THROUGH THE ABDOMINAL WALL. 719 1st. Never tap while the patient sits, but always as she lies upon the side or back. 2(1. Cut the skin with a lancet, and employ a trocar and canula, with tube immersed in water, so as to prevent entrance of air. Fig. 254. Fi( 3d. When the fluid withdrawn is viscid, always wash out the cavity of the sac, if it be emptied, with warm, carbolized water. 4th. Should there be oozing of blood from the puncture, pass a harelip pin deeply through its lips, and affix a figure-eiglit ligature. 5th. Keep the patient recumbent and very quiet for two or three days. Tapping through the Wall of the Vagina This operation has been more or less in vogue for a long time. According to Kiwisch, it was first performed by Callisen in 1775, but has received little notice until modern times. Velpeau^ declares that he advised it in 1831, and that it was adopted a few years afterwards by Neumann and Recamier. In Germany it has of late years been frequently resorted to, and Scanzoni gives the fol- lowing reasons for preferring it to abdominal paracentesis. It " more often produces a radical cure than the other method just considered, and that especially because the cyst, opened in its lowest part, can empty itself more completely. If the puncture by the vagina were always possible, the abdominal punctui-e would soon entirely disappear from chirurgical practice ; but unfortunately, this is not the case, for the conditions neces- sary for this operation are met with in but few patients ; in fact, it is rare that the lower portion of the tumor descends sufficiently low into the pelvis to be accessible to vaginal touch, and, furthermore, in many cases where the tumor can be reached, it does not present in its lower portion any cavity filled with liquid, but only solid masses of a sarcomatous, col- loid, or cancellous nature." Kiwisch declares that he " unconditionally" prefers it to abdominal tapping, whenever it is practicable. By this method, the advantages of which are thus strongly stated by the authorities just mentioned, two of the dangers of tapping, secondary escape of fluid into the peritoneum, and consequent peritonitis, are unquestionably ' Diet, de M(;d., torn, xxii, p. 589. 720 OVARIAN CYSTS. lessened, but others are as surely increased, namely, those of injury to por- tions of the intestine, and entrance of air into the sac, with consequent decomposition of contents, septicaemia, and inflammation of the sac walls. My experience with the method is not large, but it leads me to agree with Spencer "Wells that, " as a rule, air enters the cyst, the opening fills up, and the fluid remaining in the cyst, or that freshly secreted, putrefies. Suppurative inflammation of the lining membrane of the cyst comes on, and is accompanied by a low form of exhaustive fever or pyaemia." Where a cyst is firmly fixed in the pelvis, however, this method, followed by drainage and antiseptic injections, is one of great value. The operation is thus performed : the bladder and rectum having been carefully emptied, and tlie patient anossthetized, she should be placed upon a table in the position for lithotomy. The operator then introducing the index, or, as is better, the index and middle fingers of the left hand, places them against the most dependent and accessible part of the tumor. Upon the finger or fingers, a canula ten inches long is passed up and pressed against the tumor, the point of the trocar being drawn in a little. The operator then plunges the trocar through the vaginal walls into the tumor, and withdrawing it allows the fluid to flow away through the canula. The patient is then put to bed, quieted by opium, and guarded against all influences which might induce inflammation as long as such an accident is probable. Explorative Incision Of all the means for definite and certain settle- ment of the question of diagnosis in abdominal tumors, I esteem explora- tive incision most highly. As, however, it involves not only opening the peritoneal cavity, but usually considerable manipulation- of its contents, it necessarily involves a certain amount of danger. While the other methods may be practised several days or even weeks before the operation of ova- riotomy, this should constitute, or rather be merged into, its first step. If it yield information which makes the surgeon decide against operation, the opening made should be closed ; if the light which it throws upon diagno- sis favors the radical procedure, the incision should be at once enlarged and prolonged into the final abdominal opening. Explorative incision should be thus performed. The patient having been prepared for the procedure exactly as if we had determined upon ova- riotomy, she is placed upon the table and surrounded by assistants, etc., as in the case of the radical operation. An incision is then made by the bistoury upon the median line, one inch in length. This is canned down to the tumor, and the finger is at once gently swept over this in every di- rection, so as to ascertain its character. The tumor may be emptied with a very small trocar, so small tliat the opening made may be readily closed if it be deemed best to desist from radical operation, or by the aspirator. If the sac be emjitied by this means, the hand is then passed into the abdominal cavity and complete exploration made. If it be not comiilolely TREATMENT. 721 emptied, a sound should be passed into tlie uterus and two fingers or the hand carried down through the abdominal opening to the fundus uteri, to ascertain as accurately as possible the origin and attachments of the solid mass. In case abdominal effusion have existed, this of course at once Hows away, and any growth existing in tlie abdomen comes within the reach of the finger. Before leaving this part of my subject let me lay before the reader a few rules, the observance of whicli will diminish very greatly tlie chances of his falling into errors of diagnosis in operating for ovarian tumors. 1st. Never perform ovariotomy without carefully exploring the uterus by the sound, if tliis be possible. 2d. Before operation, should doubt exist as to diagnosis, ahvays i-emove a small amount of fluid by the hypodermic syringe or aspirator for chemical and microscopical examination. 3d. If any doubt whatever exist as to diagnosis, anaesthetize the patient and examine carefully. 4th. If doubt still exist, emi)ty the cyst or cysts by aspiration or tapping. 5th. Should all doubts not be cleared up at the moment of operation, begin it as an explorative incision and proceed or not as instructed by what is discovered. Spiegelberg' makes the important declaration that when upon drawing off fluid either from a cyst of the broad ligament or an ovarian cyst, it is found to be of low density and of serous nature, it may be taken as evi- dence that the cyst wall has ceased to grow actively, and is merely being distended by accumulation of its contents. He opposes operation under such circumstances, declaring that emptying the cyst will of itself often effect a radical cure. Treatment — The medical treatment of ovarian dropsy by diuretics, hy- dragogue cathartics, diaphoretics, mercurials, absorbents, mineral waters, etc., has now been faithfully tested and found to be inefficacious. After a careful search through the records of the subject, one is forced to the conclusion that there is a lack of evidence substantiating the possibility of the accomplishment of absorption by these means. All that can be anticipated in these cases from medication is sustaining the nervous and sanguineous systems by tonics and stimulants; regulating disordered functions by diaphoretics, cathartics, diuretics, and anti-emetics; and relieving local inflammations by the ordinary means usually resorted to under such circumstances. I am the more urgent in insisting upon the fact of the inefficacy of constitutional treatment, because I so often meet with fully developed cases of ovarian dropsy which bear evidence of a variety of attempts by cupping, leeching, inunction, painting with iodine, ' Archiv fiir Gyuiikolugiu, vol. xiv. s. 175. 4G 722 OVARIOTOMY. and correspondingly active internal treatment, to dissipate the accumu- lation. There is but meagre proof extant that such means have effected cures, and there is nothing more certain than that they lower the tone of the system and depreciate the vital forces. A recognition of this fact led Dr. W. Hunter, before the introduction into practice of the present methods of surgical treatment, to say that, "the patient will have the best chance of living long under it (ovarian dropsy) who does the least to get rid of it." Not only is it to surgery alone that we must look for aid, but to one surgical procedure — ovariotomy. Even after the acceptance of ovariotomy as an operation, the medical profession strove, and very properly, too, against its universal adoption in cases of ovarian tumor, and endeavored to discover less radical processes which were to share the field with it. Thus up to a late day were tried, and even now, in rare cases, are tried, tapping, drainage, incision, and injection of the sac. I do not give the details of these procedures here, for the reason that I question the pro- priety of their adoption. In the present state of our knowledge, whether the tumor be large or small, simple or complex, the attempt to employ other curative means than ovariotomy can scarcely be regarded as warrant- able, in view of the dangers attaching to them and their uncertainty of success, and, on the other hand, the hope of good results which is held out if the patient is sustained until complete extirpation can be accom- plished. CHAPTER XLIX. OVARIOTOMY. Definition. — Ovariotomy consists in the extirpation of the diseased ovaries. History. — The history of the operation goes back only to a very recent date. It has become customary for those who have written upon it to cite ancient authors to prove that even as long ago as the time of the early Greeks the ovaries were often removed in the inferior animals as is done in our own time. The writings of Aristotle put this beyond question. It is even asserted that among the Lydians castration of the human female was practised in order to enable them to serve as eunuchs. In more recent periods, we are told by Wierus that a Hungarian swineherd, in- censed by the lasciviousness of his daughter, removed her ovaries, in hope of reformation, after the manner in which he was in the habit of spaying his swine. Towards the close of the eighteenth century both ovaries. HISTORY. 723 which had descended into the inguinal canals, were removed by Dr. Per- cival Pott, of England. But all this, though interesting as a matter of physiology, has little to do with the operation of ovariotomy, according to the true signification of the term. In the one case a minute and healthy gland, which is sparsely supplied with blood, was removed from a healthy peritoneal cavity. In the other a huge sac, which is supplied by large bloodvessels, and has in many instances contracted adhesions to ^ diseased peritoneum, requires extirpation. The idea of removing large ovarian cysts, even, is not new, since it was discussed in 1G85 by SchorkopfF, in 1722 by Schlenker, in 1731 by Willius, in 1751 by Peyer, and in 1752 by Targioni. In 1758, Delaporte even went so far as formally to propose the operation to the Royal Academy of Surgery. As the eighteenth century approached its close, the sugges- tions of the writers already mentioned were not forgotten, but were from time to time repeated ; among others by John Hunter in 1787, and later still by William Hunter. In 1798, Chambon ventured to prophesy that it would in time become a recognized resource in surgery ; and in 1808,' Samuel d'Escher, a student of Montpellier, proposed a specific plan for its performance based upon the teachings of one of his masters, M. Thumin. In 1786, one observer stood upon the very verge of the great discovery, very much nearer than Laumonier, by some supposed to be the discoverer, ever did, and yet failed to systematize it as a surgical resource. Like many a man before and since his time, he recognized and appreciated a facti but failed to connect this with a law. The following is a quotation from a work written by Thomas Kirkland, an Englishman, and published in London in 178G. It is entitled, "An Inquiry into the Present State of Medical Surgerv.'"^ "A woman, betwixt twenty and thirty years of age, had been tapped twice for an ascites, and a large quantit}^ of water taken away at each time ; but after the last operation the puncture did not heal, and, In a little time, a substance they did not understand protruding, I was desired to see her. It was evidently a part of a cyst, and, as it had already dilated the sore, I persuaded her to let it alone till the opening became lai'ger, in hope of a l)etter opportunity of affording relief. Accordingly, in ten days or a fortnight the protrusion was much larger, and by the help of a dry cloth a cyst, that would contain five or six gallons of water, was gradually ex- tracted. More than a quart of matter immediately followed, and more was daily discharged for some time, yet the woman recovered without further trouble than keeping the parts clean, and afterwards bore several children." Later on in his work he says : — "We have given an instance, p. 195, where a cyst being taken away cured an ascites ; and, seeing medicines do not avail in encysted dropsies ' Wieland and Dubrisay, Froiicli translation of Cliurcliill on Dis. of Women. 2 Mod. Record, June 15, 1867, from Exchange. 724 OVARIOTOMY. of the abdomen, is it not wortli our while to consider whether, when they are unconnected with tlie adjacent parts, after talking away the water, the patient might not sometimes be cured by enlarging the puncture, pressing the cyst forward, and drawing it out V" He then proceeds to examine the difficulties in the way and the objec- tions which may be brought against the operation, and thus concludes : — " At present, I offer these hints to those who think the subject deserving attention, and time will probably determine the question," Thus, as we advance from more remote periods to the beginning of the nineteenth century, we find the minds of physicians being gradually pre- pared for the reception of ovariotomy, as its consummation was step by step approached. But all that we find accomplished up to this time is the promulgation of ideas, prophecies, and propositions, and the performance of accidental operations, or of those upon healthy ovaries. In 1809, the first real case of ovariotomy ever undertaken was success- fully performed by Dr. Ephraim McDowell, of Kentucky. His first case was successful, the patient living twenty-five years afterwards. Subse- quently he operated thirteen times, with eight favorable results. It may confidently be asserted that the history of no operation has been more thoroughly sifted than this, and that, up to the present time, nothing can be clearer than the fact that to McDowell belongs the credit of priority of performance. It is interesting to examine the competitive claims which have been put forward in reference to the matter. First, in chronological order, is that of Dr. Houstoun,' of Scotland, who operated in 1701, and whose case, says Mr. Wells, ^ makes it "appear that ovariotomy originated with British surgery, on British ground." This statement will excite wonder, and the claims of the operator fail to attract attention when it is stated that nowhere does Houstoun claim to have removed the cyst, or even a part of it. He merely treated a case of ovarian cyst successfully by incision. The second is that of Laumonier, of France. Of him Baker Brown says: "The first who attempted extirpation appears to have been Aumo- nier, of Rouen, in 1782, and he was successful." In this statement, as Dr. Parvin lias pointed out, Mr. Brown was wrong in three points: first, as to the fact; second, as to the name of the operator; and third, as to the date. The supposed ovariotomy was performed in 1776, by Laumonier, and was really the opening of a pelvic abscess. The third is that of Dzondi, of Halle. As the patient was a boy, the claim requires no further consideration. In 1821, Dr. Natlian Smith, of this country, operated successfully. In 1^23 Dr. Lizars endeavored to introduce the operation into Scotland, and ' Amer. Jouni. of Med. Sciences, vol. vii., 1849, p. .'534. ^ Op. cit., p. 299. HISTORY. 7'25 operated four times, but his results were bad. In one case the tumor was uterine and was not removed ; in one no tumor could be discovered after abdominal section ; and one of the two cases upon which ovariotomy was performed died. Since this period, Atlee, Peaslee, Kimball, and Dunlap have been most influential in establishing the operation in America. In England, Dr. Charles Clay, in 1840, pressed it upon the notice of the profession, and he was soon ably sustained by Lane, Wells, Keith, Bryant, Baker Brown, and many others, whose names have become famous in connection with it. " It is only within the last five years," says Grenser, writing in 1871, " tliat much progress has been made in Germany in this operation." Unfortunately, for many years insuccess appeared to attend it, and thus tiie voices of the most eminent and authoritative were raised against it. Of the first three patients ever operated upon there (by Chrysmar, in Wurtemberg), two died. Chrysmar commenced operating in 1819, and his results were certainly not such as to popularize a new and dangerous procedure. In 1828 the adverse criticism of tlie great Dieffenbach was pronounced in these strong terms : " Whoever' considers the opening of the abdominal cavity as a light matter, and, as Lizars seems to believe, tiiat the difficulties are small, whoever thinks that this operation is accom- panied by no more dangers than other operations, must be very thought- less ; for me, my one case is sufl[icient." The ■' one case" to which he refers, and from which he drew so illogical and hasty a conclusion, was an incomplete operation. In spite of the adverse weight of this opinion, in 1835 Quittenbaum, in 1841 Stilling, and in 1851 Martin, operated in a few cases, and with varying success. Writing of the operation at this time, when overclouded by repeated insuccesses, it had failed to command the confidence of the profession, Grenser says : " Most of the ovariotomies performed within the last forty years had a fatal termination, and as a consequence reliance could not be felt in it, and confidence in it was alto- gether sliattered when the celebrated Dieffenbach took ground against the operation." DietFenbach's opinion in 1828 has been given ; let us see how the experience of twenty years affected it. In 1848 he wrote : " The operation does not benefit either patient or physician ; the idea of opening into the abdomen of a sick, cachectic woman, affected with a hard tumor of the ovary, or even employing Lizars' method with cross-incisions, in order to remove the tumor by force, seems neither reasonable nor useful." He modified his opinion somewhat where the tumor was fluid, of small size, and movable. Tlius wrote the great surgical light of Germany, and while he wrote American and English surgeons were gaining great results for humanity and for science in this same field. It must not be supposed that even in his own country advances were not being made, for Stilling, ' Grenser, Report on Ovariotomy in Germany, 726 OVARIOTOMY. Biiring, and others were carrying on the work. In 18r)0 the latter an- nounced an important advance, namely, that adliesions should not be considered as a contra-indication to removal. In 1852 Edward Martin declared that the question was no longer as to the propriety and efficiency of ovariotomy, but of circumstances favorable to success. Martin's rules for operating, read even by our present lights, are most of them excellent. About this time the voice of Kiwisch was raised against the operation. He* collected the statistics of 54 cases, of which 51 ended fatally, and concluded that certainly over half of all submitted to operation died. It was soon after this that Scanzoni and Gustav Simon gave their evidence against the operation, and increased its disfavor to such a degree that, as Grenser says, " its very existence was threatened." This opposition seems to have lasted up to 1864, when the tide appeared to turn in its favor, and it soon numbered among its advocates Breslau, Gusserow, Hildebrandt, Spiegelberg, Martin, Stilling, Veit, "Wagner, and Billroth. Grenser collected in 1871 the statistics of 129 operations jierformed in Germany, of which 60, a little less than half, recovered. When these results are compared with English and American statistics of that period, they show that Germany had much to make up. That she has done this is proved by the excellent results obtained by Schrceder and other operators of the present time, and to-day it must be conceded that in this department of surgery she stands fully abreast with other countries. According to Grenser we owe to Germany two of the most important of the improvements which have taken place in the operation since the days of McDowell : first, the adoption of the short incision and tapi)ing the sac in situ, wdiich originated with Quittenbaum ; second, the external treat- ment of the pedicle, which he declares was first resorted to and its advan- tages insisted upon by Stilling in 1841, and not by Duffin in 1850. In 1849, Martin first secured the pedicle in the lips of the wound. There are other advances which have been made in Germany ; but I mention only those which have had a decided influence on the operation. Into France the operation was introduced, or as some French'^ writers express it, " reintroduced," by Dr. Woyerkowski, in 1844. It was sub- sequently performed by VauUegeard, in 1847, and later still by Nelaton, Maisonneuve, Jobert, Demarquay, and other surgeons of Paris. The re- sults of these attempts, however, had the effect of casting discredit on the operation, from which it is only now emerging, thanks to the writings of Jules Worms, Oilier, Labalbary, Vegas, and more especially to those of Koeberle, of Strasbourg. When it is stated that all these writers have published since 1862, it will be appreciated how recent is the favorable reception of the operation in France. ' Grenser, loc. cit. * Wielaad and Dubrisay, the French translators of Churchill. VARIETIES DANGERS. 727 M. Boinet, in 1867, read an essay^ before the Academy of Medicine, strongly advocating it, and " reprobating the timidity of French surgeons who have so long recoiled before it." Up to July, 1868, Pean, of Paris, had had seven recoveries out of ten cases, and in 1870 and '71, out of thirty-two operations, twenty-six re- coveries took place. In 1873, he wrote a work upon Hysterotomy for Fibroids and Fibro-Cysts, in which he claims seven recoveries for nine operations. Nothing could more surely mark the advance of the operation, as well as the rapidly increasing boldness and skill of French surgeons, than this announcement. It is needless to point out the fact that to-day all opposition to the ope- ration has disappeared, and that in every civilized country of the globe it stands among the proudest achievements of surgery. In concluding the history of ovariotomy, it may be said that the concep- tion of the operation in all its steps is over a hundred years old, and is of European origin ; that for its accomplishment we are indebted to what M. Piorry once styled, " une audace Americaine," which was supplied by Ephraim McDowell ; and that many of the important improvements which have since been introduced, we owe to Great Britain. Pre-eminently an Anglo-American procedure, it has only within the last decade assumed its legitimate place in Germany and France, but in both countries it is not merely maintaining itself, but being improved and advanced towards per- fection. Varieties — There are two forms of the operation : one, abdominal ova- riotomy, in which the cyst is removed through the incised abdominal walls ; the other, vaginal ovariotomy, in which a small cyst is removed by in- cision through the fornix vaginse. Incomplete cases, or those in which only a portion of the sac is removed, have also been grouped under the first head, but very improperly so, for less than complete removal constitutes an entirely different operation, which is known as partial excision. Dangers. — The dangers which attend it are numerous and grave. The following table, constructed by Dr. Peaslee upon the post-mortem evidence of 50 cases, will exhibit them at a glance : — Peritonitis . 12 Strangulation of intestine in Septicaemia 9 wound , . 1 Shock or collapse . 7 Diarrlioja . . 1 Exhaustion . 7 Erysipelas . . 1 Shock and septicc-emia . 1 Tetanus . 1 Hemorrhage . . 9 Ulceration. through bladder 1 Unknown . . 9 It will be seen from this table that peritonitis destroyed one-quarter of all who died from the operation ; and septicaemia, or absorption of putrid material, one-sixth. After these causes followed those directly resulting from the depressing influence of the operation upon the nervous system. • N. Y. Med. Record, July, 1867. 728 OVARIOTOMY. Dr. John Clay makes the following analysis of the causes of death in 150 fatal oases, reported in his tables : — Shock or collapse . Hemorrhage . Peritonitis Phlebitis Tetanus Intestinal affections Abscess Chest diseases Congestion of brain Diabetes Not stated 25 24 64 1 2 6 3 4 1 1 19 150 That in these lists many cases of septicasmia ending in peritonitis are catalogued as peritonitis, I think is proved by tlie light which we now have on the subject. My own observation would lead me to put the causes of fatal issue after ovariotomy in the following order as to frequency and importance : — Septicjcmia ; Peritonitis ; Hemorrhage ; Shock. The first of these is the great evil to be feared, and combined with the second causes more deaths than all the other causes added together and multiplied by ten. Statistics. — So hard was the struggle of ovariotomy for existence, so vigorous and malign the attacks made against it by the leaders of profes- sional opinion all over the world, and so delicate the position of those bold and enterprising men who in the United States and England still clung to its fortunes, that up to a very recent period it was necessary to deal fully with statistical evidence endorsing it. That time has now happily passed, ovariotomy now standing upon a basis every whit as firm as that of amputation of the leg or any other operation of general surgery. Then, too, a new era has dawned upon ovariotomy within the past five years which will almost surely greatly improve the statistics of the future. An- tiseptic surgery applied to this operation has already accomplished a great deal; it will in all probability do in the future much more than it has done thus far. Conditions favorable to the operation — Clearness and certainty of diagnosis ; Good constitutional condition ; Patient being hopeful and desirous of operation ; Paucilocular character of cyst ; CONDITIONS FAVORABLE TO THE OPERATION. 729 Absence of mucli solid matter in its structure ; Abdominal walls not veiy thick ; Absence of strong pelvic adhesions. The possibility of error in diagnosis has been already sufficiently dwelt upon. The importance of clearly understanding the nature of the tumor cannot be over-estimated. The operator should, by repeated and most careful examinations, alone or with counsel, endeavor to determine all the features of the case, not merely the fact that a tumor exists, but that it is ovarian and not uterine, that pregnancy does not exist with it, that it is not cancerous, that its contents are fluid, and that the fluid felt is all ovarian and none of it abdominal. In two cases I have, in company with a number of others who consulted with me, been greatly deceived. In one case, when upon the point of operating upon a large, multilocular tumor, the patient lying on the table, I discovered the coexistence of pregnancy in the fifth month. In another, which I supposed to be a large ovarian tumor, upon cutting through the abdominal walls, an im- mense amount of fluid escaped, leaving for removal a solid tumor of the ovary not larger than the adult head. Cases are on record in which sur- geons of great experience and skill have cut down upon uterine fibroids, cysts of the kidneys, the pregnant uterus, and other abdominal enlarge- ments, under the impression that ovarian cysts existed, and instances have occurred in which abdominal section discovered no tumor of any kind, the operator having been deceived by tympanites. As to the period at which the operation should be undertaken, there is, and probably always will be, a great deal of diversity of opinion. As the decision of this point will always involve a great deal of responsibility on the part of the operator, it will not be without interest to refer to the views of weighty authorities. Baker Brown operated quite early, as soon as the diagnosis was fully established, in order to avoid changes in the cyst and peritoneum. Peaslee and Tyler Smith waited for some degree of impairment of health and emaciation, as does Keith likewise. "Wells operates when the patient cannot walk a mile without difficulty. Bryant does so when the tumor, by its size, inconveniences the patient and inter- feres with her domestic duties; while Greenhalgh postpones the operation as long as it is justifiable, in order to secure changes in the peritoneum which will render it less liable to traumatic peritonitis. It appears to me that the general rule should be this : if a small cyst be discovered which is removable by the vagina, it should be removed as soon as possible, while one too large for this should be interfered with when it is evident that the patient is failing in strength, and becoming emaciated, depressed, and nervous. To this rule there are, however, marked exceptions. In a patient of calm, philosophic mind, who does not chafe at the knowledge that a tumor exists, delay is often advisable in the case of a tumor which, in a nervous, fretful, cowardly woman, who is 730 OVARIOTOMY, rendered almost insane by such knowledge, should be removed at a much earlier period. The following table, constructed by Dr. J. Clay, of 299 cases in which the general health was ascertained, displays the important fact that even great emaciation does not produce a very unfavorable result : — Class of cases. Health good. Health impaired. Much emaciated. Complicated with other disease. Complicated with pregnancy. Successful .... Unsuccessful . 21 21 17 25 47 4G 21 27 48 2 2 Total . . . 42 42 93 4 The mental state of the patient has so marked an influence on the result that operators agree that a depressed and apprehensive condition commonly produces an unfavorable issue. The greater the amount of solid matter in an ovarian tumor, the more favorable will be the prognosis as to rate of growth and the more unfavor- able as to cure. The following is Dr. Clay's table in reference to the character of the tumor : — Class of cases. Monocystic. Polycystic. Solid. Small. Medium. Large. Successful . . . Unsuccessful . . 19 25 66 106 8 13 4 3 14 17 30 18 Total . . . 44 172 21 7 ' 31 48 The greater the thickness of the abdominal walls, the more extensive will be the surface which must unite to effect closure of the abdominal opening, and the greater the probability of suppuration occurring between the lips of the wound and pus pouring into the peritoneum. The presence of adhesions to the abdominal viscera greatly complicates the case, but, as this can be determined only after abdominal section, its consideration will be postponed until that point in the description of the operation is reached. Conditions unfavorable to the oper-ation — The following circumstances, although unfavorable to the operation, do not contraindicate it, unles? they exist in the most exaggerated degree : — Obscurity as to diagnosis ; Great constitutional impairment; Gastric or intestinal disorder; Depression of spirits ; Presence of much solid matter in tumor; VAGINAL OVARIOTOMY, 731 Extensive and firm adhesions to viscera ; Complication with other diseases; Great thickness of abdominal walls. Vaginal Ovariotomy. — In certain cases, rare ones T admit, in which a tumor not larger than the head of a child a year old falls down into Douglas's cul-de-sac, it will be possible to cut through the vagina, seize the sac, draw it down, ligate the pedicle, and fasten it by suture in the lips of the vaginal opening. If this can be done, a great deal of risk will be avoided, and the patient spared a lengthy period of suspense, with the prospect of a serious capital operation at the end. I will lay the steps of this operation before the reader by relating the first case in which it was resorted to by myself. The patient having been etherized was placed in the knee-elbow posi- tion, and secured upon the apparatus of Dr. Bozeman. This apparatus not only completely fixes the patient in this position, by straps and braces, but makes the position perfectly comfortable for any length of time, and also favors the administration of an anaesthetic. It is shown in Fig. 256. Fig. 256. Bozhe cyst wall should be cut out and allowed to remain upon the surface to which it so pertinaciously clings. M. Boinet points out the propriety of removing the secreting surface of such a piece before leaving it. Sometimes instead of adhesions here and there the cyst is found uni- versally attached over the pelvis, and the operator sees cause to fear lest the removal of the whole cyst may prove impracticable. Tliis condition of things may be dealt with in one of two ways. The opei-ator may strip the envelopes of the sac away from it about three inches above the attached surface and enucleate its lower segment ; or if he find this impossible, or deem it to be very hazardous on account of hemorrhage, he may pass into the extremity of the sac a glass drainage tube, tie the sac firmly around this, and fixing both sac and tube between the lips of the abdomi- nal wound drain it and inject with carbolized fluid. There are little manoeuvres which experience will teach the operator which will greatly assist in removal of the sac from the abdomen when difficulties present themselves. One of these, which I learned of Mr. Spencer Wells, consists in ignoring the attachments at the upper part of the sac, seizing its lowest, inner portion, pulling this out through its mouth, and thus completely inverting it. Another consists in ligating the tumor, when much solid matter exists at its lower extremity, before complete emptying of it, turning it over, and delivering the pelvic extremity first. A third plan is applicable when the upper portion of the tumor is fluid, 740 OVARIOTOMY, and that below the umbilicus solid, and consists in passing the long trocar through the solid portion obliquely upwards, emptying the upper sac, pull- ing this down and out tirst, and then dragging out the solid portion near the pelvis. By adopting these methods in suitable cases, it is surprising to see through how short an incision a colossal and semi-solid tumor may be extracted. Very recently I removed one in the Woman's Hospital weighing- over sixty pounds, through an opening of less than five inches. The tumor being freed from attachments is now drawn forth, and the pedicle seized in the fingers. At this point there is usually a delay caused by the time required by the operator for determination as to the plan which will be best adapted to securing the pedicle. There is often, too, some discussion upon this point, for no operator should be wedded to any single plan which he adopts in all cases. If the sac be left attached to Fig. 258. Dawson's temporary clamp. the pedicle during this time, it is greatly in the way, drags heavily, soils the clothing, and usually forces entrance of its contents into the abdomen. I have been in the habit of rapidly encircling the mass some inches from the pedicle with a strong ligature, cutting off the sac, and then at leisure examining the pedicle. Dr. B. F. Dawson has devised for this purpose the temporary clamp shown in Fig. 258. By this the vessels of the pedicle are secured, and this part compressed circularly instead of later- ally, while it is secured by the means which are to be permanent. Securing the Pedicle This, which constitutes one of the most import- ant steps of the operation, is at times easily and satisfactorily accomplished, while at others it is invested with great difficulties. Unless the pedicle be excessively short, the sac may be drawn outside of the abdomen and its pedicle grasped by the fingers. When very short it has to be manipu- SECURING THE PEDICLE. 741 lated in the abdomen. It may be managed after one of the followino' methods, that one being selected which best meets the retiuirements of the particular case. 1st. The pedicle may be constricted by a clamp and held outside of the abdominal cavity. 2d. The pedicle may be securely ligated and held between the lips of the wound by pins or sutures. 3d. Tlie pedicle may be transfixed by double ligatures, which being cut short, it is drop[)ed into the pelvic cavity. 4th. The tumor may be enucleated. 5th. The pedicle may be constricted by a temporary clamp and severed by the actual cautery. A large number of other methods have been advised and practised, and to those interested in the matter, I would recommend the work of Dr. Peaslee on Ovarian Tumors wiiere they are considered at length. I men- tion here only those which appear to me deserving of special consideration and unquestionable reliance. Fig. 259. Thomas's clamp. The prevention of hemorrhage by the ligature and clamp is evidently identical in principle. The clamp, however, has the advantage of being simpler and more easily applied. The clamp shown in Fig. 259 is that which I invariably employ. It appears to me to present all the advan- tages and few of the evils which attach to others. It is thus employed : the pedicle or neck of the tumor being held in the fingers ; the clamp. Fig. 259, is adjusted so that one limb passes over one, and the other over the other side of it ; the two branches are then closely approximated so as to obliterate the vessels, and the sac is amputated above this by a bistoury. The clamp is then laid flat upon the abdomen and the incision closed. When the ligature is employed in the extra-peritoneal method, the sac 742 OVARIOTOMY. is amputated and the stump placed between the lips of the wound and transfixed by large pins, or the sutures which close this part of" the incision. Dr. Tyler Smith was instrumental in rendering popular a method which was practised, according to Dr. Peasleo, as long ago as 1829, by Dr. Rogers, and afterwards by Dr. Billington, of this city. It consists in ligating the stump, cutting both ligature and pedicle as short as possible, returning them to the abdomen, and closing the abdominal incision. A great deal of prejudice has existed against this return of the pedicle. By theoretical reasoning it is true that the practice can be made to appear very objectionable, but it is not theory which should decide us in reference to so grave a matter ; the results of practice should outweigh all theory, and no one should yield aught to mere feeling. This unwarrantable preju- dice against the leaving of silk in the peritoneum, for so I regard it, has been strengthened by the report of 34 cases of ovariotomy by Spencer Wells; of these, 4 were treated by return of ligature to the abdomen, and all died; 30 were treated by clamp, and all recovered. Peaslee, whose statistics were 17 recoveries out of 2(» Ofjcrations ; Tyler Smith, who reported 14 successes in 17 operations; and Bradford, who saved 28 out of 31 cases, all employed this plan universally. I confess that I once shared in the prejudice to which I have made allusion, but experience has caus(!d me to change my mind with regard to it. In 1878 Mr. Knowsley Tliornton, of London, whose success as an ovariotomist entitles his opinion to great weight, reported very strongly in favor of the silk ligature and return of the pedicle. An objection to the use of the ligature cut short and returned to the peritoneal cavity which has been raised upon theoretical grounds is, that gangrene of the portion of the stump distal to the ligature was likely to occur, and prove a source of septicaemia. Spiegelbe.-g and Waldeyer have, however, proved that after the application of a ligature upon the horns of the uterus the portions of tissue distal to them do not become gangrenous, but are encapsulated by effused lymph. Kojberle, of Strasbourg, employed the clamp when the pedicle w:is long; but when short, he compressed the stump by a species of constrictoi- which tightens a metallic wire that surrounds the pedicle. Enucleation will never [)rove ap[)licable to a large number of cases, for where a pedicle can be treated by any of the methods thus far mentioned, it will offer no advantages. Where, however, there is no pedicle, it pre- sents itself as a most valuable resource, and comes into use in a class of cases to which no other i)lan is applicable. The most remarkable results have attended the use of flu; actual cautery in the treatment of the |)edicle, combined with the antiseptic method in the hands of Mr. Thomas Keith, of Edinburgh. Out of his last seventy ovariotomies, he lias not liad a death ! SECURING THE PEDICLE. 743 No rule can be given with reference to a choice between all these methods other than this : when the pedicle is long and slender, it does not appear to matter very much which plan is selected, for all have yielded and are daily yielding excellent results ; but when it is very short, the external does not promise nearly so well as the internal method of man- aging the stump. Fig. 260. Storor's clamp-shield. As to the special cases for applying the different plans, the following suggestions, not rules, may be of service : — a. The clamp is applicable to long pedicles, requiring powerful ligation, and presenting a large amount of tissue for suppuration and decay. b. Ligation and return is applicable to tumors with pedicles too short for treatment by the clamp, and to slender pedicles. c. Enucleation gives a method of removal of tumors which have no pedicles. d. Since the experience of Mr. Keith, the use of the actual cautery should be again fully tried, for its utility may now be considered beyond question. Where it is employed deep in the pelvis, Storer's clamp-shield, Fig. 260, is an excellent adjuvant for prevention of hemorrhage during its use, and a good protection to the surrounding parts. The statement just made as to its being immaterial whether the pedicle 744 OVARIOTOMY, is returned or not, in ordinary cases, is based upon tlie comparative results of those who do not return it, with tliose of other operators who do. The following analysis of a large number of cases is given with reference to this point by Dr. J. Clay : — Class of eases. , , ^ Inferred Stated lefti igft ^ith. witbm the' j^ ^jjg abdoiueu. ; abdomen. Kept without by various methods. Tied in two or more portions. Simply ligatured. stitched in wound. Ecraseur used to divide it. Successful . . Unsuccessful 113 58 76 97 20 25 122 57 22 26 3 3 2 1 Total . . . 171 173 45 179 48 6 3 Upon theoretical grounds it would appear tliat parturition in the future would be much less unfavorably affected alter the performance of ovari- otomy with return of the pedicle to the abdominal cavity than after the same operation, the clamp being employed. Statistical evidence upon the subject is wanting. Dr. "Walter F. Atlee^ relates a case where death oc- curred to mother and child from powerless labor, of which he says : — "I think myself that the difficulty in this case arose from the irregularity of the contractions in a deformed womb. The left horn being fast to the abdominal wall at the lowxr end of the old cicatrix, which was just above the iDubis, the womb, as it developed around the child, must have done so in a very diflferent way from what occurs in ordinary cases. As it is, I have thought it well to report the case as bearing upon the question of the proper mode of securing the pedicle, when very short, in ovariotomy." Before proceeding to the next step of the operation, the remaining ovary should always be carefully examined as to the existence of disease. Upon the removal of a large ovarian cyst, it is very common to find very small cysts disseminated throughout the other ovary. If any of these have ob- tained considerable size, it is advisable that this should be removed. But if they be too small to call for this course, the matter may be compro- mised by puncture of them with a needle. Pippingskoeld,^ of Helsingford, Finland, advises that the small cysts should be punctured and their walls rapidly but efficiently cauterized with a pointed actual cautery. He de- clares that he has resorted to this plan in many cases and with unifoi-mly good results. Cleansing the Peritoneum The sac having been removed and hemor- rhage checked, all fluids contained in the peritoneal cavity should be care- fully removed by soft sponges squeezed out of warm, carbolized water. Not only the intestines and abdominal walls, but especially the pelvis, should be completely and thoroughly cleansed. This is a point of great 1 Amer. Journ. Med. Sci., April, 1880, p. 394. 1 Am. Journ. Obstetrics, April, 1880. ESTABLISHING DRAINAGE. 745 importance, and may decide the issue of the case. Every particle of fluid left may undergo decomposition, and expose to the great dangers of septi- caemia and peritonitis. Establishing Drainage No one familiar with ovariotomy will to-day doubt the assertion that the two factors which prove most fatal after it, septicaemia and peritonitis, are both in great degree due to the retention of putrescent materials within the peritoneal cavity. These materials may have escaped from the cyst during or before the operation, may consist of blood or serum oozing from vessels while the operation proceeds, or some hours after it has ended, or arise from emptying of pus into the peritoneum from inflammatory action. The importance of not only preventing the entrance of such elements into the peritoneum, and of removing them be- fore closing the abdominal opening, but also of giving them free vent during the period of convalescence has attracted the attention of many ovariotomists. Peaslee introduced the plan of leaving a cloth tent in the lower angle of the wound in order to facilitate drainage in case of the de- velopment of septicaemia. Koeberle not only inserted channels of metal through the abdomen, but even opened through the cul-de-sac of Douglas and inserted tubes, so as to drain per vaginain, and Sims more recently has urged this plan as one very greatly calculated to diminish the liability to these conditions. The removal of the cloth tent, fixed between the lips of the wound by congealed blood, is often difficult and painful, and the passage of a catheter or other tube down into Douglas's sac, the most dependent })art of the peritoneum, is not rarely impossible after a slight effusion of lymph has occurred. Drainage per vaginam by means of tubes passed up into the peritoneum is, I think, calculated to increase tlie dangers of ovariotomy, by opening a way for putrid fluids from the peritoneum into the pelvic cellular tissue. I have practised it twice and seen it adopted many times, and it is upon the evil results thus far observed at the bedside that I base my estimate of its value. For the past fifteen years, whenever, from the remaining of a portion of the sac in the pelvis, or from escape of fluids into the pelvic peritoneum, drainage has seemed advisable, I have, until recently, employed for this purpose a curved glass tube, which entered and rested in Douglas's pouch. This was kept closed by a cork or by a roll of carbolized cotton, and through it the pelvic cavity was syringed ont with carbolized water, carried in by a catheter if symptoms of septicaemia developed. Since the use of antiseptic dressings I have, however, discarded this, and now employ a double tube with lateral branches, which pass out through the antiseptic dressings. This renders it unnecessary to disturb it when washing out vhe abdominal cavity, and the rubber tubing with stopcocks arranged at the extremities of the lateral arms enables us to exclude air very perfectly. Tlie two halves of the tube do not communicate. As it is forced in tlu'ough 746 OVARIOTOMY. one lateral branch, the fluid runs out at its lowest extremity, rises in the cavity, and escapes through the other tube. Obstructing the escape-tube will more completely till the cavity with fluid, it" this be considered desirable. Fig. 261. Thomas's drainage tube of metal, vulcanite, or glass. Closing the Wound This is accomplished by two sets of sutures, the deep and superficial. The first, composed of silver, may be passed in the following manner : a thread of silver wire is passed at each of its extremi- ties through a long and stout, straight needle. One of the needles, being grasped by strong needle-forceps, is passed through the peritoneum of one abdominal flap near the edge of the incision and made to emerge through the skin about an inch from the edge. Then the other needle is seized and passed through the other side. The suture is then secured by twisting. These deep sutures, placed at the distance of half an inch apart, will bring the whole incision into contact from the peritoneum to the skin, and favor healing by first intention. A much better method is to pass through both walls of the abdomen a long needle with fixed handle and an eye near its point armed with a short loop of silk as recommended by Peaslee. Into this loop or into the eye of the needle a bit of metallic wire is fitted and immediately drawn into place. Besides these, superficial sutures or pins like those employed for harelip should be used, which pass through the skin and areolar tissue, but do not involve the peritoneum. Around the pins thread is wrapped in figu.re of" 8. The operation having been performed under Lister's method throughout, the wound is now covered with his antiseptic dressing, which is secured in place by a heavy covering of carbolized cotton, and this again by a firm bandage. Then the patient should be removed from the table to her bed, given a dose of opium or one of its salts, and covered up warmly, with warmth to the feet even in hot weather. It is well to move the patient now to another room. The temperature of the operating room should have been about 7")°, that of the chamber in which she is to remain should be less. This apartment should be kept at a temperature of 65° to 08° Falir., and thorough ventilation should be secured, not by the unpleasant method of admitting cold, damp, and chilling air, but by the more philnsopliical CLOSING THE WOUND. 747 one of causing the rapid escape of foul air. This can best be done by- lighting a fire in the chimney, by immediate removal of offensive sub- stances, and by general cleanliness. A quiet, attentive nurse who understands the use of the catheter should be in attendance day and night. The effects of the operation upon the nervous system should be guarded against by the means just enumerated as general rules of manacrement, and by administration of stimulants, as brandy or champagne, if the strength appear to be failing. In addition, the most complete quietude of mind and body should be afforded. All conversation and noise should be interdicted, the patient's hopefulness excited and fostered, and ajl muscular effort avoided. For four or five days the catheter should be employed for .evacuating the bladder, and the bowels be kept constipated by opium for ten days or a fortnight. The avoidance of cathartics during this time is essential to safety, a neglect of this precaution often producing a fatal issue. Some years ago I was present at the removal of an immense cystic sar- coma by the late Dr. John O'Reilly, who made an incision extending from the xiphoid cartilage to the symphysis, and after detacliing many adhesions extirpated the mass. The patient did perfectly well for a week, and was in a fair way to recover. She was, however, very urgent that her bowels should be moved, and the doctor refusing to comply with her solicitations, she took surreptitiously a full dose of bitartrate of potash. This acted as a hydragogue cathartic, but its action was not limited as it usually is. Diarrhoea, and soon dysentery, supervened and destroyed the patient's life. After the seventh or eighth day, tympanites may call for an alvine evacuation, which can be effected by an ordinary injection of soapsuds or an infusion of linseed, chamomile, or fennel. The patient should be kept quiet and free from pain by opium, given either by the mouth or rectum, so soon as she has rallied from the anaes- thetic ; or, in case of suffering, by the hypodermic method. Her nourish- ment should consist of milk, beef-juice, or gruel with milk. Even these digestible substances should be given in small amounts and with caution. Should there be a tendency to nausea and vomiting, pieces of ice may be held in the mouth or swallowed, and if these symptoms be so severe as to threaten rupture of the sutures, the hypodermic use of morphia should be resorted to. Should any marked irritability of the stomach exist, all efforts at giving nutriment by that viscus should at once be stopped, and the patient be nourished entirely by the rectum. From two to three ounces of mashed beef, bullock's blood, or strong meat essences, should be given every two hours. With this brandy or, as Mr. Thornton advises, port wine may be given, and if necessary the tincture of opium. I have, in many cases, had patients nourished almost entirely in this way from the time of operation until ten days' convalescence have been passed. Tlie evils which are chiefly to be feared as sequels of tlie operation are, within the first twenty-four hours, hemorrhage ; from second to fourth day, 748 OVARIOTOMY. peritonitis ; from completion of" operation to third or fourth day, nervous prostration ; and from fourth to fourteenth day, septicaemia. Shoukl hemorrhage be ascertained to be taking place, all dressings should be at once removed, and the stump, if out of the abdomen, securely ligated or touched with the actual cautery. If it have been returned to the abdo- minal cavity, there is but one course available, that is, opening the wound, ligating the bleeding vessel, and cleansing the peritoneal cavity. Such a necessity is very unfortunate, yet this course holds out the only prospect of success. Last year I had twice to resort to this alternative, and boik my patients recovered. Septicaemia, which is now admitted to be the most frequent cause of death after ovariotomy, is, when once fully established, a most dan- gerous state. It is ushered in by dizziness ; excessive muscular pros- tration ; anorexia ; great pallor ; high temperature ; small, rapid, and very weak i)ulse ; sometimes a low delirium ; dry tongue ; and a sweetish odor of the breath. It is this condition which is so often alluded to as a "typhoid state" after operations, and one cannot but suspect that many, if not most, of those cases quoted in Dr. Clay's tables as shock or collapse, occurring as late as the fifth, sixth, seventh, and tenth days, wei'e really instances of this affection. In one of my fatal cases, the patient was doing quite well on the evening of the seventh day. On the morning of the eightli I was struck by her wild, maniacal expression and cadaverous countenance ; upon examination I found all the symptoms of septiccemia present, and she very soon succumbed to them. The gravity of this sequel has rendered all operators anxious to possess the means to avoid or remedy it. Most of the methods- of avoidance have been already stated ; the importance of the subject will, however, excuse my again referring to them as — 1st. Completely cleansing the peritoneum; 2d. Checking hemorrhage before closing the abdominal wound ; 3d. Establishing drainage, whenever fluids are likely to collect in the peritoneum ; 4th. Adhering strictly to Lister's method. SepticjBmia, being the result, first, of the decomposition, and, second, of the absorption, of fluids in the peritoneum, is not likely to occur for several days, but it may take place two or three weeks after tlie operation. The development of peritonitis and septicaemia should be carefully looked for. All the rational and physical signs which mark them should be constantly investigated, and their inception be met by appropriate thera- peutic means. A written record of pulse-rate, temperature, and number of respirations should be systematically kept, an entry being made as to the three conditions at least as often as every six or eight hours. In case a competent assistant remain at the bedside, it may be done more fre>- quentiy, but never often enough to annoy or harass the patient. After the lapse of twelve hours, in consequence of the anaesthetic, the CLOSING THE WOUND. 749 vomiting which this commonly induces, and the effect of a capital suro-ical operation upon the nervous system, the pulse usually runs up to 110 or even 120, and the temperature to 102° or 103°, but as the irritative influence of these agencies passes off a subsidence ordinarily occurs, the pulse ranging from 90 to 105, and the temperature from 99° to 101° as con- valescence proceeds. If at any time the temperature should gradually or suddenly advance to 103°, 104°, or 105°, except just as the patient rallies from the imme- diate effects of anaesthesia and operation, fears should be entertained that peritonitis or septicaemia is developing. If it occur within four days after operation, it is likely to be the former. If after that time, the probabili- ties .are greatly in favor of the latter. The pulse will usually become rapid at the same time whichever morbid condition is developing, and it must not be forgotten that the two are often combined. I have already stated that in cases in which fluid remains in the peri- toneal cavity, or collects there subsequent to operation, it is my custom to pass to the very bottom of Douglas's cul-de-sac the tube elsewhere shown, Through this, should the temperature run up, I inject warm carbolized water once or twice in every twenty-four hours. In no instance have I seen evil result from this course. Even where a tube has not thus been left in place, when the temperature or pulse rises and the other symptoms of septicsemia develop, such an injection may often, with advantage, be practised once in every eight hours. But without the tube left from the time of operation, it is difficult and sometimes impossible to reach the most dependent part of the peritoneum, and hence I urge its employment. The following tabulated record of temperature taken by Dr. Kuentzler, in a desperately bad case of double ovariotomy occurring in my practice, will show what marked variations may occur, what elevations may be reached and yet the patient recover, and how decided is sometimes the effect of antiseptic injections into the pelvic cavity in rapidly lowering the animal heat. Fig. 262. DiMe Jufyt2 f.J /'/ /.5- /6 /7 /S iV 20 21 22 L'J2i 2S 2G 27 2fl 2tl .to :il OArs DISC M m J: 5 "^ < It or /09' 1 M E ^K M r. /, ■5 ME ME 7 S Ml .9 M£ 10 ME II M E IS M E 10 M E /J M E /6 ME ^1^ «E IS^ 31 E l!/\20 SI E.-M E /OS'- 107" ''ei ^P p/ i/u. rf/ oh rn t,T / t> ... mi. ulh /Off ,o.r lOW fo.v a \ \ ,9 WS" \ \A \ A ^ /Of 1 ^^ f- V 1 y 1 V !) \ A \ / A A V 100' .9T + Si y h 7__ ^1 0 4 7~ i h 1 if \r / f V s 9,r s- s V ,1 ■ a b s 36' — .A._ «_ rh •'.sA irs *)i nrl an '0 ejt axi !/// yo at '>t, jerJoi ICU \H' .J 750 OVARIOTOMY, Fig. 263. TkdeJIitfff g s ^ .^ 6 7 'S .'j ,io h is a /^ j,s /»■ /j^jffjs zo Fig. 264. \K^,rfuq2n2 ?■? g^ 2.5 2B 21 2,9 2,9 30 3f 1 Z 3 U- ,5 6 7 S .9 Let no one suppose that septicaemia once established becomes irremedia- ble. Experience disproves this ; it is the prolongation of exposure to absorp- tion of septic elements that constitutes the great danger of the condition. This method of meeting in an efficient and satisfactory manner the most fruitful source of danger after ovariotomy, I regard as second in impor- tance to no other improvement which has been introduced since the dis- covery of the operation itself. It emanated from Dr. E. R. Peaslee, and has even now, I think, not assumed its legitimate position in the scale of importance. It is a matter of moment, in reference to this method, to know how an experience of fifteen years in its use should have affected its originator towards it. In an article written in 1870, he expressed the following conclusions : — "1. Intra-peritoneal injections of water, with the addition of liq. sodiB chlorinat. or carbolic acid, as before explained, arc entirely safe after ovari otomy in the conditions requiring them. AFTER-TREATMENT. T51 *' 2. They should be used with a curative intention in all cases of septicse- mia already developed, and in all cases for ]^)revenUon whei'e it is feared, from the presence already of a fluid in the peritoneal cavity, whose decom- position will produce it. "3. Thus used, they will diminish the percentage of deaths from septi- caemia after ovariotomy from one-sixth (seventeen and eleven-seventeenths per cent.) of all who die after it, to one-thirty-sixth (two and sixteen- seveuteenths per cent. ) ; and increase the average success of ovariotomy from seventy to seventy-four or seventy-five per cent, "4. Intra-peritoneal injections are never to be thought of except for the purpose of removing a fluid already in the peritoneal cavity, which either has, or assuredly will have, produced septicaemia. "•5. A tent may be inserted for two to four days at the lower end of the incision, with entire safety, in any case of ovariotomy where the accumula- tion of such fluid is apprehended. "6. Finally, septicemia would more rarely occur after ovariotomy if all fluid were removed from the peritoneal cavity by the most careful sponging before closing the incision." Peritonitis, which proves the cause of death to many of those who die from this operation, is best avoided by leaving as few ligatures as possible in the peritoneal cavity, by removal of all putrefactive matters, by keep- ing the abdominal viscera at rest by preventing vesical and rectal action, and by com[)lete antisepsis. Should peritonitis develop, it shoidd be at once treated by free and steadily continued use of opium, after the [)lan of Alonzo Clark. The bowels should be kept strictly constipated, the patient perfectly quiet upon the back, the diet be restricted to milk, and no other medicine than opium be administered. A difiference of opinion exists as to the benefit arising from a[)plications over the abdomen. Mine is, that, as a rule, stupes of turpentine, bladders of ice, and warm poultices, alike do harm. In cases where the disease is limited to the pelvis the last often do good, but in general peritonitis the comfort of the patient appears to be favored by an avoidance of them. Should peritonitis arise after the lapse of four or five days, it should, I think, be looked upon as a septic peritonitis due to putrefaction of con- tained fluids, and it is a question whether such cases should not be treated in their very inception by peritoneal injections. Should it arise still later, for instance, about the tenth or twelfth day, it should be looked upon as a result of discharge into the peritoneum of encapsulated fluid material, and miglit likewise be met in this way, particularly if injection can be accomplished without reopening the abdominal wound. It is to avoid this necessity that I employ a drainage tube in appropriate cases. In a patient exposed to the dangers of ovariotomy the temperature is a matter of the greatest moment, and its excessive elevation often proves 752 OVARIOTOMY. of itself, that is, without the full and fatal development of peritonitis or septicfemia, the cause of death. The establishment upon a firm and enduring basis of clinical thermo- metry, as an adjuvant to the practice of medicine and surgery, constitutes one of the most important advances which has marked the nineteenth century, prolific as it has been in progress. No longer like his fore- fathers, groping in the dark and dealing with surmises and conjectures, the practitioner of to-day finds the former, both in diagnosis and prognosis, replaced by certainty and the latter by scientific deduction. By the aid of this accurate method he watches his patient's progress from day to day, nay, even from hour to hour, with the calm confidence of one who has a reliable knowledge of the present and a certainty that he will be fore- warned as to the future. . But it is not only in reference to diagnosis and prognosis that thermo- metry aids us at the bedside. It having been observed that prolonged high temperature kills; that, the animal heat being kept for days at 106°, the patient almost invariably succumbs, the knowledge of this fact natu- rally suggested the adoption of means which, even although they did not cure the existing disorder, lowered the high rate of temperature, and barred at least this avenue to the approach of death. The importance of doing this has been recognized by ovariotomists, and partial results have been obtained by the use of quinine in large doses, the administration of salicylic acid, alone or in combination with soda, and the application to the head of the ice-bag of Wells. Struck by the very apparent inefficiency of tliese means, I have for some time been endeavoring to adopt some plan by which refrigeration , of the trunk could be effected without the necessity of exhausting my patient by removal from the bed; and the "cold pack," sponging, and the apposition of wet cloths were, in turn, tried. The use of the cold bath I likewise considered, but the idea was at once abandoned ; for the removal of a patient re- cently exposed to laparotomy from her bed to the tub was attended by risks which evidently must be much greater than those attending the same process in an ordinary case. The difficulties presenting themselves had well-nigh caused me to forego all hope of employing this means of combating hyperpyrexia, when the late Dr. G. W. Ivibbee brought to my notice an ingenious device of his for accomplishing the desired result. He placed the patient upon what he called his "fever cot," which I here exhibit and describe in the words in which he advertised his invention. ^ Upon this cot a folded blanket is laid so as to protect the patient's body from cutting by the cords of the netting, and at one end is placed a pillow covered with India-rubber cloth, and a folded sheet is laid across the mid- dle of the cot about two-thirds of its length. Upon this the patient is now laid, her clothing is lifted up to the arm[)its and the body enveloped by the folded sheet, which extends from the axilla) to a little below the AFTER-TREATMENT. 753 trochanters. The legs are covered by flannel drawers, and the feet by warm woollen stockings, and against the soles of the latter bottles of warm Fig. 26.'). "Tlie bed on which the jiatieut lies cousists of a strong elastic, cotton uettiug, manufactured for the purpose, through which water readily passes to the bottom below, which is of rubber cloth, so adjusted as to convey it to a vessel at the foot. When not in use it can be close folded so as to occupy but little space." water are placed. Two blankets are then placed over her, and the appli- cation of water is made. Turning the blankets down below tlie pelvis, the physician now takes a large pitcher of water at from 75° to 80° and pours it gently over the sheet. This it saturates, and then, percolating the net- work, it is caught by the India-rubber ajjron beneath, and, running down the gutter formed by this, is received in a tub placed at the extremity of the cot for that purpose. Water at higher or lower degrees of heat than this may be used. As a rule, it is better to begin with a high temperature, 85° or even 90°, and gradually diminish it. The patient now lies in a thoroughly soaked sheet with warm bottles to her feet, and is covered up carefully with dry blankets. Neither the por- tion of the thorax above the shoulders nor the inferior extremities are wet at all. The water is applied only to the trunk. The first effect of the affusion is often to elevate the temperature, but the next affusion, practised at the end of an hour, pretty surely brings it down. It is better to pour water at a moderate degree of coldness over the surface for ten or fifteen minutes than to pour a colder fluid for a shorter time. The water slowly poured robs the body of heat more surely than when used in the otlier way. The water collected in the tub at the foot of the bed, having passed over the body, is usually 8° or 10° warmer than it was when poured from the pitcher. On one occasion Dr. Van Vorst, late house-surgeon to the Woman's Hospital, tells me that it gained 12°. At the end of every hour the result of the affusion is tested by the therniometer ; and, if the temperature have not fallen, another affusion is practised, and this is kept up until the temperature comes down to 100° or even less. It must be appreciated that the patient lies constantly in a cold, wet sheet ; but this never becomes a fomentation, for the reason that, as soon 48 754 OVARIOTOMY. as it abstracts from the body sufficient heat to do so, it is again wet with cold water and goes on still Avith its work of heat abstraction. I have kept patients upon this cot enveloped in the wet sheet for two and three weeks without discomfort to them and with the most marked control over the degree of animal heat. Ordinarily, after tlie temperature has come down to 99° or 100°, four or five hours will pass before affusion again be- comes necessary. This device of Dr. Kibbee is so simple that one wonders that any per- plexity attended his accomplishing all that it does before it was shown to him, and at once the thought suggests itself how easily a substitute for it could be improvised. It is the old story of the egg of Columbus. The idea, once suggested, by its very simplicity assumes its place in the mind as a familiar one. Simple as it is, it aftbrds the means of using a most important therapeutic resource, and, in my estimation, leaves nothing to be desired in this respect. Recognizing in this a method by which cold could be applied to the surface for any length of time without fatigue or exhaustion to the patient and without the danger of excessive chilling, since any great depression of temperature can be obviated by the affu- sion of warm water, I determined at once to adopt it after ovariotomy. In adopting this plan of treatment after ovariotomy, and as I have in several cases done after parturition, I did not propose by it to check peri- tonitis, or to cut short septicaemia, the great evils to be feared at this time. My hope was to rob these diseases of one of their chief weapons of de- struction— hyperpyrexia, and thus to resist the primary assault in the hope of bearing up against a more prolonged though less violent siege. In all acute and grave diseases, the invasion of the disorder produces great commotion, which rapidly subsides as the system becomes familiar- ized with the invading ailment. This is most marked in pneumonia — and to a less degree in peritonitis and septicaimia, if the patient does not suc- cumb very early. How often has every ovariotomist been surprised, in making an autopsy of a |)atient who has apparently died of acute perito- nitis, to find only a slight field of pelvic peritonitis which most unsatis- factorily accounts for the destruction of life ! Robbed of its lengthy and wearing high temperature, which lasts for weeks, depraving the blood, altering the nerve centres, and degenerating the muscles, typhoid fever runs a mucli more manageable and less violent course. So septicaemia and peritonitis, kept from the commencement of their courses within normal limits as to temperature, are wonderfully different in their manifestations from the same diseases uninterfered with in this respect. Under these circumstances the system of the patient may be likened to a city exposed to attack from an armed foe. The great danger is from the first assault; but, once having resisted that, its prospects of holding out against a siege would be good, although in the end it might yield even to this. Still the prospects of successful defence would be AFTER-TREATMENT. 755 greatly increased if the primary, most energetic, and most vio-orous at- tack were defeated. I have now employed this method very freely for more than a year, and my confidence in it increases with growing experience. I would alter but one statement concerning it whicli I have formerly made ; that is, I do not now often use water at very low temperatures, but usually at 90°, lowering it gradually to 80°. As to the time at which the sutures should be removed, no fixed rule can be given, for it will depend upon the rapidity and completeness of union. Should union by first intention occur, some of them may be removed on the sixth, seventh, or eighth day. But great care should always be observed, and only those at points where the union is strong should be withdrawn. After withdrawal the abdomen should be firmly supported by adliesive plaster. The clamp, if employed, or the ligature, if passed out through the wound, should be removed when they lose their hold by reason of sloughing, and incline to fall off". No traction should be applied to them. A case was recently reported before a society in London in which too early removal of the clamp had resulted in obstinate protru- sion of a knuckle of intestine, which produced fatal peritonitis. Mr. Wells used it as a text by which to urge that the clamp sliould always be left in place until it was ready to drop off. This will usually be about the ninth or tenth day. The patient should be cautioned against i-ising too early after convales- cence. Even after she is able to go about she should be very careful not to make any violent efforts, and for a year or two she should wear a well- fitting abdominal corset to guard against ventral hernia. I have had this occur in several cases. The abdominal walls were separated over a space measuring about four inches, and the intestines were supported only by skin, areolar tissue, and peritoneum. In one case these yielded to pres- sure, and one year after ovariotomy a tumor about the size of a kidney, with a mass of attached omentum, escaped. The occurrence of ventral hernia is not the result of any bad manage- ment on the part of the operator. It may occur in any case^ and some- times comes on when no operation has been performed. Y56 OOPHORECTOMY. CHAPTER L. OOPHORECTOMY. Synonyms This operation has been styled female castration, spaying, and Battey's operation. History. — As the creation of the male eunuch by removal of the testicles has long been known as a procedure practised for other than scientific pur- poses, so probably has that of the female eunuch by removal of the ovaries. The former procedure was, however, very commonly put into practice; the latter very rarely so. The former is substantiated by unquestion- able evidence ; the latter rests merely upon vague tradition, which asserts that a king of Lydia had it practised upon a lewd daughter, and that in India female eunuchs were thus created in the olden time. In the lower orders of animals spaying has long been very extensively practised, and is so to-day. In 1823 James Blundell, of London, formally suggested the practice of this operation in a paper presented to the Royal Society of Medicine and Surgery of London. In this he suggested that th6 extirpation of the healthy ovaries would probably prove remedial for severe dysmenorrhuea and for the menorrhagia which accompanies inversion of the uterus where amputation is not practicable. In 1872 Dr. Robert Battey, of Georgia, performed the operation for removal of the healthy ovaries for the premature production of the meno- pause. He was soon followed by Hegar, of Germany, who has since not only contributed more than any other to the clinical history of the subject, but has likewise done more than any predecessor or contemporary for the scientific elucidation of the procedure. His name is indeed almost as much associated with the operation as that of its originator, Battey. Theory of the Operation Dr. Battey, basing his reasoning upon the fact that ovulation is the cause of menstruation, with all its accompanying pelvic engorgement and nervous exaltation, drew the deduction that extir- pation of the ovaries by putting a stop to ovulation, would check its con- sequence, menstruation, and that thus many evils dependent upon these two processes would by it be cured. Such was his conclusion, and to test the question he began practising the procedure. A^ery soon he was fol- lowed by others, so that now the operation is recognized as a surgical resource in every civilized country, and sufficient testimony is in existence from which to draw conclusions as to its propriety. THEORY OF THE OPERATION. 757 Indications — Ovarian extirpation is recommended for the following conditions : — Severe dysmenorrhcea ; Excessive menorrhagia ; Insanity occurring at limes of ovulation ; Hystero-epilepsy ; Excessive hemorrhage with uterine tumors ; Plystero-neuroses, other than epilepsy of severe character ; Chronic ovaritis with severe symptoms ; Absence of vagina or uterus, the ovaries being present. Of course the surgeon would have to decide according to his judgment and his conscience whether the evils for which he proposed operating were of so grave a character as to warrant his exposing his patient to a pro- cedure of the gravity which the sequel will prove this to be. The difficulties, the dangers, and the doubtful results of Battey's opera- tion render it one to be avoided until all other resources have been tried, but when these have been exhausted and death, or what is oftentimes worse, a life of suffering, becomes the certain fate of the patient, it offers itself as a resource of great value. Results} — In February last a table was published giving the results in 130 cases in which this operation has been performed, and since that time five others have been reported. Of these 106 recovered and 29 died, giving us a mortality of a little over 21 per cent. Unfortunately not all those who recovered from the operation were cured by it of the evils for which it was endured. Munde very justly remarks, "if the positive benefits of the operation were as assured as its rate of recovery, the opposition to it would soon cease." Of 24 patients who recovered fi"om the operation, Simpson'' reports that 2 received no benefit, that 11 were greatly improved, and that 9 only were entirely cured. Of the remaining 2 he makes no mention. Names of those ivho have operated In estimating the degree of favor with which a new operation has been received, a great deal can be gathered from a survey of the names of those who liave performed it. The table which I here subjoin will present tliis at a glance, at the same time that it will show the number of times that laparotomy and elytrotomy have been selected. • Archives of Medicine, vol. iv., No. 1, Feb. 1880. 2 British Med. Jour., May 24, 1879. 758 OOPHORECTOMY. Total. Laparotomy. Elytrotomy. Recov- eries. Deaths. Recov- eries. Deaths. Hegar Schroeder 42 2 35 2 7 Freund . 4 3 1 V. Langenbeek Martin . 1 3 1 3 Miiller 3 3 Czerny . Schucking 3 1 2 1 1 Battey Treuholme 12 2 2 1 8 1 2 Goodell . 6 1 1 3 1 Sims 7 2 1 4 Engleman 3 3 Thomas . 2 1 1 Peaslee . 1 1 Sabine 1 1 • ■ Von Nussbaum 1 1 Tauffer . 1 1 Netzel 1 1 Pernice . 2 "2 Alberts . 1 1 Spencer Wells 1 1 Simpson . Kaltenbach 1 1 1 1 J. Gilmore 1 1 Martin 2 2 Fallen . 1 1 E. Koeberle 1 1 W. C. Frew . 1 1 Prince 1 1 Welponer Esmarch . 1 1 1 1 Tait 2 2 West 1 1 Sims 3 "3 Noeggeratli 11 8 3 Hunter McGuire 2 2 Lusk 1 1 ■Tyng . Savage . Mann 1 1 1 1 1 1 Borner . 1 1 135 80 23 17 4 Mr. Lawson Tait reports in the British Medical Journal for July, 1880, 28 operations of oophorectomy, which he had performed within the twelve months previous. Of these 25 were complete operations, with only 1 death ; in the other 2 cases he failed to remove the ovaries entirely, and of these 1 recovered and 1 died. Methods of Operating — The ovaries may be extirpated, either by cut- ting throuirh the vagina into the peritoneal cavity, elytrotomy ; or by cutting through the abdominal walls, laparotomy. The statistical evi- ESTIMATE OF BATTEY's OPERATION. 759 dence is somewhat in favor of the former of these, but the difficulties, the uncertainty of success, and the possibility of cutting into the rectum make the latter decidedly preferable, except in certain exceptional cases which will soon be mentioned. In a number of cases, even after elytrotomy, it has been found impossible to remove the ovaries, which were hidden away under masses of effused lymph, and as a secondary procedure laparotomy has been resorted to. I should, from my experience, offer this rule as to the choice of operation. If the ovaries can be distinctly felt as movable bodies in the pouch of Douglas, elytrotomy should be preferred ; if they cannot be felt there, and if signs of old pelvic inflammation can be discovered, laparotomy should be selected as the most reliable and safe procedure. Should elytrotomy be preferred, the patient may be placed in Boze- man's position, as shown in Fig. 256, and the perineum be lifted by Sims's speculum ; or upon the back, in a modified Simon's position. Fig. 102, and the perineum be drawn down by the same speculum. Then the vagina being pulled down by a tenaculum fixed in it near its junction with the cervix, it should be cut through by scissors, the ovaries hooked down by the finger, drawn into the vagina, their ligaments ligated by carbolized silk or catgut, returned to the pelvis, and the vaginal opening closed by suture. Laparotomy should be performed as in ovariotomy, the ovaries lifted, their ligaments tied, and the ligated pedicle dropped back into the abdomen. The operation which is selected should be performed under the anti- septic method, and the after treatment of the patients should be the same as after ovariotomy, to whicli the reader is referred for details. Estimate of Battey^s Operation. — In concluding this subject let me express my views concerning this procedure in a series of propositions. 1st. Battey's operation will, by reason of the fact that there is a class of cases, the great sufferings attached to which can be relieved only by the cessation of ovulation and menstruation, survive all opposition, and exist in the future as a surgical resource of great value. 2d. It is an operation attended by grave dangers, and by doubtful bene- fits. Nevertheless, the chances are greatly in favor of its affording relief. 3d. It will ever prove more difficult and dangerous than ovariotomy, because pelvic peritonitis will frequently be found to exist in cases demand- ing it; because the ligature of the pedicle must often take place deep down in the pelvis ; because the abdominal walls, instead of being stretched as in ovariotomy, are contracted and resisting ; because the removal of the ovary often involves tearing the surrounding tissues ; and because the abdominal peritoneum has not been prepared for interference by friction from a large tumor as it has been before ovariotomy. 4th. While the practice of the operation for checking menstruation where vagina and uterus are absent is fully sustained, it is very doubtful whether benefit will result from it in cases of large uterine fibroids. 5th. A greater degree of surgical skill is necessary for the successful performance of this operation than for ovariotomy. 760 DISEASES OF THE FALLOPIAN TUBES CHAPTER LI. DISEASES OF THE FALLOPIAN TUBES. Anatomy. — The identity of structure of the Fallopian tubes and uterus will be appreciated by the study of the formation of these organs in the embryo, as described by recent observers, more especially by Leukart, Thiersch, and KoUiker. In the walls of the Wolffian body, situated near the kidneys, on each side, in the female embryo, a narrow canal develops which ends below in the two horns of the uterus, while the distal extremity performs " a move- ment of rotation from before backwards, and from above downwards ; the whole, together with the ligaments of the ovaries and the round ligaments, being enveloped in double folds of the peritoneum, which enlarge with the growth of the parts themselves, and constitute finally the broad liga- ments of the uterus."^ Coming together at the median line these canals coalesce, or undergo fusion, forming the lower portion of the uterus, and the entire vagina down to the hymen. The fundal arch is now formed in all probability from fusion progressing from below upwards, although this is somewhat doubtful. Thiersch- thinks from observation on the embryos of sheep that it occurs from below upwards ; while KoUiker, who experi- mented on those of cattle, believes that it occurs from the centre. Prof. Dohm, who experimented upon embryonic foxes, sheep, pigs, and cattle, concludes that it begins between the middle and lower third, and extends upwards and downwards. All this occurs very early in embryonic life ; according to Dohm it is completed by the end of the second month. From the fact of this identity of structure there naturally exists between these organs a close sympathy in health and disease. In the adult woman, according to Carl Hennig,^ the right tube is nine and a half centimetres (three and three-fourths inches), while the left measures only eight and a half. The abdominal extremity has attached to it five large and ten small fimbriae. The walls of these tubes consist : 1st. Of peritoneum, which covers them to the fimbriated extremities. 2d. Of connective tissue, in which are interspersed two sets of muscular J Treatise on Human Physiology, by J. C. Dalton, p. 645. 2 Prof. Dohm, of Marburg. Transac. Insbruck Convention, Obstet. Journ., vol. iii. p. 1(37. 3 Uterine Catarrh. Translation in Obstet. Journ. voL iii. p. 468. ANATOMY. 761 fibres, external or longitudinal, and internal or transverse, which are con- tinuations of the muscular tissue of the uterus and broad ligaments. At the point where these tubes enter the uterus, Hennig declares that the longitudinal and transverse layers of fibres both become greatly developed, and that the latter forms here a distinct sphincter tubce. 3d. We find within and lining the tube a mucous membrane, which is thrown into large and small folds, which are very evident near the fimbriated extremity, and gradually become insignificant as we advance towards the uterus. Within this membrane Mr. Bowman discovered tubal glands, which consist of grape-like structures, extending downwards towards the subjacent mus- cular fibre. Tiiey differ from the muciparous follicles of the vagina, the Nabothian glands of the cervix, and from the utricular follicles of the ute- rine cavity. Kolliker denies the existence of these, but Hennig^ describes them very fully. These compound glands of the Fallopian tubes are lined with an epithelium of basement form. The mucous membrane covering over the tubes, and not dipping down into these glands, is covered by a ciliated epithelium, the broom-like action of which is exerted towards the uterus. The object of this seems to be to sweep the products of the ovaries into the uterus, and to force in the same direction menstrual blood oozing into the tubes from their mucous lining, as a result of ovulation. The zoosperms, which are known to pass through the uterus and proceed as far as the ovaries, are themselves endowed with powerful ciliary action in the single cilia which each possesses, and by this they overcome the opposing force of the tubal cilife. It is highly probable, to say the least, that the erectile condition induced in the mucous membrane of the uterus and tubes by contraction of the middle coat of their muscular fibres produces in the latter, as in the for- mer, rupture of bloodvessels and consequent hemorrhage. Hennig declares tliat " during^ menstruation throughout its entire surface, it (the mucous membrane of tlie tubes) assumes a dark red color." Ruysch, an old anatomist of Amsterdam, who wrote in 1737, describes a post-mortem examination in which he discovered the Fallopian tubes containing blood. This has by some of the writers upon the history of hematocele been con- strued into a record of that affection, but the passage appears to refer merely to a condition which depends upon ovulation. Messrs. Bernutz and GoupiP mention instances of the collection of blood in the Fallopian tubes in consequence of obstruction of these canals. Dr. Duncan* admits that some blood may come from the tubes in natural menstruation. In two of my cases of ovariotomy in which I employed the clamp, the pa- tients menstruated regularly through the tube ibr three periods, when at the same time menstruating per vaginam. The abdominal opening then ' Loc. cit., p. 473. 2 Loc. cit., p. 470. * Op. cit., vol. i. * Fecundity, Fertility, and Sterility, p. 388. T62 DISEASES OF THE FALLOPIAN TUBES. closed, and the discharge was thereafter confined to the vagina. Other c^ses of the same kind are on record. Now as in these cases there was free exit of blood per vaginam, there can be no reason for believing that a regurgitant action occurred. The blood flowing by the tube was more probably the result of hemorrhage into that canal, the uterine end of which was constricted by traction, efi'ected by the confinement of the abdominal end in the wound. The diseases by which the Fallopian tubes may be affected are the following : — Inflammation ; Stricture ; Distention ; Displacements. Inflammation of the tubes, or salpingitis, consists in inflammation of their mucous membrane, and may be either acute or chronic. The acute variety generally results from puerperal endometritis, or from gonorrhoea, which has extended through the uterine mucous membrane. I have twice seen this disease almost destroy life by attacking the uterine mucous membrane, and subsequently producing pelvic peritonitis, doubtless reaching the peritoneum by traversing the tubes. Chronic salpingitis is one of the sources of uterine leucorrhcea, and com- monly produces permanent interference with the calibre of the tubes. In some cases it results in constrictions, while in others it produces dilatation. The latter condition it probably is which produces the discrepancy observed between the reports of various observers as to the dangers i-esulting from intra-uterine injections. When the sphincteric action of the sphincter tub« of one or both sides is destroyed, fluid thrown into the uterus will sometimes enter the tubes, and produce in them contraction, spasm, and violent acute salpingitis, which may go on to the production of peritonitis and death. When dilatation has occurred it is not at all rare for the uterine sound to be passed for several inches up the tube. I have met with several unquestionable cases of this kind. I say unquestionable, be- cause the sound must have followed one of two courses— through the fundus into the peritoneum, or up the canal of one of the tubes. As this subject has created some discussion, I will rapidly allude to two of these cases. A physician, residing near this city, wrote to me concerning the case of his wife, who had chronic corporeal endometritis of several years' duration. Upon using the sound, he was alarmed at finding it pass into the uterus nearly six inches. The lady came down to me, and upon repeated measurement I found the sound pass a little over three inches. The patient went home, and her husband, surprised at my results, used the sound again, when, as before in his hands, it passed in over five inches. To solve the para- dox he at once came down with her, and when examining with him I SALPINGITIS AND STRICTURE. 7(3^ distinctly showed him the normal measurement, a little over three inches, and then twice passed the sound up one tube a distance of two inches. One of my clinical assistants pointed out to me at my clinique, as a fit subject for a lecture, a patient whose uterus measured five inches, and who presented no symptoms except those of ordinary uterine catarrh. I had occasion to examine this patient, after stating this measurement, before the class, when I found that the sound passed only three inches. Confi- dent, from the well-known accuracy of my assistant, that he could not have erred, I at once stated to the class what I believed to be the cause of the discrepancy, and in its presence passed the probe up the right tube, making a measurement of five inches. To avoid all cliance of error, I then requested my assistant to verify my two measurements, when he also passed it first three inches to the fundus uteri, then two inches up the right tube. Hildebrandt^ relates two cases in which he passed a probe up the tube, and similar instances are recorded by Veit,^ Matthews Dun- can,^ Noeggerath,* and others. The great danger in both acute and chronic salpingitis is pelvic perito- nitis, which may spread and destroy life. This arises in part from escape of the contents of the inflamed tubes into the peritoneum. Of the symptoms very little can be said. The chronic variety may continue for years, and result in dilatation of the tube with no symptoms which arrest attention ; while the acute form so quickly produces local peritonitis, tiiat its symptoms are lost in those of that affection. No special treatment is applicable to it except the adoption of means to prevent peritonitis, as rest, opiates, leeches, and strict avoidance of sexual intercourse. The great obscurity of the diagnosis of tubal diseases renders the sub- . ject one upon which it is not profitable to speak further, although as a pathological study it is one of great interest. Stricture — The Fallopian tubes, which are often imperfect or wanting when the uterus is absent or undeveloped, may, even after full develop- ment, be affected by stricture. The condition may be produced by these causes : — Calcific deposit ; Senile atropliy; Salpingitis ; Pelvic peritonitis ; Tubercle or fibrous tumors. Partial obliteration of the canal results in sterility if it affect both sides simultaneously, and sometimes, by causing the accumulation of fluids, it ' Barnes's Report on Midwifery, Brit, and For. Med.-Cliir. Review, Oct. 1868. 2 New York Obstet. ■Journ., vol. i. p. 2(37. 3 Edinburgh Med. Journ., 1856. * Remarks before Obstetrical Society, New York. Y64 DISEASES OF THE FALLOPIAN TUBES, produces tubal dropsy. It is not rare for rupture of the tubes and conse- quent hematocele and peritonitis to result from imprisonment of menstrual fluid in them. M. Fuech analyzed two hundred and fifty-eight cases of congenital atresia of the genital organs, and found that in fifteen cases the Fallopian tubes were dilated, and in five were ruptured. The condition is rather a study for the pathological anatomist than for the gynecologist, for it can neither be diagnosticated nor relieved by treatment. Distention The tubes may be distended by accumulation of mucus, pus, menstrual blood, or a muco-serous material secreted by the altered mucous membrane accompanying great and prolonged distention. This condition invariably has as its moving cause stricture, which prevents the tube from emptying itself into the uterus. When very great distention takes place, the accumulated fluid either forces its way out of the uterine extremity, constituting the profluent dropsy of Rokitansky, or passes out of the fimbriated extremity into the peritoneum, or a rupture of the tube occurs. Such an accumulation may produce a tumor equal in size to the head of a child of ten years, and some say even much larger, though thcR, is doubt as to the authenticity of the latter cases. Virchow has established a class of cysts which he styles cysts from retention, to which distention of the tube by sero-mucus properly belongs. Fig. 266. Tubal dropsy. (Boiviu and Duges.) The diagnosis in advanced cases, where, for example, the tumor has developed to the extent just mentioned, is difficult and often impossible. Sometimes, however, it may be made by the following means : An elon- gated, fluctuating, movable tumor is felt in the retro-uterine space a little to one side ; in its outlines the tumor is wavy, and it can be separated from the uterus. Scanzoni quotes Kiwisch as declaring that, in such cases, the presence at tlie side of the fundus of a mammillated, elastic, and EXTRA-UTERINE PREGNANCY. Tt)5 elongated tumor, justifies the diagnosis of tubal dropsy, but lie differs from him, and regards the positive diagnosis as impossible. In case the diag- nosis can be arrived at, the most appropriate treatment would consist in tapping per vaginam. Displacements. — The tubes may pass with hernial protrusions into the inguinal or crural openings, and, in case of inversion of the uterus, may descend into the cavity of the displaced organ. It is generally in com- pany with the ovary that the tube leaves its place, but at times it descends alone. Dr. Scholler^ reports an instance in which, in a child who died twenty days after birth, a tumor was discovered which extended from the inguinal region to the right labium, and contained the Fallopian tube, which was non-adherent. A crural hernia of the tube alone which ended fatally is likewise recorded by M. Berard. Prof. Rokitansky,^ and Dr. Turner, of Scotland, have both drawn attention to severance of the tube from the ovary by traction from in- creased weight of the latter or from false membranes. The former cites twelve instances in support of the fact. Other Diseases of the Tubes In addition to these diseases the tubes are sometimes affected by cancer, tubercle, fibrous tumors, abscess, and accumulation of blood in their canals from hemorrhage from the mucous membrane. There is so strong an analogy between these disorders and the same in other organs, that it is not deemed necessary to enter upon their consideration. CHAPTER LII. EXTRA-UTERINE PREGNANCY. It is evident that to condense into the narrow^ limits of a short chapter a subject wdiich would require a volume for its extended consideration, involves of necessity a superficial review of its essential points only. It may even be thought by some that this subject is out of place in a work upon gynecology, and that it should have been left for one devoted to obstetrics. Its admission here is proof of the fact that I do not share this feeling. Ectopic gestation, although theoretically falling in the domain of the obstetrician, in reality almost always claims tlie attention of the gynecologist from the fact that the existence of pregnancy is in these cases very generally not recognized, the patient being supposed to suffer from some pelvic tumor or obscure uterine or ovarian disorder. It is very frequently necessary to differentiate it from a variety of disorders which * Court^f, op. oit. 2 Sydenham Soc. Year-Book, 18G1. 766 EXTRA-UTERINE PREGNANCY. will soon be mentioned, and even its treatment involves rather a familiarity with the resources of gynecology than with those of obstetrics. Definition and Synonyms — I^xtra-uterine pregnancy, extra-uterine or ectopic gestation signifies the fixation and development of the impregnated ovum outside of the uterine cavity. Varieties. — For the physiologist and pathologist there are many varieties of this abnormal, gestation ; for the gynecologist tliere are but three. For him the tubo-ovarian, tubo-abdominal, ovarian, and some other varieties are niceties beyond the appreciation of diagnosis, and he is forced to limit himself as far as practice is concerned to the classification of all varieties into, 1st, tubal ; 2d, interstitial ; and 3d, abdominal pregnancies. These by rational and physical signs he may differentiate from each other, and in certain cases base the propriety of surgical interference upon his conclusions. These, and these only, then, are the varieties which we shall consider in this chapter. Tubal pregnancy, the most dangerous of all varieties of extra- uterine gestation, consists in the arrest of the impregnated ovum in the Fallopian tube and its development there. It may be that instead of being abso- lutely in the tube the fructified ovum may develop just where the fimbri- ated end of the tube clasps the ovary. Interstitial pregnancy consists in an advance of the ovuin tlu-ougli the tube until it begins to pass through the uterine wall. Then an arrest taking place before the ovum enters the uterus, it attaches itself, distends the parenchyma of the uterus to make its nidus, and causes it to protrude partly towards the uterine cavity, partly towards the abdominal. In abdominal pregnancy one of two things occurs: either the tube holding the impregnated ovum in its grasp breaks away from its ovarian attachment, falls into the abdominal cavity, and remains there, while the ovum casting out tentacula attaches itself to the peritoneum and grows ; or, as some suppose possible, the impregnated egg falls out of the grasp of the tube, and, getting its nourishment from the peritoneum, develops in- dependently of the lining membrane of the uterus which extends through- out the tubes. Etiology It is a fact universally accepted that in the human female, as in the lower order of animals, impregnation of the ovule often occui-s at or near the ovary. In some cases, by a stricture in the tube, due to lessening of its calibre by inflammation, the development of a little tumor, or con- traction of lymph poured out by pelvic peritonitis, an obstruction is offered to the progress of the ovum towards the uterus. In contact with a mucous membrane closely resembling that of the uterus, it at once accommodates itself to its vicarious quarters, attaches itself, forms a placenta, and steadily grows. There are many points in pathology concerning which no one has a right to an opinion who has not made researches of a more or less personal character in regard to them. The pathology of extra- PATHOLOGY. 767 uterine pregnancy is one of them, and although my experience in refer- ence to this condition is quite large, as I shall soon show, I express myself upon it with great hesitation. Although extra-uterine gestation has been divided by pathologists into abdominal, tubal, ovarian, interstitial, tubo-abdominal, and tubo-ovarian, it seems highly improbable that the ovum at the moment of its impregna- tion could attach itself to any other tissue than the lining membrane of the uterus, which is so especially constructed to accommodate it. Once having undergone development in this connection, however, it rapidly invades adjoining structures, the omentum, peritoneum, etc., and forces them to nourish it. Pathology Should the arrest of the ovum have occurred in one of the tubes, it develops rapidly and endeavors to furnish a uterus for the grow- ing child. But the muscular structure of the tubes, being scanty compared with that of the uterus, although it develops to accommodate its contents, gradually grows thinner and thinner under distention until, towards the end of the first, second, or third month, it usually ruptures, and the con- tents of the ovum, as well as much blood escaping from the ruptured ves- sels of the tube, escape into the peritoneal cavity. A true hematocele is thus created, the patient generally becoming col- lapsed, and dying, and very rarely escaping by absorption of the blood and by encapsulation or discharge of the foetus. Veit' declares that about one-fifth of all cases of hematocele are due to the rupture of tubal preg- nancies, and that recoveries occur under these circumstances much more commonly than is generally supposed. I do not agree with him as to the frequency of this cause of hematocele, but I am quite sure that I have seen it thus produced, and have seen recovery follow. These are the cases of hematocele which are classed by Barnes under the name of "cataclysmic." As a rule the violence of their onset entitles them to that name, but it is highly probable that some of those occurring at early periods of gestation develop with less violent and overwhelming symp- toms. Hecker reports 45 cases of tubal pregnancy. In 26 cases rupture oc- curred in the first month, in 11 cases in the third month, in 7 cases in the fourth, and once in the fifth month. Spiegelberg'' reports a case of an ovum advancing to maturity in the tube. Interstitial pregnancy is much less frequent and less dangei'ous than the variety just mentioned. It is much more likely to advance to full term, and while it may produce death by rupture and discharge into the perito- neum, it may, as in my fourteenth case, discharge into the uterus and be expelled through the natural passages. Dr. Lenox Hodge once succeeded in recognizing the existence of such a case at full term, cut through the • Deutsche Zeit. fiir prakt. Med., No. 49, 1878. * Arch. f. Gyu., Bd. i. p. 406.^ 768 EXTRA-UTERINE PREGNANCY. layer of parenchyma which shut the foetus off from the uterus, and con- ducted the case to a successful issue. Although not attended by as great dangers as attach to tubal and in- terstitial pregnancies, the abdominal variety is a most serious aberration from normal gestation, and one which commonly destroys life. In the first two forms the rapidly developing ovum is imprisoned in tissues which are inapt for great distention, and which rupture under its influence. In the third the fcetal ball has at its disposal for expansion and growth the whole peritoneal cavity, the placenta encroaching in its search after nu- triment upon the bladder, the omentum, the intestines, and any portion of the peritoneum within its reach. The events of this form of pregnancy are the following: First, the foetus unnaturally attached and nourished may die in the early months of its life, become encysted, and in time be cast off through the rectum, the bladder, or through the abdominal walls. Second, the pregnancy may advance to the end of the ninth month, when, labor coming on, nature makes a persistent effort to expel the child, but, on account of there being no way of exit, fails, and the child, with its en- velopes, is retained, and becoming encysted remains in its nidus for years, creating no disturbance by its presence. Third, the child, shut up in its unopened shell, acts as a foreign body, creates suppurative action in its envelopes, and becomes surrounded with pus in place of liquor amnii. Or, the liquor amnii being absorbed, the foetal bones become closely hugged by the walls of the cavity which contains them, and act as an intense irritant, which sets up formation of pus and in this way leads to hectic fever from absorption of septic material. Hecker found that out of 132 cases of abdominal pregnancy, 76 termi- nated in recovery. Recovery took place in 28 cases after expulsion of foetus per anum, in 17 cases after formation of lithopaedion, in 15 cases after elimination through the abdominal wall, in 11 cases after laparotomy, in 3 cases following vaginal section, in 2 cases from undefined causes. Death followed from hectic in IS cases, peritonitis in 12 cases, operations in 12 cases, rupture and hemorrhage in 7 cases, fecal vomiting in 2 cases, dropsy in 1 case, cause not defined in 4 cases. Causes of Death The causes of death in the various forms of extra- uterine pregnancy may thus be presented: — Shock ; Hemorrhage ; Septicasmia ; Peritonitis ; Hectic fever ; Perforation of important viscera by bones. Symptoms. — The suspicion of extra-uterine pregnancy is usually created in one of the following ways : 1st. A woman who has passed over one, two, or three menstrual epochs is suddenly seized with the symptoms of SYMPTOMS DIFFERENTIATION. 769 hematocele, agonizing pelvic pain, faintness, coldness of extremities, bathing of face with cold sweat, rapid and feeble heart action, and nausea and retching. She dies of overwhelming nervous paresis, called " shock," of hemorrhage, of peritonitis, or of septicaemia ; or she gets well, the diag- nosis of pregnancy is regarded as a mistake, and she is said to have re- covered from hematocele which was the result of temporary suppression of menstruation. 2d. A woman who supposes herself to be pregnant becomes alarmed by the development of one, two, or three sets of abnormal symptoms : (a) the occurrence of irregular, immoderate, sudden, and excessive gushes of blood ; (b) the rapid and disproportionate enlargement of the hypogas- trium ; or (c) the manifestation of a dull, grinding pain, fixed in one iliac fossa or extending thence down the thighs, and, as time passes, becoming markedly paroxysmal and spasmodic. Suspicion is thus excited, not of the existence of this vice of gestation, but of something being wrong, and a careful examination by rational and physical signs is instituted. Should such examination be made after rup- ture of the vicarious uterus, and escape of its contents into the peritoneal cavity, the ordinary physical signs of hematocele will be detected, and to their enumeration in the chapter devoted to that subject the reader is re- ferred. Physical Signs Besides the symptoms mentioned pointing to the advi- sability of a physical examination, the uterus is usually found enlarged, lifted up in the pelvis, and pressed forwards or laterally by a tumor which exists posterior to it or on one side. This tumor is found to be nearly immovable, very slightly sensitive upon pressure, and marked by a peculiar degree of hyperajmia, which gives, to an exaggerated degree, the violet hue of gestation to the vagina. It is marked by a very rapid growth, so that a week's watching will show a decided increase in its dimensions. The tumor alone would not furnish sufficient grounds upon which to found a diagnosis of ectopic gestation, but a rapidly growing pelvic tumor accompanied (a) by the gastric and mammary symptoms of pregnancy, (6) by cessation of menstruation, (c) by enlargement of the uterus, (c?) by the purple hue of the vagina, and (, Dawson's temporary, in ovari- otomy, 740 Thomas's, for securing the pedicle in ovariotomy, 741 used in removal of uterine fibroid tumors, 550 Clitoris, anatomy of, 121 Closure of the vagina, 224 (see Atresia of the vagina). Cocoyodynia, 151 anatomy, 151 Coccyodynia — causes, 152 definition, 151 diflferentiation, 151 frequency, 151 history, 151 pathology, 152 prognosis, 153 symptoms, 152 treatment, 153 Colloid degeneration of the ovary, 680 Colporrhaphy, 176 Emmet's operation, 178 "posterior," 180 Sims's operation, 177 Colpo-perineorrhaphy, Jenks's opera- tion, 203 Conception, prevention of, a cause of disease, 50 Congenital and infantile malformations of the female sexual organs, 112 physical examination of, 117 malformations of generative organs, varieties, 114 misijlacement of the uterus, 119 Constipation, habitual, a cause of dis- ease, 52 Corporeal hyi^erplasia of the uterus, 321 (see Areolar hyperjilasia of the uterus). Cup, Lente's, for fusing nitrate of silver, 287 and stem for gradual reduction of inverted uterus, 465 Cupping in amenorrhoea, 640 cervix uteri, hard rubber cylinder for, 334 Curette, dangers of, 351 -forceps, Emmet's, 351 Recamier's, 27, 350 Sims's 289 steel, 350 Thomas's wire, 350, 634 Cylinder of hard rubber for dry cupping the cervix uteri, 334 Cyst of vulvo-vaginal gland, 126 Cystic degeneration of the cervix uteri, 343 causes, 343 definition, 342 pathology, 343 prognosis, 343 synonyms, 343 treatment, 343 Cystic degeneration of the chorion, 604, 605 (see Uterine hydatids). Cysto-carcinoma of the ovary, 676 Cystocele, 172 Cysto-fibroma of the ovary, 677 Cysto-fibromata, 551 (see Fibro-cystic tumors of the uterus). Cystomata and cysts, ovarian, 682 (see Ovarian cysts and cystomata). INDEX. 791 Cysto-sarcoraa of the ovary, 677 Cysts, broad ligament, of the, 696 dermoid, of the ovary, 679 hydatid, f;97 parasitic, 697 subperitoneal, 699 DEPRESSOR, Sims's, 96 Dermoid cysts of the ovary, 679 Descent of the uterus, 381 (see Prolap- sus of the uterus). Development of the generative organs, 113 uterine, in childhood, anomalies of 119 Diagnosis, aspirator as a means of, 109 exploring needle as a means of, 109 Diagnosis of female diseases, 80 ansesthesia, 87 examination, physical, man- agement of patient during, 84 exploration, vesico-rectal, 92 manipulation, conjoined, 88, 89 inspection, 90 palpation, abdominal, 89 conjoined with use of the sound, 90 bimanual, 88 physical diagnosis, means of, 86 signs, rational, 82 speculum, 93 touch, rectal, 91 vaginal, 87 Diagnosis, imperfect, a frequent cause of unsuccessful treatment of ute- rine disease, 62 microscope as a means of, 109 of pelvic disease, recapitulation of means used in, 111 physical, means of, 86 Diaphragm, action of, in prolapsus of the uterus, 400 Dilator, Molesworth's uterine, 534 Priestley's, for constricted cervix, 616 Schultze's, for the cervix, 617 Diseases of the Fallopian tubes, 760 anatomy, 760 displacements, 765 distention, 764 inflammation of, 762 other diseases of the tubes, 765 salpingitis, 762 stricture, 763 Diseases resulting from retention and alteration of the foetal envelopes, 602 of women, predisposing causes of, 42 Displacement a primary factor in ute- rine disease, 33 Displacements of the uterus, 363 anatomy, 366 Displacements of the uterus — anteflexion, 410 anteversion, 405 camplications, 375 congenital, 373 definition, 366 etiology of, 376 flexions, causes, exciting, 378 predisposing, 378 frequency, 370 general considerations, 363 history, 363 influences exciting traction on, 377, 379 increasing weight of, 377, 378 pressing uterus out of place, 377, 379 weakening uterine sup- ports, 377, 378 pathological significance of ver- sions and flexions, 364 pathology, 372 results, 375 synonyms, 366 treatment of anterior, 413 of posterior, 438 varieties, 369 Displacements, uterine, pathological views upon, 32 Distention of Fallopian tubes, 764 Divided uterus, 118 Double uterus, 118 Drainage tube, Thomas's, 746 Dress, improprieties of, a predisposing cause of disease in women, 45 Dressing-forceps, Thomas's, 74 Dropsy, tubal, 697, 764 Dupuytren's operation for atresia vagi- nae, 229 Dysmenorrhoea, 606 pathology, 608 seat of pain in, 608 varieties of, 608 Dysmenorrhoea, congestive, 611 causes, 611 definition, 611 difi'erentiation, 612 prognosis, 612 symptoms, 612 treatment, 612 Dysmenorrhoea, inflammatory, 611 (see Dysmenorrhoea, congestive). Dysmenorrhoea, membranous, 620 definition, 620 difljerentiation, 622 etiology, 621 frequency, 622 membrane in, 624 pathology, 620 prognosis, 623 symptoms, 622 treatment, 624 Dysmenorrhoea, neuralgic, 609 792 INDEX, Dysmenorrlioea, neuralgic — causes, 609 differentiation, 609 prognosis, 610 symptoms, 609 treatment, 610 Dysmenorrlioea, obstructive, 613 causes, 613 cervical constriction, treatment of, 615 differentiation, 614 pathology, 613 prognosis, 615 symptoms, 614 treatment of cases caused by fibroids, 620 by obturator hymen, 620 by polypus, 620 dependent on flexion or version, 619 vaginal stricture, 620 Dysmenorrlioea, ovarian, 625 definition, 625 pathology, 626 prognosis, 626 symptoms, 625 treatment, 626 Dysmenorrhceal membrane, 624 1j>CRASEUR, 536 J wire-rope, Hicks's, 565 Elastic sound, Jenks's, 102 Electricity in amenorrhoca, 640 Elytro-episiorrhaphy, 405 Elytrorrhaphy, 176 inferior, 405 Emmet's treatment of laceration of the cervix uteri, 37 Endometritis, acute, 268 causes, 269 complications, 272 course, 273 differentiation, 271 duration, 273 frequency, 269 pathology, 271 physical signs, 270 prognosis, 273 symptoms, 260 synonyms, 269 termination, 273 treatment, 273 varieties, 269 Endometritis, chronic cervical, 275 anatomy of cervical mucous membrane, 276 causes, exciting, 278 XJredisposing, 277 course, 277 curette, Siuis's, in, 289 definition, 275 duration, 280 Endometritis, chronic cervical-= frequency, 275 pathology, 277 physical signs, 277 prognosis, 281 symptoms, 279 synonyms, 276 termination, 280 treatment, 281 applications, alterative. 284 emollient, 283 diseased glands, destruC' tion and ablation of, 288 general regimen, 281 villi of cervical canal, 276 Endometritis, chronic corporeal, 290 anatomy, 291 applications to uterine cavity, 298 causes, exciting, 293 predisposing, 293 complications, 298 course, 297 duration, 297 frequency, 290 ointments, use of, in, 300 pathology, 292 physical signs, 297 prognosis, 292 favorable and unfavorable, contrasted, 293 symptoms, 295 synonyms, 290 termination, 297 treatment, 298 application of alteratives (solid) to endometrium, 300 injections into the uterine cavity, 301 intra-uterine injections, dangers of, 302 Molesworth's syringe for iniecting uterine cavity, 306 substances used for intra- uterine injections, 306 Endometrium, application of alteratives (solid) to, 300 Enemata, stimulating, in amenorrhoea, 641 Enterocele, 173 Eijisio-perineorrhaphy, 405 Episiorrhaphy, 405 Epithelioma, vegetating, 583 Erroneous prognosis a frequent cause of failure in treating uterine disease, 62 Eruptive diseases of the vulva, 128 Etiology of the diseases peculiar to wo- men, 41 Examination, physical, management of patient during, 84 INDEX, 793 Excessive development of tlae nervoiis system a predisposing cause of dis- eases of women, 44 Exciting causes of diseases of women, tabulation of, 54 Exercise and physical develo].iment, neglect of, a predisposing cause of diseases of women, 43 Exploring needle, as a means of diag- nosis, 109 External organs of generation, tumors of, 154 Extirpation of the uterus, 545 cases, 546 methods of removal, 548 operation, Pean's, 548 Schrceder's, 549 Thomas's, 549 statistics, 547 Extra-uterine pregnancy, 765 cases, 770 death, causes of, 768 definition, 766 diiferentiation, 769 etiology, 766 pathology, 767 physical signs, 769 prognosis, 771 rupture, approaching, symp- toms of, 771 symptoms, 768 synonyms, 766 table of cases, 772 treatment, 773 varieties, 766 FAILURE of successful treatment in uterine diseases, reasons for, 61 Fecal fistulse, 265 (see Fistulse, fecal). Female physicians, 38 Fever-cot, Kibbee's, 752, 753 Fibre cell of fibro-cystic tumors, 556 Fibro-cystic tumors of the uterus, 551 course, 557 definition, 551 differentiation, 554 duration, 557 fibre cell characteristic of, 556 frequency, 551 pathology, 552 physical signs, 554 prognosis, 557 symptoms, 554 synonyms, 551 termination, 557 treatment, 557 Fibroid, submucous, 560 Fibroids causing obstructive dysmenor- rhoea, 620 Fibroid tumors of the uterus, 519 Atlee's views on surgical treat- ment of, 533 avulsion, 537 Fibroid tumors of the uterus — cases illustrating removal by the "spoon-saw," 541, 542 causes, 523 clamp, Thomas's, used in re- moval of, 550 complications, 523 course, 527 curative medicinal means, 529 surgical procedures, 532 Cutter's treatment of, 532 definition, 519 diagrams of cases, 542, 543 differentiation, 525 from partial inversion, 460 dilatation of the cervix uteri, 534 duration, 527 ^crasement, 536 elastic, flat whalebone probe for examining, 540 enucleation, 537 excision, 535 extirpation, plans for the, 533 forceps, Nelaton's, 535 frequency, 526 Hildebrandt's method of treat- ment, 530 history, 519 laparotomy in, 545 Molesworth's dilators, 534 oophorectomy in, 551 operation, Pean's, 548 Schroeder's, 549 Thomas's, 549 Paquelin's thermo-cauteryused in incising tlie cervix in, 535 patliology, 520 physical signs, 524 polyptome, Aveling's, 535 prognosis, 526 removal, methods of, 548 sloughing, production of, 538 "spoon-saw," Thomas's, 539 statistics, 547 symptoms, 524 synonyms, 519 termination, 527 treatment, 528 uterine fibroma, 522 varieties, 522 Fibroma of the ovary, 675 Fibrous polypus, 560 tumors of the ovary, 675 Fistula, perineo-vaginal, 267 peri toueo- vaginal, 267 Fistulas, blind vaginal, 267 entero-vaginal, 267 Fistulse, fecal, 265 causes, 265 definition, 265 physical signs, 266 prognosis, 266 symptoms, 265 794 INDEX. Fistulse, fecal — treatment, 266 varieties, 265 Fistulse of tlie female genital organs, 233 definition, 233 varieties, 233 simple vaginal, 267 definition, 267 perineo-vaginal, 267 peritoneo-vaginal, 267 uretero-uterine, 263 uretero-vaginal, 263 Fistulse, urinary, 233 bistoury for paring edges of, 246 causes, 235, 236, 237 classes, 235 complications, 238 edges of, bevelled, 247 elements of successful treat- ment of, 240 elytroplasty, 258 fork for adjusting sutures in, 250 fulcrum for sujiporting wire while twisting, 250 history, 239 hook for engaging needle in, 250 kolpokleisis, 260 means for obtaining a natural cure for, 244 needle forceps used for repair- ing, 248 operation, after treatment, 257 Gosset's, 241 Metzler's, 242 method of uniting edges, 256 Simon's, 252 Sims's, 246 physical signs, 238 prognosis, 238 requiring special treatment, 261 scissors curved for paring edges of, 246 sinuses, long, tortuous, capil- lary, remaining after opera- tion, treatment of, 654 Sims's catheter used in, 251 sutures, mode of twisting, 250 twisted, 251 symptoms, 237 treatment, 245 by cauterization, 244 by sutures, 245 operation, Sims's, 246 approximating edges and se- curing sutures. 250 paring edges of fistula, 246, 247 passing sutures, 248,^249 Fistulse, urinary, operation — preparation of the patient, 245 vivifying edges of, 254, 255 uretero-uterine, 263 uretero-vaginal, 263 urethro-vaginal, 234 vagina, closure of, 259 obliteration of, 260 vesico-uterine, 234, 261 vesico-utero-vaginal, 234, 262 vesico-vaginal, 233 with extensive destruction of the base of the bladder, 262 Fistulse, vesico-uterine, 261 vesico-utero-vaginal, 262 with extensive destruction of the base of the bladder, 262 Flexion of the uterus, influences caus- ing, 378, 379 (see Displace- ment of the uterus, 363) pathological significance of, 364 varieties, 380 Foetal envelopes, diseases resulting from retention and alteration of, 602 Follicular degeneration of the cervix uteri, 342 (see Cystic degeneration of the cervix uteri). Follicular vulvitis, 124 (see Vulvitis, follicular). Food, insufficient, a cause of disease, 51 Foi'ceps, Nelaton's, 536 Fossa navicularis, anatomy of, 121 Fungosities, uterine, 346 causes, 347 course, 348 curette, dangers of, 351 definition, 346 duration, 348 frequency, 346 history, 346 pathology, 347 physical signs, 348 prognosis, 349 results, 349 symptoms, 347 synonyms, 346 termination, 348 treatment, 350, 634 Fungous degeneration of the uterine mucous membrane, treatment of, 634 GALVANIC pessary, 641 Galvano-caustic battery, Byrne's 655 Generative organs, development of, 113 Genital track, atresia of, and retention of menstrual blood, 220 " Genu-pectoral" position, 441 Gland, vulvo-vaginal, cyst and abscess of, 126 Glands, Nabothian, 276 INDEX. 795 Glandular polypus, 559 Gonorrhoea, 215 causes, 215 complications, 218 definition, 215 ditferentiation, 216 duration, 217 pathology, 215 physical signs, 216 symptoms, 216 terminations, 217 •' Granular cell" of Drysdale in ovarian fluid, 690 Granular degeneration of the cervix uteri, 337 causes, exciting, 337 predisposing, 337 course, 339 definition, 337 duration, 339 frequency, 337 patliology, 339 physical signs, 339 prognosis, 339 symptoms, 338 treatment, 339 Granular and cystic degeneration of thf cervix uteri, 336 vaginitis, 218 Growths, intra-uterine, ascertained by the sound, 100 Gynecology, historical sketch of, 17 list of journals devoted to, 40 desirable works upon, 39 therapeutic resources of, 66 diet, 66 exercise, 66 pessaries, 67 precautions for preventing sep- ticaemia and pyaemia in ope- rations, 70 tampon, 77 temperature, means of control- ling, 78 vaginal injections, 74 HABITUAL constipation a cause of disease, 52 Haematocele, pelvic, 509 (see Pelvic haematocele). peritoneal, 513 pudendal, 131 causes, 133 definition, 131 development, 133 natural course, 134 pathology, 132 prognosis, 133 symptoms, 133 treatment, 134 subperitoneal, 513 Hemorrhage, pudendal, 130 causes, 131 Hemorrhage, pudendal — symptoms, 131 treatment, 131 Hernia, pudendal, 134 anatomy, 134 causes, 135 definition, 135 symptoms, 135 treatment, 135 recto-vaginal, 172 vaginal, 173 supplementary support in, 175. surgical procedures, 175 treatment of, 173 Historical sketch of gynecology, 17 Hunter's speculum, 97 Hydatids, uterine 604 (see Uterine hy- datids). Hydrocele, 136 anatomy, 136 definition, 136 difi"erentiation , 137 frequency, 136 pathology, 136 treatment, 138 Hygiene and general management, in- attention to, a cause of failure in treat- ing uterine disease, 64 Hymen, anatomy of, 122 causing atresia vaginae, 228 imperforate, causing distention of vagina by retained blood, 224 obstructive dysmenorrhcea, treat- ment of, 620 Hyperaesthesia of the vulva, 145 causes, 146 definition, 145 diS'erentiation, 146 frequency, 145 pathology, 145 symptoms, 146 treatment, 146 Hyperplasia, areolar, of the uterus, 307 (see Areolar hyperplasia of the uterus), cervical, of the uterus, 321 Hysterotome, Simpson's, 617 Stohlman's, 618 White's, 618 IMPERFECT diagnosis in uterine dis- eases, a frequent cause of failure is their treatment, 62 Inflammatory ulceration of the uterus, 29 Injections, intra-uterine, dangers of, 302 in endometritis, 301 vaginal, 74 Inspection, a means of diagnosis, 90 Insufficient food as a cause of disease among women, 51 Intestines, prolaj^se of, 173 Intra-uterine injections, dangers of, 302 796 INDEX. Intra-nterine injections — important facts connected witli, 305 substances used for, 30(! Inversion of the uterus, 453 anatomy, 454 amputation of the uterus for, methods of, 471 objections to, 472 causes, exciting, 456 predisposing, 45(5 complete, 453 course, 460 cup and stem for gradual re- duction, 465 definition, 453 differentiation, 459, 460 duration, 460 elastic pressure by vaginal water-bag, for reducing, 466 gradual reduction by a reposi- tor, 465 methods of checking hemor- rhage in, 462 of replacing, 463 taxis in, 467 Barrier's, 469 Courtey's, 469 Emmet's, 469 Noeggerath's, 469 Thomas's, 469 White's, 470, 471 partial, 453 pathology, 454 physical signs, 459 prognosis, 461 rapid reduction by old methods of taxis, 467 reduction by a stream of cold water, 467 symptoms, 458 termination, 460 treatment, 462 resume of plans, 474 varieties, 453 [ENKS'S elastic sound, 102 ' Journals, list of, devoted to gyneco- logy, 40 KNIFE, Sims's, 431 Kolpokleisis, 260 LABIA majora, anatomy of, 121 phlegmonous inflammation of, 129 symptoms, 129 treatment, 129 Labia minora, anatomy of, 121 Lacerated perineum, dangers arising from, 166 Lacerated perineum — effects of, 165 evils arising from, 167 varieties, 186 (see also Rupture of the perineum), 182 Laceration of the cervix uteri, 352 anatomy, 353 bilateral, 356 causes, 354 definition, 352 denuded, 360 differentiation, 358 Emmet's operation for repair of, 37 frequency, 352 history, 352 pathology, 353 physical signs, 355 prognosis, 359 resialts, 358 "stellate," 357 sutures passed in operation for, 361 twisted in operation for, 362 symptoms, 355 synonyms, 353 treatment, 359 unilateral, 357 varieties, 353 Latero-flexion, 452 Leucorrhoea, 642 cervical, microscopical appearance of, 645 definition, 642 frequency, 642 history, 642 pathology, 643 prognosis, 645 results, 645 synonyms, 642 treatment, 646 vaginal, microscopical appearance of, 644 varieties, 643 MALFORMATIONS, congenital and in- fantile, of the female sexual organs, 112 Mamma, cancer of, stroma and cells, 576, 577 Management, general and hygiene, in- attention to, a cause of failure in treat- ing uterine disease, 64 Manikin figure for teaching diagnosis, 112 Manipulation, conjoined, 88, 89 Marriage with existing uterine disease a cause of disease, 51 Means used in diagnosis of pelvic dis- eases, 111 of retaining position of uterus after anterior displacements, 417, 418> 419 INDEX. 797 Menopause a cause of ameuorrhoea, 638 Menorrhagia, 628 causes, 629 definition, 628 differentiation, 631 frequency, 628 patliology, 628 prognosis, 632 results, 632 treatment, 632 curative, 633 Menstrual blood, retention of, etc., 220 Menstruation, imprudence during, a pro- lific source of disease among wo- men, 47 tardy, differentiated from amenor- rlioea, 638 Metalbumen, test for, 687 Metritis, chronic parenclxymatous, 307 (see Areolar hyperplasia of the litems). Metrorrhagia, 628 causes, 629 definition, 628 differentiation, 631 frequency, 628 pathology, 628 prognosis, 632 results, 632 treatment, 632 curative, 633 Microscope as a means of diagnosis, 109 Misplacement (congenital) of the uterus, 119 Moles, uterine, 602 (see Uterine moles). Molesworth's cervical dilators, 534 Mucous membrane, cervical, anatomy of, 276 Myo-fibromata, 519 (see Fibroid tumors of the uterus). NABOTHIAN glands, 276 Neck of the uterus, amputation of, 652 (see Amputation of the neck of the uterus). Needle-forceps used in repairing urinary fistulse, 249 Needle used in repairing urinary fistulse. 249 Neglect or non-recognition of injuries following parturition, a frequent cause of disease in women, 50 Nelaton's forceps for removal of uterine fibroids, 535 Neurasthenia, Weir Mitchell's treatment for, 330 Non-recognition or neglect of injuries due to partxirition a frequent cause of disease among women, 49 Nott's speculum, 97 rFDEMATOUS elongation with pro- \£j lapse of the neck of the uterus, 390 Ointments, use of, in chronic corporeal endometritis, 300 Oophorectomy, 756 estimate of operation, 759 history, 756 indications, 757 means of treatment of uterine fibroids, as a, 551 methods of operating, 758 names of operators, 758 results, 757 synonyms, 756 tlaeory of operation, 756 Ovarian apoplexy, 663 definition, 663 prognosis, 664 symptoms, 664 treatment, 664 Ovarian cysts and cystomata, 682 aspii-ation in, 715 broad ligaments, cysts of, 696 causes, 691 chemical constituents of fluid from, 686 conditions likely to complicate, 695 simulating, 705 contents of, 686 cure, spontaneous, of, 694 death, methods by which pro- duced, 695 diagnosis, rules for, 721 differentiation from abnormal thickness or tension of the abdominal walls, 706 from cystic disease of other parts of the abdomen, 709 from diseased states of the pelvic walls and areolar tissue, 712 fi'om distention of abdomi- nal viscera, 706 trom excessive development or displacement of other viscera, 711 from fluid peritoneal accu- mulations, 707 from fibrocyst, uterine, 710 from pregnancy, 711 diseased conditions affecting, 694 "does a tumor exist ?" 701 explorative incsion in, 720 fluid, microscopical appearance of, 688, 689 "granular cell" of Drysdale, 690 hydatid cysts, 698 "is the tumor ovarian ?" 702 meltalbumen, test for, 687 798 INDEX. Ovarian cysts and cystomata — microscopical investigations of Noeggerath, 685 natural liistory of, C93 paralbumen, test for, 687 pathological processes in, gene- ration of, 683 pedicle in, long, 713 short, 714 twisted, 714 physical exploration, means of, 702 signs, 701 spinal cord, cysts connected with, 699 subperitoneal cysts, 699 symptoms, 699 table showing conii^arative fre- quency of affection of right and left ovary, 686 tapping in, 716 through abdomen, 718 through vaginal wall, 719 treatment, 721 tubal dropsy, 697 Ovarian disease a cause of symptoms of uterine disease, 33 fluids, microscopical appearance of, 688 Ovarian tumors, 672 carcinoma, 673 colloid, 680 cysto-carcinoma, 676 cysto-flbroaia, 677 cysto-sarcoma, 677 dermoid cysts, 679 fibroma, 675 malignant, symptoms of, 674 table of, 673 Ovaries, absence of, 660 and rudimentary development of, 115 state of, 119 atrophy of, 662 Ovaries, diseases of, 656 absence of, 660 anatomy, 658 atrophy of, caiises, 662 treatment, 663 development, imperfect, of, 660 treatment of, 661 displacement of, 664 treatment, 665 history, 656 ovarian apoplexy, 663 (see Ova- rian apoplexy), ovaritis, 665 definition of, 665 treatment of, 665 acute, 666 (see Ovaritis, acute), chronic, 669 (see Ovaritis, chronic) . Tilt's views upon, 34 Ovaries, diseases of— varieties, 660 Ovariotomy, 722 abdominal, 733 conditions favorable to operation, 728 unfavorable, 730 dangers, 727 definition, 722 "fever cot," Kibbee's, afterj 752, 753 history, 722 injections, antiseptic, after, 750 operation, after-treatment, 747 steps of, 734 applying antiseptic dress- ing, 746 cleansing peritoneum, 744 closing abdominal wound, 746 drainage (if necessary), es- tablishing, 745 incision through abdominal walls, 734 removal of sac, 738 securing pedicle, 740 tapping tumor, 737 peritonitis after, 751 septicaemia following, 748 methods of avoiding, 748 statistics, 728 sutures, removal of, after operation, 755 temperature ajfter, 749 vaginal, 731 varieties, 727 Ovaritis, 665 definition, 665 varieties, 665 Ovaritis, acute, 666 causes, 668 differentiation, 668 prognosis, 668 symptoms, 668 treatment, 668 Ovaritis, clironic, 669 prognosis, 671 signs, physical, 670 i-ational, 670 treatment, 671 Ovary, carcinoma of, 673 colloid degeneration of, 680 cysto-carcinoma of, 776 cysto-fibroma of, 677 cysto-sarcoma of, 677 cysts (dermoid) of, 679 fibroma of, 675 fibrous tumors of, 675 PALPATION, abdominal, 89 conjoined with the use of ihe sound, 90 bimanual, 88 INDEX. 799 Papillae, filiform, of the vagina, 212 Paquelin's thermo-cautery, 149, 535 Paralbumen, test for, 687 Parturition, imprudence after, a frequent cause of disease among women, 48 Pathological views of uterine disorders, 29 displacements, 32 Pathology and treatment, uterine, gen- eral considerations upon, 54 Plan's operation for removal of uterine fibroid tumors, 548 Pelvic abscess, 502 causes, 502 closure of sac, means for caus- ing, 508 course, 503 definition, 502 diflTerentiation, 503 duration, 503 evacuation, best point for, 507 operating, methods of, 507 pathology, 502 physical signs, 503 prognosis, 504 puncture per vagina, 507 routes for discharge of, 503 sac, means of closure of, 507 symptoms, 502 termination, 503 treatment, 504 Pelvic hematocele, 509 causes, 512 course, 516 definition, 509 difl'erentiation, 515 duration, 516 frequency, 510 history, 509 operating in, methods of, 518 pathology, 510 peritoneal, 513 physica' signs, 515 prognosis, 516 reflux of blood from the uterus, 511 rupture of bloodvessels in the pelvis, 510 of pelvic viscera, 511 subperitoneal, 513 symptoms, 514 synonyms, 509 termination, 516 transudation from bloodvessels, 511 treatment, 517 varieties, 512 Pelvic peritonitis, 487 cases, chronic, treatment of, 500 causes, 491 course, 496 definition, 487 differentiation, 476 Pelvic peritonitis — diiration, 496 evacuation of pus and serum, modes of, 501 frequency, 490 history, 478 importance of differentiation from pelvic cellulitis, 498 pathology, 490 physical signs, 495 prognosis, 498 results, 498 "roof of the pelvis," 490 symptoms, 493 termination, 496 treatment, 498 varieties, 493 Pelvis, roof of the, 490 Percussion and auscultation as a means of diagnosis in pelvic disease. 111 Perineal body, 158, 182 anatomy, 183 descent of rectal and vesical walls after destruction of, 419 diagrams of, 160, 161, 163, 183, 184 surgical means for the restora- tion of, 182 Perineal laceration, 187 causes, 187 natural history of, 187 operation, denudation for repair of, 194 diagrams of "triangle" to be united, 195 first part of, 192 instruments and appliances needed for, 191 preparation of the patient, 191 schematic view of part to be denuded, 193 for complete, 198 denuded surface and sutures (diagram of) 201 diagrams, 198, 199, 200 rules to be observed in, 201 for partial, 192 dentist's "burr" used in, 196 method of securing ends of sutures, 198 profile view of recently closed perineum and sutures, 198 surface denuded and sutures in position (diagrams), 197 prognosis, 187 time for operation, 188 800 INDEX, Perineal laceration — treatment of cases which have cicatrized, 190 varieties, 186 Perineal support in prolapsus of the ute- rus, 404 Perineorrhaphy in cases of prolajisus of the uterus, 404 Perineum, 154 anatomy, 154 diagram of, 156 functions of, 159 physiology of, 159 improperly repaired, 185 Perineum, laceration of, 165 dangers arising from, 166, 167 effects, 165 varieties, 186 Perineum, profile view of, 192 rupture of, 165 subinvolution of, 164 Peritoneal hematocele, 513 Peritonitis, pelvic, 487 (see Pelvic peri- tonitis). Periuterine cellulitis, 475 anatomy, 476 causes, 481 complications, 477 consequences, 485 course, 480 definition, 476 ditferentiation, 484 duration, 480 frequency, 476 history, 475 pathology, 477 physical signs, 483 prognosis, 481 symptoms, 482 synonyms, 476 termination, 480 treatment, 485 Pessaries in anterior displacements of the uterus, 420, 421, 422, 423, 425, 428, 429 in prolapsus of the litems, 401 Pessary, Albert Smith's, 446 Campbell's soft-rubber, spring-stem, 429 Cutter's " T," for anterior displace- ments, 423 prolapsus, 403 modification of, with cervical rest, for posterior displace- ments, 451 retroversion, 449 elastic bulb, 447 Fowler's, for anterior displacements, 425 galvanic, 461 Hewitt's, 448 anteversion, 424 Hodge's closed lever, 445 Pessary — HoflFman's inflated soft-rubber, for posterior displacements, 444 Kurd's, 447 intra-uterine stem for anteflexion, 428 glass stem for anterior displace- ments, 428 latero-flexion, for, 452 Meigs's elastic ring, 447 retroflexion, with cervical rest, 451 Thomas's anteversion, with fixed projection, 442 elastic, for antei-ior displace- ments, 422 modification of Cutter's, 403, 423 for posterior disjilace- ments, 449 retroflexion, 446 Phlegmonous inflammation of the labia majora, 129 symptoms, 129 treatment, 129 Physical signs of uterine disease, 59 Polypi, uterine, 558 (see Uterine polypi) Polyptome, Aveling's, 535 Simpson's, 564 Polypus, causing obstructive dysmenor- rhoea, treatment, 620 cellular, 559 fibroid, 560 glandular, 559 differentiation from inverted uterus, 459 Position, "genu-pectoral," 441 of i^atient for introducing Sims's speculum, 99 Posterior disijlacements of the uterus, 432 causes, exciting, 434 predisposing, 434 consequences of, 438 definition, 432 dift'erentiation, 437 forces api:)lied in reduction, 450 frequency, 432 "genu-pectoral" position, 441 Hoffman's inflated soft-rubber pessary in, 444 means of retaining uterus in position, 442 methods of reduction, 438 pessaries, 444, 445, 446, 447, 448, 449, 451 physical signs, 437 prognosis, 438 retroversion, degrees of, 436 Sims's uterine repositor, 440 symptoms, 436 tampon in, 443 treatment, 438 varieties of retroversion, 435 INDEX, 801 Posture, recumbent, in prolapsus of the uterus, 398 Pregnancy, extra-uterine, 765 (see Ex- tra-uterine i^regnancy). Primary pathological conditions produc- ing utering disease, 57, 58 Probe, Budd's elastic, 286 Lente's silver caustic, 287 silver, Sims's, for aj^plying medi- cated cotton to cervix uteri, 288 Thomas's flat elastic whalebone, 540 Probing the uterus, method of, 101 Prognosis, erroneous, a frequent cause of failure in treating uterine disease, 62 in uterine affections, 60 Prolapse of the bladder, 172 of the intestines, 173 Prolapsus urethrae, 150 treatment, 150 Prolapsus of the uterus, 381 acute, 394 anatomy, 382 astringents in the treatment of, 398 causes, 383 complications, 393 course, 390 definition, 381 diagrams of, in the three de- grees of, 383 diaphragm, action of the, in, 400 differentiation, 392 duration, 390 episiorrhaphy for, 405 frequency, 381 means to diminish uterine weight, 398 to prevent pressure from above, 397 to prevent traction by the vagina, 404 to strengthen or supple- ment uterine supports, 398 methods of replacing, 394 of sustaining, 395 cedematous elongation, with prolapse of the neck, 390 pathology, 385 perineal support, 404 perineorrhaphy, 404 pessaries, 401 physical signs, 392 posture, recumbent, in, 398 prognosis, 392 sudden, 394 symptoms, 391 synonyms, 381 termination, 390 tonics in the treatment of, 398 treatment, 394 varieties, 383 51 Prolapsus of the vagina, 168 causes, 170 course, 171 definition, 167 duration, 171 pathology, 170 prognosis, 171 symptoms, 171 synonyms, 169 treatment, 171 varieties, 171 Pruritus vulvae, 138 causes, exciting, 140 predisposing, 139 course, 138 definition, 138 development, 138 pathology, 138 treatment, 141 Pubo-coccygeus muscle, 204 Pudendal hematocele, 131 causes, 133 definition, 131 development, 133 history, 132 natural course, 134 pathology, 132 prognosis, 133 symptoms, 133 .treatment, 134 Pudendal hemorrhage, 130 causes, 131 symptoms, 131 treatment, 131 Pudendal hernia, 134 anatomy, 134 causes, 135 definition, 135 symptoms, 135 treatment, 135 Purulent vulvitis, 122 (see Vulvitis, purulent). Pyaemia and septicaemia, precautions against, in operations, 70 REASONS for the frequency of failure in the treatment of uterine diseases, 61 Recamier's speculum, 25 Recapitulation of means used in diag- nosis of pelvic disease. 111 Rectal touch, 91 Rectocele, 172 Recto-vaginal hernia, 172 Rectum, prolapse of, 172 Relation between uterine disease and constitutional depreciation, 31 Retroflexion of the uterus, 432, 433 (see Posterior displacements of the uterus). Retroversion of the uterus, 432, 433 (see Posterior displacements of the uterus). Rod for making applications to cervix uteri, 285 802 INDEX. Rudimentary state and absence of the ovaries, 119 of the vagina, 119 Rules for the introduction of tents, 108 SALPINGITIS, 762 Sarcoma of the uterus, 566 causes, 569 course, 570 definition, 567 differentiation, 570 duration, 570 frequency, 567 history, 566 pathology, 567 phj'sical signs, 569 prognosis, 570 symptoms, 569 synonyms, 567 termination, 570 treatment, 570 Scarificator, Bnttle:5's spear-pointed, 333 Schroeder's operation for removal of ute rine fibroid tumors, 549 Scissors, sharply curved, Emmet's, 192 slightly curved, 191 Scoop, Simon's, for removing cancer, 595 Screw for removing tampon, Sims's, 78 Sea-tangle tents, 103 advantages of, 104 Septicaemia and pyaemia, precautions against, in operations, 70 Sigmoid catheter, Sims's, 251 Signs, physical, of uterine disease, 59 Simon's operation for urinary fistulae, 252 advantages of, 254 position of patient in, 253 Sims's operation for urinary fistulae, 246 speculum, 37 advantages of, 37 an era in gynecology, 35 (and varieties of) introduction of, 98 position of patient in introduc- tion, 99 Sinuses, treatment of long, tortuous, capillary, remaining after operation, 264 Skirt sui^porter, 397 Sound, uterine, as a means of diagnosis, 100 difficulties and dangers attend- ing its use, 100 facts ascertained by, 100 Jenks's elastic, 102 Jennison's, 415 method of introduction, 100 passage of, in amenorrhoea, 640 Simpson's and Sims's, con- trasted, 101 used by tin; ancients, 24 Specula, ancient, 23 valvular and cylindrical, method of introduction, 98 Speculum, bivalve, 23 Cusco's, 94 Fergusson's, 93 Howard's modification of Cusco's, 95 Hunter's, 97 invented by Recamier, 25 mentioned by ancient writers, 24 Neugebauer's, 95 Nott's, 97 Sims's, 96 advantages of, 37 an era in gynecology, 35 (and varieties of) introduction of, 98 Thomas's modification of, 97 Thomas's telescopic, 94 trivalve, 23 Wylie's cervical, 299 Spinal cord, cysts connected witli, 699 Sponge-holder, Sims's, 247 Sponge-tents, 103 Spoon-saw, Thomas's, for removal ol uterine fibroids, 539 Sterility, 648 causes, 648 definition, 648 diflTerentiation, 651 history, 648 prognosis, 651 results, 651 synonyms, 648 , treatment, 651 Stricture of Fallopian tubes, 763 Subperitoneal hematocele, 513 Symptoms of uterine disease dependent on ovarian disease, 33 Syphilitic ulcer of the cervix uteri, 344 course, 345 differentiation, 345 frequency, 344 termination, 345 treatment, 345 Syringe, Davidson's, 76 for dry cupping the cervix, 640 for removing cervical mucus, 284 Molesworth's double canula and bulb for injecting the uterine cavity, 306 vaginal, nozzle with revei'se cur- rent, 76 TABLE, gvnecological, Thomas's, 85, 86 Tampon, 77 in posterior displacements of the uterus, 443 Taxis, old methods for replacing inverted uterus, 467 Taxis, rapid reduction of inversion of uterus by, INDEX. 803 Taxis, rapid reduction of inversion by — Barrier's method, 469 Courty's method, 469 Emmet's method, 469 Noeggerath's method, 469 Thomas's method, 469 White's method, 470, 471 Tenaculum for fixing the uterus, 106 Tent, Wallace's spring, 416 Tents, 102 dangers of using, 106 in amenorrhoea, 640 metliod of introduction, 105 rules for the introduction of, 108 sea-tangle, 103 sponge, 103 tupelo, 105 Therapeutic resources of gynecology, diet and exercise, 66 pessaries, 67 precautions for preventing sep- ticaemia and pyaemia in ope- rations, 70 tampon, 77 temperature, means of control- ling after operation, 78 vaginal injections, 74 Therapeutics, inefficient or inapi:)ro- priate, a cause of failure in treating uterine disease, 62 Thermo-cautery, Paquelin's, 149 incision of the cervix uteri by, 535 Thomas's operation for removal of ute- rine fibroid tumors, 549 Tight bandaging a cause of disease among women, 48 Tilt's views on ovarian disease, 34 Tonics, in the treatment of prolapsus of the uterus, 398 Toothed forceps, Thomas's, 191 Trivalve speculum, 23 Trocar and canula, Emmet's, for tapping cysts, 737 for tapping ovarian cysts, 719 Tubal dropsy, 697, 764 Tumors of the external organs of gene- ration, 154 Tumors, fibrocystic, of the uterus, 551 (see Fibrocystic tumors of the uterus), fibroid of the uterus, 519 (see Fibroid tumors of the uterus). ovaria,n, 672 (see Ovarian tumors), uterine, diiferentiation of, from dis- placements, by the use of the sound, 100 Tupelo tents, 105 ULCER, syphilitic, of the cervix uteri, 344 (see Syphilitic ulcer of the cervix uteri). Ulcers of the uterus, Astruc on, 26 Ulcerations of the uterus, cancerous, 29 Ulcerations of the uterus — inflammatory, 29 Unicorn uterus, IIS Urethrse, prolapsus, 150 treatment, 150 Urethral caruncle, irritable, 147 causes, 147 course, 148 differentiation, 148 duration, 148 pathology, 147 physical signs, 148 prognosis, 148 treatment, 148 Urethral venous angioma, 150 Urethro-vaginal fistulse, 234 Urinary fistulas, 233 (see Fistulae, uri- nary). Uteri, cervix, cystic degeneration of, 342 causes, 343 definition, 342 pathology, 343 prognosis, 343 synonyms, 343 treatment, 343- Uteri, cervix, granular degeneration of, 337 causes, exciting, 337 predisposing, 337 course, 339 definition, 337 duration, 339 frequency, 337 pathology, 339 physical signs, 339 prognosis, 339 symptoms, 338 treatment, 339 Uteri, cervix, laceration of, 352 (see Laceration of the cervix), syphilitic ulcer of, 344 (see Syphi- litic ulcer of the cervix). Uterine adenoma, 570 (see Sarcoma of the uterus), atresia at os externum, 223 at OS internum, 223 in one half of a double uterus, 223 canal, deviations of, determined by the sound, 100 cancer, 571 (see Cancer of the ute- rus), cavity, applications to, in chronic corporeal endometritis, 298 injections into, in chronic cor- poreal endometritis, 301 development in childhood, anoma- lies of, 119 disease in its relations to constitu- tional depreciation, 31 physical signs of, 59 primary pathological conditions causing, 57, 58 prognosis in, 60 804 INDEX. Uterine — disorders, diflFerent pathological views on, 29 displacements, differentiation from tumors by the sound, 100 pathological views upon, 32 primary factors in uterine dis- ease, 33 fibromata, 522 fungosities, 346~(see Fungosities, uterine), hydatids, 604 causes, 605 definition, 604 differentiation, 606 pathology, 604 physical signs, 605 prognosis, 606 symptoms, 605 synonyms, 604 treatment, 506 moles, 602 causes, 603 definition, 602 ditt'ereutiation, 603 history, 602 pathology, 602 physical signs, 603 prognosis, 604 symptoms, 603 treatment, 604 pathology and treatment, general considerations upon, 54 polypi, 558 causes, 560 cellular, 559 complications, 562 course, 562 definition, 558 difi'erentiation, 561 ^craseur, Hicks's wire rope, 565 fibrous, 560 glandular, 560 history, 558 pathological anatomy, 559 physical signs, 561 polyptome, Aveling's, 535 Simpson's, 564 prognosis, 562 symptoms, 560 termination, 562 treatment, 562 curative, 563 palliative, 563 varieties, 558 repositor, Elliot's, 415 Sims's, 440 sarcoma, 566 (see Sarcoma of the uterus), sound, difficulties and dangers at- tending the use of, 100 facts ascertained by, 100 means of diagnosis, as a, 100 Uterine sounds method of introduction, 100 Simpson's and Sims's con- tracted, 101 used by the ancients, 24 Uterus, ablation of, 545 (see Ablation of the uterus). absence and rudimentary develop- ment of, 115 amputation of the neck of, 652 (see Amputation of the neck of the uterus). anteflexion of the, 410 (see Ante- flexion of the uterus). anteversion of the, 405 (see Ante- version of the uterus). areolar hyperplasia of, 307 (see Are- olar hyperplasia of the uterus). atresia of, 221 (see Atresia oi the uterus). axes of the, in anteflexion, 411, 430 bicorn, 118 cancer of the, 571 early views on, 26 capacity of, ascertained by use of the sound, 100 congenital misplacement of the, 119 divided, 118 double, 118 extirpation of the, 545 for cancer, 598 inflammation of, J. H. Bennet's views on, 28 inflammatory ulcerations of, 29 inversion of, 453 (see Inversion of the uterus). method of probing, 101 mobility of, determined by the sound, 100 natural position of, 366, 368 pathological significance of versions and flexions of the, 364 prolapsus of the, 381 (see Prolapsus of the uterus). retroflexion of the, 432, 433 (see Posterior displacements of the uterus). retroversion of the, 432, 433 (see Retroversion of the uterus). ulcers of the, Astruc on, 26 unicorn, 118 Uterus and ovaries, absence and rudi- mentary development of, 115 and vagina, distended with blood from imperforate hymen, 224 rAGINA, absence and rudimentary state of, 119 anatomy of, 211 atresia of, 224 (see Atresia of the vagina), closure of, treatment for, 229 INDEX, 806 Vagina — distended by blood from imperforate hymen, 224 filiform papillse of, 212 prolapsus of, 168 causes, 170 course, 171 definition, l(i7 duration, 171 pathology, 170 prognosis, 171 symptoms, 171 synonyms, 169 treatment, 171 varieties, 171 transverse section of. If' 7 Vagina and uterus distended with blood from imperforate hymen, 224 Vaginal dilator, Sims's, 207 hernise, supplementary support in, 175 surgical procedures, 175 leucorrhcea, microscopical appear- ance of, 644 ovariotomy, 731 prolapse, treatment of, 174 Vaginal stricture, treatment of, 620 touch, 87 water-bag for elastic pressure in inverted uterus, 466 Vaginismus, 203 anatomy, 204 causes, 205 course, 206 definition, 203 differentiation, 206 duration, 206 frequency, 203 history, 204 operation, Sims's, 209 Burns's, 210 pathology, 204 , physical signs, 206 prognosis, 206 symptoms, 206 treatment, 207 Vaginitis, 211 anatomy of vagina, 211 definition, 211 epithelium in, 214 granular, 218 causes, 219 definition, 219 pathology, 218 symptoms, 219 synonyms, 218 treatment, 219 simple, 212 causes, 213 complications, 215 definition, 212 differentiation, 215 pathology, 213 physical signs, 214 Vaginitis, simple — symptoms, 214 specific, 215 causes, 215 complications, 218 definition, 215 diflerentiation, 216 duration, 217 pathology, 215 physical signs, 216 symptoms, 216 termination, 217 synonyms, 211 treatment of, 219 varieties, 212 Valvular and cylindrical specula, method of introduction, 98 Venous angioma, urethral, 150 Versions of the uterus, pathological sig- nificance of, 364 Vesico-vaginal fistulse, 233 (see Fistulae, urinary). Vesico-uterine fistulse, 234 Vesico-utero-vaginal fistulse, 234 Vestibule, anatomy of, 121 Villi of canal of cervix uteri, 276 Vulva, diseases of, 121 eruptive diseases of, 128 treatment, 129 hypersesthesia of, 145 causes, 146 definition, 145 difi'erentiation, 146 frequency, 145 pathology, 145 symptoms, 146 treatment, 146 Vulvae, pruritus, 138 causes, exciting, 140 predisposing, 139 course, 138 definition, 138 development, 138 pathology, 138 treatment, 141 Vulvitis, definition, 122 follicular, 124 causes, 124 course, 125 definition, 124 duration, 125 i:)hysical signs, 125 symptoms, 125 synonyms, 124 treatment, 125 purulent, 122 causes, 123 course, 123 symptoms, 123 termination, 123 treatment, 123 varieties of, 122 Vulvo-vaginal glands, abscess and cyst of, 126 806 INDEX, Vnlvo- vaginal glands — anatomy of, 126 inflammation of, 127 causes, 127 course, 127 diflferentiation, 127 duration, 127 symptoms, 127 treatment, 127 WAIST for supporting skirts, 397 Water-bed, Kibbee's 752, 753 Water, stream of cold, for replacing in- verted uterus, 467 Women, etiology of diseases peculiar to, 41 Works on gynecology, list of, 40 PLAYFAIR'S MIDWIFERY. A Treatise on the Science and Practice of Midwifery. By W. S. Playb^air, M.D., F.R.C.r., Professor of Obstetric Mediciue in King's College, London, etc. Third American edition, revised bj' the Author. Edited, with additions, by Robert P. Harris, M.D. In one handsome octavo volume of 659 pages, with 183 illustrations. Cloth, $4; leather, |5; half Russia, $5.50. If inquired of by a medical student what work on obstetrics we should recommend for him, ^jar excellence, we would undoubtedly advise him to choose Playfair's. It is of convenient size, but what is of chief impor- tance, its treatment of the various subjects is concise and plain. While the discussions and descriptions are sufficiently elaborate to render a very intelligible idea of them, yet all details not necessary for a full under- standing of the subject are omitted. — Cincin- nati Medical News, Jan. 1880. It certainly is an admirable exposition of the science and practice of midwifery. Of course the additions made by the American editor, Dr. R. P. Harris, who never utters an idle word, and whose studious researches in some special departments of obstetrics are so well known to the profession, are of great value. — The American Practitioner, April, 1880. SMITH ON CHILDREN. A Complete Practical Treatise on the Diseases of Children. By J. Lewis Smith, M.D., Clinical Professor of Diseases of Children in the Bellevue Hosj)ital Medical College, New York. Fifth edition, thoroughly revised and re- written. In one handsome octavo volume of 836 pages, with illustrations. Cloth, $4.50; leather, $5.50; very handsome half Russia, raised bands, $6. It is a pleasure to peruse such a work as the one before us, and as reviewers we have but one difficulty— there is but little to find fault with. The author understands what he writes about from a practical acquaint- ance with the diseases incident to infancy and childhood, and also thoroughly compre- hends their pathology and therapeutics. The work is full of original and practical remarks which will be particularly acceptable to the student and young physician; but at the same time we can with great sincerity com- mend it to the notice of the profession in general. — Editibiirgk Med. Journ., May, 1882. The Mother's Guide in the Management and Feeding of Infants. By John jM. Keating, M.D., Lecturer on the Diseases of Children in the University of Pennsylvania, etc. In one handsome 12mo. volume of 118 pages. Cloth, $1. Works like this one will aid the physician immensely, for it saves the time he is con- stantly giving his patients in instructing them on the subjects here dwelt upon so thoroughly and practically. Dr. Keating has written a practical book, has carefully avoided unnecessary repetition, and success- fully instructed the mother in such details of the treatment of her child as devolve upon her. He has studiously omitted giving pre- scriptions, and instructs the mother when to call upon the doctor, as his duties are totally distinct from hers. — Ainerican Journal of Obstetrics, October, 1881. ' A Manual of Obstetrics. By A. F. A. King, M.D., Professor ot Obstetrics and Diseases of Women in the Medical Department of the Columbian University, Washington, D. C, and in the University of Vermont, etc. In one very handsome 12mo. volume of 321 pages, with 58 illustrations. Cloth, $2. tome of the present state of obstetrical science. The. mechanism of labor is clearly and most exhaustively explained, and some This book may be taken as an example of the immense amount of information that can be contained within a limited number of pages, where the author writes clearly and concisely, and avoids repetition and verb- osity; and, though written for students, it will be found a convenient, useful, and re- liable work of reference for the busy practi- tioner, being an excellent, though brief, epi- very useful diagrams introduced to elucidate the text. The various operations of mid- wifery are faithfully described. As a typical student's mamial it is the best we have seen, and we most cordially recommend it. — London Medical News, October 27, 1882. HENRY a LEAS SON & CO., PHILADELPHIA. BARNES' SYSTEM OF OBSTETRICS. In Press. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. By Robert Barnes, M.D., Physician to the Greneral Lying-in Hospital, London, and Fancourt Barnes, M.D., Obstetric Physician to St. Thomas' Hospital, London. The Section on Embryology contributed by Prof. Milnes Marshall. In two handsome octavo volumes, profusely illustrated. RICHARDSON'S PREVENTIVE MEDICINE. Jast Ready. Preventive Medicine. By Benjamin Ward Ricuardson, M. A. , M. D. , LL.D., F.R.S., F.S.A., Fellow of the Royal College of Physicians, London. In one octavo volume of about 750 pages. Cloth, $4; leather, $5; very hand- some half Russia, raised bands, $5.50. THE immense strides taken "by medical science during the last quarter of a cen- tury have had no more conspicuous field of progress tlian tlie causation of dis- ease. Not only has this led to marked advance in therapeutics, but it has given rise to a virtually new department of medicine — the prevention of disease — more important, perhaps, in its ultimate results than even the investigation of curative processes. Yet, thus far, there has been no attempt to gather into a systematic and intelligible shape the accumulation of knowledge acquired on this most interesting subject. Fortunately, the task has been at last undertaken by a writer who, of all, is perhaps best qualitied lor its performance, and the result of his labors can hardly fail to mark an epoch in the histor}^ of medical science. EXCERPT FROM CONTENTS. I. — Disease as a Unity, with a variety of Plienomena. The Preventive Scheme of Medi- cine. General Diseases of Mankind. 1. Constitutional Diseases. 2. Local Diseases. 3. Diseases from Natural Accidents — Lightning — Sunstroke — Starvation — Poisons — Venoms — Poisonous Food — Pregnancy. II. — Acquired Diseases of Artificial Origin ; Phenomena and Course. 1. Acquired Diseases from Inorganic and Organic Poisons — Tea — Cofi'ee — Alcohol — Tobacco — Soot — Gases. 2. Acquired Diseases from Physical Agencies, Mechanical and General — Dusts — Pressure on Lungs — Concussions and Shocks — Muscular Overwork and Strain — Acquired Deformities — -Physical Injuries — Surgical Operations. 3. Acquired Diseases from Mental Agencies — Moral, Emotional and Habitual. Diseases from Mental Shock, from Moral Contagion — Tarantism — Suicide, from Hysterical Emotion, from Passion, from Habits of Life — Insomnia — Dementia — Sloth — Lu.xury- — Secret Immorality. III. — 1. Origins and Causes of Disease— Congenital, Hereditary or Constitutional Causes; Atmos- pheric and Climatic Causes; Parasitic Causes — Bacteria — Bacilli — Spirilla — Trichinte; Zymotic Causes; Industrial and Accidental Causes; Social and Psychical Causes; Senile Degenerative Causes. 2. Preventions of Disease. Prevention of Hereditary or Constitu- tional Diseases — Personal Rules for Pregnancy, Infancy, Adolescence, Maturity ; Preven- tion of Atmospheric and Climatic Diseases; of Parasitic Diseases — Personal Rules; of Zymotic Diseases — Contagion — Drainage — Isolation of Sick — Water and Milk Supply — Hospitals — Regi'stration— Vaccination — Other Inoculations — Legislation; Prevention of Industrial Diseases — Lead Poisoning — Dusts — Gases, etc.; Prevention of Social and Psychical Diseases — Warming and Ventilation — Light — Water — the Bed-room — Bread — Abattoirs — Schools — Sepulture — Drunkenness; Prevention of Senile Disease. LEISHMAN'S MIDWIFERY. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. By William Leishman, M.D., Regius Professor of Midwifery in the University of Glasgow, etc. Third American Edition, revised by the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather, $5.50; very handsome half Russia, raised bands, $6. HENRY a LEAS SON & CO., PHILADELPHIA. LEA BBOTHEBS &i CO.'S (Late HENRY C. LEA'S SON & CO.) CLASSIFIED CATALOGUE OF MEDICAL AND SURGICAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance of the confi- dence earned for the publications of the house by their careful selection and accuracy and finish of execution. 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All letters pertaining to the Business Department of these journals should be addressed exclttsively to Lea Brothers & Co., 706 and 708 Sansom Street, Philadelphia. MARTSSORNE, HENRY, A, M., M. !>., Lately Professor of Hygiene in the Unicersity of Pennsylvania. A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. Second edition, thoroughly revised and greatly improved. In one large royal 12mo. volume of 1028 pages, with 477 illustrations. Cloth, ^4.25 ; leather, $5.00. The object of this manual is to afford a conven- j industry and energy of its able editor. — Boston lent work of reference to students during the brief • Medical and Surgical Journal, Sept. 3, 1874. moments at their command while in attendance | We can say, with the strictest truth, that it is the upon medical lectures. 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STVDENTS' SERIES OF MANJJALS, A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following vol- umes are now ready: Gould's Surgical Diagnosis, Eobertson's Physiological Physics, Bruce's Materia Medica and Therapeutics, Power's Human Physiology, Clarke and Lockwood's Dissectors' Manual, Kalfe's Clinical Chemktry, Treves' Surgical Applied Anatomy, Fepp^eu's Surgical Pathology, and Klein's ^emewte of Histology. The following are in press : Bellamy's Operative Surgery, Bell's Comparative Physiology and Anatomy, Pepper's Forensic Medicine, and CuRNOw's Medical Applied Anatomy. For separate notices see index on last page. SERIES OF CLINICAL MANUALS, In arranging for this Series it has been the design of the publishers to provide the profession with a collection of authoritative monographs on important clinical subjects in a cheap and portable form. The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and woodcuts. The following volumes are just ready: Treves on Intestinal Obstruction; and Savage on Insanity and Allied Neu- roses; The following are in active preparation: Hutchinson on Syphilis; Bryant on the Breast; Morris on Surgical Diseases of the Kidney; Broadbent on the Pulse; BuTLiN on the Tongue; Owen on Surgical Diseases of Children; Lucas on Diseases of the Urethra; Marsh on Diseases of the Joints, Pick on Fractures and Dislocations, and Ball on the Rectum and Anus. For separate notices see index on last page. NEILL, JOHN, M, jD., and SMITH, F, G,, M. !>., Late Surgeon to the Penna. Hospital. Prof, of the Listitutes of Med. in the Univ. of Penna. An Analytical Compendium of the Various Branches of Medical Science, for the use and examination of Students. A new edition, revised and improved. In onelarge royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; leather, $4.75. LUDLOW, J.L.,M.I)., Consulting Physician to the Philadelphia Hospital, etc. A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised, and grea.tly extended and enlarged. In one handsome royal 12mo. volume of 816 large pages, with 370 illus- trations. Clpth, $3.25 ; leather, $3.75. The arrangement of this volume in the form of question and answer renders it espe- cially suitable for the office examination of students, and for those preparing for graduation. 4 Lea Brothers & Co.'s Publications — Dictionaries. Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Ofhcinai, Empirical and Dietetic Preparations, witli the Accentuation and Etymology of the Terms, and the French and other Synonymes, so as to constitute a Frencli as well as an English Medical Lexicon. Edited l)y Kichabd J. Dunglisox, M. D. In one very large and handsome royal octavo vohuue oi 1139 pages. Cloth, $6.50 ; leather, raised bands, $7.50 ; very handsome half Eussia, raised bands, $8. Tlie object of the author, Irom tJie outset, has not been to make the work a mere lexi- con or dictionary of tenns, but to afford under each word a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition "to maintain this enviable reputation. The additions to the vocabulary are more numerous than in any previous revision, and particular attention has been bestowed on the accentuation, which Avill be found marked on every M^ord. The typographical arrangement has been greatly improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The volume now contains the matter of at least four ordinary octavos. A book of which every American ought to be I work has been well known for about forty years, proud. When the learned author of the work j and needs no words of praise on our part to recom- passed away, probably all of us feared lest the book I mend it to the members of the medical, and like- should not maintain its place in the advancing ■ wise of the pharmaceutical, profession. The latter science whose terms it defines. Fortunately, Dr. ; especially are in need of a work which gives ready Richard J. Dunglison, having assisted his father in and reliable information on thousands of subjects the revision of several editions of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it as a work of the kind should be edited — to carry it on steadily, without jar or inter- ruption, along the grooves of thought it has trav- elled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and and terms which they are liable to encounter in pursuing their daily vocations, but with which they cannot be expected to be familiar. The work before us fully supplies this want. — American Jour- nal of Pharmacy, Feb. 1874. Particular care has been devoted to derivation and accentuation of terms. With regard to the , latter, indeed, the present edition may be consid- carried through, it is only necessary to state that j ©red a complete " Pronouncing Dictionary of more than six thousand new subjects have been j Medical Science." It is perhaps the most reliable added in the present edition.— P/iitadeij3/iia Medical \ work published for the busy practitioner, as it con- sumes, Jan. 3, 1874. j tains information upon every medical subject, in Av,„„+ +!,„«,.=+ K^^i- r^,-,,.„iiocori ^^,r+ll'ork, many of them being the size of nature, nearly all oi'iginal, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descrijitions at the foot. They thus form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting-room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. This well-known work comes to us as the latest | There is probably no work used so universally American from the tenth English edition. As its by physicians and medical students as this one. title indicates, it has passed through many hands It is deserving of the confidence that they repose and has received many additions and revisions, in it. If the present edition is compared with that The work is not susceptible of more improvement, issued two years ago, one will readily see how Taking it all in all, its size, manner of make-up, , much it has' been improved in that time. Many its character and illustrations, its general accur- ; pages have been added to the text, especially in acy of description, its practical aim, and its per- those parts that treat of histology, and many new spicuity of style, it is the Anatomy best adapted to ' cuts have been introduced and old ones modified, the wants of the student and practitioner. — Medical — -Tournal of the A inerican Medical Association, Sept. Record, Sept. 15, 1883. ', 1, 1883. Also for sale separate — HOLDBN, LVTHEB, F. B. C. S,, Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. Keex, M. D., Professor of Artistic A^natomy in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 14S pages. Cloth, §1.00. This little book is all that can be desired within | almost to learn it by heart. It teaches diagnosis by its scope, and its contents will be found simply in- i external examination, ocular and palpable, of the valuable to tlie young surgeon or phj'sician', .since I body, with such anatomical and physiological facts they bring before him such data as he requires at I as directly bear on the subject. It is eminently every examination of a patient. It is written in the student's and young practitioner's book.— P/iy- language so clear and concise that one ought | sician and Surgeon, Nov. 1881. TVILSON, FItAS3IUS, F, B. S. A System of Human Anatomy, General and Special. Edited by ^Y. H. GoBRECHT, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. ' S3IITH, H. JET., 31. 2>., and HOBJS^EB, W3f. E.,3I.n,, Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, $4.50. CLFLJJVD, JOSN, 31. JO., F. B. S., Professor of Anatomy and Physiology in Queen's College, Galway. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, $1.25. Lea Brothers & Co.'s Publications — Anatomy. ALLEN, SABMISOJV, M. !>., Professor of Physiology in the Unioersitij of Pennsylvania. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. "With an Intro- ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Section I. Histology. Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. Organs of Sense, op Digestion and Genito-Urinary Organs, Embryology, Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, AND General and Clinical Indexes. JilsI ready. Price per Section, each in a handsome portfolio, $3.50 ; also bound in one volume, cloth $23.00 ; very handsome half Eussia, raised bands and open back, $25.00. For sale by subscription only. Apply to the Publishers. Extract from Introduction. It is the design of this book to present the facts of human anatomy in the manner best suited to the requirements of the student and the practitioner of medicine. The author believes that .such a book is needed, inasmuch as no treatise, as far as he knows, contains, in addition to the text descriptive of the subject, a systematic presentation of such anatomical facts as can be applied to practice. A book wliicli will be at once accurate in statement and concise in terms ; which will be an acceptable expression of the present state of the science of anatomy ; which will exclude nothing that can be made applicable to the medical art, and which will thus embrace all of surgical importance, wliile omitting nothing of value to clinical medicine, — would appear to have an excuse for existence in a country where most surgeons are general practitioners, and where there are few general practitioners who have no interest in surgery. It is to be considered a study of applied anatomy 1 care, and are simply superb. There is as much in its widest sense — a systematic presentation of | of practical application of anatomical points to such anatomical facts as can be applied to the practice of medicine as well as of surgery. Our author is concise, accurate and practical in his statements, and succeeds admirably in infusing an interest into the study of what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the ground is travelled over by one thoroughly famil- iar with it. The illustrations are made with great the every-day wants of the medical clinician as to those of the operating surgeon. In fact, few general practitioners will read the work without a feeling of surprised gratification that so many points, concerning which they may never have thought before are so well presented" for their con- sideration. It is a work which is destined to be the best of its kind in any language. — Medical Record, Nov. 25, 1882. CLAJRKE^W. B., F.B.C.S. & LOCKWOOn.C. B., F.B.C.S, Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustration|. Limp cloth, red edges, $1.50. Just ready. See Students' Series of Manuals, page 3. This is a very excellent manual for the use of the ' part, are good and instructive. The book is neat student who desires to learn anatomy. The meth- ' and convenient. We are glad to recommend it. — ods of demonstration seem to us very satisfactory. : Boston Medical and Surgical Journal, Jan. 17, 1884. There are many woodcuts which, for the most TBEVES, FBEDEBICK, F. B. C. S., Senior Demoristrator of Anatomy and Assistant Surgeon at the London Hospital. Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. Just ready. See Students' Series of Manuals, page 3. He has produced a work which will command a | quickened by daily use as a teacher and practi- larger circle of readers than the class for which it i tioner, has enabled our author to prepare a work ■was written. This union of a thorough, practical which it would be a most difficult task to excel. — acquaintance with these fundamental branches, I The American Practitioner Feb. 1884. CVBNOW, JOHN, M, L>., F, B. C. B., Professor of Anatomy at Kincfs College, Physician at King's College Hospital. Medical Applied Anatomy. In one pocket-size 12mo. volume. Preparing. See Students' Series of Manuals, page 3. BFLLA3IY, FDWABB, F. B, C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital, Loiulon. The Student's Guide to Surgical Anatomy : Being a Description of the most Important Surgical Regions of the Hiunan Body, and intended as an Introduction to operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. HARTSHORNE'S HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second edition, revised. In one royal 12mo. volume of 310 pages, with 220 woodcuts. Cloth, $1.75. HORNER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition, extensively revised and modified. In two octavo volumes of 1007 pages, with 320 woodcuts. Cloth, $6.00. Lea Brothers & Co.'s Publications — Auat., Physics, Physiol. 7 I) ALTON, JOSK a, M. !>., Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. The Topographical Anatomy of the Brain. In three very handsome quarto volumes comprising 17S pages of descriptive text. Illustrated with forty-eight full page photographic plates of Bi'ain Sections, with a like num1)er of outline explanatory plates, as well as many carefully-executed woodcuts through the text. Price for the com- plete work, $36. Just ready. For sole by subscription. As but few of the copies reserved for this country now remain unsold, gentlemen desiring the work will do well to apply to the publishers at an early date. This is one of the most magnificent works on precise and accurate, and the methods by which anatomy that has appeared during the present tlie sections were made and the specimens re- generation, and will not only supersede all its produced are given very plainly in an introductory predecessors on the topographical anatomy of the chapter, which cannot fail to be of the greatest brain, but make any farther work on the same value to any one desirous of making similar prep- lines unnecessary. It contains forty-eight ex- arations. Criticism on such a work is super- quisite illustrations of the brain en masse and in fluous. We can only congratulate Dr. Dalton, his sections. Not only has perfect accuracy been assistants, and the publishers on the energy they secured, but one of the finest and most artistic have shown in undertaking such a work, and the works of recent times has been presented to the success with which they have overcome a task medical public. Its value as a work of reference presenting so many mechanical difficulties. We is considerably increased by the very careful out- envy our American confreres the authorship and line sketches which accompany the plates and execution of so beautiful and useful an addition which enable them to be easily followed and to medical literature. Much light is thrown understood. These sketches are' very complete on some obscure relations of parts of the brain and accurate, and have been reproduced from which have never before been seen in correct tracings. The descriptions bj' the author are clear, juxtaposition. — London Lancet, April 18, 1885. BY THE SAME AUTHOR. Doctrines of the Circulation of the Blood. A History of Physiological Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 12mo. volume of 293 pages. Cloth, $2. Just ready. In the progress of physiological study no fact few years b}^ American physicians. It is in several was of greater moment, none more completely respects the most complete. The volume, thorfgh revolutionized the theories of teachers, than the small in size, is one of the most creditable eon- discovery of the circulation of the blood. This tributions from an .'Vmerican pen to medical his- explains the extraordinary interest it has to all tory that has appeared. — Medical and Surgical Ri- medical historians. The volume before us is one porter, Dec. 6, 1884. of three or four which have been written within a ELLIS, GBOJRGE VINER, Emeritus Professor of Anatrrmii in University College, London. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised London edition. In one very handsome octavo volume of 716 pages, with 249 illustrations. Cloth, §4.25 ; leather, $5.25. JROBEBTS, JOHN B., A. M., M. D., Prof, of Applied Anat. and Oper. Snrg. in Phila. Polyclinic and Coll. for Cfraduates in Bledicine. The Compend of Anatomy. For use in the dissecting-room and in preparing for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. nBArEB, JOHN^^M. J>., LL, !>., Professor of Chemistry in the University of the City of New York. Medical Physics. A Text-book for Students and Practitioners of Medicine. In one octavo volume of about 700 pages, with 376 woodcuts, mostly original. In afeic days: The object of the author has been to present in a clear and concise manner, without undue technicalities, the most modern views of physics in their special bearing on medical science. Familiarity with the laws and principles which govern the relations of force and matter is necessary, not only to a clear comprehension of physiology, but is an ines- timable aid to the physician and surgeon in their daily practice; yet the subject is strangely neglected in professional education and is one for which the medical student has no special text-book. This want Professor Draper has endeavored to supply, and his distinguished reputation guarantees such a presentation of the subject that the work will be not only essential to the student, but of importance to the practitioner. ROBERTSOW, J, McGBEGOB, M, A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- tions. Limp cloth, §2.00. Just ready. See Students' Series of Manuals, page 3. The title of this work suflSciently explains the ments. It will be found of great value to the nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we his test-book in physiology, and it would be particu- heartily recommend it.— Journal of the American larly useful as a guide to his laboratory experi- ' Medical Association, Dec. 6, 1884. BELL, F. JEFFREY, M, A., Professor of Comparative Anatomy at I\ing's College, London. Comparative Physiology and Anatomy. Shortly. See Students' Series of Manuals, page 3. Lea Brothers & Co.'s Publications — Physiology, Chemistry. DALTOJS^, JOSN C, M, JD,, Professor of Phijsiologi/ in the College of Physicians and Surgeons, New York, etc. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thoi-oughlv revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised hands, $6.50. The merits of Professor Dalton's text-book, his smooth and pleasing style, the remarkable clear- ness of his descriptions, which loave not a chapter obscure, his cautious judgment and the general correctness of his facts', are perfectly known. They have made his text-book the one most familiar to American students.— i)/ed. Record, Blarch 4, 1882. Certainly no physiological work has ever issued from the press that presented its subject-matter in a clearer and more attractive light. Almost every page bears evidence of the exhaustive revision that has taken place. The material is placed in a more compact form, yet its delightful charm is re- tained, and no subject is thrown into obscurity. Altogether this edition is far in advance of any previous one, and will tend to keep the profession posted as to the most recent additions to our physiological knowledge. — Michigan Medical News, April, 1882. One can scarcely open a college catalogue that does not have mention of Dalton's Physiology as the recommended text or consultation-book. For American students we would unreservedly recom- mend Dr. Dalton's work.- Va. Med. Monthly, July,'82. FOSTER, 3IICMABL, M, D., F, B. S., Professor of Physiology in Cambridge University, England. Text-Book of Physiology. Third American from the fourth English edition, with notes and additions by E. T. Eeichert, M. D. In one handsome royal 12mo. volume of over 1000 pages, with about 300 illustrations. Cloth, $3.25 ; leather, $3.75. In a few days. A notice of the previous edition is appended. A more compact and scientific work on physiol- I eration the late discoveries in physiological chem- ogy has never been published, and we believe our- selves not to be mistaken in asserting that it has now been introduced into every medical college in which the English language is spoken. This work conforms to the latest researches into zoology and comparative anatomy, and takes into eonsid- istry and the experiments in localization of Ferrier and others. The arrangement followed is such as to render the whole subject lucid and well con- nected in its various parts. — Chicago Medical Jour- nal and Examiner, August, 1882. POWER, MFNRT, M, B,, F. R, C. S,, Examiner in Physiology, Royal College of Surgeons of England. Human Physiology. In one handsome jjocket-size 12mo. volume of 396 pages, with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, page 3. The prominent character of this work is that of I to every one of our readers. — The American Jour- judicious conden.^ation, in which an able and sue- I nal of the Medical Sciences, October, 1884. cessful effort appears to have been made by its I This little work is deserving of the highest accomplished author to teach the greatest number praise, and we can hardly conceive how the main of facts in the fewest possible words. The result facts of this science could have been more clearly is a specimen of concentrated intellectual pabu- I or concisely stated. The price of the work is such lum seldom surpassed, which ought to be care- ' as to place it within the reach of all, while the ex fully ingested and digested by every practitioner who desires to keep himself well informed upon this most progressive of the medical sciences. The volume is one which we eordiallv recommend cellence of its text will certainly secure for it most favorable commendation — Cincinnati Lancet and Clinic, Feb. 16, 1884. CARJPENTER, WM. B., M, jD., F, R, S., F. G. S., F. L. S,, Registrar to the University of London, etc. Principles of Human Physiology. Edited by Henry Power, M. B., Lond., F. R. C. S., Examiner in Katural Sciences, University of Oxford. A new American from the eighth revised and enlarged edition, with notes and additions by Francis G. Smith, M. D., late Professor of the Institutes of Medicine in the University of Pennsylvania. In one very large and handsome octavo volume of 1083 pages, with two plates and 373 illus- trations. Cloth, $5.50 ; leather, $6.50 ; half Russia, $7. FOWJVES, GEORGE, JPh. B. A Manual of Elementary Chemistry; Theoretical and Practical. Re- vised by Henry Watts, B. A., F. R. S. New American edition. In one large royal 12mo. volume of over 1000 pages, with 200 illustrations on wood and a colored plate. Cloth, $2.75; leather, $3.25. In press. A notice of the previous edition is appended. The book opens with a treatise on Chemical [ of late years, the chapter on the General Principles Physics, including Heat, Light, Magnetism and of Chemical Philosophy has been entirely revvrit- Electricity. These subjects are treated clearly [ ten. The latest views on Equivalents, Quantiva- and briefly, but enough is given to enable the stu- | lence, etc., are clearly and fully set forth. This dent to comprehend the facts and laws of Chemis try proper. It is the fashion of late years to omit these topics from works on chemistry, but their omission is not to be commended. As was required by the great advance in the science of Chemistry last edition is a great improvement upon its prede- cessors, which is saying not a little of a book that has reached its twelfth edition. — Ohio Medical Re- corder, Oct., 1878. Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. GALLOWAY'S QUALITATIVE ANALYSIS. New edition. LEHMANN'S MANUAL OP CHEMICAL PHYS- IOLOGY. In one octavo volume of 327 pages, with 41 illustrations. Cloth, $2.25. CARPENTER'S PRIZE ESSAY ON THE USE AND Abuse of Alcoholic Liquoks in Health and Dis- EASE. With explanations of scientific words. Small 12mo. 178 pages. Cloth, 60 cents. Lea Brothers & Co.'s Publications — Chemistry. ATTFIELn, JOSN, Ph. J>., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain etc. Chemistry, General, Medical and Pharmaceutical; Including the Chem- istry of tlie U. S. Pharmacopoeia. A Manual of the General Principles of the Science and tlieir Application to Medicine and Pharmacy. A new American, from the tenth English edition, specially revised by the Author. In one handsome royal 12mo. volume of 728 pages, with 87 illustrations. Cloth, §2.50 ; leather, §3.00. A textrbook which passes through ten editions j to put himself in the student's place and to appro- in sixteen years must have good qualities. This ciate his state of TainA.— American Chemical Jour remark is certainly applicable to Attfield's Chem- | 7ial, April, 18S-1. istry, a book which is so well known that it is hardly necessary to do more than note the appear- ance of this new and improved edition. It seems. however, desirable to point out that feature of the book which, in all probability, has made it so popular. There can be little doubt that it is its thoroughly practical character, the expression being used in its best sense. The author under- stands what the student ought to learn, and is able It is a book on which too much praise cannot be bestowed. .4s a text-book for medical schools it is unsurpassable in the present state of chemical science, and having been prepared with a special view towards medicine and pharmacy, it is alike indispensable to all persons engaged m those de- partments of science. It includes the whole chemistry of the last Pharmacopoeia.— Paci/ic Medi- cal and Sugrical Journal, Jan. 1884. BLOXAM, CMABLJES i., Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New American from the fifth Lon- don edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $3.75 ; leather, §4.75. I the best manuals of general chemistry tn the Eng- I lish language.— Detroit Lancet, Feb. 1884. j The general plan of this work remains the j same as in previous editions, the evident object I being to give clear and concise descriptions of all ! known elements and of their most important [ compounds, with explanations of the chemical laws and principles involved. We gladly repeat now the opinion we expressed about a" former edition, that we regard Bloxam's Chemistry as one ot the best treatises on general and applied chemistry. — American Jour, of Pharmacy, Dec. 1883. Comment from us on this standard work is al- most superfluous. It differs widely in scope and aim from that of Attfield, and in its way is equallj' beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse andlucid, and its arrangement of matter so logical in se- quence that the student never has occasion to complain that chemistry is a hard study. Much attention is paid to experimental illustrations of chemical principles and phenomena, and the mode of conducting these experiments. The book maintains the position it has always held as one of SI3ION, W., Ph, ID., 31, JD,, Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland College of Pharmacy. Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. In one 8vo. vol. of 410 pp., with 16 woodcuts and 7 plates, mostly of actual deposits, with colors illustrating 56 of the most important chemical reactions. Cloth, §3.00; also without plates, cloth, §2.50. Just ready. This book supplies a want long felt by students | plates, beautifully executed, illustrating precipi- of medicine and pharmacy, and is a concise but [ tates of various reactions, form a novel and valu- thorough treatise on the subject. The long expe- \ able feature of the book, and cannot fail to be ap- rience of the author as a teacher in schools of predated by both student and teacher as a help medicine and pharmacy is conspicuous in the ! over the hard places of the science. — Man/land perfect adaptation of the work to the special needs ! Medical Journal, Nov. 22, 1884. of the student of these branches. The colored i FRANKLAND, M, 2>. C.X., F. It,S,, &JAFP, Fh, J)., F. I. C, Professor of Chemistry in the Normal School of Science, London. Assist. Prof, of Chemistry in the Normal School of Science, London. Inorganic Chemistry. In one handsome octavo volume of 600 pages, with 51 woodcuts and 2 lithographic plates. Cloth, §3.75 ; leather, §4.75. In 2y)'ess. This work on elementary chemistry is based upon principles of classification, nomen- clature and notation which have been proved by nearly twenty years experience in teaching to impart most readily a sound and accurate knowledge of the science. BEMSEN, IMA, 31, D., Ph, 2)., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. Second and revised edition. In one handsome royal 12mo. volume of 240 pages. Cloth, $1.75. J?«< ready. of chemistry. The high reputation of the author assures its accuracy in all matters of fact, and its judicious conservatism in matters of theory, com- bined with the fulness with which, in a small compass, the present attitude of chemical science towards the constitution of compounds is con- sidered, gives it a value much beyond that accorded to the average text-books of the day. — American Journal of Science, March, 1884. The book is a valuable contribution to the chemi- cal literature of instruction. That in so few years a second edition has been called for indicates that many chemical teachers have been found ready to endorse its plan and to adopt its methods. In this edition a considerable proportion of the book has been rewritten, much new matter has been added and the whole has been brought up to date. We earnestly commend this book to every student 10 Lea Brothers & Co.'s Publications — Chemistry. CSABLES, T. CBANSTOUJ^, M. 1>./^. C. S., M. S., Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. Dr. Charles' manual admirably fulfils its inten- tion of giving his readers on the one hand a sum- The work is thoroughly trustworthy, and in- formed throughout by a genuine scientific spirit. The autlior deals with the chemistry of the diges- tive secretions in a systematic manner, which leaves nothing to be desired, and in reality sup- plies a want in English literature. The book ap- pears to us to be at once full and systematic, and to show a just appreciation of the relative import- ance of the various subjects dealt with. — British Medical Journal, November 29, 1884. mary, comprehensive but remarkably compact, of the mass of facts in the sciences which have be- come indispensable to the physician ; and, on the other hand, of a system of practical directions so minute that analyses often considered formidable may h.e pursued by any intelligent person. — Archives of Medicine, Dec. 1884. HOFFMANN, F., A.M., JPIuD., <& FOWEM F.B., Ph.I)., Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. A Manual of Chemical Analysis, as applied to the Examination of Medicinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much enlarged. In one very handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. "We congratulate the author on the appearance i tion of them singularly explicit. Moreover, it is of the third edition of this work, published for the j exceptionally free from typographical errors. We first time in this country also. It is admirable and the information it undertakes to supply is both extensive and trustworthj'. The selection of pro- cesses for determining the purity of the substan- ces of which it treats is excellent and the descrip- have no hesitation in recommending it to those who are engaged either in the manufacture or the testing of medicinal chemicals. — London Pharma- ceutical Journal and Transactions, 1883. CLOWES, FRANK, D. Sc, Zondon, Senior Science-Master at the High School, Newcastle-under-Lyme, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. Third American from the fourth and revised English edition. In one very handsome royal 12mo. volume of about 400 pages, with about 50 illustrations. Cloth, $2.50. In a few days. The demand for four editions of this work proves the success of Professor Clowes' effort to provide a simple, concise and trustworthy guide to c]ualitative analysis. The use and preparation of apparatus, and the directions for working liave been so fully and clearly detailed that the work is admirably adapted not only to relieve the teacher of unnecessary labor, but also to answer all the recpiirements of self-instruction. BALFE, CSABLES S., M. I)., F. B. C. F., Assistant Physician at the London Hospital. Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 3. This is one of the most instructive little works that we have met with in a long time. The author is a physician and physiologist, as well as a chem- ist, consequently the book is unqualifiedly prac- tical, telling the physician just what he ougiit to know, of the applications of chemistry in medi- cine. Dr. Ralfe is thoroughly acquainted with the latest contributions to his science, and it is quite refreshing to find the subject dealt with so clearly and simply, yet in such evident harmony with the modern scientific methods and spirit. — Medical Record, February 2, 1884. CLASSEN, ALEXANDEB, Professor in the Royal Polytechnic School, Aix-la-Chapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by Edgak F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. It is probably the best manual of an elementary I and then advancing to the analysis of minerals and nature extant insomuch as its methods are the i such products as are met with in applied chemis- best. It teaches by examples, commencing with | try. It is an indispensable book for students in single determinations, followed by separations, | chemistry. — Boston Journal of Chemistry, Oct. 1878. GBEENE, WILLIAM S., M. I>., Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow- man's Medical Chemistry. In one i2ino. volume of 310 pages, with 74 illus. Cloth, $1.75. It is a concise manual of three hundred pages, the recogniticm of compounds due to pathological giving an excellent summary of the best methods conditions. The detection of poisons is treated of analyzing the liquids and solids of the body, both j with sufficient fulness for the purpose of thestu- forthe estimation of their normal constituents and \ dent or practitioner. — Boston Jl. of Chem., June, '80. Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 JPAMItlSS, EnwABn, Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. A Treatise on Pharmacy: designed as a Text-book for the Student, and as a Guide for tlie Physician and Pharmaceutist. With many Formula and Prescriptions. Fifth edition, thoroughly revised, by Thomas S. '\^''IEGAND, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. Cloth, $o ; leather, |6. No thoroughgoing pharmacist will fail to possess ' This well-known work presents itself now based himself of so useful a guide to practice, and no ; upon the recently revised new Pharmacopoeia, physician who properly estimates the value of an . Each page bears evidence of the care bestowed accurate knowledge of the remedial agents em- upon it, and conveys valuable information from ployed by him in daily practice, so far as their ! the rich store of the editor's experience. In fact miscibility, compatibility and most effective meth- , all that relates to practical pharmacy— apparatus' ods of combination are concerned, can atford to : processes and dispensing— has been arranged and leave this work out of the list of their works of described with clearness in its various aspects, so reference. The country practitioner, who must | as to afford aid and advice alike to the student and always be in a measure his own pharmacist, will to the practical pharmacist. The work is judi- find it indispensable. — Louisville Medical News, ^ ciously illustrated with good woodcuts — American March 29, 1884. I Journal of Phartnacy, January, 1884. BRUJ^TOJV, T. LAUnEH, M. D., Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. A Text-book of Pharmacology, Materia Medica and Therapeutics. In one handsome octavo volume of alwut 1000 pages, with over 20U illustrations. Cloth, $5.50 ; leather, §6.50. In press. It is with peculiar pleasure that the early appearance of this long expected work is announced by the publishers. Written by the foremost authority on its subject in Eng- land, it forms a compendious treatise on materia medica, pharmacology, pharmacy, and the practical use of medicines in the treatment of disease. iSpace has been devoted to the fundamental sciences of chemistry, physiology and pathology, wherever it seemed necessary to elucidate the proper subject-matter of the book. A general index, an index of diseases and remedies, and an index of Ijibliography close a volume which will undouljtedly be of the highest value to the student, practitioner and pliarmacist. HERMANN, JDr. l7, ~'~ Professor of Physiology in the University of Zurich. Experimental Pharmacology. A Handbook of Methods for Determining the Physiological Actions of Drugs. Translated, with tlie Author's permission, and with extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 illustrations. Cloth, i?1.50. Prof. Hermann's handbook, which Dr. Smith has | plains the various methods and instruments used translated and enriched with many valuable addi- | and points out what lines of investigation are to tions, will be gladly welcomed by those engaged in I be pursued for studying different phenomena, this department of physiology. It is an excellent and also how and what particularly to observe. — little book, full of concise information, and it . American Journal of tlic Medical Sciences, Ja,n.lSSi. should find a place in every laboratory. It ex- ! MAISCH, JOSJV3I., JPhar. n7, Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists and Physicians. New (second) edition. In one handsome royal 12mo. volume of 550 pages, with 242 illustrations. Cloth, $3.00. Just ready. This work contains the substance, — the practical j excellent, being very true to nature, and are alone "kernel of the nut" picked out, so that the stu- worth the price of the book to the .student. To the dent has no superfluous labor. He can confidently , practical physician and pharmaei.'it it is a valuable accept what this work places before him, without | work for handy reference and for keeping fresh any fear that the gist of the matter is not in it. ! in the memory the knowledge of materia medica Another merit is that the drugs are placed before and botany already acquired. We can and do him in such a manner as to simplify very much heartily recommend it. — Medical and Surgical Re- the study of them, enabling the mind to grasp . porter, Feb. 14, 1SS5. them more readily. The illustrations are most , BBUCE, J, MITCHELL, M. D., F. B. C. P., Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. Materia Medica and Therapeutics. An Introduction to Rational Treat- ment. In one pocket-size 12mo. volume of 555 pages. Limp cloth, ^1.50. Just ready. See Students' Series of Manuals, page 3. One of the very latest works upon Materia i recommend it as one of the very best for either Medica and Therapeutics, replete with informa- i medical student or practitioner of medicine. — tion abreast of the times, we unhesitatingly ; Cincinnati Medical Neu's, August, 1884. GBIFEITH, BOBEBT EGLESFIELD, M, D. A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists. Third edition, thoi-oughly revised, with numerous additions, by John M. Maisch, Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. STILLE, A., M.D.,ZL.D., <& 3IAISCH, J. M., I>7iar. D,, Professor Emeritus of the Theori/ and Prac- Prof, of Mat. Med. and Botany in Phila. tice of Medicine and of Clinical Medicine Colleqe of Pharmacy, Se&y to the Ameri' in the University of Pennsylvania. can Pharmaceutical Association. The National Dispensatory : Containing the Natural History, Chemistry, Phar- macy, Actions and Uses of Medicines, inchiding those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent imperial octavo volume of 1767 pages, with 311 fine engravings. Cloth, $7.25 ; leather, $8.00; half Eussia, open back, §9.00. With Denison's " Keady Reference Index " $1.00 in addition to price in any of above styles of binding. Just ready. In the present revision the authors have labored incessantly with the view of making the third edition of The National Dispensatory an even more complete represen- tative of the pharmaceutical and therapeutic science of 1884 than its first edition was of that of 1879. For this, ample material has been afibrded not only by the new United States Pharmacopoeia, but by those of Germany and France, which liave recently appeared and have been incorporated in the Dispensatory, together with a large number of new non- oflScinal remedies. It is thus rendered the representative of the most advanced state of American, English, French and German pharmacology and therapeutics. The vast amount of new and important material thus introduced may be gathered from the fact that the additions to this edition amount in themselves to the matter of an ordinary full-sized octavo volume, rendering the work larger by twenty-five per cent, than the last edition. The Therapeutic Index (a feature peculiar to this work), so suggestive and convenient to the j)ractitioner, contains 1600 more references than the last edition — the General Index 3700 more, making the total number of references 22,390, while the list of illustrations has been increased by SO. Every effort has been made to prevent undue enlargement of the volume by having in it nothing that could be regarded as superfluous, yet care has been taken that nothing should be omitted which a pharmacist or physician could expect to find in it. The appearance of the work has been delayed by nearly a year in consequence of the determination of the authors that it should attain as near an approach to absolute ac- curacy as is humanly possible. With this view an elaborate and laborious series of examinations and tests have been made to verify or correct the statements of the Pharma- copoeia, and very numerous corrections have been found necessary. It has thus been ren- dered indispensable to all who consult the Pharmacopoeia. The work is therefore presented in the full expectation that it will maintain the IDOsition universally accorded to it as the standard authority in all matters pertaining to its subject, as registering the furthest advance of the science of the day, and as embody- ing in a shape for convenient reference the recorded results of human experience in the laboratory, in the dispensing room, and at the bed-side. Comprehensive in scope, vast in design and up to date. The work lia's been very well done, a splendid in execution, The National Dispensatory large number of extra-pharmacopceial remedies may be justlj'regarded as the most important work having been added to those mentioned in previous of its kind extant. — Louisville Medical Neivs, Dec. editions. — London Lancet, Nov. 22, 1884. 6,1884. Its completeness as to subjects, the comprehen- AVe have much pleasure in recording the appear- : siveness of its descriptive language, the thorough- ance of a third edition of this excellent work of I ness of the treatment of the topics, its brevity not reference. It is an admirable abstract of all that i sacrificing the desirable features of information relates to chemistry, pharmacy, materia medica, I for which such a work is needed, make this vol- pharmacology and therapeutics. It may be re- 1 ume a marvel of excellence. — Pharmaceutical Re- garded as enibodying the Pharmacopoeias of the ■ cord, Aug. 15, 1884. civilized nations of the world, all being brought i fahqvhamson, jrobebt, m. n., Lecturer on Materia Medica at St. Mary's Hospital Medical School. A Guide to Therapeutics and Materia Medica. Third American edition, specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by Frank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. Dr. Farquharson's Therapeutics is constructed \ umned pages — one side containing the recognized upon a plan which brings before the reader all the physiological action of the medicine, and the other essential points with reference to the properties of : the disease in which observers (who are nearly al- drugs. It impresses these upon him in such a way [ ways mentioned) have obtained from it good re- as to enable him to take a clear view of the actions 1 suits — make a very good arrangement. The early of medicines and the disordered conditions in i chapter containing rules for prescribing is excel- which they must prove useful. The double-col- , lent. — Canada Med. and Surg. Journal, Dec. 1882. STILLBf ALFBED, 31, !>., LL, !>., Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. Therapeutics and Materia Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. Cloth, $10.00 ; leather, $12.00 ; very handsome half Russia, raised bands, $13.00. We can hardly admit that it has a rival in the in pharmacodynamics, but as by far the most corn- multitude of its citations and the fulness of its plete treatise iipon the clinical and practical side research into clinical histories, and we mustassign I of the question. — Boston Medical and Surgical Jour- it a place in the physician's library; not, indeed, nal, Nov. 5, 1874. as fully representing the present state of knowledge [ Lea Brothers & Co.'s Publications — Pathol., Histol. 13 COATS, JOSBBH, M. 2>., F, F. F. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one with 339 beautiful illustrations. Cloth, $5.50 The work before us treats the subject of Path- ology more extensively than it is usually treated in similar works. Medical students as well as physicians, who desire a work for study or refer- ence, that treats the subjects in the various de- , partments in a very thorough manner, but without ' prolixity, will certainly give this one the prefer- ence to any with which we are acquainted. It sets i forth the most recent discoveries, exhibits, in an ; interesting manner, the changes from a normal very handsome octavo volume of 829 pages, ; leather, $6.50. condition effected in structures by disease, and points out the characteristics of various morbid agencies, so that they can be easily recognized. But, not limited to morbid anatomy,it explains fully how the functions of organs are disturbed by abnormal conditions. There is nothing belonging to its de- partment of medicine that is not as fully elucidated as our present knowledge will a,dmit.— Cincinnati Medical News, Oct. 1883. GREEN, T. HENRY, M, JD,, Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. Pathology and Morbid Anatomy. Fifth American from the sixth revised and enlarged English edition. In one very handsome octavo volume of 482 pages, with 150 line engravings. Cloth, $2.50. Just ready. The fact that this well-known treatise has so ! No work in the English language is so admirably rapidly reached its sixth edition is a strong evi- < adapted to the wants of the student and practi- deuee of its popularity. The author is to be con- i tioner as this, and we would recommend it most gratulated upon the thoroughness with which he I earnestly to every one. — Nashville Journal of Medi- nas prepared this work. It is thoroughly abreast j cine and Surgeryj Noy. 1884. with all the most recent advances in pathology. [ WOODHEAI), G. SIMS, M. !>., F. R. C. F, E., Demonstrator of Pathology in the University of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. In one beau- tiful octavo volume of 497 pages, with 136 exquisitely colored ilhistrations. Cloth, $6.00. It forms a real guide for the student and practi- i The author merits all praise for having produced tioner who is thoroughly in earnest in his en- \ a valuable work. — Medical Record. May 31, 1884. deavor to see for himself and do for himself To ■ It is manifestly the product of one who has him- the laboratory student it will be a helpful com- ; self travelledoverthe whole fieldand who is skilled panion, and all those who may wish to familiarize i not merely in the art of histology, but in the obser- themselves with modern methods of examining | vation and interpretation of morbid changes. The morbid tissues are strongly urged to provide | work is sure to command a wide circulation. It themselves with this manual. The numerous I should do much to encourage the pursuit of path- drawings are not fancied pictures, or merely ; ology, since such advantages in histological study schematic diagrams, but they represent faithfully have never before been offered. — The Lancet, Jan. the actual images seen under the microscope. I 5, 1884. CORJSriL, V,, and RANVIER, i., Prof, in the Faculty of Med. of Paris. Prof, in the College of France. A Manual of Pathological Histology. Translated, with notes and additions, by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia Hospital, and by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Russia, raised bands, $7. One of the most complete volumes on patholog- Thus side by side physiological and pathological ical histology we have ever seen. The plan of study anatomy go hand m hand, affording that best of embraced within its pages is essentially practical. 1 all processes in demonstrations, comparison. The Normal tissues are discussed, and after their thor- admirable arrangementof the work affords facility ough demonstration we are able to compare any 1 in the study of any part of the human economy. — pathological change which has occurred m them, j New Orleans Medical and SurgicalJournal,3un6,18S2. KLEIN, E., M, n., F. R. S,, Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomeic's Hosp., London. Elements of Histology. In one pocket-size 12mo. volume of 360 pages, with 181 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 3. Although an elementary work, it is by no means The illustrations are numerous and excellent. We superficial or incomplete, for the author presents commend Dr. Klein's Elements most heartily to in concise language nearly all the fundamental facts the student. — Medical Record, Dec. 1, 1883. regarding the microscopic structure of tissues. FEFFER, A. J., M. B., M, S., F. R, C. S,, Surgeon and Lecturer at St. Mary^s Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00. See Students' Seines of Manuals, page 3. It is not pretentious, but it will serve exceed- ingly well as a book of reference. It embodies a treat deal of matter, extending over the whole eld of surgical pathology. Its form is practical, its language is clear, and the information set forth is well-arranged, well-indexed and well- illustrated. The student will find in it nothing that is unnecessary. The list of subjects covers the whole range of surgery. The book supplies a very manifest want and should meet with suc- cess.— New York Medical Journal, May 31, 1884. SCHAFER'S PRACTICAL HISTOLOGY. In one handsome royal 12mo. volume of 308 pages, with 40 illustrations. GLUGE-S ATLAS OF PATHOLOGICAL HISTOL- OGY. Translated by Joseph Leidy, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored and des- criptive letter-press. Cloth, $4.00 14 Lea Brothers & Co.'s Publications — Practice of Med. FLINT, AUSTIN, M. !>., Prof, of the Principle.^ and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y, A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. With an Appendix on the Kesearches of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed octavo volume of 1160 pages. Cloth, $5.50 ; leather, $6.50 ; half Eussia, $7. Koch's discovery of the bacillus of tubercle gives promise of being the greatest boon ever conferred by science on humanity, surpassing even vaccination in its benefits to mankind. In the appendix to his work, Professor Flint deals with the subject from a practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard work will be more than ever a necessity to the physician who duly appreciates the re- sponsibility of his calling. A well-known writer and lecturer on medicine recently expressed an opinion, in the highest de- gree complimentary of the admirable treatise of medicine that it would seem hardly worth while to Dr. Flint, and in eulogizing it, he described it ac- curately as "readable and reliable." No textrbook is more calculated to enchain the interest of the student, and none better classifies the multitudi- nous subjects included in it. It has already so far won its way in England, that no inconsiderable number of men use it alone in the study of pure medicine; and we can say of it that it is in every way adapted to serve, not only as a complete guide, but also as an ample instructor in the science and practice of medicine. The style of Dr. Flint is always polished and engaging. The work abounds in perspicuous explanation, and is a most valuable text-book of medicine. — London Medical News. This work is so widely known and accepted as the best American text-book of the practice of give this, the fifth edition, anything more than a passing notice. But even the most cursory exami- nation shows that it is, practically, much more than a revised edition; it is, in fact, rather anew work throughout. This treatise will undoubtedly continue to hold the first place in the estimation of American physicians and students. No one of our medical writers approaches Professor Flint in clearness of diction, breadth of view, and, what we regard of transcendent importance, rational esti- mate of the value of remedial agents. It is thor- oughly practical, therefore pre-eminently the book for American readers. — St. Louis Clin. Rec, Mar. '81. SAUTSHOItNE, SBNRY, M. 2>., ii. D., Lately Professor of Hygiene in the University of Pennsylvania. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. Within the compass of liOO pages it treats of the ; this one; and probably not one writer in our day history of medicine, general pathology, general \ had a better opportunity than Dr. Hartshorne for symptomatology, and physical diagnosis (including : condensing all the views of eminent practitioners laryngoscope, ophthalmoscope, etc.), general ther- ! into a 12mo. The numerous illustrations will be apeutics, nosology, and special pathology and prac- j very useful to students especially. These essen- tice. There is a wonderful amount of information tials, as the name suggests, are not intended to contained in this work, and it is one of the best i supersede the text-books of Flint and Bartholow, of its kind that we have seen.—Glasgoio Medical \ but they are the most valuable in affording the Journal, Nov. 1882. ' j means to see at a glance the whole literature of any An indispensable book. No work ever exhibited I disease, and the most valuable treatment.— CTi'capo a better average of actual practical treatment than i Medical Journal and Examiner, April, 1882. BBISTOWE, JOHN STEB, M. I),, F, It. C. JP., Physician and Joint Lecturer on Medicine at St. Thomas' Hospital. A Treatise on the Practice of Medicine. Second American edition, revised by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. The reader will find every conceivable subject connected with the practice of medicine ably pre- sented, in a style at once clear, interesting and concise. The additions made by Dr. Hutchinson | are appropriate and practical, and greatly add to its usefulness to American readers. — Buffalo Med- ical and Surgical Journal, March, 1880. WATSON, SIB THOMAS, M. D., Late Physician in Ordinary to the Queen. Lectures on the Principles and Practice of Physic. A new American from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. LECTURES ON THE STUDY OF FEVER. By A. Hudson, M. D., M. R. I. A. In one octavo )' volume of 308 pages. Cloth, S2.50. STOKES' LECTURES ON FEVER. Edited by John William Moore, M. D., F. K. Q. C. P. In one octavo volume of 280 pages. Cloth, $2.00. A TREATISE ON FEVER. By Robeet D. Lyons, K. C. C. In one 8vo. vol. of 354 pp. Cloth, S2.25. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1468 pp. Cloth, 87.00. SSfi A CENTURT OF AMERICAN MEDICINE, 1776—1876. By Drs. E. H. Claeke, H. J. BiGELOW, S. D. Gboss, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. Cloth, 82.25. Lea Brothers & Co.'s Publications — Systems of Med. 15 For Sale by SiibscriptiOH Only, A System of Practical Medicine. BY A3IERICAN AUTHORS. Edited by WILLIAM PEPPER, M. D., LL. D., PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF J CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, / Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the Hospital of the University of Pennsylvania. In five imperial octavo volumes, containing about 1100 pages each, with illustrations. Price per volume, cloth, $5; leather, $6; half Russia, raised bands and open back, $7. Volume I. (General Pathology, Sanitary Science and General Diseases) contains 1094 pages, with 24 illustrations and is just ready. Volume II. (General Diseases [con- tinued] and Diseases of the Digestive System) will be ready June \st, and the subsequent volumes at intervals of four months thereafter. The publishers feel pardonable pride in announcing this magnificent work. For three years it has been in active preparation, and it is now in a sufficient state of forwai-d- ness to .justify them in calling the attention of the profession to it as the work in which for the first time American medicine is thoroughly represented by its worthiest teachers, and presented in the full development of the practical utility which is its preeminent characteristic. The most able men — from the East and the West, from the North and the South, from all the prominent centres of education, and from all the hospitals which afford special oi^portuuities of study and practice — have united in generoits rivalry to bring together this vast aggregate of specialized experience. The distinguished editor has so apportioned the work that each author has had assigned to him the subject which he is peculiarly fitted to discuss, and in which his views will be accepted as the latest expression of scientific and practical knowledge. The practitioner will therefore find these volumes a complete, authoritative and unfailing work of reference, to which he may at all times turn with full certainty of finding what he needs in its most recent aspect, Avliether he seeks information on the general principles of medi- cine, or minute guidance in the treatment of special disease. So wide is the scope of the work that, with the exception of midwifery and matters strictly surgical, it embraces the whole domain of medicine, including the departments for which the physician is accustomed to rely on special treatises, such as diseases of women and children, of the genito-urinary organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology and otology. Moreover, authors have inserted the formulas which they have found most efficient in the treatment of the various affections. It may thus be truly regarded as a Complete Library of Practical Medicine, and the general practitioner possessing it may feel secure that he will require little else in the daily round of professional duties. In spite of every effort to condense the vast amount of practical information fur- nished, it has been impossible to j^resent it in less than 5 large octavo volumes, containing about 5500 beautifully printed pages, and embodying the matter of about 15 ordinary octavos. Illustrations are introduced wherever they serve to elucidate the text. As material for the work is substantially complete in the hands of the editor, the pro- fession may confidently await the appearance of the remaining volumes upon the dates above specified. A detailed prospectus of the work will be sent to any address on appli- cation to the publishers. It is a large undertaking, but quite justifiable in ; this eountiy as authorities on the particular topics the case of a progressive nation like the United ; on which they deal, whilst the others show by the States. At any rate, if we may judge of future way they have handled their subjects that they volumes from the first, it will be justified by the , are fully equal to the task they had undertaken, result. We have nothing but praise to bestow ' * * * A work which we cannot doubt will make upon the work. The articles are the worli of ■ a lasting reputation for itself. — London Medical writers, many of whom are already recognized in ; Times and Gazette, May 9, 1885. HBYWOLDS, J, MUSSELLf M. D., Professor of the Principles and Practice of Medicine iti University College, London. A System of Medicine. With notes and additions by Henry Hartshorne, A. M., M. D., late Professor cf Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00 ; sheep, §6.00 ; very handsome half Russia, raised bands, $6.50. Per set, cloth, $15 ; leather, $18 ; half Russia, $19.50. Sold only by subscription. There is no medical work which we have in himself in need of. In order that any deficiencies times past more frequently and fully consulted may be supplied, the publishers have committed when perplexed by doubts as to treatment, or by the preparation of the book for the press to Dr. having unusual or apparently inexplicable symp- Henry Hartshorne, whose judicious notes distrib- toms presented to us, than "Reynolds' System of uted throughout the volume afford abundant evi- Medicine." It contains just that kind of mforma- i dence of the thoroughness of the revision.— ^mer- tion which the busy practitioner frequently finds ; ican Journal of the Medical Sciences, Jan. 1880. 16 Lea Brothers & Co.'s Publications — Clinical Med., etc. 8TILLE, ALFMBjD, M. X>., ii. J>., Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the TJrdv. of Penna. Cholera: Its Origin, History, Causation, Symptoms, Prevention and Treatment. In one handsome 12mo. volume of about 175 pages, with a chart. Cloth, §1.25. Shortly. The threatened importation of cholera into the country renders peculiarly timely this work of an authority so eminent as Professor Stille. The history of previous e^ii- demics, their modes of jDropagation, the vast recent additions to our knowledge of the causation, prevention and treatment of the disease, all have been handled so skilfully as to present with brevity the information which every practitioner should possess in ad- vance of its visitation. FLINT, AUSTIN, M. D. Clinical Medicine, A Systematic Treatise on the Diagnosis and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Russia, $6.00. It is here that the skill and learning of the great | sistently with brevity and clearness, the different clinician are displayed. He has given us a store- ! subjects and their several parts receiving the house of medical knowledge, excellent for the stu- I attention which, relativel3' to their importance, dent, convenient for the practitioner, the result of j medical opinion claims for them, is still more diffi- a long life of the most faithful clinical work, col- cult. This task, we feel bound to say, has been lected by an energy as vigilant and systematic as executed with more than partial success by Dr. untiring, and weighed b}' a judgment no less clear ! Flint, whose name is already familiar to students than his observation is close. — Archives of Medicine, of advanced medicine in this country as that of Dec. 1879. the author of two works of great merit on special To give an adequate and useful conspectus of the subjects, and of ni extensive fieldof modern clinical medicine is a task originality and e ofno ordinary difficulty; but to accomplish this con- Journal, Dec. 1879 By the Same Author. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. BBOADBFWT, W. M,, M, D,, F, R, C. P., Physician to and Lecturer on Medicine at St. Mary's Hospital. The Pulse. In one 12mo. volume. See Series of Clinical Manuals, page 3. SCHBEIBEH, DB, JOSEFS, A Manual of Treatment by Massage and Methodical Muscle Ex- ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome octavo volume of about 800 pages, with about 125 fine engravings, Preparing. FINLAYSON, JAMES, M, J>., Editor, Physician and Lecturer on Clinical Medicine in the Glasgoic Western Infirmary, etc. Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine. With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephens on Diseases of the Female Organs ; Dr. Robertson on Insanity ; Dr. Gemmell on Physical Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In one handsome 12mo. volume of 546 pages, with 85 illustrations. Cloth, $2.63. This is one of the really useful books. It is at- , bulkier volumes; and because of its arrangement tractive from preface to Ihe final page, and ought and complete index it is unusually convenient for to be given a place on every office table, because it | quick reference in any emergency that may come contains in a condensed form all that is valuable i upon the busy practitioner. — N. C. Med. Journ., in semeiology and diagnostics to be found in [ Jan. 1879. FENWICK, SAIIUEL, 31. n,. Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 87 illustrations on wood. Cloth, $2.25. TANNEB, TSOMAS ELAWKES, II I>. A Manual of Clinical Medicine and Physical Diagnosis. Third American from the second London edition. Revised and enlarged by Tilbury Fox, M. D., Phy- sician to the Skin Department in University College Hospital, London, etc. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. FOTHEBGILL, J. M,, M. D,, Edin., M. B, C. P., Bond,, Physician to the City of London Hospital for Diseases of the Chest. The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- peutics, xsew edition. In one octavo volume. Preparing. STURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, $1.25. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By N. S. Davis M. D. Edited by Frank H. Davis, M. D. Second edition. 12mo. 287 pages. Cloth, $1.75. Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 MICSAUDSOJ^, B. TF., M.A., M,I>., LL. 1>., f,m,s,, f,s.a. Fellow of the Royal College of Physicians, London. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, §5 ; very handsome half Eussia, raised bands, §5.50. Dr. Richardson has succeeded iu producing a ' the question of disease is comprehensive, masterly work which is elevated in conception, eomprehen sive in scope, scientific in character, systematic in arrangement, and which is written in a clear, con- cise and pleasant manner. He evinces the liappy faculty of extracting the pith of what is known on the subject, and of presenting it in a most simple, intelligent and practical form. There is perhaps no similar work written for the general public thatcontains such acomplete, reliable and instruc- tive collection of data upon the diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and scholarly; the discussion of and fully abreast with the latest and best knowl- edge on the subject, and the preventive measures advised are accurate, explicit and reliable. — The American Journalofthe Medical Sciences, April, 1884. This is a book that will surely find a place on the table of every progressive physician. To the medical profession, whose duty is quite as much to prevent as to cure disease, the book will be a boon. — Boston Medical and Surgical Journal, Mar. C, 1884. The treatise contains a vast amount of solid, valu- able hygienic information. — Medical and Surgical Reporter, Feb. 23, 1884. BAJRTHOLOW, ROBERTS, A. M., M, D., LL. D., Prof, of Materia Medica and General Tlierapeutics in the Jefferson Med. Coll. of Phila., etc. Medical Electricity. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. Second edition. In one very handsome octavo volume of 292 pages, with 109 illustrations. Cloth, $2.50. The second edition of this work following so i A most excellent work, addressed by a practi- soon upon the first would in itself appear to be a tioner to his fellow-practitioners, and therefore sufficient announcement; nevertheless, the te.^t thoroughly practical. The work now before us has been so considerably revised and condensed, \ has the exceptional merit of clearly pointing out and so much enlarged by the addition of new mat- where the benefits to be derived from electricity ter, that we cannot fail to recognize a vast improve- must come. It contains all and everything that ment upon the former work. The author has pre- : the practitioner needs in order to understand in- pared his work for students and practitioners — for i telligently the nature and laws of the a^ent he is those who have never acquainted themselves with : making use of, and for its proper application in the subject, or, having done so, find that after a > practice. In a condensed, practical form, it pre- time their knowledge needs refreshing. We think sents to the physician all that he would wish to he has accomplished this object. The book is not ' rememberafterperusingawholelibraryonmedical too voluminous, but is thoroughly practical, sim- electricity, including the results of the latest in pie, complete and comprehensible. It is, more- over, replete with numerous illustrations of instru- ments, appliances, etc. — Medical Record, November 15, 1882. vestigatioiis. It is the book for the practitioner, and the necessity for a second edition proves that it has been appreciated by the profession. — Physi- cian and Surgeon, Dec. 1882. THE TEAR-BOOK OF TREATMENT, A Comprehensive and Critical Review for Practitioners of Medi- cine. In one 12mo. volume of 320 pages, bound in limp cloth, with red edges, §;i.25. This work presents to the practitioner not only a comiDlete classified account of all the more important advances made in the treatment of Disease during the year ending Sept. 30, 1884, but also a critical estimate of the same by a competent authority. Each department of practice has been fully and concisely treated, and into the consideration of each subject enter such allusions to recent pathological and clinical work as bear directly upon treatment. As the medical literature of all countries has been placed under contri- bution, the references given throughout the work, together with the separate indexes of subjects and autliors, will serve as a guide for those who desire to investigate any thera- peutical topic at greater length. The contributions are from the pens of the following well-known gentlemen: — .J. Mitchell Bruce, M.D. ; T. Lauder Brunton, M.D., F.R.S. ; Thomas Bryant, F.R. C.S. ; F. IT. Champneys, M.B. ; Alfred Cooper, F.R.C.S. ; Sidney Coupland, M.D. ; Dyce Duckworth, M.D. ; George P. Field, M.R.C.S. ; Reginald Harrison, F.R. C.S. ; J. Warrington Haward, F.R.C.S. ; F. A. Mahomed, M.B. ; Malcolm Morris, F.R.C.S., Ed. ; Edmund Owen, F.R.C.S. ; R. Douglas Powell, M.D. ; Henry Power, M.B., F.R.C.S.; C. H. Ralfe, M.D. ; A. E. Sansom, M.D. ; Fells Semon, M.D.; Walter G. Smith, M.D. ; J. Knowsley Thornton, M.B. ; Frederick Treves, F.R.C.S. ; A. DE Watteville, M.D. ; John Williams, M.D. HABERSELON, S. O., M. J>., Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. On the Diseases of the Abdomen ; Comprising those of the Stomach, and other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, $3.50. PAVY'S treatise on THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, $2.75. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. Condie, M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cloth, $2.50. I HOLLAND'S MEDICAL NOTES AND REFLEC- I TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 18 Lea Brothers & Co.'s Publications — Throat, Lung-s, Heart. CO SEN, J. SO LIS, M. !>., Lecturer on Laryngoscopy and Diseases of the Throat and Cliest in the Jefferson Medical College. Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and Treatment of Affections of the Pharynx, CEsophagus, Trachea, Larynx and Nares. Third edition, thoroughly revised and rewritten, with a large number of new illustrations. In one veiy handsome octavo volume. Preparing. SEILER, CABL, M. 2)., Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume of 294 pages, with 77 illustrations. Cloth, $1.75. It is one of the best of the practical text-books j the essentials of diagnosis and treatment in dis- on this subject with which we are acquainted. The ; eases of the throat and nose. The art of laryngos- present edition has been increased in size, but its I copy, the anatomy of the throat and nose and the eminently practical character has been main- { pathology of the mucous membrane are discussed tained. Many new illustrations have also been j with conciseness and ability. The work is pro- introduced, a case-record sheet has been added, | fusely illustrated, excels in many essential feat- and there are a valuable bibliography and a good [ ures, and deserves a place in the office of the index of the whole. For any one who wishes to i practitioner who would inform himself as to the make himself familiar with the practical manage- I nature, diagnosis and treatment of a class of dis- ment of cases of throat .and nose disease, the book i eases almost inseparable from general medical will be found of great value.— iVew York Medical practice. With advanced students the book must Journal, June 9, 1883. i be very popular on account of its condensed style. The work before us is a concise handbook upon ; — Louisville Medical News, June 26, 1883. BROWNE, LENNOX, F. M, C. S., Eclin., Senior Surgeon to the Central London Throat and Ear Hospital, etc. The Throat and its Diseases. Second American from the second English edi- tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, designed and executed by the Author. In one very handsome imperial octavo volume of about 350 pages. Preparing. FLINT, AUSTIN, M. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- some royal 12mo. volume of 240 pages. Cloth, $1.63. It is safe to say that there is 'not in the English | the results of his careful study and ample ex language, or any other, the equal amount of clear, ' ' ' exact and comprehensible information touching the physical exploration of the chest, in an equal number of words. Professor Flint's language is precise and simple, conveying without dubiety perience in such wise that the young will find it the best source of instruction, and the old the most pleasant means of reviving and complementing their knowledge. — Ainerican Practitioner, June, 1883. BY THE SAME AUTHOR. Physical Exploration of the Lungs by Means of Auscultation and Percussion. Three lectures delivered before the Philadelphia County Medical Society, 1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. Cloth, $3.50. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. GROSS, S, n., M.D., LL.n., D.C.L. Oxon., LL.D. Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. FULLER ON DISEASES OF THE LUNGS AND i SMITH ON CONSUMPTION; its Early and Reme- AIR-PASSAGES. Their Pathology, Physical Di- | diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 475 pages. Cloth, S3.50. SLADE ON DIPHTHERIA; its Nature and Treat- LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth, S3.00. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an ment, with an account of the History of its Pre- ' analysis of one thousand cases to exemplify its valence in various Countries. Second and revised j duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. edition. In one 12mo. vol., pp. 158. Cloth, $1.25. ! jqneS' CLINICAL OBSERVATIONS ON FUNC- WALSHE ON THE DISEASES OF THE HEART I TIONAL NERVOUS DISORDERS. Second Am- AND GREAT VESSELS. Third American edi- erican edition. In one handsome octavo volume tion. In 1 vol. 8vo., 416 pp. Cloth, $;3.00. ] of 340 pages. Cloth, $3.25. Lea Brothers & Co.'s Publications — New. and Ment. Dis., etc. 19 MITCJEEELL, S, WEIJR, 31. 2>., Physician to Orthopedic Hospital and the Infirmary for Diseases of the Nervous System Phila. etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. Jwst ready. So great have been the achievements of the system perfected by the author for the treat- ment of hysterical and nervous diseases that the profession will welcome the second edition of a work which gives in detail the methods of enforced rest, massage and systematic feeding on which this mode of treatment is based. Many of these lectures are original studies of well-known diseases, and others deal with subjects which have been hitherto slighted in medical literature or which are almost unknown to it. The present edition contains several new lectures, notably those on the difficulties of diagnosis in hysterical diseases of joints on the relations of hysteria to organic disease of the spine, and on hysterical disorders of the rectum. SAMILTOW, ALLAN McLAJ^B, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelUs Island, N. Y. Nervous Diseases ; Tlieir Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. When thefirstedition of this good bookappeared ' characterized this book as the best of its kind in we gave it our emphatic endorsement, and the any language, which is a handsome endorsement present edition enhances our appreciation of tlie from an exalted source. The improvements in the book and its author as a safe guide to students oi new edition, and the additions to it, will justify its clinical neurology. One of the best and most j purchase even by those who possess the old. — critical of English neurological journals, Brain, has i Alienist and Neurologist, April, 1882. TUKE, DAJVIEL SACK, M. I)., Joint Author of The Manual of Psychological Medicine, etc. Ilkistrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with two colored plates. Cloth, $3.00. It is impossible to peruse these interesting chap- j method of interpretation. Guided by an enlight- ters without being convinced of the author's per- | eued deduction, the author has reclaimed for feet sincerity, impartiality, and thorough mental I science a most interesting domain in psychology, grasp. Dr. Tuke has exhibited the requisite | previously abandoned to charlatans and empirics. amount of scientific address on all occasions, and j This book, well conceived and well written, must the more intricate the phenomena the more firmly commend itself to every thoughtful understand- has he adhered to a physiological and rational 1 ing. — Neio York Medical Journal, September 6, 18Si. CLOVSTON, TH03IAS S., M. D., JP. B. C. B,, L. B. C, S,, Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Abstract of the Statutes of the United States and of the Several States and Territories re- lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor of Mental Diseases, Medical Department of Harvard University. In one handsome octavo volume of 541 pages, illustrated with eight lithographic plates, four of which are beautifully colored. Cloth, $4. The practitioner as well as the student will ae- i the general practitioner in guiding him to a diag- cept the plain, practical teaching of the author as a ' nosis and indicating the treatment, especially in forward step in the literature of insanity. It is i many obscure and doubtful cases of mental dis- refreshiug to find a physician of Dr. Clouston's experience and high reputation giving the bed- side notes upon winich his experience has been founded and his mature judgment established. Such clinical observations cannot but be useful to ease. To the American reader Dr. Folsom's Ap- pendix adds greatly to the value of the work, and will make it a desirable addition to every library. — American Psychological Journal, July, 1884. )r. Folsom's Abstract mav also be obtained separately in one octavo volume of 108 pages. Cloth, $1.50. " SAVAGE, GEORGE S., M. !>., Lecturer on Mental Diseases at Gvy's Hospital, London. Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol- ume of 551 pages, with 18 typical illustrations. Cloth, $2.00. Just ready. See Series of Clinical Manuals, page 3. As a handbook, a guide to practitioners and stu- i common sense is everywhere apparent. TVe re- dents, the book fulfils an admirable purpose. The i peat that Dr. Savage has written an excellent many forms of insanity are described with char- | manual for the practitioner and student.— ^ot- acteristie clearness, the illustrative cases are care- j erican Journal of Insanity, April, 1885. fully selected, and as regards treatment, sound ! PL AYE ALB, W. S., M. L)., F. B. C. P., The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Blandford on Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. 20 Lea Brothers & Co.'s Publications — Sm-gery. GROSS, S. I)., M, JD., LL, J>., JD. C, L. Oxon., LL, 2>. Catitab»f Etncritus Professor of Surgen/ in the Jefferson Medical College of Philadelphia. A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15; half Kussia, raised bands, $16. Dr. Gross' System of Surgery has long been the i material has been introduced, and altogether the standard work on that subject for students and distinguished autiior has reason to be satisfied practitioners.— iojzdon Lancet, May 10, 1884. 1 that he has placed the work fully abreast of the The work as a whole needs no commendation. | state of our knowledge. — Jl/ed. iiecord, Nov. 18, 1882. Many years ago it earned for itself the enviable rep- | His System of Surgery, which, since its first edi- utation of the leading American work on surgery, ' tion in 1859, has been a standard work in this and it is still capable of maintaining that standard, country as well as in America, in "the whole The reason for this need only be mentioned to be domain of surgery," tells how earnest and labori- appreciated. The author has always been calm ' ous and wise a surgeon he was, how thoroughly and judicious in his statements, has based his con- he appreciated the work done by men in other elusions on much study and personal experience, countries, and how much he contributed to pro- has been able to grasp his subject in its entirety, mote the science and practice of surgery in his and, above all, has conscientiously adhered to : own. There has been no man to whom America truth and fact, weighing the evidence, pro and 1 is so much indebted in this respect as the Nestor con, accordingly. A considerable amount of new I of surgery. — British Medical Journal, May 10, 1884. ASSHUMST, JOHW, Jr., M. D., Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. Fourth edition, enlarged and revised. In one large and handsome octavo volume of about 1100 pages, with about 575 illustrations. In press. GOVLn, A, JPBAMCE, M. S., M. B,, F. R. C. S„ Assistant Surgeon to Middlesex Hospital. Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 Cloth, §2.00. Just ready. See Students' Series of Manuals, page 3. and if practitioners would devote a portion of their leisure to the study of it, they would receive immense benefit in the way of refreshing their knowledge and bringing it up to the present state of progress. — Cincinnati Medical News, Jan., 1885. The student and practitioner will find the principles of surgical diagnosis very satisfactorily set forth with all unnecessary verbiage elimi- nated. Eveiy medical student attending lectures should have a copy to study during the intervals, GIBNEY, F. J>., M, J>., Surgeon to the Orthopccdic Hospital, JVew York, etc. Orthopaedic Surgery. For the use of Practitioners and Students, some octavo volume, profusely illustrated. Preparing. In one hand- ROBERTS, JOJETW B,, A. 31., M. D., Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. The Principles and Practice of Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 pages, with many illustrations. Preparing. BELLAMY, EnWARIf, F. R. C. S., Surgeon and Lecturer on Surgery at Charing Cross Hospital, Examiner in Anatomy Royal College of Surgeons, London. Operative Surgery. Shortly. See Students' Series of Manuals, page 3. STIMSOK, LEWIS A., B. A Prof, of Pathol. Anat. at the Univ. of the City A Manual of Operative Surgery. of 477 pages, with 332 illustrations. Cloth, $; This volume is devoted entirely to operative sur- gery, and is intended to familiarize the student with the details of operations and the different modes of performing them. The work is hand- somely illustrated, and the descriptions are clear and well-drawn. It is a clever and useful volume ; ., M. n., of New York, Surgeon and Curator to Bellevue Hosp. , In one very handsome royal 12mo. volume 2.50. every student should possess one. This work does away with the necessity of pondering over larger works on surgery for descriptions of opera- tions, as it presents in a nutshell what is wanted by the surgeon without an elaborate search to find it. — Maryland Medical Journal, August, 1878. SARGENT ON BANDAGING and OTHER OPERA- TIONS OF BIINOR SURGERY. New edition, with a Chapter on military surgery. One 12mo. volume of 383 pages, with 187 cuts. Cloth, $1.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of 638 pages, with 340 illustrations. Cloth, S3.75. MILLER'S PRACTICE OF SURGERY. Fourth and revised American from the last Edinburgh edition. In one large 8vo. vol. of 682 pages, with 364 illustrations. Cloth, $3.75. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. COOPER'S LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one Svo.vol. of 767 pages. Cloth, $2.00. SKEY'S OPERATIVE SURGERY. In one vol. 8vo- of 661 pages, with 81 woodcuts. Cloth, $3.25. GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth edition. In two octavo vols, of 965 pages, with 34 plates. Leather $6.50. Lea Brothers & Co.'s Publications — Surgery. 21 EBICSSBN, JOHX E., F. It. S., F, B, C, S., Professor of Surgery in University College, London, etc. The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- eases and Operations. From the eiglitli and enlarged English edition. In two large and beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. Cloth, S9; leather, raised bands, §11 ; half Eussia, raised bands, $12. Just ready. After the profession has placed its approval upon j munh to be said in the way of comment or eriti- a work to the extent of purchasing seven editions, | eism. That it still holds its own goes without saj'- it does not need to be introduced. Simultaneous j ing. The author infuses into it his large experi- with the appearance of this edition a translation ; enee and ripe jtidgment. Wedded to no school, is being made into Italian and Spanish. Thus \ committed to no theory, biassed by no hobby, he this favorite text-book on surgery holds its own in ■ imparts an honest personality in his observations, spite of numerous rivals at the endof thirty years, j and his teachings are the rulings of an impartial It is a grand book, worthy of the art in the interest i judge. Such men are always safe guides, and their of which it is written. — Detroit Lancet, J a,n. 10, 18S5. I works stand the tests of" time and experience. After being before the profession for thirty j Such an author is Erichsen, and such a work is his years and maintaining during that period a re- Surgery— Medical Record, Feb. 21, 18S5. putation as a leading work on surgery, there is not I BItYANT, THOMAS, F. M, C. S,, Surgeon and Lecturer on Surgery at Guy's Hospital, London. The Practice of Surgery. Fourth American from the fourth and revised Eng- lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustrations. Cloth, §6.50; leather, §7.50 ; half Eussia, §8.00. Just ready. This most magnificent work upon surgery has The treatise takes in the whole field of surgery, that of the eye, the ear, the female organs, orthb- peedies, venereal diseases, and military surgery, as well as more common and general topics. All of these are treated with clearness and with sutficient fulness to suit all practical purposes. The illustrations are numerous and well printed. We do not doubt that this new edition will con- tinue to maintain the popularity of this standard work. — Medical and Surgical Reporter, Feb. \i, '85. reached a fourth edition in this country, showing the high appreciation in which it is held by the American profession. It comes fresh from the pen of the author. That it is the very best work on surgery for medical students we think there can be no doubt. The author seems to have understood just what a student needs, and has prepared the work accordingly. — Cincinnati Medical Neirs, January, 1885. By the same Author. Diseases of the Breast. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 3. FSMAJRCH, Dr. FBIEDHICH, Professor of Surgery at the University of Kiel, etc. Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans- lated by H. R. H. PKiJfCESS Christi.\n. In one handsome small 12mo. volume of 109 pages, with 24 illustrations. Cloth, 75 cents. The course of instruction is divided into five sections or lectures. The first, or introductory lecture, gives a brief account of the structure and organization of the human body, illustrated by clear, suitable diagrams. The second teaches how to give judicious help in ordinary injuries — contu- sions, wounds, hsemorrhage and poisoned wounds. The third treats of first aid in cases of fracture and of dislocations, in sprains and in burns. Next, the methods of affording first treatment in cases of frost-bite, of drowning, of suffocation, of loss of consciousness and of poisoning are described; and the fifth lecture teaches how injured persons may be most safely and easily transported to their horhes, to a medical man, or to a hospital. The illustrations in the book are clear and good. — 3fedi- cal Times and Gazette, Nov. 4, 1882. TREVES, FMEnEBICK, F. M. C. S., Assistant Surgeon to and Lecturer on Surgery at the London Hospital. Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 illustrations. Limp cloth, blue edges, §2.00. page 3. X standard work on a subject that has not been so comprehensively treated by any contemporary English writer. Its completeness renders a full review ditfieult, since every chapter deserves mi- nute attention, and it is impossible to do thorough Just ready. See Series of Clinical Manuals, justice to the author in a few paragraphs. Intes- tinal Obstruction is a work that will prove of equal value to the practitioner, the student, the pathologist, the physician and the operating sur- geon.— British Medical Journal, Jan. 31, 1885. BALL, CHARLES B., M. Ch., Hub., F. B. C. S. E., Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. Diseases of the Rectum and Anus. In one 12mo. volume of 550 pages. Preparing. See Series of Clinical Manuals, page 3. BUTLIW, HEj\BY T., F. B. C. S., Assistant Surgeon to St. Bartholomew's Hospital, London. Diseases of the Tongue. In one 12mo. volume. Manuals, page 3. Shortly. HBUITT, BOBEBT, M. B. C. S., etc. The Principles and Practice of Modern Surgery. From the eighth London edition. In one 8vo. volume of 687 pages, with 432 illus. Cloth, $4 ; leather, %o. See Series of Clinical 22 Lea Brothers & Co.'s Publications — Surg-ery. SOLMBS, TIMOTSY, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A System of Surgery ; Theoretical and Practical. IN TEEATISES BY VAEIOUS AUTHOKS. American edition, thoroughly revised and re-edited by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. In three large and very liandsome imperial octavo volumes containing 3137 double- cohimned pages, with 979 iUustrations on wood and 13 lithographic plates, beautifully colored. Price per volume, cloth, $6.00 ; leather, §7.00 ; half Russia, $7.50. Per set, cloth, 118.00 ; leather, $21.00 ; half Kussia, §22.50. Sold only by subscription. Volume I. contains General Pathology, Morbid Processes, Injuries in Gen- eral, Complications of Injuries and Injuries of Regions. VoLUBiE II. contains Disea.ses of Organs of Special Sense, Circulatory Sys- tem, Digestive Tract and Genito-Urinary Organs. Volume III. contains Diseases of the Respiratory Organs, Bones, Joints and Muscles, Diseases of the Kervous System, Gunshot Wounds, Operative and Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals). This great work, issued some years since in England, has won such universal confi- dence wherever the language is spoken that its republication here, in a form more thoroughly adapted to the wants of the American practitioner, has seemed to be a duty owing to the profession. To accomplish this, each article has been placed in the hands of a gentleman specially competent to treat its subject, and no labor has been spared to bring each one up to the foremost level of the times, and to adapt it thoroughly to the practice of the country. In certain cases this has rendered necessary the substitution of an entirely new essay for the original, as in the case of the articles on Skin Diseases, on Diseases of the Absorbent System, and on Anaesthetics, in the use of which American practice ditFers from that of England. The same carefid and conscientious revision has been pursued throughout, leading to an increase of nearly one-fourth in matter, while the series of illustrations has been nearly trebled, and the whole is presented as a coniplete exponent of British and American Surgery, adapted to the daily needs of the working practitioner. In order to bring it within the reach of every member of the profession, the five vol- umes of the original have been compressed into three by employing a double-columned royal octavo page, and in this improved form it is offered at less than one-half the price of the original. It is printed and bound to match in every detail with Reynolds' System of Medi- cine. The work will be sold by subscription only, and in due time every member of the profession will be called upon and offered an opportunity to subscribe. The authors of the original English edition are ' the library of any medical man. It is more wieldly- men of the front rank in England, and Dr. Packard and more useful than the English edition, and with has been fortunate in securing as his American its companion work — "Reynolds' System of Medi- coadjutors such men as Bartholow, Hyde, Hunt, cine"— will well represent the present state of our Conner, Stimson, Morton, Hodgen, Jewell and science. One who is familiar with those two works their colleagues. As a whole, the work will be : will be fairly well furnished head-wise and hand- solid and substantial, and a valuable addition to 1 wise.— The Medical IVews, Jan. 7, 1882. STIMSON, LEWIS A., B. A., M. D., Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator to ieUevue Hospital, Surgeon to the Presbyterian £[ospital. New York, etc. A Practical Treatise on Fractures. In one very handsome octavo volume of 598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. The author has given to the medical profession \ the surgeon in full practice. — N. O. Medical and in this treatise on fractures what is likelj' to be- j Surgical Journal, March, 1883. come a standardwork on the subject. It is certainly ] -pjje author gives incfear language all that the not surpassed by any work written m the English, practical surgeon need know of the science of or, for that matter, any other language. The au- fractures, their etiology, symptoms, processes of thor tells us in a short, concise and comprehensive i union, and treatment, according to the latest de- manner, all that IS known about his subject. There velopments. On the basis of mechanical analysis is nothing scanty or superficial about it, as in most ^^e author accurately and clearly explains the other treatises; on the contrary, everything IS thor- clinical features of fractures, and by the same ough. The chapters on repair of fractures and their method arrives at the proper diagnosis snd rational treatment show him not only to be a profound stu- ' treatment. A thorough explanation of the patho- dent, but likewise a practical surgeon andpatholo- logical anatomy and a careful description of the gist. His mode of treatment of the different fract- I various methods of procedure make the book full uresis eminently sound and practical. Weconsider ^f y^lue for every mB.., LL. J>., Surgeon to Belleviie Hospital, New York. A Practical Treatise on Fractures and Dislocations. Seventh edition, thoroughly revised and much improved. In one very handsome octavo volume .of 998 pages, with 379 illustrations. Cloth, |5.o0 ; leather, $6.50 ; very handsome half Russia, open back, $7.00. Just ready. Hamilton's great experience and wide acquaint- i other language. — Medical Record, January 24, 1885. ancewith the literature of the subject have enabled ' With its first appearance in 1859, this worli took him to complete the labors of Malgaigne and to i rank among the classics in medical literature place the reader in possession of the advances and has ever since been quoted by surgeons the made daring thirty years. Tlie editions have fol- world over as an authority upon the topics of lowed each other rapidly, and they introduce us which it treats. The surgeon, If one can be to the methods of practice, often so wise, of his found who does not already know the work, will American colleagues. More practical than Mai- find it scientific, forcible and scholarly in text, gaigne's work, it will serve as a valuable guide to 1 exhaustive in detail, and ever marked by a spirit the practitioner in the numerous and embarras ing cases which come under his observation. — Archives Generates de Medccine, Paris, Nov. 1884. There is no longer any necessity for reviewing this admirable work. It has triumphantly ad- vanced to its seventh edition, its venerable and talented author still keeps abreast of the times, and it is still the most exhaustive practical trea- tise on fractures and dislocations in this or any of wise conservatism. — Louisville Medical Neios, Jan. 10, 1885. For a quarter of a century the author has been elaborating and perfecting his work, so that it now stands as the best of its kind in any lan- guage. As a text-book and as a book of reference and guidance for practitioners it is simply invalu- able.— New Orleans Medical and Surgical Journal, November, 1884. JVLBB, HENMY E., F, B. C. S,, Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp. ; late Clinical AssH, Moorfields, London. A Handbook of Ophthalmic Science and Practice. In one handsome octavo volume of 460 pages, with 12o woodcuts, 27 colored plates, and selections from the Test-types of Jaeger and Snellen. Cloth, $4.50; leather, $5.50. Just ready. This work is distinguished by the great num- 1 and typical illustrations of all important eye ber of colored plates which appear in it for illus- trating various pathological conditions. They are very oeautiful in appearance, and have "been executed with great care as to accuracj'. An ex- amination of tlie work shows it to be one of high standing, one that will be regarded as an authority among ophthalmologists. The treatment recom- mended is such as the author has learned from actual experience to be the best. — Cincinnati Medi- cal Ne>cs,T>&Q.. 1884. It presents to the student concise descriptions affections, placed in juxtaposition, so as to be f rasped at a glance. Beyond a doubt it is the est illustrated handbook of ophthalmic science which has ever appeared. Then, what is still better, these illustrations are nearly all original. We have examined this entire work with great care, and it represents the commonly accepted views of advanced ophthalmologists. We can most heartily commend this book to all medical stu- dents, practitioners and specialists. — Detroit Lancet, Jan. 1885. WELLS, J. SOELBERG, F, B. C, S., Professor of Ophthahnology in Kiyvfs College Hospital, London, etc. A Treatise on Di.seases of the Eye. Fourth American from the third London edition. Thoroughly revised, with copious additions, by Charles S. Bull, M. D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. In one large octavo volume of 822 pages, with 257 illustrations on wood, six colored plates, and selections from the Test- types of Jaeger and Snellen. Cloth, $5.00 ; leather, $6.00 ; half Russia, $6.50. The present edition appears in less than three ' shows the fidelity and thoroughness with which years since the publication of the last American the editor has accomplished his part of the work, edition, and yet, from the numerous recent inves- The illustrations throughout are good. This edi- tigations that have been made in this branch of , tion can be recommended to all as a complete medicine, many changes and additions have been • treatise on diseases of the eye, than which proba- required to meet the present scope of knowledge 1 bly none better exists.— ilfedicaJ iiecord, Aug. 18, '83. upon this subject. A critical examination at once | NETTLESHLP, EnWABD, F, B, C. S., Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' Hospital, London. The Student's Guide to Diseases of the Eye. Second edition. With a chap- ter on the Detection of Color-Blindness, by William Thomson, M. D., Ophthalmologist to the Jefferson jNIedical College. In one royal 12mo. volume of 416 pages, with 138 illustrations. Cloth, $2.00. This admirable guide bids fair to become the i and well chosen. This book, within the short eom- favorite text-book on opluhalmic surgery with stu- j pass of about 400 pages, contains a lucid exposition dents and general practitioners. It bears through- | of the modern aspect of ophthalmic science.— out the imprint of sound judgment combined with i Medical Record, June 23, 1883. vast experience. The illustrations are numerous [ BBOWNE, EL>GAB A,, Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. How to Use the Ophthalmoscope. Being Elementary Instructions in Oph- thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 pages, with 35 illustrations. Cloth, $1.00. LAWSON ON INJURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. 8 vo., 404 pp., 92 illus. Cloth, ^3.50. LAURENCE AND MOON'S HANDY BOOK OF OPHTHALMIC SURaERY, for the use of Prac- titioners. Second edition. In one octavo vol- ume of 227 pages, with 65 illust. Cloth, 82.75. CARTER'S PRACTICAL TREATISE ON DISEAS- ES OF THE EYE. Edited by John Geeen, M. D. In one handsome octavo volume. 24 Lea Brothers & Co.'s Publications — Otol., Urin. Dis.,Deut. BVniSrBTT, CMAMLES B., A. M,, M. D., Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. New (second) edition. In one handsome octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. Just ready. carried out, and much new matter added. Dr. We note with pleasure the appearance of a second edition of this valuable work. When it first came out it was accepted by the profession as one of the standard works on modern aural surgery_ in the English language; and in his second edition Dr. Burnett has fully maintained his reputation, for the book is replete with valuable information and suggestions. The revision has been carefully Burnett's work must be regarded as a very valua- ble contribution to aural surgery, not only on account of its comprehensiveness, but because it contains the results of the careful personal observa- tion and experience of this eminent aural surgeon. — London Lancet, Feb. 21, 1885. POLITZEIt, ADAM, ImperiaURoyal Prof, of Aural Thera.p. in the Univ. of Vienna, A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by James Patterson Cassells, M. D., M. K. C. S. In one handsome octavo vol- ume of 800 pages, with 257 original illustrations. Cloth, $5.50. The work itself we do not hesitate to pronounce the best upon the subject of aural diseases which has ever appeared, systematic without being too diffuse on obsolete subjects, and eminently prac- tical in every sense. The anatomical descriptions of each separate division of the ear are admirable, and profusely illustrated by woodcuts. They are followed immediately by the physiology of the section, and this again by the pathological physi- ology, an arrangement which servesto keep up the interest of the student by showing the direct ap- plication of what has preceded to the studv of dis- ease. The whole work can be recommended as a reliable guide to the student, and an efficient aid to the practitioner in his treatment. — Boston Med- ical and Surgical Journal, June 7, 1883. ROBERTS, WILLIAM, 31, J)., Lecturer on Medicine m the Manchester School of Medicine, etc. A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. In one hand- some octavo volume of about 650 pages, with 81 illustrations. Cloth, §3.50. Jks^ ready. GROSS, S. n., M. D., LL, n., D. C, L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by Samuel W. Gross, M. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, Philadelphia. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. MORRIS, HENRY, M. B., F. R. C. S,, Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. Surgical Diseases of the Kidney. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 3. LUCAS, CLEMEJVtTmIb^ B. S., F. R. C. S., Senior Assistant Surgeon to Guy's Hospital, London. Diseases of the Urethra. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 3. TMOMFSOW, SIR HENRY, Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Fistulse. From the third English edition. In one octavo volume of 359 pages, with 47 cuts and 3 plates. Cloth, $3.50. COLEMAN, A,, L~R, C, F., F. R. C, S., Exam. L. D. S., Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, ' M. A., M. D., D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. This volume deserves to rank among the most important of recent contributions to dental litera- ture. BIr. Coleman has presented his methods of practice, for the most part, in a plain and concise manner, and the work of the American editor has been conscientiously performed. He has evidently laboredto present his convictions of the best modes pf practice for the instruction of those commenc- ing a professional career, and he has faithfully en- deavored to teach to others all that he has acquired Iby his own observation and experience. The book deserves a place in the library of every dentist. —Dental Cosmos, May, 1882. BASHAM on renal diseases : A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. Guide to their Diagnosis and Treatment. In | Cloth, 82.00. Lea Brothers & Co.'s Publications — Venei-eal, Impotence. 25 BU3ISTEAI>, F. J,, cmcl TAYLOB, M, W., M. D., LL, D., A. 31., M. D., Late Professor of Venereal Diseases Surgeon to Charity Kospital, New York, Prof, of at the College of Physicians and Venereal and Skin Diseases in the University of Surgeom, New York, etc. Vermont, Pres. of the Am. Dermatological Ass'n. The Pathology and Treatment of Venereal Diseases. Including the results of recent investigations upon the suliject. Fifth edition, revised and largely re- written, by Dr. Taylor. In one large and handsome octavo volume of 898 pages with 139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, $5.75 ; very handsome half Russia, $6.25. It is a splendid record of honest labor, wide ; The character of this standard work is so well research, just comparison, careful scrutiny and i known that it would be superfluous here to pass in original experience, which will always be held as review its general or special points of excellence, a high credit to American medical literature. This ' The verdict of the profession has been passed; it is not only the best work in the English language , has been accepted as the most thorough and com- upon the subjects of which it treats, but also one ■ plete exposition of the pathology and treatment of wnich has no equal in other tongues for its clear, venereal diseases in the language. Admirable as a comprehensive and practical handling of its model of clear description, an exponent of sound themes. — American Journal of the Medical Sciences, J pathological doctrine, and a guide for rational and Jan, 1884. I successful treatment, it is an ornament to the medi- It is certainly the best single treatise on vene- ^ cal literature of this country. The additions made real in our own, and probably the best in any Ian- ' to the present edition are eminently judicious, guage. — Boston Medical and Surgical Journal, April | from the standpoint of practical utility. — Journal oj 3, 1884. I Cutaneous and Venereal Diseases, Jan. i884. MUTCHIJVSOW, JONATHAJS^, F. B. S., F. B. C, S., Consulting Surgeon to the London Hospital. Syphilis. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 3. COBWIL, F., Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. The anatomical and histological characters of the [ the whole volume is the clinical experience of the hard and soft sore are admirably described. The author or the wide acquaintance of the translators multiform cutaneous manifestations of the disease i with medical literature more evident. The anat- are dealt with histologically in a masterly waj', as ■ omy, the histology, the pathology and the clinical we should indeed expect them to he, and the ' features of syphilis are represented in this work in accompanying illustrations are executed carefully ' their best, most practical and most instructive and well. The various nervous lesions which are j form, and no one will rise from its perusal without the recognized outcome of the syphilitic dyscrasia j the feeling that his grasp of the wide and impor- are treated with care and consideration. Syphilitic tant subject on whicli it treats is a stronger and epilepsy, paralysis, cerebral syphilis and locomotor i surer one. — The London Practitioner, Jan. 1882. ataxia are subjects full of interest; and nowhere in | GBOSS, SAMUFL W., A. M., 31. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand- some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. The author of this monograph is a man of posi- 1 This work will derive value from the high stand- tive convictions and vigorous style. This is iusti- , ing of its author, aside from the fact of its passing fied by his experience and by his study, which has ' so rapidly into its second edition. This is, indeed, gone hand in hand with his experience. In regard ' a book that every physician will he glad to place to the various organic and functional disorders of in his library, to be read with profit to himself, the male generative apparatus, he has had ex- and with incalculable benefit to his patient. Be- ceptional opportunities for observation, and his sides the subjects embraced in the title, which are book shows that he has not neglected to compare ■ treated of in their various forms and degrees, his own views with those of other authors. The spermatorrhcpa and prostatorrhcea are also fully result is a work which can be safely recommended considered. The work is thoroughly practical in to both physicians and surgeons as a guide in the character, and will be especially useful to the treatment of the disturbances it refers to. It is ; general practitioner. — Medical Record, Aug. 18, the best treatise on the subject with which we are j 1883. acquainted. — T/ie il/edicai iVeios, Sept. 1, 1883. ' CUZZFBIFB, A., <& BU31STFAD, F. J., Jtf.2)., LL.D., Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians and Surgeons, New York. An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- stead, M. I). In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Strongly bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. HILL ON SYPHILIS AND LOCAL CONTAGIOUS FORMS OF LOCAL DISEASE AFFECTING DISORDERS. In one 8vo vol. of 479 p. Cloth, S3.25. PRINCIPALLY THE ORGANS OF GENERA- LEE'S LECTURES ON SYPHILIS AND SOME I TION. In one 8vo. vol. of 246 pages. Cloth, $2.25. 26 Lea Brothers & Co.'s Publications — Diseases of Skin. MTDJE, J. NBVIWS, A, M., M, D., Professor of Dermatology and Venereal Diseases in Hush 31edic(il College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- orate illustrations. Cloth, $4.25 ; leather, ^5.25. The author has given the student and practi- tioner a work admirably adapted to the wants of each. We can heartily commend the book as a valuable addition to our literature and a reliable guide to students and practitioners in their studies and practice. — Am. Journ. of Med. Sci., July, 1883 cian in active practice. In dealing with these questions the author leaves nothing to the pre- sumed knowledge of the reader, but enters thor- oughly into the most minute description, so that one is not only told what should be done under given conditions but how to do it as well. It is Especially to be praised are the practical sug- j therefore in the best sense "a practical treatise." gestions as to what may he called the common- ; That it is comprehensive, a glance at the index sense treatment of eczema. It is quite impossible i will show. — Maryland Medical Journal, July 7, 1883, to exaggerate the judiciousness with which the i Professor Hyde has long been known as one of formulae for the external treatment of eczema are j the most intelligent and enthusiastic representa- selected, and what is of equal importance, the full tives of dermatology in the west. His numerous and clear instructions for their use. — London Medir ' contributions to the literature of this specialty cal Times and Gazette, July 28, 1883. ! have gained for him a favorable recognition as a The work of Dr. Hyde will be awarded a high ; careful, conscientious and original observer. The position. The student of medicine will find it remarkable advances made in our knowledge of peculiarh' adapted to his wants. Notwithstanding diseases of the skin, especially from the stand- the extent of the subject to which it is devoted, point of pathological histology and improved yet it is limited to a single and not very large vol- methods of treatment, necessitate a revision of ume, without omitting a proper discussion of the topics. The conciseness of the volume, and the setting forth of only what can be held as facts will also make it acceptable to general practitioners. — Cincinnati Medical Neios, Feb. 1883. The aim of the author has been to present to his readers a work not only expounding the most the older text^books at short intervals in order to bring them up to the standard demanded by the march of science. This last contribution of Dr. Hyde is an effort in this direction. He has at- tempted, as he informs us, the task of presenting in a condensed form the results of the latest ob- servation and experience. A careful examination modern conceptions of his subject, but presenting of the work convinces us that he has accomplished what is of standard value. He has more especially his task with painstaking fidelity and with a ered- devoted its pages to the treatment of disease, and itable result. — Journal of Cutaneous and Venereal by his detailed descriptions of therapeutic meas- ] Diseases, June, 1883. nres has adapted them to the needs of the physi- I Physician to the Department for Skin Diseases, Vniversity College Hospital, London. FOX, T., M.JD., F.n. C. JP., and FOX, T. C, B.A., 3I.It. CS., Physician for Diseases of the Skin to the Westmin.'iter Hospital, London. An Epitome of Skin Diseases. With Formulse. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, |] .25. The third edition of this convenient handbook ' manual to lie upon the table for instant reference, calls for notice owing to the revision and expansion Its alphabetical arrangement is suited to this use, which it has undergone. The arrangement of skin for all one has to know is the name of the disease, diseases in alphabetical order, which is the method and here are its description and the appropriate of classification adopted in this work, becomes a positive advantage to the student. The book is one which we can strongly recommend, not only to students but also to practitioners who require a treatment at hand and ready for instant applica- tion. The present edition has been very carefully revised and a number, of new diseases are de- scribed, while most of the recent additions to compendious summary of the present state of dermal therapeutics find mention, and the formu- dermatology. — British Medical Journal, July 2, 1883. ■ lary at the end of the book has been considerably We cordially recommend Fox'' s Epitome'to those \ augmented. — The Medical News, December, 1883. whose time is limited and who wish a handy 3IOJRMIS, MALCOLM, M. !>., Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. Skin Diseases; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo, volume of 316 pages, with illustrations. Cloth, $1.75. To physicians who would like to know something for clearness of expression and methodical ar- about skin diseases, so that when a patient pre- rangement is better adapted to promote a rational sents himself for relief they can make a correct conception of dermatology — a branch confessedly diagnosis and prescribe a rational treatment, we diflicult and perplexing to" the beginner. — St. Louis unhesitatingly recommend this little book of Dr. Courier of Medicine, April, 1880. Morris. The aflfections of the skin are described in a terse, lucid manner, and their several charac- teristics so plainly set forth that diagnosis will be easy. The treatment in each case is such as the experience of the mosteminent dermatologists ad- vises.— Cincinnati Medical Ncios, April, 1880. This is emphatically a learner's book ; for we can safely say, that in the whole range of medical literature there is no book of a like scope which The writer has certainly given in a small compass a large amount of well-compiled information, and his little book compares favorably with any other which has emanated from England, while in many points he has emancipated himself from the stub- bornly adhered to errors of others of his country- men. There is certainly excellent material in the book which will well repay perusal. — Boston Med. and Surg. Journ., March, 1880. WILSON, FBASMUS, F, B. S. The Student's Book of Cutaneous Medicine and Diseases of the Skin. In one handsome small octavo volume of 535 pages. Cloth, $3.50. HILLIFM, TffOMAS, M. D,, Physician to the Skin Department of University College, London. Handbook of Skin Diseases; for Students and Practitioners. Second Ameri- can edition. In one 12mo. volume of 853 pages, with plates. Cloth, $2.25. Lea Brothers & Co.'s Publications — Dis. of Women. 27 AN AMBItlCAN SYSTBM OF GYJSfMCOLOGY. A System of Gynsecology, in Treatises by Various Authors. Edited by Matthew D. Mann, M. D., Professor of Obstetrics and Gyiifecology in the Uni- versity of Buffalo, N. Y. In two handsome octavo volumes, riclily illustrated. In active preparation. LIST OF CONTRIBUTORS. FORDYCE BARKER, M. I)., CHARLES CARROLL LEE, M. D., ROBERT BATTEY, M. I)., WILLIAM T. LUSK, M. D., SAMUEL C. BUSEY, M. D., MATTHEW D. MANN, M. D., HENRY P. CAMPBELL, M. D., ROBERT B. MAURY, M. D., BENJAMIN F. DAWSON, M. D., C. D. PALMER, M. D., WILLIAM GOODELL, M. D., WILLIAM M. POLK, M. D., HENRY F. GARRIGUES, M. D., THADDEUS A. REAMY, M. D., SAMUEL W. GROSS, M. D., A. D. ROCKWELL, M. D., JAMES B. HUNTER, M. D., ALBERT H. SMITH, M. D., WILLIAM T. HOWARD, JM. D., R. STANSBURY SUTTON, A. M., M. D., A. REEVES JACKSON, M. D., T. GAILLARD THOMAS, M. D., EDWARD W. JENKS, M. D., CHARLES S. WARD, M. D., WILLIAM H. WELCH, M. D. TS03IAS, T, GAILLABD, 31. D., Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $-5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. The words which follow " fifth edition" are in vious one. As a book of reference for the busy this case no mere formal announcement. The practitioner it is unequalled. — Boston Medical any alterations and additions which have been made are Surgical Journal, April 7, 1880. both numerous and important. The attraction ' It has been enlarged and carefully revised. It is and the permanent character of this book lie in a condensed encyclopaedia of gynsecologieal m edi- the clearness and truth of the clinical descriptions cine. The style of arrangement, the masterly of diseases ; the fertility of the author in thera- manner in which each subject is treated, and the peutic resources and tlie fulness with which the honest convictions derived from probably the details of treatment are described; the definite largest clinical experience in that specialty of any character of the teaching; and last, but not least, in this country, all serve to commend it in the the evident candor which pervades it. We would highest terms to the practitioner. — Nashville Jour. also particularize the fulness with which the his- ' of Med. and Surg., Jan. 1881. tory of the subiect is gone into, which makes the That the previous editions of the treatise of Dr. book additionally mterestmg and gives it value as , Thomas were thought worthy of translation into a work of reference.— Xojidon Medical Times and t German, French, Italian .and Spanish, is enough Gazette, July 3(1, 1881. 1 to give it the stamp of genuine merit. At home it The determination of the author to keep his I has made its way into the library of every ob.stet- book foremost in the rank of works on gynaecology rician and gynaecologist as a safe guide to practice. is most gratifying. Recognizing the fact that this No small number of additions have been made to can only be accomplished by frequent and thor- i the present edition to make it correspond to re- ough revision, he has spared no pains to make the cent improvements in treatment. — Pacific Medical present edition more desirable even than the pre- j and Surgical Journal, Jan. 1881. BDIS, ABTJIUM m^M^n,, L07id., I\R. C. P,, 31. JR. C. S., Assist. Obstetric Phi/sician to Middlesex Hospital, late Physician to British Lying-in Hospital. The Diseases of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. It is a pleasure to read a book so thoroughly \ The greatest pains have been taken with the good as this one. The special qualities which are sections relating to treatment. A liberal selection conspicuous are thoroughness in covering the i of remedies is given for each morbid condition, whole ground, clearness of description and con- the strength, mode of application and other details ciseness of statement. Another marked feature of being fully explained. The descriptions of gynae- the book is tlie attention paid to the details of i eological manipulations and operations are full, many minor surgical operations and procedures, clear and practical. Much care has also been be- as, for instance, the use of tents, application of stowed on the parts of the book which deal with leeches, and use of hot water injections. These " " "'' -•-ii- ti.- j h»-™ are among the more common methods of treat- ment, and yet very little is said about them in many of the text-books. The book is one to be warmly recommended especially to students and general practitioners, who need a concise but com- diagnosis — we note especially the pages dealing with the differentiation, one from another, of the different kinds of abdominal tumors. The prac- titioner will therefore find in this book the kind of knowledge he most needs in his daily work, and ^ ^ , _ he will be pleased with the clearness and fulness plete resume of the whole subject. Specialists, too, 1 of the information there given.— Tfce Practitioner, will find many useful hints in its pages. — Boston \ Feb. 1882. Med. and Surg. Journ., March 2, 1882. BABWjES, BOBEBT, 31. D., F. B. C. B., Obstetric Physician to St. Thomas^ Hospital, London, etc. A Clinical Exposition of the Medical and Surgical Diseases of Women. In one handsome octavo volume, with numerous illustrations. New edition. Preparing. WEST, CHABLES, 31^1). Lectures on the Diseases of Women. Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. CHURCHILL ON THE PUERPERAL FEVER MEIGS ON THE NATURE, SIGNS AND TREAT- AND OTHER DISEASES PECULIAR TO WO- MENT OF CHILDBED FEVER. In one 8vo. MEN. In oneSvo. vol. of4G4pages. Cloth, S2.50. volume of 346 pages. Cloth, S2.00. 28 Lea Brothers & Co.'s Publications — Dis. of Women, Midwfy. E3IMET, THOMAS AI>DIS, M, JD., LL. D., Surrjeon to the Woman^s Hospital, New York, etc. The Principles and Practice of Gynseeology ; For the use of Students and Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and ver}' handsome octavo volume of SSO pages, with 150 illustrations. Cloth, $5 ; leather, $6. (Just ready.) Excerpt from the Author's Preface to the Second Edition. So great have been the advance and change of views during the past four years in Gynaecology, that the preparation of this edition has necessitated almost as much labor as to have rewritten the volume. Every portion has been thoroughly revised, a great deal has been left out, and much new matter added. The chapters on the relation of education and social condition to development, those on iDelvic cellulitis, the diseases of the ovary and on ovariotomy, together with that on stone in the bladder, have been nearly rewritten. The cliapters on prolapse of the vaginal walls and lacerations of the vaginal outlet, the methods of partial and complete removal of the uterus for malignant disease, the surgical treatment of fibrous tumors, diseases of the Fallopian tubes, and the diseases of the urethra, are essentially new, with the views and experience of the author in a form which has not been presented to the profession before. To these chapters not less than one hundred and seventy-five pages of new material have been added. The work may now be said fairly to represent j it is second to none other. No one can read the present position of gyniecology in America, i Emmet without pleasure, instruction and profit, and is one of the best, if not the best, in the Eng- ■ — Cincinnati Lancet and Clinic, Jan 31, 1885. lish language. It remains a worthy exponent of i It is with a feeling of pleasure that we welcome a life devoted to the study and practice of gynse- ! a work on diseases of women from so eminent a oology ; a book that will be of immense value to gynreeologist as Dr. Emmet. The work is essenti- the profession at large, and one which will be a ally clinical, and leaves a strong impress of the stimulus to better work wherever it is read. — author's individualitJ^ To criticize the work Boston Medical andSiirgical Journal, Jan. 29, 1885. throughout with the care it merits, would demand Any work on gynicologj' by Emmet must far more space than is at our command. In part- always have especial interest an'd value. He has ing, we can say that the work teems with original for many years been an exceedingly busy prac- ideas, iVesh and valuable methods of practicej^ and titioner'in this department. Few men have had is written in a clear and elegant style, worthy of his experience and opportunities. As a guide tlie literary reputation of Longfellow and 0. W. either for the general practitioner or specialist, , Holmes. — "Tlte Southern Practitioaet , 'Feb. 1885. DUJVCAW,_ J. MATTHEWS, M.JO., LL. D., F, M. S. E., etc. Clinical Lectures on the Diseases of "Women ; Delivered In Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. They are in every way worthy of their author ; ] stamp of individuality that, if widely read, as they indeed, we look upon them as among the most I certainly deserve to be, they cannot fail to exert a valuable of his contributions. They are all upon j wholesome restraint upon'the undue eagerness matters of gre.at interest to the general practitioner. ; with which many young physicians seem bent Some of thein deal with subjects that are not, as a j upon following the wild teachings which so infest rule, adequately handled in the text-books; others i the gynecology of the present day. — N. V. Medical of them, while bearing upon topics that are usually | Journal, Marcli, 1880. treated of at length in such works, yet bear such a \ HODGE, HVGHL., 31. !>., Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. On Diseases Peculiar to Women; Including Displacements of the Uterus. Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 pages, with original illustrations. Cloth, $4.50. By the Same Author. The Principles and Practice of Obstetrics. Illustrated Avith large litho- graphic plates containing 159 figures from orighial photographs, and with numerous wood- cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in cloth, $14.00. * * * Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. TAMWIEB, S., and CHANTREUIL, G, A Treatise on the Art of Obstetrics. Translated from the French. In two large octavo volumes, richly illustrated. MAMSBOTHAM, FRANCIS H., 31. D. The Principles and Practice of Obstetric Medicine and Surgery; In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., in the Jefferson Medical College of Philadelphia. In one large and handsome imperial octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. ASHWELL'S PRACTICAL TREATISE ON THE ; American from the third and revised London DISEASES PECULIAR TO WOMEN. Third edition. In one 8vo. vol., pp. 520. Cloth, S3.50. Lea Brothers & Co.'s Publications — Midwifery. 29 JPZAYFAIM, TV. S,, 31, J>., F. M, C. J>., Professor of Obstetric Medicine in King's College, London, etc. A Treatise on the Science and Practice of Midwifery. JS'ew (fourth) American edition, revised by the Author. Edited, with additions, by Egbert P. Har- Bis, M. D. In one handsome octavo vokime of about 700 pages, with 183 illustrations and 3 ph^tes. Clotli, $4 ; leather, $5 ; half Russia, §5.50. Just ready. A few notices of the previous edition are appended: The medical profession^has now the opportunity j choose Playfair's. It is of convenient size, but what is of chief importance, its treatment of the various subjects is concise and plain. While the discussions and descriptions are sufficiently elabo- rate to render a very intelligible idea of them, yet all details not necessary for a full understanding of the subject are omitted.— C'mciimait Medical News, Jan., 1S80. It certainly is an admirable exposition of the science and practice of midwifery. Of course the additions made by the American editor. Dr. R. P. Harris, who never utters an idle word, and whose studious researches in some special departments of obstetrics are so well known to the profession, are of great value. — The American Practitioner, of adding to their stock of standard medical works one of the best volumes on midwifery ever pub- lished. The subject is taken up witli a master hand. The part devoted to labor in all its various presentations, the management and results, is ad- mirably arranged, and the views entertained will be found essentially modern, and the opinions ex- pressed trustworthy. The work abounds with plates, illustrating various obstetrical positions ; they are admirably wrought, and afford great assistance to the student. — N. 0. Medical and Sur- gical Journal, March, 1880. If inquired of by a medical student what work on obstetrics we should recommend for him, par excellence, we would undoubtedly advise him to | April, 1880 KING, A, F, A,, M. 2>., Professor of Obstetrics and Diseases of Women m the Medical Department of the Columbian Univer- sity, Washington, D. C, and in the University of Vermont, etc. A Manual of Obstetrics. New edition. In one very handsome 12mo. volume of 331 pages, with 59 ilhistrations. Cloth, §2.00. In a series of short paragraphs and by a con- i correct idea of them. The general practitioner densed style of composition, the writer has pre- : will also find it very useful for reference, for the sented a great deal of what it is well that every , purpose of refreshing the mind. We can confi- obstetrician should know and be ready to practice ' dently assert that it will be found to be the best or prescribe. The fact that the demand for the class text-book upon obstetrics that has been volume has been such as to exhaust the first issued from the press. — Cincinnati Medical News, edition in a little over a year and a half speaks March, 1884. well for its popularity. — American Journal of the , It must be acknowledged that this is just what Medical Sciences, April, 1884. " , it pretends to be — a sound guide, a portable epit- This little work upon obstetrics will be highly j ome, a work in which only indispensable matter valued by medical students. We fee! quite sure i has been presented, leaving out all padding and that it will be in great demand by them, so suited I chaff, and one in which the student will fifcd pure is it to their wants. Of a size that it can be easily ' wheat or condensed nutriment. — ±yew Orlcam Med- carried, yet it contains all of the main points in i ical and Surgical JournaL 3Iay, 1S84. obstetrics sufficiently elaborated to give a full and i BARNES, JROBEBT, M. D,, and FANCOUJRT, M. I)., Phys. to the General Lying-in Hnap., Load. Obstetric Phys. to St. Thomas' Hasp., Land. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For tlie Student and the Practitioner. The Section on Embryology contributed by Prof. Mihies Marshall. In one handsome octavo volume of about 1000 pages, profusely illustrated. Cloth, §5 ; leather, 86. In press. BAJRNES, FANCOTIBT, 31. D., Obstetric Physician to St. Thomas'' Hospital, London. A Manual of Midwifei'v for Midwives and Medical Students. In one royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. FABnW, TMEOFMILTJS, 31. D., LL. !>., Professor of Obstetrics and the Diseases of Women and Children m the Jefferson Medical College. A Treatise on Midwifery. In one very handsome octavo volume of about 550 pages, with numerous illustrations. In press. FABBY, JOSN S., 31. D., Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy : Its Clinical History, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. TANNEB, TS03IAS SAWKES, 31. J>. On the Signs and Diseases of Pregnancy. First American from the second English edition. In one handsome octavo volume of 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25. WUSrCKEZ, F. A Complete Treatise on the Pathology and Treatment of Childbed, For Students and Practitioners. Translated, with the consent of the Author, from the second German edition, by James Read Chadwick, M. D. In one octavo volume of 484 pages. Cloth, $4.00. 30 Lea Brothers & Co.'s Publications — Midway., Dis. Cliildn. LBISHMAN, WILLIAM, M. D., Regius Professor of Midwifery in the University of Glasgow, etc. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, with additions by John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, |4.50 ; leather, 15.50 ; very handsome half Kussia, raised bands, $6.00. The author is Vjroad in his teachings, and dis- cusses briefly the comparative anatomy of the pel- vis and tlie mobility of the pelvic articulations. The second chapter is devoted especially to the siudy of the pelvis, vphile in the third the female "organs of generation are introduced. The structure and development of the ovum are admirably described. Then follow chapters upon the various subjects embraced in the study of mid- wifery. The descriptions throughout the work are plain and pleasing. It is sufBcientto state that in this, the last edition of this well-known work, every recent advancement in this field has been brought forward.— Pfo/s/cirtn ai^d Surgeon, Jan. 1880. We gladly welcome the new edition of this ex- cellent text-book of midwifery. The former edi- tions have been most favorably received by the profession on both sides of the Atlantic. In the preparation of the present edition the author has made such alterations as the progress of obstetri- cal science seems to require, and we cannot hut admire the ability with which the task has been Performed. We consider it an admirable text- ook for students during their attendance upon lectures, and have great pleasure in recommend- ing it. As an exponent of the midwifery of the present daj' it has no superior in the English lan- guage.— Canada Lancet, Jan. 1880. To the American student the work before us must prove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demonstrations noted for clearness and precision, it will gain in favor and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended. — N. O. Med. and Surg. Journ., March, 1880. SMITS, J. LEWIS, M. !>., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. A Complete Practical Treatise on the Diseases of Children. Fifth edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, with illustrations. Cloth, |4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6. This is one of Ihe best books on the subject with which we venture to say will be a favorable one. — which we have met and one that has given us Dublin Journal of Medical Science, March, 1883. satisfaction on every occasion on which we have There is no book published on the subjects of consulted it, either as to diagnosis or treatment, which this one treats that is its equal in value to It is now in its fifth edition and in its present form the physician. While he has said just enough to is a very adequate representation of the subject it impart the information desired by general practi- treats of as at present understood. The important ^ tioners on such questions as etiology, pathology, subject ^f infant hygiene is fully dealt with in the , prognosis, etc., he lias devoted more attention to early portion of the Dook. The great bulk of the i the diagnosis and treatment of the ailments which work is appropriately devoted to the diseases of I he so accurately describes ; and such information infancy and childhood. We would recommend is exactly what is wanted by the vast majority of any one in need of information on the subject to " family physicians." — Va. Med. Monthly, Feb. 1882. procure the work and form his own opinion on it, KEATING, JOHN 31., 31 D,, Lecturer on the Diseases vf Children at the University of Pennsylvania, etc. The Mother's Guide in the Management and Feedjng of Infants. In one handsome 12mo. volume of 118 pages. Cloth, $1.00. Works like this one will aid the physician im- the employment of a wet-nurse, about the proper mensely, for it saves the time he is constantly giv- food for a "nursing mother, about the tonic effects ing his patients in instructing them on the sub- of a bath, about the perambulator uersws the nurses, jects here dwelt upon so thoroughly and prac- arms, and on many other subjects concerning tically. Dr. Keating has written a practical book, whicn the critic might say, "surely this is obvi- has carefully avoided unnecessary repetition, and ous," but which experience teaches us are exactly successfully instructed the mother in such details the things needed to be insisted upon, with therich of the treatment of her child as devolve upon her. \ as well as the poor. — London Lancet, J a,nuiiry,2S18S2 He has studiously omitted giving prescriptions, a book small in size, written in pleasant style, in and instructs the mother when to call upon the language which can be readily understood by any doctor, as his duties are totally distinct from hers, mother, and eminently practical and safe; in fact —American Journal of Obstetrics, October, 1881. a book for which we have been waiting a long Dr. Keating has kept clear of the common fault \ time, and which we can most heartily recommend of works of this sort, viz., inixing the duties of ] to mothers as the book on this subject. — New York the mother with those proper to the doctor. There i Medical Journal and Obstetrical Review, Feb. 1882. is the ring of common sense in the remarks about OWEN, EDMUND, M, B,, F. It. C. S., Surgeon to the Children's FTospital, Great Ormond St., London. Surgical Diseases of Children. In one 12mo. volume. Prepurinfj. See Series of Clinical 3funval.i, page 3. WEST, CHARLES, M. D., Physician to the Hospital for Sick Children, London, etc. Lectures on the Diseases of Infancy and Childhood. Fifth American from 6tli English edition. In one octavo volume of 686 pages. Cloth, $4.50 ; leather, $5.50. By the Same Author. On Some Disorders of the Nervous System in Childhood. In one small 12mo. volume of 127 pages. Cloth, $1.00. CONDIE'S PRACTICAL TRE.\TISE ON THE DISEASES OF CHILDREN. Sixth edition, re- | vised and augmented. In one octavo volunne of 779 pages. Cloth, $5.25 ; leather, 8tj.25. Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 TIDY, CSAItLES MEYMOTT, M. B., F. C, S., Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital etc. Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- tion, Kape, Indecent Exposure, Sodomy, Bestiality," Live Birth, Infanticide, Asphyxia Drowning, Hanging, StranguLation, Suffocation. Making a very handsome imperial oc- tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Volume I. Containing 664 imperial octavo pages, with two beautiful colored plates. Cloth, $6.00 ; leatlier, $7.00. The satisfaction expressed with the first portion of this work is in no wise lessened by a perusal of the second volume. We find it characterized by the same fulness of detail and clearness of ex- pression which we had occasion so highly to com- mend in our former notice, and which render it so valuable to the medical jurist. The copious tables of cases appended to each division of the subject, must have cost the author a prodigious amount of labor and research, but they constitute one of the most valuable features of the book, especially for 'reference in medico-legal trials.— American Journal of the Medical Sciences, April, 1884. TAYLOR, ALFRED S., M. D., Lecturer on Medical Jurisprudence and Chemistry in &uy's Hospital, London. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by John J. Keese, M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00; half Russia, raised bands, $6.50. The American editions of this standard manual have for a long time laid claim to the attention of the profession in this country; and the eighth comes before us as embodying the latest thoughts and emendations of Dr. Taylor upon the subject to which he devoted his life with an assiduity and success which made him facile princeps among English writers on medical jurisprudence. Both the author and the book have made a mark too deep to be affected by criticism, whether it be censure or praise. In this case, however, we should only have to seek for laudatory terms. — American Journal of the Medical Sciences, Jan. 1881. This celebrated work has been the standard au- thority in its department for thirty-seven years, both in England and America, in both the profes- sions which it concerns, and it is improbable that it will be superseded in many years. The work is simply indispensable to every physician, and nearly so to every liberally-educated lawyer, and we heartily commend the present edition to both pro- fessions.— Albany Law Journal, March 26, 1881. By the Same Author. The Principles and Practice of Medical Jurisprudence. Third edition. In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; leather, $12. Just ready. For years Dr. Taylor was the highest authoritj' in England upon the subject to which he gave especial attention. His experience was vast, his judgment excellent, and his skill beyond cavil. It is therefore well that the work of one who, as Dr. Stevenson says, had an "enormous grasp of all matters connected with the subject," should be brought up to the present day and continued in its authoritative position. To accomplish this re- sult Dr. Stevenson has subjected it to moat careful editing, bringing it well up to the times. — Ameri- can Journal of the Medical Sciences, Jan. 1884. By the Same Author, Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50 ; leather, $6.50. FFFPER, AUGUSTUS J,, M. S,, M. B., F. R. C. S,, Examiner in Forensic Medicine at the University of London. Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Student^ Series of Maivials, page 3. LEA, HENRY C, Superstition and Force : Essays on The Wager of Law, The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volimie of 552 pages. Cloth, $2.50. This valuable work is in reality a history of civ- ilization as interpreted by the progress of jurispru- dence. . . In " Superstition and Force " we have a philosophic survey of the long period intervening between primitive barbarity and civilized enlight- enment. There is not a chapter in the work that .should not be most carefully studied ; and however well versed the reader may be in the science of jurisprudence, he will find much in Mr. Lea's vol- ume of which he was previously ignorant. The book is a valuable addition to the literature of so- cial science. — Westminster Review, Jan. 1880. By the Same Author. Studies in Church History. The Rise of the Temporal Power— Ben eflt of Clergy — Excommunication. octavo volume of 605 pages. Cloth, $2.50. The author is pre-eminently a scholar. He takes up every topic allied with the leading theme, and traces it out to the minutest detail with a wealth of knowledge and impartiality of treatment that compel admiration. The amount of information compressed into the book is extraordinary. In no other single volume is the development of the New edition. In one very handsome royal Just ready. primitive church traced with so much clearness, and with so definite a perception of complex or conflicting sources. The fifty pages on the growth of the papacy, for instance, are admirable for con- ciseness and freedom from prejudice. — Boston Traveller, May 3, 1883. Allen's Anatomy .... American Journal of the Medical Sciences American System of Gynecol ogj' . American System of Practical Medicine *Ashhurst' s Surgery .... Ash well on Diseases of Women Attfield's Chemistry .... Ball on the Rectum and Anus . '. Barlow's Practice of Medicine Barnes' Midwifery .... *Barnes on Diseases of Women '. Barnes' System of Obstetric Medicine Bartholow on Electricity Basham on Renal Diseases . Bell's Comparative Physiology and Anatomy Bellamy's Operative Surgery Bellamy's Surgical Anatomy Blandford on Insanity Bloxam's Chemistry .... Bowman's Practical Chemistry wBrlstowes Practice of Medicine . Broadbent on the Pulse . . ' . Browne on the Ophthalmoscope . Browne on the Throat Bruce's Materia Medica and Therapeutics Brunton's Materia Medica and Therapeutics Bryant on the Breast .... *Bryant's Practice of Surgery *Bumstead on Venereal Diseases . *Burnett on the Ear .... Butlin on the Tongue .... Carpenter on the IJse and Abuse of Alcohol ^Carpenter's Human Physiology . Carter on the Eye • . . , Century of American Medicine Chambers on Diet and Regimen Charles' Physiological and Pathological Chem Churchill on Puerperal Fever Clarke and Lockwood's Dissectors' Manual Classen's Quantitative Analysis Cleland's Dissector .... Clouston on Insanity .... Clowes' Practical Chemisti-y Coats' Pathology .... Cohen on the Throat .... Coleman's Dental Surgery Condie on Diseases of Children . '. Cooper's Lectures on Surgery Cornil on Syphilis .... *Cornil and Ranvier's Pathological Histology Cullerier's Atlas of Venereal Diseases Curnow's Medical Anatomy Dalton on the Circulation *Dalton's HumanPhysiology Dalton's Topographical Anatomy of the Brain Davis' Clinical Lectures Draper's Medical Physics Druitt's Modern Surgery Duncan on Diseases of Women *Dunglison's Medical Dictionary . Edison Diseases of Women . Ellis' Demonstrations of Anatomy Emmet's Gynaecology *Erichsen's System of Surgerv Esmarch's Early Aid in Injuries and Accid'ts Parquharson's Therapeutics and Mat. Med. Eenwick's Medical Diagnosis Einlayson's Clinical Diagnosis Flint on Auscultation and Percussion Flint on Phthisis .... Elint on Physical Exploration of the Lungs Flint on Respiratory Organs Flint on the Heart .... *Flint's Clinical Medicine Flint's Essays ....'• *Flint's Practice of Medicine Folsom's Laws of U. S. on Custody of Insane Foster's Physiologv .... ♦Fothergill's Handbook of Treatment . Fowues' Elementary Chemistry . Fox on Diseases of the Skin . Frankland and Japp's Inorganic Chemistry Fuller on the Lungs and Air Passages . Galloway's Analysis .... Gibney's Orthopredic Surgery . '. Gibson's Surgery .... Gluge's Pathological Histology, by Leidy Gould's Surgical Diagnosis . *Gray's Anatomy . . . . [ Greene's Medical Chemistrj' . Green's Pathology and Morbid Anatomy' Griffith's Universal Formulary Gross on Foreign Bodies in Air-Passages" Gross on Imj)otence and Sterility . Gross on Urinary Organs *Gross' System of Surgery Habershon on the Abdomen *Hamilton on Fractures and Dislocations Hamilton on Nervous Diseases Hartshorne's Anatomy and Physiology . Hartshorne's Conspectus of the'Med. Sciences Hartshorne's Essentials of Medicine Hermann's Experimental Pharmacology Hill on Syphilis ..... Hillier's Handbook of Skin Diseases Hoblyn's Medical Dictionary Hodge on Women .... Books marked '* are 21 17 29 27 29 17 24 3,7 3,20 6 19 9 9 14 3,16 23 18 11 11 3,21 21 25 24 3,21 8 8 23 14 17 10 27 6 10 ! 5 19 10 13 18 24 Hodge's Obstetrics Hofimann and Power's Chemical Analysis Holden's Landmarks . . Holland's Medical Notes and Reflections" *Holmes' System of Surgery Horner's Anatomy and Histology Hudson on Fever Hutchinson on Syphilis '. Hyde on the Diseases of the Skin . Jones (C. Handfield) on Nervous Disorders Juler s Ophthalmic Science and Practice Keating on Infants King's Manual of Obstetrics . Klein's Histology La Roche on Pneumonia, Malaria, "etc. *. La Roche on Yellow Fever . Laurence and Moon's Ophthalmic Surgery Lawson on the Eye, Orbit and Eyelid . Lea's Studies in Church History . Lea's Superstition and Force Lee on Syphilis . Lehmann^s Chemical Phj-siology '. =*Leishman's Midwifery Lucas on Diseases of the Urethra ." Ludlow's Manual of Examinations Lyons on Fever . Maisch's Organic Materia Medica '. '. Marsh on the Joints Medical News . . Meigs on Childbed Fever Miller's Practice of Surgery . Miller's Principles of Surgery Mitchell's Nervous Diseases of Women . Morris on Diseases of the Kidneys Morris on Skin Diseases Neill and Smith's Compendium of Med. Sci. Nettleship on Diseases of the Eye . Owen on Diseases of Children *Parrish's Practical Pharmacy Parry on Extra-Uterine Pregnancy Parvin's Midwifery Pavy on Digestion and its Disorders '. Pepper's Forensic Medicine . Pepper's Surgical Pathology Pick on Fractures and Dislocations Pirrie's System of Surgery . Fi'}^'^^''" "" Nerve Prostration and Hysteria *Playfair's Midwifery . . . Politzer on the Ear and its Diseases I Power's Human Physiology . ! Ralfe's Clinical Chemistry . Ramsbotham on Parturition Remsen's Theoretical Chemistry . *Reynolds' System of Medicine Richardson's Preventive Medicine Roberts on Urinary Diseases Roberts' Principles and Practice of Surgery I Robertson's Physiological Physics Rodwell's Dictionary of Science Sargent's Minor and Military Surgery . I Savage on Insanity, including Hysteria . Schafer's Histology Schreiber on Massage ..." Seller on the Throat, Nose and Naso-Pharynx 1 Series of CUnical Manuals Simon's Manual of Chemistry Skey's Operative Surgerj'- Slade on Diphtheria .... Smith (Edward) on Consumption . Smith (H. H.) and Horner's Anatomical Atlas *Smith (J. Lewis) on Children { StUle on Cholera .... *Still^ & Maisch's National Dispensatory *Still6's Therapeutics and Materia Medica Stimson on Fractures .... Stimson's Operative Surgery Stokes on Fever ..... Students' Series of Manuals . Sturges' Clinical Medicine . Tanner on Signs and Diseases of Pregnancy Tanner's Manual of Clinical Medicine . Tarnier and Chantreuil's Obstetrics Taylor on Poisons .... *Taylor's Medical Jurisprudence . Taylor's Prin. and Prac. of Med. Jurisprudence =*Thomas on Diseases of Women . Thompson on Stricture Thompson on Urinary Organs Tidy's Legal Medicine .... Todd on Acute Diseases Treves' Applied Anatomy . Treves on Intestinal Obstruction . Tuke on the Influence of Mind on the Body Walshe on the Heart .... Watson's Practice of Physic . * Wells on the Eve .... West on Diseases of Childhood West on Diseases of Women West on Nervous Disorders in Childhood Williams on Consumption . Wilson's Handbook of Cutaneous Medicine Wilson's Human Anatomy . Winckel on Pathol, and Treatment of Childbed Wohler's Organic Chemistiw Woodhead's Practical Pathology . Year-Book of Treatment also bound in half Russia. LEA BROTHERS & CO., Philadelphia. 4 . \ Date Due LIBRARY OF THE UNIVERSITY OF MASSACHUSETTS MEDICAL CENTRE AT WORCESTER :-^M A " ■*W^;. S ,