THE 
X - . v\- - ' 
PHILOSOPHY OF UTERINE 
DISEASE, 
WITH THE TREATMENT APPLICABLE TO 
DISPLACEMENTS AND FLEXURES. 
BY 
THOMAS ADDIS EMMET, M. D., 
STJROEON TO THE WOMAN’S HOSPITAL OP THE STATE OP NEW YORK. 
[REPRINTED FROM THE NEW TORE MEDICAL JOURNAL. JULY, 1874 ] 
NEW YORK: 
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1874. TWELVE YEARS OF THE WORLD’S HISTORY! 
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XW“ The Annual Cyclopaedia for 1873 will be published in May, 1874. THE 
PHILOSOPHY OF UTERINE 
DISEASE, 
WITH THE TREATMENT APPLICABLE TO 
DISPLACEMENTS AND FLEXURES. 
BY 
THOMAS ADDIS EMMET, M. D., 
SURGEON TO THE 'WOMAN’S HOSPITAL OP THE STATE OP NEW YORK. 
[PREPRINTED FROM THE NEW YORK MEDICAL JOURNAL, JULY, 1874.] 
NEW YORK; 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1874. THE PHILOSOPHY OF UTERINE DISEASE, WITH 
THE TREATMENT APPLICABLE TO DIS- 
PLACEMENTS AND FLEXURES.1 
It would be difficult to present a subject on which a greater 
diversity of opinion exists in the profession than the one I 
now have the honor of offering for your consideration. 
This difference is not only as to cause and effect, but to as 
great an extent in relation to the proper means of treatment. 
Indeed, at first sight, this great difference is incomprehensible, 
and it seems impossible to reconcile the extreme views held by 
men of honest purpose and equally based on personal observa- 
tion. But experience has long since taught me that a medi- 
um course is the most successful one, as from this stand-point 
we can utilize and better appreciate the views based on the 
practice of either extreme. In years past I have honestly 
overcome all obstructions, and by the aid of the knife I have 
opened up the uterine canal to such an extent that it was im- 
possible for any mechanical obstacle to exist; and I did not cure 
my patients. In turn I have devoted no little mechanical skill 
to overcome every displacement, and have succeeded beyond 
my expectations; yet the results were not satisfactory. At 
length I became confident that local congestion and inflam- 
mation were the causes of the evil, producing hypertrophy, 
liypersesthesia, versions and flexures. I directed my treatment 
1 Bead before the Medical Library and Journal Association of New 
York, June 5, 1874. 4 
THE PHILOSOPHY OF UTERINE DISEASE. 
now exclusively to relieving the congestion, as I will describe 
hereafter. My results were better, for I found that as I di- 
minished the congestion, the hyperaesthesia disappeared, the 
flexures lessened in degree, and there was, with less hyper- 
trophy, a great improvement in the versions; but my patients 
frequently relapsed, and the results were not such as I had an- 
ticipated. I ultimately recognized the fact that there was a 
stage in the treatment of almost every case when mechanical 
support was indispensable as an adjunct, and under certain 
circumstances the use of the knife could not be ignored. The 
fact also presented itself to me that in a large number of cases 
the local condition was secondary to that of the general system, 
and in no case could we conscientiously overlook the connec- 
tion. I became convinced that, as a rule, the local difficulty 
in the beginning was the effect, but a point was reached ulti- 
mately when the uterine condition became the most promi- 
nent, and exercised a direct influence in reducing still further 
the tone of the general system. In addition, experience taught 
that we cannot restore the female to health by local treat- 
ment alone, nor by devoting our attention exclusively to the 
general condition can we relieve the local one. I regard some 
degree of anteversion as a normal position of the uterus, while 
retroversion is always incident to, and a flexure is an exaggera- 
tion due to, causes to be considered hereafter. 
Any conceivable amount of deviation from a normal stand- 
ard may and does frequently exist without discomfort, so long 
as the circulation remains unobstructed and the proper func- 
tions are performed. Deviations may result from congenital 
causes, or from accident, and a degree of tolerance may be- 
come established which ultimately seems to be a normal con- 
dition for the individual. Yet there is in each case a limit to 
the immunity, as sooner or later Mature exacts the penalty. 
A retroversion may exist for years "without producing incon- 
venience, but from some accidental cause the general health 
may become impaired ; the vaginal walls will gradually lose 
their integrity, a miscarriage, or some other cause, will pro- 
duce an undue congestion, with enlargement of the uterus, 
and we have at length the most urgent symptoms presenting 
themselves for relief. There is less immunity from flexures of THE PHILOSOPHY OF UTERINE DISEASE. 
5 
the body of the uterus, yet a moderate amount of disease may 
he borne so long as the general health remains good. A flex- 
ure of the cervix below the vaginal junction, at a right angle 
even to the body, or a partially constricted os, may produce 
but little discomfort for an indefinite time, beyond a slight dys- 
menorrhoea in the unmarried female; but in the wife, if the 
condition has produced sterility, we are at length forced by a 
train of nervous symptoms to recognize a local cause of irri- 
tation. In other words, anteversion may exist without caus- 
ing irritation of the bladder, retroversion without symptoms 
of prolapse or obstruction to the rectum, and flexure without 
dysmenorrhcea, so long as the nutritive functions maintain 
their integrity. 
Impaired nutrition, as the cause and not the effect, depre- 
ciates the nervous force, and without this needed stimulus 
functional derangement naturally follows, a loss of balance re- 
sults, and we have congestion or the opposite condition. Con- 
gestion produces enlargement of the tissues, and it may remain 
passive or result in inflammation, while a want of nutrition 
causes atrophy. Congestion is always the result of some local 
irritation, a condition which is but temporary in duration if 
the reparative powers are in a state of integrity. Congestion, 
however, does not imply inflammation, although the latter 
cannot have a beginning without it. If the congestion 
reaches a degree sufficient to establish inflammation, we have 
at once instituted a distinct train of symptoms which is acci- 
dental and secondary to the primary condition. The terms 
congestion and inflammation are synonymous with many in 
application to uterine disease, and it leads to confusion. In- 
flammation cannot exist without molecular death, and its 
products are easily recognized until the injury has been re- 
paired. We may look in vain, post mortem, for any evidence 
of a previously-existing endometritis, so called, or ulceration 
of the cervix, as it is termed. We find the tissues blanched, 
the blood from the capillaries having passed into the larger 
vessels as the heart failed in keeping up the supply, but there 
is neither loss of tissue on the surface of the mucous membrane 
beyond the epithelium, if so much, nor are products of in- 
flammation to be found in the tissues of the organ itself. In- 6 
THE PHILOSOPHY CF UTERINE DISEASE. 
flammation can only exist in an acute form, although its 
products may remain for an indefinite period. Therefore the 
term chronic inflammation is a misnomer. 
From congestion and increased weight the uterus will nat- 
urally settle into the pelvis, and a version mechanically results 
toward the heavier side. The neck of the uterus soon becomes, 
as it were, a fixed point, and can move but forward in the axis 
of the vagina, while the body above becomes bent on itself 
in the opposite direction. Hence, a flexure of the body, a chor- 
dee, as it were, to be augmented by any increase or obstruc- 
tion to the circulation. Violence or an accidental cause may 
produce partial retroversion, and, if the fundus advances into 
the hollow of the sacrum beyond a certain point, we have at 
once two forces operating, in opposite directions, to produce a 
retroflexion. The cervix becomes pressed upward against the 
anterior wall of the vagina, which can only yield to a certain 
degree, and, with the weight and downward pressure in the 
opposite direction, the body of the uterus is gradually bent 
upon itself. We have two causes of flexure which may be 
termed congenital, or at least having an origin previous to 
puberty. As the uterus becomes developed, the growth of 
the cervix is, in length, out of proportion to the body. Grad- 
ually, from a want of room, the cervix slides along the pos- 
terior wall, in the direction of the least resistance, until it 
presents in the axis of the vagina, causing a sharp flexure 
just at the vaginal junction. In a narrow vagina, with a de- 
ficiency or absence of the posterior cul-de-sac, a degree of re- 
troversion must exist. At puberty, with increased weight of 
the uterus and from other causes, the fundus gradually settles 
into the hollow of the sacrum, and we have a flexure pro- 
duced in the same manner as I have shown to follow this dis- 
placement when resulting from accident. 
Congestion of the mucous follicles, limited to the cervix 
or extending through the uterine canal, with increased secre- 
tion and some enlargement of the organ, is the most common 
form of uterine disease. In my experience, some degree of 
flexure of the body, with an increase of anteversion, lias been 
more frequently met with than in the displacement backward. 
Partial obstruction of the uterine canal, at a given point above 7 
THE PHILOSOPHY OE UTERINE DISEASE. 
the vaginal juncture, is caused by flexure, and is increased 
by congestion, with passive oedema of the mucous membrane 
and possibly of the submucous tissues. A resort to surgical 
means for the relief of this condition has been a favorite pro- 
cedure with many in the profession. For years I have not 
divided the cervix laterally except for the removal of fibroids. 
At an early date in my experience, I satisfied myself that a 
flexure of the body could not be relieved by a lateral division, 
even if extended to the vaginal junction, and that the prac- 
tice was based on unscientific principles. I have never seen 
a case permanently benefited by the operation, except in rare 
instances, where pregnancy fortunately took place during a 
slight remission of symptoms, due to the revulsive action at- 
tending the process of reparation. I can, moreover, state that 
I have never known the malpractice of any other surgical 
procedure followed at times by such evil consequences. When 
practised by skillful hands, under proper surroundings, and 
with the requisite after-treatment, the operation is attended 
with comparatively little risk, but without benefit. It has 
been regarded by the profession at large as a simple operation ; 
and it is certainly one in execution, but it requires no little ex- 
perience to decide when it can be practised with safety, even 
when it is advisable. I believe that there are but few of us 
who have not in years past seen the most deplorable results fol- 
lowing the indiscriminate practice of this operation, through 
reckless inexperience and neglect afterward. 
November 28, 1862, I operated on a patient, who had re- 
ceived, in labor, a double lateral laceration of the cervix to the 
vaginal junction, by denuding and bringing together with sil- 
ver sutures the anterior and posterior flaps. It was a case in 
my private hospital. I was assisted by Dr. G. S. Winston, then 
my assistant, and I believe Dr. T. G. Thomas was also present 
at the operation. This lady suffered from hypertrophy of the 
uterus, with an intractable erosion covering a cervix apparently 
some two inches in diameter. The erosion by great care had 
been several times healed, but its recurrence took place as soon 
as she began again to exercise. She had been some time un- 
der treatment before I appreciated the laceration, as the tissues 
had undergone fatty degeneration, and were so softened and 8 
THE PHILOSOPHY OF UTERINE DISEASE. 
flattened out as to give no evidence, on inspection, of the real 
condition. My attention was first attracted to the width of 
the cervix in comparison with the body, during an examina- 
tion with the finger, as the patient was lying on the hack. 
The relative size of the cervix to the body of the uterus was 
as the top of a half-grown mushroom would be to its stalk. 
By seizing the anterior and posterior portions of the cervix 
with a tenaculum in each hand, I found that, when the flaps 
were brought into apposition, the inverted portion rolled in- 
ward to the canal, and the cervix was in fact then but little 
larger than natural. The remedy at once suggested itself to 
me, and I performed the operation to which I have referred, 
the effect being that the hypertrophy rapidly diminished, with 
no recurrence of the erosion afterward. It was evident that 
the hypertrophy and erosion had been due to the rolling out 
of the tissues, as the flaps were forced apart on standing, by 
the posterior one catching on the recto-vaginal septum, while 
the anterior flap was crowded forward in the axis of the canal, 
in the direction presenting the least resistance. This case.was 
one of great importance to me, for it has been my practice 
from that time to close all lateral lacerations which have 
passed under my observation as a result of labor. It led me 
also to appreciate exactly the same condition as a result of 
lateral division of the cervix in all cases where the operation 
had been thoroughly done; and I have since in every in- 
stance endeavored to correct the damage by reuniting the 
flaps before resorting to any other treatment. I know of no 
one previous to this time who had recognized this chronic 
condition as a cause of hypertrophy and extensive erosion, 
when resulting from childbirth, or as a consequence of lateral 
division of the cervix ; and I believe the above operation to 
have been the first practised for its reparation. In a paper 
entitled “ Surgery of the Cervix,” published in the American 
Journal of Obstetrics, and read before the Medical Society 
of the County of Hew York, February 8, 1869, I have pre- 
sented my views at greater length in reference to this condi- 
tion and operation. 
When the flexure occurs at or below the vaginal junction, 
it is seldom in the unmarried that we are called upon for the THE PHILOSOPHY OF HTEEINE DISEASE. 
9 
relief of any serious uterine disturbance until later in life. 
Dysmenorrhoea, it is true, always exists in the beginning of 
the flow, but is relieved as soon as it has become established, 
while the contrary is the case when the flexure is in the body of 
the uterus. In the latter condition the dysmenorrhoea does not 
begin until menstruation has already made its appearance, it 
then increases in degree, and continues until the flow ceases. 
In the first instance, the long and narrow cervix becomes thick- 
er, shorter, and straighter, in consequence of the menstrual con- 
gestion, so that the mechanical obstruction is removed for the 
time. With flexure of the uterine body, in either anteversion 
or retroversion, the obstruction becomes exaggerated on in- 
creased congestion. This is due to the fact that the disease is 
confined chiefly to one side of the organ, while the circula- 
tion is comparatively unobstructed on the opposite side. 
For the relief of the flexure at the vaginal junction, I al- 
ways divide, with scissors, the posterior lip backward in the 
median line. This operation is attended with but little risk, 
if the case is properly cared for, from the fact that the organ 
is otherwise in a comparatively healthy condition ; unless the 
history of the case points to the existence of a previous attack 
of cellulitis, resulting from some accidental cause, there will 
be but little danger of this complication from the operation. 
Quite the contrary will be the case when the body has been 
involved in either anteflexion or retroflexion of long standing, 
for a certain amount of perimetritis is almost certain to have 
existed at some previous date, leaving a condition afterward 
requiring but a slight provocation to reestablish the inflam- 
mation in a more serious form. The ultimate result of the 
operation is to bring the neck to a natural length, for, by a 
division of the circular fibres, the longitudinal ones gradually 
retract, and the canal becomes straight; were other advan- 
tages equal, the backward operation is preferable to the lateral 
one, as the cervix is divided only on one side, and the risk 
from haemorrhage is less, as the circular artery can be easily 
avoided. Moreover, there will be no gaping or rolling out of 
the edges, after they have healed, as the flaps are kept suffi- 
ciently in contact by the lateral walls of the vagina. Al- 
though there may be no bleeding at the time of the opera- 10 
TIIE PHILOSOPHY OF UTERINE DISEASE. 
tion, the use of a tampon for some ten days is a necessary 
precaution to guard against subsequent haemorrhage. The 
incision must be kept open by gently drawing the point of a 
sound through the angle of the wound, and the edges apart 
by daily dressings of cotton pledgets saturated with glycerine. 
To guard against inflammation, it is indispensable that the 
patient should be kept in bed, and protected from cold, until 
the parts have healed. The object of the operation is to re- 
move a very common cause of sterility, and one liable to re- 
sult in retroversion, from sexual intercourse, with prolapse 
afterward, so soon as the body becomes forced over in line 
with the axis of the vagina. In the unmarried the dysmen- 
orrhoea is relieved by the operation, the tendency to retrover- 
sion obviated by shortening the neck, and an exciting cause 
of future disease removed by allowing of a free escape of the 
secretions from the canal. 
When a flexure of the body has long existed, the tissues, at 
the point of greatest constriction, gradually undergo fatty de- 
generation from pressure, and absorption takes place, causing 
a permanent deformity, as after caries of the spine. When a 
point has been reached, after careful treatment of such a case, 
at which all tenderness on pressure has been removed, it is often 
judicious to divide the cervix backward, and to incise forward 
the seat of flexure above, sufficiently to open the canal. This 
will facilitate the application of any after-treatment which 
may be found necessary to the canal above, and guard against 
a relapse from any mechanical obstruction afterward. But, 
if done too soon, without the proper preparation and the 
requisite subsequent care, all previous gain will be lost by pel- 
vic cellulitis, and even general peritonitis may result. The 
patient’s life may be saved for the time, but there is seldom 
vitality enough remaining even to regain the condition exist- 
ing previous to the operation. 
During the time I held the position of surgeon-in-cliief to 
the Woman’s Hospital, from September 1, 1862, to May 1, 
1872, there were 1,842 patients treated under my charge. This 
operation was performed sixty times in the institution, as will 
be seen by the following statement taken from the records 
and furnished me by Dr. William II. Baker, the house-surgeon. THE PHILOSOPHY OF UTERINE DISEASE. 
11 
From September 1, 1862, to the close of the year, eight opera- 
tions; 1863, nine; 1864, six; 1865, four; 1866, three; 1867, 
three; 1868, five; 1869, six; 1870, thirteen; 1871, one; 1872, 
to May 1st, two. During the year 1870 four lateral operations 
were performed for the removal of fibroids, making a total of 
fifty-six operations for flexure of the cervix. The operations 
were all, I believe, performed by myself, except during the year 
1870, when my assistants, Dr. J. G. Perry and Dr. Bache Em- 
met, operated six times—the former five times, the latter once. 
Three cases of serious cellulitis followed these operations, but 
from which complete recovery took place ; one death occurred 
from general peritonitis, coming on after the patient was well 
enough to be up, and it could be attributable alone to her own 
imprudence. This patient was sent to the hospital by Dr. 
Baur, of Brooklyn, but now of St. Louis; after permission had 
been refused, she took a cold bath with her windows open, and 
was seized with a violent chill before she had completed her 
toilet; it was followed immediately by a most violent attack 
of peritonitis, and death resulted in a few days. 
During the past thirteen years I have operated some forty- 
nine times in my private hospital, and have in the same pe- 
riod treated two thousand and thirty-six uterine patients, with 
one death and one serious case of cellulitis, terminating in 
pelvic abscess, from which recovery took place after an illness 
of two years. The cause of death was peritonitis, occur- 
ring in a case where I operated the day after her arrival 
from a long and fatiguing journey, to oblige her physician, 
who wished to return home without delay. I have since held 
myself culpable for the death of this patient, so far as to have 
deviated from my rule in never operating until a patient has 
been sufficiently long under observation for me to appreciate 
fully her condition and to prepare her properly for it. The 
pelvic abscess, following an attack of cellulitis, wras brought 
about by the patient’s imprudence in sitting up and exposing 
herself to cold in her night-dress, and bare feet. To the 
best of my recollection, I have performed this operation but 
twice outside of my private hospital, and in both instances 
the patients remained under the charge of their physician. 
One of these cases, on whom I operated for retroflexion, died 12 
THE PHILOSOPHY OF UTERINE DISEASE. 
ultimately from the effects of a pelvic abscess. It occurred 
some years ago, before I had learned from experience that in 
cases of retroflexion a certain amount of cellular inflammation 
has previously existed, and that its products are seldom if ever 
absent so long as the organ remains in this position. The 
lady was a foreigner with whom I was unable to hold any per- 
sonal communication ; the operation was performed at a large 
hotel where she did not get the proper care, and I have no 
doubt she suffered from exposure. 
The number of cases treated in private practice has been 
given, that they may be added to those cared for at the hos- 
pital, from the fact that many of the patients were sent to the 
institution by me specially for the operation—as otherwise 
the proportion would be too large. The ratio to the whole 
number treated can be but an approximation, however, since I 
can give no estimate of the number seen by consultation in 
private practice, or with accuracy the number treated in the 
outdoor department of the institution; and yet many of the 
operations performed were on patients received from these 
sources, although the proportion of operations to the given 
number of uterine cases under treatment is larger than it 
would be in reality, could we arrive at the total number 
under observation, yet it is sufficiently small to show that this 
operation has never been with me the rule of treatment. 
We will now consider briefly the mechanical means to be 
resorted to for the relief of displacements. I am ignorant of 
any instrumental means, safe or reliable, for correcting the po- 
sition of an anteverted uterus. Great relief may sometimes be 
obtained, on increasing the degree of anteversion, by the use 
of a pessary with a long-enough curve in the posterior cul-de- 
sac to lift the neck of the organ from the floor of the pelvis. 
On thus slinging the organ, as it were, with the fundus resting 
against the pubis and the cervix elevated, the circulation will 
be improved, and the irritability of the bladder lessened. We 
gain time by this means, and enable the patient to take more 
exercise, since we break the force or jar which would be other- 
wise transmitted to the organ so long as the cervix rested on 
the floor of the pelvis. The various devices for forcing the 
uterus into an upright position to a point which the organ THE PHILOSOPHY OF UTERINE DISEASE. 
13 
likely never occupied even when in a healthy state, are faulty 
in theory and wrong in practice. If we can lift, by any appli- 
ance, the uterus to a point where the obstructed venous circu- 
lation can be relieved through the neighboring tissues, which 
have been put on the stretch by the sagging organ, it is all 
that can be accomplished by such means, and the mere antever- 
sion is of no consequence. Any instrument making direct 
pressure on the anterior wall, the chief seat of disease and the 
point of greatest tenderness, must prove a source of irritation. 
I deprecate even more the intra-uterine stem-pessary, for, had 
this instrument been the device of the Evil One himself, its use 
could not be productive of more danger. Its use in a flexure 
seems as rational as would be the introduction of a straight 
<D 
steel sound into the urethra for the relief of an existing chordee; 
the penis might be straightened by force, but the cause of dif- 
ficulty would certainly not be removed. The treatment of retro- 
version of the uterus is more satisfactory, mechanical means 
can be better applied, and the good resulting from relieving 
the obstructed circulation is well marked on restoring the or- 
gan to its natural position. A recent case of retroversion can 
be reduced with comparative ease, and an instrument can 
readily be adjusted which will keep the organ so far anteverted 
as to render it difficult for it to return to its former position. 
If, however, the displacement has been of long duration and 
the uterus has become flexed, the condition will, in all probabil- 
ity, have acted as a source of irritation in causing cellulitis to a 
greater or lesser extent. Even should adhesions not have formed, 
a degree of congestion will have been kept up so as to require 
but a slight provocation to establish a fresh attack of inflamma- 
tion. It is therefore wise to proceed with the greatest caution 
in any attempt at reduction until we have fully appreciated 
the condition. Should we find the uterus firmly bound down 
by adhesions, it can be replaced in time, for with care, patience, 
and good judgment, in not attempting too much in a single 
effort, these bands will gradually become so stretched and at- 
tenuated as to offer no longer any resistance. The utero-sacral 
ligaments, in a state of health, are scarcely worthy of note, 
being formed but of a reduplication of the peritonaeum and a 
little cellular tissue. These, however, become frequently thick- 14 
THE PHILOSOPHY OF UTERINE DISEASE. 
ened, and, having closed partially over an enlarged and retro- 
verted uterus, can be readily mistaken for adhesions, in con- 
sequence of the obstacle they sometimes present in an attempt 
to restore the organ to its normal position. I have long accus- 
tomed myself to rely on the index-finger for the reduction of 
this displacement, and with a little practice it becomes the most 
reliable means we can employ. It is one certainly attended 
with the least risk, as wre are able to appreciate at once the 
point and extent of resistance. When we have once ascertained, 
the fact that there are no adhesions nor lurking inflammation in 
the neighboring cellular tissue, an experienced operator may, 
with comparative safety, use the sound or any other means 
to which he has been accustomed. But the method which 
I will describe is attended with less pain, and I believe with 
the least danger, under all circumstances. The patient is to 
be placed on the back, with the knees flexed, and the hips 
drawn down to the edge of the operating table or chair. 
Introduce then the index-finger into the vagina, and direct 
the point of a tenaculum, which is to be hooked into the pos- 
terior lip, just within the os. This instrument is to be used 
for the purpose of gently drawing forward the organ, suffi- 
ciently toward the vaginal outlet, that we may be satisfied 
the fundus is distant enough from the hollow of the sacrum 
to pass the promontory when elevated. At the first attempt 
this must be done with care, and if a point is reached at 
which great pain is caused, we must then desist. By this 
manoeuvre the uterus has, of course, become more retroverted 
than before. To correct this, the perinoeum should be pressed 
firmly back, that the finger in the vagina may be passed as 
far up behind the uterus as possible, and made at the same 
time to lift up the organ. When the uterus has been thus 
elevated, and while it is being held up by the finger, the cer- 
vix is suddenly carried in an arc of a circle, downward and 
backward, by means of the tenaculum held in the other hand. 
By aid of the finger in the vagina, the fundus has been pressed 
up against the utero-sacral ligaments. These ligaments, having 
been put slightly on the stretch, gape as the tension is sud- 
denly relaxed by carrying the cervix backward, and the fun- 
dus slips between them. The finger must be then placed THE PHILOSOPHY OF UTEKHSTE DISEASE. 
15 
against the anterior lip, the tenaculum withdrawn, and the 
organ anteverted by passing the finger repeatedly down the 
anterior face of the uterus, so as to press the cervix downward 
and backward into the hollow of the sacrum. If an unusual 
degree of pain is experienced at any point, we must use our 
judgment as to how far it may be safe to proceed, or desist 
entirely for the time being, until all active symptoms have 
subsided under the proper treatment. When successful, I 
frequently make no attempt, by mechanical means, to hold 
the uterus in position, until I have again replaced it and have 
satisfied myself that no tenderness on pressure exists at any 
point which would come in contact with the pessary to be 
used. The form of the instrument should be adapted to carry 
the cervix well back, and with a sufficient curve in the pos- 
terior cul-de-sac to keep it elevated, so that the organ must re- 
main anteverted. I have been consulted, more than on any 
other point, as to the best form of pessary to be used in prac- 
tice. A difficult question to answer, as there is some indi- 
vidual peculiarity about nearly every case, on the apprecia- 
tion of which to a great extent success will depend. Some 
modification of closed lever pessary, however, will 
be found applicable to the largest number of cases, as it con- 
forms more than any other to the natural shape of the vagina. 
A pessary, to do no harm, should be small enough to admit of 
the passage of the finger between it and the vaginal wall at 
every point, while the patient lies on the back. It must be 
just large enough to give the needed support to the uterus, 
and be at the same time small enough for the vagina to regain 
gradually its natural size. The elasticity of the canal is suf- 
ficient to admit of a dilatation to the extent of the pelvic 
excavation ; but it will prove an exception to the rule if a 
pessary, properly curved, need ever be over three inches in 
length and an inch and a half in width. Whenever it is pos- 
sible to avoid making the pubis the chief point of support, I 
do so. But it is often unavoidable in cases of long-standing 
retroversion, where the anterior wall of the vagina has become 
shortened in consequence, and in cases of prolapse of the pos- 
terior wrall, from laceration of the perinseum. But where the 
vaginal outlet is not too large, and the posterior cul-de-sac is 10 
THE PHILOSOPHY OF UTERINE DISEASE. 
of a natural deptli, the principle of the lever-pessary is appli- 
cable to nearly all cases. The fulcrum of this double lever 
rests on the posterior wall of the vagina at the bottom of the 
cul-de-sac. It should be so curved in reference to this cul-de- 
sac and posterior wall at one extremity, and at the other end 
bent with a lesser curve in the opposite direction, so that the 
instrument may be balanced. As the patient stands on her 
feet, the weight of the uterus will cause the other end of the 
instrument to rest against the anterior wall of the vagina, 
near the neck of the bladder. On assuming the horizontal 
position, the instrument will present in the axis of the vagina 
near the outlet. It will thus compensate itself by a change 
of position, so that it cannot, from continued pressure at any 
one point, cut into the vaginal tissues. A longer curve will 
be needed in the cul-de-sac where retroversion has existed, 
than with prolapse from hypertrophy, where the object is sim- 
ply to lift the organ from the floor of the pelvis. In the lat- 
ter condition, the upper portion of the vagina will be more 
dilated, as a rule, than the lower part, and the instrument 
must be made to correspond. The closing in of the vaginal 
walls around an instrument, made larger above, has the effect 
of crowding it upward in the canal. When even the outlet 
is larger than natural, and dilated from a prolapse of the vagi- 
nal walls, we must restore the canal to a natural size and close 
the laceration through the perinseum, by a surgical operation, 
before an instrument can be worn with advantage for correct- 
ing the retroversion. An instrument, under the circumstances, 
to be used as a temporary means of relief, must be made wider 
below, with the greater curve also at this point, so as to get 
the needed support from behind the pubis, and with a depres- 
sion to guard the neck of the bladder from pressure. We find 
occasionally a difference in the curve on each side of the sym- 
physis, so that, if an instrument is made symmetrical, it will 
bury and cut into the soft parts covering the lesser curve. On 
the corners of the instrument there should be no sharp angles, 
but a gradual curve; and frequently it is necessary to bend 
the corners downward, to correspond with the roof of the 
vagina at this point. In the posterior cul-de-sac the instru- 
ment should never be so abruptly curved as to make pressure THE PHILOSOPHY OF UTERINE DISEASE. 
17 
directly against the uterus at its junction with the vagina, 
hut at some little distance beyond. The circulation in the 
neck is easily obstructed by pressure at this point, so that it 
will soon cause an erosion about the os; and frequently an in- 
tolerance to the presence of any instrument in the cul-de-sac 
becomes established, in consequence of irritation or inflam- 
mation of the lymphatic glands found in this neighborhood. 
The shorter the vagina, the straighter must the instrument 
be made, for if curved too much it will rotate and remain 
across the axis of the canal. A straight instrument has to be 
wider in the middle, in proportion to its length, than a curved 
one. The widest part of the vagina is from one sulcus to the 
other, while the lateral walls and posterior surface of the canal 
form a concavity; consequently, a curved instrument should 
be made rather smaller in the middle, as its support is chiefly 
derived from the posterior wall. It is a very common occur- 
rence to And an instrument, wThen too wide, cutting its way 
along the lateral walls of the vagina, at the bottom of a deep 
fold formed as the pessary is carried downward from the press- 
ure above. It may be accepted as a rule that, so long as a 
patient can recognize from her feelings that she is wearing an 
instrument, it either does not fit, or she is in no condition to 
wear one; and in either case it will do her harm. So soon as 
an instrument has been properly adjusted, and there is no ten- 
derness on pressure at any point in the vagina coming in con- 
tact with it, the patient will be unconscious of its presence. 
I prefer at first the use of block-tin rings, on account of their 
greater malleability. After modeling one of a proper size to 
the case, and having fairly tested its use, I then have the in- 
strument reproduced in aluminium, silver gilt, or hard rubber. 
These are, in brief, the main points to be observed in adjusting 
a pessary properly, but in each case there will be a necessity for 
some modification in consequence of individual peculiarities. 
Success will depend entirely on an accurate appreciation of 
these differences, and on the mechanical skill innate to the 
operator. To a want of both or of either gift, must be at- 
tributed the unsatisfactory results so often complained of. 
The uterus, an erectile organ, and surrounded by a mass 
of blood-vessels passing in every direction through loose cellu- 18 
THE PHILOSOPHY OF UTERINE DISEASE. 
lar tissue, is directly affected by any increase or diminution in 
the neighboring circulation. We must, appreciate that in no 
other part of the body have we such a matted net-work of ves- 
sels in the same space. In consequence of the erectile char- 
acter of all the tissues, these vessels become varicose from any 
continued obstruction to the circulation, and have an almost 
incredible venous capacity. As a stream of water will satu- 
rate the ground and lose itself in a marsh, so will the circula- 
tion through the pelvic cellular tissue, and become in disease 
equally sluggish. On theoretical grounds the difficulty could 
be easily overcome by local bloodletting; but the chief objec- 
tion to the treatment, if there were no other, would be the 
already reduced general system of the patient. In this over- 
distended condition of the veins, the balance has been lost, and 
they are no longer able to return to the general circulation the 
same quantity of blood received by them from the arterial 
capillaries. Local depletion would, therefore, act rather as a 
source of irritation, to increase the congestion, where this loss 
of tone existed in the coats of the vessels. There are certain 
conditions where a few leeches applied to the anus, or free 
scarification of the cervix, may be resorted to with great benefit. 
We will take, for an example, a sudden suppression of men- 
struation, from exposure or any other accidental cause, where 
the congestion is almost entirely arterial, and above the secret- 
ing point, as it were. Under such circumstances by tempo- 
rarily lessening the congestion we assist the vessels, which 
have not yet lost their tone, to regain their normal size ; the 
circulation is stimulated, soon the organ is able to resume its 
function, and the equilibrium is restored. If we apply leeches 
to the uterus of a female who has been long suffering from 
local disease, we will find although a momentary sense of re- 
lief may have been experienced, that the organ has increased 
in weight and is lower in the pelvis than before. As her gen- 
eral vitality had been previously lowered, even a slight addi- 
tional loss of blood will be found sufficient to greatly increase 
the previous liyperaestliesia. 
There can be no restoration to health, in either the local 
or general condition, so long as anaemia exists, since the blood 
has lost those elements by which organic life is properly stim- THE PHILOSOPHY OF UTERINE DISEASE. 
19 
ulated. Throughout the menstrual life of the female, the 
organs of generation exercise a dominant influence over the 
nervous system; in health, through the reflex system, they act 
as the fly-wheel to the mechanism. Therefore, so soon as any 
serious local difficulty of a chronic character is established, the 
nervous force becomes lowered, general functional derange- 
ment supervenes, and impaired nutrition follows as a sequence. 
Although we are unable to cure the local difficulty until we 
have improved the general condition, yet we can set the ball in 
motion by lessening the local source of irritation. Unless we 
can control the pelvic circulation, and at least impart a tem- 
porary tone to these vessels, it will be found in the end that 
little has been accomplished. ¥e have our remedies for local 
application within the uterine canal, and much can be accom- 
plished by mechanical means when appropriate. But in the 
simple remedy, hot-water vaginal injections, we possess the 
most valuable means of relief when properly administered. 
Although it has now been many years since this remedy was 
first introduced into practice, but a small portion of the profes- 
sion appreciate its use or understand its action. It is generally 
conceived that the application of heat by this method relaxes 
the vessels and increases the congestion. This it does at first, 
but, if prolonged, the capillaries are excited to increased action ; 
as they contract, the tonic stimulus extends to the coats of the 
larger vessels, their calibre becomes lessened, and, with an ap- 
proach to healthy action, the congestion diminishes. Uo one 
applies a hot poultice with the view of increasing the conges- 
tion of the parts, but, as any old woman would explain it, “ to 
draw the inflammation out,” that is, to lessen the congestion by 
causing contraction of the vessels. That such is the effect of 
the continued use of a poultice is shown by the bleached and 
wrinkled appearance of the tissues after its removal. We can 
cause capillary contraction also by the use of cold, and the 
effect is even more prompt, but, when reaction comes on, the 
tissues will become more congested than before. In brief, the 
immediate effect of cold is contraction, and with reaction we 
always have dilatation; heat, on the contrary, causes dilata- 
tion at first, and its action is followed by contraction after- 
ward. 20 
THE PHILOSOPHY OE UTEEIHE DISEASE. 
If a woman be placed on her back, with the hips elevated by 
a properly-shaped bed-pan under her, and a gallon or more of 
hot water at 98° or of a higher temperature be slowly injected 
into the vagina by means of a Davidson’s syringe, the mucous 
membrane will become blanched in appearance, and the canal 
as diminished in size as if a strong astringent had been admin- 
istered. "While the hips are elevated, the vagina will retain, 
during the injection, a large quantity of water, which by its 
weight will distend every portion of the canal, so that it will 
come in direct contact with the whole mucous membrane un- 
der which the capillaries lie. The vessels of the neck and body 
of the uterus pass along the sulcus on each side of the vagina, 
and their branches encircle the canal in a most complex net- 
work. The vessels of the fundus, through the veins of which 
the blood passes by the liver back into the general circulation, 
communicate with those below by anastomosis. "We can thus, 
through the vagina, influence directly or indirectly the whole 
pelvic circulation. "We can so diminish the supply as not 
only to check congestion, but we can literally, by the use of 
hot water, starve out an inflammation. I know from my own 
personal observation that several of these injections a day, at 
100° to 106°, will abort an attack of cellulitis if resorted to 
early enough, and their use persevered in, with the aid of rest 
and anodynes. These injections exercise a most beneficial 
eflect on the reflex system by allaying the local irritation. I 
know of no better means for removing the nervousness and 
sleeplessness of an hysterical woman than a prolonged liot- 
water vaginal injection, when administered by an experienced 
hand. These injections will frequently soothe a patient to sleep 
in less time than could be done by any anodyne in the phar- 
macopoeia. To receive permanent benefit from their use, they 
must be continued until the patient is restored to health. 
They should be given at least once a day, and the best time is 
on retiring at night. The only position in which the patient 
can receive any benefit from them is on the back, with the hips 
elevated, as I have described. She cannot administer them 
properly to herself, and I know of no arrangement, by siphon 
or other means, which can take the place of an intelligent 
nurse. As the patient improves in health, the quantity of THE PHILOSOPHY OF UTEKIHE DISEASE. 
21 
water can be diminished, and the temperature lowered until 
the injections are discontinued from daily use, but for some 
time they should be employed for a few days after each 
period. 
In 1859 I first used tepid and then liot-water injections, 
in the treatment of a member of my own family; at that time 
and for years afterward cold-water injections, at a low tem- 
perature, were used by every one in the treatment of uterine 
disease. I continued to employ hot injections in my private 
practice until the autumn of 1862, when I was appointed to 
the charge of the "Woman’s Hospital. From that date to the 
present, in this institution, and in my private practice, nearly 
every patient coming under my care has been treated by this 
method, merely varying the quantity of water and the tem- 
perature according to the circumstances of the case.1 
The patient will be in a better condition for getting out 
into the open air after we have lifted up a uterus with ver- 
sion, or prolapsed, by an instrument to aid in restoring the cir- 
culation through the organ. The general condition will, how- 
ever, in all probability, yet admit of little local treatment. 
Beyond the vaginal injections, to which a little chlorate of 
potash, or any other remedy indicated, may be added, with a 
daily pledget of cotton saturated with glycerine, and intro- 
duced into the vagina, our treatment will be limited until we 
have directed our attention somewhat to the general system. 
In a case of long standing we will scarcely find an organ in 
1 The action of hot water in surgery, as a means of preventing haemor- 
rhage, was first brought to my notice by the late Dr. Pitcher, of Detroit. 
He stated that for many years he had been in the habit, when operating, 
of applying to a bleeding surface sponges taken from water as hot as could 
be borne. His explanation was, that, after a clot had formed in the mouth 
of a dilated vessel, the continued application of heat caused it, on reaction, 
to contract so firmly on the clot that secondary hemorrhage could not oc- 
cur. With his views of the action of heat, when continued, on the coats 
of vessels, and my own in regard to the condition of the circulation in the 
pelvis, came the first suggestion to my mind of its application in the treat- 
ment of uterine disease. I have been so thoroughly identified with this 
mode of practice, that it seems scarcely necessary to claim the priority. 
Certainly, no one in this country is on record as an advocate for the prac- 
tice previous to myself; and, as far as I have been able to ascertain, the 
same is true in regard to the practice of gynaecologists abroad. 22 
THE PHILOSOPHY OF UTERINE DISEASE. 
the body which is not suffering from functional derangement. 
The connection of one function with another is so intimate in 
the organic circle of nutrition that the derangement of any one 
soon jeopardizes the integrity of the whole. 
The result will be enfeebled digestion, a sluggish portal 
circulation, and imperfect respiration; so the blood is no 
longer oxygenized properly, and with but partial elimination 
it is returned to the general circulation in a condition not un- 
like that of a cold-blooded animal. The kidneys are over- 
worked, and the skin is inactive ; repair to a great extent has 
ceased, and a general waste is the rule. In addition, we often 
have, combined in the same subject, the pernicious effects 
from the habitual use of alcohol in some form, anodynes, and 
coffee. The first step must be at once, without a compromise, 
to break up the dependence upon either of these now active 
poisons to the nervous system. Their indiscriminate use hav- 
ing in the beginning aided not a little in bringing about the 
general wreck, a continuance would but defeat the best-devised 
efforts for a restoration. We can aid digestion but little at first 
by the use of medicines; our chief dependence must be simple 
and nutritious food, small in bulk and often administered. 
An attempt must be made to bring about a healthy action 
of the skin by means of hot-air baths, general friction, and ex- 
posure of the body to the direct action of sunlight. With any 
improvement in the condition of the skin we will relieve, 
through the circulation, the over-taxed kidneys, the portal sys- 
tem, and indirectly assist digestion. The action of sunlight 
is beneficial in relieving the anaemia, by creating a rapid toler- 
ance of the stomach to the administration of iron. The use of 
iron, in any form, and sunlight, must go together, for, without 
the aid of the latter, ferruginous preparations are not properly 
taken up by the stomach, and must only act as an irritant. As 
we lessen the anaemia and improve the condition of the blood, 
the capillary action will become more vigorous, and the power 
of assimilation and elimination must increase ; we can then do 
more by medicinal means to assist digestion. We can relieve 
the portal system by the use of mild salines and other reme- 
dies, and by doing so we remove the chief obstacle to the prop- 
er return of the venous blood from the pelvis into the general THE PHILOSOPHY OP TJTEEIEE DISEASE. 
23 
circulation. As we continue the use of baths, and friction to 
the whole surface of the body, the patient gains strength, and 
is able to exercise and remain more in the open air. With in- 
creased action of the skin, we will find that the bowels can be 
better regulated, and constipation relieved by less aid from 
artificial means. Having advanced so far in the general 
treatment of the case, the physician will have already thor- 
oughly tested his knowledge of the practice of medicine, and 
by the least resort to drugs his- success will have been in 
proportion to his resources. 
After we have appreciated any existing displacement of the 
uterus, or simple prolapse from enlargement of the organ, due 
probably to imperfect involution, the most common cause, our 
attention will be directed to the existence of an erosion or 
excoriation of the epithelium; but so-called ulceration of the 
cervix is a condition in itself of but little moment, as it will 
heal by attention to cleanliness, and on lessening the discharge 
from the uterine canal. In practice we cannot appreciate 
the full extent of disease in the mucous membrane, whether 
confined exclusively to the neck, body, or fundus, and it is but 
a question of time before the whole canal may become in- 
volved. We learn, however, from experience, that recovery is 
more rapid when the disease exists near the os, than when sit- 
uated in the upper portion of the canal. The most common 
point of origin has yet to be determined ; but my impression 
is that, in females who have not borne children, the disease 
generally has a beginning in the cervix, while the seat of the 
placenta is the point with others, and from which the disease 
extends toward the cervix, or in the opposite direction. The 
uterine discharge is more profuse when from the cervical canal, 
clearer and of a more gleety character from the neighborhood 
of the internal os, and diminishes in quantity and consistency 
on approaching the fundus. The selection of remedies varies 
somewhat with the seat of disease, but my present knowledge 
is not sufficient to be explicit. The truth is, that our practice 
here becomes somewhat empirical, for we can neither map out 
the boundary nor direct with accuracy our applications to the 
diseased surface alone : so that a remedy, which was appar- 
ently most efficacious in a previous case, may prove inert under 24 
THE PHILOSOPHY OF UTERINE DISEASE. 
a like condition, so far as we yet possess tlie knowledge of ap- 
preciating a difference. We know, however, that remedies of a 
more stimulating character, with astringents as adjuvants, are 
useful as applications to disease about the cervix, and alteratives 
for the upper portion of the canal. In our selection we must 
use those calculated to do the least harm to the mucous mem- 
brane which may still be in a normal condition. Hare indeed 
is the necessity for applying, within the uterine canal, caus- 
tics, the cautery, or the strong mineral acids. It is true that 
these remedies act promptly, so far as to heal an erosion and to 
check all uterine discharge. But we cannot restore the patient 
to health by so far changing the character of the mucous mem- 
brane as to leave it a mere cicatricial surface. Our ultimate 
success will be directly in proportion to the condition in which 
we leave this membrane, for we will need its healthy action in 
the after-treatment of the case. That individual cases escape 
with but little daipage is only due to protection afforded by 
the secretions; yet the practice, as a rule, is disastrous enough 
to deprecate their use. We have no remedy which will act 
with more promptness than the nitrate of silver, when applied 
to the mucous membrane of the cervix, yet it has done more 
damage than any other. From being in common use it is the 
more dangerous, for its repeated action will ultimately destroy 
the mucous follicles, harden the tissues, and close the os as cer- 
tainly as the application of the actual cautery. The evil 
effects of its application on the mucous membrane of other 
parts of the body are so well recognized, that its continued use 
for the uterine canal is remarkable. 
I have found most useful for applications to the cervix, 
Squibb’s impure carbolic acid, or creosote-tar. Its action is 
very different from that of the pure carbolic acid ; it exerts a 
local anaesthetic effect, and is not a caustic. This may be ap- 
plied at intervals of ten days, with the intermediate use of 
tannin and glycerine, or the pinus canadensis. It is advisable 
to add to the last pint of the liot-wrater vaginal injection a cer- 
tain quantity of chlorate of potash, chloride of sodium, borax, 
carbonate of soda, or alum, as may seem indicated. When 
the disease is above the cervix, and the patient is in a fit con- 
dition for their use, sponge-tents may be employed for their 
alterative effect. THE PHILOSOPHY OF UTERIHE DISEASE. 
25 
They may be used, of a small size, merely to set up a new 
action by their presence, and by moderate pressure may be of 
benefit in relieving congestion, on remaining long enough to ex- 
cite a free discharge; or of a larger size, with the view of dilat 
ing the canal fully and exciting the uterus to contraction, in 
cases of hypertrophy. After removing a large tent, and while 
the canal is still dilated, it is beneficial to wash out the cavity 
with a continued but gentle stream of hot water from the 
nozzle of a Davidson syringe introduced well up to the fundus. 
Before the uterus has contracted, it is well to make a thorough 
application of the strong tincture of iodine throughout the 
canal. I sometimes alternate with the use of iodine by intro- 
ducing within the canal either the dry persulphate of iron, the 
oxide of zinc, or powdered alum. This is done by means of 
a roll of moist cotton twisted around the applicator and well 
covered with the powder. After wrapping the cotton firmly 
around the applicator and giving it the proper curve, the twist 
is reversed with the fingers so as to loosen the cotton suffi- 
ciently, so that when introduced to the fundus it will remain 
behind on withdrawing the instrument. The presence of the 
cotton can produce no irritation, as it occupies so little space, 
and it will be thrown out from the uterus in a few hours if a 
portion is left projecting from the os. The profuse white-of- 
egg-like discharge does not seem to be a product so much of 
congestion of the mucous membrane as from disease of individ- 
ual glands, which project and can be felt with the 
probe. In addition to the treatment given, I frequently re- 
move these little projecting bodies by means of scissors when 
within reach. Disease at the fundus is a more serious condi- 
tion to overcome, and one but little influenced by any special 
application. The lining membrane of the upper portion of the 
canal is so different in character, that I doubt if disease is 
ever confined exclusively to it, but at the same time the uter- 
ine tissues beneath are always more or less involved. The 
frequent use of iodine, with the view of lessening the size of 
the whole organ, must be our main reliance, with more care 
for improving the general system than where the disease seems 
to be confined to the mucous membrane itself. 
I feel that I cannot, in justice to the subject or myself, 26 
THE PHILOSOPHY OF UTERINE DISEASE. 
enter more into detail. The views of treatment which I have 
already advanced are equally applicable in some respects to 
any form of uterine disease. But, from the fact that displace- 
ments and versions cannot be treated by mechanical or sur- 
gical means alone, the propriety of entering in addition on a 
subject of such scope might be questioned. It is but just that 
I should state that my views have been based to a great extent 
on a hospital practice, yet I hope they may prove no less use- 
ful as an experience in the treatment of an exaggerated form 
of disease which must always be opprobrious in private prac- 
tice. Imperfectly as these views have been given, they have 
been gathered from a most extended field of observation. In 
consequence of a continuous service of some twenty years in 
the "Woman’s Hospital, when it was so long the only institution 
for the treatment of these diseases in the country, I have been 
favored with advantages which could scarcely occur again ; 
while, in addition, from holding the position of surgeon-in- 
cliief to the institution during so great a portion of the time 
since its foundation, I have had a rare opportunity for observ- 
ing the practice of others and for correcting my own mistakes. 
A record has been preserved of every case which has been 
under treatment in the Woman’s Hospital, and in my own 
practice, so that I have been able to keep for years a large 
number of former patients under observation. By the aid ot 
these records, and by personal observation on the return of the 
patients at stated intervals, I have been able from time to 
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