OF THE COMMITTEE 
ON 
G-Y1TJECOLOGY. 
BY GEORGE SYNG BRYANT, M. D., 
Chairman, Lexington, Ky. 
EXTRACTED FROM 
“The Transactions of the Kentucky State Medical Society,” for 1871. 
LEXINGTON, KY: 
PRESS AND FARMERS’ HOME JOURNAI PRINT. 
1871. F(EPOF(T OF THE COMJVIITTEE 
ON 
GYNJECOLOGY. 
BY GEORGE SYNG BRYANT, M. D., 
Chairman, Lexington, Ky. 
EXTRACTED FROM 
“The Transactions of the Kentucky State Medical Society,” for 1371. 
LEXINGTON, KY: 
PRESS AND FARMERS’ HOME JOURNAL PRINT. 
1871. T|yn/ecoloqy. 
BY GEORGE SYNG BRYANT, M. D., CHAIRMAN. 
ITH a normal pelvis in view, it is not difficult to 
understand that Sims’ speculum, or some modi- 
fioation of it, exposes more of the vagina and enables 
the operator to get more thorough and easy access to 
the os and the cavities of the cervix and body of 
the uterus, than any other speculum now in use. 
The posterior commissure with the perineum, by any of these 
specula is easily carried back to the point, or lower end of the 
coccyx, and with a volcella or hook attached to the anterior lip of 
the cervix, it is possible to drag the os uteri quite down to the vulva, 
should it ever be necessary. 
The antero-posterior diameter of the superior strait is about 
tbe same as that of the inferior strait, if the measurement be made 
from the sub-pubic ligament to the lower end, or apex of the sa- 
crum. Both these diameters are about four inches.. The diameter 
from the arch of the pubis to the point of the coccyx, is about 
three-quarters of an inch less. But the flexibility of the coccygeal 
articulations is sufficient to allow the lower end of the coccyx to be 
carried back about one inch. 
A line drawn from the promontory of the sacrum to the lower 
end, or coccygeal extremity, will show the excavation to be about 
three-quarters of an inch deep ; thus giving greater capacity to 
the excavation of the pelvis than at either strait. 
The viscera of the pelvis are composed of the rectum, uterus, va- 
gina, fallopian tubes, ovaries, bladder and urethra bound together 
by the pelvic ligaments. Many folds of the small intestines are 
lodged in the Douglas cul-de-sac and in the utero-vesical pouch, or 
cul-de-sac within the cavity of the pelvis. 
The uterus is situated about the center of tbe pelvis. It is in 
front of the rectum, except at the very lowest extremity, and at 4 
Gynaecology. 
that point it is above it. It is behind and somewhat above the 
bladder, and it is above the upper portion of the vagina. The 
bladder and urethra are also above the vagina. 
The uterus and bladder are below the small intestines, which, 
as before stated, occupy the upper portion of the pelvic excava- 
tion. 
The axis of the womb is about that of the superior strait, with 
the fundus looking upward and forward, and the os downward and 
backward. 
When the rectum and bladder are both in the normal condition, 
that is, not distended with fecal matter and gas or urine, the fun- 
dus of the uterus will look to a point about midway between the 
pubis and umbilicus, and the os uteri will look about to the last 
articulation of the coccyx. 
The virgin womb is not straight, but is bent slightly upon it- 
self, in a fomvard direction ; this flexion is, however, not generally re- 
cognized by anatomists. Quain and Sliarpey, Gray and ot hers describe 
the virgin womb as being straight in its axis, and convex exte- 
riorly in both the posterior and anterior walls of the body. 
The concavity of the anterior of the virgin womb looks to the 
bladder in front, and the convexity looks to the rectum behind. 
The os uteri looks into the vagina at a right angle—indeed some- 
times at an acute angle; the anterior lip being shorter and thicker, 
the posterior one longer and thinner. 
The os uteri in women who have borne children is usually trans- 
verse and oval shaped, but in the virgin it is round and very 
small. 
From the vulva to the os uteri the measurement, in the supine 
position, is about two inches, but it is even less than this in the 
erect posture. 
To the posterior cul-de-sac or fornix the vagina is an inch and 
a half or two inches longer. 
The axis otf the vagina does not exactly correspond with the 
axis of the inferior strait. But a line drawn from the arch of the 
pubis to the lower end of the fourth sacral vertebra will nearly corre- 
spond with the axis of the normal vagina. It should be borne in 
mind that the vaginal canal is a little curved downward, the cen- 
tral portion being lower than at either extremity. 
The womb is attached to the bladder in front, from its vaginal 
connection along its entire cervix up to the commencement of the 
body, corresponding to the coarctation or internal os; and it is 
just at this portion of the uterus—the junction of the cervix and body 
—that flexions are most likely to occur if force be applied either to 
the body or fundus, especially in the antero-posterior direction. 
The vagina is connected with the rectum behind, about three- 
fourths of its length, but its attachment to the bowel is not as firm 
and as strong as it is with the bladder. Over the remaining fourth of 
the vagina the pelvic peritoneal membrane is reflected; theperitoneum Gynaecology. 
5 
is also reflected over the entire posterior supra-vaginal neck, the 
body, fundus, anterior portion of the body to its connection with 
the bladder and over the bladder to the abdominal walls in front. 
It will be seen that a hsematocele, or an abscess situated either in 
the Douglas cul-de-sac or in the utero-vesical pouch or cul-de-sac, 
can be easily reached with a trocar through the upper portion of 
the vagina behind, or in front of the os through the septum be- 
tween the uterus and bladder. 
The front wall of the vagina is firmly attached to the bladder 
and urethra, which it supports. The anterior vaginal wall is much 
thicker than the posterior wall. 
Exteriorly the womb is from two and a half to three inches 
long, it is about one and a half inches wide and one inch thick. 
The length of the cervical canal is from an inch and a quarter to 
an inch and a half; the cavity of the body is about one inch long. 
The weight of the nongravid uterus is about an ounce and a 
half; the gravid womb weighs from thirty to forty ounces. 
The womb may be said to be a floating organ in the pelvis, mov- 
able in every direction; it is compared by Dr. Elliot to a ship at 
her moorings, and it is called by Dr. Meigs a see-saw organ—but 
motion is made with the greatest facility in the antero-posterior 
direction. 
Although the external genitalia are of great interest to the 
Gynecologist and Obstetrician, I will pass them by with a brief 
notice, for to describe them minutely, both anatomically and physi- 
ologically, would consume unnecessarily the valuable time of the 
Society. 
Just within the labia minora or nymphos, and about midway their 
basal line, and outside of the carunculce myrtiformes, on either side 
will be found the orifices of the yulvo-vaginal glands, or glands of 
Bartholine. These glands are thought to be the analogue of 
Cowper’s glands in the male. These glands are about the size of a 
small almond, and they secrete a lubricating fluid, which, under 
erotic excitement, is greatly augmented. Sebaceous and mucous 
follicles are also distributed over the external genitalia in great 
abundance for lubricating purposes. These organs are very vas- 
cular, and are erectile, when in a state of physiological hypersemia. 
The vagina, as before stated, is a slightly curved tube, the con- 
cavity looking upwards, and it is larger in the middle portion than 
at either extremity, but very much the smallest at the outlet or 
vulva ; it has been called, not inaptly, a funnel shaped organ. It 
is composed of a mucous membrane, a muscular band at its lower 
extremity and a dense fibro-cellular envelop. There is perhaps no 
organ in the body so elastic as the vaginal tube ; it is easily dilated 
to a great extent, and under the action* of astringents its contrac- 
tion is sometimes so powerful that Gnyaecologists have thought 
there must be superior constrictor vaginal muscles. 
Dr. Marion Sims is among the number who believe there are su- 6 
Gynaecology. 
perior constrictor muscles of the vagina. These muscles as yet 
have not been demonstrated, but there are muscular fibres running 
through every portion of the vaginal walls. 
In both the anterior and posterior walls of the vagina, along 
their entire extent, there is a column of considerable thickness run- 
ning in a longitudinal direction. The anterior column is larger, 
and it is the shorter by about two inches; it therefore puckers and 
folds the anterior wall upon itself laterally more than the posterior 
one. These transverse folds, which are much deeper in front, ex- 
tend obliquely backwards, and are lost on the posterior column. 
These columns and rugje are larger and deeper in the vagina of 
the virgin than in the child-bearing woman. The mucous lining 
of the vagina is regarded as not being a true mucous membrane, as 
it partakes somewhat of the nature of the skin, in both its anato- 
mical and physiological characters. 
The epithelium covering the vaginal lining membrane is of the 
scaly variety. Kilian, who, by the way, was the first to describe 
minutely the papilla? which are thickly spread over the mucous 
membrane of the vagina, and covered with tessellated epithelium, 
regarded these delicate filiform bodies as possessing an exquisite 
sensibility. The mucous membrane is highly supplied with mucip- 
arous follicles which are continually pouring out a lubricating fluid 
—this fluid in its normal condition is of acid reaction. 
The lining membrane of the cervix and cavity of the womb is a 
true mucous membrane; it is thinner in the canal of the cervix 
than it is in the cavity of the body. These membranes are not 
alike either in their anatomical or physiological characters. Dr. 
Tyler Smith was the first to describe the minute anatomy and 
physiology of the cervical mucous membrane. 
This membrane affords a striking and beautiful example of the 
wise provisions of Nature in arranging columns and plicated fur- 
rows for the amplification and stretching, or folding out of the 
cervix in parturition. Without this provision for dilatation in 
child-birth, the os and cervix would invariably be contused and 
lacerated, for a body so large as a child at term, could not bo forced 
through an opening so small and the tissues maintain their integ- 
rity. The arrangement of the folds and ruga; offers another ad- 
vantage which should not be overlooked by the Obstetrician or 
Gynaecologist, which is this, that it gives an abundant surface for 
the development of the muciparous crypts—so-called glands of 
Naboth—which secrete a lubricating fluid in the nongravid uterus, 
and in the gravid womb, the mucous thickens—concretes as it 
were—and acts as a stopper or plug, effectually closing up the 
mouth and cervix uteri until near the termination of pregnancy. 
This fluid when normal is a clear, transparent, rather tenacious 
mucus of alkaline reaction. 
The membrane lining the cavity of the body and fundus is 
thicker than that of the cervix uteri, it is also much smoother—has- Gynaecology. 
7 
no rugae nor plicae, and has a smaller number ol muciparous 
glands developed in it. This membrane is about the eighth of an 
inch thick, in its normal state. 
These uterine or utricular glands are, perhaps, in addition to 
sacreting mucusi the excreting or the exuding apparatus of men- 
struation : that is, they are the channels through which the blood 
escapes from the hyperaemic womb occasioned by the maturation 
of an ovule or ovules in the Graafian follicles in the ovaries. 
In the physiological hyperaemia of the menstrual epoch the 
mucous membrane of the uterus is always thickened, not of neces- 
sity by actual proliferation of its tissues, but by simple congestion 
or fullness of the vascular structure and elongation of the utricular 
glands. 
The mucous membrane is, however, sometimes proliferated and 
partially shed, or disintegrated at the menstrual period. I have 
never seen it cast off in an entire sac, but I have several times 
examined portions of the mucous membrane of the body and 
fundus of the uterus, that had been exfoliated by dysmenorrhceal 
patients during the menstrual epoch. 
Last year I obtained a beautiful specimen of this exfoliated 
membrane from a patient who had long been laboring under 
chronic endo-metritis, or rather chronic fundal endo-metritis. 
The orifice of one of the fallopian tubes was well displayed, and 
under the microscope the mouths or openings of the utricular 
glands could be seen in great numbers. It is probable when this 
“menstrual decidua,” or so-called •fdysmenorrhoeal membrane,” is 
thrown off in this thickened and entire or partially entire state, 
that it is a true decidual membrane resulting from a fecundated 
ovum, and the ovum failing to become attached perishes, and is 
castoff. This view of the matter is taken by Eokitansky, and ad- 
mitted by Klob. 
Dr. Grailey Hewitt thinks it probable that at every normal 
menstruation the mucous membrane of the uterus thickens, softens 
and is partially or wholly cast off, but it is so completely disinte- 
grated that even shreds of it are not to be seen. 
I trust the Society will pardon me for extending the discussion 
of this interesting subject to the pregnant and post-puerperal 
states. For nearly a century past until recently, very erroneous 
ideas have been held by a large portion of the profession concern- 
ing the formation of the decidual membranes; and also as to what 
is the condition of the interior surface of the womb after delivery 
either at the full term or at abortion. 
The truly great William Hunter taught (1775) that the decidual 
membrane is an efflorescence of the mucous coat of the uterus, 
which is shed as often as a woman miscarries, or has a child at full 
term. He farther held that one stratum of this decidual membrane 
is never thrown off, but always remains adherent to the internal 
muscular surface of the uterus. This theory is held at the present time 8 
Gyncecology. 
by Dr. Mathuse Duncan of Edinburgh, Dr. Barnes of London, and 
Klob, Rokitansky and others, but it has not been taught except by very 
few, until the last fifteen years, either in this country or in Europe. 
After the death of William Hunter, errors soon sprung up, 
which resulted in the false teaching that after the delivery the 
muscular internal surface of the uterus is left bare—denuded—and 
that the mucous membrane which is to line the womb after par- 
turition, is formed de novo. But how this new formation is to 
take place, neither John Hunter, who seems to have originated 
this theory, nor any of his followers have ever undertaken to tell 
us. Nor can it be explained by any theory known to the pro- 
fession at the present day, how a true mucous membrane with its 
glandular apparatus can be reformed from a denuded fibro-muscu- 
lar tissue. The inner surface of the womb, after delivery, has 
been compared to the amputated stump of a limb. As just stated 
above it is only recently that the anatomy and physiology of the 
decidua vera and reflexa have been perfectly understood by Ob- 
stetricians and Pathologists, 
Rokitansky, Klob, Duncan, and I may include Robin and 
Priestley, with many others, now teach that the fibro-muscular 
structure of the uterine cavity after delivery at term or abortion 
is never left bare, but that there is a layer of the decidua vera, 
which always remains attached to the fibro-muscular surface, and 
that this layer is composed of a soft, succulent, wide-meshed struc- 
ture, or formed epithelial cells, fibro-cellular structure and fat 
granules which speedily return to the true mucous membrane that 
lines the unimpregnated womb. Dr. Duncan, M. Robin and 
others now teach that the site of the serotina or after-birth is not 
denuded, but it, too, is covered by a layer of soft pulpy epithelial 
membrane, even thicker than that which covers the rest of the 
surface of the cavity of the womb. Outside of the mucous mem- 
brane is the tissue proper or fibro muscular structure which con- 
stitutes the neck and bod}* of the uterus. The walls are thinnest 
around the orifices of the fallopian tubes, and thickest in the 
fundus and middle portions of the body. 
The muscular tissue of the bod}' and fundus is arranged in 
bundles and layers which interlace and cross each other obliquely, 
transversely and longitudinally. There is a large amount of fibro- 
cellular tissue interwoven throughout the entire muscular structure 
of the womb. The tissue proper of the uterus is dense but some- 
what friable in the unimpregnated state: it is covered exteriorly, as 
before mentioned, by the pelvic peritoneum; the muscular fibers 
of the uterus are of the plain or simple variety ; the muscular fibers 
ramifying and strengthening the ligaments of the pelvis are also 
of the same character. These fibers are given off from the uterus, 
and add greatly to the elasticity and resistance of the ligaments. 
As soon as impregnation takes place, the physiological hyper- 
semic condition of the womb is augmented and the organ increas- G-yncecology. 
9 
ing in size, and being of greater weight, sinks lower into the 
cavity of the pelvis until about the fourth month when its increase 
in volume is so great, that it is forced out of the pelvic cavity into 
that of the abdomen. The augmentation of the muscular fibers of 
the uterus is very rapid until about the sixth month of gestation; 
its substance then becoming softer and more succulent. 
The cervix uteri participates only to a slight degree in these 
anatomical and physiological changes until the last month of 
pregnancy, when the cervix rapidly enlarges at its superior por- 
tion, shortens and allows the foetus to descend low down to the os, 
which now becomes thin and soft, but it remains closed until 
labor sets in. 
The os does not participate in active contraction during labor, 
and this is fortunate for the well being of the child, and also for the 
os and cervix, for otherwise these tissues would almost of necessity 
be lacerated. 
Laceration of the os and cervix uteri in parturition, especially 
in primiparce, is not of unfrequent occurrence; and I will add in 
this connection that the perineum also frequently suffers in first 
labors by laceration. To assert that there is a greater or less 
laceration, either of the os uteri or perineum in one out of every 
three labors in primiparous women, would perhaps not be an ex- 
travagant estimation. In a gynecological practice of many years, 
I remember to have seen very few perfect fourchettesin women who 
have borne children. I am aware that the general practitioner 
will dissent from this assertion, but this must be accounted for by 
the want of attention to this class of injuries at the time of labor. 
The Gyna)Cologist has a far better opportunity for detecting lacer- 
ations which have occurred in parturition, either by the cicatrices 
remaining, or by a failure of continuitj’. 
Fatty degeneration of the muscular fibers of the uterus begins 
about the fourth day after labor, under favorable circumstances. 
Dr. Elliot says it may begin within twenty-four hours after labor. 
By fatty degeneration is meant the metamorphosis of the fiber 
cells into fatty granular cells. The cervix participates in this met- 
amorphosis, but in a less degree. After complete metamorphosis 
and absorption of the proliferated tissues of the gravid uterus, the 
organ may be said to have regained its normal size. New formation 
of muscular fibers is said not to begin sooner than about the fourth 
week, and the complete involution of the uterus seldom takes place 
before the end of the second month. 
On either side of the superior portion of the body of the uterus, 
just at the junction of the body with the fundus are given off the 
fallopian tubes, The word tuba signifies a trumpet, and the re- 
semblance of a fallopian tube to that instrument is very striking. 
At the uterine extremity of the tube it is smallest, but it soon be- 
gins to enlarge, and increases in size until near the fimbriae, when 
it is somewhat contracted, but again suddenly expands with a 10 
Gynaecology. 
fringe-like border, called morsus diaboli, from its supposed satanic- 
like grip. These tubes are from three to four inches long, a little 
tortuous in their course, which is outward and then backward on 
either side. The interior of the tubes exactly corresponds with their 
exterior form. The uterine orifice of the tubes is very small—just 
large enough to receive a bristle, such as is used by shoemakers. 
The ovaries are attached to the outer extremities of the fallopian 
tubes by a single filament, which is longer than the rest of thefim- 
brite. 
Under the influence of excitement, and more especially when 
the ovaries and the bulbs are highly engorged with blood—physio- 
logical hypersemia—the expanded and beautifully tufted extremi- 
ties of these tubes grasp firmly the ovaries and maintain this posi- 
tion for a considerable time. In have seen in the dead room the 
free or fimbriated extremity of the fallopian tube grasp the ovary, 
from the irritation produced by being pinched with the forceps. 
It is probable that the fimbria} remain in close contact with the 
ovary or ovaries during the entire menstrual epoch. M. Rouget 
and Dr. Savage both agree that in addition to the congestion of 
the ovaries and their bulbs, there is a beautiful arrangement of 
muscular fibres heretofore undiscovered, which assist in drawiug 
and holding firmly the fimbriated extremities of the tubes in close 
contact with the ovaries. 
This close contact seems to be a necessity; otherwise the ovule 
and the blood which issue from the ruptured Graafian follicle or fol- 
licles, might escape and be retained in the abdominal cavity, some- 
times causing sterility or extra uterine foetation with peri-uterine 
h&'matocele and pelvic peritonitis. The mucous membrane of the 
tubes is continuous with the uterine mucous membrane at their 
inner extremities, and at their outlet or fimbriated borders the 
peritoneum unites with the mucous membrane lining the inner 
surfaces of the fimbriae. It is worthy of remark that this is an ex- 
ceptional bond of union, a mucous with a serous membrane. The 
epithelial cells lining the mucous membrane of the tubes are of 
the columnar and ciliated varieties. As before stated, there is an 
ovary ,on each side corresponding with the fallopian tubes. An 
ovary weighs about a drachm and a half in the virgin, but it is 
usually not so heavy in women who have borne many children. 
The ovary is about one and a half inches long and three-quarters 
of an inch wide, but a little less than this in thickness. These 
bodies are attached by their anterior borders to the broad liga- 
ments, in whose folds they are completely enveloped, and it is at 
their inner borders, or facets of attachment, that vessels and nerves 
enter them. They are directly connected to the uterus by their 
inner borders, through the ovarian ligaments. The proper in- 
vestment of the ovaries is a dense fibrous sheath. The stroma, 
which is a vascular structure of a pinkish color and firm to the 
touch, lies immediately beneath the fibrous envelop. It is in the Gynaecology. 
11 
stroma that the Graafian vesicles are situated. These vesicles vary 
in size from a pin’s head to that of a pea, according to their situa- 
tion, and they number from ten to fifty in each ovary. These 
Graafian follicles or vesicles possess a double sac, and contain with- 
in their inner walls the ovules. At the menstrual epoch one or 
more of these vesicles become greatly distended with blood, caus- 
ing an increase in size, and thus forcing the vesicle above the sur- 
face of the ovary, and when the distention can be no longer borne, 
the walls of the follicle burst and discharge the little ovule, which 
is either received into the orifice of one of the follopian tubes and 
conveyed to the uterus, or it escapes into the abdominal cavity. 
Between the walls of the sac of the vesicle and also beneath them, 
blood is effused, which soon assumes a yellowish or reddish yellow 
color, and this is the corpus luteum. The presence of the corpus 
luteum in the ovary after menstruation was once regarded as an in- 
fallible evidence of impregnation ; but I need hardly add it is not 
so regarded at the present day. 
We now come to speak of the ligaments of the uterus,.their con- 
nection with the adjacent viscera arid the surrounding pelvic walls. 
These ligaments are arranged in pairs, and are eight in number; 
the round ligaments—ligamenta rotunda; the broad ligaments— 
ligamenta lateralia, the vesico-uterine and the recto-uterine liga- 
ments or plicae semilunares, of Douglas. 
The round ligaments are about five inches long, and are attached 
internally to the anterior cornua of the uterus, just in front of the 
insertion of the fallopian tubes, and externally they are inserted 
on either side of the pubic symphysis in the dense substance of the 
mons veneris. In the upward and forward course of these round 
cord-like bundles, they pass through a fold of the pelvic peritoneum, 
which constitutes the anterior borders of the broad ligaments. 
The round ligaments extend in an anterior and forward direction 
from the uterus to the internal abdominal rings; and it must be 
seen that their force when contracting, will be in the same direc- 
tion. These ligaments contain numerous muscular fibers which 
are given off from the womb. The round ligaments are very strong, 
and exert a powerful influence in holding the fundus and body of 
the uterus in a forward position. The direct auxiliary ligaments 
to the round ones, are the utero-rectal or sacral ligaments. The 
utero-sacral folds also possess a considerable muscular element 
which is derived directly from the uterus. 
Besides the muscular fibers, the cellulo-elastic tissue, vessels and 
nerves; these ligaments are composed of the posterior duplications 
and expansions of the pelvic peritoneum. The inferior posterior 
portion of the cervix affords attachments for these ligaments; they 
then pass in a backward direction to be affixed to the rectum, and 
there dividing are inserted/upon the inner facets of the sacrum on 
both sides. These ligaments are also very strong and hold the 
cervix firmly back towards the rectum, and thus assist the round 12 
ligaments in keeping the womb in an oblique position, that is, in 
the axis of the superior strait. 
The broad ligaments are firm, strong tissues, being eomposed of 
a double fold of the pelvic peritoneum, a large amount of fibro- 
cellular tissue, nerves, arteries, veins, absorbents and muscular 
fibers. 
The broad ligaments and connective tissue occupy all the space 
laterally on each side between the lower segment of the uterus and 
the pelvic walls. Between the duplications of these ligaments, on 
either side, are situated the fallopian tubes and ovaries with their 
ligaments. 
The uterus recives a strong support from the broad ligaments, 
and they also assist in sustaining it in its oblique position. 
The utero-vesical ligaments connect the anterior-inferior portion 
of the cervix uteri with the bladder. These are the most delicate 
of all the pelvic ligaments; their office is to attach the uterus to the 
bladder. Between these organs there is a large amount of fibro- 
cellular tissue intervening. 
Througli all of the duplications and folds of the pelvic ligaments 
there is a large amount of connective tissue interposed. This 
fibro-connective tissue is also extensively distributed all around the 
pelvic walls, connecting and tying firmly every tissue together. 
The whole inferior portion of the pelvis is also lined with this 
same elastic cellular tissue, and all of the viscera there are con- 
nected together by it. The lateral walls of the vagina are attach- 
ed to the pelvic walls by this tissue, which flattens them out on 
either side, and thus collapses their antex*o-posterior walls; and 
the lower portion of the rectum is connected with the vagina and 
the posterior pelvic walls by this extensive fibro-cellular element. 
The extent to which this fibro-cellular tissue is deposited, and also 
the extensive duplications of peritoneum in the pelvic cavity, 
should be remembered by the Gynaecologist and Obstetrician, in 
practice, in cases of pelvic cellulitis and peritonitis, and moi*e 
especially should they terminate in suppuration. And here, I 
would remark, that pelvic peritonitis is generally regarded to be of 
rare occurrence except in the puerperal state, but it has happened 
to the writer to meet with pelvic peritonitis in practice very fre- 
quently complicating non-puei*peral uterine diseases. 
I have under my charge, at the present time, two eases of un- 
usual interest. One a case of ehi’onic endo-metritis complicated 
with pelvic peintonitis and peri-metritis or pelvic cellulitis. This 
patient is about thirty years old, she was married at twenty, and 
lias never been pi’egnant. She is of small stature, neither a blonde 
nor a brunette, and her temperamept is of the nervous variety. 
The menstrual eruption occurred at the age of fourteen, and 
continued to return at regular intervals, and was normal in char- 
acter, until several years after marriage. This case set in so 
insidiously that neither the exact time of its commencement can 
Gynaecology. Gynaecology. 
13 
be dated nor a cause of its origin satisfactorily assigned. For the 
last three or four years there has been distressing dysmenorrhcea 
with continued leucorrhoea of a more or less thick, (sometimes yel- 
lowish) tenacious, ropy (white of egg) discharge. Before and immedi- 
ately after the periods this discharge has been very profuse. Dysuria 
has been almost a constant attending symptom in this case. The 
lumbar region, the sacro-iliac synchondrosis and the inguinal 
regions have suffered greatly with dull aching pains. There has 
generally been tenderness in the left iliac, inguinal and hypogastric 
regions, with more or less fullness in the latter region. The body 
and fundus of the womb have been very tender to the touch, and 
the introduction of the sound has always been attended with 
severe pain. 
This case was treated by gentle aperients, warm hip-baths, hot 
salt-water douches, rest in the horizontal posture the most of the 
day, a mild nutritious diet, anodynes, small blisters frequently re- 
peated in the groins, and cauterization with tincture of iodine and 
pure carbolic acid (Calvert’s) applied with a fluid porte caustic to 
the cavities of the cervix and body of the uterus once or twice a 
week. 
The dysuria was always increased by exercise, and hence the 
more urgent necessity for confinement to bed. 
The progress of this case was favorable but slow until June, 
1870, when two vascular tumours just within the meatus urinarious 
exturnus were excised with the scissors, and there were also, at 
the same time, removed by the scissors, two “tits,” from near the 
posterior commissure. These little bodies were remnants of the 
hymen, and they were in a state of hyperaesthesia. Three days 
after the operation fever set up with furred tongue and chilly sen- 
sations, or rigors frequently recurring, total loss of appetite, urgent 
thirst, pulse ranging from one hundred and ten to one hundred 
and thirty-five, and tenderness and swelling with severe pain in the 
right iliac region just above Poupart’s ligament. There was also to be 
felt on the right side of the vagina about an inch below the os 
uteri a hard unyielding body, very tender on pressure, which ex- 
tended from this point up to the os and cervix uteri to be finally 
lost in the tumour of the right iliac region. The two tumours, that 
is, the tumour in the p'elvis to the right of the vagina, and the tu- 
mour in the iliac region, seemed to be continuous, and I doubt not 
constituted one and the same tumour, which extended from the 
iliac region down through the right side of the pelvis to within less 
than an inch of the perineum, displacing the womb to the left side 
of the pelvic cavity. The uterus was immovable, being fixecl in 
its new position by extensive effusion of lymph. Under the use of 
the iodide and bromide of potassium, aperients, close confinement 
to the horizontal position, blisters and a mild nutritious diet, the 
tumour was completely absorbed. If this tumour passed to the 
suppurative stage, I was not able to detect it either by fluctuation 14 
Gynaecology. 
or any particularly softened spot. West, McClintock, Hewitt and 
Thomas all concur in the opinion that pelvic abscesses may be ab- 
sorbed even after fluctuation and other evidences of suppuration 
have' been observed. 
Had this patient remained quiet in her room, it is probable that 
complete recovery would have resulted in a short time ; but soon 
after this she removed her quarters to the distance of several 
blocks, and in the preparation for moving she became greatly fa- 
tigued and excited mentally, which resulted in a chill followed by 
fever, and acute pains in the right side of the pelvis with swelling in 
the rightiliae region extending into the pelvis on the right side ofthe 
womb and vagina, and pushing the womb over to the left side of 
the pelvis, as was the case when the first tumour existed. 
The tumour continued to enlarge, displacing the womb against 
the pelvic walls on the left side, and completely fixing it by effu- 
sion in this new situation. The treatment adopted was with a 
little alteration the same as that given above ; but the tumour 
after several weeks softened and pointed on the right side of the 
perineum. I opened the abscess with a bistoury, and an enormous 
amount of matter was discharged. More than half a pint of pus 
was collected, and a good deal Avas lost on the cloths. The pus 
was normal in character, but very offensive. The abscess dis- 
charged profusely for two weeks, and it has not completely healed, 
but the discharge is now periodical. When the orifice closes for a 
few days, the iliac region becomes full and painful, and there is 
more or less fever every afternoon; but just as soon as the matter 
begins to discharge again the pain, fulness and fever all subside, 
aud the patient brightens up and is cheerful and hopeful of recov- 
ery. I have seen this patient to-day; she is improving in flesh 
and gaining strength, and the discharge is very small in quantity, 
an4 the iliac and hypogastric regions are soft, natural and free 
from tenderness. Her appetite is almost voracious, and her di- 
gestion is good. 
Query. Gould all of this inflammation, effusion or infiltration of 
lymph with suppuration exist in the pelvic cellular connective tissue, 
and yet not involve the peritoneal duplications composing the pelvic 
ligaments? 
The other case is a woman, about forty-two years of age. She is 
of medium size and fair complexion; the menstrual eruption oc- 
curred at the age of fourteen, and her periods have continued nor- 
mal and regular, with only an interruption of several months, 
during the year of 1857, until about eighteen months past. This 
woman married at the age of eighteen, is childless, says she has 
never been pregnant, and has enjoyed pretty good general health 
up to about five years ago. Being unusually exposed in the win- 
ter of 1865 she took a violent cold, which terminated in a chronic 
bronchitis. 
The bronchial affection was not relieved for about three years; Gyncecology. 
15 
her cough during most of the time was very troublesome, and she 
became very much emaciated; at the present time her general 
health is greatly improved. Her menstrual epochs, for ten or 
twelvemonths past, have been accompanied with distressing full- 
ness and tenderness, amounting to soreness, and sometimes they 
arc attended with the most acute suffering, in the hypogastric and 
iliac regions. Occasionally during her periods, but usually im- 
mediately after menstruation, acute, or rather sub-acute inflam- 
mation of the pelvic pci itoneum sets up. These inflammatory 
attacks are sudden, without any warning, save the symptoms 
given above, and they always set in with violent pain in the iliac 
and hypogastric regions. The pain is sometimes paroxysmal, but 
there is always a degree of pain present, which is scarcely bear- 
able without giving utterance to expressions indicating the most 
intense suffering. The tenderness in the pelvic region is so great 
that the slightest pressure cannot be borne without intense suf- 
fering—the lower limbs are constantly drafwn up to relieve the 
pressure by the abdominal muscles on the pelvic viscera. During 
the acute stage, which usually lasts from three to four days, there 
is constant nausea, and the temperature of the body is raised to 
from 102 deg. to 104 deg., the skin is dry, and the pulse rises to 
120 or 125. and is small and quick, and the bowels are obstinately 
constipated. Although there is great fullness in the hypogastric and 
iliac regions and the temperature of the vagina is greatly aug- 
mented, no effusion of lymph in the pelvic connective tissue has 
been detected at any of the attacks, although strict attention has 
been directed to such a pathological result. There is always 
present at these attacks a tympanitic condition of the small in- 
testines. which adds greatly to the general distress. 
There is in this case one constant attending symptom which is 
worthy of notice. About the subsidence of the menstrual period 
tits of the most deadly nausea are induced by assuming the erect 
posture, and sometimes even by turning in bed, and what is more 
remarkable the nausea is frequently attended while in the hori- 
zontal posture with syncope, which lasts frequently for several 
minutes, even under the most active measures to relieve the 
fainting. These attacks always leave the patient very much ex- 
hausted. and the swelling and soreness, which are so distressing in 
the pelvic region, do not pass away for six or eight days after 
the acute symptoms have subsided. 
During the acute stage of these attacks there is frequently the 
most distressing dysuria. This patient is approaching the meno- 
pausis, and it is possible that after ovulation ceases, her uterine 
troubles may be entirely removed by appropriate treatment, and 
her general health become good. 
When it is borne in mind how frequently inflammation of the 
pelvic tissues complicates uterine diseases in the non-puerperal 
state, an apology sufficient, I trust, will be offered for the intro-  Gynaecology. 
duetionand partial detail of the prominent symptoms in the cases 
given above. I could give at length other type cases equally in- 
teresting ; but it is hoped that these examples will impress upon 
the practitioner the importance of early attention to the possibility 
of pelvic peritonitis and pelvic cellulitis setting suddenly up and 
complicating chronic uterine disorders. 
When it is remembered that all of the dense, clastic and strong 
ligaments with their arteries, veins, lymphatics, neryes, fibro- 
connectivc tissue and muscular fibers, and also the iliac fascia, the 
pelvic fascia and the levatores ani muscles constitute the pelvic 
floor, which has great firmness and. elasticity, it will be seen, that 
the pelvic organs, especially in women who have not borne 
children, or even Avomen who lia\’e borne only feAV children, are 
avcII sustained. The perineum also assists in supporting the 
pelvic organs. And furthermore, the pelvic floor is covered over 
on its internal surface by another layer of peritoneum, which 
adds to its strength, thus enabling it to support the superincum- 
bent abdominal viscera, and also to resist under exertion, the most 
active contraction of the abdominal muscles, if the pelvic organs 
are in a normal state. 
It is observed in civilized life that laboring women, Avho remain 
much in the open air, are comparatively exempt from uterine 
displacements, except in connection with neoplasms; subin\-olu- 
tion and chronic inflammation with hypertrophy. 
The Gynaecologist should not lose sight of the ample supports 
Avhich nature has given to the pelvic organs in the treatment of 
chronic inflammation and hypertrophy complicated with displace- 
ment. 
There are now, as there have been, both in Europe and in this 
country, for some years past, two schools, the one attributing 
most of the uterine diseases to displacements, and the other re- 
garding the displacements as a secondary matter, and dependent 
on chronic inflammation and enlargement. Both these opposites 
—“camps”—cannot be in the right: it is probable that the truth 
lies intermediately between these extreme vieivs, and that, in the 
treatment of uterine disorders the medical philosopher will neglect 
neither the inflammatory condition and hypertrophy nor' the dis- 
placement. And here I AA’Ould remark that if mechanical support 
to the displaced uterus bo resorted to, that form of instrument 
should be selected, A\Thich will keep both the vagina and the womb 
in their normal axes, Avithout undue pressure either upon any 
portion of the uterus or the vagina. It is noAV admitted, almost 
universally, by Gyngeologists that Hodge’s le\Ter pessary, or some 
modification of it. more completely fulfills the above indications, 
and is therefore preferred to all other supports. Hr. Graily 
IleAvitt’s lever pessaries are only modifications of Hodge’s pessary, 
and Hodge’s pessary is a modification of Meigs’ ring pessary. The 
colpenrynter or gum bag. and the cotton glycerole Avad of Sims may, under some circumstances, be used with advantage in dis- 
placements. 
When the natural supports of the uterus are considered and the 
normal relation of the vagina to the womb is not forgotten, it will 
be seen that Hodge’s, or some of Hodge’s modified pessaries can be 
better adapted to the vagina, and will therefore give a safer and 
easier support to the prolapsed or retroverted womb than any 
other passary now in use. Of the numerous passaries used and 
recommended by Gynaicologists all are preferable to that variety 
which includes the intra-uterine stem, and the stem and cup pes- 
saries. 
I must agree with Hr. Savage in his comment upon Sir James 
Simpson’s stem pessary before the Obstetrical Society of London, 
that no form of stem or stem with cup pessary can be made a safe 
support to the uterus; he says, “is not the record of stem pessaries 
one of grievous disaster?” 
In rejecting the stem pessary (and every modification of it) I 
deeply regret that I am compelled to dissent from any opinion 
held by that great and good man, whose wisdom the gynaecologi- 
cal world has so recently been deprived of by his much lamented 
and untimely death. 
An organ like the uterus, so delicate and so changeable, sit- 
uated by the Creator, in His infinite wisdom, in the center of the 
pelvis, and there so perfectly balanced that it is movable in all di- 
rections with the greatest facility, cannot be confined or fixed in 
any position by instrumental means without the greatest hazard of 
doing violence to the tissues, and thereby exciting dangerous in- 
flammation. 
It will be seen, if the plane and axis of the superior strait and 
also the axis of the body when erect are borne in mind, that the 
force of gravity acting upon the abdominal viscera must incline 
them in the direction of the axis of the body. How, if this be so, 
and it cannot be doubted, the force of the viscera must be spent 
mainly upon the body of the pubis, for a vertical line drawn 
centrally through the body when erect, will fall directly upon the 
symphysis pubis. So it is clear that the pelvic floor does not re- 
ceive all the weight of the abdominal viscera. This arrangement 
of the axis of the body and the axis of the superior strait not cor- 
responding is another example of nature’s wise, and beautiful pro- 
visions. 
The small intestines which occupy the Douglas cul-de-sac to- 
gether with those in the utero-vesical pouch, instead of really 
bearing down the womb as has been generally supposed, do unques 
tionably assist the pelvic ligaments in their office of keeping the 
fundus and body of the uterus in an oblique and normal position. 
I am indebted to Prof. Hodge, of Philadelphia, for directing my 
attention specially to the wise and admirable arrangements of 
Gynaecology. 
17 18 
Gynaecology. 
nature for preserving the delicate and changeable pelvic organs in 
their proper relations. 
The nerves of the ovaries and fallopian tubes are derived from 
the spermatic or ovarian plexus. The fallopian tubes have in ad- 
dition a branch from the uterine nerves. The uterus is supplied 
with nerves from the hypogastric and spermatic or ovarian plex- 
uses; the third and fourth sacral nerves also give off branches to 
the uterus. It is not an easy task to dissect out minutely the nerves 
of this organ, for they are so densely matted together by connec- 
tive tissue, muscular fibres, blood-vessels and lymphatics that it is 
almost impossible to trace them out with perfect accuracy; and a 
want of accurate knowledge of these nerves has led to conflicting 
statements by investigators concerning their development, and 
more especially their augmentation in the gravid uterus. But the 
proliferation of the nerves of the pregnant uterus, as believed by 
Hunter, and boldly asserted by Dr. Robert Lee, of London, is de- 
nied by Dr. Snow Beck and others—indeed, this theory of Dr. 
Lee’s is now universally admitted to be erroneous. The honors 
which were conferred upon Dr. Lee by the “Royal Society of 
London” for his contributions to the anatomy and physiology of the 
gravid uterus, have been formally withdrawn from him by that 
“body.” 
The nerves distributed to the vagina are from the hypogastric 
plexus of the sympathetic, and also from the pudic nerve of the 
fourth sacral nerve. The external genitalia are supplied from the 
genito-crural, the inferior pudendal and the internal pudic nerves. 
The glans clitoridls receives large branches from the pudic nerve. 
The entire erectile tissue of the genital organs is supplied with 
nerves from the pudic and hypogastric plexuses. There is an 
abundant distribution of lymphatics to the organs of generation. 
The arrangement for supplying with blood the ovaries, uterus 
and vagina with their bulbs or erectile apparatus, and the external 
organs of generation is so ample and complete, that they are not 
only well nourished, but they can sustain when under erotic ex- 
citement a physiological hyperaemia of a high degree, for a con- 
siderable time. This turgescence is maintained by the erectile 
structure provided for this purpose, at the outlet of the vagina on 
either side, and along its whole extent laterally, and also up the 
sides of the womb and beneath the ovaries. The erectile apparatus 
on the sides of the vulva compose the vaginal bulbs, which are 
oblong bodies of more than an inch in length, and half an inch 
thick, and are made up of tortuous veins, and are enveloped in a 
fibrous sheath. These veins communicate freely with the vaginal 
plexus, and empty themselves finally into the obturator veins, 
after receiving large branches from the internal pudic arteries. 
The os, cervix and body of the uterus are furnished with blood 
from the utero-ovarian arteries. These vessels are four in number, 
and give off numerous branches to the sides of the uterus, forming Gynaecology. 
19 
:i complete net-work over the lateral Avails of the uterus and 
terminating in the pudendal, uterine and spermatic, or ovarian 
veins. The spermatic or ovarian vein of the right side empties 
directly into the great vena cava, but the ovarian vein of the left 
side takes a longer and indirect course, by first emptying itself into 
the left renal vein, and thence into the vena cava. This 
indirect route, besides frequently meeting with a sluggish 
circulation in the renal vein may in some degree explain 
the comparative frequency and enlargement on the left 
side of the uterus," and also the pain in the left inguinal region. 
Whatever may he the cause of the greater susceptibility of the 
left iliac and inguinal regions to pain and tenderness, and also of 
the more frequent occurrence of congestion and enlargement of 
the left side of the cervix and body of the uterus, a tardy circu- 
lation of the venous apparatus of the left side frequently recurring, 
may with some degree of propriety be regarded as an aggravating 
influence after diseased action has been set up, if it really be not 
causative of it. The spermatic arteries together with the utero- 
ovarian arteries supply the ovaries with blood; these trunks pass 
onto the base of the ovaries and there branching in great num- 
bers finally penetrate the ovaries. The bulbs of the OA'aries— 
vascular bodies—only’recently known through the labors of Mr. 
Traer, M. Rouget and I)r. Savage, are composed of a very great 
number of tortuous veins, which come directly from the ovaries; 
they are bound together by a fibro-elastic investment and are 
about the size of the vaginal bulbs. 
The \7ascular apparatus of the entire genital system is so con- 
structed that a large amount of venous blood may be temporarily 
—physiologically—retained in the venous plexuses under erotic ex- 
citement of these organs, and through this means both the ex- 
ternal and internal genitals are erectile—not only the clitoris and 
labia, but the vagina, uterus, fallopian tubes and ovaries partake 
of this erectile nature in a larger degree. 
With a thorough knowledge of the relations that the urinary 
bladder and the urethra sustain to the rest of the pelvic organs, 
and more especially to the uterus, it is plain to perceive that no 
uterine displacement can take place without changing the position 
or relations of the urinary bladder in a greater or less.degree. 
The anatomical relations of these viscera should always be borne 
in mind in the treatment of uterine diseases and displacements, 
and more especially in those disorders of the womb in which the 
bladder is also a source of trouble. 
I have seen bladders severely dealt with, and medicines freely 
administered for supposed chronic cystitis, when the urinary 
trouble was wholly sympathetic or mechanical, and dependent upon 
either chronic inflammation of the uterus, enlargement, or uterine 
displacement.