NLM 0DSfl0D3fl 7 ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section- Number 2l23lUl!L Form 113o, W. D., S. G. O. 3—10543 (Revised June 13, 1936) NLM005800387 \ A TRACTICAL TREATISE ON THE DISEASES OF WOMEN. ILLUSTRATED BY fcolflub fkttes anb Numerous Moou (tngtalrinqs. By JOHN M. SCUDDER, M. D., pbofessob of the theory and practice of medicine in the eclectic medical inst1t.uts Cincinnati; formerly professor of obstetrics and diseases of women and children in the same; author of the eclectic practice of medicine, eclectic materia medica, etc. WITH A PAPEE ON THE DISEASES OF THE BREASTS, BY ROBERT S. NEWTON, M. D., LATE PBOFESSOB OF 6UROEBY IN THE ECLECTIC MEDICAL INSTITUTE, OF CINCINNATI. Fourteenth Edition, Thoroughly Revised. CIXCIXXA TI: PUBLISHED BY THE AUTHOR. 1887. 9 Wr -j . - a 1887 Entered, according to act of Congress, in the year 1878, by JOHN M. SCUDDER, M. D., In the Clerk's Office of the District Court of the United States for the Southern District of Ohio. PREFACE. In commencing the practice of Medicine my attention was espe- cially drawn to the study of those diseases peculiar to women— diseases of the uterus and its appendages, from the proportionally large number of cases of these disorders in which I was consulted. It was evident that my success in general practice depended, in a great degree, upon the success of my practice in these special forms of disease, and yet, in the literature of the Eclectic branch of the profession, I could find nothing that could be considered a sufficient guide to the young practitioner. It is true that we have a mass of information scattered through the pages of our medical journals, and it is equally true, and can not be disputed, that the Eclectic practice is far more successful in these diseases than the Allopathic or old- school practice ; yet this information required to be collected and arranged before it could be available for the student or general prac- titioner. I also found that in those articles which have been published on this subject, that the pathology of these morbid processes was scarcely referred to — all that was given being the arbitrary name of the disease, the general symptoms, and the treatment, which, though successful, was not founded upon the pathological character of the diseased action. On examination of the numerous Allopathic works on this subject, I found that the pathology of uterine disease had been carefully and successfully studied, and that, in this respect, this branch of medical science was at least equal, if not in advance of the general practice of medicine: and yet, with this accurate knowledge of the nature and character of the diseased actions, their treatment was far less success- ful than our own, so far as medicinal agents were used for the cure, but where operative interference was required, nothing more could be desired than was jriven in these works. (3) 4 PREFACE. From this investigation, commenced for my own benefit, the present work has grown. For the description and pathological character of the diseases described in the following pages, I am principally indebted to old school authorities; but the practice is strictly Eclectic, eve^ measure recommended having been fully tested by myself or by our most successful Eclectic practitioners. PREFACE TO THE EIGHTH EDITION. For twenty 3-ears this work has been before the profession, and the fact that it has passed through seven editions is its best recommendation to new readers. In some respects it urged a departure from the ordinary practice, especial 1}Tin displacements of the uterus, wholly discarding pessaries. Time has proven the truth of these views, and a large number of the best physicians have adopted them. This edition has been thoroughly revised, especially in the treatment of disease and use of remedies All the new means are described, and the indications for the selection of individual remedies pointed out. In the future we will depend more and more upon general treatment, and the direct action of remedies, and Avill find in consequence that the practice will be pleasanter both to physician and patient, and more successful. Cincinnati, October 10th, 1877. PREFACE TO THE FOURTEENTH EDITION, In re-reading this work I find but few changes necessary. As time passes the truth of "specific medication " is more clearly established, and the selection of remedies in diseases of women is shown to be biased upon the same principles as in ordinary dis- eases. Given, the indications for a remedy, and its action is as certain here as elsewhere. Conversely, if medicines are not so selected, the action will be as uncertain as in other cases. Cincinnati, October 10th, 1886. CONTENTS. p asf- Prf.face, ...................3 Introduction,.................1? CHAPTEP 1. Anatomy of the Female Organs of Generation. Preliminary Observations,.............33 Classification of the Organs of Generation,.......34 Mons Veneris,.................34 Labia Majora,.................35 Nymphse,...................36 Clitoris,...................37 Vestibule,.......•..........38 Meatus Urinarius................3S Hymen,...................38 Vagina,...................40 Uterus,..................• 43 Fallopian Tubes,................54 Ovaries,...................55 Bladder and Urethra...............56 Perineum,..................58 Levator Ani,.................58 Triangular Ligament,..............59 Sphincter Vagina,...............59 Sphincter Ani,.................59 Transversus Perinei,..............60 Pelvic Fascia..................60 Ligaments of the Uterus,.............61 Broad Ligaments,................61 Pound Ligaments,...............62 Structures which support the Uterus,.........62 vi CONTENTS. CHAPTEE II. Pathology and Diagnosis. PAGE Preliminary Observations,............63 Pathology of Uterine Disease,...........63 Primary Disease,................63 Secondary Disease,............• . . 64 Symptoms,..................64 General Symptoms,...............65 Physical Signs,.................Co Supra-pubic Examination,.............6G Examination per Vaginam by the touch,.......67 Examination per Rectum,...........• . 69 Examination by the Speculum,...........70 Examination with the Uterine Sound,....... . 72 Dilatation of the Os Uteri,........... . 77 Examination of the Discharges,...........77 CHAPTER III. Diseases of the External Organs of Generation. Superficial Inflammation of the Vulva,........79 Appearances,................79 Causes,..................79 Treatment,.................79 Phlegmonous Inflammation of the Vulva,.......80 Causes,..................80 Diagnosis,.................80 Treatment,.................81 (Edema of the Labia,..............82 Cohesion of the Labia,..............82 Treatment,.................82 Inflammatory (Edema,..............83 Encysted Tumors of the Labia,...........83 Diagnosis,.................84 Treatment,............... .84 Oozing Tumor of the Labia,.......... .85 Treatment,.................85 CONTENTS. vii PAGE Varices of the Labia,..............86 Causes,..................87 Treatment,................87 Thrombus, or Sanguineous Tumor of the Labia, .... 88 Diagnosis,..................89 Treatment, .................89 Venous Hemorrhage from the Vulva,........90 Warty Tumors of the Vulva,...........92 Symptoms,................92 Causes,.................92 Treatment,................92 Vulvar Enterocele,...............93 Treatment,................93 Vaginal Enterocele,...............94 Pruritus of the Vulva,.............94 Symptoms,................94 Treatment,................95 CHAPTER IV. Diseases of the Urethra. Introduction cf the Catheter,...........96 Urethritis,..................98 Symptoms,................98 Treatment,................99 Stricture of the Urethra,.............102 Treatment,................102 Occlusion of the Urethra,............103 Treatment,................103 Vascular Tumor of the Meatus Urinarius,......104 Symptoms,................104 Treatment,................104 Foreign Bodies in the Urethra...........106 Urinary Calculi,................107 CHAPTER V. Diseases of the Vagina. Occlusion of the Vagina,..............10 Vlii CONTENTS. PAGI Imperforate Hymen,..............109 Treatment,................110 Acquired Occlusion,...............Ill Treatment,................Ill Stricture of the Vagina,.............113 Treatment,................114 Acute Vaginitis,................115 Causes, .................116 Diagnosis, ................116 Treatment,................117 Chronic Vaginitis—Vaginal Leucorrhea,.......118 Symptoms,................118 Diagnosis,................119 Causes, .................119 Treatment,................120 Prolapse of the Vagina,.............122 Vaginal Cystocelc,...............123 Symptoms,................123 Diagnosis, ................124 Treatment,................124 Vaginal Rectocele, ;..............128 Causes,..................129 Symptoms,................129 Diagnosis, ................130 Treatment,................130 Prolapse of the entire circumference of the Vagina, . . . 131 Symptoms,................131 Diagnosis, ................132 Treatment,................132 Tumors, Morbid Growths, etc., ..........133 Diagnosis, ................133 Cancer of the Vagina,..............-134 Diagnosis,................135 Prognosis, ................135 Treatment,................136 Vesico-Vaginal Fistula,............. 137 Causes, .................137 Diagnosis,................13g Treatment,.............. _ 139 .Palliative Method,..........* . . . 140 CONTENTS. ix PAGE Desault's Method, .............140 Cauterization, ..............141 Suture, .................143 Special Instruments for the Approximation of the Edges of the Fistula,............147 Anaplasty,................147 Recto-Vaginal Fistula,.............149 Treatment,................150 Case of Prof. Freeman's,...........151 Laceration of the Vagina,............154 CHAPTER VI. Laceration, or Rupture of the Perineum,.......156 History,.................156 Causes, .................156 Means of Prevention,............158 Consequences of Ruptured Perineum,........159 Treatment,................159 Operation of Mr. Baker Brown,........161 Contra-Indications to Operating,........161 Time of Operating,.............162 Instruments Required,............162 Mode of Operating,.............163 Division of the Sphincter Ani,.........164 Insertion of the Quill Sutures,.........164 Insertion of Interrupted Sutures,........165 Operation in Recent Cases,..........166 After Treatment,..............166 CHAPTER VII. Felvic Cellulitis,.................168 History,.................168 Causes, .................168 Terminations,....... .......169 Duration, ................170 Symptoms,................17C X CONTENTS. PAOE * Diagnosis, >...............171 Treatment,................171 Fistulous Passages remaining after, ......173 Cases of,.................173 CHAPTER VIII. Venereal Diseases. Classification,............ ... 177 Gonorrhea,..................177 Different Varieties of Gonorrhea,........178 Symptoms,................178 Diagnosis, ........... ... 182 Treatment,...............182 Syphilis,....................186 Stages of, ................188 Inoculation, ...............189 Simple Chancre,.........., . . 190 Indurated, or Hunterian Chancre, .......190 Phagedenic Chancre, ............191 Secondary Symptoms,............192 Syphilitic Vegetations,............197 Mucous Tubercles, .............198 Diagnosis, ................198 Treatment of Primary Syphilis,.........200 Treatment of Secondary Syphilis,........203 CHAPTER IX. Diseases of the Uterus. Classification,.................206 Occlusion of the Os Uteri,.............207 Symptoms,................ 207 Diagnosis,................208 Treatment,................208 Congestion of the Cervix Uteri,...........209 Symptoms,.................209 Causes,..................210 Treatment,................210 CONTENTS. xi pagb [nflammation of the Cervix Uteri,..........211 Causes, .................212 Symptoms,................214 Treatment,................218 Results of Inflammation of the Cervix Uteri, .... 223 Hypertrophy of the Cervix,............225 Causes, . . /...............225 Symptoms—Treatment,............226 Erosion of the Cervix,..............230 Symptoms—Treatment,............232 Elevations the result of Inflammation.......232 Treatment,................234 Ulceration of the Cervix,.............234 S}Tmptoms—Treatment,............236 Corroding Ulcer of the Uterus,...........240 Pathology,..........•......240 Symptoms,................241 Diagnosis—Treatment,............242 Cauliflower Excrescence,.............243 Pathology,.................244 Symptoms,.................246 Diagnosis—Prognosis,............247 Treatment,................248 Excision of the Cervix Uteri,............248 Cancer of the Uterus,..............249 Pathology,.................250 Symptoms,................252 Diagnosis, ................255 Prognosis—Treatment,............257 Metritis,...................262 Acute Metritis,.................262 Causes—Symptoms,.............263 Treatment,................264 Chronic Metritis,................266 Causes — Symptoms,.............266 Treatment,................268 Internal Metritis—Uterine Catarrh—Uterine Leucorrhea, . 270 Pathological Anatomj^............270 Causes — Symptoms,.............272 Terminations,...............274 xii CONTENTS. PAOB Treatment,................275 Physometra,..................279 Symptoms—Diagnosis,........... • 281 Treatment,................282 Hydrometra,.................282 Varieties,.................282 Causes — Symptoms,.............283 Diagnosis, ................284 Treatment,................285 Moles—Hydatids,...............286 Blighted or False Conception,..........286 Fleshy Mole,................287 Hydatids, or Vesicular Mole,....... . . . 288 Symptoms,................289 Diagnosis—Treatment,............290 Fibroid Tumors,................291 Pathological Anatomy,............291 Metamorphoses and Diseases of,.........296 Symptoms of non-pediculated Fibroid Tumors, .... 300 Diagnosis, ................302 Treatment,................303 Symptoms of Pediculated Fibroid Tumors, or Polypi, . 305 Diagnosis,.................310 Prognosis—Treatment—By Ligation,.......312 By the Ecraseur,..............315 By Torsion—By Excision,...........318 By the use of Caustics,............320 CHAPTER X. Hysteralgia or Neuralgia of the Uterus,.......321 Symptoms,................321 Irritable Uterus,................322 Diagnosis,.................323 Treatment,................324 Rheumatism of the Uterus,............326 Causes — Symptoms,...........• • 327 Influence on the Progress of Pregnancy,...... 329 Influence on Labor,.............330 Diagnosis—Treatment,............331 CONTENTS. Xiii CHAPTER XI. PAGE Displacements of the Uterus,............333 Classification,................333 Prolapse of the Uterus,..............334 Causes,..................334 Symptoms,................339 Diagnosis,.................340 Treatment,.................341 By Rest in the horizontal position,......341 By Astringent Injections,..........341 Pessaries,...............343 Rational method,.............346 Galvanism,...............348 Perineal Supporter,............349 Episcraphia,..............350 Retroversion and Retroflexion of the Uterus,......350 Causes — Symptoms,.............352 Diagnosis,.................355 Treatment,.................356 Antcvcrsion of the Uterus,............362 Causes,..................363 Symptoms—Diagnosis,............364 Treatment,................365 Inversion of the Uterus, . . . . ".........365 Causes,..................366 Symptoms,.................368 Diagnosis—Treatment,............369 CHAPTER XII. Diseases of the Fallopian Tubes and Ovaries,......372 Inflammation of the Fallopian Tubes,.........373 Inflammation of the Ovaries,............374 Causes — S}Tmptoms,............374 Terminations,...............375 Diagnosis—Treatment,............376 Ovarian Dropsy,................377 Pathology,".................378 XIV CONTENTS. PAGE Simple Cysts,...............378 Multilocular or Proliferous Cysts,........379 Structure,.................380 Contents — Symptoms,............382 Diagnosis,.................383 Treatment,.................385 By Compression and Palpation,.......385 By Tapping,..............386 By Tapping with Pressure,.........388 By Tapping and Injection of Iodine,.....388 By Artificial Oviduct,...........389 Excision of a portion of the Cyst,........391 Extirpation, or Ovariotomy,..........392 Reasons for and against, ...........392 Conditions rendering Ovariotomy justifiable, .... 395 Preparations for the Operation,.........395 Mode of operating,..............396 Dangers to be apprehended after Ovariotomy, .... 399 Tumors of the Ovar}T,..............401 Fibroid Tumors of the Ovary,...........401 Cancer of the Ovary,..............401 Sj^mptoms,.................402 Diagnosis—Treatment,............403 CHAPTER XIII. Puerperal Fever,................404 Causes,..................404 Pathological Anatomy,............407 Puerperal Endometritis,............409 Inflammation of the Veins and Lymphatics of the Uterus, 410 Inflammation of the Peritoneum,........412 Puerperal Ovaritis,.............413 Summary of the Anomalies in other organs, accompany- ing the above-described processes,.......414 Secondary terminations, ...........420 Symptoms—Symptoms in the Inflammatory form, . . 421 Symptoms in the Typhoid form,.........423 Diagnosis, ................426 Prognosis—Treatment,............428 CONTENTS. XV PAUE Phlegmasia Dolens,...............435 Pathology of,...............436 Symptoms,................437 Diagnosis—Treatment,............439 CHAPTER XIV. Functional Diseases,...............441 Classification,................441 Leucorrhea,..................442 Amenorrhea,.................444 Emansio Mensium, or Absent Menstruation,.....444 Symptoms,................446 Causes—Treatment,.............447 Suppressio Mensium, or Suppressed Menstruation, . . 448 Symptoms,................448 Diagnosis,.................449 Treatment,................450 Dj'smcnorrhca,.................453 Neuralgic Dysmenorrhea,...........453 Symptoms — Causes,.............454 Treatment,................455 Inflammatory Dysmenorrhea—Diagnosis,.....457 Treatment,................458 Mechanical Dysmenorrhea,...........458 Treatment,................459 Menorrhagia,.................459 Menorrhagia, with the discharge of the Normal Men- strual Fluid — S}*mptoms, . ........460 Causes—Treatment,.............401 Menorrhagia, with the Discharge of Blood directly from the Uterine Vessels,............ 462 Symptoms,................462 Causes—Diagnosis—Treatment,.........465 Chlorosis,...................467 Pathology,................468 Causes,..................470 Symptoms,.................471 Treatment............; . . . . 472 XVI CONTENTS. PAOl Hysteria,.............,.....477 Pathology,.................477 Symptoms,................478 Diagnosis—Causes—Treatment,.........480 CHAPTER XV. Diseases of the Breasts. Introductory Remarks,..............483 Classification of Diseases,.............484 Anatomy of the Breasts,.............484 Pathology,..................492 Diseases before Puberty,.............494 Milk-like Secretion from the Mammary Gland of the Infant, 494 Inflammation of,................495 Inflammation of, following Hemorrhage from the Vulva, . . 495 Malignant disease near the age of Puberty,.......496 Effects of Simple Inflammation,...........498 Treatment,..................498 Mammary Abscess,...............501 Chronic Abscess,..............• . 502 Lactiferous Swelling,..............503 Cellulose Hydatids,...............503 Chronic Mammary Tumor,............506 Irritable Tumor,................507 Carcinoma, or Cancer of the Breast,..........508 Pathology of,.................510 Treatment of,............ .... 514 INTEODUCTION. The first questions that require study are, why is disease of the reproductive organs of women so common, and why are they so difficult of cure? I answer the first by saying that they are com- mon because the reproductive organs are not properly cared for, and are subject to continuous abuse. They are difficult of cure for the same reasons, and because the physician will not see the neces- sity of rest and a restorative treatment. The reader may think these claims are broad, but we hope to be able to substantiate them, and in doing so, point out the way for a better treatment. The law of development reads, " as a part is rightly used, it gets increased development and strength " The reproductive appara- ratus is intimately associated in its development with the condition of the lower portion of the body—with the apparatus of locomo- tion. Show me the woman who has well developed legs, and the capacity for active and continued movement, and I will show you one who has a well developed and strong reproductive apparatus. If this is the fact, we see the importance of active out-door exer- cise in girlhood—leg exercise; and the importance of well regu- lated exercise in the adult. If a feeble woman is about to enter the married state, and call into use this apparatus, there is especial reason why a well regulated exercise for pelvic development should be adopted. If, now, exercise in the open air is commenced, and gradually increased from day to day, we will find a most marked improvement in the tone of the pelvic structures in the course of a few months Inattention to the bowels and bladder is a very common cause of uterine disease. The girl or woman has so much occupation, or knows so little of the importance of these functions, that she neglects them, becomes irregular, and must suffer physical lesions of the pelvic viscera in consequence. ■ No woman who neglects 18 INTRODUCTION. these important functions can have perfect health, and very many will grow some disease in this way. Want of rest, and exposure during the menstrual period, is a frequent source of disease, and it is well to impress upon the minds of our women the need of care at these times. Not but that a woman who had inherited a vigorous body, and had lived an ac- tive, health}'' life, might not endure very great exposure without suffering, Congenital hydrophobia is a very common cause of uterine dis- ease. Some women never wash — anything but their faces—and have to be taught that in civilized life cold water may compensate for sedentary habits. The woman of lax fibre and feeble develop- ment will find the vigorous application to the pelvis, abdomen, and genitalia, of cold water, with brisk friction in drying, a most important means of development. I am free to say, that no woman has a right to enter the marital relation, unless she can perform the duties appertaining to it. If the body is feeble, or lacks development, her duty to herself, her husband, her children, and to society, demands that she employ all means to recover physical and sexual health. I leave it to the reader to say, from his experience, if these are not facts; if they are, the physician's duty in the premises is very clear—educate the people to right views of life. With the use of the reproductive apparatus comes abuse, and from this many cases of uterine disease are grown. In early mar- ried life comes too frequent copulation, and excessive excitement of the reproductive apparatus, sometimes without the relief that comes from the completed venereal orgasm. Then pregnancy follows without a knowledge of the care that should be used in this condition, and frequently a too early return to the exhausting labors of the household after childbirth. Then possibly exhaust- ive and prolonged lactation comes in to complete the wrong to the previously exhausted reproductive apparatus. In many cases the cares of life are so great as to exhaust the vital forces ; in other cases the labor in the care of the household is exhaustive, and in others the food is so imperfectly prepared that the woman can not make blood enough to sustain health}7 life. In thus naming the common causes of the diseases we meet in women, the physician may see how they can be avoided, and he INTRODUCTION. 19 certainly will see the necessity of rectifying those wrongs, if he is to have success in the use of remedies. It not only suggests the good that may come from popular education in these matters, to prevent female diseases, but the necessity of avoiding them, if per- manent cures are to be effected. If we think for a moment of the acute diseases of women, we will see that they do not differ materially from diseases of the other sex, and if we select remedies according to special expres- sions of disease (general principles?), we have excellent success. As with other organs or parts, we find there are remedies which have a special action upon the uterus and ovaries, and this class is frequently brought into requisition. But it Avill not do to forget, in using them, the large classes that influence the appetite, diges- tion, blood-making, the circulation of the blood, the nutrition of tissue, its waste, and its excretion, with the general and local tem- perature and innervation. If, for instance, I am called to treat a case of acute ovaritis or metritis, what remedies shall I employ? Adopting the physio- logical plan, I will select the proper sedative, the proper bath, the local application, means to establish secretion from the skin, kid- neys and bowels, and to give right innervation. What more will I do? If there is or has been a wrong of the menstrual function, I use the special remedy indicated after the treatment first named. Or if there has been, or is, or will be, abuse of the reproductive function, I give the advice necessary. Have I to do vevy much more than if it was a case of inflammation of the lungs? Let us have an example in a recent case. Mrs. II. has recently returned from a long journey, and the fatigue, and the frequent change of temperature in the cars, produced irritation and deter- mination of blood to the pelvic viscera, increased by its being about the time of the menstrual period. The discharge made its appearance for a few hours, and then ceased, followed by high .fever and evidence of inflammatory action. Pulse 120, full; tem- perature 105 ; tongue somewhat full, and covered with a yellowish fur; severe pain in the pelvic region, and exquisite tenderness on pressure. There was much irritation of the nervous system, and a scanty urine passed with difficulty. Prescribed—R Tinct. Veratrum, gtt. x ; Tinct. Gelseminum, gtt. xx.; water, siv.; a teasjioonful every hour. Bowels moved with 20 INTRODUCTION. an enema of tepid water. The next morning there was a decided improvement, and substituted—R Tinct. Veratrum, gtt. v ; Tinct. Macrotys, gtt. x.; water, |iv.; a teaspoonful every hour. Pretty comfortable the next day; pain gone, but little tenderness; com- plained of some dullness and unpleasant sensations in the ears. Continued the medicine every three hours, and ordered a single grain of quinine at 10 A. M. The menstrual discharge came on that night, and convalescence was rapid and good. I give this case to show the similarity of the treatment to that of other diseases. But one special remedy was employed, Macro- tys, and even that would have been quite as useful in an inflamma- tion of the lungs, if there had been the same tensive, wave-like pain. Now let us have two cases, male and female, as an example. Miss T. follows the occupation for which Solomon was so famous, ("But King Solomon loved many strange women,") and suffered severely at times with ovarian neuralgia, and slight inflammation. I had treated her several times, but the influence of medicine was not satisfactory. Finally I was called when, with the ovarian trouble, was a sore throat with the peculiar aching indicating Phy- tolacca. I prescribed it in the usual dose—R Tinct. Phytolacca, gtt. x.; water, %\v.; a teaspoonful every two hours. The result— she was wholly free from pain in twelve hours. It has been re- peated once since with the same result. S. R. has neuralgia of the testes from the same cause, which has troubled him for months. The scrotum is pendulous, the testes full, and tender on pressure, and the dragging pain is sometimes almost insupportable. Pre- scribed—R Tinct. Phytolacca, gtt. x.; water, 3iv.; a teaspoonful every three hours ; no support. There was speedy relief, and no recurrence of the trouble after taking the second bottle. I have an object in giving these cases, that will appear further along, but the reader can draw his own conclusions now. 1 think the majority will agree with me that a right treatment of acute diseases of the reproductive organs of a woman must be based upon right general principles, and that it should be such a treatment as would cure a similar disease of any other part, plus the remedy or remedies that exert a special influence upon these tissues. Agreeing upon this, can we not agree that a right treat- ment of chronic diseases of the reproductive organs of women INTRODUCTION. 21 should be such a treatment as would cure a similar disease of any other part, plus the remedies that influence specially these tissues, or this function ? This conceded and we are then able to do our thinking in straight lines. In the cure of a chronic disease, functional or structural, what is the first condition? To get as good a condition of the general health as possible. "What is the second condition ? To give the organ or part rest. Let us apply this to the cases in hand. The woman requires the common conditions of healthy life, sunlight, good air, good food, and reasonable exercise. In order to have good tissue and a healthy body, she needs good digestion and blood-making, a good circulation, tissues called into use, good waste, excretion, temperature, and innervation. Will any special remedy compensate for these? Is the local use of the speculum, and the instrument bag and medicine chest of the gynaecologist, compensation ? Let us think for a moment of rest as a means of cure. Recall the cases of uterine disease that have come under your notice, and see in how many of these exhaustive household labor has been a prominent cause; in how many too rapid childbearing has been a cause ; in how many prolonged lactation has been a cause ; in how many mental troubles and worn/ has been a cause; and in how many marital excesses (not the fault of the woman) has been a cause. When I have taken these cases out, I find but few left. It is true that many girls are not properly raised, and have not a right development for the mothers of families, but these give but few cases, if the abuses named above are not added. These are not only causes producing the common diseases of women, but they are present causes continuing disease. One of the first lessons we learn in the practice of medicine is, that present causes of disease must, be removed. In the treatment of chronic disease this is essential, and we do not expect success unless we look closely to this. Now let us reason together. If a woman suffering from uterine disease is overburdened with house- hold cares, what needs be done to insure a cure? If a woman is bearing children so rapidly as to exhaust her life, what needs be done to insure a return to health ? If a woman's life is exhausted by lactation, what needs be done ? If a woman's life is exhausted 22 INTRODUCTION. and the reproductive organs diseased by marital abuse, what needs be done ? We want a clear and intelligible understanding of these matters at the commencement, and I claim that no one can have success who fails to regard them. I will not concede that it is impossible to correct these wrongs of life in the larger number of cases, even among the poor, or the hard worked women on the farms of the frontiers. If the physician makes the suggestions in a kindly manner, and gives a sufficient reason for the proposed changes in the methods of lite, means will be found to accomplish the object. Standing next to good food well prepared, we rank water as a curative agent. As a means for retaining health, it can not be overestimated. As a rule, the woman who habitually uses a sponge bath of cold water to the pelvic region will remain healthy. I have had occasion to recommend it in several cases to pregnant women, as a means of avoiding the many unpleasant symptoms they suffered from during the last months of gestation, and after childbirth, and it has proven so uniformly satisfactory, that it has been continued afterward. There is no mistake but that the use of cold water, followed by brisk friction in drying, increases the strength of the circulation, the innervation and the nutrition of parts. Among the advantages following the use of cold water is the less liability to take cold. Let it be recollected that the feeble part always suffers in the wrong of the circulation we call "cold." If we have an enlarged or ulcerated cervix, a leucorrhoea, or a dis- placement of the uterus, it grows worse at every exposure or change of temperature, and we lose as much at these times as we have gained between them. Let me report a case as an example of the use of cold Avater. Mrs. M----is a chronic sufferer from uterine disease, and has been the rounds of gynaecologists, but without permanent benefit. Her back is so weak and painful that she is not able to take exer- cise. Examination shows an enlarged uterus, cervix full and doughy, os open, and abundant cervical discharge, a large ulcer of the os extending to the cervical canal, with prolapsus to the extent that at the menstrual periods the os would come to the vulva. At the menstrual period there was marked congestion of the pelvic viscera, relieved after a time by profuse menstruation. The treat- ment was commenced with the cold water sponge bath, the patient INTRODUCTION. 23 lying between blankets, which were used to dry the surface. It would be applied briskly to the spine its entire length, then thor- oughly dried by friction through the blanket; then the water would be applied to the abdomen, with the same thorough rubbing; then to the perineum and vulva, and then to the hips and upper part of the thighs. She was instructed to keep the vagina and vulva free from the discharges by washing in water. A perineal supporter was employed to sustain the pelvic organs when on her feet, and moderate exercise was taken daily in the open air. There was a decided improvement, and with change of scene, and pleas- ant company, there was an entire restoration of the health. No medicines were used, and a case of some eight years' standing was cured with cold water, brisk frictions, and the perineal supporter, Let me call attention to the well adjusted abdominal bandage and perineal supporter as a means fur giving rest to the debilitated tissues closing the outlet of the pelvis. Rest is absolutely essen- tial to success, and yet if these tissues are forced to support the organs, they arc overworked every day. This temporary support gives rest until by increased nutrition we have grown tissues strong enough to give support. Let me call attention to the advantage of passive movements in the treatment of all affections that show debilily and relaxation of tissues. For twenty years I have employed the Swedish move- ment cure in these cases, and with most flattering results. The treatment is usually a combination of means to give rest, i. e., to lessen household labor on the feet, and the perineal supporter to support the structures, and passive movement to stimulate a better innervation and circulation. The employment of electricity takes the place of this "movement cure," and when judiciously employed gives most satisfactory results. Let us see what we have thus far. Good food, well prepared. Fresh air and sunshine. Moderate exercise, that is not work. Relief from care, worry, and exhaustive labor. The stimulus of cold, the cleanliness of water, and the invigoration of frictions. Cold water as a means of preventing colds. Rest by proper out- side support, and stimulus to nutrition by the "movement cure." Now add good clothing, freedom from exhaustive discharges, a right use of the reproductive apparatus, and we have the basis for a successful practice. 24 INTRODUCTION. There is a general treatment for many of these cases that must not be neglected, but it is not one that can be formulated in a R. No "compound syrup," thank you. No "restorative bitters," if you please. No " uterine renovator," if our ears are level. If the tissues of the body are not well made, it will be necessary to make them over. How ? you ask. By the methods named in Chambers' Renewal of Life. We see that the excretory organs are active, and the processes of retrograde metamorphosis go on well, that the old body may be carried out. Then we use such means as may be necessary to give good digestion, blood-making, a good circulation and innervation, that a new and better body may be built in its place. Here we have an old and diseased ute- rus, diseased because it is old, and disease irreparable unless Ave can get a better organ. You ask, hoAV an " old uterus " in a young woman ? Easy enough—a, tissue has a life of about four months, and is continuously being born again. If the life of the tissue is prolonged beyond four months, and it is not reborn frequently enough, it becomes old. What shall we do? Stimulate the gene- ral processes of Avaste and nutrition, and renew the entire body to newness of life, uterus and all. Again, my experience in the use of special remedies has proven to me that Avhen special symptoms calling for a remedy are prom- inent, it Avill cure uterine as Avell as any other disease. Let me give a couple of examples from the last season. Mrs. T. has suffered more or less since the birth of her last child, now over two years. She complains of bearing down, fullness in the pelvis, a weak back, has leucorrhcea, and her general health is impaired. A digital examination shows an enlarged uterus, cervix hypertrophied, tissues inelastic, organs low down in the pelvis. Her face is full, there is venous fullness, her tongue is full, inclined to be dirty; she has sense of dizziness in the head, pain in the ischiatic notches, and lumpy faces, folloAved by thin faeces and mucus. All the indications for Podophyllin, and I prescribe—R Podophyllin. gr. j.; Phosphate of Hydrastia. gr. x.; make twenty pills. One to be taken at mid-afternoon. Exercise in the open air and good food. You Avould say that this Avas scant treatment, and yet she is sound and Avell, nothing else having been employed, and the prescription not renewed. You say it Avas the exercise in INTRODUCTION. 25 the open air and good food that did it; so be it, cure your cases in the same way. Mrs. W. has suffered for some months with the usual symptoms of uterine disease. Monthly periods irregular, discharge scanty and dark in color. Has been treated before with escharotics for disease of the cervix and ulceration, and does not want to go through the same process again. Examination determined a cer- vix slightly enlarged, tissue dense, and a peculiar A^elvety sensa- tion at points—erosion ; near the os a well defined ulcer. The tongue showed the marked violet color, calling for nitric acid, which was prescribed. And without change of medicine she was relieved in a couple of weeks. Her health for the past three months has been better than for years. The menstrual function plays an important part in the life of the woman from puberty to the " change of life," at the age of forty to fifty years. It ma}' be stated as a truism, that health of the reproductive organs is dependent upon a normal performance of the menstrual function. It is possible that there may be normal menstruation with considerable disease of these organs, but a wrong of the menstrual function is sooner or later folloAved by structural disease. So markedly is this the case that the estab- lishment of normal meustruation is one of the essentials of suc- cessful treatment. This brings us to the consideration of those remedies that influ- ence the menstrual function. We may classify them as agents which promote the discharge, agents which diminish the discharge, and agents which rectify perversions of the discharge. If Ave were classifying the lesions of menstruation, Ave might group them in three classes—arrest, tardy in appearance, scanty—too free, too frequent in recurrence, prolonged in duration—painful, changed in character. Whatever remedies are recommended for either of these lesions, look to a right performance of function, and a single agent Avill sometimes relieve cither of the three lesions. Standing first in the list of these remedies is the Mncrotys, and for these uses Ave employ a tincture of the fresh or recently dried root, the dose being small, gtt. v. to gtt. xx. to four ounces of water, a teaspoonful CArery ODe, two, three, or four hours. It seems to kave a direct action in restoring the menstrual discharge, if the arrest is associated Avith undue vascular or nervous excitement, 26 INTRODUCTION. It exerts a special influence upon the tissues, looking towards the normal period, whether tardy or 1,avo frequent, but in the last case must be employed in very small doses. And it is one of the most important remedies we have for painful menstruation, or Avrong of evolution or involution in pregnancy and after childbirth. Having a someAvhat similar action are the remedies Caulophyl- lum, and the two species of Actaea, alba and rubra. These reme- dies have a marked action upon the reproducf derangements in the vital actions of the uterus, or of other parts and organs secondarily affected, or of the constitution at large. Up to a late date in the history of uterine diagnosis, most practi- tioners remained, as some are still satisfied, Avith the degree of knOAvledge, which is afforded by the above sources of information. No one, hoAvever, Avho is practically acquainted Avith diseases of the uterus, can have any hesitation in declaring that the symptoms derivable from these sources are utterly inadequate, in the general routine of such cases, for the purposes of correct diagnosis, and are constantly liable to lead into fallacy and error when their indi- vidual evidence is alone trusted." 78. As Ave have seen that, though the general symptoms are sufficient in most cases to locate the disease, but entirely insuffi- cient to determine its character, our main dependence in forming a correct diagnosis rests upon the physical or anatomical signs— the result of a careful examination of the diseased parts. There are several modes of examination proper to determine the diag- nosis of disease of the uterus and its appendages, which might be classified as follows : First, the Supra-pubic examination, or the examination of the abdomen by sight, touch, auscultation, and percussion. Second, a manual or tactile examination by the vagina. Third, a manual or tactile examination by the rectum. Fourth, a visual examination with the speculum. Fifth, the use of the uterine sound. Sixth, dilatation of the os uteri so as to permit the examination of the cavity of the uterus by the intro- duction of the finger. Seventh, the microscopic and chemical examination of the discharges from the uterus and vagina. Supra-Pubic Examination. 79. By an examination above the pubis, Ave ascertain the exist- ence or non-existence of enlargement of the uterus from pregnancy, tumors, hypertrophy, etc.; secondly, disease of the ovary, pro- ducing enlargement of that organ ; thirdly, the presence of inflam- mation by the tenderness on pressure ; fourthly, in some degree, EXAMINATION PER VAGINAM. 67 the presence or absence of adhesions in ovarian or uterine dis- ease. By auscultation, whether or not the enlargement is due tc pregnancy, when it has existed for more than five months. By percussion, the character of the enlargement, whether it is solid, fluid or gaseous. In making this examination, the patient should lie upon her back Avith the head and shoulders slightly raised, and the thighs semi-flexed upon the abdomen. The hypogastrium should then be examined in every direction by careful pressure with the hand, in order to ascertain whether there is any enlarge- ment in that region; if there is, the fingers should be applied to it so as to ascertain its form, size, consistence, position as regards the median line, etc., by trying to move it from side to side, Ave may ascertain its degree of mobility, and the presence or absence of adhesions. By pressing the hypogastrium doAvnward behind the pubis, the fundus uteri may frequently be detected, and if at this time the uterus be elevated by the finger introduced into the vagina, or by the use of the uterine sound, its size, and condition can be pretty accurately determined. The iliac regions should be next examined, as the ovaries and fallopian tubes are frequently found there Avhen diseased. When examining the abdomen by percussion, the position of the patient should be varied in different cases, so as to bring the diseased organ or part in as close relation to the abdominal walls as possible. In auscultation of the abdo- men, the stethoscope should be used, as it is less disagreeable to the patient, than an examination Avith the ear. In the supra-pubic examination the results Avill be greatly modified by the condition of the patient, thus in those of a spare habit, Avith thin and lax abdominal Avails, very accurate information may be obtained on all the points above mentioned; but in those of an opposite con- dition the results will be unsatisfactory. In making this examina- tion, it is necessary that the bladder and large intestines should be previously evacuated. Examination per Yagixam by the Touch. 80. This is one of the most valuable means of diagnosis the experienced physician has at hand, and yet one of the least value to the inexperienced. To make this an available means of diag- 68 DISEASES OF WOMEN. nosis, it is necessary that the finger should first be educated tc recognize .the healthy state of the parts, and then the changes caused by disease. It requires long practice and repeated trials to accomplish this, and yet any one may accomplish it, if he im- proves every opportunity that offers. The dissecting-rooms of our colleges offer facilities for obtaining this practical knoAvledge, that should never be neglected by the student. There, by repeated trials upon the dead subject, he will not only make himself famil- iar Avith the shape and relation of the interior genital organs, but he Avill so educate the touch, that with but a slight amount of after experience, (comparatively speaking,) he will be enabled to distin- guish the various lesions of these organs. 81. In making an examination per vaginam, it is customary to place the patient on her left side, near the edge of the bed, with her back to the physician, the thighs drawn up toward the abdomen and separated, by placing a pillow betAveen the knees. The phy- sician should seat himself, with the right hand, toward the patient, as this Avill give him the use of this hand in the examination. The index finger should be well oiled, and the hand then passed under the clothes to the vulva: separating the labia, the index should be passed from behind, forward until it enters the vagina. The vaginal Avails should then be carefully examined, as well as the meatus urinarius, course of the urethra, bladder, and rectum, the caliber of the vagina, its temperature, sensibility, moisture, the pres- ence or absence of ulceration, of morbid groAvths. etc., the thickness of the perineum, the laxity or tonicity of the vaginal Avails, Avhether a proper support is given to adjacent organs, etc. The finger should then be passed backward and upAvard, until it comes in contact with the os uteri. Greater care is necessary in examining the vaginal portion of the cervix uteri, from the frequency of dis- ease of this part, and the difficulty of its detection. The finger should be passed around the cervix, in the groove betAveen it and the vagina, and the pulp of the finger should be passed carefully over it, ascertaining its form, situation, volume, density, tempera- ture, sensibility, the presence or absence of ulceration, morbid or malignant groAvths, etc. The os should then be examined as to size, form, softness, moisture, fissures, cicatrices, induration, etc. EXAMINATION BY THE RECTUM. 69 By elevating the uterus on the tip of the finger, the size, weight, and mobility of the entire organ may be nearly ascertained, as well as any deviation in its position. After having obtained the necessary information, the finger should be carefully Avithdrawn, to judge of the character of the discharges. 82. The position of the patient on her side as above described, is the one generally adopted under all circumstances; yet Avhere the principal points to be ascertained are the size, weight and position of the uterus, especially in any form of prolapse, the examination will be more satisfactory if made when the patient is in an upright position. Examination by the Rectum. 83. In making a rectal examination, the position of the patient may be the same as in an examination by the vagina; yet it is much better to have her placed so that the pulp of the finger may be brought in contact Avith the anterior Avail of the rectum. Having the index finger well oiled, it may be readily passed into the rectum, by steady and gentle pressure against the sphincter; the finger should be introduced far enough to distinguish the body of the uterus, the other hand being placed upon the hypogastrum, pressing the bladder and uterus doAvnward and toward the rectum. By a rectal examination Ave are enabled to examine the uterus in its entire length, fundus, body, and cervix, to determine the degree of uterine enlargement, to distinguish the character of its contents, Avhether hard, heaA-y or incompressible, or fluctuating and elastic; to detect tumors formed upon the posterior Avail of the uterus, or between the uterus and the rectum. We may also ascertain the existence of disease of the ovaries and fallopian tubes, Avhile they occupy the pelvis. It is also an important means of detecting displacements, especially retroversion and anteversion. In making an examination by the rectum, the phy- sician should always ascertain whether it is in a healthy condition or not. 70 DISEASES OF WOMEN. Examination by the Speculum. 84. Though the means already mentioned may suffice, in many sases, to diagnose the existing disease, yet in many others they will be insufficient, for while the touch enables us to recognize structural changes in the bulk, firmness and sensibility in these parts, the sight rectifies and perfects an erroneous or incomplete opinion, by shoAving the nature and limits of ulceration, excoriation or eruption, the appearance of the cervix and vagina in various stages of disease, etc. In addition to its use in forming a correct diagnosis, the speculum is an indispensable instrument in the application of caustics and other remedies to the diseased parts. 85. Many varieties of the speculum have been introduced and used by the profession. Some of these are very complicated, Avhile others are adapted for some peculiar condition of the parts, and but few of them meeting all the requirements of the general practitioner. The tAvo that are best adapted for general use, ful- filling all the indications required of the instrument, .are the cylindrical glass speculum of Mr. Ferguson, and the four-bladed speculum of M. Ilicord. The first of these is a stout glass cylinder, about an inch and a quarter in diameter, having the inner extremity slightly beveled, and the outer extremity expanded, the vaginal portion of the tube being of the same diam- eter throughout; this is covered externally Avith a brilliant metallic coating, and this again with a thin layer of India rubber. The reflecting poAver of this instrument is very great, giving a clear vieAV of the parts examined. This instrument is preferable to any other, Avhen caustic has to be applied to the cervix uteri, as it is not corroded by any sub- stance, always keeping clean and bright, while Avith the metallic speculum great care is necessary to prevent the caustic from coming in contact with the blades. The speculum of M. Ilicord consists of four metallic, semi-cylindrical blades, joined together at a short distance from the outer extremity. When closed, this instrument forms a cone, but by pressing the handles together, after the Fig. 9.—Fergu- son's Speculum. examination by the speculum. 71 instrument is introduced, the inner extremity may be expanded to any extent desired. This speculum is so constructed that two of the blades may be removed, leaving a com- mon bivalve instrument. This enables the operator to examine the condition of the vag- inal Avails, and make local applications to them, through the interval betAveen the blades. This speculum is furnished Avith an obturator of polished A\ood, having a button on its inner extremity to receive the points of the blades ; this completes the cone, and facilitates its introduction, and obviates the pain which the inequalities of the point of the speculum might otherwise produce. When the instru- ment is introduced, and the blades expanded, the obturator is disengaged by a spring at its cuter extremity Avhich, acts against the sides of the speculum. 86. There are tAvo positions in which the patient may be conveniently placed for the introductio i of the speculum. In the firs' and most common position, the patient lies upon her back, with the pelvis raised, and brought near the edge of the bed, her legs separated, and her feet resting on two chairs. The physician standing or sitting in front of the patient, introduces the fore and middle fingers of his left hand into the vagina, dilates its Avails, and passes the speculum well greased and Avarmed, gently and steadily between and under them. After the instiument has been introduced four or five inches into the vagina, the obturator may be Avithdrawn, and light throAvn in at the outer end of the instru- ment, unless the patient be placed opposite a Avindow. If the os uteri is then in vieAv, the speculum should be carefully moved in the vagina, until the os is fairly placed in the center of the internal orifice of the instrument; if it is not in view Avhen the obturator is withdrawn, the speculum should be carefully passed up to it. Alter it has been brought to vieAv, it should 0 carefully examined, in regard to its color, length and thicknes , 72 diseases of women. the presence and character of erosions, ulceration, morbid growths, etc., the state of the os uteri, its size, form, color, presence, and character of the secretion, etc. In withdrawing the speculum, the vaginal Avails, course of the urethra, meatus urinarius, and vulva should be examined with the same care. 87. The second position of the patient, for the introduction of the speculum, is the one adopted by Mr. Simpson: he says, "in this country great difficulties have been raised against the more general introduction of the speculum into practice, in consequence of the very disagreeable exposure of the person of the patient, Avhich is usually considered necessary in its employment. In my oAvn practice, I have laterally endeavored to avoid this very natural objection, by teaching myself to introduce and use the instrument Avhen the patient Avas placed on her left side, in the position usually assumed in making a tactile examination, and Avith the nates near the edge of the bed. I strongly recommend my professional brethren to follow this plan, as by it, and Avith attention to the management of the bed-clothes, I have found that the instrument can be perfectly employed, with little, or indeed Avithout any exposure of the body of the patient. The speculum is easily introduced, Avithout the assistance of sight, and the mouth of it only requires to be afterward uncovered, in order to enable us to examine the cervix uteri, and top of the vagina." Examination with the Uterine Sound. 88. The profession is indebted for this, as Avell as for many other improvements in medicine, to Dr. Simpson of Edinburgh. Finding a great difficulty in detecting the existence and character of lesions of the body, fundus and cavity of the uterus, he pro- posed to obviate this, by an internal ex<\mination of the uterus, by means of the uterine sound. This instrument consists of a solid stem of silver, or some other metal capable of being bent in any manner required, and still of sufficient strength to retain any curve that is given to it. This stem is about nine inches in length, one-fifth of an inch in diameter, at its thickest portion riear the handle, and one-tenth of an inch at its thinnest part, mar the other extremity; the stem thus tapers from the handle UTERINE SOUND. 73 to the extremity, Avhich terminates in a bulb, about one-eighth of an inch in diameter. The curvature of the instrument is like that of a common male catheter, the convex surface being marked by grooves, placed half an inch from each other, so that the finger, introduced into the vagina, may mark the length of the uterine cavity. The handle of this sound is flat, smooth on the convex surface of the instrument, and roughened on its concave surface, so as to keep the operator constantly aAvare of the direction of the point of the instru- ment. 89. In introducing the uterine sound, the patient may be placed on her back, the physician introduces the index finger of the right hand into the vagina, and brings its extremity in contact Avith the indentation formed in the cervix uteri by the os tincse, so as to act as a guide to the point of the instrument. The sound is held in the left hand, and its point slipped along the palmar surface of the finger in the vagina, and directed by it into the uterine orifice; it generally afterward glides easily, under a slight propulsive force, through the canal of the cervix, and to the fundus uteri. !>0. Though I have not space for a lengthy description of the uses of this instrument, yet as it comes highly recommended, and is likely to prove an important auxiliary to our other means of diagnosis, I have given the folloAving observa- tions on its use, by its originator, Dr. Simpson. 1)1. "If, after the bougie is introduced into the uterine cavity, Ave carry the handle backward toAvard the perineum, the upper extremity of the instrument— and consequently the fundus uteri placed upon that extrem- it\—Avill be carried proportionally fonvard into the hypogastric region. One hand placed above the ; ubis will now feel the F:g. 11.—Uter- ine Sound. 74 DISEASES OF WOMEN. fundus uteri, with the central and thinnest part only of the abdominal parietes intervening betAveen the fingers and the surface of the uterus. Provided the Avoman be not of a full habit, and the abdominal muscles sufficiently relaxed by posi- tion, Ave can noAv pretty accurately examine, with the hand placed on the hypogastric region, the state of the uterus as it is held forward on the end of the bougie, and Ave may alwayu make ourselves still more certain of its condition, by retracting and otherwise moving the handle of the instrument, so as to bring the different parts of the superior and anterior surface of the uterine tumor under the touch of the fingers. By a slight turn of the instrument to either side, the lateral surfaces of the upper part of the viscus may, in the same Avay be brought under our tactile examination ; and in spare subjects, I have occasion- ally found it possible, Avhen the fundus Avas pushed against the abdominal parietes, to extend the manual examination to some distance along the posterior Avail of the organ. In those cases Avhere it can not be effected, the sound still enables us to make a more perfect examination of this, the posterior part of the uterus, than Ave could othenvise effect, by giving us the power of tem- porarily depressing and reflecting its posterior Avail, so that it may be felt by a rectal examination. The vaginal examination of the loAver part of its anterior surface may, in general, be more complete, by a similar aid of the instrument. 92. " In these different steps of examination, the degree and accuracy of information obtained is varied in different individuals by the differences Avhich exist in the thickness of the tissues placed betAveen the uterine surface and the fingers; but in most instances the presence of any marked irregularity in the uterine structures—such as the presence of one or more small fibrous tumors—their hypertrophic thickness, etc., may be readily made out, and under still more favorable circumstances, the exact physical conditions of the organ, in relation to its volume and dimensions, the morbid tenderness of individual parts of it, etc., may be precisely determined. 93. " WThen Ave employ the sound, for the purposes alluded tc in the preceding sentences, namely, for enabling us to make hypo- UTERINE SOUND. 75 gastric examinations of the fundus and body of the uterus, the instrument, before its introduction, should have its extremity bent upon its stem at as nearlv a right angle as the conformation of the genital canals admit, and, after being introduced, its handle should be Avell retracted toward the perineum. By attending to these circumstances, the fundus and body of the uterus will be more easily and fully turned forwaid, and our examination of it greatly facilitated. The same object will also be much promoted by retaining the directing finger at the cervix, during the course of the examination, both to steady the instrument and to serve as a fulcrum to it. In that case the handle may be retracted or pushed forward to any required degree by the forearm, Avhile the other hand is employed in the hypogastric examination. 94. " The preceding remarks apply to the examination of the fundus and body of the uterus, parts Avhich—unless when much enlarged, or the patient very thin—are generally looked upon as beyond the reach of any physical diagnosis. 95. " The physical states and relations of the cervix uteri, are generally ascertainable by the finger alone. Still, in various morbid conditions of the cervix, our tactile examination of the organ may be much promoted by the assistance of the bougie introduced into the uterine cavity. For instance, in chronic enlargement, caulifloAver excresence, and other organic diseases of that part, it is sometimes a matter of moment, both as regards our prognosis and our treatment, to involve or not the lower portion of the body of the uterus. In several such cases, I have found much assistance in determining this point, by gently depressing the uterus by the bougie introduced into it, and having the poAver thus of examining the organ immediately above the cervix, by compressing the structures of that part between a fino-er or two in the vagina, and the resistant sound placed in the uterine cavity, and consequently in the very axis of the viscus. In this A\ay, each point in the circumference of this portion of the organ may be successively examined. 96. " These observations apply generally to such indications as can be made out through the use of the bougie, when the uterus 76 DISEASES OF WOMEN. still retains that freedom of motion Ave have seen it possess, when it is itself in a healthy condition, and when there are no obstruc- tions or impediments to its mobility in the surrounding parts. But there are cases Avhere, from the organ having become more or less fixed and immobile, no advantage can be taken of those facil- ities which the power of partially displacing it in general allows us. In these instances the very circumstance, however, of the mobility of the organ being lost, and still more the degree and extent of its immobility, often materially assists in pointing out the true nature of the affection that is present. Thus in scirrhus of the cervix, the early immobility of that part, in consequence of the morbid degeneration invading the contiguous tissues from almost the very commencement of the disease, is often one of the first and best characteristics of that dreaded malady. In this instance, the fixed state of the cervix of the organ is detected by the direct application of the finger. In other states of disease, the cervix remaining comparatively free and unaffected, the body and fundus may be immobile from various pathological causes, as from morbid adhesions, the consequence of inflammation of its peritoneal surface, from the pressure of tumors or abscesses, etc. Or, again, both cervix and fundus may be immobile at the same time, from general carcinoma of the organ, etc. In all these cases the immobility of the body and fundus, its degree, extent, and seat can only be discovered by the bougie; and its use, along Avith other considerations, may further lead us to detect the special pathological state that may be the cause of the morbid attachment or fixture of these parts of the organ." 97. In reference to the use of the uterine sound, Dr. Churchill makes the following remarks: " This instrument has recently been the subject, Avith others introduced by the same distinguished author, of so much obloquy, that it seems but just, that I should here express my own opinion of its great value in experienced hands ; at the same time, I must add, by way of caution, that it is one by Avhich much mischief may be done, if it be not used wisely and with great gentleness. The uterus, even in a state of health, is by no means insensible; but in disease it mav become EXAMINATION OF THE DISCHARGES. it very sensitive. So that the careful use of the uterine sound may be occasionally folloAved by severe pain, and its indiscriminate and rough use may be highly injurious." Dilatation of the Os Uteri. 98. In some cases of uterine disease, it becomes necessary to ascertain the condition of the uterine cavity, Avith greater preci- sion than can be accomplished by the means heretofore described. This maybe done by dilating the os and cervix uteri sufficiently to make an examination with the finger. The os uteri can be readily dilated by the use of a series of prepared conical sponge tents, each succeeded by a larger one, until the necessary amount of dilatation is attained. These sponge tents may be prepared, by taking a piece of sponge of the requisite size, dipping it in a strong solution of gum arabic, and then compressing it into the required form, by Avrapping it Avith Avhip cord; as soon as it has dried, it will retain the shape given it and the cord can be re- moved; they should be slightly coated Avith lard, or some unctous substance, to facilitate their introduction. The best mode of in- troducing these tents, is to fix them on a bent director, and pass them up by the finger, which has previously been introduced, to the canal of the cervix; the gum arabic is softened by the secretion of the parts, and the sponge expands to its natural size. 99. By this means avc may be able to detect the presence of intra-uterine polypi, tumors, etc ; yet it should not be employed without the patient's life is endangered from frequent hemorr- hages, or some other cause, traceable to some disease of the cavity of the uterus, which may admit of removal. Examination of the Discharges. 100. In all cases of disease of the uterus and its appendages, the discharges from the vagina should be carefully examined by the physician himself, never trusting to the description given bv the patient, or by a third person. The discharges from the vagina may be divided into four classes: discharges of blood, mucus, pus and serum. Though the result of an examination of these dis- charges is in no case sufficient for the formation of a diagnosis, 78 DISEASES of women. yet in many cases it Avill prove a valuable auxiliary to the other modes of examination mentioned. 101. Blood. From the period of puberty until the female has at- tained the age of forty or fifty years, there is a periodical discharge of blood, occurring at intervals of from twenty-eight to thirty days, the duration of the discharge being from three to six days. This blood, forming the catamenial discharge, contains the product of the secretion of the tubular glands of the uterus, which would be appropriate to the formation of a decidual membrane; and is mixed Avith the secretions of the mucous membrane of the vagina and cervix uteri. This discharge presents all the characters of blood, except the power of coagulating. The presence or absence of this discharge should be ascertained in all cases, as Avell as the regularity of its recurrence, quantity, A\hether accompanied by pain or not, etc. 102. Discharges of blood occurring at other times than these, may arise from many different causes, as polypi, morbid growths, etc.; it may also be in various states of coagulation, discolora- tion and decomposition. The cause of these discharges should, in every case, be ascertained by the means heretofore named. 103. As the other discharges from the vagina arise from causes so various, a full description of their diagnostic value Avould increase this chapter to an unnecessary length. I wTould, there- fore, refer the reader to the chapter on leucorrhea, Avhere thev are fully considered. INFLAMMATION' OF THE VULVA. 79 CHAPTER III. DISEASES of the EXTERNAL ORGANS OF GENERATION. Superficial Inflammation of the Vulva. 104. Any part of the external organs of generation may be the seat of inflammation. This inflammation may be superficial, merely affecting the skin or the mucous membrane, or it may be very severe, affecting both the skin and the sub-cutaneous tissues. The superficial form of this inflammation docs not give the patient much uneasiness, and it is very rarely that a physician is consulted, Avithout the inflammation has produced an intolerable pruritus, Avhich is much more distressing than any pain. This inflammation may continue, producing ulceration, and a discharge of a Avhite, or yellowish-Avhite muco-purulent secretion. In a feAv cases it assumes a phagedenic character, and leads to a. rapid destruction of the adjacent tissues. 105. Appearances.—The skin or mucous membrane is reddened, and slightly tumefied, the mucous follicles are prominent, some- times of a pale color, at others they present a deep red or purple- ish appearance. If there is ulceration, the ulcers will be small and oval, and not more than from one to three lines in the long- est diameter. Or there may be an apthous exudation covering a en-eater or less amount of the surface. 106. Causes.—This form of inflammation generally arises from a Avant of cleanliness ; or from the acrid character of the vaginal or uterine secretions ; though it may arise from causes that Avould produce inflammation of any other part of the body. 107. Treatment.—In many cases internal remedies will be im- portaut. and they Avill be selected by special indications, as in other diseases. If there is general feverishness, Aconite will be used as the basis of the prescription. For burning pain, sense \ of rawness or smarting, give Ithus. If the patient complain of extreme itching, use A pi-. If there is pain in the back or limbs, 80 DISEASES OF WOMEN, Macrotys. If much irritation of the bladder and urethra, and painful urination, Eryngiuin. If incontinence of urine, Gossypi- um. If the patient has sensations of chilliness and cool extrem- ities, Ignatia. T The best local application in the majority of cases will be— R Salicylic Acid, Borax, aa. gr. xxx.; water gviij. to sxvi. In some cases a weak lotion of permanganate of potash will be bet- ter, and once in a while Yeratrum or Aconite, if there is great tumefaction and threatened suppuration. 109. Other means have been employed to relieve the pruritus. but if this symptom arises from an inflammation or irritation of these parts, the means we have recommended will remove it. In all cases strict attention to cleanliness should be required. Phlegmonous Inflammation of the Vulva. 110. This form of inflammation involves both the skin, and sub-cutaneous tissues, and occurs most commonly in the labia pu- dendi, though it sometimes attacks the mons veneris. It may affect one or both labia, and at times gives rise to great swelling of the parts. The patient's attention is first drawn to it, by uneasiness in standing, sitting, or walking, for Avhich she can assign no cause; then follow pain, heat, redness, and swelling. Owing to the char- acter of the tissues, the inflammation runs a rapid course, and most generally terminates in suppuration. When suppuration takes place, the patient will complain of a throbbing pain in the part, and the pain upon motion or sitting will be greatly increased. 111. Causes.—It arises in most cases from some accident, a fall, or bloAV of any kind may give rise to it. It has been observed to arise after a first connection, from masturbation, and after de- livery from the pressure of the child's head, as it passes through the outlet; it has also been observed to arise Avithout any assign- able cause, and it sometimes occurs during pregnancy. 112. Diagnosis.—This disease should be carefully diagnosed from vulvular enterocele, for nothing could be more dreadful than to plunge a lancet into the intestine confined Avithin the labium of INFLAMMATION OF THE VULVA. 81 a patient, under the mistaken design of discharging a supposed abscess. This, however, can never happen, if the differential points are remembered. It may be distinguished from hernia by the greater hardness of the SAvelling, and by its circumscribed character, and more especially by its not being changed by cough- ing, and not being reducible. It may be distinguished from oede- ma of the labium by its more circumscribed character, and darker color, from tumors of the labium, by its acute course, and by the greater degree of heat, redness, and pain. 113. Treatment.—In the forming stages of this inflammation, the treatment named in superficial inflammation should be em- ployed, and with the topical use of Aconite or Yeratrum the inflammation may be arrested. But it may be said that in the most of cases, the physician will be consulted too late to prevent suppuration ; as soon as suppuration has taken place, the abscess should be opened by means of a longitudinal incision on the inside of the labia externa; this should be done as soon as the presence of pus is ascertained, in order to prevent the burrowing of the matter in the lax tissues of the pat, and its disposition to open in several places and terminate in fistulas. It will be found that the tissues here do not heal readily, and, in the most of cases, it Avill be necessary to make use of stimulating injections. The best injection that I have ever used for this purpose, is a solution of Sesqui-Carbonate of Potassa,—one drachm to four ounces of Avater will be found sufficient in the most of cases; though I have occa- sional! v used a saturated solution. 114. Abscess of the labia, which, from feelings of delicacy on the part of the patient, may have been left Avithout any treatment, often terminate in fistulas. These may be very tortuous,—forming a communication between the rectum and the vagina,—producing recto-vaginal fistula, or passing from the rectum to the external surface of the labium, or from the vagina out through the labium. The two last varieties of fistula are to be treated in the same manner that Ave treat fistula in ano : by the use of the caustics to destroy the callous Avails of the fistula, and the use of the ligature. See Howe's Surgery, pages 820-1. The treatment of recto-vagi- nal fistula will be given, when treating on dis< ases of the vagina. 6 82 DISEASES OF WOMEN. (Edema of the Labia. 115. This is characterized by swelling of the labia, Avhich becomes tense, shining, of a rose color, transparent, and has but little sensibility to the touch. When seen, it is generally accom- panied with anasarca. 116. The treatment of this, in addition to that made use of for the general dropsy, will consist in steady compression of the parts. If the parts are very much distended, and produce great inconvenience, Ave might procure the discharge of the fluid by means of small punctures made with the point of the lancet. Cohesion of the Labia. 117. This affection may be either congenital, or it may be the result of accidental disorders. It is very rarely, in either case, that the cohesion is complete ; a small passage generally exists sufficient for the passage of the urine. 118. Sometime-, but very rarely, the cohesion is complete at birth; in this case, the evacuation of urine Avould be entirely pre- vented, and death Avould inevitably ensue, if the necessary division was not made. Cohesion of the labia may be caused by acute inflammation of the vulva, either spontaneous, or from the effects of a laborious labor ; of a burn, of a venereal affection, of a wound or laceration, or any other cause sufficient to excite violent in- flammation of these parts. 119. Where the cohesion is partial, and occurs at the posterior commissure of the vulva, there is ahvays an accumulation of urine, and other discharges at that point, which, if suffered to remain, may produce lamentable effects, such as ulceration of the Avails, fistulas of the rectum and perineum, e;c. 120. Treatment.—The treatment consists in dividing the adhe- sions in the median line. This may be done with a bistoury, guided upon a grooved director ; the parts should be carefully separated, breaking doAvn the adhesions as much as possible with the fingers, or the director, as in many instances the adhesions may be broken up Avithout the aid of the bistoury. To prevent reunion, pledgets of lint, spread with the mild zinc ointment, ENCYSTED TUMORS OF THE labia. 83 should be introduced betAveen the cut surfaces, and continued until the parts are healed. Inflammatory (Edema. 121. (Edema sometimes occurs Avith inflammation of the con- tiguous parts. In these cases, it presents all the symptoms of phlegmonous inflammation, but which are increased by the pre- sence of the oedema. With this there is generally fever, a dry and constricted state of the skin, scanty and high colored urine, etc. Here the special sedatives, with such other remedies as may be indicated (usually Apocynum) will give the best results. In many cases, much relief may be given by the employment of a brisk hydragogue carthartic, as the compound powder of Jalap and Senna with Cream of Tartar. In addition to this, the same local treatment should be employed that we have recommended for inflammation of the labia. Encysted Tumors of the Labia. 122. Encysted tumors of the labia are of more frequent oc- currence than any other variety. They are of various sizes ; some not being larger than a partridge's egg, Avhile others have been reported as large or larger than a goose egg. These tumors are generally circumscribed and tense,—forming a round or oval pro- jection from the vulva,—and they are often semi-transparent. The contents of the cyst are very various; sometimes a yellow serum, at others, a glairy, viscid fluid, a dark-colored puriform matter, or a semi-solid, lardaceous matter; the cavity is always lined Avith a distinct secreting membrane—the proper cyst wall. 123. These tumors, Avhen small, may continue for years, and give the patient but very little uneasiness; in other cases, they may augment rapidly in A^olume, and give the patient much un- easiness, by their size and the tension of the parts, Avhich is generally aggravated by motion. They very rarely produce any pain; though, in some cases, they have produced, by their pre- sence and Aveight, irritation of the adjacent organs. Dr. AsIiavcII states that " the cyst, oAving to the injudicious handling, sometimes inflames, and its contents are converted into a semi-purulent, thin 84 DISEASES OF WOMEN. matter, tinged with blood. A great deal of irritation is established in the vulva, and the feeling of simple enlargement and fullness, which at first is alone felt by the patient, is now aggravated by heat and shooting pains, and tenderness in walking or sitting doAvn. In some rare cases, ulceration has taken place in them, and a very unpleasant sore has been formed." On making an examination, the labium will be found enlarged, and the tumor may be, in general, defined beneath the skin; it is- less identified with the surrounding parts than a phlegmonous abscess; it is not tender on pressure, nor is there any change of color. ] 24. Diagnosis.—This tumor may be distinguished from phleg- monous inflammation from its sIoav growth, and from the absence of the characteristic symptoms of inflammation, pain, heat, and redness; it may be distinguished from oedema of the labia by its circumscribed form, by its being confined to one labium, and by its sIoav groAvth. 125. The diagnosis between these tumors and inguinal and pudendal hernia, is often a matter of much greater difficulty; for both diseases may occupy the same position, and both have the same soft and elastic feeling. The distinguishing points between the two are, that the cyst does not swell and distend while cough- ing, and it can not be returned into the abdomen; if, however, there is any doubt on this point, the exploring needle should be used before making an incision into the tumor. 126. Treatment,—To remove these tumors, it is necessary that the cyst should be emptied, and the cyst-Avail entirely destroyed. If the cyst-wall is not destroyed, it Avill continue to secrete fluid, and keep up the disease indefinitely. It has been recommended by some authors to dissect out the entire cyst; this Avould no doubt entirely eradicate the disease ; but it is a painful and difficult ope- ration, and, if the tumor is large, it is not unattended with danger. The surest and best method will be to make a sufficiently large incision into the tumor to evacuate the fluid, and then inject the cavity Avith a saturated solution of the Sesqui-Carbonate of Potassa. This injection will produce considerable pain for the first ten or fifteen minutes, but it is not followed by a high degree of inflammation. It changes the character of the secreting membrane, ENCYSTED TUMORS OF THE LABIA. 85 excites adhesive inflammation of its walls, and thereby effectually destroys the reproductive poAver of the cyst. This injection can be repeated as often as may be necessary, until the parts are healed. 127. Oozing Tumor of the Labia.—This disease was first described by Sir Charles Clark. It arises in one or both labia, and sometimes extends to the mons veneris. He states that this tumor is sometimes so large as to leave scarcely any part of the labia free from it; it seldom projects far above the plane of the surrounding skin, often not more than a line or tAvo, and rarely more than one-third of an inch. 128. The color of the tumor varies little from that of the cuti- cle of the neighboring parts ; and a projection very much resem- bling it, might be made by the firm application of a piece of fine netting to the oedematous part, during a feAv seconds, the surface being unequal, consisting of irregular depressions and eminences, from the former of Avhich the fluid oozes. In the immediate neighborhood of the tumor, oedema is occasionally met Avith, but the tumor is not itself oedematous; soon after the surface of the tumor has been wiped quite dry, a Avatery fluid begins to ooze from it, and forms drops, Avhich having become large, at length run off, and keep the surrounding parts in a constant state of humidity. 129. This disease having once begun, continues to enlarge, and insulated patches of it appear in other neighboring parts ; and after a time they will be found to run together, forming a single tumor. At first it does not produce much inconvenience, but as the tumor enlarges, the fluid increases in quantity, and by its con- stant passage over the neighboring parts, they become excoriated and irritable, and occasion much local suffering. Hence, smarting and shooting pains about the inner side of the labium, Avith a general sense of heat in the external organs, and pain and heat in passing Avater, become troublesome symptoms. 130. Treatment.—As these tumors are of very rare occurrence, being seldom met with in general practice, Ave have no means of knowing what effects would be produced upon them by those rem- edies used by Eclectics for analagous affections. Dr. Ashwell states, that this condition of the labium is not much under the 86 DISEASES OF WOMEN. control of remedies. Contrivances to imbibe the fluid as it exudes, and prevent its running over the adjacent parts, are important. Lint, moistened with cold Avater, or a Aveak solution of alum or sulphate of zinc, covered with oiled-silk and supported by a ban- dage, Avill be found to give relief. In addition to these local means, great benefit will be derived from attention to the general health, Avhich is always more or less impaired. A nutritious diet, Avith a moderate quantity of stimulants, in conjunction Avith the use of chalybeates and the vegetable tonics, will reestablish the general health of the patient, lessen the local disease, and prepare the patient for a radical cure. Sir C. Clark operated once for the removal of this tumor, by excision of the labium. More recently the operation was performed by Mr. Rump. Both of these cases were successful. Churchill thus describes the operation performed by this last Surgeon: "The patient having been secured in the lithotomy position, the tumor was drawn fonvard from the pubis, and its base transfixed near the clitoris, and on a level Avith the nymphae, with a straight bistoury, Avhich Avas then carried downward to the fourchette, and brought out. The knife was reapplied, and directed upAvard toAvard the mons veneris. By this means the labium was speedily removed. The round ligaments were laid bare, and three small arterial branches bled, but did not require a ligature. The edges of the long elliptical wound Avere brought together by interrupted sutures and cold water-dressing applied." This appears to be the only means of effecting a radical cure of the disease. Varices of the Labia. 134. According to Colombat, varices of the labia constitute a rather rare affection. They may be distinguished from other affections of the labia, by the folloAving characters: The dilated veins form beneath the skin on one, and the mucous membrane on the opposite side of the labium; certain lumps, Avhich are more or less protuberant as they are of older or more recent date. The tumors are indolent upon pressure, of a bluish color, and of consistence so soft that they disappear under pressure, to reappear again, as soon as the weight is taken off. In some instances these VARICES OF THE LABIA. 87 tumors become irritated and then inflame, Avhen they become the seats of fungus ulcers difficult to heal. This affection sometimes becomes very distressing in consequence of the pruritus with which it is accompanied. 135. Causes.—These are various; it may arise from too fre- quent coitus, from pregnancy too often repeated, from difficult labors, especially Avhere instruments have to be used, and from any cause Avhich obstructs the free passage of the venous blood through the pelvis. 136. Treatment.—If the cause producing the varicose condi- tion of the vulvar veins can be ascertained, our efforts should be directed to its removal, for very frequently the varix disappears spontaneously. Avhen the cause that produced it ceases to act. In many cases the internal use of Pond's Extract of Hamamelis, in doses of ten to twenty drops four times a day, and its local use, Avill prove of great benefit. Tin; parts should be properl}*- sup- ported and kcqit free from discharges. 137. With these applications, steady compression of the parts should be maintained. To relieve the pruritus, which often accom- panies this affection, nothing will be better than Meigs' lotion of borax and morphia. U Soda1 Borat ^ss. Morphia Sulphas gr. vj. Aq. l\os;e Distillat. 5iv. M. F. Misturge. If the varices have terminated in the fungus ulcers above ^ spoken of, it will be necessary to make free use of the sesqui-car- bonate of potassa, until the ulcer assumes a healthy appearance. The best means of applying this is to saturate a small portion of cotton with the potassa, as strong as it can be dissolved, and then sprinkling on it as much of the dry poAvder as will adhere. This should be carefully placed in the ulcer, protecting the adjacent parts with the dry cotton. As soon as the fungus growth has been destroyed, I would recommend the use of the following so- lution until the ulcers are entirely healed : R Salicylic Acid, Borax, aa. ,5j. Water, sxij. M. 88 DISEASES OF WOMEN. Thrombus or Sanguineous Tumor of the Labia. 138. This consists in an extravasation of blood into the cellular tissue of the labia, and results from a rupture of some vessels of the parts, most generally of the veins; and according to some authors, of those varicose veins Avhich are not unfrequently found about the origin of the vagina and the labia. These tumors have always, so far as I have seen cases reported, occurred as a com- plication of parturition, thus it may occur previous to the delivery of the child, during labor, but much more frequently immediately after its termination. 139. This effusion of blood may effect one or both labia; it may also extend upward into the pelvis, or doAvnAvard to the perineum ; the tumor thus formed is of a variable size, OAving to the distensibility of the tissues, sometimes becoming as large as a child's head ; it is very irregular and of a livid or black color. As the distension of the parts increases, it Avill become intensely painful; the patient lies on her back, with the thighs draAvn up and Avidely separated. She is scarcely able to move, and can not even support the Aveight of the bed-clothes. Dr. DeAvees states, that should the parts not give Avay, the pain arising from disten- sion is unceasing and truly agonizing;' fever of a very active kind is kindled; delirium sometimes attends, and the female's life becomes severely threatened. Her sufferings are also augmented by retention of urine, as its passage is prevented by the tumor pressing firmly against the meatus urinarius of the urethra. These tumors have occured, both during protracted and natural labors, but most frequently durin_; the latter; so that there is nothing in the character of the labor that would cause the practi- tioner to suspect its occurrence. In some cases its progress is very rapid, the quantity of blood effnsed being so great as to produce syncope ; in other cases, the SAvollen mucous membrane gives Avay in a short time, g'n'ing rise to dangerous hemorrl age If, hoAvever, the labor is concluded Avithout a rupture of the tumoi after the lapse of a short time, the mucous membrane is observed to vesicate, and then to become gangrenous, Avhen it yields to the pressure, and the contents of the tumor are discharged. In this THROMBUS OF THE LABIA. 80 last case the blood is always found more or less coagulated, forming clots, and the subsequent hemorrhage is not so great. 14<>. There is no other affection of these parts Avith which this tumor could be confounded, if proper care be used in its diagnosis: thus it may be diagnosed from hernia by the rapidity of its forma- tion, by its irregular form, the entire fluidity of its contents, its color, and by its not being reduceable, and not being changed by coughing. From inversion of the uterus, by the position of the tumor, Avhich occupies the side or sides of the vagina; while the canal is free, the uterus and bladder being felt in their normal position. 141. Treatment.—The treatment of this difficulty -will vary, according to whether it arises previous to, or during labor, or after the birth of the child. If it arises during labor, the tumor may become so large as to interfere Avith the birth of the child. If this be the case, Ave have to take our choice between leaving the case to the natural poAvers of the system, or of making an incision into the tumor and discharging the fluid. The danger in trusting the case to nature is, that if the tumor be large it will either prevent the passage of the head, or give Avay before it, giving rise to serious hemorrhage. It is, therefore, recommended in this case, to make a free incision on the mucous surface of the SAvelling, and alloAv the effused blood to escape. Should there be serious hemorrhage after the incision, avc may check it, by steady compression over the part, and the application of ice. If, hoAV- ever, the enlargement is not so great as to offer a serious obstruc- tion to delivery, it Avould be better to Avait, and not lay open the tumor, (if the pain be bearable,) until the lapse of a feAV hours, for in this time, coagulation of the blood Avill take place, and the orifices of the ruptured vessels will be somewhat occluded; yet inasmuch as an incised Avound heals more readily than one that results from sloughing of the tissues, the incision should be made at least as soon as any appearance of vesication is discovered. It would be Avell not to remove all the coagula at once, as it might produce a fresh return of hemorrhage. 142. If this effusion occurs either before or after labor, and the tumor formed is but of small size, Ave might attempt to pro- 90 DISEASES OF WOMEN. duce resolution. For this purpose, there is nothing better than the Tincture of Arnica Montana (S'j to Svj of water) applied to the parts cold, by means of cloths saturated with the fluid. This will also be found to be one of the best applications that can be made to the parts, after the fluid has been discharged, without there is considerable fetor, Avith a tendency of the parts to slough ; when it would be Avell to alternate this Avith the Liquor Sodae Chlorinate;, Sj to gx of water. It is always necessary to sustain the strength of the patient by appropriate stimulants and tonics, nourishing diet, etc. The bowels should be kept regular, the patient quiet, and all untoward symptoms met by appropriate treatment. Venous Hemorrhage from the Vulva. 143. In this connection it may be well to mention, that cases of venous hemorrhage from the vulva, of a dangerous character, have been reported by several authors; some of which have been the subject of legal investigation, in consequence of the death of the female, and the supposition that the hemorrhage arose from a wound made with criminal intent. 144. Dr. Simpson relates a case of this kind, as reported to him by Dr. Kyle of Dundee; Avho Avas called to see the Avoman, but did not arrive until after she had expired. No grounds could be discovered for any suspicion that the Avoman had received a Avound. She Avas in the loAver rank of life, but respectable, and living on good terms Avith her husband and neighbors. She had been straining at the night-stool, Avhen the hemorrhage came on. A large quantity of blood was found about her person ; it had flowed into the genital organs. On making the autopsy, Dr. Kyle paid particular attention to the state of the uterus, Avhich Avas fully expanded in pregnancy; but no effused blood Avas discovered in or around it. On examining the vagina and vulva, Dr. Kyle found a recent aperture in one labium, which, on further dissec- tion, he traced into a large vein. 145. Dr. Simpson also alludes to the anatomical fact, that there was, at the root of each labium, a plexus of very large veins, which extended some way into the vagina. One of these veins. VENOUS HEMORRHAGE. 91 probably in a varicose state, had burst in this instance. Possibly the coat of the vein was thickened, as well as dilated, and conse- quently it would not collapse, as veins usually do, but remained open, like an elastic artery. 146. He further states, that the case seemed to him particularly interesting and important, in relation to medical jurisprudence. A number of criminal trials had taken place in Scotland within the memory of the members, in consequence of women, generally but not always pregnant, having died from hemorrhage from the pudenda, similar to the above. In most or all of these cases, it had been averred, that the wound had been inflicted Avith criminal intent, by the husband or others. Dr. Watson has recorded tAvo or three such cases; Dr. Seller has recorded others; and Dr. S. himself had seen the examination of the body in tAvo criminal eases of this kind. In both the Avomen bled to death from very small Avounds of the pudenda. lie Avas not aAvare that in any of the five or six cases of late years, tried before the Scottish courts, the plea of the apparent Avound being a spontaneous rupture had been adduced. But such a case as this, that had lately occurred at Dundee, had evidently important bearings on the value of such a plea. ^Obstetric Memoirs, Vol. 1, p. 277.) 147. Another case of this kind is reported by Dr. Thompson and Dr. Martin Barry; though in this case the Avoman was not pregnant. The patient, a married Avoman, nineteen years of ao-e. had already borne tAvo children, the last only six weeks before the accident. Dr. Barry saAv her eight hours after the bleeding had commenced. He found her in a very Aveak and anemic condition, the skin blanched, the lower extremities already becoming cold; the countenance very anxious; much jactitation; pulse rapid, and extremely Aveak and fluttering. The vagina was immediately plugged; cold cloths Avere applied to the abdomen and vulva, and stimulants and astringents administered by the mouth. After some hours the patient had recovered to such an extent as to admit of her being turned upon her left side; and on examination a Avound Avas discovered, large enough to admit the finger, to the depth of about half an inch, in the anterior Avail of the vagina, at the union of its upper with its middle third. On the folloAving 92 DISEASES OF WOMEN. day, Dr. Thompson, who had been called in by Dr. Barry, found her in an extremely depressed state, but subsequently she recov- ered perfectly. This woman's husband, a cattle-drover, had been long absent from home, and on the evening of the accident, his visit lasted only half an hour, during Avhich time he had been alone with his Avife. Immediately after he had left her, the bleed- ing commenced. Had death actually occurred in this case, th< existence of the wound might have given rise to suspicion o' criminal violence having been resorted to. Warty Tumors of the Vulva. 148. These excresences may be developed upon any part of the external genitals, and are sometimes observed in the vagina. They may arise at any age, having been observed in children not more than three years old. These tumors may be single or in groups; their size varies from that of a pea to that of a hen's egg; they are generally prediculated, but sometimes the base of the tumor is the largest part; there is scarcely any difference in color betAveen these vegetations and the adjacent parts. 149. Symptoms.—These tumors may be present for some time, without giving the patient any uneasiness, but most commonly they produce considerable irritation, giAring rise to a discharge of mucus more or less profuse, and Avhich resists all means usually employed for its relief. If the tumors be large, they produce more or less inconvenience in Avalking, sitting, etc. Examination is the only means by which they can be detected. 150. Causes.—These excresences sometimes arise from a Avant of personal cleanliness; at others, they are produced by chronic inflammation of the parts. In many cases they are undoubtedly of venereal origin, being the sequelae of syphilis. 151. Treatment.—If the tumors are small, they may be easily removed by clipping them off with the scissors or knife. If they are large, they will have to be removed Avith the ligature, to pre- vent the hemorrhage, Avhich is ahvays very considerable Avhen they are excised. After they have been removed, caustics should be applied to their roots, to disorganize them, and prevent their rjcurrence; probably the best caustic that can be used in this vulvar entrocele. 93 case, is Carbolic Acid ; let it be thoroughly applied with a pine pencil—so thoroughly as to reach the base of the growths. If one application is not sufficient to entirely destroy them, it may be repeated in tAvo or three days. If Chromic Acid should be used, then just enough to Avet the root of the tumor; for if it is too freely used, it will produce great inflammation and disor- ganization of the surrounding parts. 152. Should there be any suspicion that, these excresences are of venereal origin, the proper treatment for syphilis should be employed. 153. Quietness and rest is necessary for a feAv days after their removal. Should there be much irritation, folloAving their re- moval, or the application of the caustic, the parts may be fre- quently bathed with cold Avater, which will generally subdue it. Vulvar Enterocele. 154. This consists of a hernia of the small intestine, which has forced its Avay doAvnward by the side of the vagina into one of the labia, where it forms a tumor, which both raises up the skin, thus showing itself externally, and projects inward into the vulva This variety of displacement is of very rare occurrence; it was first described by S.ir Astley Cooper, under the name of pudendal hernia. It may be diagnosed from other affections of the vulva, by the fact, that Avhen the patient coughs or bears doAvn, the tumor Avill become hard and tense, and, in coughing, there may be felt a distinct impulse or succussion ; the diagnosis is also assisted by the fact, that in nearly every case it is reducible. 155. Treatment.—When called to a case of this kind, our first object is to reduce the hernia. In order to accomplish this with facility, the patient should be placed upon her back, with her hips elevated, and the thighs flexed upon the abdomen, in order to take off the tension of the abdominal muscles. The operator should then introduce one or tAvo fingers into the vagina, to support the vaginal Avail, and prevent its yielding as the intestine is passed up, while with the other hand he makes steady compression upon the tumor,—passing the boAvel upward in the direction of the axis of the pelvic cavity. We may know that the boAvel has 94 DISEASES OF WOMEN. been reduced by the void that it leaves in the labium and cor- responding portion of the vagina. For the purpose of preventing a displacement, the conoidal pessary may be used; it should be .placed with its base upward, and retained by means of a bandage; or an India rubber bottle, as Ave have recommended in prolapsus of the bladder, might be found to answer a very good purpose. Vaginal Enterocele. 156. This is but a species of the same variety of hernia; it presents itself in the canal of the vagina, instead of passing doAvn to the vulva. We notice this here, from the fact that the diagnosis and treatment are the same in both varieties. Pruritus of the Vulva. 157. I have already mentioned pruritus of the vulva as an attendant symptom in superficial inflammation, and some other diseases of the vulva; it is, hoAveArer, of more common occurrence as a symptom in other diseases, than those of the vulva. Thus, it may occur during pregnancy, from disease of the cervix uteri, from leucorrhea, from disease of the bladder, or meatus urinarius, from disease of the rectum, especially from the presence of anal Avorms, the ascaris vermicularis, from the presence of the pedieulus pubis at the roots of the hair of the genitals, etc. In other cases, none of these causes can be detected; the pruritus appearing to be due to a perverted action of the nerves of the part. 158. The symptoms of this affection, according to Dr. Ashwell, are a tormenting irritation of the vulva, sometimes affecting the Avhole genital fissure, and occasionally the vagina some Avay doAvn, and the mons veneris. Where this latter part is implicated, it should be ascertained Avhether there be parasite animals at the roots of the hair. 159. " The itching is increased by the warmth of the bed, by lull and stimulating diet, high temperature, and fatigue from walking. If the parts be examined after the disease has existed for some time, little pimples, slightly elevated, will be discovered : and, if the patient has scratched severely Avith her nails, or even only with the ends of the fingers, these spots Avill be highly inflamed,—an acrimonious discharge, slightly tinged with blood, PRURITUS OF THE VULVA. 9*i oozing from them. In a more advanced stage of the affection, these points may be covered Avith a broAvn crust, the surrounding membrane being of a dark color, and somewhat thickened. 160. " Venereal thoughts are often excited from this irritation of the sexual organs, and they sometimes become so dominant and imperious as to constitute almost a mania. There is also some- times leucorrhea, Avhich Aveakens the vagina, and pelvic weight and pains are added to the other local symptoms. After a time, the genitals, especially the labia and nymphae, become someAvhat enlarged, and the mucous membrane occasionally loses its vascular appearance, and assumes a white, sodden look. The general health soon suffers ; the constant loss of rest, and watchfulness, induces much nervous derangement; the boAvels become irregular; the appetite impaired; and defective nutrition is seen in the loss of flesh and palid aspect of the patient." 161. Treatment.—When consulted upon a case of this kind, our first object should be to ascertain the producing cause. Thus, the condition of the bladder, the urethra, vaginal Avail, cervix uteri, rectum, etc., should be carefully ascertained. If the disease arises from any of the causes before-mentioned, our treatment should be directed to the removal of this cause; for, with this removal, in many cases, Ave will have a cessation of the pruritus. Without this, Ave can not expect a cure of this affection ; and our efforts directed to the arrest of the external symptoms, might greatly aggravate the primary and more important disease. 102. Many agents have been used as local applications for the relief of the pruritus, and with a variable degree of success. In the pruritus attending pregnancy, Professors Dewees and Meigs recommend the lotion of Borax and Morphia. Professor Meigs says, '• ha vine been consulted a great many times for the relief of pruritus vulv.c, and most frequently in pregnant women, I have rarely had occasion to order any thing more than the folloAving formula,—viz : R Soda Borat, 3 ss. Morphia Sulphas, gr. ij. Aq. Rosre, distillat, 5 iiij. M—F. to sec. art. misturae. 96 DISEASES OF WOMEN. I direct the person to apply it thrice a day to the affected parts, by means of a bit of sponge or a piece of linen,—taking the pre- caution first to Avash the surfaces Avith tepid water and soap, and to dry them before applying the lotion." 163. In some cases permanent relief Avill only be obtained by the use of internal remedies, and these Avill be selected by the special indications. Rhus is indicated by the burning pain ; Apis by the itching and burning extending to the urinary passages ; Collinsonia by the sense of contraction and pain about the anus ; Hamamelis by the sense of fullness and inclination to prolapse; Macrotys by the lumbar pain, painful menstruation, and pain in the thighs; Pulsatilla by the nervousness and mental despon- dence; Bromide of Ammonium by hysterical sjnnptoms, oppres- sion in the chest, loss of consciousness, etc. 164. I like the lotion of Salicylic Acid and Borax as well as the one of Dr. Meigs, and if there is some erosion, it will prove better. CHAPTER IV. DISEASES OF THE URETHRA. Introduction of the Catheter. 165. Before describing the diseases to Avhich this canal is liable. it may be Avell to give some information in regard to the use of the catheter. This may seem like a very simple operation, Avhich any one could perform ; but, Avhen the young practitioner has occasion to test his skill, Avithout he has thoroughly acquainted himself with the anatomy of the parts, he will, in all probability, find much difficulty in its introduction, and may, unknowingly, inflict great injury upon the patient. / INTRODUCTION OF THE CATHETER. 97 166. We distinguish four different conditions of the parts, ir. either of which the catheter may have to be used. First, in the unmarried woman ; Second, in the married woman ; Third, during pregnancy; Fourth, during, or soon after, delivery. These differ- ences consist either in an alteration of the position of the meatus urinarius, or in the direction of the urethra. 167. By referring to the anatomy of these organs, it will be seen, that the external orifice of the urethra is situated about one inch farther inward than the clitoris. At its commencement in the anterior wall of the vagina, it is somewhat protuberant, and the orifices of numerous mucous ducts may be seen around it. From this point, the canal of the urethra extends upward and backAvard, along the anterior Avail of the vagina, in which it appears to be imbedded; as its projection into the canal of the vagina can be plainly felt. The length of the urethra is between one and two inches. The differences named, consist in, 1st. In young persons, the external orifice of the urethra is immediately IjcIoav the symphisis pubis, and nearly level with the anterior face of that bone. 2d. In women, Avho have borne many children, the urethra is retracted or shortened, so as to be rarely more than an inch and a quarter in length ; and the orifice w ill be found behind the pubis, near its posterior face. 3d. In any enlargement of the uterus, whether it be the result of gestation or disease, the direction of the urethra will change with the ascent of the uterus, so that in the latter stages of preg- nancy, the urethra Avill be found nearly perpendicular ; passing along the internal surface of the symphisis pubis ; and the meatus will be found behind the pubis, near its posterior face. 4th. During labor, the direction of the urethra will be the same, but the descent of the head into the pelvis, in some cases, so compresses the urethra, that the catheter can Avith difficulty be introduced. In this case, it is recommended to place tAvo or three fingers of one land on the head, and carefully raise it; and with the other, introduce the catheter. Immediately after labor, the tissues are very much relaxed, and considerable care must be used in its introduction. 98 DISEASES OF WOMEN. 168. In introducing the catheter, the patient should be placed on her back, with the thighs flexed, and brought to the edge of the bed, so as to facilitate the manipulations of the physician. Under ordinary circumstances, exposure of the patient is neither neces- sary nor justifiable. The index finger of one hand should then be introduced into the vagina, carrying its radial surface along the vestibule, until it comes in contact with the protuberance marking the orifice of the urethra; if this elevation is absent, as is some- times the case, the finger should be carried upward, until it comes in contact with the projecting wall of the urethra; the finger should then be gently Avithdrawn along the course of the urethra, when it will come in direct contact Avith the meatus urinarius. Having then one finger at the orifice of the urethra, this serves as a guide for the catheter, Avhich being previously oiled, is introduced by the other hand. Having carried the point of the instrument along the finger, the apex of which is placed on the meatus, it will be found to readily enter the orifice. It should then be in- troduced in the direction of the urethra, carefully passing it, using but gentle force, until it enters the bladder; this may be knoAvn by the discharge of urine, Avhich should be received in some small vessel prepared for the purpose. Urethritis. 169. This affection, though rare, is sometimes met Avith by the physician. It may be either acute or chronic, though in all the cases that I have seen reported, the chronic disease ahvays resulted from an acute attack. It may occur in Avomen of any age, and independently of an}' venereal affection. 170. The symptoms of this disease are: constant pain along the course of the urethra, Avhich is greatly increased by passing the urine; there is also considerable bearing doAvn; the urine is passed with great difficulty, and but a small quantity at a time ; the patient having a constant desire to evacuate the bladder. In some cases, indeed, it can not be passed at all, for as soon as the urine touches the inflamed mucous membrane, spasmodic con- traction takes place, Avhich prevents the excretion of even the smallest quantity. Upon introducing the finger, and passinor it URETHRITIS. 99 over the course of the urethra, it Avill be found to be extremely painful, in acute cases ; and in the chronic, it will be so tender, that the patient can bear but very little pressure on it; in these cases, sexual intercourse is very distressing. If the orifice of the urethra be dilated, the mucous membrane is seen to be unusually florid, and it may be so swollen, as to be everted, and protrude from the orifice ; the passage of the catheter gives very severe pain, which does not extend, hoAvever, to the bladder. There is no discharge attending the acute stage of this disease, and it may thus be diagnosed from gonorrhea; but in tAvo cases of chronic inflammation, Avhich I attended, there Avas ulceration, and a very small discharge of muco-purulent matter. 171. This disease may arise simply from cold, and maybe asso- ciated Avith considerable irritation of the bladder, and sometimes kidneys. The urine is scanty ; there are frequent calls to pass it, and the patient complains of scalding and irritation of the vulva. In some cases it Avill be associated with disease of the vagina, and uterus, and will only be relieved Avhen this is cured. Prostitutes not unfrequently suffer from severe urethral irritation, and some urethritis, and sometimes, though the disease is not gonorrhoeal, it may be transmitted to others, I am also satisfied that promis- cuous intercourse on the part of the husband may sometimes give rise to an irritation Avhich may be transmitted to the Avife, and assume the form of simple urethritis. 172. The diagnosis is not ahvays easy, and Avhen persons have been exposed it is sometimes difficult to determine Avhether it is simple urethritis or gonorrhoea. There is very much difference in persons with regard to this. A Avoman may carry gonorrhoea for months, and suffer ATery little from it, Avhilst others Avould suffer most intensely. So in this case : the simple inflammation may run as high, there may be as much suffering, and as abundant a discharge, as in the severest cases of gonorrhoea. When a person has suffered from urethritis once, especially if not properly treated, the urethra is likely to be left in an irritable condition, and maybe a life-long source of -annoj-ance. Every functional Avrong of the reproductive apparatus seems to manifest itself here by sympathy, and after a time the bladder becomes per- • manently diseased, its Avails and mucous membrane either being 100 DISEASES OF WOMEN. thickened, or from atony of bladder and vagina there is partial prolapse of the bladder. In both cases there will probably be increased secretion of mucus, and a plentiful deposit of the triple phosphates. Thickening of the tissues of the urethra may also result, and the development of those irritable epithelial growths sometimes knoAvn as irritable tumors of the urethra. The following case will illustrate the usual symptoms : Mrs. M., aged 17, had been recently married, was attacked Feb. 9, 1857, with great pain and tenderness along the course of the urethra, and difficulty in micturition ; the urine, as it Avas passed, producing excessive pain, and sometimes, as she said, appearing to stop in the middle of the passage. After the first day, she complained of a pressing, Or bearing down, which was greatly increased whenever she attempted to evacuate the bladder. For the first three days, there Avas a considerable discharge of blood from the urethra, but after this it gradually ceased. I was called to see her on the second day of the attack. On making an exam- ination, I found considerable heat in the lower portion of the vagina, Avhich Avas more apparent along the course of the ure- thra, and more especially near the meatus urinarius. The ten- derness of the parts was so great that I could scarcely make an examination. Upon separating the labia the meatus could be seen very much swollen ; the orifice was dilated, and the mucous membrane slightly everted. There Avere also slight constitutional symptoms present. She had been married five or six days, and from the first she had felt some difficulty in passing her urine, and considerable tenderness of the parts. 173. Treatment.—If the disease is acute and severe it is best that the patient should have rest in a recumpent position, espe- cially if near the menstrual period, or associated with metritis. In this case I like the action of Veratrum and Gelseminum, or Veratrum and Macrotys, if there is uterine or pelvic pain. Some- times a hot fomentation of hops, stramonium or poppy heads give great relief at first, and if there is much vesical tenesmus this may be supplemented by a rectal enema of Tinct. Opium and Lobelia. If the bowels are constipated, and the patient suffers from this, a free evacuation may be had by the use of Crab Or- chard Salts and Sulphur, or if easily influenced, by a Seidlitz powder. URETHRITIS. 101 There are cases in which we would give Rhus, Biyonia, Dios- corea, Eryngium, Pulsatilla, Apis, (rossypium, or even Copaiba and Cubebs, earty in the disease. Our rule is—and Ave find it good policy to folloAV it in all cases—to give any remedy that may be specialty indicated Avithout reference to the situation or the name of the disease. The burning character of the pain, pain in forehead, peculiar appearance of the papillae of tip of tongue, calls for Rhus. The Biyonia av.11 be called for by cutting pains in the region of the bladder, almost always associated with an inclina- tion to cough ; the(Dioscorea by abdominal pains and tenderness ; the Eryngium by burning in the bladder, constant desire to pass Avater, and painful micturition ; Pulsatilla by the Dervousness and fear; Apis by the itching and burning in the parts; Gr0SS3~pium by the dribbling of urine, or by non appearance of menses, if it is time for them ; Copaiba and Cubebs by the abundant yellow purulent discharge. As the disease goes along the acute somptoms subside, and the patient complains only of difficulty in passing Avater, uneasiness in its passage, a sensation of bearing doAvn, and more or less dis- charge from the vagina or urethra. It may be sufficient to estab- lish an unpleasant leucorrhoea, or even permanent displacement of the uterus. Hence the remedies must be carefully selected from such as have been named ; or we may think of the Cannabis Indica, Staphysagria, Euphorbia Hypericifolia, Apocynum, Phos- phorus, Hamamelis, and others. As a general rule, I like the topical action of Salicylic Acid and Borax better than any thing I have used. If it becomes neces- sary to inject the urethra, nothing is so good as a solution of Phos- phate of Hydrastia. Irritable Urethra. 174. In the last feAv years Ave have had maiw cases of irritable urethra. It is not confined to public women, but is usually the result of sexual excesses. The patient complains of burning or scalding along the course of the urethra, frequent desire to pass water, and tenesmus. In some cases it is paroxysmal, the patient suffering severely for a time, and then for some hours having relief. In some cases it is only felt during the day, and especially if she is much on her 102 DISEASES OF WOMEN. feet, but in others the patient has to pass water several times during the night, and suffers constantly. Pretty soon you will see it wearing upon the general health, and as weeks go by, the patient has a worn and haggard appearance, and complains of various functional lesions. 175. Treatment.—I have obtained the best results in these cases from the use of Rhus, Apis and Eryngium, according to the spe- cial indications heretofore named. I select the remedy, and use it in alternation Avith Aconite. Prof. King's prescription of Ela- terium will be found a specific in those cases in which there is inflammation of the base of the bladder, Avith deep pain and tenesmus. Of a tincture of Elaterium Ave would give twenty drops three times a day, until it acted upon the bowels, then in doses of five drops. If there is frequent micturition Avith pain and great tenesmus, extending to the bladder, I would recommend Stramonium, as follows: li Tinct. Stramonium, gss.; Comp. Tincture Cardamom, 3'iiiss.; from half to one teaspoonful every tAvo or three hours. If the patient has been in the habit of using Opium, the dose will be larger. When the disease is persistent, and resists the action of reme- dies, forcible dilatation of the urethra may be proposed as a radi- cal cure. Usually the patient will have to be placed under the influence of chloroform, when a large bougie or catheter may be passed, followed by one as large as the forefinger; or the finger well oiled may be passed quite as well. The patient is kept in a recumbent position, and full doses of Veratrum are given. The operation is repeated in two or three days, usually Avithout the chloroform. Stricture of the Urethra. 176. This is of verv rare occurrence in the female, owino- to the large size and great dilatability of this canal. The symptoms of this affection are, a difficulty in micturition, the urine passing in a small stream, and accompanied Avith pain; when the catheter is passed, the difficulty can readily be detected. 177. Treatment.—All the cases that I have seen reported, have OCCLUSION OF THE URETHRA. 103 ocen successfully treated by dilatation, Avith graduated bougies. The best bougie for this purpose, probably, is the gum elastic, or gutta percha; beginning with one of small size, and gradually enlarging it, until the canal has acquired the proper size. The bougie should be passed beyond the stricture, and retained for ten or fifteen minutes each time, Avhen it will be found that a larger size Avill be readily admitted the next day. The occasional use of the bougie should be continued for some time after the stricture is removed, to perfect the cure. Occlusion of the Urethra. 178. Occlusion of the urethra is, in general, a congenital affec- tion, and may exist independently of any malformation of the other genital organs. The malformation generally consists of merely a thin membrane, stretched across the orifice of the urethra, though cases have been reported in which the closure affected a larger portion, or even the Avhole canal. The urethra may be mechanically obstructed by cohesion of the labia. 17ih A strict examination should be made, Avhen the napkins of the infant are found not to be wetted with the usual discharge from the bladder, and Avhere, after the meconium has been evacu- ated from the bOAvels, the infant still continues to cry and to strain Avithout effect. 180. Treatment.—Where the meatus is obstructed by a mem- brane, it may yield to slight pressure; or if this should not remove it, the membrane may be punctured Avith a narroAV bistoury, keeping the passage open, by the introduction of a small catheter, for two or three days. Where the obstruction occupies the greater portion of the canal, it has been recommended to puncture the bladder by means of a delicate trocar, which should be introduced at the meatus, and carried along where the urethra should be, until it enters the bladder. Or, if this can not be done, the bladder should be punc- tured through the vagina. These cases are ahvays dangerous, yet the physician should use such means as would give a probability of relief. 104 DISEASES OF WOMEN". Vascular Tumor of the Meatus Urinarius. 181. These tumors are by no means of unfrequent occurrence. They may be developed in patients of any age, though they more frequently attack the young, Avhether married or single. 182. According to Dr. Aslnvell, this tumor is generally pedicu- lated and movable, attached to one part of the margin of the meatus urinarius, or just Avithin the urethra. Its tAvo prominent characteristics are, great vascularity and exquisite sensibility. Sometimes these growths are not movable, but appear like several raised coalesced granulations; or, occasionally, tAvo or more isolated and independent ones may be seen near together. Every noAV and then they extend partly along the urethra, and may even be located at the neck of the bladder. They are covered by a very delicate membrane, Avhich is often broken by being touched during examination, and blood exudes from the soft, feeble, and injected capillaries. They vary in color, from a pale rose tint to the deepest red; they are generally small, not being larger than a pea in most cases, yet in some cases they have been much larger. 183. Symptoms.—The symptoms that arise from 'this, are mainly owing to the extreme sensibility of the tumor. Thus, if it is so situated that the urine comes in contact Avith it, the act of passing Avater produces great distress, and this is usually one of the most prominent symptoms. There is also constant pain in the vulva, Avhich is increased by motion ; sometimes this pain is accompanied by a sense of Aveight, the urethra and bladder become irritable, and the frequent desire to micturate is suppressed by the dread of the pain which it excites. Sexual intercourse is intensely painful, and is, therefore, obliged to be suspended. No mistake can be made in the diagnosis, if an examination be made. 184. Treatment.—No means that may be made use of, will have the least effect, until the tumor is removed; this may be done by ligature, caustic, the knife or scissors. When the tumor is large, or has a thick base, the ligature would be preferable, from the fact that there is less hemorrhage accompanying it, and less liability of a return of the tumor. The use of the ligature is very painful in these cases, and if the tumor be small, and TUMOR OF THE MEATUS URINARIUS. 105 attached by a pedicle, the better plan would be to cut them ofl close to the mucous membrane, Avith a pair of curved scissors The urethra should ahvays be dilated and examined, to see whether there is any groAvth Avithin it; if there is, this should also be removed. Whatever means is adopted for the removal of the tumor, Avithout the base of it is destroyed by caustic, it Avill rapidly reappear ; as soon, then, as the tumor is removed, Avhether by the ligature or scissors, its base should be destroyed, either by the application of Nitric Acid, or a solution of the Chloride of Zinc, carefully shielding the adjacent parts from injury. This should be repeated, at intervals, until the disposition to reproduc- tion has entirely ceased. It Avas from this disposition of the tumor to reappear, that Dubois and Cullerier recommended cauterization Avithout excision. Mad. Boivin sprinkles the parts with poAvdered alum. Where a considerable extent of the mucous membrane of the urethra is affected, Dr. Churchill recommends the application of the Nitric Acid. His means of applying this, is, to take a pointed pencil of soft Avood, dip it in the strong nitric acid, and gently put it in the urethra as far as may be necessary; this, though tedious, he has always found effectual. One of our practitioners informed me, that in one case he destroyed the morbid groAvth in the urethra, by using pulverized Alum and Sanguinaria, equal parts. His mode of using this Avas to take a tube about the size of a common catheter, fill it Avith the poAvder, and carefully introduce it into the urethra, as far as the morbid growth extends; then, as he withdreAV it, he pushed the poAvder out with a small rod made to fit the tube: this covered the entire growth with the powder. The introduction of this excited con- siderable inflammation, but it Avas readily subdued by the use of cold applications. Two applications of this powder removed the groAvth, Avhich has since shoAvn no tendency to return. 185. After removing these tumors, the patient should be kept quiet, and all symptoms of inflammation should be subdued by cold applications and Araginal injections. » 106 DISEASES OF WOMEN. Foreign Bodies in the Urethra. 186. These consist of substances, which, in some manner, have been introduced from Avithout, and calculi Avhich have passed from the bladder into the urethra. Of the first variety, many different substances have been removed, as parts of a bougie, pencils, pins, pieces of wrood, hair pins, etc. It is not necessary here to inquire how these articles gained admission into the urethra, but, how they can be removed with the least injury to the parts. As the female urethra is very dilatable, calculi of considerable size may pass into it. These, by contact Avith the Avails of the passage, produce considerable irritation and spasmodic contraction, Avhich prevents their further passage. In either of these cases, the patient Avill so describe her situation, that there can be no difficulty in forming a correct diagnosis. The catheter or sound should be introduced carefully into the urethra, to ascertain exactly the character and position of the obstruction. If this can be ascer- tained, its removal should be immediately attempted. The best instrument for this purpose is (Avhether the obstruction is a calcu- lus, or any other substance,) a pair of small polypus forceps; these should be at least tAvo and a half inches long in the blades, so that they may be passed to the neck of the bladder, or into it if necessary. Having oiled the forceps, they should be carefully introduced, using but a gentle degree of force, and passed up until they come in contact with the obstruction. Then, by opening them as much as the urethra Avill permit, they may be carefully passed up until the offending substance can be grasped. Here considerable care must be used, to prevent the forceps including in their grasp any part of the mucous membrane ; if this should be the case, it may be knoAvn by the pain it occasions when the forceps are pressed together, and before any retraction is made. Having then obtained a firm hold on the body, it should be care- fully and slowly"withdraAvn, giving sufficient time betAveen the tractions to permit the urethra to dilate for its passage. 187. Should the foreign body be so large, as is sometimes the case Avith a calculus, that it will not pass without great laceration of the urethra, the forceps should be removed, and means used to relax the parts. This may be accomplished by using vaginal URINARY CALCULI. 107 injections of a decoction of Stramonium, and directing the patient to sit over the vapor of hot Avater. After it is removed, if much inflammation should arise, it may be subdued by cold applications to the parts. Urinary Calculi. 188. It may be Avell, in this connection, to give a description of the means employed, of late years, to remove calculi from the female bladder. IS!). Owing to the great dilatability of the female urethra, cal- culi are frequently passed, Avithout any assistance, and, probably, this is one of the reasons Avhy the physician is less frequently consulted by Avomen suffering from stone than by men. In proof that the urethra can be dilated sufficient for the passage of almost any sized calculi, Mr. Brown gives the following Avell authenticated cases. Middleton relates a case Avhere a stone Aveighing four ounces, Avas expelled in a fit of coughing, after lodging in the pas- sage for a Aveek. Collet speaks of another instance, Avhere a stone about as large as a goose egg, after lying in the meatus uri- narius seven or eight days, and causing retention of urine, was voided in a paroxysm of pain. Dr. Molineaux relates a case in Avhich a Avoman voided a stone, of Avhich the longest circumference Avas between seven and eight inches; the shortest (in the thickest parts) five and three-quarter inches. 190. These instances are sufficient proof, that the urethra may be dilated to give passage to any calculus that could be removed by the sub-pubic operation of lithotomy. The objections that have been brought against the practice of dilatation are, First, that it frequently takes a long time and gives great pain to dilate it effectually; Second, that laceration is liable to occur ; Third, that incontinence of urine has sometimes folloAved. 191. As Mr. BroAvn has fully ansAvered these objections, I shall quote from him. "First. The tediousness of the operation and the pain it produces, are objections, the Avhole force of Avhich has been dissipated by the introduction of anaesthetics into operative sur- gery ; and in this case chloroform has a double claim upon our notice. It not only prevents all pain, but it preA'ents all tedious- 108 DISEASES OF WOMEN. ness likewise. So long as the patient is conscious, the process of dilatation is rendered difficult and tedious by the contraction of the sphincter fibers of the meatus ; but, under chloroform, these fibers are relaxed, and the dilatation can be accomplished easily and quickly. Second. The second objection is disposed of in the same Avay. Laceration can only occur in the Avails of this loosely arranged structure, in consequence of the rigidity of the muscular fiber; relax this rigidity by chloroform and the danger of lacera- tion no longer exists. Third. Incontinence of urine does not occur after dilatation under chloroform, and I think this may be thus explained. When the dilatation has been a tedious and pain- ful process, it has been accomplished (physiologically) by exhaust- ing the irritability of the fibers, and thus rendering them poAver- less for the time; or (mechanically) their structure may have given Avay under tension ; or both these circumstances may have occurred ; and in either of these occurrences, subsequent imperfect contraction and consequent incontinence, are perfectly explicable. Whereas, under chloroform, there is no Avasting or bearing doAvn of the local nervous irritability, nor, as the rigidity of the canal is destroyed, is there any danger of laceration; there is, therefore, no probable cause for incontinence, as a subsequent evil; I state these things advisedly, and after considerable experience, having had frequent occasion to dilate the female urethra, not only in cases of stone in the bladder, but in operating for vcsico-vaginal fistula." 192. When, then, a calculus has been discovered in the bladder, the patient should be placed under the influence of chloroform, and the urethra should be dilated, by the use of graduated bouo-ies, until the finger can be introduced; after the finger has been inserted, dilatation can be rapidly effected by it. As soon as the urethra is sufficiently dilated to pass the stone, the forceps should be introduced, and the stone grasped ; after it has been grasped, the forceps should be turned round, to be certain that no part of the mucous membrane is included in their grasp ; the stone should then be slowly withdraAvn, carefully dilating the urethra in its passage. OCCLUSION OF THE VAGINA. 109 CHAPTER V. DISEASES OF THE VAGINA. Occlusion of the Vagina. 193. Occlusion of the vagina may be either congenital, or the result of disease. It may also occur in any part of the canal, or involve it in its entire extent. Congenital occlusion may be due to an imperforate hymen, or to some malformation of the parts, whereby a greater or less extent of the canal is closed. Imperforate Hymen. 194. The existence of an imperforate hymen, is not likely to be discovered, until the female has arrived at the age of puberty, and at the commencement of menstruation. At this time it may be suspected, if the female have all the symptoms which precede and accompany the menses, Avithout any discharge of the menstrual fluid; and if these symptoms should continue to recur at regular intervals, accompanied Avith a sense of Aveight and fullness in the vagina ; and, especially, if an enlargement is discoverable in the hypogastrium, accompanied with great pain and tenderness on pressure. These symptoms ahvays become ameliorated in the course of a few days, but return with increased violence at each successive menstrual epoch. In these cases the cause of the dif- ficulty may be easily detected, by an examination, Avhich should ahvays be requested Avhen these symptoms are present. We may be certain that the obstacle that closes the passage is an imper- forate hymen, Avhen Ave discover betAveen the labia a hemispherical tumor of a livid or bluish color, soft and fluctuating, and rendered salient by the Aveight of the contained blood. After having ascer- tained that the obstruction is caused by the hymen, Ave should next ascertain, as near as possible, its thickness and degree of organization. In the most of cases, the membrane has been 110 DISEASES OF WOMEN. found quite thin, though of considerable strength ; in some cases, hoAvever, the membrane is thickened and indurated, and from a fourth to three-eighths of an inch in thickness. . 195. Treatment.—In the case of imperforate hymen, where the menstrual fluid has been retained, foiming accumulations in the- vagina, uterus, and fallopian tubes, it is recommended, by some authors, to make an incision through the center of the membrane, Avith a bistoury, or with a trocar, so that the fluid may be grad- ually eA'acuated, thus lessening the liability to peritoneal inflam- mation, which has so frequently occurred when the membrane was entirely removed, and the fluid evacuated at once. As soon as the fluid has been entirely evacuated, the hymen may be divided by a crucial incision, and the flaps clipped off Avith a pair of scissors. The vagina and uterus should be Avell syringed out with Avarm water, and a bandage applied around the abdomen ; the patient should be kept quiet, in the horizontal position, until the organs have regained their natural condition. In children, the occlusion may, in general, be very readily overcome Avithout any resort to the knife. The little patient being placed in the lithotomy position, the thumb of each hand should be applied against the obstruction, and Avith but a small degree of force, the parts may be separated. 196. It is in those cases where the obstruction is of long stand- ing, and Avhere the hymen is thickened and indurated, that the greatest difficulty will be experienced. Tavo methods of operating are recommended in these cases. The first is to make an incision through the upper part of the hymen with a bistoury, and care- fully carry it doAvn in the median line.until the entire structure is divided. Great care will have to be used in this operation, to avoid injuring the urethra, bladder, or rectum. A catheter in the bladder, and a finger introduced occasionally into the rectum, will prove valuable guides; as soon as the incision is large enough to admit the finger, the tissues may be broken down Avith it, or if the bistoury should still be required, it may be guarded by the finger on the inside of the obstruction. Pledgets of lint, saturated with oil or the mild zinc ointment, should be introduced and kept betAveen the cut surfaces until they have healed. If the IMPERFORATE HYMEN. Ill orifice should be small, or contract after the operation, it should be dilated bv the use of the bougies. 197. The second method of operating is by the excision of the entire hymen. This is recommended by Mr. Baker BroAvn as the safest operation that can be performed, especially where there is much thickening and induration, diminishing the liability to con- traction or adhesion. His mode of operating is to place the patient in the lithotomy position, administer chloroform, and dissect out the hymen by a semi-circular incision on each side, completely removing the Avhole structure. The parts should be dressed Avith oiled-lint, and the dressing repeated, from day to day, until the parts are healed. He reports tAvo cases success- fully treated in this Avay, in neither of Avhich was the operation accompanied Avith much hemorrhage. 197. Occlusion may occur at any portion of the vaginal canal, and be of variable extent and consistence. Seme cases have been reported, in Avhich there Avas a small passage connecting the outer portion of the vagina with the internal part surrounding the os uteri; conception occurred, and the obstruction had to be divided before the child could be born. If the occlusion is per- fect, and the uterine organs in a normal condition, the same symptoms Avill be present, as in occlusion from imperforate hymen, and even if there be no symptoms of menstruation present, the difficulty should be removed, if possible, providing that upon an examination per rectum, the uterus should be found in a normal condition. 198. Acquired occlusion.—According to Professor Rokitansky, acquired atresia may be complete or incomplete, and result from adhesion of the anterior and posterior Avails of the vagina, to a greater or less extent, in consequence of excoriation or ulcera- tion ; or it may be produced by flat or rounded cords that pass horizontally or diagonally across the vagina, and reduce its caliber. The latter may consist of vaginal folds, brought on by traction, or of the membranous bands left after the cure of ulcer- ative loss of substance. 199. Treatment.—The treatment of congenital or acquired occlusion of the vagina is more or less difficult, in proportion to 112 DISEASES OF WOMEN. the amount of the canal involved, and the character of the occlu- sion. Thus, if a large portion of the canal is involved, its restoration will be difficult, and should not be attempted, unless the condition of the patient is such that its restoration is indis- pensable. So, likewise, where the occlusion has resulted from agglutination of the vaginal Avails : the operation will be difficult from the extreme thinness of the structure in Avhich the division has to be made. Having decided to operate, the patient should be placed in the lithotomy position, having first evacuated the bladder and rectum. Chloroform should be administered by one assistant, Avhile the labia are to be held apart by another. After introducing a sound into the urethra, Avhich will enable the operator to distinguish both the urethra and the bas-fond of the bladder; and ascertaining the exact position of the rectum, and as near as possible the extent of the intervening space, the opera- tion may be commenced. In this operation the knife should be used as little as possible, the tissues being broken up by the fingers ; Avhere the tissues do not give Avay to the pressure of the fingers, incisions should be made to a slight depth, making care- ful examinations per rectum at each incision ; thus using the fingers as much as possible, and the knife Avhen the adhesions are too dense to be broken doAvn by them, the obstructions may be removed up to the cervix uteri. The operator should then ascer- tain that the os uteri is pervious ; if it is not, an opening should be made through the canal of the cervix Avith a trocar or bistoury. 200. If, Avith occlusion of the vagina, the labia are adherent, they should be carefully separated ; carrying the incision from above dowmvard, to the full extent of the external orifice, a free incision being requisite to permit the necessary manipulations to remove the internal adhesions. The question will arise here, Shall the incision be made from above doAvnward or laterally ? These questions must be decided by the character of the occlusion. If the occlusion consist of an intermediate substance betAveen the Avails of the vagina, and the antero-posterior diameter, or the dis- tance betAveen the urethra and rectum is sufficient for a perpen- dicular incision ; this should be chosen in preference to the other, from the fact of the greater facility of performing the operation, structure of the vagina. 113 But if occlusion results from adhesion of the walls of the vagina, the incision Avill have to be made laterally. 201. If there should be much hemorrhage, it may, in general, be controlled by the application of cold water. As soon as the parts are divided, pledgets of lint, Avell oiled, should be introduced into the vagina, between the surfaces, and changed daily until the parts are healed. This Avill not only prevent adhesions betAveen the cut surfaces, but if the vagina is filled, it Avill prevent con- traction of the canal from cicatrization. As this is a very severe operation, where much of the vagina has been occluded, great care Avill be required in the subsequent treatment, to prevent the inflammation from extending to the adjoining structures, especially to the uterus and peritoneum : to prevent this, rest,, absolute quiet, fomentations to the vulva, vaginal injections- of tepid Avater, or Avater and milk, should be used if necessary, and if symptoms of metritis or peritonitis should present themselves, th°y must be treated as described under their separate heads. Stricti're of the Vagina. 202. Cases in which the vagina is much smaller than natural are not very unfrequent; yet those cases Avhere the constriction is so great as to come under the care of the physician are uncommon. Stricture of the vagina may be either congenital, or arise in some part of the canal as the result of disease. 20-'). Congenital stricture, or as it is more appropriately named, narroAvness of the vagina, is very seldom seen.. Cases, however, have been sometimes met with where the deformity has prevented the accomplishment of the purposes fin- which it was designed by nature. In some of the instances that have been met Avith the vagina Avas not more than half an inch in diameter. Prof. Meigs reports a case in which it Avas Avith difficulty that the vagina admitted a full sized bougie. 2(>4. Acquired stricture of the vagina is much more frequent than the congenital; it may result from violent inflammation of the vagina, producing co1 esion of some part of it.* Avails, or from any cause which Avould produce thickening and induration of its Avails, as the imprudent use of astringent injections in vaginal 8 114 DISEASES of wo m e n . disease, etc. It has also been observed to folloAv protracted and difficult labor, accompanied by sloughing of some portion of the vaginal tissue. 205. Treatment.—The treatment of this difficulty, whether it be congenital or acquired, requires patience and perseverance to effect a cure. The means to be made use of, consists in the gradual dilatation of the stricture by means of graduated bougies introduced from day to day, or Avhat would be better, the use of tAvo hollow half cylinders of german silver, Avhich should be introduced into the vagina, thus forming a cylinder; into this may be pressed a conical bougie of wood, thus producing dilatation without the friction attendant on introducing the bougies. These wooden dilators may be increased in size at each subsequent introduction until sufficient dilatation has been produced. 206. Should there be an indurated condition of the parts, the Avails of the vagina feeling hard and resisting; emollient injections should be emplo}7ed, Avith the use of Avarm topical-baths. 207. It has been recommended by some authors, to make shallow incisions in the vaginal Avails to assist the process of dilatation. This I consider needless, in fact injurious, as more or less inflammation Avill folloAv, and prevent the use of the dilatators until the incisions have cicatrized. The knife should never be employed without it is for the purpose of dividing fibrous bands which pass between the vaginal Avails, or where the stricture occupies but a small portion of the canal. 208. As these cases of acquired occlusion and stricture of the vagina so frequently folloAv protracted labor, or Avhere instruments have been used, Avhen folloAved by inflammation, and sloughin^ of the vaginal Avails, we should never forget the chances of deformity resulting, and should use such means, at the time, as will prevent any of the serious consequences just described. 209. In all such cases, careful examinations should be made from time to time, to ascertain the exact nature of the morbid processes. At first, Avhen the inflammation is acute, emollient injections should be used, together with the application of poultices and fomentations to the vulva, and such other measures as will suggest themselves to the mind of every well-informed practitioner.. inflammation of the vagina. 115 As soon as the inflammation has somewhat subsided, pledgets of oiled-lint should be introduced betAveen the abraded surfaces to prevent adhesions; this should be folloAved as soon as circumstances will admit, by a roll of oiled-lint sufficient to distend the vagina, and prevent any contraction that might take place from cicatrization. Acute Vaginitis—Inflammation of the Vagina. 210. Inflammation of the vagina may be confined entirely to the mucous membrane, or it may affect both this and the sub- mucous cellular tissue. Acute vaginitis is attended Avith pain, SAvelling and redness of the vaginal canal. The patient feels a sensation of heat and fullness in the vagina; and if a digital examination be made, the canal is found SAvollen and tender to the touch. On bringing the vaginal mucous membrane into view by means of the speculum, should the pain and SAvelling not be too great to admit of its use, it is found of a vivid red color, and the rugae appear more developed and prominent than in the normal state. At first there is an arrest of secretion, as in the first stage of inflammation in mucous membrane generally ; but after a day or two, more or less abundant secretion sets in, at first serous, and then purulent, and of a yellowish or greenish color. As soon as this secretion is fairly established, the heat, swelling, fullness, and pain diminish greatly. The development of these local symptoms is seldom accompanied by much general febrile reaction, unless the sub-mucous tissues become involved; in that case the inflam- mation may assume a phlegmonous form, and terminate in puru- lent collections, Avhich empty into the vagina, or at the vulva. Instead of terminating in suppuration, hoAvever, it most generally leads to considerable thickening and coriaceous induration of the vaginal parietes ; the latter at the same time becomes less movable, so as to seem agglutinated to the adjoining parts. 211. The amount of fluid secreted by the inflamed surfaces varies greatly ; in sune it is slight, and formed by a mixture of the white mucus, secreted in the upper part of the vagina, and of the yellow matter, the product of the acute inflammatory action ; 116 DISEASES OF WOMEN. in others it is very abundant, thick, and of a yelloAv or greenish color. 212. Causes.—Acute vaginitis may arise from cold, which is the most frequent cause ; from Anolence, (as in rape,) excessive s -xual indulgence, exertion soon after delivery, high living, etc. The sub-mucous form of the inflammation arises more frequently from injuries of the vagina or parts adjacent; after delivery. either in protracted labors where the head of the child has been long in passing, pressing upon the parts, or what is more uncom- mon in very rapid labors, where the soft parts have been dilated very rapidly. 213. Diagnosis.—It becomes of great importance in some cases to diagnose, if possible, simple vaginitis from gonorrhea. The diagnosis here is very difficult, if not impossible in many cases. In gonorrhea there is nearly ahvays a greater discharge from, the urethra than in simple vaginitis ; yet this is not positive, for in some cases gonorrhea affects the urethra but very slightly ; not as much as in some cases of vaginitis, Avhere the inflammation extends to the urethral mucous membrane, in consequence of the continuity of tissue, involving it to nearly the same extent as the vagina. Probably the observations of Donnd, if they are borne out by future investigations, will furnish the most reliable means of diagnosis. He states that in the gonorrheal discharge there are certain animalcule, which may be detected by the microscope, and which are never found in any other discharges from the vagina. These animalculae, he says, may be recognized by the elongated filliform appendix attached to their bodies, and which may be seen in motion if the discharge is recent. Bicord states, that he can distinguish the diseases by the specific character of the erosions on the cervix uteri. The glands of the groin are also less affected in simple vaginitis than they are in gonorrhea. After all, it is probable that the character of the patient and her husband will give the best evidence of the nature of the disease. In some cases where, from the known character of the parties, there could not be the slightest suspicion of gonorrhea, the hus- band has contracted a blennorrhea from connection with his Avife, INFLAMMATION OF THE VAGINA. 117 and which presented all the characteristics of true gonorrhea, and which Avas amenable to no other treatment than that resorted to for that disease. Such cases as these, and the extreme difficulty of forming a diagnosis, should make the physician very careful hoAV he expresses an opinion in regard to the character of the disease, even if he should be convinced in his own mind that it was gonorrhea. 214. Treatment. — The consequences of an attack of acute vaginitis are seldom of much importance, if the disease is treated in time. If it be neglected, narroAving of the vagina, or adhesion of its sides may possibly take place, but if discovered in time, they are easily remedied. If much constitutional disturbance be present, the special sedatives, Avith such other remedy as may be indicated, should be given and continued until the inflammation is arrested. Especial attention is called to Rhus when there is burning pain and acrid discharges ; Macrot.ys when there is deep tensive pain in back and hips; Viburnum when the pains are pressing doAvn; Apis Avhen there is itching and burning; Pulsa- tilla when the patient is depressed and nervous ; Belladonna when there is incontinence of urine; Santonine Avhen there is partial or complete retention, etc. 215. As local appliances in the acute stage, fomentations of Stramonium or the flowers of Arnica, applied over the vulva, will give great relief; in connection Avith this, vaginal injections of warm Avater, or Avhat is better, of a decoction of Stramonium, should be used every feAV hours. A Avarm hip-bath, occasionally, will also be found a poAverful adjunct in abating the inflammation. 216. If there be constipation of the boAvels, they should be moved as often as once a day ; any agent that is preferred may be used for this purpose. As soon as the acute symptoms have been subdued, if there is still a discharge, accompanied with a lax condition of the vaginal mucous membrane, an injection of Salicylic Acid and poAvdered Borax should be used to give strength and tone to the organs, and prevent the disease from running into the chronic form. The decoction of these articles should be made of such strength as will suit the case on hand. 217. In the majority of cases, if these means be made use of in 118 DISEASES OF AV 0 M E N . the early stage of the disease, a perfect cure will result; if not, in all probability it will assume the chronic form. Chronic Vaginitis—Vaginal Leucorrhea. 218. This is one of the most common diseases to which the female is subject; very few, indeed, escaping attacks of it. at some period of their lives ; and this is not surprising, when we consider the many causes of irritation to which this canal is subject. 219. Chronic vaginitis is an important disease, not only on account of the extreme loss of fluids Avhich it often entails, but also on account of its constant tendency to extend to the uterus and the fallopian tubes, and the consequent morbid affections of these organs. It predisposes to intussusception of the vagina, and the displacement of the uterus, OAving to the relaxation it induces ; it leads to excoriation and superficial ulceration, both of the vagina, the external pudenda, the parts in their vicinity, and of the cervix uteri, to closure of the os tincae, to follicular suppuration, permanent hypertrophy of the follicles, and dilata- tion of the vaginal vessels. 220. This disease may be general or partial; it may continue indefinitely, for years, like chronic inflammation of all other mucous membranes, giving rise to a constant secretion of mucus or muco-purulent fluid, and varying in intensity according to the epoch of the month, and to the state of the health and social and hygienic position of the patient. In the course of time, it often passes into a mere mucoso-purulent flux. Its existence, in this chronic form, is a sonrce of general debility and weakness, but by no means to the extent supposed by some authors; the svmpathetic connection betAveen the vagina and the rest of the economy being slight, Avhen compared with that which exists between the uterus and the system in general. " When the health of a patient, laboring under chronic vaginitis, suffers greatly, it will be found, on examination, that there is also disease of the neck or body of the uterus or of the ovaries." 221. Symptoms.—The symptoms of this disease are a dis- charge from the vagina, sometimes thin and colorless, but more VAGINAL leucorrhea. 119 frequently Avhite, or of a slightly yellowish cast; as the disease pi ogi esses it becomes muco-purulent, and varies in color from a slightly yellowish white to a broAvnish cast. In the majority of cases, the discharge is of a bland character, producing no exco- riation or other difficulty ; yet in some few cases it becomes very acrid, excoriating the vulva and other parts Avith Avhich it comes in contact, and producing in the male all the symptoms of gonorrhea, and sometimes ulceration of the prepuce. There is scarcely ever an increase of heat in the parts, and seldom any pain or tenderness. So long as the disease is confined to the vagina, there is very little constitutional disturhance, though if the discharge is profuse, and has continued for some time, there may be considerable Aveakness, Avith pain in the back and loins, loss of appetite, constipation, etc. 222. Upon examination with the speculum, the vagina will appeal flabby, its mucous membrane tumefied and pale, invested with a pale thick coating of epithelium, or excoriated or red- dened, with enlargement of the follicles, Avhich are surrounded by a vascular ring. Or the follicles may be found ulcerated, forming small apthous sores ; these, however, are generally limited to the lower portion of the vagina. The continuance of the morbid pro cess to the cervix uteri, and to the lining membrane of the uterus, will be considered in the chapter on leucorrhea. 22-3. Diagnosis.—The diagnosis between this disease and gonorrhea will have to be made—if made at all—in the manner described when treating of acute vaginitis. It may generally be distinguished from uterine leucorrhea, by the discharge being unconnected with uterine irritation, by its not increasing before and after menstruation, by the minor degree of constitutional suffering, and by the acrid character of the secretion in vaginitis, which reddens litmus, Avhile the uterine discharge has an alkaline reaction. In many cases, hoAvever, and especially Avhere the leucorrhea has continued for some time, the uterine mucous membrane Avill be found more or less affected. 224. Causes.—The causes producing vaginal leucorrhea are various. Thus it may result from an acute attack of vaginitis ■ from exposure to cold and moisture Avhen the system is enfeebled 120 DISEASES OF WOMEN. excessive sexual indulgence; frequent child-bearing; abortions, from Avhich the patient has only partially recovered ; the irritation of a pessary, or stimulant injections into the vagina ; displacements. morbid groAvths, etc. There is one cause of chronic vaginitis that is very rarely referred -to, which not only produces the disease in some cases, but which also prevents a perfect cure in many others ; this cause is functional or structural disease of the rectum. It has doubtless been noticed by eA'ery practitioner, how intractable those cases of leucorrhea are in persons subject to piles, to habitual constipation, Avith accumulated faeces in the rectum, fissure of the rectum, etc. In these cases, the cause of the difficulty should be first removed before attempting any specific treatment for the vaginitis. 225. Treatment.—Much has been Avritten on the treatment of leucorrhea, yet very few authors make any distinction in recom- mending remedies, in regard to the part from Avhich the discharge proceeds, or the conditions present producing it. As I will give, under the head of leucorrhea, a full description of the various causes producing a discharge from the genital organs, together with the treatment appropriate to each, I will confine myself here to the treatment of chronic vaginitis, independent of other affections. 226. The treatment in this affection consists in the use of both general and topical medication. The general treatment in the first place, should be directed to obtain a healthy performance of all the functions of the system; should the patient be debilitated, the vegetable tonics and iron will be required; should there be torpor of the skin, kidneys, or bowels, these organs should be stimulated to a normal performance of their functions. This Avill be found to be of the utmost importance, not only in this disease, but in all others accompanied with a chronic discharge; for in these cases, it might be said Avith truth, that the diseased organ is performing a vicarious secretion, which prevents the normal action of the proper excretory organs, and, to subdue the diseased action, it Avill first be necessary to provide for this elimination through the natural channels, 227. In the second place, general remedies are employed to VAGINAL LEUCORRH0EA. 121 remove the local inflammation, and check the morbid action of the parts. For this purpose many remedies have been used, but to have success the remedies must be selected with reference to the special case in hand. Any of the remedies named for acute vaginitis may be required, the indications there given being suffi- cient to call for them here. In some cases characterized by more or less uterine pain, pain in the back and thighs, the use of Ma- crotys with Pulsatilla will give good results. The case Avith sen- sations of fullness and weight, dragging in the pelvis, etc., may be met by Hamamelis and Viburnum. When associated Avith passive hemorrhage, the Aoav prolonged, recurring too frequently, with pallid transparent skin, it is met with Carbo veg., 2d decimal trituration ; and blood-making is promoted by the administration of tincture of Copper. Again, we have cases benefited by the use of iron—tincture of the Muriate Avhen the tongue is deep red, iron by hydrogen when it is pallid. Phosphorus is indicated by impaired innervation, or if we regard the condition of the parts, full, relaxed and pallid. Want of sexual poAver or appetite is remedied by the use of Iodine and Nux, as in the Compound Iodine Pill (Iodine, Ext. USTux, aa. gr. vj; Hydrastin, grs. xxx.; make thirty pills.) As an injection I like a solution of Chlorate of Potash for the simple cases (3ij. to water Oj.), with the addition of a small por- tion of Sulphate of Zinc, if the discharge is markedly purulent. Salicylic Acid and Borax (aa. gij. to water Oj.) is a most excellent injection, as is a solution of Phosphate or Sulphate of Hydrastia, (gr. ij. to water gj.) In addition to these a large number of the vegetable tonics and astringents have been used with good success. Among these I may name the Hamamelis, and the Eumex Crispus with Quercus. Some of our practitioners use the Hydrastis Canadensis in com- bination Avith the Statice Limonum, the Khus Glabrum, or the Rulms Villosus; either of Avhich, ansAver an admirable purpose; not alone from their astringent properties, but also from their tonic effect on the mucous membrane. In some cases, Avhere there is a lax and flabby condition of the mucous membrane, with 'lilatation of the vessels, hypertrophy of the follicles, or ulcera- 122 DISEASES OF WOMEN tion, an injection of the Sulphate of Zinc (£j. to ^atj. of water,) may be used with much benefit. Still I would prefer the Sali- cylic Acid and Borax, as recommended in the first prescription, increasing the quantity as the patient could bear it, until the difficulties were removed. 229. These injections should be used with a female syringe, the patient being in a horizontal position, with the hips elevated. As soon as the injection is thrown in, the external parts should be compressed with a napkin, thus retaining the injection in con- tact with the vaginal Avails, for ten or fifteen minutes. Without these directions are given, the patient will, in all probability, use the syringe in a standing or sitting posture, letting the injection immediately pass away; in these instances, the physician may be surprised, that remedies which he places great confidence in, have produced but little effect, yet, upon inquiry, the difficulty will be found entirely in the mode in Avhich they are used. 230. The treatment after the vaginitis has been subdued, and the discharge stopped, deserves careful attention, for it is prob- able that there is no morbid condition of the system so likely to recur as this; if the cause of the affection be known, the patient should be cautioned against exposing herself to it. Strict atten- tion to cleanliness should be enjoined, and that unfounded dread of water, Avhich most females have, should be removed, if pos- sible. After an attack of this disease, the patient should be directed to use vaginal injections of cold Avater, at least once a day; and if there should be a tenacious secretion from the parts, a little Castile soap will not be amiss. This Avill insure perfect cleanliness, and give tone and strength to the genital organs, and prove a perfect prophylactic against any future attack. Prolapse of the Vagina. 231. This affection is not uncommon, arid has very often been taken for prolapsus uteri. It generally occurs in females who have borne children, and Avho have passed the middle aere, thouo-h in some feAv instances, it has been observed in the young, and before marriage. We distinguish three varieties of this affection k ch of Avhich derives its importance from the displacement of VAGINAL CYSTOCELE. 123 the viscera connected with the vagina. First, prolapse of the anterior wall of the vagina, and of the bladder which lies upon and is closely connected Avith it. This has received the name of '•Prolapsus Vesicae," or "Vaginal Cystocele." Second, prolapse of the posterior wall, accompanied by the rectum, called "Vaginal Rectocele." Third, prolapse of the entire circumference of the vaginal canal. Vaginal Cystocele. 232. This is the most common form of vaginal prolapsus, and may arise from any cause Avhich has a tendency to Aveaken and relax the vaginal Avails; such as repeated child-bearing, difficult labors, etc. This relaxation of the vaginal Avail causes an altera- tion in the position of the bladder, and, in consequence of this, there is retention of urine, Avhich, distending the bladder, forces it downw-ard into the vagina. The more the bladder is displaced, the greater will be the difficulty in evacuating the urine, OAving to the backAvard curvature of the urethra ; and, in consequence of this, there will be accumulations in the bladder, by the Aveight of Avhich the vagina is stretched still further, and thrust doAvnward and fonvard; if this continues, complete prolapse or protrusion through the external parts Avill be the result. 233. Symptoms.—The patient complains of a constant weight and pressing doAvn into the vagina, a sensation of uneasiness and dragging doAvn in the loAver portion of the abdomen; uneasiness and pain in Avalking; great difficulty in evacuating the bladder, Avhich sometimes amounts to almost complete dysuria,—the bladder becoming paralyzed from retention of urine, and losing its poAver of contraction ; in some cases, the patients are obliged to replace the bladder before they can complete the evacuation. In many cases, the patients will complain of a burning pain in the base of the bladder, Avith a sensation of distention, and a constant and torturing desire to pass urine. On examination, there will be found a round, soft, elastic, fluctuating tumor, of a red or bluish- red color, and which is covered by the mucous membrane of the vagina; the finger can be passed into the vagina beloAV the tumor, and the os uteri can be felt behind, nearly in its normal position. The surface of tfie tumor is smooth and shining Avhen the bladder 121 DISEASES OF WOMEN. is distended ; but, Avhcn the bladder is empty, it is throAvn into transverse folds. A very unpleasant consequence of this displace- ment has been pointed out by Dr. Golding Bird. This, consists in a chronic inflammation of the bladder, caused by the retention of urine, and. under the influence of this chronic inflammation, the mucous membrane of the bladder secretes so much of the earthy phosphates, and unhealthy mucus, as to render the urine puriform and offensive. Often there is a very considerable mucous dis- charge from the vagina, Avhich is exceedingly irritating to the labia and soft parts. 234. Diagnosis.—This affection may be readily diagnosed from any displacement of the uterus, if the folloAving points are regarded. The tumor formed by prolapse of the bladder, varies in size according to the quantity of urine retained; it may be decreased someAvhat by draAving off the urine with the catheter; and if the extremity of the catheter is elevated, its point may be felt in the most depending portion of the tumor. The tumor is soft and fluctuating, and the finger can be passed posteriorly to it up to the os uteri, Avhich will be found in its natural position. It may be distinguished from vaginal rectocele, by the fact that it is softer and fluctuating, and the finger passes into the vagina, posteriorly to it, while in rectocele it can only be introduced anteriorly. 235. Treatment.—The treatment of this disease will vary much, according to the state of the parts, and the length of time the difficulty has existed. The indications to be regarded, are, first, to give temporary relief by emptying and replacing the bladder, using some mechanical means to keep it in position; secondly, to correct the secretions, and subdue any inflammatory action that may be going on in the bladder; and, thirdly, to use such means as will produce a radical cure of the difficulty. 236. To fulfill the first indication, the urine should be drawn off Avith the catheter, elevating the depressed portion of the bladder, so as to remove it entirely, or if the patient can empty the bladder herself Avithout the use of the catheter, it will be better. The main point should be to entirely empty the bladder, leaving no urine in the prolapsed part, to keep up irritation; this should be done very frequently. The prolapsus niay be very VAGINAL CYSTOCELE. 125 easily returned when the bladder is empty. To retain it in its position, a small India Rubber bag, inflated with air, and retained with a perineal bandage, Avill be found to be much better than any of the hard pessaries recommended. This, by being elastic; molds itself to the parts, admits of perfect freedom of motion Avithout pain or inconA'enience; produces but very little, if any irritation, and does not produce dilatation of the canal, and yet furnishes a perfect support to the bladder. This pessary should be removed twice a day and cleaned, a vaginal injection of a decoction of Hydrastis Canadensis, Ilubus Villosus, and Statice Limonum, equal parts (3j to Oct j of water) should be used at these times. With this treatment, if the irritation of the bladder has been sub- dued, as I have recommended below, many cases, especially those of recent date, can be perfectly cured. 237. The irritation or low degree of inflammation of the bladder, that often exists, will be found to be one of the most troublesome complications of this disease, and Avithout this is removed, a permanent cure is impossible. I have already stated that the bladder should be frequently and entirely evacuated, to prevent the irritation Avhich the retained and decomposing urine would produce, as Avell as to remove the weight which Avas continually pressing upon the relaxed Avails of the vagina ; this point in the treatment is so important that it will bear repetition. To subdue the irrita- tion and give tone to the mucous membrane of the bladder, I Avould recommend the muriated tincture of Iron and the Eryng- ium given in the usual doses* If the urine should become muco-purulent and fetid, the folloAving injection should be throAvn into the bladder. R Hydrastis Canadensis, Sj. Aqua Bullientis, Oct j. Let it stand until it is cold, then strain and inject one-third of it into the bladder once a day. This may increase the irritation in some cases the first feAv times that it is used ; if it does, its use should be suspended for three or four days until the irritation has subsided, and then commence its use again. If there is mucus secreted of a ropy or fetid character, it will be Avell to alternate 126 DISEASES OF WOMEN. this injection with one of an acid character, as distilled Vinegar Sss to oct j of Avater; of this, one or two ounces should be used at each injection. Dr. NeAvton informs me that he has used with much success, an injection of Glycerine, throwing into the bladder from half an ounce to an ounce through a catheter. This forms a very soothing and healing application to the inflamed bladder. 238. In all recent cases, and indeed in some of long standing, the measures above recommended will effect a permanent cure if the general health be good, but there are some in which they will give but temporary relief. In these cases there will be found great laxity of the tissues, a flabby and dilated state of the vagina, Aveakness of the perineal muscles, and often an enlarged pelvis, and extreme thinness of the perineum. Different measures have been recommended in these cases to remove the difficulty. Some have recommended plugging the vagina Avith pessaries, made especially for that purpose; others, the introduction of a soft sponge, cut in the form of a pessary, and saturated Avith some astringent solution ; or a sack made of soft cotton or linen cloth in the form of a pessary, and filled with some astringent substance. It is certainly obvious that these measures will do no more than give temporary relief, while they are very liable to produce irrita- tion, and by keeping the vagina distended ultimately increase the diseased condition. Other authors recommend surgical measures to decrease the size of the vagina, and thus relieve the difficulty. M. Jobert, of Paris, incloses within tAvo curved lines an oval space, more or less considerable in the posterior surface of the tumor, or the anterior surface of the vagina, by means of caustic, until it forms an isolated spot, repeating the application of the caustic until the mucous membrane is destroyed. He then pares the edges with scissors or a bistoury, draAvs them together and maintains them in apposition by means of straight needles (the points of Avhich are removed) and a twisted suture. This opera- tion consists in contracting the anterior Avail of the vagina and thus forming a support to the bladder. He reports the operation as successful in three cases. 239. There can be no doubt but that this operation wouW prove successful in those cases where the difficulty depended on a lax VAGINAL CYSTOCELE. 127 and dilated condition of the vagina; but where it was dependent on Aveakness of the perineum, it Avould probably fail. The opera- tion of Mr. Baker Brown appears to me to fulfill all the indica- tions of the case. He operates for this difficulty in the same manner that he does for ruptured perineum; dissecting off a longi- tudinal slip of mucous membrane, about an inch and a quarter Fin. 12.—Operation for Prolapse of the Vagina. long and three quarters of an inch broad, just within the lips of the vagina ; the upper edge of the denuded part being on a level with the meatus urinarius. The edges of the mucous membrane are then brought together by means of interrupted sutures. He then dissects the mucous membrane from the posterior portion of the vaginal orifice, and brings the denuded parts together by means of the suture. (For further particulars of this operation see ruptured perineum.) By these means the vagina is not only contracted above, but the perineum is greatly increased in thick- ness and strength, forming a firm support to the pelvic viscera. 43 128 DISEASES OF WOMEN. Fig. 13.—Condition of the Parts after the Operation is completed. Prolapse of the bladder may occur during parturition, and may attain such a size as to prevent delivery of the child. This has occurred in several instances, in some two or three cases of which, the bladder Avas ruptured in consequence of the pressure of the child's head against it. In these cases the bladder must be emptied by the catheter, and then replaced; it will be found impossible, in the majority of cases, to introduce the common silver instrument, OAving to the great degree of curvature of the urethra, and a gum-elastic catheter should be used in its stead. If the bladder can not be evacuated by the catheter, the most depending portion of the tumor will have to be punctured with a trocar, and the bladder emptied through the canula. Vaginal Rectocele. 240. Prolapse of the posterior wall of the vagina is not of as frequent occurrence as prolapse of the anterior; yet it can not be VAGINAL RECTOCELE. 129 called an unfrcquent affection. The mechanism of this displace- ment is similar to that of vaginal cystocele; the posterior Avail of the vagina becoming relaxed, the rectum is distended Avith fieces and pressed anteriorly and doAvnward into the vaginal canal. The size of the tumor varies, from a slight projection into the vagina, to the extension of it into a tumor projecting betAveen the labia In its more aggravated form the uterus is generally involved with it, being dragged doAvnAvard and displaced. 241. Causes.—The principal cause of this displacement is habitual constipation, giving rise to a constant accumulation in, and distention of the rectum. This undue stretching; of the rectum, by local accumulations, brings about a relaxed and loose condition of its tissues ; and the same cause stretching the parie- ties of the vagina, produces a looseness of that canal. This is greatly increased by the use of drastic cathartics so often taken in these cases. It may also be occasioned by an enlarged or displaced uterus, which by its prcssuie upon the rectum, prevents its evacuation and consequently gives rise to fecal accumulations, and distension of the rectal and vaginal Avails. It may also be caused by an entire or partial rupture of the perineum, the sphinc- ter muscle remaining entire. In these ca.-es the rectum has lost its support anteriorly ; there not being sufficient poAver in the peri- neum to antagonize the action of the sphincter, the anterior part of the rectum is forced into the vagina until it meets with sufficient resistance to overcome this contraction. 242. Symptoms.—The general symptoms are much the same as in the other variety of prolapse, Aveight in the vagina, an uneasv and dragging sensation in the abdomen, uneasiness and pain in Avalking, habitual constipation with difficulty in passing the frcces, a mncous discharge from the vagina, etc. If there is much displacement, there Avill be tenesmus, Avith a frequent desire to evacuate the boAvels, generally fruitless and accompanied Avith much Daiii. It Avill be noticed that the tumor increases in size when the frcces have not been passed for some time, and during defecation, and that it decreases in size after this. 243. On making an examination, a globular tumor will be found occupying the cavity of the vagina, compressible but not fluctuat- 9 130 DISEASES OF WOMEN. ing, and through the walls of which scybalae may often be felt By passing the finger over the tumor, it will be found to be covered by the mucous membrane of the vagina, and that the finger can be passed anterior to it, up to the cervix uteri. By making an examination per rectum, the finger can be passed into the tumor so as to be felt at its projecting part in the vagina. 244. Diagnosis.—From what I have stated above, I should not suppose it possible that there could be a mistake in the diagnosis, yet it can do no harm to repeat. This may be diagnosed from vaginal cystocele, by its greater hardness, and the absence of fluc- tuation, from the fact that the finger passes anterior to it in the vaoina, and that it diminishes after fecal evacuations. From any displacement of the uterus, by the results of a rectal examination, by the variable size of the tumor OAving to retention or evacuation of the faeces, and by the fact that the finger can be passed above it, so as to discover the os uteri in situ. 245. Treatment.—The treatment of this variety of vaginal pro- lapse should be the same as that recommended for the first variety, so far as the local applications to the vagina are con- cerned, the same kind of a pessary, as there recommended, will be found .to be Avell suited to these cases ; the perineal bandage, however, should be so applied as to furnish a constant and efficient support to the perineum. 246. If a cure is effected in these cases Avithout a surgical operation, it Avill have to be accomplished by strict attention to the state of the rectum. Constipation of the boAvels being the producing cause in the majority of cases, and Avhich, as long as it remains, will prevent any permanent improvement. This may be overcome by the use of injections and mild laxatives ; all cathar- tics of a drastic character should be sedulously avoided. After the boAvels have been evacuated by an injection, much benefit may be derived from a second injection into it of the astringent decoc- tion used for the vagina. 247. In all cases of this disease it aa ill be proper to make an examination of the rectum, to ascertain the condition of the mucous membrane, and Avhether any structural lesions exist, as hemorrhoids, fissures, ulceration, and especially, Avhether it is PROLAPSE OF THE VAGINA. 131 compressed by an enlarged or displaced uterus. If either of these complications exist, they will have to be removed by appro- priate treatment. 248. In the early stage of the disease, or where the prolapse is not large, this treatment, if perseveringly pursued, will gener- ally give permanent relief. But Avhere the prolapse has existed for some time, attended Avith great laxity of the tissues, and defi- cient strength of the peiineum, recourse to surgical measures should not be delayed. The object of an operation in these cases is to increase the thickness of the perineum, and thereby enable it to resist the action of the diaphragm and abdominal muscles in defecation, and to contract the too capacious vagina. For this purpose the operation last recommended for vaginal cystocele should be employed, omitting the anterior denudation and sutures. By this operation the perineum is thickened and rendered capable of supporting the rectum, and the cavity of the vagina is likeAvisc diminished in size. Prolapse of the entire Circumference of the Vagina. 240. This form of displacement is very rare, and occurs as the result of great laxity of the lining membrane of the vagina. In its mechanism it resembles prolapsus ani ; the mucous membrane and the cellular tissue beneath it being extremely lax, this cellular tissue gives rise to a morbid thickening of the mucous membrane, which so increases its weight, that it overcomes the resistance at the outlet, and prolapse is the consequence. Prolapse of the vagina mav be either partial or complete ; in partial prolapse the mucous membrane merely forms a prominence Avithin the os externum ; Avhile in complete prolapse, the mucous membrane forms a circular tumor of variable size, which projects beyond the vulva. Several cases are reported Avhere the tumor projected from three to five inches beyond the vulva. 2.")0. S>/mp/<>ius.-—'Th.e symptoms of this affection vary accord- ing to the amount of displacement; thus in slight cases, Avhere the tumor, docs not project beyond the vulva, the symptoms Avill be slight; as a feeling of Aveight and uneasiness in the loAver portion of the vagina, a dragging sensation in the loAver portion 132 DISEASES OF WOMEN. of the abdomen, etc. In the more severe forms of the disease these symptoms become greatly aggravated ; there is a discharge of puriform mucus, obstinate constipation, difficulty and pain in passing the urine, etc. The action of the urine on the tumor, and the friction produced by exercise, gives rise to excoriation, and often to inflammation. On examination, the tumor will be found to have a circular form, arising from the entire circumfer- ence of the vagina,, and having an aperture in its center. On passing the finger up external to the tumor, it will be stopped in the cul-de-sac formed between the tumor and the vagina ; but by introducing the finger through the central orifice, it will pass up to the os uteri. 251. Diagnosis.—It may be distinguished from any displace- ment of the uterus, by the character of the central opening, and by the fact that the finger can be passed up through this, and the os uteri felt above. 252. Treatment.—As this affection occurs for the most part, in persons of a feeble and broken doAvn constitution, such means should be employed as Avill restore the general health. Where the prolapse is slight and of recent origin, it will be found that this, Avith the use of vaginal injections of cold water, Avill remove the difficulty. Where the tumor is larger, it "will be necessary to replace it and keep it in position by means of the pessary, before recommended; here, also, the vaginal injections recommended in the other two varieties of prolapse should be used. If these measures should fail in giving relief, and the patient be passed the age of child-bearing, it would be proper to resort to surgical measures for the relief of the difficulty. The operation proposed by Br. Dieffenbach for the permanent relief of the prolapse, con- sisted in replacing the tumor, and then excising, by means of the forceps and scissors, all the loose folds of the inner surface of the labia pudendi. This operation, Avhich is easily performed, should be so conducted, that the folds, as they are removed, constitute so many radii converging to the center of the vagina, so as to allow the upper end of each one to terminate about one inch Avithin the orifice of the canal. The final treatment consists in merely cleansing the parts once a day. As the cut surfaces cicatrize, TUMORS, MORBID GROWTHS, ETC. 133 they will contract the orifice of the vagina, and thus furnish a sufficient support to the parts. The same end may be accom- plished by denuding a sufficient portion of the vagina of its mucous membrane, and bringing the cut edges of it together and r taining them with sutures. When the prolapse has been of long standing, and the tumor las become irreduceable, it may give rise tc so much incon- venience that the patient may insist on its removal. This has been successfully accomplished in some cases, yet it is a dangerous operation, and should never be undertaken unless absolutely required. In deciding on this extreme measure, the operator should satisfy himself positively that the rectum, bladder, and uterus are not involved in the displacement. Tumors, Morbid Groavths, etc 253. According to Prof, llokitansky, the occurrence of tumors or morbid growths in the vagina is very unusual. The cysts that are met with in this region are developed in the cellular tissue external to the vagina, and, anatomically speaking, bear a very subordinate relation to the latter. Fibroid productions almost invariably coexist with similar groAvths in the uterus; they may be deAreloped in the external fibro-cellular layer of the vaginal parieties, and especially at their posterior surface; they then project with a larger or smaller segment in the shape of round tumors into the vaginal cavity. In other instances they are developed in the cellular tissue, that is interposed between the vagina and rectum, and though in close relation to the vagina in point of origin, project chiefly into the rectum, and more or less obstruct its inferior portion. Warty tumors are sometimes developed from the vaginal mucous membrane, oftener, perhaps, as the result of syphilis than from any other cause. The character and size of these excresences vary greatly, though they generally resemble the warty tumors of the vulva. These tumors are generally found in the external or vulvar portion of the canal. 254. Diagnosis.—Encysted tumor of the vagina may be distin- guished from vaginal enterocele, by its more circumscribed form. 134 DISEASES of womex. and from the fact that coughing produces no enlargement in it. From other diseases of these parts, by its circumscribed form, its consistence, and by the fact that its exact location can be discovered, by an examination by the rectum or by a sound introduced into the bladder. Fibrous tumors of the vagina are of very rare occurrence, and their diagnosis may be effected by the means already pointed out all that is necessary is to trace out their exact size and location, and the fact that no other disease of the genital organs exists. 255. Treatment.—The treatment of encysted tumors of the vagina is the same that Avas recommended for the same disease of the labium : make an incision into the tumor, evacuate its contents. and use injections of Sesqui-Carbonate of Potassa, to destroy the morbid function of the cyst-wall. Fibrous tumors, when they exist in the vagina of sufficient size to produce an obstruction, Avill have to be removed with the knife. The same precautions should be used in affecting this, that Avas mentioned in describing the operation for occluded vagina, to prevent wounding the bladder or rectum, or opening through the sides or upper portion of the vagina into the pelvic cavity. Warty tumors may be removed in the manner before described, —removing them with the ligature or knife, and destroying their base Avith caustic. Cancer of the Vagina. 256. " Carcinoma of the vagina is, in most cases, cancer of the uterus, Avhich has spread to the vagina; it may exist when the latter is in a very undeveloped state, and even Avithout it, in the shape of primary carcinoma of the vagina. It belongs to the fibrous or medullary variety, and, in proportion to its groAvth, induces thickening of the parieties, tuberculated condensation of internal surface, and corresponding contraction of the passage. The vagina becomes adherent to the neighboring parts in conse- quence of cancerous degeneration of the cellular tissue, surround- ing it and the rectum, and, finally, cancerous ulceration and excrescences are established. The greater part of the vagina generally becomes involved, and sometimes the lower portion of it becomes prolapsed. In time, the disease extends to the rectum, CANCER OF THE VAGINA. , 135 the urethra, the bladder, and, if the uterus Avas not primarily involved to it, by the pressure it exerts, it causes retention of the urine and dilatation of the bladder, and, when it has reached the ulcerative stage, recto and vesico-vaginal fistula frequently exist." 257. Cancer of the vagina is generally more painful than the same affection of the uterus, owing to the greater sensibility of this canal. The peculiar darting, tAvisting pain of this affection will be felt at the seat of the disease,—coming on and goini* off suddenly ; at times extending to the perineum. doAvn the inside of the thighs, and sometimes in the course of the sciatic nerve, as far down as the knee. The pain in the back is usually more severe than in any benign affection of the uterine organs. Upon making an examination, the diseased part Avill be felt rough and uneven to the touch, and the mucous membrane Avrinkled and of a leaden or purplish color; or, if ulceration has commenced, the diseased mass Avill present a fissured appearance, more or less elevated above the surrounding tissues, of a dark-red or purplish color, from Avhich is discharged a thin fetid and excoriating fluid. 25S. Diagnosis.—Cancer of the vagina may be distinguished from anv other disease, first, by the character and intensity of the pain,—benign tumors of this canal being rarely painful; by the shape, consistence, and color of the tumor,—no other tumor presenting the same shape ; condensation of the adjoining tissues, or the peculiar dark-i cd or leaden color. But supposing the points above-named are not sufficient to distinguish scirrhus of the vagina from other morbid growths, Avhenever the affection presents these symptoms, its removal is necessary, even if it be not cancer,' —the mere matter of furnishing a name to a disease being of little importance. 250. ]>ro. V>\ syphilis, Ave understand a specific disease, arising from sexual intercourse, and transmissable by the contact of its own specific pus with a tender surface, by inoculation into the system through the medium of the secretions, or by hereditary taint, under certain special conditions. It has been supposed by some authors, that syphilis and gonorrhea arise from one and the same poison, the difference in the tAvo being merely a difference in the intensity of the disease. This opinion Avas based upon the fact, that females suffering from venereal disease Avould communicate gonorrhea, to one person and syphilis to another, both having connection with one woman, and at short intervals from each other. Ricord has fully proved this opinion to be erroneous ; he has established beyond cavil, that the gonorrheal discharge, Avhen inoculated on the skin or mucous membrane, never, under any circumstances, produces a chancre : and, conversely, that the pus of chancre can never be made to give rise to gonorrhea. He has, however, given an explanation of the fact upon Avhich the above opinion Avas founded ; it is now well known that a woman may be affected with gonorrhea and deep seated chancre on the uterus at the same time, so that, although supposed to be laboring under one, she might easily communicate both or either of the diseases ; the true nature of her disease being only ascertainable by the speculum. 366. Ricord divides syphilis into three distinct stages. The first stage includes primary symptoms, Avhich are the immediate effect of the morbific cause, occurring on the spot Avhere the virulent agent has been deposited; as, for example, chancres. The second stage comprehends secondary symptoms, Avhich are the sequence of absorption into the system of the virulent cause. They are hereditary, but not capable of transmission by inoculation. For an example, certain affections of the skin and mucous membrane, iritis, etc. The third stage comprises tertiary symptoms, not capable of being transmitted by inoculation, nor hereditary, but subject to pathological transformations and alterations of the sub- mucous and sub-cutaneous, or of the fibrous or osseous tissues. Primary syphilis, or chancre, may be developed upon any part 188 DISEASES OF WOMEN. of the female organs of generation. Its most common location. however, is in the external parts, as the labia maj >ra, the nymplue, the folds of mucous membrane surrounding the clitoris, at the orifice or other parts of the vagina, or at the meatus urinarius. Chancres yielding a characteristic pustule by inoculation, are of very raie occurrence on the cervix uteri, though they have been met with in this situation, and even at the os uteri, and extending into the cavity of the cervix, 'i hey have likeAvise been met with just within the orifice of the urethra, on the mons veneris, on the perineum, the verge of the anus, and within the sphincter ani. 367. According to M. Erichsen, " Avhen chancres are caught in connection, they usually commence with a small excoriation, Avhich appears to have been directly inoculated with the specific poison. In other cases, again, though more rarely, they may be seen at first in the shape of a small pointed pustule, Avhich speedily breaks, leaving an ulcer of a specific character in its site. Very generally, however, this pustule escapes observation, and the disease is presented in the first instance as an ulcer. The chancrous ulcer, Avhatever form it assumes, seldom makes its appearance until a feAV days—five or six—after connection. In some cases, however, I have observed it, evidently from the infec- tion of a fissure or crack, on the day folloAving impure intercourse, and, occasionally, in rare instances, it does not occur until a much later period than that Avhich has been mentioned. 368. "Whatever may be the appearances presented by a chancre, there can no longer be any doubt that the disease arises from one kind of virus only, the modifications in the sore depending on its situation, the constitution of the patient, and occasionally on that of the individual Avho communicates the infection. That this is so, is evident from the fact that any chancre, Avhen inoculated, reverts to one typical form, and that, hoAvever much chancres may ulti- mately differ, they all present the same characters during their early stages.' The progress of a chancre that has been artificially inoculated on any part of the cutaneous surface is as follows, and its study will serve to elucidate what takes place under other circumstances. During the first twenty-four hours after the intro- duction of the specific pus into the skin on the point of a lancet, Plate! o • mj^Mp '• ^^^SiJiP «\i5^ vv,. Ilfl ^ *■"■ ^§p;^ SYPHILIS. 1S9 we find that some inflammation is set up around the puncture, which becomes hot, red, and itchy. About the third or fourth day, a pointed pustule is produced, Avhich is at first deep-set, but becomes on the following day more superficial, Avith some depres- sion in the center, resembling pretty closely a small-pox pustule; on close examination this will be found not to be a true pustule, Dut rather a mass of epithelial scales and pus not included in a distinct Avail. On the fifth day it has become hard at the base, apparently from the infiltration of plastic matter, arid on the sixth, it has usually dried, forming a small round scab, and leaving an ulcer, Avhich presents the typical characters of a true chancre, being circular and depressed, with a foul grayish surface that can not be cleansed, sharp cut edges, a hard base, and an angry look- ing red areola around it. This is the typical chancre, and these are the appearances that every true syphilitic sore on the skin will present, about the fifth or sixth day after inoculation ; from this time it may diverge more or less completely from these char- acters, but will yet, if inoculated at any time during the poisonous stage, produce an ulcer that will run the specific course up to the same period, after Avhich it may in its turn again deviate into one or other of the special forms that chancres occasionally assume. When inoculated on a mucous surface, chancres do not so early assume an indurated character around their base." 369. By reference to plate I., the progress of an inoculated chancre may be seen from its commencement to the fully-formed chancre. Fi"-. 2, sIioavs the result of the inoculation tAvo hours after the matter was inserted by the lancet; already may be marked a tumefaction of the tissues, and in the center is seen the puncture made by the lancet, surrounded by a reddish areola of small extent, almost confining to the projecting parts. Fig. 3. DraAving six hours and' a half after inoculation. The inoculation is still more elevated. The areola is of a deeper color. Fis;. 4. Drawing twenty-four hours after inoculation. The projecting parts appear clearly defined, and their base is of a deep-red hue. On the summit is seen a grayish point, corres 190 DISEASES OF WOMEN. ponding to the incision of the lancet. The inflammatory areola has comparatively greatly extended. Fig. 5. DraAving in thirty-one hours. The pustule is formed. .The grayish point of the morning has become completely black," ;.nd forms a small gangrenous eschar, around which the epidermis is elevated by the pus. , Fig. 6. DraAving forty-eight hours after inoculation. All the elements of the pustule are progressing. Fig. 7. Drawing three days after inoculation. General progress. We remark an irregularity in the periphery of the pustule, Avhich during the night discharged some pus, and in the center of Avhich the gangrenous eschar is depressed, and appears to be adherent to the subjacent parts. Fig. 8. DraAving four days after inoculation. General pro- gress. The pustule is lacerated at several points, and appears to be free from pus. Fig. 9. DraAving five days after inoculation. General progress with the exception of the inflammatory areola, Avhich appears less intense. The irregular eschar, covering the Avound made by inoculation, was removed, and beneath it is seen a roseate base studded Avith yelloAv spots. On the edges which are scarcely separated, is seen a whitish border formed by the epidermis. We may distinguish three varieties of chancres: 370. First, The simple chancre, characterized by the absence of induration, and but a Ioav degree of irritability, or inflammation. It consists of an excoriation of shalloAV character, with sharp cut edges, and someAvhat circular in shape, and having a taAvny- grayish, or yellowish surface, surrounded with a narroAV red areola; it is in many cases attended Avith much heat and itching. This is the variety of chancre most generally found on the female genitals. 371. Second, The indurated or true Hunterian chancre ; this is very rarely met with. It is characterized by the induration of its edges and base, its circular shape, its elevation above the surrounding parts, and the very adherent gray slough that covers its surface. SYPHILIS. 191 372. Third, The sloughing or phagedenic chancre; this is characterized by its more or less rapid destruction of the tissues of the parts. One variety of this is not covered by a slough; it spreads rapidly, has sharp cut edges, and is attended Avith some inflammatory action. The other variety is coATered by a slough, either Avhite, gray, or black ; it has the same tendency to erosion, though in general it does not progress so fast. Chancres of the vulva or vagina are easily detected ; those. hoAvever, Avhich arise on the os uteri may exist for a great length of time, sometimes, in fact, until secondary symptoms are observed, before there are sufficient local symptoms manifest to justify an examination. Ricord states that non-indurated chancres of the neck of the uterus are often painful, especially on pressure, and in sexual intercourse. They cause a sensation of Aveight at the fundament, and pain in the lumbar and hypogastric region. Like chancres in other places, they have a greater tendency to extend and assume a phagedenic form. The suppuration to Avhich they give rise is abundant, may stimulate a vaginal discharge, and give rise to a suspicion of blennorrhagia, and subsequently to the transmission of chancres to the male, by a Avoman Avho had only a discharge. The presence of these symptoms should cause the physician to make a rigid examination of the parts with the speculum. No matter what the nature of the disease is, the symptoms point directly to the cervix as the scat of it, and an examination should be instituted, or the patient given up to some practitioner avIio depends more upon the knowledge of the agents he uses, than upon the character of the disease for Avhich he uses them. In my practice I never take no for an ansAver. I must knoAV exactly the nature of the disease, before prescribing, and if, from motives of delicacy, this is denied, I advise them to employ some one else. 373. Upon examination, a chancre of the cervix may be dis- tinguished from any other ulceration, by its circular form, by its well-defined edges, by the red areola Avhich surrounds it, by the grayish slough Avhich covers it, and especially, by the results of inoculation. There have been doubts raised, hoAvever, in regard to this last means of diagnosis, some ulcers exactly resembling 192 DISEASES OF WOMEN. chancres, not producing the characteristic pustule; but the evi- dence is positive, if the inoculation succeeds. 374. Plate I., Fig. 1, presents an illustration of chancre on Jlie posterior lip of the uterus. It has assumed a slight phage- denic character, and has lost its circular appearance. On the / ft thigh may be seen the characteristic pustule produced by inoculation. , 375. Syphilis in the female very rarely produces enlargement of the inguinal lymphatic glands, or bubo, without the chancre is located on the labia majora, and even then, it is of much less frequent occurrence than in the male. 376. The length of time that elapses betAveen impure coition and the production of a chancre, or between the formation of a chancre and the development of one, and the manifestation of secondary symptoms, varies much in different individuals. Thus, it is said, that the period betAveen exposure and the production of a chancre, in some feAv cases, has been as long as three or even six months, and in some of these cases, the primary and second- ary symptoms Avere developed simultaneously. Again, it is stated, that the constitution may be affected in a few days after the development of the pustule. In a majority of cases, Iioav- ever, constitutional infection will not have taken place, until the chancre has been fully formed, and secreting the specific virus for several days. 377. Secondary Symptoms.—The secondary symptoms will be considered here, only so far as they affect the uterine organs and the function of reproduction. Secondary symptoms may be developed as the result of an imperfectly cured chancre on the external parts, or from the absorption of the virus from a sore, before any treatment Avas adopted; or, as the result of a virulent chancre on the cervix uteri, but Avhich, on account of the Ioav degree of sensibility of this part, did not manifest sufficient symptoms to direct the attention of the patient to the disease ; or, Avhen the mother, being in health, becomes impregnated by a husband, avIio is at the time affected by secondary syphilis, and receives the secondary disorder through the medium of the ovum. M. Ricord, the greatest modern authority in syphilis, believes that Plate I to 11 13 SYPHILIS. 193 when the primary poison is taken, it remains for several davs in a state of incubation, during which time the poison may be destroyed, Avithout any danger of the subsequent occurrence of constitutional disease ; that after this time, chancres take certain characters, and infect the Avhole constitution, giving rise to a train of evils, known as constitutional syphilis. lie does not believe that a sore or chancre, capable of communicating syphilis by inoculation, can ever appear as a secondary symptom. He is of an opinion, that for the presence of constitutional symptoms, it is absolutely necessary that a primary sore should have preexisted, except under the conditions, namely : that a man suffering from constitutional syphilis, may impregnate a healthy woman, and the germ may, in the first place, have constitutional syphilis; and in the second, communicate it to the mother, Avithout the exist- ence of any primary disease in either mother or child. He does not believe in the communication of syphilis in the secretions, or by the discharges from secondary eruptions and sores. Nor does he believe, that a child affected with secondary syphilis, can com- municate the disease to a healthy nurse ; or, that a nurse affected with constitutional syphilis, can convey the disease to a healthy infant, through the medium of the milk. The following are the propositions laid down by M. Ricord: 1st. The father and mother may transmit the disease to their child indifferently, if either or both of them be affected. 2d. Transmission may occur from the parents to the child, when they are affected with constitutional symptoms, or when a concealed syphilitic diathesis exists in them. 3d. The absence or existence of constitutional symptoms in parents at the moment of impregnation and conception, exerts no influence on the form the disease, which may afterward appear in the child. The distinction established by M. Cazenave between congenital and hereditary syphilis, and which is based on the absence of constitutional symptoms in the parents at the moment of generation, or which have been developed in the mother during 13 194 DISEASES OF WOMEN. gestation, is totally erroneous ; and indeed M. Cazenave confesses that his opportunities of observing have not been ample. 4th. The character and period of the manifestation of the symptoms in the child are governed by the stage to which the disease had advanced in the parents, at the moment of generation. The treatment to Avhich the parents Avere subjected may also retard, prevent, or modify the appearances of the child. 5th. If the parents are both healthy at the time of generation, and the mother contracts syphilis during gestation, she may tranmnit the disease to her child. Of this I have seen several examples at various periods of pregnancy, even to the seventh month inclusive. 6th. When the venereal poison is transmitted from the mother to the child during pregnancy, infection takes place through the medium of the placenta, and in this case, appears to occur after the fourth month of utero-ge.-tation. If the father alone be diseased at the moment of generation, an abortion may occur at any period of pregnancy. If the mother alone be diseased at the time of conception, the abortion will not take place until after the fourth month. 7th. Children born of a father or mother affected Avith syphilis may escape infection; for a certain disposition to receive constitu- tional disease is necessary for the child as Avell as the adult, and this may be absent. 8th. Observations made as accurately as possible seem to prove that constitutional syphilis may be transmitted from the child to the mother during utero-gestation. 378. Dr. Tyler Smith says, "In the cases of supposed trans- mission of secondary syphilis between man and Avoman, there almost ahvays must be the doubt of a neAv inoculation by primary matter. Indeed, the doubt must be constant, unless Ave could place implicit reliance on the truth of all the parties concerned, and this, in such cases, must seldom be possible. " In private practice in this country, the most common mode in which syphilitic leucorrhea of a secondary character occurs, is, where the husband has had syphilis before marriage, and is liable SYPHILIS. 195 to occasional outbreaks of secondary or tertiary disorders. In such cases, the ill-health of the Avife dates from the first three or four months of pregnancy. Sometimes she has other secondary mani- festations, such as alopecia, sore-throat, and cutaneous eruptions. In others, leucorrhea is the chief noticeable symptom. We knoAv that in such cases, the ovum is frequently diseased, the membranes are unhealthy, or the foetus is affected Avith secondary syphilis, or specific eruptions break out Avithin a feAv weeks after birth. We can not wonder that in such cases the mother becomes diseased; for, by means of the foetal circulation, the blood of the male parent is brought almost as directly into contact with the female, as though a tube was placed betAveen the vessels of the parties, and the circulating fluid allowed to interfuse. Generally, both mother and child are affected; more rarely, the mother is affected and the child remains healthy; and cases occasionally occur in which a mother bears a family of children by a husband suffering from secondary disorder, all of Avhom are unmistakably diseased, while she escapes apparently Avith perfect impunity. I believe I have seen cases in Avhich syphilis has caused the death of the mother, or permanent loss of health, Avhile the child remained unaffected; and I am sure I have seen cases in Avhich many children have been destroyed, the mother remaining pure. Women imbued Avith the syphilitic poison frequently bear large families; but I have seen cases in Avhich, apparently Avithout any other cause than the syphilitic taint, permanent sterility has followed upon the pregnancy Avhich occasioned the infection. When the mother is once affected, and no treatment is resorted to by the husband, a fresh dose of the secondary poison is imparted at each pregnancy. As regards the length of time after an attack of primary syphilis, during Avhich a man may beget a diseased ovum, it is difficult to give a positive opinion. It is more a matter , of temperament and constitution than of years. Some habits throAv off the syphilitic poison readily, and, to all appearances, completely; others retain it for a long course of time. It adheres, cceteris paribus, less tenaciously to the constitution in youth, than Avhen the disease has been contracted during mature manhood. 196 DISEASES OF WOMEN. 379. " The' appearances presented by secondary syphilitic leucorrhea do not differ materially from the appearances pre- sented in other severe cases of leucorrhea. It is this circum- I ance which has probably led to its doubtful recognition as a orm of secondary syphilitic disorder. Its chief characteristics are, its existence in connection with frequent abortions, and Avith pther secondary symptoms, and the difficulty experienced in its cure except by anti-syphilitic remedies. In secondary leucorrhea, the cervix uteri is generally soft, swollen, injected, and entirely denuded of epithelium. It hangs loosely in the vagina, from the weakening of the vaginal walls. Eruptions are often met Avith in the upper part of the vagina, and upon the external portion of the cervix.* The os uteri often gapes so as to exhibit the rugae of the loAver part of the cervix, and a thin yelloAv purulent matter, which, Avhen mixed Avith morbid secretions from the cervical canal, looks something like honey, or honey and Avater, exudes in considerable quantity from the lower part of the uterus. Occa- sionally, warty growths are found upon the os uteri, and the vesicles of Naboth are sometimes present at the os uteri. The amount of discharge in such cases is frequently very great." 380. Secondary ulcerations, the result of constitutional syphilis, may also be developed upon the cervix uteri. It is very difficult, however, if not impossible, to distinguish betAveen these and ulceration, the result of simple inflammation. There is no doubt but that ulceration of the cervix uteri is much more common among public prostitutes than in any other class. Dr. Bennet states, that while he was in charge of a female skin-ward in the Hospital, St. Louis, there was ahvays a great number of syphilitic skin diseases ; these he carefully examined with the speculum, to ascertain the state of the genital organs. The result of this examination Avas, that of all who presented' symptoms of inflam- mation of the cervix, he found the cervix ulcerated, and slightly indurated; and of those who presented no such symptoms, he found three out of four, " perhaps more," also presented ulcers on the cervix. Most of these patients Avere young women, who had never borne children, or had been confined several years previously, and were under treatment for syphilitic psoriasis, * See Figs. 3 and 4, Piute II. SYPHILIS. 197 litchen, rupia, etc. When questioned narroAvl)', they all admitted that they experienced slight hypogastric pain, that congress had been rather painful for some time ; and some, that they had, like- wise, a slight leucorrheal discharge. They had not, hoAvever, paid any attention to these symptoms. What Avas the nature of these ulcerations? Were they syphilitic, modified chancres, or secondary ulcerations, or Avere they merely inflammatory sores ? In their appearance I could discover little or no difference from the ulcerations observed in non-syphilitic patients, and Avas, therefore, inclined to deny their general syphilitic nature. Some were large, some were small; some had a Avell-defined margin, others not; some Avere covered with unhealthy granulations, others with small, florid, healthy granulations, Avhile others pre- sented a rnembranous film. 381. We have, then, but slight ground upon which to form a diagnosis of secondary syphilitic ulceration. If the patient pre- sent any other secondary symptoms, and -> the ulceration is some- what circular in form, with Avell-defined edges, and lias a coppery- red areola, with or Avithout small coppery-red granulations on a whitish base, scattered over the surface of the cervix, Ave Avill probably be justified in considering it the result of secondary syphilis. 382. Syphilitic vegetations may be developed upon any part of the genital mucous membrane, though they are generally found upon the vulva, or the orifice of the vagina. Some of these vegetations resemble Avarts; they are pale, small, and arise by a base which is generally as large if not the largest portion of the groAvth. Again, there is another variety, Avhich arises from a larger or smaller pedicle ; they project farther from the mucous membrane, and are of a deep-red color ; they have been named the straAvberry or raspberry excrescences. (See Figure 2, Plate II.) These vegetations often give rise to a very disa- agreeable pruritus, and they generally give rise to a discharge, which is sometimes of a very offensive odor. There is no doubt of the contagious nature of these vegetations, not that they will reproduce either primary or secondary syphilis, but that they themselves are capable of being directly transmitted. Thus, the 198 DISEASES OF WOMEN. male suffering from these vegetations, may transmit them to the female, and vice versa. 383. Mucous tubercles is another form of syphilis as it appears upon the genital organs and other parts.* They are much more frequently seen in the female than in the male, OAving to the extent of the mucous membrane lining the genital organs, and the delicacy of the skin. Though generally considered a consecutive accident, yet in females, it is said, that they most frequently exist as a primary symptom. They are generally found about the vulva, or anus, though they may be developed in any other portion of the body; they may appear singly, or occur in groups; gen- erally Avhere there is one, more is developed. According to Vidal, Avhen seated on the mucous membranes, the color is more or less of a lively red, while on the skin, in a majority of cases, they are broAvn ; around them the coppery areola of the syphilitic eruptions is often observed. The surface is sometimes smooth, slightly fungous, and sometimes presents a macerated appearance. Occasionally they are completely fungus, and of a violet color. They may have an eroded and even ulcerated appearance, resem- bling that of chancre; especially that form known as the ulcus elevatum. They generally secrete a serous-like, or sero-purulent fluid, Avhich has a peculiar and repulsive odor. The pus becomes more strongly marked, as the ulceration is established, and the pustules are irritated. 384. On the neck of the uterus, the mucous tubercle is often of a reddish-gray color, very round, distinct, and a little larger than a lentil. It has been seen at the same time, on both sides of the upper and loAver lip. These groAvths may appear in one or two Aveeks after coition, or some time after the development of a chancre, or they may appear as the first symptom ; they are then primary. M. Ricord denies the contagiousness of mucous tubercles; other Avriters, among whom are M. Yidal, M. Waller, and Wallace, have successfully proved their transmissability. 385. Diagnosis.—In many cases of female disease, it becomes -vf the greatest importance to ascertain exactly Avhether there is * See Fig. 2, Piute II. SYPHILIS. 199 a syphilitic infection of the system. We have already noticed the principal effects of this protean malady, so far as the effects differ in the two sexes ; and we have seen not only the health of the patient affected by the disease, but also her offspring. 386. The presence of syphilitic disease of the skin, the exanthemata, squamae, vesicuhe, pustulae, papula?, tubercula, etc., as avcII as the characteristic secondary symptoms of the mucous membrane, or alopecia, or the falling off of the hair, Avill hi sufficient evidence to cause us to regard either structural or functional disease of the uterine organs to be either a result of secondary syphilis, or to be greatly aggravated by it. On this point Mr. Langston Parker says : " I must think, with Mr. White- head, that the greatest majority of morbid conditions which are found on the lips and orifice of the uterus, in females who are laboring under a confirmed venereal taint, are of syphilitic character ; probably they are secondary, or rather constitutional. It is rare to find the uterus free from disease, Avhere a confirmed constitutional taint exists ; the os is cither surrounded by a ring of inflammation, or the lips are everted and red, and more or less thickened-; again, superficial ulcers exist, either having a granular appearance, or, Avhat is less common, the edges of the ulcer Avell defined, and its edges elevated and hard." M. Gilbert says, Ave must admit that this granular condition, or the ulceration of the os uteri, is due to syphilis, and belongs most commonly to secondary syphilis. Again, Avhen Ave find a patient habitually aborting after the fourth month, the probability of constitutional syphilis should cause a very careful examination and inquiry, in regard to this disease. Syphilis, at this day, has become of such common occurrence, especially secondary symptoms, that the probability of this disease being present should ahvays be borne in mind. The character of the patient has not that Aveight here that it Avould have, Avere constitutional syphilis always and invariably the result of primary disease in the female. But Ave have already seen that a female may become infected through the ovum, the husband having constitutional syphilis, though not aAvare of it, and thus communicating it to the wife. If abortion habitually occur before the fourth month, th 200 DISEASES OF WOMEN. condition of the husband should be ascertained, if possible, whether he has had syphilis, the time that has elapsed since the primary symptoms, and Avhether secondary symptoms have ever been manifested. • 387. These inquiries may seem out of place to those avIio practice medicine in the country, where a case of venereal disease is uncommon, but to those Avho practice in large cities, their necessity Avill be at once acknoAvlcdged. It is a humiliating fact, but one that is true, that a majority of young men who have been raised in the city, have, at some period of their lives, been affected Avith syphilis. This may have been eradicated, but still the presence of secondary syphilis is extremely common, as the con- sulting-rooms of our physicians will show. It is also a noted fact, that under the treatment of those who make venereal disease a speciality, the disease is often not eradicated from the system, the treatment merely checking the present symptoms, but which are liable to recur from any exposure or excess. Under these circumstances he marries, Avhen the disease, although secondary, may be transmitted to both Avife and children. 388. Treatment.—We have first to consider the treatment of primary syphilis or chancre. And here the question arises, can we prevent the infection of the system by destroying the original sore? and if so, during Avhat length of time may the abortive treatment prove successful? In many cases, no doubt, the destruction of the syphilitic sore may prove entirely effectual, in removing every trace of the specific virus from the system; but to accomplish this, it is necessary that the sore be destroyed before the proper secreting structure of the chancre is formed, in fact, in the pustular stage. This, even, is not always sufficient, for the syphilitic pus deposited upon a mucous membrane may he absorbed Avithout producing either pustule or chancre, as Ave see in primary bubo, or the bubo d'embles. Sometimes, hoAvever, a chancre may be fully formed, giving rise to the characteristic pustule by inoculation, and still, through some constitutional peculiarity of the patient, the virus is not carried into the system ; while, therefore, it is good treatment to adopt the abortive plan in the first stages of the disease, it should always be done in connec- SYPHILIS. 201 lion with the same constitutional treatment that we would adopt if we were satisfied that the virus had already been absorbed. 389. Though the abortive treatment will often prove successful in males, it can seldom be resorted to in females, from the fact that the disease produces less uneasiness Avith them, not being severe enough to call their attention to the seat of the affection, and because the female genitals being much more liable to disease than the male, the mind is not so impressed Avith their importance. Thus, the pustular stage, in nearly every case, is passed, and the sore presented to the surgeon is a fully-formed chancre, probably of some Aveeks' duration. In some cases, hoAvever, through accident, and in others avIio have had chancres before, and are, therefore, watching the first symptoms, the physician may be able to adopt the abortive treatment Avith some probability of success. This treatment consists in thoroughly destroying the primary sore with caustic, and thus converting it into a healthy ulcer. For this purpose I use the Potassa Fusa, though many others use the Strong Nitric Acid, the Nitrate of Silver, the Tincture of Chloride of Iron, etc. In using either of these agents, if the chancre be in the pustular stage, it should be opened, and the contained matter carefully removed; then apply the caustic to the surface of the sore sufficiently to entirely disorganize its base. If the Potassa Fusa is used, its application for a feAv seconds will be sufficient, and as soon as the cauterization is accomplished, the sore should be covered with Lint, saturated in Vinegar and Water. As a general rule, cauterization, to prevent constitutional infection, should be resorted to before the fifth day, and even then it may prove ineffectual. 390. In very many cases, a good Mayer's ointment, (made strictly according to the formula) will be the best dressing after cauterization. It is sufficiently tenacious to remain where placed, protects the part thoroughly, and gives the necessary stimulation. The sore heals by granulation, and the part needs rest and pro- tection. In some cases an astringent and stimulant application is necessary, and then Ave think of the old-fashioned dressing of Port Wine and Tannin—i£ Port Wine, gvj.; Tannic Acid, ^ij.; 202 DISEASES OF WOMEN. apply Avith lint. I should use this application Avhen the part was Bpongyand deep-colored. A solution of Permanganate of Potash will also be found a good dressing in some of these cases ; and once in a Avhile a weak solution of Carbolic Acid. Sometimes we find that a dry dressing answers a better pur- pose : most usually in cases where there is a free and somewhat ichorous secretion. If the part is tumid and pallid, I AvOuld use Sub-nitrate of Bismuth ; if pallid but spongy, Oxide of Zinc. Dry Calomel has been very highly recommended as a dressing for some chancres, but I doubt whether it possesses any advantages over those named. Once in a Avhile a case will present in which the chancre is spongy, secretes profusely, and is very irritable, when Oxide of Lead (powdered Avhite lead) Avill serve our pur- pose best. Rut Avhatever means are employed, it is certainly good treatment to destroy the secreting surface of the sore, and prevent the further absorption of the virus; if by this means the chancre can be more readily healed, providing that by this means the patient and practitioner is not lulled into a fancied security, and thereby omit the use of proper constitutional measures. 391. In the female, there is rarely any symptoms to contra- indicate the use of the caustic; it may be, therefore, employed in any stage of the simple chancre. Here, I still prefer the caustic Potassa, using it to a sufficient extent to destroy the secreting surface of the ulcer, using the acidulated water afterward to pre- vent any extension of the cauterization, and then applying a poultice of Ulmus Fulva, until the slough has separated. If the ulcer should be granulating in any part of its surface, this part should be shielded from the action of the caustic, by a small pledget of cotton saturated in vinegar and Avater. This cauteriza- tion changes the action of the tissues, and Ave have left a simple ulcer. To this ulcer, Ave may apply the Mild Zinc Ointment, until cicatrization is complete. Or, Ave may use, if the ulcer does not heal Avith this application, a Aveak solution of the Sulphate of Zinc, Nitrate of Silver, or Alum, or what Avill be found preferable in many cases, a solution of Tannin in port Avine. If the chancre assume a phagedenic character, the patient should be confined to her bed, and elm poultices employed, until the inflammation is SYPHILIS. 203 removed, when the Mayev's Ointment,- or some of the other dressings named, should be applied. When there is not much inflammation or irritability, the phagedna may be sooner stopped by the use of caustics; the one that is most highly recommended, is the Strong Nitric Acid. This cauterization should be deep, and repeated sufficiently often to check the progress of the gangrene. The dressings in these cases,,should be frequently changed, as the discharge is often very copious. In addition to these local measures, the patient should be put upon the use of the vegetable tonics, and some of the feruginous preparations. The diet should likeAvise be nutritious, but easily digested. In all cases of primary syphilis, strict attention should be paid to the habits of the patient, as much rest should be taken as pos- sible, and all exposure avoided. The skin should be kept in a healthy condition, by the use of the bath, and if dry and husky, by the administration of some agent that will determine the cir- culation to the surface. 392. Secondary Syphilis.—Here, our dependence is placed almost entirely on the constitutional treatment, or the use of those remedies Avhich remove the syphilitic virus from the system. He come noAV to consider the most important point in the treatment of syphilis, the agents by which constitutional infection may be prevented, and Avhich will remove the syphilitic virus from the system after it has been absorbed, and produced secondary symp- toms. Of these agents, I may enumerate the Iodide of Potas- sium, the Iodide of Iron, the Iodide of Ammonium, Phytolacca, Corydalis, Ampelopsis, Rumex, Kalmia, Thuja, Scrofularia, Alnus. etc. 393. The benefit derived from the first of these agents, the Iodide of Potassium, is so marked, that it is used by all schools of medicine. Under its administration alone, many cases of con- stitutional syphilis have been radically cured. Still, there are some cases in Avhich it will fail. Under the use of small doses (from gr. ij to v,) the appetite will generally be increased, nutri- tion active, and the strength reestablished; these doses, hoAvever, do not prove anti-syphilitic. To make the remedy effectual, it should be used in doses from gr. x to 5ss, three times a day. 204 DISEASES OF WOMEN. 394. The Iodide of Iron has similar properties to the agent above-named ; it is, hoAvever, better suited to persons of a feeble constitution, as it acts directly upon the system as a tonic and restorative. It may be administered with the agents hereafter spoken of, or in pills, according to the folloAving formula: R< Sulphate of Iron, 3ijss. Iodide of Potassium, gx. Tragacanth, gr. xxv. Sugar (powdered), 3jss. Make one hundred pills, from one to ten to be taken in the day. 395. The other agents named may be truly called vegetable anti-syphilitics, and the list of these might be considerably in- creased. They may be used separately or in combination. The combination of these agents that is generally employed by Eclec- tics, is the Compound Syrup of Stillingia; but I prefer to select my remedies according to the case in band. Some of them are much better given in weak infusion, but in large quantity, as the Alnus. Corydalis and Rumex. But others, as the Phytolacca and Thuja, may be given in quite small doses, with most excel- lent results. 396. Whi'e using these remedies, it is essential that strict attention should be paid to the general health of the patient; the boAvels kept regular, and the kidneys and skin stimulated to a full performance of their functions. With the removal of the constitutional infection, by the use of the remedies above-mentioned, the local disease of the genitals is easily treated. But Avithout this is accomplished, local appli- cations to the diseased parts are of but little use; for even if the local disease Avas subdued, the presence of the syphilitic poison in the system, Avould directly reproduce it. Sjqdiilitic condolymata may be removed from' the genitals, either by cauterization, the ligature, or excision. Very often, hoAvever, Avhen the syphilitic poison has been entirely eradicated from the system by the use of constitutional remedies, these vegetations Avill disappear spon- taneously. M. Vidal strongly recommends the folloAving method: SYPHILIS. 205 R Savine, Alum Calc. aa. 5jss. Reduce to a fine poAvder. Wash the vegetations tAvice a day with red Avine, and cover them afcenvard Avith a thick layer of the powder. In the course of three or four days the vegetations become feeble, and the patient may begin to remove them Avith the finger nails. After each separation there is a slight bloody discharge, Avhich may be arrested by the vinous lotion, after which the powder is reapplied. 397. Mucous tubercles, like the vegetations above referred to, will often disappear under the use of proper constitutional treat- ment, if strict attention to cleanliness be observed. Sometimes, hoAvever, local measures become necessary. If the tubercles are not ulcerated or inflamed, the local application of the Liquor Sodae Chlorinata will be found a very good application ; under its use the tubercles become smaller, and rapidly disappear. If there is ulceration, the solution should be diluted until but a slight smarting sensation is produced. Or a plaster of the inspissated juice of the Phytolacca Decandra may be used Avith much advan- tage. In one very stubborn case of this kind, Avhere the tuber- cles Avere ulcerated and gave rise to a profuse fetid secretion, I used the Extract of the Trifolium Pratense with entire success. It removed the troublesome itching Avhich sometimes accompanies the disease, in three or four hours, and its continued application for ten days removed every trace of the tubercles. The chronic inflammation, erosion, and ulceration of the cervix, Avhich so often accompanies this disease, Avill readily yield to the treatment recommended for simple inflammation and ulceration of the cervix. 398. The functional uterine diseases, Avhich so often appear during secondary syphilis, will, in a majority of cases, be removed, Avhen the cause that produced them is eradicated. In concluding the description of this disease, I can not too strongly impress the' fact on the mind of the reader, that in every case of uterine disease complicated with secondary syphilis. whether that disease be structural or functional, the removal of 206 DISEASES OF WOMEN. the syphilitic poison is the first step toAvard a permanent cure ; and when this is removed, the local disease will yield to the usual remedies for such affections. CHAPTER IX, DISEASES OF THE UTERUS. 399. Diseases affecting the uterus are divided into tAvo classes, Structural and Functional. Structural diseases are those in which the deviations from healthy action are indicated by symptoms during life, and by appearances after death, Avhich are ahvays the result of some, and often of very conspicuous struc- tural lesions; Avhile functional diseases are dependent on devia- tion from the natural or healthy action of any part of the uterine system, indicated by symptoms during life, which, on examination after death, are found to be unconnected with any discoverable change of structure. 400. The relative frequency of these tAvo classes of uterine disease is hard to determine. Some practitioners look upon all diseases of the uterine system as diseases of debility, and adopt their treatment to this supposed condition. Others consider that all these diseases arise from, or consist in, a local congestion and engorgement of blood, and that they are to be relieved by remedies directed to its removal. A third theory has been suc- cessfully advocated by Dr. Bennet, and adopted by a large por- tion of the profession, that the majority of uterine diseases are inflammatory in their nature, and that Ave are sure to find, in nearly every case, inflammation, or some of its results, as ulcera- tions, purulent discharges, etc. This theory of uterine disease Dr. Bennet supports by a report cf three hundred consecutive cases of uterine disease, occurring in hospital practice, in tAvo hundred and forty-six of which decided inflammatory disease of the cervix uteri Avas present. Again, Ave have other practitioners OCCLUSION OF THE OS UTERI. 207 believing that a majority of these diseases arise from displace- ment of the uterus ; and others, that they are essentially nervous or neuralgic disorders. Many other theories in regard to the nature and cause of uterine diseases have been brought forward, and have found advocates at different times, though the ones just mentioned are the principal. 401. These vieAVs are all partially correct, yet neither of them is sufficient to account for all the morbid manifestations of these organs, nor for a majority of them, if Ave except the theory of Dr. Bennet. To successfully study these diseases, it is necessary to recollect that the general principles of pathology apply to disease of the uterus the same that they do to any other organ of the body, and that any special or exclusive theory, that Avill not apply equally Avell to disease of other parts, must be fallacious. 402. As functional diseases of the uterine system involve, to a greater or less extent, both the uterus and ovaries, and as they so frequently rise from, or are aggravated, by, structural diseases of these organs, their consideration Avill be deferred until the organic diseases of the uterus and ovaries have been described. The same anatomical arrangement Avill be folloAved here that I have adopted in the previous part of the Avork, classifying the diseases, as far as possible, according to the structure affected. Occlusion of the Os Uteri. 403. This may be either congenital, or the result of disease; and it may be cither partial or complete. Congenital occlusion not unfrcquently occurs with occlusion of the vagina, as has been heretofore described, though it may be present Avhen the vagina, is perfect. In either case, it is of very rare occurrence. 404. The symptoms of congenital occlusion depend altogether upon the presence of a menstrual discharge. Until the period of puberty, Avhen this secretion takes place, this obstruction gives no sign of its presence, and in some cases reported, it had continued up to the age of forty years, Avithout producing any difficulty ; though, in these eases, there was never any symptoms of men- struation. As soon, hoAvever, as the menstrual secretion is 208 DISEASES OF WOMEN. established, we will find a monthly return of those symptoms accompanying menstruation; considerable uneasiness and distress, weight in the pelvis, uterine tenesmus, aching round the loins, and by degrees an increasing tumor'above the pelvis, resembling i 1 form the impregnated uterus. These symptoms Avill part.ally disappear in a feAv days, but will recur at each menstrual period Avith increased violence. 405. Acquired occlusion may depend upon various accidental causes. Thus, it may arise from severe inflammation of the cenix uteri, from mechanical lacerations, from the use of caustics, applied to the cervix or its canal, and as the sequelae of labor. The symptoms of acquired occlusion are the same as above described. Some cases have been reported in Avhich occlusion occurred during pregnancy. A case of this kind is reported by Prof. Bedford. 406. Diagnosis.—In cases where there is considerable accumu- lation, with enlargement of the uterus, it would be very easy to make a mistake in the diagnosis, if care was not used in making an examination. In congenital occlusion, the absence of the menstrual secretion, with the monthly recurrence of the symptoms, should lead us to suspect that the cause of the difficulty was retention of the menstrual blood. Upon making an examination, if the vagina be found perfect, the careful examination of the os Avith the uterine sound will reveal that the exit from the uterus is imper- vious. If the occlusion is acquired, some difficulty may be experienced in determining Avhether the suppression of the menses is not due to pregnancy. Yet here the recurrence of the symp- toms with no discharge, Avill be sufficient to make us suspect the difficulty. 407. Treatment.—In order to open the occluded os or cervical canal, Ave might first attempt to pass up an ordinary sound, with the vieAv of breaking doAvn the obstructions, if possible, as, in some cases, the occlusion is but slight. If this does not succeed, the opening may be made with the trocar or bistoury. We may use the speculum here Avith much advantage, bringing the cervix fairly into view; the trocar should be placed as near as possible to the CONGESTION OF THE CERVIX UTERI. 209 situation of the os uteri, and a perforation made by pressing it upward, until the contents escape. The canula ought to he left in the Avound after the trocar is AvithdraAvn, until the uterus is emptied. When the fluid has been entirely discharged, a bandage should be applied to support the abdomen, and the patient placed in bed. The vagina should be syringed out tAvo or three times a day, until the collected blood has all drained a\vay, Avhen an elastic bougie should be introduced through the cervix, and kept there, in order to prevent the closure of the uterine orifice. Congestion of the Cervix Uteri. 408. Congestion of the cervix uteri is of very frequent occur- rence ; it is, indeed, one of the most common diseases to Avhich women are subject. During the normal performance of the menstrual function, the uterus and ovaries receive an increased supply of blood, and there is, consequently, slight and temporary congestion, though this does not affect the cervix to so great an extent as the body of the uterus. This congestion is, hoAvever, removed as soon as secretion is fairly established. If the cervix uteri is examined at the commencement of menstruation, it will be found to be more voluminous, and of a deeper color ; if after the secretion is fairly established, it will be found slightly congested and near its natural size, the os being larger and more open. As soon as menstruation ceases, the cervix and os will be found in their normal conditions. 409. When this normal congestion is increased from any cause, and continues through the menstrual interval, we then consider it a disease. As congestion in the first stage of inflammation, it may rapidly assume an inflammatory form, though in very many cases, it continues for months a simple congestion. 410. Symptoms.—In many cases, the symptoms are so slight that the patient makes no complaint for some time. If, hoAvever, it continues, each return of the menstrual period will be accom- panied with greater suffering ; the menstrual function itself does not remain long intact, sometimes becoming too profuse, at others scanty, or its place supplied with a discharge nearly Avhite ; the 14 210 DISEASES OF WOMEN. periodicity of the discharge may also be affected. Thus, it may appear more frequently, or be retarded in its appearance. Between the menstrual periods the patient complains of a constant pain in the small of her back, of a weight and dragging down in the pelvis, Avhich are all increased by standing, walking, or any kind of exercise. There is almost always a constant leucorrhea, the discharge varying in character, from a thin milk-white mucus to a thick and tenacious secretion. As the disease continues, the patient Avill complain of lassitude and weakness, loss of appetite, and other symptoms, shoAving an impaired state of the general health. The symptoms described are common to congestion and inflammation; in fact, it is hard to distinguish the dividing line between the two conditions. 411. Upon making an examination, the cervix Avill he found enlarged, either in its Avhole extent, or only partially, the conges- tion being principally confined to one of the lips of the os. It will also be found loAver doAvn in the pelvis, the increased weight of the organ causing a greater or less prolapse. Upon touching the cervix, it Avill be found soft, yet elastic, and having the same smooth, unctuous surface Avhich characterizes it in health, strongly contrasting Avith its condition Avhen inflamed, when it feels indurated, dry and harsh, and increased in temperature. 412. The presence of congestion of the cervix exercises an unfavorable effect on all other uterine diseases, Avhether functional or structural, always aggravating them and making the cure much more tedious. 413. Causes.—The most frequent cause of this affection is cold, especially during, or immediately after menstruation, excessive coitus, the use of irritating injections, frequent abortions, etc. It may also be caused by violent mental emotions and long-continued and violent physical efforts ; in fact, from any cause producing unusual determination of blood to the uterus, Avithout a corres- ponding amount of secretion, cither during or in the intervals of menstruation. 414. Treatment.—As has been remarked, the continued recur- rence of the congestion is not only a cause of present unpleasant- ness, but is a fruitful source of structural disease of the cervix, INFLAMMATION OF THE CERVIX. 211 uterus and ovaries. It is well, therefore, to give the case a very thorough examination, to determine the indications for remedies. I Avould suggest the study of Macrot}7s, Caulopbyllum, Pulsatilla, Viburnum, Hamamelis, Senecio, Apocynum, Rhus, Apis, Bella- donna, Carbo-veg., Iron and Copper, in this case. 415, We find a group having dysmenorrhoea as a prominent symptom, the congestion of the cervix being attended Avith diffi- cult, or it may be tardy menstruation. In this case I like the action of Macrotys and Pulsatilla, 3s». of each (the tincture) to water §iv.; a teaspoonful four times a day for four or five days before the menstrual period, and until the flow is Avell established. When there is severe expulsive pain, and especially in the early months of pregnancy, there is no remedy equal to the Viburnum. It may be given alone, or alternated Avith either of the others named, if indicated. The Hamamelis (Pond's Extract) is espe- cially indicated when the pelvic tissues are full, feeble, and there is general venous congestion. In the majority of these eases the patient will also suffer from hemorrhoids. The dose will be one- fourth or one-third of a teaspoonful four times a day. The Apo- cynum is especially indicated by the oedema of the feet which characterizes some cases, though examination Avill sometimes sIioav a similar condition of the vulva and other tissues. The Carbo-veg. is the remed}* Avhen the menstrual Aoav continues long (passive) and recurs too frequently. Cuprum is the blood-maker in these cases. 416. Mild astringent and tonic injections sometimes prove use- ful. If there is much leucorrhoeal discharge, injections of Sali- cylic Acid and Borax, Chlorate of Potash, and Sulphate of Zinc. or Alum, may be used. Tonics and restoratives will sometimes be indicated, and in all cases a good diet, with rest, physical and mental, will aid much in effecting a permanent cure. In some cases coitus must be pro- hibited for some time, as avcII as the use of that modern cause oi uterine disease—the sewing machine. Inflammation of the Cervix. 417. Inflammation of the cervix uteri has been investigated of late years with great care, and at this time, it has assumed a great 212 DISEASES OF WOME*. importance, Avith uterine pathologists. These investigations Avere stimulated by the Avork of Dr. Bennet, on Inflammation of the Uterus, published in 1845. In this Avork, he advanced the theory, that the majority of uterine diseases Avere either essentially nflammatory, or that they arose from, or were kept up by inflam- mation. In his classification and description of uterine disease, inflammation of the cervix uteri and its results, hold a prominent place, from the fact, that it Avas the most common disease, being met Avith in five out of every six cases of uterine disease, and from the serious train of consequences which arose from it, and Avhich, by other authors and practitioners, had been considered as the result of other affections. Since the views of Dr. Bennet have been made knoAvn, they have been adopted by many of the most successful practitioners in all parts of the world, yet, there are many, Avho having the same opportunities for investigation as Dr. Bennet, deny that this disease is of such frequent occurrence. There is no difference, however, between authors, so far as the description of the disease is concerned, the main difference being as to its frequency, and its so-called results, ulceration, erosion, etc. 418. So far as my experience has extended, I am inclined to adopt the views of Dr. Bennet, as thus far I have found them borne out by the results of practice. I would especially urge my readers, to bear in mind the symptoms of this affection, when examining cases of uterine disease ; as it will often be found, that Avhat seems to be a functional affection, upon a superficial examina- tion, has its origin, or is kept up by inflammation of the cervix. In the description of the symptoms and consequences of this disease, I ha\re principally depended upon Dr. Bennet's minute treatise on this subject. 419. Causes.—The physiological functions of the uterus, men- struation and gestation, by the changes Avhich they produce in the condition of the organ, make it more liable to inflammatory action, than any other portion of the system. Thus, during the period of menstruation, the uterine system remains in a state of physio- logical congestion, and at this time it has a high degree of vitiliza- tion, and is peculiarly susceptible to all causes of disease, as cold, INFLAMMATION OF THE CERVIX. 213 ntmosphcrical vicissitudes, etc. The menstrual secretion is liable to be prevented, diminished, increased, or suddenly arrested, by many other causes than those named, either mental, social or pathological; and Avhenever this is the case, the natural uterine congestion may become morbid, and thus give rise to inflamma- tion. These causes act both in the married and single state, yet, in the last, the disease is not of such frequent occurrence. In the married state, the cervix uteri is exposed to another fruitful cause of inflammation, even Avhen conception does not take place. The physiological congestion and excitement Avhich accompany intercourse, may, if too frequently reneAved, give rise to inflam- mation, and the same results may be occasioned directly by phy- sical contusion of the organ itself. Gestation likewise increases the susceptibility of the uterus to disease, and this susceptibility appears to be more manifest in the cervix than in any other portion of the organ. At this time, the .structure of the uterus undergoes a complete transformation; its tissue, Avhich before Avas of almost a cartilaginous hardness, noAv assumes the characteristics of muscular structure; the arteries and veins previously so small as to be Avith difficulty detected, noAv become enlarged to an enor- mous extent, and the entire organ becomes one of the most, instead of one of the least vascular in the human economy. This condition, therefore, constitutes a predisposing cause of inflammation, not, hoAvever, during pregnancy, for the uterine system appears to be peculiarly exempt from inflammation at this time, but from the fact, that in the involution of the uterus, the cervix never regains its former condition ; it still remains volum- inous, looser in texture, and more plentifully supplied Avith blood, and it has, therefore, a greater susceptibility to disease. 420. Parturition is also a frequent cause of inflammation and ulceration of the cervix, as it is frequently folloAved by inflamma- tion of the uterus involving the cervix, which may perpetuate itself in the latter region, even when it has been subdued in the bodv of the organ, or it may occasion inflammation of the cervix alone, other parts of the uterine system not being simultaneously affected. 421. In addition to the predisposing causes named, inflamma- 214 DISEASES OF WOMEN. tion of the cervix may also be the result of the extension of vaginitis, blennorrhagic or non-blennorrhagic, or, it may occur like all other phlegmasia?, without being traceable to any par- ticular cause. 422. Symptoms.—When the mucous membrane which covers the cervix is inflamed, it ceases to present, to the touch, the unctuous surface Avhich characterizes it in health. If the inflam- mation extends to the deep-seated structures, or if it commences there, the cervix is more or less indurated, as well as enlarged, from the interstitial effus'on that takes place. When the uterine neck is thus increased in Aveight, it nearly ahvays falls more or less in the vaginal cavity, so as to approximate the vulva. In married females it is also generally retroverted, owing to physical pressure in congress. When the inflamed cervix is brought into vieAv by the speculum, its surface is found to offer a vivid, red tinge, instead of the pale rose-color of health. It may present a uniform red hue, and be dotted with florid, red papulae, or with Avhite pustules, consisting of mucous glands, hypertrophied or distended Avith muco-pus; or, it may offer any of the shades betAveen the bright red of arterial blood, and the livid tinge of venous blood, according to the state of the circulation. On the inflamed surface Ave find a certain amount of muco-pus, Avhich generally requires to be wiped off before the state of the mucous membrane can be clearly ascertained. Dr. Bennet attaches great importance to the presence of muco-pus as an evidence of inflam- mation, for both redness and tumefaction of the cervix may be produced by mere congestion, especially if it is carried to a morbid extent. This muco pus must not be confounded with the abundant Avhite secretion Avhich is frequently found in this region, and which is the result of congestion, and not of inflammation. Sometimes the inflamed cervix presents membranous patches, which are principally observed around the os, though they may occur on any part of the cervix. 423. In nearly every case of inflammation of the cervix uteri, there is a morbid dilatation of the cervical cavity, and to this dila- tation, Dr. Bennet attaches great importance, as a pathognomonic symptom. lie says : " Whenever the finger, instead of passing INFLAMMATION OF THE CERVIX*. 215 over a scarcely perceptible orifice, meets Avith a well-marked depression, into Avhich its extremity may be inserted to a greater or less extent, Ave may conclude that inflammation, with or Avith- out ulceration, is present, and it becomes advisable to pursue the investigation further, so as to ascertain, by ocular inspection, in a satisfactory manner, the real state of the parts. The mucous membrane that lines the cavity of the cervix, Avhen inflamed, presents a dark, livid color, which may be traced with the eye to a considerable depth, by depressing Avith the sound the lower lip of the os. This surface bleeds easily on being touched Avith a probe, especially if excoriated or ulcerated, which is not the case in the healthy condition. The inflamed mucous membrane of the cervical canal also secretes muco-pus in more or less abundance, and this muco-pus filling up the cavity, can often, with difficulty, be Aviped aAvay. I generally use, for that purpose, a small piece of cotton, inserted into the cleft of the fluid caustic-holder, which may be passed into the cavity of the cervix, owing to its dilated state, and with Avhich the mucus may be removed. Even Avhen there is no pus present, the cavity of the cervix is often com- pletely filled with a glairy, transparent mucus, evidently secreted by the mucous follicles of the inflamed lining membrane. This glairy mucus, Avhich may be compared to the uncooked white of an egg, has much attracted the attention of writers on female discharges, and is considered to be secreted by the uterine organs generally, as the result of debility ; Avhereas, in reality, it is secreted by the cavity of the cervix, and is nearly ahvays the concomitant of inflammation. It is sometimes produced in very great abundance, and constitutes one of the principal forms of the vaginal discharge commonly called the Avhites. " The presence of great quantities of this glairy mucus, along with an open state of the os uteri, may be considered as pathognomonic of inflammation of the cavity of the cervix." With inflammation of the cervix, there is frequently an extension of it to the upper part of the vagina, which will be congested and inflamed, and present the deep vascular hue and the muco-purulent secretion which characterize these conditions in a mucous membrane. If the disease be severe, and sometimes when it is not, the vagin j 216 ♦ DISEASES OF WOMEN. and the vulva are congested, swollen, and tender, and more of less inflamed. Pruritis of the vulva is not an uncommon symptom of this affection ; it often becomes very distressing, and may or may not be accompanied with inflammation or erosion of some part of the external genitals. In these cases the common local applications for the relief of this symptom will prove of but little avail until the diseased condition of the cervix is removed. 424. This inflammation, Avhen severe and of long continuance, sometimes extends to, or exercises a morbid influence on, the the rectum and bladder. The rectum is very frequently affected in chronic uterine disease, whether of the body or the cervix. If the cervix is enlarged and indurated, it is generally thrust back mechanically so as to press on the loAver bowel, the body of the uterus remaining in situ or being carried forAvard. In this case, the pressure on the loAver boAvel is attended Avith the same distressing results as Avhen it is the body of the uterus that is retroverted and pressed upon the rectum. The faeces, meeting Avith a physical obstruction to their passage into the loAver part of the rectum, accumulate above, and keep the upper part of the boAvel permanently distended. Their passage is also attended with pain, especially if they are solid, OAving to the contents of the boAvel having to lift up the inflamed and indurated organ that obstructs their exit. This pain, hoAvever, is not near so great as Avhen the body of the uterus is affected, OAving to its greater sensibility. Hemorrhoids are not an unfrequent complication with this, as well as Avith other forms of uterine disease. The attacks of piles occur, most frequently, at the period of menstrua- tion, Avhen the pelvic irritability and congestion are at the greatest hight. From the close relation of the bladder to the uterus, it is nearly as liable as the rectum to suffer, when the neck of the uterus is the seat of inflammatory disease. The bladder and urethra may become congested and irritable, giving rise to pain above and behind the pubis, accompanied by a frequent desire to pass water, to difficulty in its excretion, and to heat and scalding in the urethra as it passes. Ch\ing to the fact that the cervix uttri is very scantily supplied with nerves, inflammation of it is rarely marked by pain in the part affected; thus, pain is seldom INFLAMMATION OF THE CERVIX. 217 felt behind the pubis, the anatomical seat of the diseased cervix. Sometimes, hoAvever, the diseased cervix becomes very sensitive to pressure, so much so that coitus produces extreme pain. The locality of the pain in this disease is in the lumbo-sacral, the ovarian, and the loAver hypogastric regions. The first of these, or the pain in the small of the back, is the most constant, though it is not especially symptomatic of this disease; for it may, and often does arise from any of the many diseases of this region. On the contrary, the ovarian pain may be considered all but pathog- nomonic of this affection. According to Dr. Bennet, " in nine cases out of ten, it is the left ovarian region alone, and not the right, or both, that is the seat of pain. This localization of the pain produce 1 by inflammation and ulceration of the cervix uteri, in the left ovarian region, is, perhaps, connected with some peculiarity of the distribution of the uterine nerves, but I have, hitherto, been unable to discover any anatomical reason for the preference thus shoAvn. The fact, however, is undeniable, and renders the existence of a dull, aching, constant, circumscribed pain in the left ovarian region, all but pathognomonic of inflam- matory disease of the cervix uteri." The hypogastric pain is of much rarer occurrence than either of the others ; it arises from pain in the neck of the uterus, and is felt above and behind the pubis. It is seldom circumscribed, like the ovarian pain, but radiates all over the loAver hypogastric region. 42"). Inflammation of the cervix uteri very rarely exists for any length of time, Avithout unfavorably modifying the function of menstruation. Thus, it very often produces dysmenorrhea, and Avhen menstruation, previously easy, becomes painful, Ave may suspect the presence of inflammation of the cervix. It may also influence the periodicity or quantity of the menstrual excretion, either lengthening or shortening the intervals, or the duration of the flow; or increasing or diminishing the quantity. From the commencement of inflammation of the cervix uteri, the health gradually deteriorates, though this does not become marked until it has continued for some time, without the patient has naturally a feeble constitution. The first symptoms of constitutional affection Avill be observed in the function of digestion, caused b\ 218 DISEASES OF WOMEN. a transmission of the local irritation to the sympathetic nerves supplying the abdominal viscera. We see an illustration of this sympathetic connection between the uterus and digestive organs, in the first months of pregnancy, in the morning sickness, depraved or vitiated appetite, etc. The extent to which this function becomes morbidly modified, varies in different individuals; thus, in some, digestion is merely Aveakened, Avhile in others all the symptoms of dyspepsia are manifested, sometimes in an aggra- vated degree. The appetite may he either diminished in these cases, or it may be morbidly increased or perverted. With this disturbance of the digestive functions, there is often a torpor of the excretory organs, the skin is harsh and rough to the touch, the kidneys do not properly perform their functions, and the bowels are either habitually constipated, or else there is an alternation betAveen constipation and diarrhea, the patient being affected Avith first one and then the other. From Avhat has been already stated, Ave should suppose that if the disease continues, as it often does, for months and even years, the patient Avould become greatly debilitated, and this is the case ; patients laboring under this affection present a blanched and ex-sanguined appear- ance ; they are listless, having no desire to take exercise, and are often the subjects of hysteria. 420. Treatment.—The treatment of inflammation of the cervix uteri Avill have to be varied according to the severity of the disease, the extent of the inflammation, the length of time it has existed, and the degree of constitutional disturbance present. Simple inflammation of the cervix of recent date, rarely comes under the care of the physician ; it is only when the inflammation has extended to the deep tissues of the cervix, or has continued so long, that the general health is affected, that he is consulted. 427. In the treatment of this affection, Ave make use of both general and local medication, the first to restore the general health, correct the secretions, and to subdue the inflammation; the local measures are entirely directed to subdue the local inflam- matory process. These measures will he separately considered, though used together. 428. In the first stages of inflammation, should the physiciaD INFLAMMATION OF THE CERVIX. 210 bo called, and recognize the disease as inflammation of the cervix, such general measures should be used as we adopt for inflammation of other parts of the system. Thus, the patient should be kept quiet, in the horizontal position, the sedatives given in the usual doses, Avith such other remedies as may be specially indicated. Those named under the head of congestion of the cervix may be thought of here, though Ave are not restricted to such as specially influence the uterus. The Macrotys and Caulopbyllum are admi- rable remedies in man}7 cases, and associated Avith Aconite will frequently remove the unpha-ant symptoms in the early stage. The torpid condition of the abdominal viscera or intestinal canal may be rectified by the use of the small dose of Podophyllin and Hydrastia; nausea and abdominal pains by Nux; and abdominal tenderness by Dioscorea. Harsh remedies in the form of cathar- tics and other means are to be avoided ; and even local applica- tions over the hypogastrium are frequently harmful rather than of benefit, as also are injectionsin the early stage. The Apis may be referred to as especially a good reined}7 when there is burning and difficulty in passing urine; and the Ehus when there is the frontal headache. Where the disease has continued for some time, affecting the deep tissues of the cervix and its cavity, producing a plentiful leucorrhcal discharge, and affecting the general health of the patient, other measures Avill have to be resorted to. Here, the disease is essentially chronic in its character, and the tissues have become habituated to the morbid action, which has no tendency to terminate naturally in reso^tion ; in this stage of the disease, Ave generally find the dyspeptic symptoms already spoken of. Here, it Avill be necessary to employ such measures as will restore the general health of the patient, as Avell as to counteract the local disease. From the group of remedies that control the inflamma- tory process, select those best adapted to the case in hand, and add such uterine remedies as may be indicated. It may be that avc Avill want some of the saline diuretics, the salts of Iodine or Bromine, remedies that influence the intestinal canal, special remedies for the skin, etc. Especial attention is to De given to the menstrual and reproductive function. Sometimes (he use of Macrotj-s, Pulsatilla and Viburnum, to give normal menstruation, 220 DISEASES OF WOMEN. will be speedil}7 followed by a cure of the inflammation. In other cases, remedies like the Hamamelis, that strengthen the pelvic circulation, Avill be demanded. The constipation of the bow7els is best overcome by a drop of the tincture of iNux in the morning, with abdominal frictions—Quinine inunction being a good thing in many cases. In order to quiet the sympathetic irritation of the stomach that frequently exists, it will be necessary to apply counter-irrita- tion over the IdAver lumbar portion of the spine, and sometimes over the epigastric region; the irritating plaster is the best counter-irritant that can be used. AVhen it is applied over the stomach, there is generally no necessity of continuing it until it produces free suppuration, a slight degree of irritation kept up by it, accomplishing all that is desired. It is very important in treating these cases, that the excretory organs should be stimu- lated to a full performance of their functions; thus the skin should be kept in a healthy condition by the use of baths, either warm or cold, and by brisk frictions, and the kidneys stimulated to a normal performance of their functions by the occasional use of diuretics. In addition to the use of general remedies referred to above, Ave may greatly assist in the removal of the local inflam- matory process, by the use of internal remedies. For this pur- pose, Ave may use with much benefit the Caulophyllum, Helonias, Senecio, Aclaea, and Trillium. These agents exercise a special influence on the uterus, removing congestion, subduing inflamma- tion and increasing the tonicity of the uterine organs. They may be given either separately, or in combination with the reme- dies named above. The Iodide of Iron has likeAvise been used with considerable benefit; the solution is the best form in Avhich it can be administered; the Off. Liquor Ferri Iodidi, dose from gtt. xx. to xxxx. 429. Among the local measures employed, vaginal injections, either of Avater only, or of Avater containing some medicinal substance in solution, are among the most valuable means of treatment in this disease. Special directions, however, v\ill have to be given to the patient, or her nurse, in reference to the proper INFLAMMATION OF THE CERVIX. 221 mode of using them, or they Avill be found of little avail. In order to obtain the full benefit of vaginal injections in diseases of the uterus, it is necessary that they shall be brought in contact Avith the neck of the uterus, and be retained a sufficient length of time ; in order to administer these injections properly, the patient should lie upon her back, with her hips elevated, so that the fluid may gravitate toAvard the cervix uteri; the female syringe used should be introduced to the cervix, and Avhen AvithdraAvn, the vulva should be compressed with a napkin, in order to retain the fluid in contact with the cervix for a sufficient length of time. If these directions are not given, the probability is, that the injections will be used in a standing or sitting position, the natural consequence of Avhich would be that the fluid Avould immediately escape from the vagina as soon as ejected from the syringe; or the syringe might be only partially introduced, the injection not reaching the cervix at all; or if compression is not used over the vulva, the natural contractility of the vagina expels the injection before it has remained sufficiently long to prove effective. 430. The best syringe that can be used to give these injections, is the pump-syringe, fitting it to a vaginal tube about six inches in length. With this syringe any quantity of fluid required can he used for an injection, Avithout withdraA\ing the syringe, as has to be done when the common small female syringes are used. In the place of this instrument, a large metal syringe, fitted with a vaginal tube will be found to answer a very good purpose. If the common female syringe is used, they should be obtained as long and as large as can be well used. 4-'M. Water, either hot or cold, deserves the first place in the description of these injections, not only from its importance in cleansing the cervix and vagina from morbid secretions, but also for its therapeutic effect. Injections of water, either hot or cold, should be used in this disease as often as twice a day, whatever other local means may be resorted to, in order to remove the morbid secretions of the diseased parts, and keep the vagina in a clean and healthy condition. It will be recollected that in married women, the upper part of the vagina, or that inclosing the cervix, is somewhat dilated, and that, when healthy, it closes 999 DISEASES OF AV 0 M E N . on itself in its entire extent. As a necessary result of this structural condition, the muco-purulent matter secreted by the inflamed cervix, Avhen it is not large in quantity, is retained .around the cervix, where it tends to keep up and perpetuate the j flammation, and gives rise to ulceration. It Avill thus be seen, that much depends upon the use of water as a wash to cleanse the parts. In using Avater for this purpose, a sufficient quantity should be injected to accomplish this object. Warm Avater used as an injection, acts as an emollient, softening and relaxing the tissues, and subduing irritation ; in some cases, it Avill be found to exert a better influence than the cold ; this will be especially the case Avhere the inflammation is acute, Avhere it has extended to the vagina, or Avhere the patient is very nervous or irritable. Cold water is a poAverful tonic and astringent, and may be used very beneficially toward the subsidence of the inflammation, and it should ahvays be continued for some time after the disease has been subdued, to prevent a relapse. When there is much irritation of the cervix and upper part of the vagina, it will be necessary to use emollient or narcotic injections; a decoction of marsh- mallow, or of slippery-elm bark will be found very useful, from their soothing effect upon the inflamed mucous surface. I have also used a decoction of the leaves of the stramonium, as an injection in these cases, with marked benefit. In other cases, Avhere there is no irritability present, or Avhere it has been removed, other injections may be used to remove the inflammation. For this purpose, the injection recommended by Prof. T. V. Morrow may be used Avith much advantage. R Pulvis, Macrotys Ilacemosa, Geranium Maculatum, iia. gij. Aqua Bullions, Oct. iv. Let it boil for half an hour, strain, and use from four to six ounces, as an injection, twice a day. This injection is astringent, and it likewise exerts a peculiar influence on the vaginal walls and cervix uteri, removing congestion and inflammation, and giving tone to the mucous membrane lining the vagina and INFLAMMATION OF THE CERVIX UTERI. 223 vaginal portion of the cervix. Another injection, that will be found very beneficial in these cases, is composed of R Hydrastis Canadensis, gss. Rhus Glabrum, 3ij. Aqua Bulliens, Oct. ij. Let it boil for fifteen or twenty minutes, strain, and use as an injection. A solution of Salicylic Acid and Borax, of Chlorate of Potash, Sulphate of Zinc, or sometimes of Hydrate of Chloral, may be used as a vaginal injection with benefit. 482. If there is a copious secretion of mucus, or muco-purulent matter, the canal of the cervix should be carefully examined in regard to its degree of dilatation, and the distance this extends up it, and if it is much affected by the disease, the tenacious mucus should be removed in the manner heretofore stated, in order to alloAV the injections to come in contact with all parts of the cavity. 433. By the judicious use of the remedies above-named, a majority of these cases may be radically cured ; some few cases, however, after improving for a Aveek or ten days, will then stop, no further benefit appearing to be derived from their use. In the most of these cases, the canal of the cervix will be found to be the part mostly involved, and the treatment will have to be directed to it. The quickest way to remove the diseased con- dition of the cervical cavity is, to apply to it, as far as dilated, by means of a camel-hair pencil, a strong solution of the Sesqui- Carbonate of Potassa, or Nitrate of Silver. Results of Inflammation of the Cervix Uteri. 434. Inflammation of the cervix uteri gives rise (directly) to hypertrophy, erosions, granular elevations of different kinds, and to ulceration. It may, likeAvise, be a cause of, or greatly aggra- vate, dysmenorrhea, amenorrhea, menorrhagia, and leucorrhea. Its relation to these diseases -will, hoAvever, be hereafter con- sidered under their separate heads. Does inflammation ever give rise to cancer, corroding ulcer of the os uteri, or to cauliflower ,224 DISEASES OF WOMEN. excrescence ? It has been thought, by many Avriters, that inflam- mation of the uterus is a frequent cause of cancer. This opinion, however, does not appear to be founded on the results of careful observations. As inflammation of the cervix uteri gives rise to the formation of a true and normal pus, and very frequently to ulceration, with its secretion of normal pus, I should consider that Avhen it presented this character it Avas directly opposed to cancer formation. Ma7 reasons for this opinion are, that cancer is never accompanied by .an exudation of normal pus, neither have I been able to learn that it ever has arisen as a consequence of any morbid action producing this exudation. The formation of normal pus, in every case, appears to be diametrically opposed to the existence of any malignant groAvth. This is Avell shown in the treatment of cancer, after the diseased mass is removed, either by the knife or caustic, free suppuration is indispensable to prevent its reproduction, and Avhere this normal pus secretion is main- tained, it rarelv, if ever, recurs. If, hoAvever, a Ioav degree of inflammation exists, Avithout exudation, or, if the exudation is thin, variously discolored, presenting none of the characteristics of the normal bland pus, Ave then have the very condition of the parts necessary to the formation of malignant growths. In one case that I had the opportunity to observe, the rise and progress of carcinoma of the cervix, this low degree of inflammation Avas present before the development of the cancerous growth, and I have no doubt that it was the proximate cause. These observa- tions will also apply equally well to those cancroid growths, cauliflower excrescence, and. corroding ulcer. 4oo. Dr. Bennet formerly entertained the op'nion that inflam- mation Avas a frequent cause of cancer of the uterus ; his views, hoAvever, have since been changed. In the last edition of his work, he says : " Clinical experience has led me to modify the opinion I formerly entertained, in common Avith the rest of the profession, respecting the frequency of cancerous degenerescence of chronic inflammatory tumors. During the last ten or twelve years, I have followed the progress of many cases of uterine inflammation, and have not seen a single instance of inflammatory disease thus degenerate. In some instances, I have been told in HYPERTROPHY OF THE CERVIX UTERI. 225 consultation, that the disease respecting which my opinion was required, although then evidently cancerous, had at first been merely inflammatory. In these cases, hoAvever, the diagnosis of my informants could not be relied upon, and the antecedents of the patient were also completely at variance with their view of the evolution of the morbid phenomena. On the other hand, all the cases of cancerous disease that I have witnessed during the before-mentioned period, have been evidently such from the time> they first came under my observation." Hypertrophy of the Cer\tix Uteri. 436. Hypertrophy of the uterine tissue is, in a great majority of cases, confined to the cervix, though sometimes it extends to the body of the uterus. Inflammation may be considered the cause of hypertrophy in nearly every instance, the inflammatory products not being reabsorbed, but becoming organized, or the inflammation being of a lower kind, the circulation of the blood increased, the textural nutrition of the organ becomes morbidly exaggerated. Hypertrophy of the cervix uteri may, or may not be accompanied with induration ; one of the first effects of inflam- mation is to produce congestion and enlargement of the cervix ; the enlargement may continue for years, the cervix being soft and elastic. This, however, is not very common, induration generally accompanying hypertrophy. 4o7. Hypertrophy of the cervix may arise either before or after ulceration. Dr. Bennet thinks it to be more frequently the sequela, than the cause of ulceration: he says, "I have very often been able to folloAv the extension of the inflammation accompany- ing ulcerative disease to the deeper-seated tissues, and to Match the gradual manifestation, under its influence, of deep-seated induration. Thus, I have frequently seen cases in Avhich a slight ulceration Avas at first the only lesion, and in Avhich the general induration, Avhich subsequently made its appearance, gradually became more and more marked as the ulceration increased in extent. I am also continually meeting Avith ulceration confined to one lip, accompanied by induration, and hypertrophy of that lip only. Although I thus consider induration and hypertrophy of 15 226 DISEASES OF WOMEN. the cervix generally to be the result of extension of superficial inflammation to the central t'ssues, to be the sequela and not the cause of ulceration, the reverse may take place. Induration and enlargement of the cervix may remain as a result of general metritis, and by the irritation Avhich it produces give rise to inflammation and ulceration of the mucous surface. Whatever may have occasioned the inflammatory induration, if it persists, it certainly becomes an important cause of local disease, continually reproducing the ulceration, unless means be taken to remove it as Avell as the more superficial disease. This it does in iavo Avays; by keeping up a chronic state of inflammation of the organ, in which the mucous surface participates, and by the friction of the hypertrophied and generally prolapsed cervix against the parieties of the vagina occasions." 438. Symptoms.—The symptoms accompanying hypertrophy of the cervix are the same as those of inflammation. There is. however, a greater sense of weight and dragging in the pelvic cavity, and a sensation of pruritus or raAvness. On making an examination, the cervix -will be found more or less displaced, and increased in size; this increase in the size of the organ may be confined to one lip, or involve the entire cervix. If there have been previous lacerations in labor, the indurated cervix may be divided into lobes, as is seen in the plate. If it is likeAvise indu- rated, it will be dense to the touch, though not presenting the rough feeling that distinguishes malignant disease; if it is not indurated, it Avill be found soft and elastic. In all cases the external orifice Avill be found enlarged, but instead of the circular or nearly circular orifice, it -will be transverse, presenting well- defined lips. The cervix Avill also be more red, smooth, and moist, than natural. 439. Treatment.—The first point in the treatment of hyper- trophy of the cervix, is to subdue the existing local inflammation. For this purpose the means heretofore recommended should be employed. If the patient be debilitated, the same tonic course should be pursued to build up the health of the patient, keeping the secretions and excretions in their normal healthy condition. These means may have to be employed for a month or two before HYPERTROPHY OF THE CERVIX UTERI. 227 the Ioav degree of inflammation accompanying hypertrophy is entirely subdued. If after this the hypertrophy still continues. more energetic means will be required. The use of Macrotys with Pulsatilla in small doses, Avill sometimes give speedy relief, though to effect a cure it must be continued for a number of months—at least to the extent of regulating the menstrual flow. When oedema is a marked symptom, especially Avhen associated with monorrhagia, the Apocynum will be indicated. Associated with disease of the mammary glands, or lymphatic enlargement, I would advise Phytolacca; and Avith disease of the thyroid gland, the Iris. The Hamamelis is ao excellent remedy in those cases marked by venous fullness, and a lax condition of the tissues clos- ing the outlet of the pelvis. It maybe given in doses of from ten to thirty drops four times a day, and may also be used as a local application to the hypogastrium, and as an injection. Some of the remedies knoAvn as uterine tonics are also available here, as the Senecio, Helonias, etc. But whatever is used should be se- lected with care, and it may be an}' remedy of the materia med- ica, if there is a specific indication for it. I have had quite as much benefit from Bryonia. Rhus, Nitric Acid, Baptisia, and rem- edies of this class, as those that have direct action on the uterus. 440. Among the local applications that have been used to overcome hypertrophy of the uterus, I might mention the Sesqui- Carbonate of Potassa, Nitrate of Silver, Potassa Cum. Calc, and the Potassa Fusa. In many cases of hypertrophy, with but a slight degree of induration, the application of the Sesqui- Carbonate of Potassa to the enlarged cervix, in addition to the last injection recommended in the treatment of inflammation of the cervix, will be found to quickly remove the enlargement. In using this agent, a saturated solution should be made, and applied to the entire cervix, by means of a camel's-hair pencil; it should also be applied to the cervical cavity as far as it is open. The application of this caustic produces but little pain, and is followed by an increased secretion from the parts, which, how- ever, ceases in from one to two days, Avhen it should be reapplied. The application of this caustic should be followed in about fifteen minutes with injections of cold water, made slightly acidulous with vinegar. The Nitrate of Silver is also recommended in 22S DISEASES OF WOMEN. these cases, applying the stick nitrate by means of a caustic- holder, to the surface of the cervix; it produces a white film, or superficial eschar, Avhich falls off in the course of two or three days. Its application is rarely followed by much pain, and it nay be reapplied when the eschar falls off; of the two agents, I would prefer the Potassa. 441. The potassa cum. calce. and the potassa fusa are em- ployed in these cases, Avhere the enlargement of the cervix is accompanied with induration, and in which other measures have been found unavailing. The potassa cum. calce. is preferred by man}7 practitioners to the potassa fusa, from the great deliquescence of the latter agent, and its liability to run down the sides of the speculum and form an eschar in the bottom of the vagina. Dr. Bennet uses the potassa cum. calce. cast into sticks like the nitrate of silver; it is composed of two parts of hydrated potassa and one of lime; this he has found as efficient as the potassa fusa. Dr. Simpson uses the latter agent; he says, "Having found inflam- matory enlargement and induration of the tissues of the cervix very frequent in practice, and existing, in fact, in most cases of very chronic and aggravated leucorrhea, and in some cases having mistaken it for the induration and ulceration of carcinoma, etc., he has employed in these cases the nitrate of silver, potassa cum. calce, and nitric acid. Latterly he had abandoned these and other escharotics, and now ahvays uses the common potassa fusa. He has found it far more manageable, speedy, and certain, than any other method. He uses it, of course, through the speculum, applying a stick of it freely, with a proper caustic-holder, to the ulcerated and indurated tissues. It required to be rubbed or held strongly for a time against the part which Avas to be destroyed. In general, a piece three-quarters of an inch or an inch long Avas melted doAvn. If the induration is extensive, and the Avhole can not be removed at once, increased action and absorption are set up in what remains, and the parts adjacent become softened and diminished in size. He has never seen pelvic cellulitis or any other bad result folloAv." I have introduced this quotation from Dr. Simpson's work, not only for the purpose of showing the applicability of this method HYPERTROPHY OF THE CERVIX UTERI. 229 of treatment, and the extent to which it may be used without producing any bad effects, but also to caution the reader against tt e destruction of tissue, Avhich appears to be the chief motive Dr. Simpson has in view. The object in using these agents is not to destroy the enlargement, or, in other Avords, melt the enlarged cervix doAvn to a natural size ; but to modify the action of the part, and cause an increased absorption. After the cervix has been cauterized, nature sets up eliminatory inflammation, in order to throAv off the eschar. This inflammation extends more or less to the hypertrophied tissues, according to the size of the eschar, causing an increased absorption as Avell as an increased elimination from the hypertrophied part, by the copious purulent discharge which usually follows for tAvo or three days, and which continues in smaller quantities until cicatrization of the ulcer left by the eschar takes place. Under the influence of this very simple process, the effects of which persist during two or three weeks from the date of cauterization, any amount of hypertrophy of the uterine neck may be gradually and safely removed, and that without much suffering to the patient. 442. Of late years I have emploATed local means much less fre- quently than in the olden time, having found that internal remedies carefully selected, would accomplish the object quicker. And now when I use them, I frequently make a different selection. If there is ulceration or erosion of the canal or the cervix, I like the free application of nitric acid with a pine pencil. AVhen the surface is spongy, and secretes a muco-pus, which has an unpleasant odor, the permanganate of potash may sometimes be used Avith advan- tage, the strength varying from grs.x. to^j., to water, 3J., accord- ing to the condition of the ease. Carbolic acid and glycerine ma}7 also be thought of as a possible local reiriedy. In some casts a prescription of—R Solution of persulphate of iron, tinct. opium, aa., applied with a camei's hair pencil, Avill aid in lessening the size of the cervix. The extract of Pin us canadensis, and other of the vegetable astringents, may also be used for the same purpose. When the body of the uterus is also enlarged, the tissues being full, doughy, and evidently atonic—very much like the enlarged spleen, called " ague cake"—I have used the ointment of Uvedalia 230 DISEASES OF WOMEN. with excellent results. It should be thoroughly rubbed in over the hypogastrium, and then toasted in by a Avarm iron passed over the surface, which is C0A7ered Avith flannel. Advantage may also be found by rubbing the perineal tissues with it. Quinine in- unction must not be forgotten as a possible means in some unpleas- ant cases, where the patient has suffered from chronic ague. Even the rubbings and kneadings of the " SAvedish movement cure" Avill be found of advantage. And the use of electricity, if skill- fully applied, may be made to take the place of other treatment. 443. It is Avell to call attention to the necessity of proper dress and means of support for the pelvic organs. It will not do for a woman suffering from uterine hypertrophy to Avear her clothing suspended from the waist. All pressure upon the abdomen must be removed, and the skirts and clothing supported from the shoul- ders. Corsets are made Avhich, come down over the abdomen and hips, that serve the purpose, but in the majority of cases it is better to suspend every thing from the shoulders. Using the long abdominal corset, straps may be carried between the thighs, and a perineal pad for support Avorn. Or a nicely fitted pelvic band- age with the same straps for perineal support, will frequently be of much service. This apparatus is figured on page 349. Erosion of the Cervix. 444. By erosion of the cervix uteri, Ave understand an abrasion of the mucous membrane covering it, of greater or less extent. It forms the first stage of ulceration, and though it may extend that far, yet, it very frequently remains for some months a simple abrasion of the mucous membrane. Erosion of the cervix is invariably accompanied by inflammation, being a result of that disease. Dr. Bennet considers all breaches of continuity in the mucous membrane to be ulceration. He remarks : " That when an abrasion or excoriation only is present, the cervix is generally of a vivid red, and the granulations are often so minute, that it is difficult at first, to ascertain whether the membrane is abraded or merely congested, or perceive the limits of the ulceration, when once it has been ascertained to exist. The doubt, however, may be solved, by lightly touching the suspected surface with Nitrate of Silver. The abrasion immediately assumes a much whiter hue, EROSION OF THE CERVIX. 231 than the region Avhich is merely congested, and its margin becomes well defined and evident. An abraded, excoriated condition of the mucous surface is generally the form under Avhich ulceration presents itself in the cavity of the cervix ; granulations of any size being seldom met Avith in this region. In virgins also, ulcera- tion often presents this character, especially Avhen it is limited to the cavity of the os." These erosions have been minutely investigated by Dr. Tyle* Smith, Avith the microscope; he says: "The epithelium of the external portion of the os and cervix uteri, and of the upper por- tion of the vagina, may be partly or entirely removed; or there may be morbid patches in Avhich the epithelium is here and there wanting. When in analogous states, the epithelium has been removed in the living subjects by diseased conditions, the mucous membrane is of an intensely red color, from the presence of the naked villi, with their vascular loops, and it conveys an impression of roughness and denudation upon examination by the speculum. To the touch, the abraded surface feels erectile and velvety; a term Avhich has been very commonly applied to Avhat has been considered ulceration of the cervix and os uteri. The villi do, indeed, in this condition, stand out somewhat like the pile of velvet, and in some cases they themselves are considerably en- larged. In other cases, there is not merely the loss of the dense epithelium, but the villi, both of the external surface of the os uteri, and of the mucous surface Avithin the labia uteri are destroyed in patches. In that condition of the os uteri, Avhich, on examina- tion after death, would be pronounced to be undoubted superficial ulceration, the state Avhich generally obtains, is partial or entire loss of the epithelial layer in circumscribed patches, and here and there the loss or partial destruction of the villi. This gives an eaten, corroded appearance to the mucous surface ; such a con- dition of the os may be limited in extent, or it may spread over the whole of the os and the external cervix, and pass within the labia uteri. Sometimes small circumscribed ulcers are seen, in Avhich the denuded or partially denuded villi are found surround- ing the edge of the small ulcer; the area of the ulcer itself beirg 232 DISEASES OF WOMEN. bare of villi, or the ragged debris of villi, and their vascular loops appearing at the bottom of the ulcer." 445. With this erosion there is ahvays more or less induration, the tissues about it being slightly thickened, especially at the edges ; still, the edges are not raised or everted, either in simple erosion, or ulceration folloAving inflammation. The discharge from these erosions may be thin and sanious, but it is much more frequently purulent. 446. Symptoms.—When Ave consider that erosion of the cervix is but a result of inflammation appearing during its progress, we would not expect to find any other symptoms present than those of inflammation, this being the disease, the erosion the result. 447. Treatment.—If, after using the treatment recommended for inflammation, the erosion does not heal, or if, at any time, it should appear to be progressing toAvard ulceration, it should be freely cauterized Avith the nitrate of silver. This cauterization should be used in conjunction with the injections heretofore recommended. There are but few cases Avhich will not yield to the use of the last injection named in the treatment of inflam- mation. Elevations the Result of Inflammation. 448. Elevations of different kinds may arise on the surface of the cervix uteri, as a result of inflammation. They may arise either from the surface of an erosion, from an ulcer, or from the mucous membrane covering the cervix. So many varieties of these elevations have been noticed, that a full description is impossible, and if given, Avould be of but little benefit to the reader Avithout it was accompanied by plates. These granula- tions, however, must not be considered the disease, the inflamma- tion accompanying them being the principal affection, and the one that demands the attention of the physician. 449. Fig. 18. In this case there was sub-acute inflammation of the cervix, with its symptoms. On examination, the uterus was found low down in the pelvis, the cervix uteri was soft, and larger than usual, and presented, to the finger, some unevennesses, which ELEVATIONS. 233 were round and soft, but not tender on pressure. On brincrinc L © C3 the cervix into view with the specu- lum, these small softish bodies would be seen more distinctly; they were of a deep red color, of the volume of small peas, and without pedicles. It Avas supposed that they Avere varices. 450. Fig. 19. In this case there Avas also inflammation of the cervix; the catamenia were abundant and irregu- lar, accompanied with leucorrhea and considerable tumefaction of the uterus. The surface of the cervix uteri was livid, and beset with milliary vesicles; the os uteri bled on pressure, and in the act of defecation. 451. Fig. 20. Case of inflamma- tion of the cervix uteri, present- ing the more severe symptoms of the affection. The catamenia were frequent and very abundant, the pains very acute. On exami- nation, the cervix uteri was found resting on the perineum ; the cervix, of a brownish-red color, Avas not much larger than Avhen in its natural state; it was, however, soft, and pre- sented on its anterior labium, tAvo small,' white, and solid tumors, of the size of a small pea; this part of the uterus wTas the seat of severe pain. 452. Fig. 21. Inflammation of the cervix uteri, with hypertrophy. It will be observed that the os is large and transverse, dividing the cervix into two lips Fig. 19. Fig. 20. 234 DISEASES OF WOM !■: N . superabundant growth. This may sometimes be done by the use of astringents, as the application of Pulverized Alum to the cervix, or by the use of the Sesqui-Carbonate of Potassa, or Nitrate of Silver. If these should fail, we would haA7e to resort to the use of the Potassa Cum. Calce., observing the same pre- cautions that have been heretofore mentioned. Ulceration of the Cervix Uteri. 454. We have already seen that inflammation of the cervix uteri may exist even for yea,rs, Avithout producing ulceration; this, however, is the exception, and not the rule, inflammation of the cervix, in a majority of cases, producing ulceration or erosion. Indeed, the mucous membrane covering the cervix, and lining its cavity, especially that portion near the os, appears to be peculiarly liable to ulceration as the result of inflammation. 455. Ulceration of the cervix generally commences near the os, and from this point it may extend to the cavity of the cervix-, involving more or less of it, in some rare cases extending up it as far as the os internum, or it may extend outward, involving a greater or less portion of the mucous membrane covering the cervix. 456. This ulceration varies in character, from the slight erosion already described, and Avhich can Avith difficulty be distinguished, to the deep, perfectly-formed ulcer. The depth of these ulcers varies from one to six lines, though they never present Avell- ULCERATION OF THE CERVIX UTERI. 235 defined edges to the touch, like ulcers in other situations. The edges of the ulcer are never indurated, raised or everted, and by this single feature they may be distinguished from syphilitic or scrofulous ulceration. In general but one ulcer is found upon the cervix, and this near the os ; it may, and frequently, does extend to the cavity of the cervix, and outAvardly involving more or less of the surface of the cervix; sometimes, however, several small ulcerations may be observed around the os, in addition to the large one ; those are supposed to be formed by ulcerated mucous follicles. The bottom of the ulcer, in most instances, is filled with healthy granulations, and covered more or less Avith purulent matter. These granulations, according to Dr. Bennet, may be firm, of a vivid hue, scarcely bleeding upon pressure; or they may be large, fungous, livid, and bleeding profusely at the slightest touch. These fungous ulcerations are generally con- nected with torpor of the local circulation. When they are present, the congestion of the cervix and vagina is very great, of a livid or venous character, and the non-ulcerated cervix may present dilated varicose veins. It is the presence of these varicose veins that has led French Avriters to give to ulcerations, in which they occur, the name of varicose ulcerations. In pregnant Avomen, after the first feAV months, ulceration of the cervix generally assumes this fungous form. Sometimes the granulations of a purely inflammatory but luxuriant sore, will rise above the level of the surrounding parts, and even form small fleshy masses, which may be partly brought aAvay by the finger, or Avhich separate spontaneously. Ulcerations of this description bleed profusely Avhenever they are interfered Avith; sometimes to such an extent, that on bringing them into vieAv with the speculum, the blood partly fills the instrument as often as it is Aviped away. 457. The cavity of the cervix is ahvays more or less affected by ulceration of the cervix ; the ulceration, as we have already seen in a great majority of cases, commences near the os ; the lips of the os SAvelling, enlarging, and expanding, open the external orifice. The orifice is sometimes so enlarged that the first joint of one or tAvo fingers may be introduced into the cavity; in slighter cases, the finger merely passes betAveen its 236 DISEASES OF WOMEN. patulous lips. Very frequently the ulceration extends to the cavity of the cervix, sometimes involving its entire dilated portion. It, hoAvever, rarely if ever extends to the cavity of the uterus, the natural constriction at the os internum appearing to prove an effectual barrier to its further progress. Again, in some instances, the cavity of the cervix may be dilated, and ulceration be present in it; but the external orifice Avill be nearly closed. In these cases, if the os be not opened, and the canal of the cervix examined, the disease may remain undiscovered for months, the treatment used to relieve the difficulty proving inef- fectual. To dilate the os and examine the cavity of the cervix, take the Ricord speculum, remove its loose blades, and introduce it so that its handles will project laterally toAvard the thigh of the patient; then, when its blades are opened, it will separate the lips of the os. 458. Ulceration of the cervix uteri, in nearly every instance, aggravates the symptoms of inflammation. Thus, the lumbo- sacral, ovarian,' and hypogastric pains Avill be increased in intensity, the constitution Avill suffer more, and, therefore, the constitutional symptoms will be increased. Sometimes, though rarely, the patient will have no discharge from the vagina, but, in the majority of instances, there will be a continuous Avhite dis- charge. Mucus will form a greater or less proportion of this discharge, the irritation of the mucous follicles of the cervix and upper portion of the vagina, causing a greatly increased secretion, and the same irritation, extending to the canal of the cervix, produces an increased secretion of the peculiar, thick, ropy, transparent Avhite of egg mucus, from that canal. This mucus is mixed with a larger or smaller quantity of purulent matter, thrown off by the ulcer. When the discharge is purely purulent, it is generally thick, yelloAv, and seldom very abundant. As Ave haA7e already seen, Avhen the granulations assume a fungous form, the. vaginal secretions may be more or less mixed with blood ; this occurs especially after any exertion or severe exer- cise, or after coition, though it may take place at intervals, without any appreciable cause. 459. Treatment.—The general treatment in ulceration of the ULCERATION OF THE CERVIX UTERI. 237 cerv 1 c should be the same as that recommended in inflammation. In fact, the general and local treatment there laid down will be sufficient to overcome the mild cases of ulceration. If, however, the ulcci.Hion does not heal under the use of the local applica- cations rec.mmended, and the ulcer presents a healthy appearance, avc might u -.e, in many cases, the following injection, with much benefit: R Hydrastis Canadensis, Sss. Statice Limonum, Sj Chlorate of Potassa, 38S. Aqua Bulliens, Oct. j. Let it bod for fifteen or twenty minutes, strain Avhen cold, and use a common-sized female syringe full twice a day. This should be folloAved, in about fifteen minutes, by free injections of cold water. If it produces too much irritation, it will be better to use it but once a day, and make the Avater used after it slightly acidulous Avith vinegar. In other cases, it will be better to apply the Sesqui-Carbonate of Potassa to the ulcer. The way that I use the Potassa is to make a saturated solution of it, and dip a lock of raw cotton in it, of sufficient size to cover the entire extent of the ulcer, sprink- ling on the cotton as much of the dry Potassa as -will adhere. This is then introduced through the speculum, and applied to the ulcerated cervix ; it may be surrounded Avith the raw cotton, to prevent its affecting the vaginal Avails; a string may also be fastened to it, so that it may be withdraAvn by the patient. In from half an hour to an hour this may be Avithdrawn, and the injections of Avater and vinegar used after it. It should be repeated at intervals of two, three, or four days, as the case seems to require, until cicatrization is complete. In all the cases that have come under my notice, I have used this agent Avith entire success. It promotes healthy granulations from the surface of the ulcer, and if the granulations be too large or irritable, it breaks them down and subdues the irritability. Probably all Avho have used this agent have noticed its peculiar effects on the living tissues ; Avhile not so strong as to endanger healthy parts, even to 238 DISEASES OF WOMEN. break doAvn healthy granulations in a Avound or ulcer, yet, it is almost invariably effectual in removing fungous or callous growths, and stimulating healthy suppuration or granulation. It not only produces a healthy condition of the ulcer, but it likewise rapidly r 'duces the induration and hypertrophy accompanying it. I recommend this agent thus strongly, because I knoAv from experi- ence, that its action will be found much more beneficial than Hhe nitrate of silver, so commonly resorted to in this disease. 460. If the ulceration extends to the cavity of the cervix, the caustic should be applied to it in the same manner already spoken of. Take a lock of cotton of sufficient size, roll it into a conical form, saturate it with the solution, and introduce into the cavity of the cervix. The application of the potassa to the cavity of the cervix, will, in some instances, produce severe pain, but this always ceases in from ten to thirty minutes. 461. The nitrate of silver is the agent most commonly employed in these cases; it is applied through a speculum, by means of a proper caustic-holder, or in solution, Avith a cameis-hair pencil. It is freely applied to the surface of the ulcer, and to its edges; if thus applied, it forms a Avhite film or eschar, about the thickness of apiece of draAving-paper ; this is thrown off about the third day. The surface of the ulcer after the eschar is throAvn off, is generally found red, irritable and bleeding; in another day or tAvo, this redness and tendency to bleed has disappeared, and by the seventh or eighth day, all the benefit to be derived from the cauterization is apparent. After this time, if the caustic be not reapplied, the ulcer soon assumes the appearance it had before; its irritability returns, as Avell as the sympathetic reaction on the general system. This caustic should be reapplied as often as every five, six or seven days, until the ulcer has healed. 462. In those cases that resist the action of the agents above- named,, it will be necessary to resort to the application of the stronger caustics, the potassa cum. calce., and the potassa fusa. Whether these agents would be required, if the sesqui-carbonate of potassa was used in the manner already described, I am unable to say, never having seen a case that resisted its use. The stronger caustics are used to modify the vitality of the parts, ULCERATION OF THE CERVIX UTERI. 239 excite a healthy inflammation and suppuration, and thus promote the formation of healthy granulations and cicatrization. The mode of using these agents, has been already described in the treatment of hypertrophy. The same care should be employed Avhen using them for ulceration. If these caustics are used merely to modify the vitality of the part, they should not be kept in con- tact Avith the part but a feAv seconds; if, however, the intention is to produce a slough, they must be kept in contact longer. Accord- ing to Dr. Bennet, the eschar produced by pota-ssa fusa, does not fall off at any given time, but melts away, as it Avere, revealing a healthy, granulating surface, from Avhich it has gradually been thrown off. This gradual disintegration of the eschar is accom- plished in from five to ten days, according to the depth to which the tissues have been destroyed. At about the third day, if the cauterization has been deep, the surrounding parts Avill be found the seat of considerable inflammatory reaction, and the cervix and the upper portion of the vagina will generally be found consider- ably congested and inflamed. The elimination of the eschar mav be attended with hemorrhage, though this may be readily arrested with cold astringent vaginal injections. In the course of from seven to fourteen days, the cervix and adjacent parts return to the state in which they were before the application of the caustic. The ulcer will generally be found larger, the granulations are more florid and more developed, and appear endoAved with more vitality. For ten or fourteen days that folloAv, there is little or no change in the ulcerated surface, which continues to secrete healthy pus; but about the twenty-fifth day, from the date of the cauterization, a decided progression toward cicatrization com- mences. This tendency to heal in the ulceration, continues to be very marked, from about the tAventy-fifth to the fortieth day, when it ceases. Very frequently, the ulceration heals before the for- tieth day ; but if it does not, the influence of the strong potassa cauterization being exhausted, it must either be repeated, or the treatment be carried on with the milder caustics, if it is thought that they alone will suffice. Severe cauterization should never be resorted to, Avithin less than twelve days of the menstrual epoch, which it often slightly accelerates. 240 DISEASES OF WOMEN. 463. In using either the nitrate of silver, the potassa cum. calce., or the potassa fusa, for ulceration of the cavity of the cervix, it would ahvays be better to apply them in solution, with a camel's-hair pencil, in consequence of the danger of breaking the stick and leaving a portion of it in the cervix. The application of the stronger caustics to the cavity of the cervix should also be very light; the object not being to produce a slough, or to excite severe inflammation, but merely to modify the action of the ulcerated surface. Corroding Ulcer of the Uterus. 464. This disease, fortunately, is of very rare occurrence; it rarely attacks females under forty years of age, although it has been met with in persons younger than this. Dr. AsliAvell defines it to be "an ulcer of granular shape, commencing in the glandular structure of the cervix, rarely of large size, but destroying life by a corroding or eating aAvay of the uterus, even to its fundus, and occasionally implicating the bladder, vagina, and rectum. There is less pain than in cancer of the womb, from which it also differs in there being no indurated deposit, no immobility, and no fungoid growths in the seat of the ulceration. It is malignant, and excep in the commencement, entire'y incurable." Fig. 22.—Corroding Ulcer of the Uterus. 465. Prof. Rokitansky thinks that it may be compared to the phagedenic (cancerous) sore of the skin; Avithout having a morbid CORRODING ULCER OF THE UTERUS. 241 growth for its base, it gradually destroys the cervix, and even the greater part of the uterus, and may extend to the rectum and the bladder. It is an irregular, sinuous, jagged ulcer, the tissues at the margin and the base of Avhich are thickened or hypertrophied, in consequence of a sluggish inflammatory process. The base presents a greenish and brownish-green discoloration, with a slight glutinous and purulent, or a more copious and Avatery secretion. There are no granulations, but Ave find an exudation, and accord- ing to the immediate reaction, the tissues are converted into the above-mentioned products of the ulcerating surface." 466. Symptoms.—This disease may be preceded by pains in the pelvis, a leucorrheal discharge, and other symptoms of uterine disease ; in other cases reported, none of these symptoms Avere manifested until the ulceration Avas fully developed. In some cases, attention is directed to the disease by a profuse hemorrhage recurring at irregular intervals, and Avhich is often mistaken for a recurrence of the catamenia. When the ulceration is fully developed, a profuse discharge takes place from the vagina of a thin, Avatery, and ichorous fluid, which is generally of an offensive odor. The color of this discharge varies from a light straAv color, to a dark broAvn ; sometimes, though not often, it becomes purulent. 467. Dr. Churchill says, "soon after this disease has developed, we find the patient complaining of weakness, weight, and pain in the back; the latter sometimes extending to the loins, or round the lower part of the abdomen. The character of pain is by no means uniform ; sometimes it is described as lacerating, resembling a knife running into the back ; at others, burning like a hot iron. In a feAV of the cases that I have seen, no pain Avhatever was experienced from the commencement. The great weakness of the back, hoAvever, Avas present in all. Of course, so grave an attack can not occur Avithout severely affecting the constitution. The patient becomes emaciated ; the appetite diminishes; occasional sickness of the stomach; the bowels are irregular; the pulse is quick and small, the skin becomes dry and sallow, and a low fever sets in. From this time the disease advances with variable rapidity; in some cases it makes rapid progress; in others it 'l6 242 DISEASES OF WOMEN. may continue for years without extinguishing life. As the disease continues, the discharge is augmented, the fever increases, and the patient loses all her flesh ; the features are sharpened and the eyes sunken; the skin dry, or peihaps moist and flabby; the appetite ceases; dyspepsia is constantly present; the bowels are consti- pated, and their evacuation causes severe pain. The distress of the patient is often increased by excoriation of the vulva, caused by the acrid discharge. Ultimately, the patient sinks from exhaustion, or is carried off by peritonitis, from the "extension of ulceration to that cavity, or by hemorrhage. The latter termina- tion is, hoAvever, very rare." 468. Diagnosis.—There is no disease Avith which this can be confounded, if Ave except cancer in its ulcerative stage. These two diseases may be distinguished by the fact, that in corroding ulcer there is no increase in the size of the cervix, but the reverse. the cervix becoming smaller as the disease advances, from loss of tissue ; this ulceration does not arise from an indurated base like cancer, and there is never any fungous groAvth in its cavity ; in this disease, likeAvise, we do not find any adhesions or deposits between the uterus and adjacent parts, but it retains its natural mobility. 469. Treatment.—In this disease, Ave have a malady entirely local, and not like cancer of the uterus, affecting adjacent parts by the deposition of cancerous material, nor affecting the adjacent lymphatic glands, nor the system. It is true, the system is affected sympathetically, and by loss of fluids, yet there is no specific infection, like there iTin carcinoma. From these facts, the disease should be considered more amenable to treatment than cancer. Still, after it has extended beyond the cervix, the treat- ment will have to be merely palliative. Severe cauterization is the only treatment that has ever been found to give permanent relief. Dr. Churchill states that he has used the nitric acid, chloride of zinc, caustic iodine, etc., in several cases, and though it was impossible to get the ulcer to heal, yet its progress could be arrested, the hemorrhage stopped, the pain relieved, and the discharge moderated. In one case, he supposed that life was prolonged a long time in consequence of their application. CAULIFLOWER EXCRESCENCE. 243 470. As Ave knoAv that the potassa fusa exerts a much more favorable influence in modifying the vitality of the parts, and that under its effects cicatrization progresses much more favorably than under the use of other caustics, I think that this agent should be preferred to any other. If the disease is still confined t© the cervix, the ulcer should be freely cauterized Avith the stick potassa, using the same precautions heretofore spoken of when describing this agent. After the separation of the slough, the ulcer should be closely watched, and the stimulation kept up by the occasional application of the sesqui-carbonate of potassa. Injections of cold water Avould also be useful, to remove the discharges and prevent irritation of the vagina and vulva. The strong potassa cauterization should be repeated as soon as the effect of the first cauterization has passed off. 471. With this local treatment, such general measures should be employed, as Avould keep up the strength of the patient, and keep the secretions and excretions in their normal condition. If there be much pain Avith the disease, narcotics will have to be used to give the patient present relief. It would be better to commence with those Avhich do not constipate the boAvels, as the hyosciamus, Chloral, Cannabis Indica, etc. These, hoAvever, in time, Avill have to give place to some of the preparations of opium. In those case in which the ulceration has extended to the body of the uterus, to the rectum or bladder, nothing can be done for the patient but to palliate the symptoms, and thus smooth her patliAvay to the grave. The narcotics already mentioned may be given to allay the pain. The fetor of the discharge, as well as its ichorous properties, may be modified by the use of Carbolic Acid and Glycerine, of that strength which gives most relief. Caulifloaver Excrescence. 472. This disease, like the one last described, is not of frequent occurrence; it may be met Avith in females of all ages, Avhether married or unmarried, and without regard to constitutional peculiarities, habits or residence. Dr. AshAvell defines this to be " a morbid groAvth of the os uteri, consisting of minute ramifica- tions of arteries, connected by a flocculent tissue, and covered 244 DISEASES OF WOMEN. with a secreting membrane. Its surface has somewhat of the granulated feel of the broccoli; it bleeds on slight handling, and almost constantly pours forth a watery discharge. It varies in size, is nearly painless, and proves its malignancy by returning after removal, either by the knife, ligature, or caustic." Mr. Paget considers the true cauliflower excrescence to be a variety of the epithelial cancer; he says only a part, hoAvever, of the cases to which this name has been ascribed, have been epithelial cancers; of the rest, some Avere medullary cancers, and some, perhaps, simple non-cancerous, healthy, warty, or papillary groAvths. 473. According to Virchow, this begins as a simple papillary tumor, and at a later period passes into cancroid (epithelial cancer). At first one sees only on the surface papillary or villous growths, which consist of very thick layers of peripheral, flat and interior cylindrical epithelial cells, and a very fine interior cylinder formed of an extremely little connective tissue Avith large vessels. The outer layer contains cells of all sizes and stages of development; some of them forming great parent-structures with endogenous corpuscles. The vessels are, for the most part, collossal, very thin walled capillaries, which form either simple loops at the apices of the villi, between the epithelial layers, or toward the surface loops in constantly increasing number, or lastly present a reticulate branching. At the beginning of the disease, the villi are simple and close-pressed, so that the surface appears only granulated; it becomes cauliflower-like by the branching of the papillae, which at last groAv out to fringes an inch long, and may present the appearance of a hydatid mole. After the process has existed for some time on the surface, the cancroid alveoli begin to form deep betAveen the layers of the muscular and the connective tissue of the organ. 474. Of a specimen of the cauliflower excrescence removed by excision of the cervix, Dr. Simpson says: " The excresence, after its removal, was found to measure two inches and three-quarters at its broadest part, and two inches and a quarter at its greatest depth. The thickness of it, where it implicated the posterior lip of the os uteri, Avas one and three- CAULIFLOWER EXCRESCENCE. 245 Fig. 23.—Cauliflower Excrescence of Os Uteri. eighths of an inch, but on either side it stretched forward and involved the angle betAveen the anterior and posterior lips; thus rendering this admeasurement greater in its lateral parts. The anterior lip of the os uteri, Avhich was fully removed as high as the reflection of the vagina, seemed sound except at the above angles. The poste- rior surface of the posterior lip was densely and com- pletely covered by the excrescence up to the reflection upon the vagina. In ex- r-idiriO' thp di^PT^pd aa, Trobe passed through the Cavity of the Os and Cervix Uteri; b, UlSUJg me uiscmcu Ant0rior Lip of the Uterus; c, Posterior Lip; dd, Line of Incision by nart I removed it SO which the Cervix Uteri was removed; e, Rough Surface of the Tumor F ' attached to the Posterior Lip. high as to bring aAvay all around, a small portion of the reflection itself of the mu- cous membrane of the vagina. The surface of this portion of membrane, as thus removed in attachment to the upper edge of the excrescence, appeared quite healthy on careful exami- nation of the excised mass. The surface of the tumor pre- sented a Avell-marked small granulated appearance, with deeper fissures crossing it, and giving it an irregular and lobu- lated appearance. The sides of it Avere considerably and deeply lacerated in various places by the teeth of the vulsellum Fig. 24. aa, Under snrface of the Tumor; bb, Portions lacerated by the Vulsellum. 246 DISEASES OF WOMEN. On rubbing down any small part of the recent tumor between the finger and thumb, a kind of vascular or cellular frame-Avork Avas all that was left behind. The mass, before dividing it, was steeped in a strong alcoholic solution of Corrosive Sublimate, in order to insure its preservation. On making a section of the tumor after it had been thus sufficiently indurated, it presents to the touch and sight an appearance greatly resembling that of the brain Avhen hardened by the same menstruum. A number of minute cells Avere scattered over the surface of the section. On slightly rubbing any part of the section, but particularly the more external part of it, Avith the handle of the scalpel, its apparently homogeneous structure at once broke up, and resolved itself into a number of very small, connected, grape-like granules. These same granules imparted to the external surface of the excrescence its peculiar minutely mammillated structure; Avhile their arrangement into nodules, in consequence of the divided and lobulated arrangement of the superficies of the tumor, gave to the Avhole a striking resemblance to the head of the cauli- floAver. The accompanying Avood-cuts, from drawings of the tumor by Dr. Patterson, give excellent representations of its external form. '; On submitting some very thin slices from the surface of the section of the tumor, to a poAverful microscope in the possession of Dr. Reid, it Avas seen to be composed of a number of cells, arranged in some places in groups, in others in irregular lines. These cells each contained a large nucleus, and this nucleus inclosed several small nucleoli." 475. Symp'.oms.—The patient's attention is first drawn to her condition by a Avatery, inodorous, and almost constant discharge. This discharge may continue for weeks, and sometimes it becomes excessive in quantity, Averting several napkins a day, and yet the patient does not become sufficiently alarmed to apply for medical advice. In the course, hoAvever, of a few Aveeks, the discharge becomes tinged with blood, or considerable hemorrhage may come CAULIFLOWER EXCRESCENCE. 247 on during or after intercourse, or during defecation; in either of these cases the patient is generally alarmed, and consults her physician. As the disease progresses, this hemorrhage becomes more frequent and plentiful; sometimes alarming hemorrhages are brought on by coition or defecation, and an examination Avill often cause severe flooding. If an examination be noAv made, a tumor of larger or smaller size Avill be found attached to the os uteri, of a soft and granulated feel, and bleeding on the slightest pressure. It may be attached to either lip of the os, or involve the entire cervix; when large, the upper part of the vagina is dilated, either anteriorly or posteriorly, to make room for it. When brought into vieAv by the speculum it is of a bright flesh-red, and its granulated or fringed character Avill be readily revealed. There is hardly ever any pain with this disease, and an examina- tion with the finger or speculum produces no uneasiness. The progress of the disease is very variable. In some cases where the hemorrhage is very frequent or profuse, it makes fearful inroads on the constitution, the appetite fails, dyspeptic symptoms appear, and, in some cases, general dropsy supervenes, and the patient is rapidly carried off, not by the extent of the local disease, but by the loss of fluids consequent on it. In other cases the disease may continue for tAvo or three years, or even longer, Avhen the patients die, worn out by the constant drains on the system by the discharges and hemorrhage. 47(1. Diagnosis.—This tumor may be distinguished from polypi, and fibrous tumors, by its softness, granular surface, and profuse watery "discharge. From cancer, by the discharge, which is never fetid, as in cancer, by there being no pain, and by the distinct- ness, mobility, and softness of the groAvth, and by the peculiarity of its origin from the os. 477. Frof/nosis.—There can be no doubt but that this is a dangerous disease; still, if seen at its commencement, and properly treated, a favorable result may be looked for. Dr. Simpson's patient recovered after excision of the cervix, and the disease did not recur. Colombat reports a case of this disease, treated in the same manner, and there Avas no return of it Boivin and Dugcs report a case cured. Dr. Montgomery one 248 DISEASES OF WOMEN. Dr. Churchill reports a case treated by deep cauterization ; the patient Avas Avell two years afterward. 478. Treatment.—Two methods of treatment are presented to the practitioner as giving a probability of success; these are, removal of the tumor by cauterization, or by excision of the cervix uteri. Of these two methods of treatment, Eclectics would choose cauterization, from the great success Avhich has folloAved its employment in their hands, in the removal of malignant groAvths. Cauterization, hoAvever, to be effectual, should be deep enough to destroy the base from Avhich the tumor springs, as Ave have seen that the cervix at this point is generally infiltrated with a cancer- ous deposit, which will rapidly reproduce the morbid groAvth. Of the escharotics Ave will have our choice of three, the potassa fusa, chloride of zinc, and arsenious acid. The first has been fully de- scribed already, the second is very effective if skillfully used, and the last is especially recommended because it is attended with less pain. If we use the chloride of zinc, we make a paste of equal parts of this and gum Arabic, adding a small portion of Sangui- naria. It should be thoroughly applied and rapidly pushed to the complete extirpation of the growth, the vagina being pro- tected by the use of lint wetted with glycerine. The arsenious acid is used Avith a paste of iron, as directed under the head of cancer of the uterus, and of the strength deemed necessary in the case. If the parts are not irritable, and the growth not rapid, it may be weak and painless. 479. Excision of the Cervix Uteri has been frequently per- formed for different diseases, and Avith variable results. * " The mortality of the operation itself is about one in six or seven." Of all the methods of operating, Dr. Simpson's is the simplest, and on this account preferable. The patient is placed upon the face, the body being situated across the bed, and the loAver extremities hanging over it, as in the operation for hemorrhoids. The operator is thus enabled to make the incision, through the cervix uteri from behind forward, and thus avoid wounding the peritoneum, Avhich extends doAvn much further behind than in front. A strong pair of vulsellum-forceps is then introduced into the vagina, and attached to the cervix. This may be done CAULIFLOWER EXCRESCENCE. 249 through a speculum, if the cervix is not much enlarged ; if it is enlarged, the vulsellum will have to be guided and attached Avith the other hand. Having fixed the vulsellum, the cervix should be gradually and cautiously drawn doAvn, until it appears so far beyond the vulva as to alloAv of the excision above the morbid groAvth. As the uterus retracts strongly as the incision is made, the line of the incision is rendered uneven and confused. To remedy this defect, Dr. Simpson thinks that it would be prefer- able to use a pair of large, curved, blunt-pointed scissors. By this means Ave Avould be enabled to surround and embrace the Avhole cervix at once, and having cautiously and carefully adjusted their edges to the very points Avhich avc Avish to divide, and thus calculated by this preliminary step the exact limits of the incis- ion ; Ave may then immediately complete the amputation of the part by one or tAvo strong and rapid strokes of the instrument. As soon as the excision is completed, the uterus immediately ascends to its natural position. Serious hemorrhage very rarely occurs after this operation ; Avhen it does, it may be checked by plugging the vagina. Such symptoms as may arise after this operation, should be treated on general principles. The success attending it Avill depend upon Avhether the entire morbid growth Avas removed; for if but a single cell remains, it will probably be reproduced. Cancer of the Uterus. 480. This is one of the most fatal and distressing maladies to Avhich the female is liable ; it is the most irresistible in its progress, and the least amenable to treatment, Avithout it is seen in its earlier stages. Females of any age are liable to it, though it more commonly occurs after child-bearing, and about the time of the cessation of the menses. In four hundred and nine cases of cancer of the uterus referred to by Boivin and Duges, they occurred in the folloAving ratio : Under tAventy years of age, . . . 12 From tAventy to thirty, .... 83 " thirty to forty, .... 102 " forty to forty-five, . . . .106 250 DISEASES OF WOMEN. From forty-five to fifty, .... 95 " fifty to sixty,.....7 " sixty to seventy-one, ... 4 Total, .... 409 481. According to that close observer, Prof. Ilokitansky, " Cancer of the uterus always attacks the cervix in the first instance, and especially that portion which projects into the vagina ; the primary occurrence of carcinoma at the fundus uteri is so rare, that the above observation may be considered as an absolute rule. It is contrasted, in this respect, with fibroid and tubercular disease of the uterus, and it presents a similar con- trast in reference to its extension and ulcerative destruction. 482. " Opportunities very rarely present themselves for inves- tigating the early stages of cancer in the dead subject; according to a few observations, carcinoma, Avhen closely examined, appears to consist of dense, Avhitish, retiform fibers, differing from the normal texture of the vaginal portion of the uterus iu which they are found, and in their very minute meshes, a pale, reddish- yelloAV or grayish translucent substance is deposited. This mor- bid growth is inserted into the uterine tissue, Avithout Avell-marked boundaries ; it occupies a various extent, and from accumulating at certain points, gives rise to the irregular nodulated character and the well-knoAvn induration which accompanies the enlaro-e- ment of the cervix. 483. " Medullary cancer, in the first instance, appears as an infiltration of a Avhite lardaceo-cartilaginous or lax, encephaloid matter, in which the uterine fiber disappears. As the deposit increases, the vaginal portion of the cervix assumes an uneven nodulated character, and appears hard and elastic to the touch. Cancer of the uterus very rarely presents itself in the shape of isolated globular growths. As the cancerous degeneration pro- ceeds, and especially on the commencement of the stage of metamorphosis, with its consequent neAv formations, particularly if they belong to the medullary variety, the lower segment of the uterus undergoes a very considerable and rapid enlargement; at last, Ave find a callous, loose, spongy ulcer, developed in the usual cancer of the uterus. 251 manner, which discharges a very fetid, greenish-brown, sanioua and sanguineous fluid, and, as it extends, generally causes a progressive infiltration of cancerous matter. The tumefaction of the cervix and fungoid excrescences not unfrequently close up the orifice, and the consequent enlargement of the womb will be the larger, the more copious the secretion of mucus. 484. " Cancerous degeneration of the uterus is, generally, in a very remarkable and distinct manner, confined to the vaginal portion ; still, there are frequent exceptions to this rule, as the disorganization is sometimes found to extend, Avith great rapidity, to the body, and even to the fundus of the uterus ; this is par- ticularly the case, if the os tincse has already been attacked by ulceration. The disease may spread dowmvard, and involve the vagina, thus establishing vaginal cancer. It may extend in other Fig. 26.—Cancerous Ulceration of the Uterus, involving the Rectum and Bladder. directions, and thus give rise to cancerous degeneration of the rectum, the bladder, the pelvic, cellular, and adipose tissue, and 252 DISEASES OF WOMEN. the peritoneum; the uterus thus becomes fixed in the pelvis, and; at last, Ave find the peritoneum attacked, cancerous growths being formed upon it and its tissue, or perforating it, especially in the shape of medullary masses. 485. " Cancerous ulceration spreads in the same direction ; in rare cases Ave find the greater part of the uterus, and even its fundus destroyed. The destructive process, when attacking the vagina, sometimes predominates on the anterior, sometimes on the posterior surface; sometimes it attacks both equally, and may extend doAvnward almost to the external orifice. It also involves the degenerated parieties of the rectum and of the bladder, and generally produces extensive communications between their cavities and the original cancerous sinus. It finally extends, in the shape of sinous passages, through the remainder of the cancerous mass that fills the pelvic cavity, to the pelvic bones. In this manner a large cavity, with fungoid parieties, is at last established, which occupies a greater part of the uterus and vagina, and opens into the cavities of the rectum and the bladder; above, it is closed in by the fundus uteri and the adherent rectum and cervix vaginae, as also by the caecum and small intestine, which are agglutinated to these parts, and at last it penetrates into the cavity of the peritoneum or the intestines. The con- tents of the cavity are cancerous ichor mixed up with fecal matter, urine, and gangrenous tissue. 486. " Uterine cancer is, in most cases, a primary disease, and generally remains so for a long time, if not throughout the sole carcinomatous affection of the organism. HoAvever, it is some- times developed concurrently Avith, or consecutively to, mammary and ovarian cancer; or, it is accompanied by degeneration of the adjoining tissues above-mentioned, and of the lymphatic glands, which must be explained upon the theory of propagation by con- tact; or it is associated with cancer of the peritoneum, of the liver, stomach, and the breasts, Avith cancer of the bones, with mollites ossium, ovarian cancer, and universal cancerous deposit, as a consequence of the resulting cancerous dyscrasia." 487. Symptoms.—In the first stages of this disease, the symp- toms are so slight as to scarcely arouse the attention of the CANCER of THE UTERUS. 253 patient; in fact, in many cases the disease makes great progress before she considers that there is sufficient cause to consult a physician. The earliest symptoms consist in the derangements of the catamenia, if the disease occurs before the cessation of this discharge ; thus, the menses may appear more frequently, as often as every two or three weeks, or their appearance may be retarded. The menstrual secretion is generally much increased in quantity, though it may in some cases be decreased or even suppressed. There is nearly always present, in the forming stage of cancer, a leucorrheal discharge, of a Avhite or yellow appearance ; this may be profuse, but it is generally small in quantity, Avithout the patient has had a long-continued discharge of this kind ; this discharge may be continuous or intermitting. Previous to, or immediately after the catamenial period, this dis- charge may be tinged or streaked Avith blood, or after any local excitation, as coitus, violent emotions, severe exercise, etc. 488. As the disease progresses, the patient will feel a constant dull aching pain in the small of the back, attended by a weakness at that point. This pain may extend doAvn the course of the sciatic nerve, presenting all the symptoms of sciatica; or it may extend down to the perineum, or doAvn the inside of the thighs. There will also be ovarian pain present; it may be located in either, or in both ovarian regions. The hypogastric pain, or the pain in the loAver part of the hypogastric region immediately above the pubis, is not generally present, until the stage of ulcera- tion is manifested. With these pains, Avhich are generally inter- mittent, and scarcely ever severe, the patient feels a sense of weight in the pelvis, an uneasy tenderness, and sometimes slight pains, especially during the menstrual period, or after severe physical efforts. 489. As the disease becomes confirmed, and ulceration com- mences, all the above symptoms become aggravated. The lumbo- sacral, ovarian and hypogastric pains become aggravated, the pains in the course of the sciatic nerves, in the perineum, and doAvn the inside of the thighs, if present, become very severe. In the majority of cases, the uterine pains noAv become very severe. They are described by some as lancinating, as though 254 DISEASES OF WOMEN. knives Avere plunged into the body; by others, as burning, as though a coal or hot iron was applied to the uterus. These pains though continuous, are greatly aggravated at times, Avhen they ^extend to the back, to the ovaries, doAvn the sciatic and crural nerves; in fact, follow7 the course of all the nerves that pass out of the pelvis. In some feAV cases, there will be little, if any pain present. A very marked symptom of cancer of the uterus is a severe and circumscribed pain about the rectum and anus, simu- lating very much a severe attack of piles; this pain is almost invariably increased when the patient goes to stool. 490. The severe suffering, and the profuse discharges that sometimes occur, soon affect the general health of the patient; her appetite becomes poor, marked symptoms of indigestion develop themselves, the bowels are irregular, sometimes consti- pated, at others, there is a diarrhea, or these alternately. The patient though still retaining her fullness of habit, has a blanched and colorless appearance, or, as is most generally the case, a peculiar Avaxy, yellowish-white color. By degrees, the patient is gradually exhausted and debilitated. The digestion becomes more deranged; she is troubled Avith flatulence, vomitings, and fever. These symptoms mark the close of the disease; for under these intense sufferings the patient rapidly sinks. 491. Discharges.—Up to the commencement of ulceration, the discharges are not changed in character, though they are usually augmented in quantity; sometimes, however, they are streaked with blood at times. As soon, hoAveA7er, as ulceration has com- menced, the discharges are entirely changed in character, though they are usually augmented in quantity; its color varies from a dirty-white to a dark broAvn, green, or black, and its odor becomes almost insupportably fetid, so much as to constitute a great source of suffering to the patient. Sometimes it becomes very ichorous, excoriating the parts over which it flows, producing an erythe- matic inflammation of the vulva, extending to the anus, and sometimes doAvn the thighs. If the ulceration involves the blad- der or rectum, opening into their cavities, there will be a constant and involuntary escape of urine, and of fecal matter and flatus CANCER OF THE UTERUS. 255 In this case, the condition of the patient is truly pitiful, and death becomes to her a Avelcome visitor. 492. Upon making an examination in the forming stages of this disease, the cervix Avill be found somewhat enlarged, indu- rated, and presenting a nodulated character. The os uteri will be more or less open, and its edges will feel indurated and hard. The color of the cervix is changed in the stage of deposition; instead of presenting a pale-rose red, its natural color, it becomes of a dark red or purplish color. The cervix uteri will not present the same degree of moisture as in health, but will feel dry and rough. As the disease continues, the induration will be found to extend, the uterus loses its mobility, and gradually increases in size, sometimes to such an extent that it can be felt above the pubis. 493. When ulceration has taken place, an examination will cause great pain. The ulcerated surface Avill be found rough, unequal and tender on pressure, and the finger, Avhen it is Avith- drawn, is covered with a fetid sanies, and occasionally tinged Avith blood. In some cases the ulceration will be deep, and filled Avith a fungous substance projecting beyond the edges of the ulcer. The ulcerated surface has a grayish color, and its edges are of unequal elevation, and very uneven and ragged; the fungous groAvth from the ulcer is generally of a purplish or dusky red color. 494. Diagnosis.—In the first stages of cancer of the cervix uteri, it Avill be very hard to distinguish it from induration folloAving inflammation. Dr. Bennet states that inflammatory induration "is the disease to Avhich most authors and'practitioners give the name of incipient cancer." He says: "I must ao-ain repeat, that my own experience, as well as the analysis of that of others, leads me to the conclusion that cancerous growths of the uterus, in the incipient or non-ulcerated stage of their develop- ment, are ahvays, or nearly ahvays indolent, and give rise to no symptoms sufficiently decided to induce patients to complain, or to seek for advice; and thus Ave can explain hoAv the disease, in its incipient stage, does not come under the notice of the practi- tioner." He also says : " It is more than probable that cancer of 256 DISEASES OF WOMEN. the cervix uteri, instead of being very slow in its development. and remaining for years in the first or non-ulcerated stage, is, on the contrary, very rapid in its growth and progress, especially in women who still menstruate." 495. Dr. Bennet states distinctly that cancer rarely, if ever, arises from, or is caused by, inflammation of the cervix. Hoav, then, are Ave to account for the numerous cases of non-ulcerated disease of the cervix, Avhich, after a longer or shorter time, have become perfectly developed, ulcerated cancers, destroying the uterus, rectum, vagina and bladder ? Inflammatory induration of the cervix uteri is likewise a secondary process, which has to be preceded by inflammation, and all its attendant symptoms, and, according to Dr. Bennet, in the most of cases, by ulceration; Avhile the induration of the first stage of carcinoma uteri Avill be found, in the most of cases, not to have been preceded by the symptoms named as diagnostic of inflammation and ulceration of the cervix uteri. It is true that similar symptoms are developed in the non- ulcerated stage of cancer, but they never precede the induration. 496. We Avould then distinguish the diseases by the fact, that inflammatory induration is always preceded by morbid symptoms of inflammation of the cervix, by the purulent discharge which is the pathognomonic symptom of that disease, and its stationary character, not generally increasing in size, and never involving adjacent structures, or causing immobility of the Avomb. In the ulcerative stage Ave have to distinguish it from corroding ulcer, and venereal ulceration. We distinguish it from corroding ulcer, by the immobility of the uterus, and by the fetid character of the discharge. From venereal ulceration, by the morbid deposition, and immobility of the uterus, and by the depth and irregularity of the ulceration ; venereal ulcers being generally smooth and even, no fungous groAvths attending them, and the pain present is neither so constant nor acute. There are no other diseases of the uterus with Avhich ulcerated cancer could be confounded, unless we except a case reported, in which an intra- uterine polypus ulcerated, and there was a constant fetid discharge for more than tAvo years; this case Avas decided to be cancer by several eminent practitioners. CANCER OF THE UTERUS. 257 497. Prognosis.—This, probably, is one of the most fatal diseases to which the female is subject, yet, if seen in an early stage and properly treated, it may be cured. If the disease is still confined to the cervix, our prognosis should not be unfavor- able ; but, if it has extended beyond this, not much can be hoped for, so far as a radical cure of the affection is concerned ; Ave may hoAvever, greatly alleviate the suffering of the patient, and prolong ber life. 498. Treatment.—When cancer of the uterus is confined to the cervix, Ave may entertain strong hopes of being able to remove it by local applications. I need hardly mention that I consider excision of the cervix, in these cases, bad treatment,—in but very feAv cases in which it has been resorted to, has the patient recovered,while the malignant character of the disease, in these fewv, has been disputed. The removal of the disease, hoAvever, by caustic, has been so often accomplished, that very few at this day "will dispute the fact, that cancer of the uterus has been removed by this means. 499. The caustics that may be most successfully employed in these cases are the potassa fusa, chloride of zinc, and arsenious acid. The last is preferred by some because its operation is quite painless. In using the potassa. the patient should be placed upon her back, in the usual position for making a vaginal examination The patient should then be placed under the influence of chloro- form, as this not only prevents pain, and the severe shock upon the system consequent on the severity of the cauterization, and thus greatly conduces to .subsequent recovery, but it likeAvise places the patient completely under the command of the operator. A laro-e glass, or Ricord speculum, should then be introduced, and the cervix brought fairly in the center of it. Cotton, saturated in a solution of vinegar and water should then be introduced around the cervix, carefully isolating it from other parts, that they mav not be injured by the caustic; it would be well if the Ricord speculum is used, to introduce the cotton between the lower blades of the instrument. Having the parts thus arranged, the stick potassa should be applied, by means of a proper caustic-holder, 17 258 DISEASES OF W0 M E N . to the entire indurated portion of the cervix. The potassa should be firmly applied, and continued until the entire cancerous structure is removed; this will take from ten to thirty minutes, according to the extent of the growth. The point to be recollected is, that if the entire indurated mass is not removed, the malignant growth will be reproduced, and there is no more danger from a thorough cauterization at once, than if it has to be repeated five or six times to accomplish the same purpose. As soon as the cauterization has been effected, the vagina should be Avell syringed out Avith vinegar and Avater through the speculum, and Avhen this and the cotton surrounding the cervix is Avithdrawn, the vaginal injections should be repeated, and continued at short intervals until the pain ceases. The slough, formed by the potassa,'will separate in from ten to fifteen days, according to the depth of the cauterization. At this time, a careful examination of the parts should be made, and if any indurated portions remain, the cauterization should be repeated. The ulcer left after cauteriza- tion, Avill have to be Avatched until the cicatrization is completed, keeping down any tendency to morbid groAvth or induration, by the occasional application of the potassa, or chloride of zinc paste, described beloAV. 500. This cauterization Avill be folloAved in the most of cases by considerable inflammation. This may be counteracted by the application of hot fomentations of hops, or stramonium leaA-es, above the pubis, and over the vulva, Avith the frequent use of warm vaginal injections of Avater, or a decoction of stramonium. These measures may be aided by the administration of the seda tives in the usual doses, and also by the hypodermic injection of morphia. Instead of this, I have sometimes given very marked relief by the use of small doses of JSTux Yomica and Pulsatilla, especially when there is abdominal pain and tenderness. 501. The chloride of zinc may be used either run into sticks and applied in the same manner as the potassa, or formed into a paste. The pure chloride of zinc if run into sticks, deliquesces sc rapidly, that it can not be well applied; an impure article, how- CANCER OF THE UTERUS. 259 ever, is sometimes made in this form, Avhich ansAvers the purpose admirably. The zinc paste may be made by taking the pure chloride in crystals, and letting it stand uncorked, until it has deliquesced; Ave then have a pure saturated solution ; this may then be mixed Avith sufficient pulverized hydrastis canadensis to form a paste. In using this paste, it is spread on a strip of leather of sufficient size to cover the diseased part. In using the chloride of zinc, the same precautions should be used to protect the adjoining structures, but instead of the vinegar and water, a solution of carbonate of soda should be used. In usin. In some cases of this disease the use of the irritating plaster w ill be attended with much benefit. If there is tenderness on pressure over the lumbar or sacral regions of the spinal cord, it should always be used until this is removed, providing there is nothing to contra-indicate its use; and if there be continued pain and tenderness in the hypogastric region, it should be used there in the same manner. Physometra, or Tympanitis Uteri. 550. This is a very rare disease, and in its description I will have to depend entirely upon continental authorities, as I have never seen a case of the kind, nor has there been a case reported in the journals that I am aAvare of. The disease consists in an accumulation of gas in the uterine cavity, Avhich is supposed to arise from chemical or putrefactive changes in some substance retained within the uterus. Dr. Gooch describes two forms of this disease: in one the air is formed in the cavity of the uterus, is retained for several months, distends it to a considerable magnitude, and is then expelled ; of this kind he had never seen an instance. In the other form, the air is formed in the organ, but, instead of being retained, so as to distend the uterus, it is expelled with a noise many times a day. To prove that this escape of gas was from the uterus, he reports tire following case : the patient was subject to this infirmity only when not pregnant, 280 DISEASES OF WOMEN. but she Avas a healthy and breeding Avoman, and the instant she became pregnant, her troublesome malady ceased. She continued entirely free from it during her Avhole pregnancy: but a few weeks after her delivery it returned. 551. Boivin and Duges state that they have never known the existence of an aeriform body in the uterus, except in obstetric cases, as in retention of the memlranes, or of portions of the dead foetus, or of putrid coagula, causing gaseous exhalations, found in the uterus after death, or escaping, per vaginam, during life. In such cases, the uterus may project, more or less, into the hypo- gastric region, and into the vagina, being resonant on percussion, and constituting a tumor circumscribed and proportionate to the quantity of gas it contains,—this quantity varying, especially with the degree of inertia of the uterus. 552. Other cases have been reported in Avhich the accumulation of gas in the uterine cavity appeared to be the result of a morbid exhalation, or secretion, and not by chemical changes. A case of this kind came under the observation of Mr. John Hunter, Avhich he endeavored to elucidate, but failed; on examination after death he could not discover any disease, either of the uterus or vagina. 553. There is no doubt, however, that physometra, in the majority of cases, is the result of a chemical decomposition of some substance retained Avithin the cavity of the uterus. Thus it may arise after labor from retention of the membranes, or a por- tion of the placenta, or of a dead foetus, or in some rare cases, of a retention of the lochial discharge. At other times it may arise from decomposition of retained secretions, as of the uterine mucus, coagula resulting from menorrhagia, or even of the cata- menia ; or of the chemical decomposition of a polypus, moles hydatids, etc. Boivin and Duges report three cases illustrative of the origin of this disease. In the first case the catamenia were checked by exposure to cold, followed by pains and SAvellino- of the uterus, which extended to the umbilicus, and Avas resonant on percussion, with remittent fever. The finger Avas carried as far as the os uteri, upon which a portion of fetid gas immediately escaped; the abdomen collapsed, but soon became distended TYMPANITIS UTERI. 281 aneAv : a tube was introduced into the uterus, in order to apply fumigations, gas issued copiously, coagula folloAved, and the patient Avas cured. In the other two cases, who had been affected a long time with pains in the uterus, and fetid, aeriform exhala- tions, the uterus Avas found to be filled Avith putrid effluvia : its interior surface was ulcerated, and the os uteri closed by the swelling of its borders. 554. Symptoms.—According to M. Colombat, the symptoms of physometra consist in a feeling of uneasiness and tension in the hypogastric region ; the woman complains of a pain, beginning in the Avomb, and running off toAvards the groins, loins, thighs, and, in some instances, even to the diaphragm. In most cases the menses are suppressed, yet there arc some Avomen Avho continue to have them regularly. The abdomen, which enlarges, presents a uniform, circumscribed tumor, tense, and resounding upon per- cussion like a drum. The Avomb, Avhich gradually rises above the pubis, tends towards the umbilicus, and may even reach above it, but does not increase in Aveight, though having acquired, as in many instances, considerable magnitude. This evolution is some- times accompanied with thirst, anorexia, rigors, and slight fever, increasing generally toAvards evening ; the excretions of stool and urine are more or less disordered; the patient has some respira- tory uneasiness, becomes inactive, dislikes to move, and it is, indeed, not uncommon for the uterine distention to excite sympa- thetic action of the breasts, and even secrete a sort of milky fluid. 555. In this state of things, the expulsion of a portion of gas from the vulva gives relief, and, generally speaking, an abundant discharge of it, which is commonly accompanied with noise, dissipates all the symptoms of the malady. This sort of uterine eructation may happen at very various periods; it is rare, hoAvever, for the gas to be retained Avithin the Avomb beyond five or six months. Under such circumstances, the menses not returning, the Avoman is apt to suppose herself pregnant, and the more so, as the feelings she experiences resemble those occurring in pregnancy. 55G. Diagnosis.— This disease may be readily distinguished from pregnancy by the resonance of the tumor, by the lightnesa 282 DISEASES OF WOMEN. of the uterus when it is elevated upon the finger, and by the absence of fetal movement, and the evidence furnished by ballot- tement, ausculation, etc. From all other diseases of the uterus by the resonance of the tumor, which may be ascertained to be the uterus by the vaginal and hypogastric touch, and by the lightness of the uterus. 557. Treatment.—The first object of the practitioner in this disease is to remove the accumulation of gas in the uterine cavity. For this purpose a small cannula may be introduced into the cavity of the uterus, in the same manner that Ave introduce the uterine sound ; as soon as the cannula is introduced, the gas Avill escape, and the abdomen rapidly collapse. (See report of a case by Prof. Bedford, Clinical Lectures, p. 322.) After the evacua- tion of the gas, such measures should be employed as Avill remove the producing cause, the putrefactive substance in the uterine cavity. For this purpose Ave may use injections of ay arm Avater into the uterine cavity, and if no symptoms of inflammation arise from it, we may acid to the injection the Liquor Sodae Chlorinata, gradually increasing the strength of the injection. This injection might be replaced by an injection of an infusion of the Baptisia Tinctoria, or a very weak solution of the Pyroligneous Acid. 558. The internal treatment should be directed to the restora- tion of the general health, and to stimulate the excretory organs to throAV off any morbid material that may have been absorbed into the system. Hydrometra—Uterine Dropsy. 559. This is also a very rare disease, and, consequently, its pathology is not Avell known. It consists of an accumulation of fluid within the cavity of the uterus, Avhich is retained, either from inertia, or from some morbid change in the structure of the organ. This accumulation may consist of a serous fluid, of mucus, pus, or of a dark, sero-sanguineolent fluid. 560. Frank describes four varieties of this disease. 1. The cellular, Avhen the effusion is immediately underneath the mucous membrane of the uterus. 2. The independent, the fluid being UTERINE DROPSY. 283 in the uterine cavity. 3. The hydatic. 4. Hydro-physometra, Avhere both fluid and air are contained Avithin the womb. 5G1. We have already seen that internal metritis, or uterine catarrh sometimes gives rise to this disease, by causing an abnor- mal contraction of the os internum of the cervix, and the consequent accumulation of the secretion of the inflamed mucous membrane of the uterine cavity. As the retained secretion increases in quantity, the uterus becomes dilated, and its mucous membrane changes its phaiacter to a thin, serous membrane, secreting a colorless, serous, albuminous fluid, resembling synovia. In this case, the increase in the size of the uterus is mostly at the the expense of the thickness of its Avails, the uterus becoming a slightly thickened hydropic capsule ; or the uterine tissue may preserve its normal character, the evolution taking place in the same manner that it does in pregnancy, the contained fluid being hemorrhagic in character, or consisting of a purulent or muco- purulent secretion. Boivin and Duges state that they have observed it in a case of cancer of the uterus ; it Avould recur for a short time, and then disappear by copious evacuations. They have, also, seen it folloAv chronic metritis, presenting, on examina- tion after death, the cavity of the uterus filled \vith a large quantity of pus, and the os uteri obliterated by adhesions. The sero-mucous fluid secreted by the mucous membrane of the uterus is almost ahvays mixed Avith blood or pus. The uterus is seldom found merely thinned and distended in these cases ; the tissue is most commonly beset with scirrhus, ulcerations, hydatids, or polypi ; and the os uteri is sometimes obstructed by a tumor, sometimes merely closed by tumefaction. 562. Causes.—Inflammation of the uterus may be said to be the most frequent cause, though it has been attributed, by some authors, to constitutional debility. 563. Symptoms.—According to M. Colombat, the size of the abdomen increases, Avith more or less rapidity, and the SAvelling, which commences in the middle of the hypogastrium, gradually extends from beloAV upAvard. During the first months, the woman supposes herself pregnant; the breasts either lessen or increase in size ; the countenance, Avhich is bloated and pale, bears the 284 DISEASES OF WOMEN. impress of languor ; she has a feeling of Aveight in the pelvis, pains in the loins, dragging sensations in the groins, and some- times a slight degree of fever. By palpation, we discover a rounded and firm tumor in the hypogastrium, Avhich appears to come up from the pelvis, to a certain bight, greater or less. The position of this tumor is very little changed by the changes of the Avoman's position, and Ave find a deep-seated, obscure, circum- scribed, fluctuation in it. But the least equivocal sign is that ascertained by touching ; in fact, by introducing a finger into the vagina as far as the cervix uteri, and then pressing the tumor with the other hand, we readily feel the shock of a fluid, and a very distinct fluctuation. This is not a symptom of ascites, nor of dropsy of the ovaria or tubes, for, in those affections, the cavity of the uterus is not distended Avith fluid, but the organ is itself jammed doAvn toAvard the bottom of the pelvis, Avithout any increase of size. 564. The menses are nearly ahvays suppressed, though, accord- ing to some authors, there are some exceptions. If the disease continues for any length of time, the general health Avill suffer more or less, the appetite will become impaired, and symptoms of dyspepsia manifest themselves. In the later stages of the disease, the pulse will be found small and quick, the skin dry and harsh, the boAvels irregular, and the urine passed in small quan- tities, and depositing a brick-dust sediment. According to Dr. Churchill, the patient may die from exhaustion, in consequence of the secondary fever; or the womb, unable to dilate more, or weakness in some part by previous or present disease, may give way, and the contents escaping into the peritoneal cavity, fatal peritonitis may result immediately. This is the usual conse- quence of obliteration of the canal of the cervix in old Avomen. 565. Diagnosis.—Owing to the cessation of the menses, and the subsequent enlargement of the abdomen, hydrometra will be more liable to be mistaken for pregnancy than anything else. We may easily distinguish it from pregnancy, hoAvever, by the absence of the signs furnished by ballottement, by the stethoscope, and especially by the absence of the foetal movement. 566. It may be distinguished from physometra by the dull UTERINE DROPSY. 285 sound on percussion, and by the increased Aveight of the uterus. From ascites and ovarian disease by the results of the hypogas- tric and vaginal touch. By this means Ave may ascertain the exact extent of the enlargement, and that it is due to an increase in the size of the uterus. From tumors of the uterus by the fluctuation and softness of the enlargement. 567. Treatment.—Our first object Avhen called to a case of this kind, is clearly to evacuate the contents of the uterus. To effect this, it has been recommended to use errhines to produce severe sneezing, or emetics to produce vomiting, thereby causing a severe and sudden contraction of the abdominal muscles; the object pro- posed to be accomplished by this means, is to give a sudden shock to the system, and cause severe compression of the uterine tumor, by Avhich its contents may be expelled. This may be first tried, though it has rarely proved successful. The easiest and quickest method of evacuating the contents, is by the introduction of a small cannula or catheter, which should be alloAved to remain until all the fluid is evacuated. If there exists an unnatural degree of contraction which prevents the passage of the canula, but the canal of the cervix is still pervious, Ave may dilate it sufficiently by the use of the sponge-tents heretofore described, to admit the passage of a tube of sufficient size. 568. Should the canal of the cervix be impervious, Ave have no other means of relieving the patient but by puncturing it, and thus evacuating the fluid. Where Ave have to resort to this measure, the puncture should be made, if possible, in the course of the canal of the cervix ; a common trocar will be found as good an instrument as can be employed in this case, leaving, the cannula in the puncture until the fluid is evacuated. The artificial opening made should be kept pervious, by the occasional passage of a bougie. The danger to be apprehended from this operation, is subsequent metritis; this should be Avatched for, and on its first appearance, subdued by appropriate treatment. 569. The uterus has been punctured in other places than through the cervix. Thus, Francis Wirer performed the opera- tion successfully, by passing the trocar an inch and a half above the pubis, and at the same distance from the linea alba. Fifty* 286 DISEASES OF WOMEN. three pounds of a thick, blackish, bloody liquid escaped through the canula; steady pressure was afterward kept up Avith Munro's bandage and several napkins; the patient, Avho Avas fifty years of, rge, was completely cured; for ten months after the operation t'lere Avas no return. The puncture has also been performed through the uterine wall from the vagina; there could be no object in this, hoAvever, Avithout there was displacement of the uterus, the cervix being carried out of reach, and could not be brought down. 570. As soon as the uterus has been evacuated, a bandage should be placed around the abdomen, with a compress over the uterus; it might be Avell too, to use an injection into the uterine cavity, as was spoken of under the head of physometra; this, however, would depend upon the condition of the patient, and the character of the fluid evacuated. At any rate, the vagina should be frequently Avashed out with injections of Avater, and the canal of the cervix kept open by occasionally passing a bougie. As the disease most frequently arises from metritis, the same treat- ment should be pursued that has been recommended for that affection. Moles—Hydatids. 571. Under this head, Ave have to consider a morbid mass in the cavity of the uterus, arising from a blighted or false concep- tion. The term mole, or spurious mole, has also been applied to almost any foreign body existing in the cavity of the uterus, as the remains of the placenta after delivery, to the tough tenacious coagula, Avhich is sometimes formed from the catamenia, or in menorrha.ii;i, etc. 572. Boivin and Duges admit of three kinds of mole: 1. Blighted conception, or the false germ. 2. The fleshy mole. 3. The hydatid mole. Within these limits, they Avill always be a faulty product of conception, and their origin, necessarily, a con- sequence of impregnation. 573. I. Blighted, or False Conception, according to Dr. Churchill, is not intended (as has been supposed) to signify any imperfection in the act of generation, but merely that the vitality of the foetus having been destroyed, the obJQct of utero-gestation MOLES — HYDATIDS. 287 has failed. In most of these blighted ova, the foetus is altogether wanting, having been dissolved in the liquor amnii; Ave may, how- ever, generally discern the remains of the umbilical cord attached to some part of the inner surface. In addition, the membranes (chorion and amnion,) may be traced with the placental develop- ment on some portion of the periphery of the ovum. Still, the Avhole mass will be found a good deal changed in size, form and structure, by the effusion of blood, and the formation of coagula between the membranes, or in the placenta, by decomposition of lymph, and sometimes by apparently quite new and perfect layers of membrane. It is these very changes Avhich probably caused the death of the foetus. We can easily comprehend hoAv very frail the tenure of life must be at an early period; we see it broken by mental or bodily shocks ; by vascular or nervous irregularity; and by any deviation from normal structure, such, for instance, as a tumor at the root of the cord, or the cord beinjr inserted Avhere the flocculi of the chorion are deficient, or into a part Avhere the placenta is not. In this state, it is seldom retained for more than tAvo or three months, but, if not expelled, it may degenerate int ■ a fleshy mole. It is not easy to distinguish a blighted ovum Avhich has been retained in the womb, from a recent abortion. as in the latter, the foetus may be Avanting." 574. II. The fleshy mole is considered by most authors to arise from a false conception, the ovum remaining attached to the uterus, and receiving and appropriating the blood destined for the foetus, it increases in size and density. Tavo forms of the fleshy mole is described; in one they are holloAv, possessing a distinct lining membrane, in Avhich are the remains of the liquor amnii. The other forms a solid fleshy mass. 575. According to Boivin and Duges, the cavity of the fleshy mole is ahvays inconsiderable in proportion to the substance of its parieties. The fleshy substance is of unequal thickness, of a red color, compact, fungous, resembling the placenta in tissue, though more elastic, and less filamentous. They constitute a mass of someAvhat rounded or oval form, uneven, and of a volume varying from that of a large egg to that of the head of an infant. In some instances, portions of a foetus have been found either in 288 DISEASES OF WOMEN. the cavity, or imbedded in the substance of its walls. The solid fleshy mole presents the same character as the other; it has no central cavity, and is generally larger and more misshapen. 576. There is generally but one mole present in the uterus; it nay, hoAvever, be present with a healthy ovum, for it is said to be very uncommon for both the products of conception in a twin pregnancy to be affected at the same time, and for tAvo moles to be formed in the uterus at the same time. On the contrary, a mole has often been found to exist Avith a living foetus, the mother going her natural time, the mole being expelled immediately, or in tAvo or three days after the birth of the child. The existence of a mole in tvvin pregnancy has often been followed by abortion, the foetus and mole being expelled together; or Avhat is still more rare, the mole has been expelled some time during pregnancy, the Avoman reaching her full term, and giving birth to a healthy child. 577. III. Hydatids, or Vesicular Moles.—This degeneration of the ovum has been more closely observed, and its pathology is therefore better known. A probably not unfrequent cause of abortion is a degeneration of the villi of the chorion into pedun- culated vesicles or cysts: the formation of these cysts in the villi lead to the Avasting of the parts around it, and the consequent destruction of the ovum. These cysts are found not only on the surface of the chorion, but the same degeneration also takes place in the placenta. Mr. Paget has well described these forma- tions; he says: "A part, or even the Avhole of the chorion, is covered Avith pellucid vesicles with limpid contents, borne on long. slender, and often branching pedicles. The cysts are usually oval or pyriform ; their Avails are clear, or have minute or opaque dots; they may be simple, or may bear others projecting from their Avails." The Avhole process of their formation may probably be thus described : *' Certain of the cells in the proper villi of the chorion, deviating in their cell-form, and increasing dispropor- tionately in size, form cysts, which remain connected by the gradually elongated and hypertrophied tissue of the villi. On the outer surface of the new-formed cysts, each of Avhich would, as it Avere, repeat the chorion, and surpass its poAvers, a new MOLES —II YD AT IDS. 289 vegetation of villi sprouts out of the same structuie as the proper villi of the chorion. In these begins again a similar development of cysts, and so on ad infinitum. Each cyst, as it enlarges, seems to lead to the Avascinir aAvav of the cells around it; and then, moving away from the villus in Avhich it Avas formed, it draAvs out the base of the villus, Avhich strengthens itself, and forms the pedicle on which the cyst remains suspended." 57S. Boivin and Duges describe three forms of this hydatid or vesicular mole. 1. The vesicular mole containing the embryo. 2. The holloAv vesicular mole. And, 3. The clustered vesicular mole. The entire three varieties, hoAvever, have the same forma- tion, and the difference is not sufficient to justify a separate description. 5711. The quantity of these cysts contained in the uterus varies very much. AVhen their formation commences it generally con- tinues until the ovum is expelled, so that, if it is retained in the uterus a considerable length of time, the quantity might be very large. The cysts vary in size from a pin's-head to a grape ; they may be found singly or in groups, in this latter case resembling a bunch of grapes ; their form is generally oval, though they may he elongated or round ; the contained fluid is generally transpa- rent and clear, though in the larger ones it is often of a straAV- color ; both white and red vessels may be seen running on their surface. 580. Symptoms.—The symptoms for the first three or four months are the same as in pregnancy, suppression of the menses, SAvelling of the breasts, morning sickness, etc. It is only about the period Avhen the foetal movements should take place that doubt arises. At this time, the abdomen is frequently much larger than it should be in natural pregnacy, and the constitutional suffering much greater. In regard to the increased size of the abdomen, when containing a mole, Dr. Ashwell remarks: — "Thus, if half the term has passed, the bulk may equal that of a pregnancy near at its close, and the greater part of this vast increase may have occurred within a few weeks. If a medical opinion is now asked, additional reasons for suspicion will noAv be discovered. The stethoscope will fail to detect the pulsations of the foetal heart, or 19 290 DISEASES 0 F WO M E N . even the placental murmur; there Avill be no balancing the uterine contents by ballottement . and the uterus, although greatly dis- tended, will be soft and doughy in feel, exceedingly unlike the firm structure of the impregnated organ." 581. Sometimes the presence of moles occasions considerable aggravation of the symptoms of pregnancy ; the uterus, larger in size, occasions more uneasiness from its Aveight, especially if the increase in size has been rapid ; the patient suffers more from pains in the loins, from disuria, and from lassitude, than in an ordinary pregnancy ; there is often a degree of general illness rare in natural gestation. Sometimes there is a sanguineous discharge for sometime before the mass is expelled. 582. According to M. Colombat, Avhere the mole has attained its maturity, which is generall}7 the case from the fourth to the seventh month, the patient suffers pains like those of real labor; the Avomb contracts, its orifice btccmes dilated, and the mass is expelled. The breasts then fill with milk, the lochia folloAv in course, and all the other secondary symptoms take place as in a common lying-in. In a majority of cases the expulsion of the mole is followed by considerable flooding, and should its expulsion be difficult from its attachment to the uterus, the hemorrhage may become very alarming. 583. Diagnosis.—As this disease simulates pregnancy, we have first to note the differences betAveen the tAvo. In moles we have the absence of ballottement, of quickeivng, and of the stethoscopic signs, — the beating of the foetal heart, etc.—Avhile there is generally a disproportion betAveen the size of the tumor and the period since it Avas first observed. It may be distinguished from physometra, by the absence, and the greater Aveight of the uterus. From hydrometra, by the perceptible fluctuation in the latter, and from the greater accumulation ; the diagnosis is, Iioav- ever, very difficult, but it is of little importance from the rare occurrence of hydrometra. 584. Treatment —So long as the uterus does not contract upon its contents, there is nothing to be done, even if Ave have ascer- tained the nature of the uterine contents, without there should be flooding. In this case, Ave should try to arrest it by cold applica- FIBROID TUMOR. -29-1 tions to the vulva, plugging the vagina, and the internal use of the tincture of equal parts of oils of erigeron and cinnamon. If the flooding should not cease, under the use of these measures, we Avould have to excite contraction of the uterus, if possible, to expel its contents. For this purpose Ave may administer the caulophyllin and the ergot, and apply a bandage tightly around the abdomen. If the uterus does not expel its contents under the use of these remedies, and the hemorrhage continues, it is advised to introduce the hand into the uterus, where this can be done, and thus remove its contents. 585. The flooding that occurs after the expulsion of the mass should be treated in the same manner as flooding after delivery ; a bandage should be applied, and the patient managed as after ordinary labor, but with special reference to the flooding. Fibroid Tumors. 586. Under this head we have to describe all those morbid groAvths Avhich have a dense, fibrous structure, or which in any manner resemble fibrous tissue, and are not malignant. These groAvths may all be arranged in tAvo classes, the pediculated and the non-pediculated. The first are called polypi ; the second are distinguished by the name of fibrous tumor. As pathological anatomy furnishes the only basis of a rational system of practice, and as this is the only means by which avc can obtain a lr less blended, and there is a consent in their actions. The levators relax DROPSY OF THE UTERUS. 345 perineal muscles, causes a loss of tone and energy in these, the true supports of the pelvic contents. 716. Dr. Hamilton urges the following objections to the use of pessaries: " 1st. They can only act as palliatives, Avhatever may be the degree of the disease. 2d. They necessarily keep up a continued irritation in the passage, and of course a mucous dis- charge from the vagina. 3d. Unless properly adapted, they make injurious pressure on the contents of the pelvis. 4th. If not frequently taken out and cleaned, they become incrusted with calcareous matter, Avhich proves highly irritating. 5th. They sub- ject the patient to the charge of the medical attendant for life. coincidently with the relaxation of the sphincter ani, and their contractile efforts absolutely coincide. " Seeing now that the uterus depends for its place in the plane of the pelvic cavity, solely upon the place of the vagina, and that the latter is indissolubly connected with the bowel by means of the recto-vaginal septum, it appears clearly that all cases of prolapsion have also a clear connection with a certain morbid condition of the levator muscles. The same thing happens in the case of falling of the palate or uvula, which is clearly a muscular weakness, arising from an inflammation, either acute or chronic, of the substance of the palate or uvula. " It hence appears, that in cases of prolapsus uteri, I suppose, that one great object to be held in view is the restoration to the levators of their lost or dimin- ished contractility. "Doubtless, cases of prolapsion are most to be feared after long, tedious, or instrumental labors—labors where, from rigidity or bad proportion, the child has remained many hours within the pelvic cavity, jamming the muscular and other tissues within, against the sides of the ischia, whose bony walls on the one hand contuse these muscles, while the head on the other is equally capable of affecting them with contusion. " After such a labor, a woman is very apt to get up from her lying-in with weakened levators, with the rectum feebly supported, and the uterus consequently lower than it ought to be; in fact, very few women are to be met with in whom, after giving birth to one or two children, the womb is not found very low in the pelvis. If she early becomes a widow, or at an early age ceases to bear children, the tension of these tissues is at length restored to the womb, and the whole perineum, indeed, rises again, until the approach of age is evinced by the last and permanent fall of the perineum with all the contents of the pelvis. " Under this view, how necessary does it seem that such patients should avoid all the causes of tenesmus, such as costiveness on the one hand, and drastic or other harsh cathartics on the other, pessaries of a bad construction, or of too large a size, strangury, debilitating discharges of leucorrhea, and, in short, what- ever might serve to promote the descent of the perineal texture, the descent of 346 DISEASES OF WOMEN. And lastly. Cases from time to time occur, Avhere, from laceration of the perineum, etc., no ordinary pessary can be retained." 717. Having thus considered the three most common means of treating this displacement, and seeing that these can not be depended on to effect a radical cure of the disease, Ave will noAv consider those measures which have for their object the restora- tion of the natural support of the parts. 718. Our first object in a case of this kind, is to restore the general health of the patient, Avhich is more or less affected, and thus indirectly give tone and vigor to the perineal structures. To this end, any dyscrasia to which the patient is subject, should be corrected, the boAvels kept regular, and the urinary and cutaneous secretions kept free. The patient should be placed upon the use of the vegetable tonics and iron, and stimulants if they are needed;' she should be advised to take plenty of exercise in the which is incompatible with a due elevation of the organs whose support in situ naturally absolutely depends upon them. " I beg leave to remark that, in pursuance of a plan of treatment, by rest in a horizontal posture very long continued, the muscular force of the patient is not unapt to be exhausted, and that it is not unusual for persons subjected to such treatment, to rise from a confinement to the bed of several months duration, not at all amended in health, and, consequently, greatly disappointed, if not injured by the treatment. In such patients, a method calculated to invigorate and enhance the muscular energies would be far more likely to produce a cure which would coincide with a rise or elevation of the perineum. Hence, I have, in many instances, found my patients to recover perfectly, when I have counseled them to take exercise, to be much in the air and light, to live upon a nutritious diet, tc take wine and malt liquor, and to disregard, as far as possible, the painful or annoying sensations proceeding from the prolapsed state of the womb; assuring them that, probably, in proportion as their general health should improve, so would the local disorders, under which they suffered, gradually lessen and finally disappear. I have seen a lady this day, who, at the age of forty-nine years, informs me that she has scarcely been a day or night without a pessary for four- teen years past, an instrument for which she has not the least occasion, and perhaps never has had. " In making these remarks, I desire to apply them to cases where the use of the pessary is a question of. doubt, for, beyond dispute, there are many women who can enjoy neither comfort nor health without the aid of these remedies, which, as our author states, are sanctioned by the common consent of the profes «iou for ages past." DROPSY OF THE UTERUS. 347 open air, and to live upon a nutritious but digestible diet. Strict attention should be paid to the state of the skin, using the bath at least once a day, and accompanying it Avith considerable fric- tion. As the general health improves, in a majority of cases, an equal improvement will be observed in the local disease. Dr. Meigs in reference to constitutional treatment, remarks: "I have, in many instances, found my patients to recover perfectly, when I have counseled them to take exercise, to be much in the air and light, to live upon a nutritious diet, to take Avine and malt liquor, and to disregard as far as possible, the painful or annoying sensa- tions proceeding from the prolapsed state of the womb; assuring them, that probably in proportion as their general health improved, so would the local disorders under which they suffered, gradually lessen and disappear." 719. In regard to local measures, our first attention should be directed to the removal of any disease of the vagina or uterus that may exist. Thus, if there be a chronic inflammation of the mucous membrane of the vagina, it should be removed in the manner already described, when treating of that disease. In the first degree of prolapse, many cases will present themselves in which the displacement was caused by hypertrophy of the cervix; the removal of this diseased condition will be followed by a cure of the displacement. After the removal of these diseases, or if the prolapse existed without them, the local applications should entirely consist of cold water, applied to the lower portion of the abdomen and pelvis with the hand, and used as a vaginal injec- tion, with a pump-syringe. 720. To increase the tone and strength of the abdominal and perineal muscles, they should be exercised by compressing and kneading them with the hand. Having reduced the uterus as much as possible, the patient lying in a horizontal position, the nurse should be directed to manipulate or knead the muscles of the perineum and abdomen with the hand, and this should be repeated once or twice a day. This exercise of the muscles I have found of greater benefit than any other measure, the condition of the patient being sensibly improved by it in a foAV days. 348 DISEASES OF WOMEN. 721. Dr. Keith informs me that he and others have used the galvanic battery in these cases with marked advantage, in fact, he considers it much preferable to any other mode of treatment. He applies the positive pole of the battery to the lumbar region of the spinal cord, the negative pole being introduced into the vagina. Under its influence he has observed the vagina, which was so lax as to permit the uterus to pass down with very little resistance, become so contracted, that the uterus was retained in its normal position, though the patient was told to run up and down stairs, jump, cough, etc. He has likewise noticed, that by taking the negative pole in one hand, and intro- ducing the index-finger of the other to the os uteri, the current passing through him, that the uterus would be elevated and drawn aAvay from the finger. He further states, that the benefit derived in this manner is permanent, the muscles being stimulated and invigorated by each application, Avill in a short time be able to afford a proper degree of support. 722. The reduction of the displaced uterus is generally very easy, in the first or second stages, when unaccompanied with any complications. The patient lying in a horizontal position, with her hips elevated, and the thighs flexed upon the abdomen, the physician, by the introduction of one or two fingers to the os uteri, can readily replace it; in fact, in many cases it will itself assume its natural position. 723. In complete prolapsus the reduction is sometimes attended with much difficulty. In this case, according to M. Colombat, it is proper, before proceeding to the reposition, that the patient should empty the bladder and rectum, either spontaneously or by means of the catheter and a common enema. Provided the uterine tumor, as frequently'happens, should be found painful and sore from the action of the air, the urine, or the friction of the clothing, emollient poultices ought to be applied to it, and the swelling should be reduced by general remedies, such as fomenta- tions, baths, diluent drinks, laxatives, etc. After the parts have been brought into a condition more favorable for the reposition, the woman should be directed to lie down in a position more inclined even than that recommended in incomplete prolapsus; DROPSY OF THE UTERUS. 349 the physician, after anointing his fingers, as well as the tumor itself, with cerate or oil, should seize it with his right hand, and, giving a few rotary movements, in a gentle manner, and then elevating and depressing it by turns, should press it backAvard into the pelvis, following the direction of the axis of the inferior strait, meanAvhile using the fingers of the other hand at the labia, to facilitate the return of the womb into the body. 724. To support the uterus during the treatment for the radical cure of the disease, a perineal supporter (Fig. 34-5,) should be constantly worn by the patient through the day, when she is in an upright position, and taking exercise. This supporter consists of a Avell-fitted abdominal bandage or jacket, furnished with Avhale- bones, to keep it from wrinkling, and made so that it will give a constant and steady support to the lower and anterior portion of the abdomen ; from this jacket extends two stout and inelastic bands, which pass between the thighs, and button or buckle on the opposite part of the bandage ; immediately under the peri- neum, where these straps cross, a perineal pad is attached, which presses upward against the perineum, and gives the requisite Fig. 34. Perineal Supporters. Fig. 35. degree of support. This perineal supporter has been used by Dr. Brown and others, and is preferred to any other means of sup- port. In my practice I use it altogether, and prefer it to any and 350 DISEASES OF WOMEN. all contrivances Avhich have been recommended for the same purpose. 725. In those cases where the prolapsus arises from rupture of the perineum, the operation recommended for this difficulty should t e resorted to, and with the restoration of the perineum the uterus Avill assume its normal position. 726. In cases in Avhich the perineum is thin and much weak- ened, its restoration to a normal thickness and strength, by a surgical operation, will effectually remove the displacement. These cases are the hardest to cure; in fact, where the perineum is greatly Aveakened, as it is in some rare instances, this operation is the only sure means of relief. The principle of the operation is the same as in prolapsus vagina, to increase the thickness of the perineum, and contract the size of the vagina. As the operation is nearly the same as for vaginal prolapse, the reader is referred to that for the description. Retroversion of the Uterus. 727. This displacement, though not of such common occur- rence as prolapsus uteri, is still frequently met Avith, both in the pregnant and in the non-pregnant female. It consists in a dis- placement of the fundus uteri backward, the cervix being thrown forward against the bladder, the entire organ assuming, more or less, a transverse position in the pelvis. It will be recollected, that in its normal condition the uterus corresponds in direction with the axis of the superior strait, or a line drawn from the apex of the coccyx to the umbilicus; it is not, therefore, situated perpendicularly in the axis of the body, but is normally ante- verted. The vagina, on the contrary, is situated in the direction of the axis of the inferior strait or outlet of the pelvis, and, con- sequently, the union of the two forms an obtuse angle. The uterus is said to be retroverted when its direction corresponds with the direction of the vagina, or when the angle formed by the two is posterior instead of anterior, the displacement varying in degree from the slight form first spoken of, to that in Avhich the organ assumes a transverse position in the pelvis, or in some rare cases, Avhere the fundus descend to a lower level than the cervix. retroversion of THE UTERUS. 351 728. Retroflexion is but another form of the same disease, and practically considered, it does not need a separate consideration. In this form of the displacement the uterus is bent upon itself Fig. 36.—Retroversion of the Uterus. like a retort, the fundus being thrown backward against the rectum, the cervix retaining its natural position in the pelvis. In regard to this displacement, Dr. Bennet says : " If the neck of the uterus be healthy and soft, the body of the uterus, in falling, does not alter the position of the cervix, and a bend or angle takes place between the two, the concavity of Avhich is backAvard and doAvnward. On the contrary, if the cervix is enlarged and indurated, and the induration extends into the body of the uterus, the cervix is throvvn up toAvard the symphysis pubis, and no curvature is observed." Though this difference is found to exist 352 DISEASES OF WOMEN. in practice, yet it makes little or no difference in the symptoms developed by the disease, nor in the measures adopted for its relief; the distinction, therefore, is practically useless. 729. Causes.—The proximate causes of this displacement are, a laxity and Aveakness of the uterine supports, or an increased weight of the fundus, posterior wall, or even of the entire uterus, or both. Thus, frequent child-bearing, abortions, chronic inflam- mation of the genital mucous membrane, etc., Avill give rise to laxity of the tissues, Avhile inflammation, by producing hyper- trophy, congestion, fibrous tumors, etc., gives the increased weight to the organ. In the early period of pregnancy, the most frequent cause of retroversion is a long-continued distention of the bladder, which either gradually, or under the influence of a sudden shock or impulse, as by a fall, coughing, vomiting, etc., pushes the uterus downward and backAvard into the holloAv of the sacrum. 730. Symptoms.—In some cases of retroversion of the unim- pregnated uterus, says Dr. Simpson, more especially when the displacement is chronic, and the pelvis large, as in some other forms of uterine disease and of pregnancy, feAV or no marked functional or sympathetic symptoms, either local or general, are present; while, in other instances, the attendant functional derangements and irritations are excessively severe and distress- ing. And in this, as in other uterine affections, betAveen these two extremes Ave may meet with every shade of difference. 731. "In retroversion, as in other morbid conditions and diseases of the unimpregnated uterus, the accompanying sympa- thetic derangements or symptoms are, when they are well marked, more or less perfect imitations of the secondary phenomena of pregnancy. Dyspeptic and hysterical symptoms are sometimes present, with local neuralgic pains in the mammae, in some por- tions of the vertebral column, or, Avhat is still more frequent, in the parieties of the abdomen or chest, and, more especially, in a limited spot beneath the left mamma. The displaced position of the uterus often gives rise to mechanical irritations and symptoms of the same kind as if the organ Avas morbidly enlarged. Constipation and impeded defecation are frequent results, partly from the RETROVERSION OF THE UTERUS. 353 fundus of the displaced uterus physically compressing the caliber of the rectum, and partly from its producing a functional inability to expel the feculent contents of the bowel through the loAvest part of the canal. Occasionally the boAvel is irritated, and there' are discharged from it, from time to time, quantities of mucous or fibrinous-like effusions. The bladder frequently suffers from dysuria or retention, and, much more rarely, I have seen a degree of incontinence, especially Avhere the urine has become phos- phatic, from the want of poAver, in some cases, of completely emptying the bladder. Symptoms of Aveight, tension, and bearing doAvn in the regions of the uterus and rectum, Avith dragging at the loins and in the region of the uterine ligaments, are very common. Pains often stretch doAvn one or both of the loAver extremities. Occasionally there is an inability to bear carriage- exercise, and Avalking and standing speedily produce fatigue. In a feAV cases I have knoAvn the patients to find themselves forced to remain almost constantly in the horizontal position, from the intense and overpoAvering feeling of pressure and malaise which the erect posture ahvays brought on, and the power of standing and progression restored by the spontaneous or artificial reposition of the uterus. In general, all the symptoms, local and constitutional, Avhich I have alluded to, are aggravated, more or less, by exercise in the erect position ; and they are more particu- larly liable to be increased in their intensity Avhen the uterus hecomes periodically congested and heavier, at the recurrence of each menstrual period." 732. The menstrual function, in some cases, is not altered at all, continuing regular both as to time, duration, and quantity, but in other cases it may be affected most oppositely and variously. Sometimes the secretion is suppressed, at others there is dys- menorrhea, and at others menorrhagia. In some cases the natural mucous secretion is not increased, but generally there is a degree of irritation or sub-acute inflammation, Avhich gives rise to a more or less abundant leucorrheal discharge. It is said that Avhen a female Avith a retroverted uterus becomes pregnant, abortion is apt to take place. Many cases, however, are reported, in which utero-gestation Avent on to full term, the position of the 23 354 DISEASES OF WOMEN. uterus becoming spontaneously rectified by the consequent enlargement of the uterus ; again, some rare instances have been observed, Avhen the occurrence of impregnation increased the displacement. Very often the existence of this displacement is a cause of sterility, conception having taken place Avhen tho displacement Avas rectified. 733. When the impregnated uterus is retroverted, the displace- ment always occurs while the organ still remains within the cavity of the pelvis, or before the eighteenth week. It is generally not indicated by any marked change in the condition of the patient, and she generally remains ignorant of her condition until an attempt is made to relieve the bladder. On attempting to pass the urine, a stoppage Avill be observed in it, and sometimes even the most straining efforts are inffectual in emptying the bladder in the least. " I Avish it to be understood, hoAvever," says Dr. Blundell, "and it is very important that this should be known, that, in the retroversion of pregnancy, you have not always, nor, I think, generally, the complete retentions of urine; for, often when the uterus is retroverted, the retention is partial. Day after day the fluid is sparingly emitted, but never in such quantity as to empty the bladder completely, till by and by the secretions begin to steal away involuntarily, or she may have strong efforts to pass the urine, even against her will, and with every effort a small gush only may be produced, or there may be a continual dripping; and yet, notAvithstanding all this, an accumulation of water may go on very gradually increasing, so that several pints, nay several quarts, may be gradually accumulated." The pressure exerted by the fundus of the organ upon the rectum, gives rise to a constant desire for defecation, even Avhen the boAvels are empty, and to great difficulty in evacuating them. 734. Should these symptoms pass unrelieved, says Dr. Tyler Smith, the bladder becomes enormously distended, and it is* sometimes ruptured mechanically, or its coats inflame and ulcerate, allowing the urine to escape into the peritoneal cavity, and the patient sinks or dies of peritonitis. If the uterus can not be replaced, and the water is occasionally and with difficulty drawn off, the bladder gradually relaxes and elongates, and its mucous RETROVERSION OF THE UTERUS. 355 membrane becomes diseased; muco-purulent, ammoniacal, and bloody urine is passed, and the kidneys may become diseased, by the effects of the backward pressure of the urine. The structures betAveen the bladder and the uterus may become inflamed, and the patient be destroyed by irritative fever. In some instances all these mischiefs are averted or modified by the occurrence of spontaneous abortion. In others, the displacement continues to the fifth or sixth month, without destroying the patient, and it has been knoAvn to go on to the full term without causing a fatal result. 735. Diagnosis.—The general symptoms already named, though they point to the uterus as the seat of the disease, are not sufficient to enable us to determine its character, and here, as in most other uterine diseases, our main dependence is placed on the results of a physical examination. 736. By making an examination per vaginam Ave will feel a solid tumor at the posterior part of the vagina, smooth and roundish on its surface, and more or less sensitive to pressure. Anterior to this tumor may be felt the cervix uteri, either thrown forAvard and upward as in retroversion, or maintaining its usual position as in retroflexion. By passing the finger backward along the cervix, the connection betAveen it and the posterior projection may in general be easily made out. When the displacement is recent, and the uterus not enlarged, the diagnosis may often be greatly assisted by moving the uterus, elevating its fundus by a finger introduced into the rectum, and drawing the cervix doAvn- ward, by a finger or some suitable instrument introduced into the vagina; in this manner the connection betAveen the cervix and the posterior projection may be very easily determined. 737. The presence of the symptoms named, and the results of a tactile examination, Avill ahvays be sufficient to detect the displacement in the impregnated uterus. But we have a more certain means of diagnosis in retroversion of the unimpregnated uterus by means of the uterine sound. In the natural position of the organ, the uterine sound is readily introduced Avith its concavity directed forward) the point of the instrument being directed toward the umbilicus; but, in this displacement, the instrument can not be introduced in that manner, as it is resisted 356 DISEASES OF WOMEN. by the changed position of the organ. By turning the concavity of the instrument backward, however, so that its point will be directed toward the hollow of the sacrum, it will readily pass. This changed position of the direction of the uterine cavity is p sitive evidence of the character of the displacement. But Ave may make the examination still more complete and accurate, by ascertaining, by a vaginal or rectal examination, that the point of the bougie is lodged in the center of the tumor; showing that it is the displaced fundus, and after this, by gently turning the instrument round so that its concavity will look toward the symphisis pubis, the uterus will be replaced, and the posterior tumor can no longer be felt. 738. Treatment.—The replacement of the uterus, is obviously the first thing to be accomplished in all cases, both in the pregnant and in the non-pregnant female. As the means employed to effect this, however, differ in the tAvo cases, we will have to consider them separately. 739. In retroversion of the unimpregnated uterus, there is very frequently a chronic inflammation, or congestion of the organ, which perhaps has been the cause of the displacement. This as Avell as any other disease of the uterus predisposing to displace- ment, must be subdued before the organ will retain its position when replaced. A very good means of replacing the organ is to introduce one or tAvo fingers into the vagina, and pass them up between the cervix uteri and the rectum, pushing up the posterior vaginal wall, and thus elevate the fundus of the organ, at the same time the cervix may be drawn down by a small instrument made like one blade of the forceps, or any thing else that will answer the purpose. Another, and perhaps the best means of replacing the uterus, is by means of the uterine sound. Having introduced the sound into the cavity of the uterus, if it is gently turned so that the concavity of the instrument Avill look toAvard the symphysis pubis, the retroverted organ will be carried into its natural position by the changed position of the point of the instru- ment. This use of the uterine sound generally occasions no pain, if care be used ; but if handled roughly, much pain and mischief may be the result. RETROVERSION OF THE UTERUS. 357 739. Before the replacement is effected, the bladder and rectum should be emptied, and after the replacement it is of the utmost importance that the urine should be frequently passed, never alloAving the bladder to become in the least distended. This part of the treatment is of the greatest importance, for if the bladder is allowed to become distended, it will almost invariably reproduce prolapse. 740. Several mechanical contrivances have been used and recommended to the profession to retain the uterus in its position. To these instruments, however, the same objections hold good that were urged against the use of pessaries in prolapsus uteri, Avith but one exception, Dr. Simpson's intra-uterine pessary. This last instrument supports the uterus by a stem, which passes into the uterine cavity, the cervix resting upon a bulb attached to the stem, the entire instrument being supported from below. Dr. Simpson says, that in his practice but very little irritation has followed their use, and in no case have they produced any serious results. But from the knoAvn sensibility of the mucous membrane lining the cavity of the uterus, we should suppose that this intra-uterine stem Avould not be so readily tolerated. Dr. Aslnvell mentions some cases in which great suffering resulted from its use, and Dr. Oldham mentions others where death was the consequence. Dr. Churchill states that tAvo cases have been mentioned to him, in Avhich the instrument was introduced, but it occasioned such agony, that it had to be withdraAvn in both, Avithin tAventy-four hours. "Upon the Avhole, therefore, I should feel great hesi- tation in recommending such an instrument, although it must be admitted that some contrivance for this purpose is very desirable. If it be used, the patient should be kept very quiet, very carefully watched, and the instrument removed if it occasion any pain." 741. There is no doubt in my mind, but what if the inflamma- tion and enlargement or the congestion of the uterus be first removed, and the measures recommended in prolapsus uteri, for the restoration of the general health, and the tone and strength of the perineal structures be folloAved, that there never Avill be any necessity for direct mechanical support, "the perineal sup- 358 DISEASES OF WOMEN. porter being all that is required," and this only during the general treatment. 742. Dr. Meigs considers that in most of the instances of retro- version in the early months of pregnancy, the displacement is attributable to a distended state of the bladder, he says: " A female riding in a carriage, or placed in such a situation that she can not Avithdraw from the company Avithout being suspected of a desire to urinate, will allow the bladder to fill almost to bursting; and if she be pregnant about three months, she Avill scarcely fail to have retroversion of the Avomb. When at last she obtains an opportunity to evacuate the bladder, she finds she has a partial or total suppression of urine." Fig. 37.—Air Pessary of M. Gariel. 743. In regard to the treatment of these cases, he says: " Having succeeded in drawing off the Avater, the patient, if neces- sary, should have a copious enema, in order to unload the rectum, which, if replete Avith fecal matters, might offer considerable obstacles to the success of our attempt. In the next place, Ave ought to endeavor to raise the fundus—the patient lying on her left side—by pressing the bas-fond of the Avomb, which can be felt RETROVERSION OF THE UTERUS. 359 through the hinder surface of the vagina upAvard, Avith the fingers, so as to lift the whole mass in a direction parallel with the axis of Fig. 38. the brim. The cervix uteri is tied to the more anterior parts of the pelvis by the \Tagina and the vagino-vesical septum, so that if we carry the mass considerably upAvard, it must be by tilting the fundus in that direction. Attempts of this kind will not always succeed. Where they fail a finger may be passed into the rectum, the fore-finger of the left hand, if the woman is on her left side, and of the right hand, if she be upon her back. Before the finger has passed very far, it meets Avith the fundus uteri, which presses upon the canal of the intestine; in this situation we have far more power to move the womb than when the effort is made only from the vagina. Pushing gently and steadily upward, Ave find the mass gradually to recede, until at length the fundus, liberated from its restraint, suddenly emerges, with a sort of jerk, from under the promintory, from which instant the woman is cured." 744. Sometimes much difficulty Avill be experienced in intro- ducing the catheter, often indeed the common female catheter can not be used; in this case an elastic male catheter should be used, and the uterus may be pressed backAvard, so as to liberate the urethra until the catheter is passed. 500 DISEASES OF WOMEN. 745. If the means above spoken of should fail to replace the uterus, Ave may resort to the use of the instruments of M. Gariel, or of Dr. Henry Bond of Philadelphia. "M. Gariel's instrument consists of a dilatable air pessary, terminating in a tube, and an air reservoir, Avith small taps affixed to each. After immersion in Avarm Avater, the collapsed pessary is passed into the rectum, behind the uterus, by means of a probe. The air reservoir is then fitted to the tube of the pessary, the taps are opened, and, by the pressure of the hand, the air contained in the reservoir is transferred to the pessary, so as to lift the uterus out of the holloAv of the sacrum." 746. Dr. Bond's instrument, as described by Dr. Meigs, " consists of tAvo arcs of circles of different radii; the inner one is terminated by a small oval piece of ivory ; the outer terminates in a small ivory ball. The exterior arc is formed at its loAver extremity into a plate-piece, in Avhich is a mortise ; to the end of this plate-piece is attached an ivory handle, by Avhich it may be conveniently held. The inner or smaller piece is attached to a sliding-piece, also mortised, and overlapping by its edges the mor- tised plate-piece, and secured by a clamp or pinch traversing the mor- tises, and fastened or loosened by turning the thumb-piece. If the thumb-piece be unscrewed, the clamp may be turned lengthwise, and the arcs are then easily separated. In order to use the instrument, the arcs should first be separated, and the ivory-ball on the largest arc intro- duced into the rectum, while the oval one on the smaller arc should be introduced into the vagina. By slid- ing the smaller arc upAvard, the iavo balls can be placed opposite to each other; or the vaginal arc can be set a quarter of an inch, a half inch, or Fro. 39.—Instrument of Dr. Bond, an inch loAver down than the one ANTEVERSION OF THE UTERUS. 361 that is in the rectum. Upon being adjusted, and firmly secured by turning the thumb-piece, it it manifest that the tAvo balls can not be separated from each other, and that, if they be moved upward, parallel Avith the curve of the sacrum to the hight of the promintory, they must carry the retroverted uterus before them, and thus serve very effectually and easily to reposit the dislocated organ." 747. In cases in Avhich all measures are ineffectual in replacing the retroverted uterus, tAvo methods of procedure are still open. First, to leave the case to nature, merely palliating any severe symptoms that may arise, but carefully keeping the bladder and rectum empty, and wait until the uterus, by its increased size, has elevated itself out of the pelvis, or until labor spontaneously occurs. Or, secondly, we may induce premature labor by puncturing the membranes through the os, or by tapping the uterus through the vagina and rectum. Many objections are urged against the first of these measures, as, the very severe symptoms Avhich arise during this condition, and Avhich often prove fatal, and the little likelihood of a favorable termination in the manner spoken of. If, hoAvever, it be adopted, it would be Avell to folloAv the advice of Denman, " to alloAv but little liquid, keeping the bladder thoroughly emptied, by the use of the catheter, tAvo or three times a day, and in maintaining, for hours together, an inverted position of the pelvis, by placing the patient on her knees and elboAvs." Dr. AshAvell says: —" It is not ahvays easy to puncture the membranes through the os, OAving to the elevated position of the cervix ; and, if Ave fail in repeated attempts to accomplish this purpose, tapping the uterus is our only resource. The extreme symptoms will not often allow us, even Avere Ave disposed, to content oursehres with drawing off the Avater and palliating symptoms to the time of labor." 748. In some cases where the pehis is large, and there is great laxity of the tissues, it may be proper to confine the patient to the horizontal position, until the uterus has arisen out of the cavity of the pelvis, to prevent a re-displacement of the organ. These cases, however, are fortunately rare, in the most of instances, keeping the bladder emptied of urine, and attention 302 DISEASES OF WOMEN. to the general health will be found all-sufficient to prevent displacement. Anteversion of the Uterus. 749. This displacement is the opposite of the one just described, the fundus being carried forward toAvard the sym- physis pubis, and the cervix uteri thrown backward against the rectum. It is the least frequent of the uterine inal-positions, and is very rarely met Avith, and only in the unimpregnated condition. In this displacement we have tAvo varieties, the same as in retro- version, anteversion and anteflexion; in this last, the uterus is Fig. 40.—Anteversion of the Uterus. bent at the junction of the cervix with the body of the organ, the fundus being displaced forward, Avhile the cervix retains its anteversion of the uterus. 3G3 natural position, the angle formed looking forward and downward. This distinction, though noticed by most authors, is of very little importance, the treatment of the two conditions being exactly similar. 750. As has already been stated, in the normal condition of the parts, the uterus may be said to be slightly anteverted, the direc- tion of the uterus corresponding with the axis of the superior strait. In this position, it rests anteriorly upon the bladder, and posteriorly it is in contact with the rectum. From this oblique position of the uterus in reference to the axis of the body, it is obvious that the bladder in a measure supports it, and that so long as the bladder is moderately distended, this accident may be con- sidered impossible. When it does take place, the fundus uteri is directed toward the inner surface of the symphysis pubis, Com- pressing the urethra, the entire organ being situated transversely across the pelvis. 751. Causes.—" For the production of anteflexion or antever- sion," says Dr. Churchill, " it is necessary that the fundus uteri should be rendered somewhat heavier than natural, compared with the inferior portion of the organ, or else, that a decided tilting forward should be occasioned by a force external to the uterus. This may be effected in the unimpregnated state by means of chronic enlargement of the anterior Avail, by tumors growing from or imbedded in that part, by great congestion, etc. If the bladder be empty, and a sudden expulsive force be exerted at the same time, the uterus may be tilted over anteriorly, especially if the ligaments have been relaxed by previous pregnancies. Preg- nancy, by increasing*the Aveight of the fundus uteri, will so far fulfill one of the necessary conditions, but the displacement can only happen during the first two or three months. In some cases, it has been discovered that the first displacing power resulted from an accumulation of faeces high up in the rectum, which pressed forward the fundus uteri. In others, an attack of chronic metritis has rendered the womb top-heavy, or the same effect has been produced by a fibrous tumor, or by miscarriage. We must also suppose, I think, that some relaxation has taken place in the surrounding soft tissues. A bloAV, a fall, a shaking in an uneasy 364 DISEASES OF WOMEN. carriage, obstinate diarrhea, have all been enumerated as exciting causes." 752. Symptoms. — The symptoms of this displacement are almost entirely mechanical, and similar to those produced by retroversion, though not in general so Avell marked. If the dis- placement comes on gradually, the symptoms Avill be so slight that it will be almost impossible to determine the precise time of their origin. The most common symptoms are a sense of fullness in the pelvis, of weight and bearing doAvn Ioav doAvn behind the pubis, accompanied Avith Aveight and pain in the perineum and rectum, frequent desire to pass Avater, but great difficulty in doing so. In some cases where the displacement is suddenly produced, as by a fall, severe straining, as in coughing, vomiting, etc., the symptoms Avill be very marked, the pressure of the uterus against the urethra producing partial, or in some cases, complete retention of urine. These symptoms though indicating disease of the uterus, are not sufficient to point out the special affection, as they are common to most all the displacements, and to some other diseases of these organs. 753. If a vaginal examination be made at this time, the finger will come in contact Avith a tumor projecting into the anterior Avail of the vagina, and the cervix Avill in anteversion be found throAvn backAvard and pressing against the rectum. By passing the finger forAvard along the cervix, its connection with the anterior projec- tion can readily be made out. The diagnosis may be assisted by elevating the fundus and depressing the cervix uteri Avith the fingers, or if there is no suspicion of pregnancy, the uterine sound may be used; if this is used, it will not pass in the usual direction, but the point will have to be directed much more forAvard, the handle being throAvn backAvard toAvard the sacrum. 751. Diagnosis.—If the uterine sound be used, the diagnosis will be very easily made out. But Avithout this, it may be distin- guished from retroversion by the projecting tumor being in the anterior Avail of the vagina, and the cervix uteri being throAvn backAvard against the rectum. From pelvic tumors, by tracing the connection between the cervix and the fundus continuously across the pelvis, and by trying to replace the organ, the move- INVERSION OF THE UTERUS. 365 ment showing the connection between the two; by the same means it may be distinguished from ovarian tumors. As shoAvmg the importance of a correct diagnosis, the case of Leveret might be cited. He confessed that the only case of anteversion he ever met with, he mistook for a stone in the bladder; and the mistake Avas only corrected by a post-mortem examination, the Avoman having died after the operation for stone. 755. Treatment.—The treatment, of this displacement is much easier than that of retroversion; the distention of the bladder and efforts to evacuate the bowels, Avhich tend to aggravate the displacement in retroA7ersion, tend to replace the uterus in ante- version. To replace the uterus the patient should be placed upon her back, with the hips considerably elevated; the cervix should then be drawn doAvn with the fore-finger of one hand, while the fundus uteri is pushed up Avith the other. The uterine sound may also be used to replace the uterus in the same manner that was recommended in retroversion; after the sound is introduced, by draAving its handle forAvard the fundus uteri Avill be carried up into its natural position. Prof. Godfrey recommends that the patients be placed on the side of the bed, Avith their heads and hands on the floor, Avith only the anterior parts of the thighs and legs resting on the bed. In this position, the intestines are draAvn toAvard the diaphragm, the pelvis is consequently emptied, and the uterus, being so pressed upon, assumes its normal situation. 756. After the uterus has been replaced, the patient should be directed to keep the bladder partially distended for some time, to prevent a re-displacement. In other respects the treatment Avill be similar to that recommended in the other forms of dis- placement. Inversion of the Uterus. 757. This displacement differs widely from prolapse, for Avhile in both there is a descent or protrusion of the organ, in this the uterus is turned inside-out, the mucous membrane forming its external investment, Avhile its cavity, which is directed upward and contains the fallopian tubes and ovaries, is lined by perito- 366 DISEASES OF WOMEN. neum. Fortunately this is the rarest form of uterine displace- ment, as it is the most dangerous. Fig. 41.—Inversion of the Uterus. 758. Inversion of the uterus most frequently occurs imme- diately or soon after labor, though in some rare instances it has been observed to occur in the unimpregnated organ. Boivin and Duges divide this affection into four degrees, each of Avhich offer distinct characteristics for the diagnosis, prognosis and treatment. Each of these degrees may succeed to each other, either gradu- ally or rapidly; each may also be permanent. The first degree consists in a simple depression of the fundus uteri, presenting a concave instead of a convex surface. In the second degree the body of the uterus being inverted, falls into the cavity of the cervix, and projects through the os uteri. In the third degree', the cervix is also inverted, the os uteri alone remaining unin- verted. In the fourth degree, the entire uterus is inverted with partial inversion of the vagina, the organ being passed through the vulva, and hanging between the thighs. 759. Causes.—The causes producing this displacement, as enumerated by authors, are: hard or sudden traction on the umbilical cord, Avhile the uterus is in a relaxed condition; violent pulling aAvay of the placenta, while yet adherent to the uterus; INVERSION OF THE UTERUS. 307 shortness of the umbilical cord, or coiling of the cord around the neck or body of the child, the labor being rapid; the presence of a polypus or other tumor attached to the uterine wall, which by its weight causes inversion, etc. In reference to the cause of this displacement, Dr. Tyler Smith says : " When inversion is referred to traction of the umbilical cord, Avhether in consequence of a short funis, the sudden birth of the fetus while the mother is in an upright position, or the attempts of the obstetrician to remove the placenta, it is always believed to depend on the merely mechanical force which is in operation. It is considered that the fundus uteri is dragged doAvn mechanically through the os uteri and vagina, the uterus being supposed to be passive during the occurrence of the inversion. I have always been of the opinion, that, in the great majority of cases, the accident happens in con- sequence of irregular but active contractions of the uterus itself. No doubt cases may occur, in Avhich inversion is produced by great tension upon the cord, Avhile the placenta is firmly adherent to the fundus, and that all violent traction of the cord Avhile the placenta is attached to the fundus is reprehensible. But Avhen inversion is thus produced, there must be a consenting action of the uterus. This accident has sometimes happened Avhen the hand has been introduced to peel off the placenta from the fundus, when the hand, placenta and uterus have all been forced out by the violence of the abnormal uterine action. All the facts con- nected with this catastrophe, shoAv that it generally depends, not upon a passive, but an active condition of the organ. There are numerous points which prove that it may happen spontaneously, and apart from all interference on the part of the accoucheur. It may occur after the death of the mother, as the result of post- mortem contraction of the uterus. Numerous cases are on record, in which the uterus was found inverted, before any attempt what- ever had been made to remove the placenta, and Avhile the patient was lying quietly in bed. It has even been knoAvn to occur in the unimpregnated uterus. I have elseAvhere insisted, that the unim- pregnated and virgin uterus, particularly under irritation, pos- sesses more motor-poAver than is generally attributed to it. The nulliparous organ has been known to invert itself, as the result of 368 DISEASES OF WOMEN. spasmodic action, in long continued menorrhagia, or as the result of a small polypus or fibrous tumor in the cavity, or upon the peritoneal surface of the fundus. The more this subject is studied, the less will it be referred to merely mechanical derange- ments." 760. Symptoms.—The symptoms that arise from acute inver- sion, or inversion immediately after delivery, are ahvays severe and alarming. It produces violent disturbance of the nervous system, and most generally copious hemorrhage. It is said, that the shock to the system and the hemorrhage, is sometimes as great in partial inversion, as Avhen it is complete. The occurrence of the displacement is marked by sudden exhaustion, or sinking, the countenance becomes deadly pale, the pulse rapid, small and fluttering, the voice Aveak, nausea and vomiting occurs, etc. Dr. Tyler Smith states: " That in complete inversion, the hemorrhage is someAvhat arrested by the os uteri acting as a torniquet to the uterus. But in either case, the shock to the system may be so great, as to cause death Avithin a short time after the accident. The shock is so severe that a fatal result has ensued, Avhen little blood Avas lost, and Avhen, after a short time, the re-inversion of the uterus was affected." There is generally a very violent uterine contraction immediately preceding or accompanying the inversion, causing the patient to suspect a second child, and the passage of the inverted uterus along the vagina may serve to confirm her in this suspicion. 761. On making a vaginal examination, instead of finding the A7agina free, the finger will come in contact with a tumor, globular in form, elastic, sensible, and with a rough and bleeding surface. This tumor may only partially fill the vagina, or it may pass down to the vulva, resting on the perineum, as in the forms of incomplete inversion spoken of; or it may have passed through the A7ulva, and be situated betAveen the patient's thio-hs. If the placenta be still attached to it, it will increase the size of the tumor, and make the diagnosis much easier. 762. In the chronic form of the displacement, Avhich is extremely rarely met with, the symptoms vary so much, that their enumera- tion Avould add nothing to our practical knoAvlcdgc of the displace- INVERSION OF THE UTERUS. 369 ment. In some cases reported, the inversion had been of years' standing, and yet the patients enjoyed a tolerable degree of health ; and in none of these cases have the symptoms been more severe than in cases of complete prolapse, in fact, those described would answer as Avell for the one displacement as the other. 763. Diagnosis.—The diagnosis of this displacement is quite easy Avhen the placenta is adherent to the inverted uterus ; but Avhen the placenta has been previously expelled, and nothing but the inA-prted uterus felt in the vagina, there are circumstances Avhich make it quite hard to determine the character of the affection. Dr. Tyler Smith says : " In true inversion, the globular Avail of the uterus is entirely absent from the hypogastrium, and a bleeding mass is found in the vagina, or protruding externally. This mass may, hoAvever, he simulated to some extent by a prolapsus or procidentia, occurring immediately after labor, or by the extrusion of a polypoid tumor after the expulsion of the placenta. In the case of the prolapsed or procident uterus, the diagnosis is easy, from the presence of the os uteri in the most depending part of the tumor. The distinction betAveen polypus and inversion is not so easy, particularly Avhen the polypus is of a fibrous character, and of the same density and structure as the Avails of the uterus itself. In the case of polypus, there is the sensation of a solid mass ; and in inversion, that of a holloAv organ is conveyed to the finger. When punctured or pricked, the uterus is said to be much more sensitive to pain than the polypoid tumor. In complete inversion, the fossa round the base of the tumor is limited in extent, while in polypus the finger may be passed into the cavity of the organ, the pedicle can generally be felt, and there is the uterine tumor in the loAver part of the abdomen. Great care is required in the diagnosis, as cases have occurred in which a polypus has been mistaken for an inverted uterus, and, in some instances, inA-ersion has occurred Avithout the accident having been recognized at all, until long after the time of*labor. 764. Treatment.—Where the inversion has taken place imme- diately after delivery, the reposition of the uterus should be undertaken as soon as possible. It is laid doAvn as a rule, that the sooner the reduction is attempted the easier it may be accom- 24 370 DISEASES OF WOMEN. plished, on account of the rapidly increasing contraction of the os uteri, which, by impeding the circulation of the uterus, causes an increase in its size. Though- the most favorable time for the reposition of the uterus is immediately after the accident, yet Ave should not consider the case hopeless, though it Avas of several days' standing. Many cases are reported in which the reduction was effected after from ten to tAventy-four hours had elapsed, others after the lapse of from three days to tAvelve Aveeks, and one of fifteen months' standing, under the influence of chloroform. 765. In the incomplete form of inversion, tAvo or three fingers of one hand may be introduced into the vagina, and the fundus uteri carried up through the os to its proper position. It Avould be well to folloAv the recommendation of Prof. Meigs, to make compression on the uterus only during the absence of contraction, and Avhen the organ is someAvhat flaccid. After the reposition of the organ, the fingers should not be AvithdraAvn until after contractions have taken place, as otherwise the displacement might speedily recur. 766. In complete inversion the placenta should be detached, if it adheres, so as to reduce the bulk of the tumor, and it is also advised by some authors, to reduce the size of the uterus, as much as possible, by pressure. Then when contraction of the uterus is absent, and it is someAvhat flaccid, the hand, Avell oiled, should be pressed against the center of the fundus so as to indent it, and then by moderate but sustained pressure, the fundus should be carried up through the body cervix and os uteri, to its proper position. Dr. DeAvees and others recommend that the o-lohe should be grasped Avith the hand, and the entire mass pushed upAvard into the pelvis. Dr. Meigs, in a note to M. Colombat, reports a case in Avhich he tried the method of Dr. DeAvees, but without the least success; he says: "After I had removed the after-birth, I found that the organ became alternately soft and rigid, just as happens after delivery in an ordinarv labor; and 1 further observed that to handle it Avas to irritate its contractility and to harden it, which rendered it obdurate against every attempt at reduction. I was compelled, therefore, to do what M. Colombat so pointedly condemns: i.e., to wait until it became relaxed, and INVERSION OF THE UTERUS. 371 then indent the fundus, and to drive that cone up through the cervix and os uteri, until 1 had carried my hand so high that the external organs contained my arm to not more than four or five inches below the elboAV. I feel very confident that if, in any case, I could succeed in indenting a fundus uteri, and in bringing the cone up to the os uteri, I could ahvays perfect the operation by gently pressing that cone against the ostium uteri, which, under a persevering maintenance of the pressure, Avould yield as readily as it does to a labor-pain, or to the cone of the hand, Avhen introduced in cases of hour-glass contraction or spasm of the cervix under encysted or retained placenta. I dare recommend to the reader, therefore, to disregard the author's injunction, and to adopt the method Avhich I have found successful." 767. After the uterus has been replaced, the hand should by no means be Avithdrawn, until the uterus has contracted to expel it, and until it is certain that the restoration is complete. It is recommended that the patient should be kept longer in the horizontal position than usual, and that she should lay Avith the pelvis someAvhat elevated. The exhaustion and depression of the system should be removed by appropriate stimuli, and other measures, the same as if they had occurred from any other cause at this period. 768. WThere the inversion has been of several days' standing, it would probably be advisable to place the patient under the influence of chloroform before attempting the reposition. In the case of M. Barrier, the displacement Avas of fifteen months' standing, and the reduction was accomplished under the influence of chloroform. 769. In cases of long standing, Avhere reduction Avas impossible, it has been recommended to replace the uterus in the vagina and to sustain it there by means of the perineal supporter heretofore described. This, Avhen it can be accomplished, Avould be decidedly the best treatment. Again, it is recommended to extirpate or remove the uterus, either by means of the ligature, or by the knife. This operation has proved successful in many cases, and in other cases it Avas less fortunate, the patient surviving the operation but a short time. If the ligature is employed, it should 372 DISEASES OF WOMEN. be of stout silk or whip-cord, and applied around the tumor at its highest part; this should be gradually tightened as the patient may be able to bear it, until the tumor has sloughed off. Or after the ligature has been applied and tightened sufficiently to strangulate the viscus, it may be detached with the knife, cutting below the ligature. 770. The symptoms that arise from the application of the ligature are so severe, that many times it has to be loosened until they have passed off, and in some cases it has been followed by a fatal result. From the experiments that have been made with the •' ecraseur," I would suppose that this instrument would be more applicable in these cases than any other mode of extirpation that has heretofore been recommended, its operation being quick, not folloAved by hemorrhage, and accomplished while the patient is under the influence of chloroform. CHAPTER XII. DISEASES OF THE FALLOPIAN TUBES AND OVARIES. 771. The connection existing between the fallopian tubes and ovaries, and more especially their anatomical position, being situated closely together betAveen the layers of the broad liga- ments, and at the sides and someAvhat posterior to the uterus, make it impossible to distinguish during life betAveen the affections of the tubes and of the ovaries. Diseases of the tubes and ovaries. likeAvise, give rise to similar symptoms, and require the same treatment, so that for practical purposes no advantage can be gained by their separate consideration. Yet it may be interest- ing to the reader to point out the morbid processes to which the tubes are liable. INFLAMMATION OF THE FALLOPIAN TUBES. 373 Inflammation of the Fallopian Tubes. 772. This is said to be a very common disease, and resembles, in all its features, inflammation of the mucous membrane of the uterus or internal metritis. In the non-puerperal state the inflam- mation is principally confined to the mucous membrane lining its cavity. It may arise from inflammation of the uterus extending by the continuity of its tissues, or from the same disease of the ovaries, and also it is said from acute suppression of the menses. This inflammation may be either acute or chronic, though the acute stage soon terminates in the chronic form. 773. Inflammation of the fallopian tube causes a thickening of the mucous membrane, which is tumefied, purple or slate colored; the tube is variously dilated, and its course tortuous. It also gives rise to an increased secretion of the natural mucus, Avhich may be viscid and transparent, of a yelloAvish-Avhite color, or a bluish-gray, or yelloAv purulent mucus. Acute inflammation at either extremity of the tube may give rise to an occlusion of its canal, and consequent sterility. 771. Occlusion of the extremities of the tubes may likeAvise give rise to that condition known as dropsy of the tubes. Accord- ing to Prof. Rokitansky this dropsical condition of the tubes arises from the accumulation of the secretion of the mucous mem- brane, and from this accumulation, the tube, especially toward its fimbriated extremity, becomes so much distended, that that Avhich before represented a tortuous or bent channel, is noAv converted into a simple sac. At other times, several saccular dilatations form betAveen the separate angles and the projecting duplicatures of the tubal parieties, and give rise to an imperfectly loculated pouch, Avhich, as in the former case, may contain blennorrhoid mucus, a puriform secretion, a true purulent inflammatory pro- duct, or, if the mucous membrane has become altered, fluids of another description. It is to be observed, that, as the dilatation proceeds, the texture of the mucous membrane is changed, being converted into a serous membrane ; its secretion may be a thin watery, serous, colorless liquid, giving the tube the appearance of a transparent sero-fibrous bladder: or it may be variously colored, 374 DISEASES OF WOMEN. yellowish, brown, blackish-green, and more thick and flocculent, consisting in part of inflammatory products on the internal surface of the membrane. 775. The hydropic fallopian tube not unfrequently attains the size of a duck's or goose's egg, or even of a man's fist; although not a usual occurrence, still it is satisfactorily proved that the contents are sometimes discharged into the uterus, and thus carried off. The symptoms and treatment of this disease will be the same as in ovaritis. Inflammation of the OArARiES. 776. Inflammation of the ovaries is a rare disease Avhen occur- ring as a separate and isolated affection apart from the puerperal state; still it does occur sufficiently often to demand a separate consideration. Puerperal inflammation of the ovaries will be considered in the chapter on puerperal fever. 777. The seat of this inflammation, according to Prof. Roki- tansky, is in the follicles or Graafian vesicles. He says, " The coats of a follicle are occasionally found injected, reddened, soft- ened, and friable ; the contents are opaque, flocculent, reddened ■ by an admixture of blood, and not unfrequently purulent. This process, even in its slightest form, is folloAved by the destruction of the germ by means of the exudation ; obliteration of the follicle soon ensues, and the first impulse is thus given to its conversion into a common serous cyst, which, in its turn, may groAV into ovarian dropsy." 778. Causes.—Inflammation of the ovaries, it is said, may arise from a bloAV received in the iliac regions, from sudden suppression of the menses, etc. In other cases it may arise like inflammation of any other part of the uterine system,—from exposure to cold, to sudden changes of temperature, etc. 779. Symptoms.—In the acute form of the disease, the patient will complain of a dull, aching pain in one or both of the iliac regions, deeply seated, and accompanied with sensations of Aveight and heat, ahvays aggravated by the erect posture, or by any sudden movement, and by defecation. These symptoms are some- times preceded by a slight chili, folloAved by some fever, at other INFLAMMATION OF THE OVARIES. 375 times, the fever does not make its appearance until after the local symptoms are developed. The fever is never very high, and is generally intermittent; the paroxysms occurring generally in the afternoon or evening. Pressure over the inflamed ovary Avill generally increase the pain. M. Portal observes, " that he has often been with patients affected with ovaritis, avIio had experienced all the pathognomonic symptoms of inflammation of the uterus, but who, after the lapse of some time, and subsequently to their apparent recovery, became the subjects of fullness, and in fact of very great intumescence in one or both iliac regions, for Avhich they took various remedies without advantage. On inspecting the bodies of such persons after death, he found the uterus perfectly healthy, Avhile the ovary of one side, and in other cases of both sides, together Avith the ligament or ligaments, round and broad, of either or both sides, presented the appearance of great engorgement." 780. Inflammation of the ovaries ahvays interferes more or less with the uterine functions, checking menstruation during its existence, and, if it goes on to produce structural changes, it may be the cause of sterility. 781. Acute inflammation of the ovaries may terminate in reso- lution, or in the chronic form of the disease, or in some rare cases it may terminate in suppuration ; the pus being contained in but a single enlarged Graafian vesicle, or the entire ovary may be involved in the abscess. The. termination in suppuration will be indicated by rigors, and a mitigation of the general symptoms; the pain is also lessened, and succeeded by a sensation of throbbing and increased weight; in these cases, there is also a considerable enlargement in the iliac region. The symptoms in this case somewhat resemble those of ovarian dropsy. The two diseases maybe distinguished, says Boivin and Duges; "for, in dropsy, there is a more evident and uniform fluctuation, more considerable volume, higher ascent into the abdomen, pain and tenderness only at a late period; in inflammation of the ovary there is partial fluctuation, hardness in several parts, pain and tenderness at the first moments of turgidity, seated in the pelvis or at its circumference." 376 DISEASES OF WOMEN. 782. Chronic inflammation of the ovaries is, in almost every case, the sequence of the acute form, and its symptoms are similar but more obscure. In this form of the disease, there will ahvays be more or less enlargement in the iliac region, with a deep- seated and dull pain, tenderness on pressure, and a sensation of weight in the pelvis. These symptoms are occasionally aggra- vated by exercise in the erect position, and sometimes during the evacuation of the urine and faeces. 783. Diagnosis.—If Ave depended on the symptoms presented by the disease, the diagnosis Avould be very obscure, as the same symptoms are presented by other diseases of the uterus and its appendages. Thus, in inflammation of the cervix uteri, the pain in the ovarian regions is so constant, as to be almost a pathognomic symptom. The absence, hoAvever, of disease of the cervix uteri, or of any portion of the uterus Avhich may be ascer- tained by examination, Avould make it probable that the symptoms Avere produced by ovarian inflammation. The diagnosis may also be assisted by a rectal examination, the finger introduced into the rectum can feel the enlarged ovary, which is sensitive to pressure. 784. Treatment.—The treatment of inflammation of the ovary is similar to that recommended for metritis. In the acute stage of the disease, prescribe the special sedative, Aconite or Yera- trum, as indicated by the pulse, associating Avith it any agents that may be called for. In some cases the tensive, dragging pain, backache, and soreness of muscles, call for Macrotys so distinctly that one can not make a mistake. In others the burning pain in the part, sometimes extending to the vagina, Avith frontal head- ache and sharp stroke of the pulse, calls for Rhus. The scanty urine, Avith tenesmus, and frequently irritation and determination of blood to the brain, calls for Gelseminum, The dull, stupid headache, with inclination to sleep, and especially if associated with " hives," calls for Belladonna. The steady pain extending to the groin is an indication for Bryonia; uterine tenesmus for Viburnum ; and dragging in the groins and vuh7a, Phytolacca. 785 In many cases Ave Avill find the patient Avith a bad breath, and a heavily coated tongue. The remedy is of course not always Sulphite of Soda, but the pallid dirty7 tongue will tell the story, INFLAMMATION OF THE OVARIES. 377 If at the menstrual period there is fetor, give Chloi*ate of Potash. Cathartics should be carefully used—a Seidlitz PoAvder, "salts and sulphur," citrate of Magnesia, rather than the harsher vege- table cathartics. Still there are some cases where the old-fash- ioned compound powder of Jalap, or Podophyllin, Avill prove of advantage. 786. Fomentations of bops, stramonium, water-pepper, etc., may be employed at first, or what is better, a surface of two or three inches may be painted with Aconite and Yeralrum, and then a sponge or flannel Avrung out of hot water applied. Chlo- roform counter-irritation maybe used in some cases, but as a rule the ordinary counter-irritant does more harm than good. 787. In the sub-acute or chronic form of the disease, the irri- tating plaster may be applied over the diseased ovary, and the treatment named for chronic metritis \\ill be applicable here. 788. In regard to its termination in suppuration, Dr. Ashwell says: "If matter does form, Ave must Avatch its progress; for it may point either in the iliac fossa itself, or lower in the groin. If the pain be not acute, or the patient too much exhausted, Ave may permit the abscess to open spontaneously; but if, from feeble powers, or the thickness and induration of the integuments, this should be a prolonged process, then Ave open it either by the lancet or caustic. The former is the easier; the latter, from its producing adhesions between the ovary and peritoneum, and thus preventing the escape of pus into the peritoneum or cellular tissue of the pelvis, is the safer method. If matter be discovered through the Avails of the vagina, an opening may be made either with a small trocar or lancet. Doubtless, in cases so full of interest, every precaution must be observed, both as to the general treatment and the evacuation of the pus. It can scarcely be too strongly urged, that sexual intercourse be avoided for some time, at least till the health is restored, and the local ovarian irritation has subsided. The published cases prove that in some instances, there is a proneness to the repetition of the malady." Oa^arian Dropsy. 789. This name has been given to an accumulation of fluid contained in one or more cysts, which have their origin from the 378 DISEASES OF WOMEN. substance of the ovary. Unlike other forms of dropsy, the fluid here is secreted by a neAv and abnormal formation, and though it is furnished Avith vessels and capable of rapidly secreting an enormous quantity of fluid, yet this cyst-Avail is incapable of reab- sorbing the effused fluid. Thus we Avill see the marked difference between this and other dropsical diseases, if Ave compare it with ascites, or abdominal dropsy. In this last form of dropsy the fluid is effused from a structure "capable of absorption, and though the effused fluid is similar in both diseases, yet in this, if the blood-vessels are emptied by copious diuresis, or by the action of hydragogue cathartics, the fluid effused into the peritoneal sac Avill be reabsorbed and carried out of the system. In encysted dropsy, however, no matter hoAv copious the discharge of fluid is from the kidneys or boAvels, not the least effect is produced on the local dropsy. 790. The pathology of ovarian dropsy has been minutely in- vestigated of late years, by many eminent observers, and though the causes of the morbid cyst-production is still involved in much obscurity, yet Ave have a very complete history of their anatomical structure and mode of groAvth. 791. Ovarian cysts are divided into two classes, the simple or unilocular cyst, and the multilocular or proliferous cysts. The first are called simple or unilocular, because but one cyst is found growing from the ovary, and which contains the entire fluid, and has no poAver to reproduce similar cyst-structures. The second variety or proliferous cysts are those Avhose parieties present the very remarkable character of producing other cysts of a similar character with themselves. 792. Simple Cysts.—Though I have already stated that the characteristics of the simple cyst Avas, its separate existence or origin from the ovary, and a Avant of poAver to give origin to similar formations, yet many authors make their Avant of repro- ductive poAver the characteristic difference betAveen them and the proliferous cysts, and not their separate existence in connection Avith the ovary- It must be recollected, then, that the term unilocular as used by some authors, is not applied to the single OVARIAN DROPSY. 379 cy.>t, but to any and all cysts which have a separate origin from the ovary. 793. In reference to the simple cysts, Prof. Rokitansky says: "There are either one or several unilocular cysts in the ovary; at times they are even so numerous, that the ovary appears con- verted into an aggregation of cysts. They are placed near one another, each being formed from the stroma, independently of each other, and they have a rounded form. If they enlarge, they come into mutual contact, their parieties adhere to one another, and they are flattened by reciprocal pressure; the impression may thus arise, that several have, in the manner of the compound cysts, been formed within the parieties of the same matrix. They attain a considerable size, rarely, hoAvever, exceeding that of a man's head. In this case the solitary cyst, or one of several cysts, undergoes extreme development, Avhile the remainder con- tinue undeveloped. They generally have delicate sero-fibrous parieties, and may contain a colorless, or pale yellowish or green- ish, serous, or a more consistent yelloAv, broAvnish, colloid sub- stance, or an opaque, chocolate-colored or inky fluid. In many cast's they are undoubtedly formed from Graafian follicles, and it appears that an inflammatory process is particularly liable to give the first impulse to this metamorphosis. They are probably, hoAvever, as often neAv formations from the beginning; and this is the more likely in those cases in which their number exceeds the average number of Graafian follicles." 794. Multilocular or Proliferous Cysts.—-These cysts, like the former, are supposed to arise from the Graafian follicles, and they may be developed in the first instance as simple cysts, but in time they become proliferous, giving origin to numerous cysts of a similar character. The cysts produced from the parent structure may arise from the internal surface and project inward, attached to the original cyst-wall by a pedicle, or by a broad base ; they also vary much in number and in size. In some cases the parent cyst will be found filled with these secondary growths of various sizes, each containing a portion of the enclosed fluid. Again, the secondary cysts may arise from the external surface of the parent cyst, and project outward from it. These proliferous cysts are 380 DISEASES OF WOMEN. capable of much greater development than the simple variety; and to them and the next variety most of the large encysted ovarian dropsies are due. 795. Prof. Rokitansky describes a third form of cyst, Avhich closely resembles and belongs to the proliferous variety; he states that it is of a cancerous nature, and belongs to ihe areolar variety of carcinoma. " In the shape which Ave are about to describe, it rarely occurs any where but in the ovary. It is an accumulation of numerous fibrous sacs, Avhich contain various substances, but for the most part a glutinous, viscid matter. They diminish in size from the circumference toAvard the interior, and especially toAvard the base of the morbid groAvth; so that the latter repre- sents a condensed alveolar mass, the alveoli or follicles of which consist of a Avhite, shining, fibrous tissue, and contain a colorless or grayish, yellowish, yelloAvish-green, or reddish viscid gelatine. We have here an areolar cancer, the peripheral follicles of which are converted into large sacs. This species of dropsy, which, for the sake of distinction from the other varieties, Ave term alveolar dropsy, is proved to be malignant, not only by its being accom- panied by well-marked cachexia, but also by its complication Avith cancer (especially of the medullary variety) in the same organ, and with other varieties of cancer in other organs, as the perito- neum, stomach, etc." 796. Structure.—The cyst-wall is said to consist of three coats—an external peritoneal, a middle fibrous, and an internal fibrous, but smooth, and capable of secreting, though not of absorbing fluid. The thickness of the cyst-wall varies in different cases, and even in different parts of the same cyst; and Avhen there are several cysts, there will often be considerable difference in the thickness of their Avails. Sometimes the Avails are as thin as brown-paper, and they vary from this to an inch in thickness. The ovarian cyst is sometimes very sparsely supplied with blood- vessels, as is very generally the case Avith the simple cyst; but at other times they are very numerous and large. Cruveilheir con- siders them to be principally veins, but Delpech, Avho has carefully dissected them, considers them to be arteries; he has found them as large as the little finger. The arteries of the cyst arise from OVARIAN DROPSY. 381 the ovarian arteries, and the veins empty into the ovarian veins; both sets of vessels are found in the middle coat, 797. We have next to consider the structure and character of the pedicle, a point that has been overlooked by most authors on this subject. If we trace an ovarian tumor, whether consisting of one or of many cysts, from the surface inward to its attachment, Ave find that it gradually grows less in size, the Avails being nearer in apposition, until within a short distance of the ovary they become consolidated, forming a solid stalk of fibrous tissue of variable thickness. Within this pedicle are the blood-vessels Avhich pass to and from the cyst. The length of the pedicle varies in different cases; sometimes it is as much as tAvo or three inches in length, and flexible; at others, it is very short, not more than half an inch in length. The pedicle likeAvise varies in thickness according to the thickness of the cyst-Avails, and from other circumstances ; sometimes it is not thicker than the little finger, at others one or two inches in thickness. In the majority of cases the attachment of the pedicle is directly to the ovary, this organ being but slightly changed in structure; in other cases, however, the ovary may be very much changed in structure, or it may have entirely disappeared, or its remains may form a sort of knot on one of the parieties of the cyst. In either case, hoAvever. the point of its attachment will be the same, as its vessels are derived from the ovarian vessels, and these retain it in its position. 798. If inflammation should have occurred, either in the cyst itself or in the adjoining structures, from its presence, adhesions may form betAveen it and any of the adjoining viscera. Thus, it has been found attached to the fallopian tubes, to the uterus, to the intestines, to the liver, the abdominal Avails, both anterior and posterior, and in fact to any part of the abdomen or its contents with which it may be in relation. The character of these adhesions are various; sometimes they are but slight, readily broken down, and of a very Ioav degree of organization, at other times they are dense and firm, their tissue being plentifully supplied Avith vessels. In some cases reported, the vessels in the adhesions were so large as to give rise to dangerous hemorrhage Avhen divided. 382 DISEASES OF WOMEN. 799. Contents.—As I have already stated, the contents of the cysts varies much in character ; in addition to the fluid contents already mentioned, there have been found hair, bony matters, remains of placenta, fleshy substance, coagulated blood, pus, etc. L he examination of the cyst contents with the microscope, is said to form a very certain means of diagnosis; but, as it would rarely prove available to the general practitioner, I have omitted its description. 800. Symptoms.—In the commencement of the disease, the symptoms are very obscure; the patient may feel a dull, heavy pain or sensation of soreness in the ovarian region, Avith a sense of aveight in the pelvis, and this may cause her to notice a slight enlargement in the iliac region. It often happens that the menses are suppressed; but sometimes this is not the case. Sometimes the symptoms very much resemble pregnancy, so much so, indeed, that the patient may suppose herself pregnant; in addition to the suppression of the menses, there may be morning-sickness, painful and enlarged breasts, sometimes, as it is said, secreting milk, etc. 801. So long as the ovarian enlargement does not exceed in size the space within the pelvis, it remains partially concealed by the pelvic Avails, and it may either remain free and movable in the pelvis, or form attachment to the pelvic contents. As the cyst or cysts enlarge, they arise into the abdominal cavity, and as they change their position, the uterus is drawn upAvard by means of the ovarian ligament, and the vagina is elongated. As the enlargement continues, the dropsical ovary occupies more and more of the abdominal cavity, the intestines are pushed into the inguinal regions, and the stomach, liver, and spleen, together with the diaphragm, are forced upward into the thorax. The symptoms at this time are very graphically described by Dr. Burns. "In the course of the disease, the patient may have attacks of pain in the belly, with fever, indicating inflammation of part of the tumor, which may terminate in suppuration, and produce hectic fever; or the attack may be more acute, causing vomiting, tenderness of the belly, and high fever, proving fatal in a short time; or there may be severe pain, lasting for a shorter period, Avith or Avithout temporary exhaustion, and these paroxysms may be frequently OVARIAN DROPSY. 383 repeated; but, in many cases, these acute symptoms are absent, and little distress is felt until the tumor acquires a size so great as to obstruct respiration, and cause a painful sense of distention. By this time, the constitution becomes broken, and dropsical effusions are produced. Then the abdominal coA7erin the original puerperal disease. 893. " Our first attention is due to the exudative processes on the various mucous and serous membranes. That affecting the intestinal mucous membrane is of particular importance. The entire tract is generally involved ; it is but slightly reddened, and commonly exhibits a thin, Avatery, serous, or viscid-gelatinous, or gelatino-purulent or genuine purulent product; the tissue fuses, and the sub-mucous cellular tissue is more or less infiltrated. In this manner the diarrheas of the puerperal state are established. The exudation is rarely of a firm, fibrinous, or croupy nature, but most commonly its serous character predominates,, and this is more the case the larger or more fibrinous the product, resulting from the coexistent attack of peritonitis. In certain cases, the process that takes place on the mucous membrane of the colon assumes a dysenteric type, and, as in the above-named forms, corresponds to the exudation upon the internal surface of the uterus or to the product of metrophlebitis. S'milar processes, though generally accompanied with a coagulable product, are occasionally discovered on the mucous membrane of the stomach, the oesophagus, and the bladder, and in the lungs, in the shape of (partial) apthous pneumonia; this is chiefly the case when the blood has not been exhausted of its fibrine. 894. " Among the exudative processes that take place on serous membranes, the most frequent, after that occurring on the peritoneum, is pleuritis, which is often coexistent Avith peritonitis; pericarditis is of less frequent occurrence. We also meet with exudations in the synovial bursas, and especially in that of the knee-joint, the sterno-clavicular and humeral articulations, and, lastly, in the capsule of the aqueous humor. The exudations are very copious, fibrinous, and purulent. A thin, soft exudation is often found upon the dura mater, accompanied by a slight reddening of the latter. 895. " All these processes mav be variously combined, and 27 •A 418 DISEASES OF WOMEN. they are dependent upon the primary or secondary disorganization of the blood, and especially upon that caused by the absorption of pus in metrophlebitis. 896. " Next in order come the processes dependent upon secondary phlebitis of the larger veins, and of the capillary venous systems of various organs and tissues. 897. "The former are generally developed in the vicin'ty of the original morbid affection, as in the plexus pampiniform is. the trunk of the internal spermatic vein, the internal iliac and crura] veins; though the}7 frequently, too, are generated at a distance, as in the cerebral sinuses and the pulmonary artery. These give rise to the so-called metastases or lobular abscesses, which avc shall noAv proceed to examine. 898. "We often find larger or smaller circumscribed spots in the most various organs and tissues; the dark-red points of conges- tion, or small accumulations of pus or sanies, which avc have repeatedly adverted to. They are remarkably frequent and numerous in the organs of sanquification, especially in the lungs and the spleen ; they are next seen in the kidneys, and more rarely in the ovary; they are occasionally met with in the brain ; in the thyroid and parotid glands; in all muscles, particularly in the heart; in fibrous tissues, as in the dura mater and the perios- teum. Again, they are very common in the mucous tissue, espe- cially of the bladder and the intestines; they occur throughout the cellular tissue, but they seem to predominate in the cellular tissue of the extremities, of the mediastina, of the neck, the iliac muscles, and the intestines and stomach." 899. "We have already demonstrated that these processes are genuine exudative processes, or that they consist in a coagulation of the blood within the capillaries (capillary phlebitis). In the latter case, the coagulum fuses in a manner corresponding to the disease of the blood, and to the deleterious matter absorbed into the blood, and forms a purulent sanious fluid or gangrenous pulp." 900. " They may probably be invariably considered as the result of a secondary infection of the blood, of a poisoning of the blood by the introduction of some product from the original nidus PUERPERAL FEVER. 419 of disease, and particularly of venous pus and sanies in metro- phlebitis. They consequently ahvays give rise to purulent and sanious products, and terminate fatally as capillary phlebitis. They enter into various combinations with one another, and Avith the exudative processes occurring upon serous and mucous mem- branes. Owing to their position at the surface of the organs, Ave always find that pleurisy supervenes upon their occurrence in the lungs, and peritonitis upon their deposition in the spleen." 901. "A black softening of the mucous membrane of the fundus ventriculi, or of the esophagus, or of both at the same time, Avhich is indicated during life, by the vomiting of black coffee- ground like matter, is of frequent occurrence. It not rarely reaches that degree of intensity, that the fundus of the stomach. and sometimes the diaphragm also, and the esophagus, Avith the adjoining cellular tissue and mediastinum are ruptured, and the fluid that Avould have been evacuated by the mouth is effused into the abdominal and thoracic cavities." 902. " After difficult labor, the cartilages of the pelvic synch- ondroses are liable to inflammation, in consequence of the traction exerted upon them, and if the blood has assumed a septic condi- tion, the inflammation may terminate in gangrenous fusion of the cartilage, the latter being converted into a dirty broAvn and very much discolored fluid, contained Avithin the investing ligamentous tissue." 903. " The blood contained in the cavities and large vessels pre- sents various and more or less evident changes. Its fibrine may be converted into consistent, viscid, greenish-Avhite, or yelloAvish coagula; or after previous extensive discharges of fibrine, it may be attenuated, Avatery < exuding through the coats of the vessels and the adjoining tissues, and presenting but feAV and trifling, gelatinous, soft coagula. Again, after previous purulent or sanious absorption, it is of a dirty brown-red or chocolate color, viscid, glutinous, depositing dirty-Avhite, opaque, fibrinous concre- tions, which in the heart form numerous ramifications, or present- ing dark-red coagula, which are paler at the surface, and fusible. Lastly, if the disease has run a rapid course, the blood is much reduced in quantity, and even Avithout defibrination having taken 420 DISEASES OF WOMEN. place, it is attenuated and discolored, and transudes all the tissues. The fibrine is sometimes found deposited on the valves of the heart in the shape of vegetations, without the demonstrable occur- rence of previous pericarditis. The severe jaundice affecting women during the puerperal state, is ahvays dependent upon pyaemia, and never upon an appreciable derangement of the liver." 904. Secondary Terminations.—" Puerperal peritonitis gener- ally terminates in the same manner as ordinary peritonitis; we notice, as particularly important, the unfavorable terminations in suppurations — phthisis — of the peritoneum and the adjoining tissues (ulcerative perforations of the diaphragm, the abdominal parieties, the intestines, the bladder, the vagina, etc..) and in peritoneal tuberculosis. The exudations upon the internal sexual organs may become converted into cellular tissue, and by fixing the tubes in an unfavorable position, even Avithout occlusion of the fimbriated extremity, cause sterility." 905. " The exudative processes occurring on the internal sur- face of the uterus, as well as the exudation in the uterine paren- chyma accompanying the former and metro-phlebitis, not unfre- quently degenerate into suppuration of the uterus, and the consequent purulent and sanious abscesses, extending chiefly from the point of insertion of the placenta in various directions, may discharge themselves into the peritoneal cavity. The affec- tion generally runs its course as acute uterine phthisis." 906. " A very remarkable and important result of the exuda- tive processes on the internal surface of the uterus is tabes of the uterus, Avliich is manifested by extreme brittleness and friability of the uterine fiber. The uterus very rarely attains such a degree of involution as to resume the size of the unimpregnated organ; it generally remains considerably enlarged, of the size of a duck's egg, or a man's fist; its tissue at the same time is porous, of a pale red, and at some parts of a slate color ; the insertion of the placenta continues visible, by the relaxation of the tissue and the irregularity of the inner surface, or the mucous membrane is at this place invested by a yelloAvish-Avhite ashy sub- stance, the remains of the exudation, and generally presents a retiform appearance." PUERPERAL FEVER. 421 907. Symptoms.—The symptoms of puerperal fever vary very much in different cases and in different epidemics of the disease; this variation in different cases, depends not only upon the extent of the local inflammation, on the organ or organs attacked, but also on the constitution and habits of the patient, and the degree of constitutional affection. However much the symptoms may vary in different cases and at different times, yet they are so marked as a general rule, and indicate so distinctly the character of the pathological lesions, that there is very little danger of the disease being mistaken. Instead of considering separately the symptoms presented by each of the different local inflammations described as metritis, peritonitis, etc., all that is necessary for practical purposes, will be to consider the disease as it presents the inflammatory or typhoid form, or as the inflammatory or typhoid symptoms predominate. 908. Puerperal Fever presenting more or less inflammatory symptoms.—In a large majority of cases, in the commencement of the disease, Avhether it is sporadic, or occurs epidemically, if the local inflammation be the primary disease, it will present the inflammatory form. In from two or three days to a Aveek after delivery, the patient Avill complain of a sense of lassitude or weariness, Avith sometimes a sensation of soreness and weight in the hypogastric region, and a feeling, as she will express it, " as if she Avas not getting along well." This is shortly succeeded by rigors of greater or less severity, either partial or general, to which inflammation succeeds; these rigors or chills may be so slight, that the patient Avould not notice them Avithout her atten- tion Avas especially called to them, and in this case, the fev7er Avould appear to have been the first symptom. As soon as the fever becomes developed, the face is flushed, the skin hot and dry, there is considerable thirst, sometimes nausea and vomiting, and a moie or less violent pain across the forepart of the head. The pulse during the chill is full and strong, and someAvhat accelerated, and as the fever becomes developed, it is hard and quick, varying from 110 to 140 in a minute, and the respiration is hurried in pro- portion. The secretions are arrested or diminished in quantity; 422 DISEASES OF WOMEN. the tongue is coated with a white fur, and the mouth clammy, the urine is high colored and acid, and the bowels confined. 909. With the development of the fever the local pain becomes more or less marked, according to the seat of the inflammation; if the peritoneum is affected, it is generally very severe, and commences first in the iliac or hypogastric regions, Avhere it may continue, or it may involve a large portion or the entire abdomen. The tenderness on pressure is exquisite, and as the inflammation extends, it may become so acute that the patient can not bear the slightest pressure, not even the Aveight of the bed-clothes. In those cases in which the peritoneum is not involved in the disease; the inflammation being confined to the uterus or ovaries, the ten- derness is not near so great, the pressure having to be made deep, so that the fingers make pressure on the inflamed organs before the pain is much increased. The pulse likeAvise varies someAvhat according to the seat of the inflammation, for Avhen the perito- neum is involved, it is small and incompressible—wiry, while if the inflammation affects the uterus and ovaries alone, it is gener- ally hard and full. It must be recollected, however, that peri- tonitis exists in six out of every seven cases of puerperal fever, either as a complication of metritis, or as the primary disease. 910. These inflammatory symptoms may terminate in a longer or shorter time, in the typhoid form. Sometimes they appear only for the first few hours, or they continue for two, three, or four days, or they may continue to the termination of the disease either in recovery or death. For the first day or tAvo of the disease, the lochia may continue but groAV gradually less and less in quantity, or in some rare cases it may be suppressed from the commencement, or it may continue throughout the course of the disease. The secretion of milk is in the great majority of cases suspended in the early part of the disease, and the mammae become flaccid; though in a feAV cases reported this secretion has continued the entire course of the disease. 911. As the disease advances, all the symptoms mentioned become aggravated, the local pain and tenderness increases, the PUERPERAL FEVER. 423 patient lies upon her back, with the thighs drawn up to take off the tension of the abdominal muscles; the least motion increases the pain, the breathing becomes shorter and laborious, delirium sometimes sets in, theve is subsuitus tendinum, and hiccough, and death soon terminates her sufferings. 912. It is very rarely that puerperal fever retains its inflam- matory character to the last, yet it sometimes occurs, and these cases are marked by the same symptoms that characterize the synochal grade of fever. 913. Typhoid puerperal fever.—By the term "typhoid" v/e understand a prostrated condition of the system, the vital power being so overpoAvered by the disease that a high inflammatory reaction is impossible. In this form of the disease there is a greater or less affection of the blood mass (septic condition of the blood) caused either by the epidemic influence in this case being the primary disease, or from the absorption of some morbid mate- rial from the seat of the local inflammation (the endometritis, metrophlebitis, or peritonitis). We can readily understand Avhy puerperal fever in the majority of cases should sooner or later present these symptoms of great depression of the vital poAver. More or less exhaustion ahvays succeeds to parturition, from the intense degree of muscular poAver required to expel the foetus, the circulation is likeAvise more or less disordered from the rup- ture of the relations existing betAveen the mother and the foetus in utero, and not only this, but at this time Avithout the excre- tions are free, there is more or less matter approaching a state of disorganization circulating in the blood, Avhich needs but the stimulation of the epidemic constitution of the atmosphere here- tofore spoken of, to produce that septic condition of the blood which is the essential condition of typhus. And not only this, but the uterine organs themselves present the very conditions necessary for the absorption of morbid materials generated by the inflammatory process; there is often ruptures or lacerations of the uterus or the vagina, through which any putrid discharges may be readily absorbed, and the uterus presents at the insertion of the placenta a large traumatic surface, Avith the open mouths of the utero-placental veins constantly in contact with the contents and 424 DISEASES OF WOMEN. secretions of the uterine cavity. Any morbid material entering the circulation in this manner is liable to propagate the same morbid changes in the blood, i. e., to cause a disorganization of any material in the blood not sufficiently vitalized to resist the morbid influence. It is proved by experience that this morbid process in the blood is propagated in the same manner that diastase or yeast affects any albuminous matter Avith Avhich it is placed in contact. We have a good illustration of the effects of the absorption of putrescent materials, even in very small quan- tity, in Avounds made during dissection or in making post- mortem examinations, the absorbed material exciting such chemi- cal changes in the constitution of the blood, that its Avhole char- acter is speedily changed, and its vital properties are altogether destroyed. In a large majority of cases as already stated, the disease assumes the character above described, the constitutional affection being the principal disease ; sometimes tAvo, three, four, or more days elapse before the disease assumes this character; at others it immediately succeeds the first inflammatory reaction, and at others it is manifest in the commencement of the disease. 914. In the two first instances, the first symptoms are those heretofore described, but in a longer or shorter time they are succeeded by symptoms of prostration ; the pulse becomes small, weak, and contracted, though still rapid, the face pale, the tongue more or less coated with a dark yelloAv, or brown fur, or it may be clear, red, and dry, there is nausea and slight efforts at vomiting, diarrhea, etc. There is a morbid heat or dryness of the skin, or in some rare cases there is a constant clammy perspiration ; the countenance presents a marked change, it is sometimes suffused, more frequently salloAv, dejected, ghastly, and indicative of extreme distress; the eyes are sunken and inexpressive, and a dusky livid ring may be observed around the under lid. 915. The degree of local pain varies very much, even when there is peritonitis ; sometimes it is very severe, at other times it appears to depend wholly upon the tympanitic distension of the abdomen. The frequency and duration of pain in puerperal fever PUERPERAL FEVER. 425 where the peritoneum was involved, was carefully observed by Dr. Ferguson ; in 173 of his patients he found that The number of his patients that had no pain was 19 " Avho had pain for 1 day " 51 2 days a 48 3 " a 22 4 " a 18 5 " a 6 7 " a 5 8 " a 4 916. Shortly after the disease is established, the abdomen becomes tympanitic, and in some instances becomes very much distended and tense, and in a more advanced stage the presence of effusion may be detected. 917. When the disease assumes a Ioav or malignant type from the commencement, the first indication of the impending mischief, says Dr. Copeland, " is the great rapidity, softness, and Aveakness of the pulse, often attended by pain and tenderness at the epigas- trium, by sickness and vomiting, followed by general distension and pains darting through the abdomen. But in the majority of cases there are neither chills nor rigors ; in a few, a feeling of coldness only ; and in still fewer, slight rigors. In this state of the disease the patient soon becomes despondent, predicts her dissolution, is afterward apathetic, and makes little or no inquiry for her infant. The milk and lochia are either little or not at all diminished, or are more than usually abundant. The abdominal pain and distension are sudden and quick in their action ; but the pain soon ceases, the distension remaining, and aftenvard changing its character, if the disease continues above two or three days. The tongue, from the commencement is flabby, broad, and slimy, or covered by a mucous or creamy coating; the pulse is usually from 120 to 140, or even upAvard, fluent, soft, or broad; and the general surface presents a lurid, dusky, or dirty hue, and is covered by a clammy or offensive perspiration. The countenance is pale and inexpressive, unless where the pain is acute, when it becomes anxious and covered with perspiration. The mind is but 126 DISEASES OF WOMEN. little disturbed, beyond a state of complete apathy. As the disease proceeds, respiration is short, suspirous, or difficult; the pulse small, soft, or irregular; the bowels frequently relaxed, and the stools offensive, or passed without control. Distressing feel- ings of sinking, leipothymia, or restlessness supervene, and are soon followed by symptoms of impending dissolution." 918. At any period of the disease, the above-named symptoms may become complicated Avith those arising from pleuritis, gastritis or enteritis, pneumonia, etc. The occurrence of any of these complications alter the general symptoms of the disease, and they therefore vary greatly from this cause ; they also vary much in different cases where no complications exist. 919. When the disease progresses toward a fatal termination, there is effusion into the peritoneal cavity, and Avith this effusion there is a remission of the local pain, but Avith this absence of the local pain the other symptoms are all aggravated. The pulse becomes small and Aveak, fluttering, and so rapid that it can scarcely be counted, the patient appears to suffer more, and there is a constant watchfulness; the tongue becomes dry and broAvn, and there is sometimes vomiting of a dark coffee-ground looking fluid : the patient retains her position on the back, and there is a constant tendency to slide down toward the foot of the bed; she picks at the bed-clothes, and appears to be unconscious of any thing that is going on about her, etc. Sometimes there is deli- rium, and Avhen it occurs it may be looked upon almost as a fatal symptom. 920. But if the pulse be found less frequent and stronger, the skin cool and soft, the tongue cleaner, no nausea present, the thirst less, and the patient gets refreshing sleep, and can change her position and lie upon her side, Ave may hope for a recovery. 921. Diagnosis.—From the symptoms above named, and the time at Avhich the disease occurs, (shortly after parturition) there are but tAvo diseases, or morbid states, with Avhich there is any danger of its being confounded; these are,hysteralgia, and a disease described by Dr. Ramsbotham under the name acute tympanitis, or false peritonitis. , 922. It may be distinguished from neuralgia of the uterus by PUERPERAL FEVER. 427 the periodical exacerbations and remissions of this latter, and from the less degree of constitutional suffering. From severe and long-continued after-pains by the fact that in this the uterus can be felt to contract and harden with each pain, and that there is little or no constitutional suffering. 923. The diagnosis betAveen Avhat Dr. Ramsbotham terms acute tympanitis and puerperal fever must be very obscure, from the symptoms which he gives of the disease. Ih says, "The attack mostly commences two or three days after delivery, and is usually introduced by a rigor; this is often very severe, more so, indeed, than Avhen it proceeds from peritoneal inflammation. It is a great mistake to believe that shivering is ahvays indicative of the com- mencement of an inflammatory attack ; for here, although not the slightest appearance of inflammation can be observed after death, the rigor is strongly marked. To this succeed great heat and dryness of skin, which also is often more intense than in peri- tonitis. I have already said, that in peritonitis the surface is sometimes soft and moist from the commencement; but this I never remarked in the affection noAv under consideration. The pulse rises rapidly in frequenc}', often beating one hundred and thirty or one hundred and forty strokes in a minute; sometimes it is fluttering and tremulous; at others, fuller and firmer than in peritonitis. The mouth is generally dry; the tongue occasionally furred, or it is harsh and red. The countenance becomes early changed, though not so anxious as in peritonitis. Most severe pain in the head is experienced, with intolerance of light and noise, uninterrupted Avakefulness, and in many cases even delirium. Very early in the disease the abdomen sAvells inordinately and rapidly, becomes very tense and painful, and the transverse colon, particularly, can in many instances be distinctly traced; pressure aggravates the sufferings. The milk ceases to be secreted; the lochia are generally suppressed; there is great languor; an unwillingness to speak or take nourishment: the patient lies upon her back, with her legs dnnvn up, unsolicitous about herself, her infant, or her friends; the bowels are obstinately constipated. As the disease gains grouml, the belly increases in size, pain, and tightness; the tongue becomes dry and broAvn ; there is hiccough. 428 DISEASES OF WO M E N . or vomiting of offensive matter, muttering delirium, subsultus tendinum, and most of the symptoms that denote the last stage of fever; but if recovery is to be expected, the swelling and tenseness of the abdomen subside; the pain gradually goes off; the pulse becomes sloAver ; the tongue moister ; the skin cooler and softer; there is no vomiting; the intellect remains unimpaired; and a desire is expressed for food ; and the bowels act, together with the expulsion of a large quantity of flatus." 924. We have here a disease Avhich, according to Dr. Rams- botham, presents all the characteristics of puerperal fever, without there being any signs of local inflammation after death. This would go to prove the fact that puerperal fever is principally a disease of the blood, (a general or constitutional affection,) and not, as many writers would have us believe, a local affection. 925. As to the diagnosis between this and puerperal fever, Ave need not trouble ours Ives, as they are certainly both the same, with the exception of the local inflammation, and require similar treatment. 926. Prognosis.—The prognosis in puerperal fever Avill vary according to whether it is sporadic, or Avhether it prevails as an epidemic, and according to the character of the epidemics, some that have occurred being very malignant, while others have been comparatively mild. In those cases that present the symptoms of acute inflammation first named, the prognosis will be much more favorable than in those presenting a typhoid character. And lastly, it will vary according to the period of the disease at which the treatment is commenced, and the energy with which it is followed up. In the language of Prof. Meigs, " If the nurse allow the precious moments of the forming stage to elapse before the alarm is taken, or if the physician, through inattention or failure in making the diagnosis, pursues, in the beginning, a feeble or erroneous practice, no human skill, sagacity, or devotion can be relied upon to rescue the victim, who has already begun to die before the first hand is extended for her rescue." 927. Treatment.—The indications to be fulfilled in the treatment of puerperal fever are, to subdue the local inflammation as soon as posihle, and thus prevent the severe constitutional affection; to PUERPERAL FEVER. 429 stimulate and keep free the secretions and excretions, and thus relieve the system of all disorganized material as soon as formed; to neutralize or destroy the septic material as it is introduced into or formed in the blood ; to rectify wrongs of innervation ; and to support the strength of the patient by appropriate food, tonics and stimulants. 928. A careful practitioner attending a puerperal patient will be able to distinguish the disease at its commencement, or shortly afterward ; for, as a general rule, it is ushered in during bis daily attendance. But if an epidemic of the disease exists, careful directions should be left with the nurse or friends to apprise him of the first morbid symptoms. As soon as the disease is recog- nized, we examine the patient carefully to determine the initial lesion, and promptly adopt such means as are indicated. I am satisfied that this early attention will many times arrest the pro- gress of the disease in its early stage, when, if neglected for a single tAventy-four hours, the case would be most serious. The reader is already aAvare that I do not believe in allowing my pa- tient to suffer even the usual aches and unpleasantnesses before, during, or after confinement, and I am always on the alert for these possible wrongs. What is described as an ordinary chill is followed by what the nurse calls milk fever, and the "busy prac- titioner " ( a synonym for a careless or lazy doctor) takes it for granted that the nurse or attendant knows, makes a superficial examination, and comes back the next morning to find a full}7 de- veloped puerperal fever. If it bad been taken in time, the ad- ministration of Aconite with Macrotys, or other indicated remedy, and Chlorate of Potash or Sulphite of Soda, it might have been nothing but an ephemeral fever. I Avish to say in this connection that " cleanliness is next [better than] to godliness," and the phy- sician who alloAvs his patient to lie in a bed befouled Avith decom- posing blood or locbial secretion, or allows the vagina to remain clogged Avith decomposing blood or secretions, falls far short of bis duly. I have seen these cases, and know that they are far too common. I recall one in which the second day folloAving the chill the patient had a pulse of 130, with a temperature of 105°; was furiously delirious, Avith a dirty7 brown tongue, arrested secre- tion of urine, and exquisite tenderness of the abdomen—symp- toms of a most grave attack. The intenscl}7 putrescent odor 430 DISEASES OF WOM EN. coming from the bed caused me to make inquiry and an exami- nation, and I found the clothes adherent to the vulva and thighs, the vagina packed with blood-clots as with a tampon, and the uterus distended to some extent Avith the lochial secretion. The removal was a most unpleasant job, and it Avas some hours before the uterus was Avholly freed, but the thorough cleaning up, and washing with chlorate of potash, and its internal administration with tincture Aconite and Macrotys, were followed by rest and sleep, relief of the abdominal tenderness, and a disappearance of the puerperal fever. In a second case, with very similar symp- toms, the removal of a small portion of placenta Avhich had en- gaged in and closed the os, was followed by an abatement of all the symptoms. 929. I Avisb to call attention to the condition of the tongue in the earl}7 stage of the disease, as indicating remedies. In eA7ery case avc want a good condition of stomach for the reception and absorption of medicine, for taking the necessary food, and for the relief of the sympathetic nervous system, always unpleasantly impressed by derangements of this viscus. We Avill sometimes find our case, even before the chill, with a pallid and dirty tongue, and the conviction will come to us that with this dirty mouth the ordinary remedies will fail to exert their usual influence. Here we give Sulphite of Soda in doses of ten grains every two hours, until the unpleasant condition is removed. In another case the evidence of atony, the heavily coated tongue at ba?e, fullness and oppression in the epigastrium, and oppression of the nervous sys- tem, Avill suggest that it may be Avell to use an emetic. There is a case for Podophyllin, even the old-fashioned sharp dose, and we can hardly get along without it, but Ave must know our case. The face is full, the tissues full, the tongue full, and especially the cu- taneous veins are full. Then Ave have our cases of irritable stom- ach, in which the nausea and vomiting are unpleasant features. In one case the sallow relaxed face and expressionless mouth with moist relaxed tongue say, Nux Vomica in small dose. In another the red contracted tongue, elongated, and especially red at lip and edges, is the evidence of irritation and determination of biood, and calls for counter-irritation over the epigastrium the smali aud frequently repeated dose of Aconite and Ipecac, in- PUERPERAL FEVER. 431 fusion of Peach-tree bark, or minute doses of Morphia with Bis- muth. These are vital things, and should not be neglected. 930. In the selection of the sedative we are guided by our general rules—Veratrum if the pulse is full and strong, Aconite if it Is small. As a rule, the Veratrum may be given Avith Gelse- minum, Asclepias or Dioscorea, and the Aconite Avith Rhus, Ma- crotys, Bryonia, or Belladonna. This is only suggestive of the associate remedy, as Ave are ahvays guided by the symptoms. In some cases Veratrum may be given in large doses, (full, strong pulse, flushed surface), say—R Tinct. Veratrum, 3j ; Water. 3iv.; a teaspoonful every half hour or hour, until the pulse is brought down to its normal frequency, and then in smaller doses to main- tain its influence. The Aconite is used in the usual small dose, gtt. v. to gtt. x. to Avater §iv. 931. Gelseminum is indicated by the flushed face, bright eyes, contracted pupils, increased heat of the scalp, restlessness, and by scanty urine passed with great difficulty. Asclepias exerts a most kindly influence in those cases in which, notwithstanding the high range of temperature, the skin is moist. The Eupatorium Pert, is employed in a somewhat sim- ilar case, the pulse being full, oppressed, and the patient com- plaining of dull pain in the head. Both remedies are associated with Veratrum. Dioscorea is an admirable remedy in puerperal peritonitis, and when the intestinal canal is involved. It may be given Avith either the Veratrum or Aconite, the tincture being added to the prepa- ration of these, or it may be given in infusion. Rhus is indicated by the burning pain, dry and constricted skin, sharp pain in frontal region, especially in left orbit, and sharp stroke of the pulse. It is one of our most certain and valuable remedies, and will meet many unpleasant cases. Macrotys is the remedy indicated by uterine pains (as of labor), and by muscular soreness. It is especially useful in the forming stage of the disease, and will be replaced by other agents later. Bryonia is indicated by the steady vibratile pulse, the tendency to implication of the serous membranes of the chest; as Avell as the peritoneum, and by the peculiar pain in the head, extending from forehead to occiput, especially on the right side. The right cheek is usually flushed. 432 DISEASES OF WOMEN. Belladonna is indicated by dullness of intellect and inclination to sleep, and the development of coma. It is exhibited in the usual small dose with Aconite.. I Avish to call especial attention to the use of Cbionanthus in those cases which show symptoms of jaundice, with pain in the region of the liver and stomach, and sometimes nausea and vomiting. Ten-drop doses of the tincture of Cbionanthus every tAvo hours will be found to give much relief and will sometimes arrest the progress of this disease. 932. Among the remedies which have been deemed specific in puerperal fever, I may name the Potent.illa Canadensis, or cinque- foil. It may be given in infusion, or the tincture used in doses of ten to tAventy drops every two or three hours, associated with the sedative. 933. Antiseptics. As the fever progresses those symptoms known as typhoid make their appearance. The reader Avill not understand that Ave have a typhoid fever, Avith disease of Peyer's glands, but only the evidences of sepsis of the blood and prostra- tion that Ave observe in typhus and typhoid fevers. The AA7ord "typhoid " is here used as an adjective to denote a condition sim- ilar to that noticed in the fevers named. To meet these symp- toms Ave use a class of remedies called antiseptics, and Avhen espe- cially indicated,.Ave obtain definite results from them. We may here consider the folloAving of this group—Sulphite of Soda, Muriatic Acid, Sulphurous Acid, Baptisia, and Chlorate of Potash. I may premise by saying that the special evidences of sepsis, or typhoid disease of the blood, Ave find in the exudation upon the tongue. The tongue is moist and dirty—nasty—or the coatings have a tinge of brown, groAving deeper as the disease advances. Bad odors—putrefactive—are also evidence of typhoid. 934. Sulphite of Soda. The indication for this remedy is the moist, pallid, dirty tongue. We give it in doses of from five to twenty grains every three hours. Muriatic Acid. The indications for an acid have already been named—the deep red color of mucous membranes. The evidence of the typhoid condition is brown coating of the tongue, sordes on the teeth, nervous prostration, and pungent heat of surface. Sulphurous Acid. Tins is a very feeble acid, and is not given to fulfill the general indications for an acid. We give it Avhere there is normal color of mucous membranes, and Avhere the dirty PUERPERAL FEVER. 433 coat and sordes sIioav sepsis. It may be given in doses of ten to< thirty drops every three or four hours. 935. Baptisia. It is not so easy to see the exact indications for Baptisia, yet it is one of our very best remedies, if the diag- nosis is rightly made. There is a dull red coloration of skin where it has a free circulation, of the lips, and of the tongue and fauces ; or, as Ave sometimes say, there is an off-eo\or of the tongue —livid, purplish, dull red. In the advanced stage of the disease, the tongue is protruded with difficulty, is stiff, fissured, and bleeds, and the tissues of the mouth and fauces look full and lifeless. The pulse is oppressed, and the skin is dry, husky and lifeless. The excretions are frequently fetid. I prescribe—R Tinct. Bap- tisia, gtt. x.; water, ^iv.; a teaspoonful every tAvo hours, usually alternated Avith the proper sedative. Chlorate of Potash. We may get a better idea of the special in- dication for this agent if Ave think of it as the remedy for the puerperal state. Given, offensive locbial discharge following abortion or delivery at full term, I use Chlorate of Potash. I use this remedy in cynanche maligna, and, as will be recollected, a characteristic symptom here is the putrefactive odor. So in the advanced stages of a fever, if there is this unpleasant odor of decomposition, I prescribe Chlorate of Potash, ^ij.; Water, 3iv.; a teaspoonful every tAvo or three hours. 936. Disinfectants. We recognize the fact that a patient suf- fering from puerperal fever may be poisoned by the exhalations from her own body, by decomposition of the excretions in the room, and by dirt from any source. This is something that must be thought of and looked after in every case. Be sure that the bed coverings are kept clean ; that the clothing of the patient is changed frequently; that the room is kept clean ; that the cham- ber utensils are thoroughly cleansed after use. See that fresh air is admitted to the room, and that the foul air has a chance to get out (through an open fire-place, if possible, in which a small fire -is kept.) 937. But if bad odors develop, destroy them with antiseptics. If in the cellar or out-buildings, Avbite-wash Avill answer; drains may also be limed, or Chloride of Lime may be used. The vessels about the bed may be Avasbed in a solution of Chlorinated Soda, or Sulphurous Acid, and the air of the room may be disinfected 434 DISEASES OF WOMEN. by a spray of Sulphurous Acid, or a solution of Chlorinated Soda. The air spray apparatus is noAv so cheap and good, that we can employ it more in these cases. 9H8. In malarial regions puerperal fever may be distinctly pe- riodic, and require full doses of quinine, being careful that the patient is properly prepared for its use—having a soft open pulse, a moist cleaning tongue, relief of nervous irritation, and a skin inclined to moisture. These are the only eases in which the large dose of quinia will prove beneficial, and in all others it will most surely do harm. In the advanced stage of the disease, and Avhen Ave ha.A7e the fever under control, Ave may use small doses (one grain), as a stimulant, with good effect. Stimulants may be em- ployed in the same cases, giving small portions properly diluted, and repeated sufficiently often to keep up thegood effect. 939. The ordinary use of Opium and Morphia by mouth is to be avoided, as it. acts unkindly both upon stomach and brain. I do not object to the " diaphoretic powder," in five-grain doses, Avhen it is needed to give rest, if the stomach Avill take it kindly, and the pulse is soft; but when the necessity for the relief of pain is imperative, I prefer the hypodermic injection of Morphia. The medium quantity Avill be fifteen drops of a solution of grs. x. to distilled water 3j„ and the best place for insertion will be the thigh or leg, though there wi 11 be many reasons for taking the arm. 940. Do not use cathartics unless specially indicated. It is Avell to open the boAvels occasionally, but an enema is preferable to medicine by stomach, and this can be selected Avith reference to the condition of the bowels, especially as to the tympanitis. At first it may be a solution of compound pow7der of Jalap ; then it may contain a small portion of tincture Xanthoxylum, or even turpentine; and lastly, it may be antiseptic, as Avith Chlorate of Potash or Chlorinated Soda. 941. To relievc'the local pain, fomentations of Stramonium or of Hops may be used in many cases -with great advantage ; they should be applied as hot as they can be borne, and frequently changed, so as to keep up a continuous heat; careful directions should always be given to the nurse in regard to their application ; for, if left on until they become cold, they will aggravate the disease instead of proving a benefit; or if they should be applied too wet, the patient's clothes as Avell as the bed Avill become damp PHLEGMASIA DOLENS. 435 and make her uncomfortable. From the difficulty of having fomentations properly applied, several authors, among whom may be mentioned Gooch, Ferguson, and Locock, prefer a Avell-made Linseed poultice, as a constant application to the abdomen. The best local application Avith Avhich lam acquainted, is the Tincture of Stramonium, diluted with four'parts of Avater, kept hot on the stove, and three or four thicknesses of flannel Avrung out of it and applied to the abdomen ; in changing it, the layer next to the abdomen may remain, and the applications made upon it; in this manner the abdomen is not exposed. 942. Vaginal injections of warm Avater have been highly recommended as afford.ng great relief in this disease; they not only assist in relieving the local pain and tenderness, but they also remove any morbid secretion from the parts, and thereby lessen the dangers of absorption. If the lochia or the discharge attendant on metritis be fetid, a Aveak solution of chlorinated soda may be used. Phlegmasia Dolens. 944. This affection has received and is knoAvn under various names, as, phlegmasia dolens, phlegmasia alba dolens, cedema lactium, sparganosis, milk leg, white leg, swelled leg, etc., etc., and as many theories have been advanced in regard to its character as it has names. It is a disease of the puerperal state, occurring generally betAveen the fourth day and third Aveek after delivery. It may arise after first pregnancies, though in a large majority of cases it occurs in females Avho have borne several children; it is also said to arise more frequently in Avomen of a delicate consti- tution, and those Avho suffer from uterine irritation after delivery- 945. The disease consists in a colorless swelling of one or both legs, the left leg being said to be more frequently affected than the right; Avith swelling, there is pain, tenderness on pressure, and more or less fever. As to the pathological lesions causing these symptoms, there are various and conflicting opinions; some regard it as an inflammation of the veins of the thigh and leg, and hence one of its names, "crural phlebitis;" others, again, consider it a species of cellulitis, involving the cellular tissue of the leg, while others consider that the disease is confined to the lymphatics, 136 DISEASES OF WOMEN. and others have combined these different lesions in varying pro- portions to suit their individual fancy. In support of the opinio i that the disease was, as one of its names indicates, crural phlebitis, Dr. Robert Lee gives the folloAving conclusions derived from post- mortem observations: " That the inflammation of the iliac and femoral veins gave rise to all the symptoms of phlegmasia dolens, and that the inflammation commenced in the uterine branches of the hypogastric veins, and thence extended to the femoral trunks of the affected side." Prof. Rokitansky's observations go tc support, partially, this view of the subject, yet he appears to consider the cellulitis the prominent affection; he says: "Two lesions seem to be essentially connected with this affection. It either depends upon an inflammation of the veins of the inferior extremity, and especially of the crural vein, or upon an inflamma- tion of the cellular tissue, which gives rise to the most various products. The latter form is particularly likely to cause the characteristic symptoms which a so-called sero-lymphatic or sero- purulent product, i. e., fibrinous or purulent exudation, diluted by a large amount of serum, induces." Among those who considered that the lymphatic system of vessels were first affected, and that the disease Avas inflammatory, might be mentioned Drs. Denman, Ferrier, Caspar, and DeAvees. The reasons for this opinion are well-given in a very able paper by Dr. J. D. Collins, of Kentucky; he says: " From a careful investigation of the history and symptoms of this disease, I have been brought to the following conclusions: That it is caused by the pressure of the foetus on the numerous lymphatics that are located about the loAver part of the superior and upper part of the inferior straits of the pelvis. " This pressure causes obstruction in the lymphatic circulation—■ this obstruction induces irritation, and the irritation idtimates in inflammation, which soon involves the glands of the Avhole of the loAver extremity, unless arrested by some agent. What are the evidences upon which I come to these conclusions ? They are of tAvo kinds, viz.: positive and negative. The positive are— 1. " That the lymphatics of the pelvic straits stand out more prominently than any other circulating vessels. PHLEGMASIA DOLENS. 437 2. " They are less able to resist pressure than any other vessels. Why ? Because the visatergo of the lymphatic circu- lation is more feeble than any other circulation in these parts. 3. " There is an effusion of lymph long before the veins become involved. How do I know this ? 1st, because of the peculiar character and appearance of the SAvelling; 2d, because the serum draAvn off by scarifying the parts is found to contain large quantities of lymph. 4. " Because we find the lymphatics much swollen, etc., before the veins become involved. " My negative reasons are— 1. " It can not be the veins, because the phenomena of inflam- mation of the veins is not evidenced in this disease, until it has existed for some days, and sometimes weeks. 2. " Because inflammation of the veins elsewhere does not present the same appearance and phenomena that exist here, viz.: effusion of lymph in cellular tissue, etc. 3. " Because the treatment Avhich is successful in combating inflammation of the veins elseAvhere does not answer the same purpose in this case. 4. " Because a dissection of a portion of vein from the diseased parts, in its primary stage, does not show any trace of inflam- mation. 5. " If it were inflammation of the veins, resulting from pressure of the foetus upon them, they would take on the inflam- mation sooner than they do here. " There is no doubt in my mind that the veins do become involved ultimately, unless the disease is arrested in its primary stage. All of the post-mortems show the veins, as Avell as the lymphatics, to be involved, but the post-mortems are not reliable, so far as determining the primary cause of hardly any disease— they oniy shoAv the extent of diseased action." 946. Symptoms.—The disease is usually ushered in Avith rigors of greater or less severity, and Avhich continue for a longer or shorter time; these chills are succeeded by more or less fever, the pulse often rising to 120 or 140 beats in a minute; the bowels are mostly constipated, the tongue furred and moist, the skin dry. 438 DISEASES OF WOMEN. and the urine scanty and high colored. There are also the other symptoms of pyrexia sometimes present, as headache, want of sleep, nausea, or vomiting, etc. Shortly after the rigors, the patient complains of deep-seated pain in the hypogastrium and loins, which is soon referred to one or other groin. In a short time, the affected limb commences SAvelling, and this is accom panied Avith more or less pain and tenderness. In a majority of cases, the swelling will be found to commence in the calf of the leg ; if examined, it will feel hard and tense, and as if it Avas closely attached to the bone; pressure at this part will produce considerable pain. This is a valuable diagnostic symptom, as it appears before the SAvelling of the thigh; it soon, however, involves the entire upper portion of the limb. Dr. Denman observes, " that before the appearance of any SAvelling or sense of pain in the limb about to be affected, Avomen become very irritable, Avith a sense of great Aveakness, and grievously oppressed in their spirits, Avithout any apparently sufficient reason; com- plaining only of transient pains in the region of the uterus, and from these the approach of thp disease has frequently been foretold. After a short time, they are seized with an extremely acute pain in the calf of the leg, extending to the inside of the heel, and then, observing the course of the lymphatics, stretching up to the ham, along the internal part of the thigh, to the groin, occasioning a slight soreness on the lower part of the abdomen." 947. The fever accompanying the disease generally assumes an intermittent or remittent form, the paroxysms occurring in the after part of the day. If the disease has commenced during the period of the lochial discharge, this will be very apt to be sup- pressed, or become changed and fetid in character. 948. The enlarged limb is Avhite, pale, and shining; it may be, and is generally, Avarmer than natural, though sometimes its tem- perature is not changed, and at others it feels colder than the other limb. At the commencement and toAvard the termination of the swelling, the leg will be found to pit upon pressure, but when it is at its hight, it is tense, and no impression can be made upon it. The entire limb is more or less tender on pressure, though this is particularly marked along the course of the vessels. PHLEGMASIA DOLENS. 439 It is stated that the femoral vein may be traced from the groin down the thigh, feeling hard, or rolling under the finger like a cord; the inguinal glands are likewise sometimes enlarged, and they have been known to suppurate. 949. Terminations.—Under appropriate treatment, the disease usually terminates in resolution ; the febrile symptoms subsiding in a short time, and the swelling being gradually reduced, the patient regains the use of her limbs. It is a tedious affection, and it may be months after the acute symptoms have subsided before the sensations in the affected parts will become natural. Suppuration may take place in any portion of the affected part, involving more or less of the cellular tissue of the thigh, leg, or groin; the suppuration has been knoAvn in some cases to be so extensive as to cause death from the consequent exhaustion. The disease may terminate fatally, though this is not common. Dr. Burns says, "This is not generally a fatal disease; but it is tedious and often accompanied with hectic symptoms. Death, hoAvever, may be caused by suppuration or gangrene, or by exhaustion proceeding from the violence of the constitutional disease ; or by exertion made by the patient, which has sometimes suddenly proved fatal; or, after the leg appears to be getting better, daily shivering, Avith vomiting, pain in other parts, and rapid pulse, with delirium precede death." 950. Diagnosis.—This disease may be distinguished by its occurring shortly after parturition, by the tense, Avhite swelling of the limb affected, by the pain and tenderness along the course of the vessels, and by the hard, cord-like, and painful condition of the femoral vein. 951. Treatment.—Whilst Ave have special remedies for this pecu- liar condition of the leg, Ave Avant a cood condition of the stom- ach and intestinal canal, and a good condition of the excretory organs. As a rule, Ave find an unpleasant condition of stomach as indicated by the tongue, and this must be rectified before other remedies will act kindly. In some cases the pallid, salloAv, ex- pressionless face, with more or less nausea, and a full expression- less tongue, will call for Nux Vomica in small doses. The elon- gated and pointed tongue, Avith reddened tip and edges, and ten derness on pressure over the epigastrium, asks for minute doses 440 DISEASES OF WOMEN. of Aconite and Ipecac, Avith an infusion of Peach-bark. The pallid tongue is the indication for a salt of Soda, and we usually give it in weak solutions as a drink, as much as the patient wishes. The deep red tongue calls for an acid, and we give this as a drink, either muriatic acid, cider or whey. The heavily coated tongue at base, bad taste in the mouth, and feelings of weight and full- ness in the epigastric region, may require an emetic. The pallid dirty tongue asks for Sulphite of Soda. And the full tongue, full tissues, full veins, dullness and dizziness, are the indications for Podophyllin. 952. Other than these, we commence the treatment with the indicated sedative, and such special remedy as will be named hereafter. There are cases in which Veratrum is the best remedy— a vigorous circulation—pulse full and strong, and surface flushed, but in the majority Aconite will be the remedy. We use them in the ordinary dose every hour ; and in the early stage of the disease it is Avell to apply (hem over the course of the saphenous veins. 953. Rhus is a prominent remedy Avhere there is burning pain in the leg, frontal headache, and sharp stroke of the pulse. In one case with the symptoms pronounced, its action Avas promptly curative. Iris has its indication here in marked fullness of the thyroid glands, and in these cases exerts a very marked influence upon the affected limb It should be thought of in chronic cases. Phytolacca is the remedy when the tongue is pallid, sore, Avith enlargement of lymphatic glands, tendency to engorgement and inflammation of the breasts, and mottled appearance of the affected limb. A tincture of the green root should always be employed, in the usual small dose internally, and diluted Avith one to three parts of water, as an application to the leg. Apocy- nurn is decidedly the remedy when there is oedema of both feet, the affected leg pitting on pressure. The indications become stronger if there is fullness of the eyelids, or puffiness of the hands. If the bowels are constipated it may be used to the ex- tent of giving one or two actions a day—say 3J to water siv., a teaspoonful every three hours. Salicylic Acid I am confident will prove a good remedy in those cases in which there is severe pain, with lochia! fetor, fetor of breath, the tongue having a leaden pallor. I should give four or fiv7e grains every two hours. Igna- tia is indicated by morning chills, and coldness of the lower°ex- FUNCTIONAL DISEASES. 441 tremities, with pain in the loAver dorsal spine. It may be asso- ciated with Rhus, Bryonia, or Apocynum. Belladonna is indi- cated by dullness and disposition to sleep, and by the abundant secretion of limpid urine. Hamamelis has its usual indications here in enfeebled veins, swollen vulva, and hemorrhoids, Avith relaxation of the perineum. It is giA7en in doses of one-fourth teaspoonful every three or four hours, and the leg is bathed with it. Apis Avill be indicated by stinging pains, and burning and itching about the bladder and vulva. 954. The principal local remedies have already been named as we studied their internal administration. I do not like the use of hot fomentations or poultices, and think the simple bathing, or at least a cloth wet with the agent, the best application. In ad- dition to those named, I suggest Permanganate of Potash (gr. xx. to Avater 3iv.) to any part showing signs of suppuration ; and a solution of Salicylic Acid and Borax as a Avet dressing. CHAPTER XIV. Functional Diseases. 955. Functional diseases are said to be those " which are dependent on deviation from the natural or healthy action of any part of the organization, indicated by symptoms during life, which on examination after death, are found to be unconnected with any discernible change of structure. Under this head, Ave class Leucorrhea, Amenorrhea, Dysmenorrhea, Menorrhagia, Chlorosis and Hysteria. We have already noticed the numerous structural changes of the uterus and its appendages, which are capable of producing, and do produce, each of these morbid con- ditions, they being but symptoms arising from the structural diseases, so that the definition given of a functional disease will not apply in a majority of instances to these conditions. Still, as each of these diseases may arise without there being any percept- 442 DISEASES OF WOMEN. ible structural lesion, it is necessary to give them a separate consideration. Leucorrhea. 956. Leucorrhea is defined by Dr. Ashwell to be: " An exces- sive and altered secretion of the mucus, furnished by the mem- branes lining the vagina and uterus, by the follicles of the interior )of the cervix uteri, and by the lacunas of the vestibulum ; gener- ally Avhite, or nearly colorless and transparent; usually Avithout much odor; glutinous, muco-purulent, or purulent; sometimes yelloAv, green, or slightly sanguinous, and of varying degrees of consistency. The amount of constitutional derangement depend- ing on the severity of the affection and the susceptibility of the patient." This definition correctly describes the symptom, the vaginal discharge, but it does not give the slightest idea of the cause producing the discharge called leucorrhea. Dr. Tyler Smith, in his recent Avork on leucorrhea, considers that hyper-secretion of mucus is the disease, or, in other Avords, that the discharge is the disease, not admitting that a previous change in the struc- ture of the parts, or an inflammatory action Avas essential to the production of the discharge. He also attributes structural dis- eases, such as erosions, ulcerations, etc., to this morbid discharge. He says: "In maintaining the important part played by the cervical secretions in inducing morbid conditions of the os uteri, I do not wish to be understood as saying that they are the only causes of these conditions. AVhat I contend for is, that in the majority of cases in Avhich leucorrhea is present, in combination with non-malignant disease of the os and cervix, the morbidly active condition of the cervical glands is the primary and essential disorder. Among the other causes of morbid change in the os and cervix uteri, the varying vascular and mechanical conditions of these parts in menstruation, coitus, pregnancy and parturition, must of course be enumerated. Eruptive conditions of the cutaneous covering of the os uteri, in the shape of aptha, herpes, or eczema, form another class of causes of cervical discharge, etc." 957. The first and most important question that arises in the consideration of this morbid condition is, Avhat causes are capable of giving rise to a hyper-secretion of mucus? In considering this LEUCORRHEA. 443 question, we must bear in mind, that the same causes that produce a hyper-secretion of mucus from other mucous membranes, will give rise to it in the mucous membrane lining the genital organs, and that the same pathological laAvs govern diseases of the mucous membrane wherever situated. Suppose, for instance, we take the hyper-secretion of mucus from the posterior nares and upper portion of the pharynx as the type of similar processes in other portions of the system, as it is equally frequent, and can be better observed. We find that this hyper-secretion depends upon an inflammatory action, which may have been at first acute, but soon subsides into the chronic form. This chronic inflammation gives rise to permanent dilatation of the vessels, to thickening of the mucous membrane, and to hypertrophy of the mucous follicles; Ave may observe, that the mucous membrane is tumid, receiving an inordinate supply of blood, and that this tumefaction extends to the follicles, Avhich are enlarged and prominent, and Avith this tumefaction Ave have an increased secretion of mucus. This pro- cess here and in other portions of the system is called chronic inflammation, and is amenable to the treatment used for chronic inflammatory conditions elseAvhere. Why the lining membrane of the vagina, the cavity of the cervix, or of the cavity of the uterus should form an exception to this, I am at a loss to discover. 958. It has been urged against this vieAv of the subject, that the debility of the system Avhich so frequently exists, is proof positive that the local disease is also one of debility. This, how- ever, is but a poor argument, for it is Avell knoAvn that debility of the entire system may exist, and that there may yet be a hyper- aemic, congested, or inflamed condition of any single organ or part. 959. That chronic inflammation is the cause of a very large majority of cases of leucorrhea, I have strongest reason to believe. I have never been consulted in a case of this disease but what I could readily satisfy myself of this fact. There is no doubt, how- ever, but that there is frequently transient leucorrhea without the presence of inflammation, but these cases being slight do not often come under the notice of the practitioner. Dr. Bennet thinks " that this term leucorrhea, if retained at all, ought in sound 414 DISEASES OF WOMEN. pathology, to be reserved for those forms of passive mucous hyper-secretion of the vaginal, cervical, and intra-cervical mucous membrane which often temporarily exist independently of inflam- matory lesions, and independently of uterine ailment. These passive and fleeting conditions of hyper-secretion, really and truly are the reflex of general conditions of health, and seldom come under the eye of the profession as distinct morbid states." 960. We have already described the three principal sources of this discharge, from the vagina, the canal of the cervix, and the cavity of the cervix, under the heads of vaginitis, inflammation of the cervix uteri, and internal metritis, giving the character of the discharge, the pathological conditions producing it, the means of diagnosis, and the treatment, and I have only referred to it in this place to direct the reader's attention to what I consider to be the true pathological condition of the parts, Avhen the discharge ("leucorrhea") exists. Amenorrhea. 960. By amenorrhea we understand the suppression of the menstrual discharge after it has once appeared, or its non-appear- ance at the age of puberty, or the age at which it Avould normally appear. The first of these, in which the menses having once appeared are suppressed, has received the name of " suppressio mensium," Avhile in the second, Avhere it has never appeared, it is called " emansio mensium." We "will first consider emansio men- sium, or the non-appearance of the menses. 961. Emansio mensium, or absent menstruation.—According to Dr. Carpenter, "in the Human female, the period of Puberty, or of commencing aptitude for procreation, is usually betAveen the thirteenth and sixteenth years; it is generally thought to be some- what earlier in Avarm climates than in cold, and in densely popu- lated manufacturing tOAvns than in thinly peopled agricultural districts. The mental and bodily habits have also considerable influence upon the time of its occurrence; girls brought up in the midst of luxury or sensual indulgence undergoing this change earlier than those reared in hardihood and self-denial. The changes in which puberty consist? are, for the most part, AMENORRHEA. 445 connected Avith the re-productive system. The external and in- ternal organs of generation undergo a considerable increase of size; the mammary glands enlarge; and a deposition of fat takes place in the mammae and on the pubes, as Avell as over the whole surface of the body, giving to the person that round- ness and fullness, Avhich are so attractive to the opposite sex at the period of commencing womanhood. The first appearance of the catamenia usually occurs while these changes are in pro- gress, and is a decided indication of the arrival of the period of puberty; but it is not unfrequently delayed much longer; and its absence is by no means to be regarded as a proof of the want of aptitude for procreation, since many Avomen have borne large families, Avithout having ever menstruated." 962. Without, therefore, the non-appearance of the menses has produced a derangement of the general health, Ave can not justly consider it a pathological state, and any and all medication should be positively avoided. Amenorrhea here may be dependent upon congenital deficiency, malformation, or upon structural disease of the genital organs; or it may depend upon a slow and partial development of the uterine organs ; or upon debility; or upon the opposite condition, plethora. 963. In the first case, the ovaries may be wanting, and if this is the case, menstruation as Avell as conception can not occur; the general health may be good, the body Avell developed, and the female strong and vigorous. But there will be no development of the generative organs, the breasts will resemble those of the male, the voice will be deeper, and in all respects there will be a mixture of masculine with feminine peculiarities. In this case, the absence of menstruation will be normal. Again, the uterus may be wanting, though the ovaries are present; the female will be well developed, the breasts prominent, and all the characteristics of puberty present, with the exception of the menstrual secretion. In this case, also, the absence of menstruation can not be con- sidered a pathological condition. 964. We have already noticed in a previous part of the Avork, that amenorrhea may be caused by congenital or acquired occlu- sion of the os or cervix uteri, of the vagina or vulva, or from the 446 DISEASES OF AVOMEN. presence of an imperforate hymen. In each of these cases, all the symptoms of menstruation may be present, and the menstrual fluid secreted, but its escape will be prevented by the mechanical impediment. The symptoms, means of diagnosis, and treatment Live all been given under the separate heads, and the reader is referred to the previous description of each ,of these lesions for the necessary information. 965. The absence of menstruation may depend upon a sloAvand partial development of the uterine organs, either with or Avithout general debility. In this case, there is nothing to be done, or that can be done, without this partial development depend upon debility, Avhen the same measures recommended in chlorosis should be adopted; amenorrhea, dependent upon debility of the system, will also be considered under the same head. 966. We have then only to consider amenorrhea Avhen it exists in connection Avith a full development of the body and of the sexual organs, and when this retention has caused more or less disturbance of the general health, the symptoms being those due to a vascular turgescence. 967. Symptoms.—According to Dr. Ashwell, the symptoms of this condition are "headache, tension and Aveight about the brain, Avith a sensation of fullness and throbbing in the center of the cranium, or about the cerebellum ; a florid countenance, torpor, lassitude; pain in the back and loins; a full and generally a slow pulse, though occasionally, in irritab'e females, it is rapid; irregu- lar circulation, evidenced by the feet and hands being the one hot and the other cold, or at short intervals both remarkably hot and remarkably cold; the skin sometimes harsh and dry, and at others clammy. It is not to be supposed, if the amenorrhea continue, that these symptoms Avill pass away after the attempt at menstruation is over. They may do so for the first few periods, but subsequently they continue during the catamenial intervals, recurring with aggravation as the menstrual epoch again approaches. If the malady has been long neglected, or inefficiently treated, a cure Avill not soon be accomplished. The constitution sympathizes so entirely, that months and perhaps years may elapse before it resumes its healthy and natural actions. AMENORRHEA. 447 968. Causes.—It is said that this variety of amenorrhea is most frequently met with in females who have led sedentary and indolent lives, and Avho have indulged in luxurious and gross diet; it is attributed by some authors to excessive uterine congestion, to torpor of the uterine vessels, or to spasm of their extremities. 969. Treatment.—The treatment Avill have to be varied accord- ing to Avhether it be undertaken during an interval, or at the menstrual period. If at the menstrual period, the feet should be bathed in Avarm Avater, and the warm hip-bath used, or instead of this last the patient may be directed to sit over the vapor of a decoction of bitter herbs, as tansy, hops, etc.; this should be repeated two or three times a clay. 970. If there is vascular excitement, I would advise the ad- ministration of Aconite in the usual doses, with such other rem- edy as may be indicated. Macrotys has a Avide range of applica- tion here, the pain in the pelvis, back and thighs being the indi- cation. With tensive, bearing down pain, I should substitute Viburnum. If the face is flushed and the eyes bright, Avith con- tracted pupils, give Gelscminum. If, in place of vascular excite- ment, there is a feeble circulation, sallow expressionless mouth and face, and pain simulating colic, give Nux Vomica, either alternated Avith or combined Avith Macrotys. If the patient is pale, despondent and nervous, use Pulsatilla and Macrotys. In cases Avhere there seems no special reason Avhy the discharge should not appear, and none of the above indications, the Gos- sypium may be given in doses of one-fourth to one-half teaspoon- ful every three hours. 971. In the inter-menstrual period the remedies must be care- fully selected with reference to special indications, of which I Avill name a few. Iron is indicated by pallor and blueness of the veins, with dull headache in the back of the head; Cuprum by the greenish sallow color, and small pulse; Graphites by the pe- culiar clear and transparent *kin, with tendency to hemorrhage from other parts; the hypophosphites (lime) by pain in the chest and inclination to cough; Hamamelis by fullness and Aveight in the perineum. ' 972. In the larger number of cases, having given one of these or a restorative and bitter if needed, for the first two or three 448 DISEASES OF WOMEN. Aveeks, we will give Macrotys r.nd Pulsatilla in the usual dose, four times a day for the week before the expected period. 973. Suppressio Mensium, Suppressed Menstruation.—Under this head Ave have to consider those cases in Avhich the menses being once established have become suddenly suppressed. This may occur at any period of menstruation, or at any age ; it most frequently arises from cold taken during the menstrual period. from getting the feet wet, sitting on the damp ground, or cold applied to the vulva. Though this is the most frequent cause, yet it may arise from severe mental emotions just preceding or during the menstrual floAv; from coitus during menstruation, from fever or other acute disease commencing at this period, etc. I have also noticed in several cases that suppression of the menses of a very intractable character has occurred from a long sea voyage; in the cases that I have noticed, menstruation Avas checked either at the first period after going on board ship, or else that after this period had passed, there Avere no more symptoms of their appearance during the voyage, the constitutional suffering commencing in one, tAvo, or three months after landing. 974. Symptoms.—The amount of disturbance consequent upon suppression of the menses varies very much in different cases in some cases, there is a slight headache, a feeling of weight in the pelvis, pain in the back, and in the limbs, etc, but so slight as to give the patient but little uneasiness; but more frequently there is a slight chill, folloAved by more or less fever, Avith head- ache, hot skin, quick pulse, thirst, nausea, etc. Sometimes the suppression is followed by inflammation of the uterus, either general, or of the cervix only; in these cases, the symptoms present will be more severe. Dr. Churchill states that the most puzzling sequlae of suppression is, " a species of hysteria, simu- lating inflammation, but Avithout the usual accordance of S}7mptoms, (some one or other of the important being absent,) and changing from one organ to another as soon as our remedies are brought to bear upon it. I have seen the head, lungs, and stomach successively thus affected, and suddenly and apparently spontane- ously relieved. The patient is very liable to attacks of fainting and hysteric paroxysms." Capuron mentions that attacks of apo- AMENORRHEA. 449 plexy and paralysis sometimes result from sudden suppression of the menses. Other authors state that aphonia, derangements of vision, amaurosis, and cutaneous disorders follow from the same cause. 975. These symptoms are very much mitigated in some cases by the occurrence of vicarious menstruation, or the establishment of a supplementary hemorrhage from some other portion of the body. The mucous membrane of the nose, of the lungs, stomach, and bowels, are the most common seat of this discharge, though it has been known to occur from the axilla, from the ears, the mammae, the mouth and gums, fingers and toes, from ulcers, in fact from nearly every portion of the body. This hemorrhage generally consists of blood only, and unless very great in quantity, lasts for several days, and it may reappear at each menstrual period until the menses are reestablished. Though this hemorr- hage might at times seem alarming, as when from the lungs to indicate tuberculosis, yet when the suppression of menstruation is taken into consideration, it has not that importance Avhich it would otherwise have. This vica.ious hemorrhage is probably an effort of nature to establish a supplementary issue for the men- strual secretion, Avhich has been suppressed. 976. Again, there are other cases where the suppression of the menses does not assume the acute form spoken of, the discharge, instead of being at once checked, continuing for several menstrual periods, though each time it becomes less in quantity and lighter in color, being preceded and succeeded by a leucorrheal discharge, until at length it does not present the slightest trace of color. This supplementary leucorrheal discharge occurring at eash men- strual period might be classed with vicarious menstruation. 977. Diagnosis.—There is no difficulty in determining that the discharge has ceased, but the important point that we have to decide is, whether the cessation is, or is not, due to pregnancy. In married women the suppression will nearly always be attributed to pregnancy, but in some cases, both in the married and unmar- ried, the female will consult the physician for suppression of the menses, hoping that the remedies used will produce abortion. In such cases, therefore, we should be very cautious in giving cmen- agogues, unless we can satisfy ourselves that pregnancy does not 29 450 DISEASES OF WOMEN. exist, or if Ave can not do this, to use palliative measures until such time as it may be ascertained. 978. Treatment.—The first point to be attended to in this form of amenorrhea, is to remove any inflammatory condition of the uterus, if this should exist, in the manner heretofore described. If the patient is seen soon after the discharge is suppressed, Ave should employ such measures as will tend to recall the discharge, For this purpose her feet should be bathed in AYarm Avater, the Avarm hip-bath should be used, or she might sit over the vapor of a decoction of bitter herbs, and some warm diaphoretic infusion should be given, as an infusion of Eupatorium Perfoliatum or Pennyroyal. These may be called " domestic means," and though frequently successful in cases of suppression from cold, and usually harmless, yet sometimes they may do serious injury by causing an increased circulation to the pelvic viscera, and increased con- gestion. In place of these, the modern treatment Avith small doses of direct remedies, will give better results. If there is an excited circulation, give—R Tinct. Aconite, gtt. viij.; Tinct. Macrotys, gtt. xx.; Water, siv.; a teaspoonful every tAvo hours. If the cir- culation is not excited, the patient despondent or nervous, use— R Tinct. Pulsatilla, Tinct. Macrotys, aa. jss.; Water, 3iv.; a tea- spoonful every three hours. If associated with nausea, abdomi- nal pain (uterine colic), give—R Tinct. Nux, gtt. v.; Tinct. Ma- crotys, gtt. xx.; Water, 3*iv.; a teaspoonful every hour. If there is tensive, bearing doAvn pain, substitute Viburnum for Macrotys in either of these prescriptions. ; 979. In some cases we may see that it is best to give a remedy that Avill exert a more marked influence in " forcing " a discharge But the case must be carefully diagnosed. There should be free- dom from local disease of the reproductive organs, and an. assu- rance that pregnancy does not exist. In such cases, half tea- spoonful doses of a tincture of the Gossypium (made from the green root before the bolls have matured) may be given every tAvo hours until the Aoav appears. If there is excitement of the circuhition, Aconite and Macrotys may be given as above, or if there is uterine colic the Nux maybe used. There is but one case in which I should use Ergot—when the patient Avas dull, drowsy, and showed evidence of want of spinal innervation. AMENORRHEA. 451 Here the tincture may be used in doses of ten or fifteen drops every three hours. 980. When the patient has passed one period, we use any means that may be indicated during the first Aveeks of the inter- menstrual period, and give some remedy to favor the discbarge for the Aveek before it is expected. I have been in the habit of prescribing Pulsatilla and Macrotys for this purpose, and they meet the indications in a large number of cases. But in some the Gossypium in small doses, or other remedies, may be given. 981. In chronic suppression, or where the disease has existed for some time, and where it is accompanied with a debilitated state of the system, other measures Avill have to be employed. The general health should be restored by the administration of tonics and the preparations of iron, by the use of the bath, and appropriate exercise. Any inflammation of the uterus, especially of its cervix, must be removed by appropriate treatment. The frequency of inflammatory disease of the cervix uteri in chronic suppression of the menses, should always cause a rigid examina- tion of the symptoms present, and if these should justify it, of the uterine organs, both by the touch and sight. 982. Do not imagine that Iron is the only restorative in these cases. It is a valuable remedy when indicated, but worse than worthless when not indicated. The evidences of anemia may7 be sufficient, but blueness of A7eins, of lips and tongue, and dull pain in the posterior part of the head will be better. In some cases a tonic like the triple phosphate of Quinia, Strychnia and Iron, may be used Avith advantage. The compound syrup of the Hypopbos- phites is a good restorative, as is cod-oil, when there is tendency to scrofulous inflammation of cellular tissue. Iodine or Nux, as in the compound Iodine pill, will serve a good purpose in stimulat- ing the reproductive function. Phytolacca alone, or with Dono- van's Solution, will be the remedy when there is glandular disease with cutaneous eruption, or hard, painful engorgement of cellular tissue. Phytolacca and Apocynum are used Avhen there is oedema of the extremities, and the engorgements above named. Cuprum is indicated by the greenish pallid coloration of skin and tongue: Arsenic by the feeble pulse, expressionless tongue, and inelastic skin, (minute doses) ; and Graphites by the blanched transparent skin, and inclination to menstrual molimen at frequent intervals, 452 DISEASES OF AVOMEN. 983. That the reader may be familiar Avith the emmenagogue remedies in ordinary use, I may here enumerate as such the savin, black hellebore, aloes, gamboge, etc., which prove emmena- gogue by their drastic cathartic effect upon the bowels, acting especially upon the large intestine, causing an irritation and determination of blood to the pelvis, and thus indirectly proving emmenagogue ; again, the black cohosh, blue cohosh, and their active principles, macrotin, and caulophyllin, guiacum, madder rue, borax, etc., have been termed emmenagogues, though the modus operandi of their action is not known. Electricity, mag- netism and galvanism act as direct stimulants to the uterine organs and the nerves that supply them, and they have therefore proved efficient emmenagogues. Of the emmenagogue combina- tions that I have seen used with good effect, I may mention first a favorite prescription of my own in the olden time : R Caulophyllin, 3j- Ext. Aconiti, gr. iij. Aloes, Ferri-Sulphas, aa. gr. xxxx. M. Ft. Pillula, No. xxxx. The dose of these pills are two morning, noon and night. They have thus far proved very efficient in my practice, under the circumstances named. If the female be troubled with piles, hoAvever, the aloes should be omitted, and one-eighth of the quantity of podophyllin substi- tuted for it. The alkaline tincture of guiacum, formula of Dr. DewTees, will also be found to be a valuable remedy, principally in those cases where the suppression is accompanied with pain in the lower extremities and back, and a sensation of weight and fullness in the pelvis; it is composed of " £ Pulv. g. Guiaci.opt. 5 iv. Carb. sod. vel. Potass., 5 iss. Pulv. Pimento, 3 j. Alcohol dih, lb j. Digest for a few days." The dose of this tincture is oir DYSMENORRHEA. 453 drachm three or four times a day. Another combination which Is used extensively, is : 5* Aloes, Myrrh, Sulphate of Iron, aa. 3 j. Oil of Savin, f. 3 j. Make thirty pills; one of them may be given three, four, five, or six times a day. This list might be increased almost indefi- nitely, but these emmenagogue formulas must be empirical, as the disease occurs under so many different circumstances and presents such varying characters. The only rational mode of practice is, to correct any dyscrasia to which the patient is subject, especially any disease of the uterine organs, restore the general health, and nature, in a large majority of cases, will re-produce the physiolo- gical menstrual secretion. Dysmenorrhea. 984. By dysmenorrhea, we understand a painful and difficult flow of the menses, they being generally, though not invariably, scanty in quantity, in severe cases containing clots, fibrous shreds, or even an entire false membrane. In many Avomen, the menstrual floAv is ahvays accompanied and preceded by pains in the back, limbs, and in the hypogastric region; these pains, however, are but slight and of short duration, and do not produce much uneasi- ness, and are not to be considered as dysmenorrhea; but Avhen these symptoms are aggravated, so as to produce extreme suffer- ing, this disease is said to exist. We have to notice three varie- ties of this affection: Neuralgic Dysmenorrhea, Inflammatory Dysmenorrhea and Mechanical Dysmenorrhea. 985. Neuralgic Dysmenorrhea.—This form of dysmenorrhea may attack females of any age, though it is said to occur more frequently after the age of thirty than earlier in life, and in unmarried females than in the married, or in married Avomen who have had no children. It is also more frequently observed in those of a delicate and nervous habit of body, but it may arise it those of an opposite condition. 454 DISEASES OF WOMEN. 986. Symptoms.—Sometimes the menstrual period is preceded for a few days by a disordered condition of the general health ; the bowels are constipated, the appetite impaired, there is great languor, irritability, etc. Most generally, hoAvever, the first symptoms appear but a feAV hours before, or at the commencement of the menstrual flow. The patient then complains of a sharp, darting, lancinating pain in the region of the uterus, and Avhich radiates from this point to the ovarian regions, to the back, down the thighs, etc.; sometimes the pain in the lumbo-sacral region, in the groins and thighs is excessive, far Avorse than the uterine pain. Again, there may be severe pain in the mammas, Avhich may precede the appearance of the menses for two, three, or four days; or it may occur at the commencement of the discharge. Sometimes during the Aoav of the discharge, there may be severe expulsatory pains resembling those of labor, and Avhich greatly aggravate the suffering. There is rarely any febrile excitement present, though the pulse is sometimes quickened, and in a majority of cases, the skin will be found harsh and dry. The character and quantity of the discharge varies much in differ- ent cases; sometimes for the first feAV hours, or for a day or two, it is passed in drops, but it then becomes free, and Avith the free discharge there is an entire or partial cessation of pain; at others, it may occur in slight gushes, each discharge being accompanied Avith severe pains, or small clots or fibrinous shreds may be discharged at this time; in others, again it may appear for a day or tAvo, and then cease to again reappear, or it may con- tinue throughout the menstrual period in usual quantity. As soon as the menstrual period is past, the pain ceases, and the patient regains her usual health. This species of dysmenorrhea may exist for only one menstrual period, or it may be habitual, or it may occur or be greatly aggravated at one period, and then for the next, or for tAvo or three periods, it may be absent or very mild, but will again recur upon the least over-excitement or exposure. 987. Causes.—Cold is considered to be the most frequent cause, especially Avhen taken during menstruation, soon after delivery, or after abortion. It is also said to arise from violent DYSMENORRHEA. 455 mental emotions, sudden shocks, etc , when occurring at the menstrual period. 9SS. Treatment.—We have made important additions to our remedies for the relief and cure of this unpleasant disease in the past twenty years, and a very large proportion of cases may now be cured by the use of internal remedies alone, Even many of those which were diagnosed as "mechanical dysmenorrhcea" have been relieved, even after a failure by dilatation or incision of the cervix. The remedies to be specially studied in this con- nection are the Pulsatilla, Macrotys, Viburnum, and Nux, though there are others that exert a very marked influence over the dysmenorrhea when specially indicated. If there is vascular excitement at the commencement of the Aoav, I combine Aconite Avith the Macroty78 or Viburnum. Taking the ordinary case, I prescribe—R Tinct. Pulsatilla, Tinct. Macrotys, aa. 3ss.; Water, giv.; a teaspoonful four times a day. commencing four to six days before the menstrual period, and continuing until it is fully established Avithout pain. In chronic cases Ave repeat it every month in this Avay until the desired object—painless menstrua- tion—is established, even though it takes months to accomplish it. The special indication for Pulsatilla in this case is nervous- ness, usually depression. Viburnum should be chosen Avhen the pains are tensive and explosive, as if there Avas something to be passed. It may be giAren with Aconite or Macrotys, rarely Avith either of the others. Nux is the reined}7 for " uterine colic," and we have a species of dysmenorrhea in Avhich the pain simulates a colic, the patient being greatly prostrated, Avith a feeble circu- lation, pallid, salloAv face, and sometimes uausea. The remedy may be combined Avith Macrotys. or Caulophyllum, or Dioscorea. 989. While the remedies named are those indicated in the ma- jority of cases, Ave Avill fiud some in which Gelseminum, Bella- donna, Rhus, Apis, Ignatia, Collinsonia. and Lobelia, are reme- dies. Scanty and difficult urination, Avith flushed face and bright eyes, Avill call for the first; profuse discharges of urine, dullness and drowsiness, the second ; burning pain and frontal headache, the third; burning, Avith intense itching, the fourth ; seA7ere chill and coldness of the extremities, the fifth; tensive, tearing pain about the rectum, as if some rough or pointed substance had lodged there, the sixth; great precordial oppression, difficult 456 DISEASES OF WOMEN. respiration, and full rigid pelvic tissues, the seventh. This is a very brief description of the remedies used, but every word has a meaning, and it will be very difficult to mistake it. 990. The use of carbonic acid as a local anaesthetic to the vagina and uterus, has been strongly recommended by Dr. Simp- son and others, in this affection, it is said not only to give tem- porary relief, but that a permanent cure may be effected by it. Dr. Simpson uses a common Avine-bottle for the formation of the carbonic acid gas, and forms it by mixing in the bottle six drachms of crystalized tartaric acid, with a solution of eight drachms of bi-carbonate of soda, in six or seven ounces of Avater. A long flexible caoutchouc tube conducts the gas from the bottle into the vagina. The cork fixing this tube into the mouth of the bottle, should be adapted so as to prevent the escape of gas by its sides. With this vieAv, the cork should be perforated by a metallic tube, and covered externally Avith a layer of caoutchouc. Dr. Dewees used the same kind of an apparatus, but formed the gas by mixing dilute sulphuric acid and carbonate of lime; he recommended it strongly as a palliative in carcinoma uteri. 991. In regard to the benefit to be derived from its use, Dr. Simpson says: " I have used carbonic acid as a local anaesthetic, principally in neuralgia of the vagina and uterus, in dysmenorrhea, and in morbid states of the pelvic organs, accompanied Avith pain, as in carcinoma, etc. I have found it also sometimes of use in irritable states of the neighboring organs. Two years ago, I had under my care, from Canada, the wife of a medical gentleman, Avho Avas suffering from that most distressing disease—dysuria and irritability of the bladder. Many modes of treatment had been tried in vain. The injection of carbonic acid gas into the vaginal canal several times a day at once produced relief, and ultimately effected a perfect cure. She has remained Avell since her return to America, and lately became a mother. Occasionally relief follows immediately. In tAvo or three instances I have seen the use of the gas continued daily for months. I have the notes of one case Avhere the patient was invalided and almost entirely kept the supine posture for years, from feeling of pain and bearing doAvn in the uterus and neighboring parts, particularly on attempt- DYSMENORRHEA. 457 ing to sit or walk. Many modes of treatment were tried by myself and others, with little or no benefit. She has, however, at last regained in a great measure the power of progression, and freedom from suffering in the erect posture, a result which she herself ascribes to the local application of carbonic acid gas, which I recommended to her some months ago; and in the use of it she has regularly persevered. Dr. Major states that in dys- menorrhea he has employed the injection of carbonic acid gas into the vagina in a great number of instances, and generally with decided advantage, the pain being almost ahvays relieved by this treatment. He directs the remedy to be used two or three times a day, and for five or six minutes each time." 992. Inflammatory Dysmenorrhea.—This form of dysmenorrhea presents nearly the same symptoms as the neuralgic form during the menstrual period; but instead of the patient being free from pain during the menstrual interval, she has all the symptoms of the inflammatory affection continuing. This form of the disease likeAvise affects the general health more than the preceding. Dr. Bennet thinks that we may connect with inflammatory dysme- norrhea that form which has been described under the head of pseudo-membranous, and Avhich is characterized by the expulsion of shreds and casts of plastic lymph from the cavity of the uterus. " I believe that the formation of these membranes coincides almost invariably Avith the present or past existence of uterine inflamma- tion. In other Avords, I have found, in the great majority of cases of this description that have come under my observation, that there has been at first inflammatory disease, although the removal of this disease has not ahvays freed the patient from the liability to the formation of the pseudo-membranous casts. It would appear as if habit alone sufficed in some instances to perpetuate their formation, or at least their occasional occurrence, even after the removal of inflammation, if they have once occurred under its influence." The production of these dysmenorrhea! mem- branes always aggravates the uterine suffering, their expulsion being accompanied by severe tormina like the pains of labor. 993. Diagnosis.—This form of dysmenorrhea may generally be distinguished from the other tAvo, by deArelopment of pain as a 458 DISEASES OF WOMEN. permanent menstrual condition in a person othenvise menstruat- ing Avithout pain. In this form likewise the symptoms of inflam- mation Avill generally be present through the menstrual interval. If these symptoms be present, or if the disease resists the usual remedies for the affection, an examination should be made to determine the condition of the uterine organs, Avhen the inflamma- tion Avill be detected. 994. Treatment.—The treatment during the menstrual Aoav will be the same as for neuralgic dysmenorrhea, our object being to mitigate the pain and promote the menstrual discharge. But during the menstrual interval our efforts should be directed to the removal of the inflammation ; this being the cause of the pain- ful menstruation, its removal Avill be folloAved by a cure of the dysmenorrhea, Avhich is but a symptom. 995. Mechanical Dysmenorrhea.—The term mechanical dysme- norrhea is applied to that form Avhich is supposed to arise from stricture of the canal of the cervix. The attention of the profes- sion Avas fir^t called to this cause by Dr. Mackintosh of Edinburgh. He states that he has found it a very frequent cause of the affec- tion, though this is denied by other authors. There can be no doubt that stricture of the cervix, eitlier congenital or acquired, does sometimes exist, but from the contradictory statement of authors it is impossible to determine its frequency; when it does exist, hoAvever, it may be a cause of dysmenorrhea. The symp- toms of this form of dysmenorrhea do not differ materiall}' from those of the other forms. The peculiar character of the dysme- norrhea, when caused by congenital contraction, according to Dr. Bennet, is the absence of any uterine symptom during the interval of menstruation, and intense agonizing pain for a feAV hours before the Aoav of blood appears, eitlier then disappearing, or lasting throughout the period; these pains commencing Avith men- struation in early youth. The obstruction may merely be at the os internum, spasmodically contracted ; in Avhich case, as soon as it has been overcome, the blood escapes freely, and pain disap- pears. But, if the os internum is permanently contracted, or the contraction exists in the cervical canal, the pain may continue throughout the catamenial period. MEN ORE II AG I A. 459 996. Treatment.—Where it is ascertained that the dysmenorr- hea is dependent upon contraction of the cervical canal, it may be relieved by its cautious dilatation. This dilatation may be effected by the use of graduated elastic or metallic bougies, com- mencing with one of a small size, and gradually increasing it until the canal is suiTic'ently dilated. In using these bougies the patient should be placed in the usual position for making an examination, the index-finger of one hand being introduced to the cervix uteri, the bougie may be guided by it to the os, and by a slight rotatory motion it should be carefully introduced through the cervix to the fundus. The frequency with Avhich the bougie is introduced, must depend altogether upon the degree of irrita- tion it produces; if any should arise, every tAvo or three days will be sufficient. Incision of the cervix uteri has been recommended and many7 instruments have been devised for the purpose. The one in most common use is made like a pair of scissors, the cutting blades shutting into a staff like a uterine sound. The instrument being introduced as far as the operator deems it necessary, the blades are spread and allowed to cut their way out as the instru- ment is AvithdraAvn. I think its use objectionable. 997. Each of the three varieties of dysmenorrhea generally causes sterility; this is almost invariably the case in the severe forms, but in the slighter impregnation may occur. If conception does occur, it may be folloAved by an entire disappearance of the dysmenorrhea afterward. Menorrhagia. 998. Menorrhagia, or profuse menstruation, may occur at any age, and either in the plethoric and robust, or in those of a delicate and exhausted habit of body. The term monorrhagia signifies merely an increase in the catamenia, the standard with which it is compared being the normal quantity discharged by the female, and not any definite amount supposed to be the average quantity of blood discharged during menstruation. Thus, in some females the discharge is ahvays very profuse, and yet still compatible Avith health, while this same amount of discharge Avould be considered as monorrhagia in others. Excessive menstruation may occur in two Avays; either as it regards the frequency of ita 460 DISEASES OF WOMEN. return, or the quantity lost at each period : in the first, the excessive menstrual discharge, either as to frequency or quantity, is the normal uterine secretion, shoAving no tendency to coagulate either within the uterus or when discharged ; in the second, the discharge is actually a hemorrhage, resulting, probably, from an exhalation from the uterine vessels, the discharge coagulating both within the uterus, forming clots, and after it has passed from the genital organs. These tAvo varieties Ave Avill consider separately. 999. Menorrhagia, with the discharge of the normal menstrual fluid.—As I have already stated, Ave have no standard by Avhich we can determine the existence of this species of monorrhagia; the fluid being normal in quality, its variation in the frequency of its recurrence, or in the quantity discharged, Avill have to be determined by the previous history of the patient. Thus, if the periods of recurrence were twenty-eight days, the appearance of the menses at intervals of tAvo or three weeks Avould be called menorrhagia; or, if the normal quantity discharged was six or eight ounces, the loss of fifteen or tAventy ounces Avould be profuse menstruation, and still each of these circumstances, occurring in other females, would be normal. 1000. Symptoms.—The symptoms attending profuse menstrua- tion are such as we should anticipate from any exhausting discharge; thus, there is debility, languor, inactivity, the face is pale, the hands and feet cold, etc. There is generally a sensation of Aveakness or slight pain in the back, and, as the disease continues, a constant aching, more or less severe, in the lumbar regions, in the hips and thighs, and in the hypogastrium. "If," says Dr. Churchill, "the disease be not relieved, and especially if uterine leucorrhea be present, all these symptoms become aggra- vated. The exhaustion and languor increases, the face becomes salloAV, an aching pain is felt across the loins, extending around the lower part of the abdomen; pain in the left side, repeated and severe headaches, derangement of the stomach and boAvels; in short, all the secondary symptoms, and the derangement of the health which follow in the train of anemia, no matter in Avhat Avay this may have been produced. In some extreme, but rare cases, MENORRHAGIA. 461 Ave have diarrhea and anasarca, with nervous symptoms, melan- choly, and even epilepsy resulting from this disorder." 1001. Causes.—As already stated, menorrhagia of this, as Avell as the other variety, may occur both in the debilitated and the plethoric, though much more rarely in the latter. It may be caused by cold, by too great physical exertion, or mental excitement, and, it is said, from immoderate sexual indulgence. A very frequent cause of menorrhagia is undue lactation; it also arises from hemorrhage after parturition or abortion. 1002. Treatment.—The treatment of profuse menstruation will vary according to whether the patient is plethoric or debilitated, but in either case the first indication is to remove the exciting cause. 1003. In the plethoric, if the discharge is not too profuse, and it can not Avell be if the discharge still retains the menstrual character and the patient is not debilitated, but little treatment is necessary during the menstrual period. If the discharge is excessive, the patient should keep the recumbent posture, the room kept cool, and the diet plain and unstimulating, and all kinds of excitement avoided. If the bowels are constipated, they may be evacuated by the administration of the Carbonate, Sul- phate, or Citrate of Magnesia, or by the use of laxative enemas. If Ave should wish to check the discharge, cold water or vinegar may be applied to the abdomen and vulva, with the internal ad- ministration of the tinctures or the oils of Erigeron and Cinna- mon, or small doses of ipecac. 1004. During the menstrual interval the diet should be plain and unstimulating; daily exercise in the open air should be taken ; the bowels kept regular, and the cutaneous secretions free by the daily use of the bath. 1005. In the debilitated it is important that this exhausting discbarge should be checked as soon as possible. In passive ute- rine hemorrhage I have placed more dependence upon Carbo- veg., 2d decimal trituration, than any other remedy, though of course it is not adapted to all cases. I give it in grain doses, every one to four hours, and usually follow it with the tincture of Cuprum as a blood maker. When the eyelids look full, or slight 462 DISEASES OF WOMEN. swelling of the feet, Apocynum is the remedy, gtt. x. being added to half a glass of Avater, and given in doses of a teaspoonful every hour. Ergot may be employed in some cases, but I Avould restrict it to those in Avhich the uterine globe bad been enlarged from some cause, or in which there Avas marked evidence of Avant of spinal innervation. Gallic Acid is one of the older remedies, and maybe used in doses of three to five grains every two hours. The oil of Erigeron, in doses of five drops, or tincture of Cinna- mon in 3ss. doses as often as necessary, is also recommended. The Erigeron or Cinnamon maybe combined in the form of tinc- ture, if the physician prefers it. If nothing better is at band, small portions of grated nutmeg Avith alum will serve the purpose. 1006. During the menstrual interval, such measures will have to be employed as will restore the general health ; and by this means prevent the excessive discharge at the next menstrual period. In addition to the means employed for this purpose, the patient should make daily use of vaginal injections of cold Avater, and, in addition to the daily sponge-bath, the entire pelvis, loins, and hypogastrium may be bathed daily Avith salt Avarer, and accompanied Avith brisk frictions Avith the hand; this will be found to be an important means of restoring tone and vigor to the pelvic organs. For the Aveek preceding the next menstrual period the patient may use with advantage the trituration of Carbo-veg. in grain doses four times a day. - 1007. Menorrhagia, with the discharge of blood directly from the uterine vessels, the discharge being coagulable.—This variety of menorrhagia is of very rare occurrence, without there exists some structural disease of the uteius, which may be detected by an examination. This form of menorrhagia mav occur either in the robust or plethoric, the hemorrhage being acute, or in those of a debilitated or feeble constitution, the hemorrhage be'tig; passive. 1008. Symptoms.—In active menorrhagia, siys Dr. Ashwell, " there generally exists immediately before the expected period, and occasionally for a few days prior to the Aoav, considerable ten ion and fullness Avithin the pelvis, accompanied by a feel in"1 of Aveight and throbbing in the uterus. The mammae often sym- pathize, becoming tumid, hot, and tender on pressure, and the external genitals are sometimes slightly swoolen and painful. The MENORRHAGIA. 463 pulse is quickened, there is oppression of the head, and often decided headache, with sympathetic fever. In this way the acute or active form of menorrhagia is ushered in, and is throughout characterized by a predominance of inflammatory or spasmodic symptoms, or by a combination of both. When inflammation is present, there will be fixed pain in the uterine regions; a hot, dry skin, and a frequent, hard and full pulse. Where spasm prevails, the pain will not be constant; but, having continued a longer or shorter time, and often most severely, it will subside, and after an interval again occur with throes resembling the pains of labor. The discharge, too, is equally variable, ceasing for short periods, during the pain, and returning Avhen it subsides. The pulse, during the spasm, is contracted, irritable, and quick ; afterward it becomes softer and slower, giving proof by this rapid change of a state of the system, neither of inflammation nor debility, but of irritation. The progress, duration, and severity of these attacks are extremely variable. Sometimes the discharge comes on and continues by gushes, and numerous coagula are expelled. The patient, in many instances, is thus relieved, the headache, tension, and pain in the uterine region are quickly diminished ; the pulse is softer and less quick ; the skin cooler and moist; and the remainder of the period is passed over with tolerable comfort. In the more protracted and aggravated cases, the discharge often continues from three to six days, not Avithout diminution, but still with such proneness to return, that the patient is compelled to avoid exertion, and to maintain almost constantly the recumbent position. On the subsidence of the flow, she is weak and exhausted, and several days elapse before she regains her usual freshness of countenance and strength of pulse. It is easy to mark the transition from this to the passive form of menorrhagia; for, although at first, the recurrence of the events just noAv described, may not seriously impair the health, yet, after a time, the loss produces a marked impression on the system ; the Aoav lasting longer, and the number of days between the catamenial periods being so diminished that scarcely one attack is over before another approaches. Thus, the active and acute variety is merged in the passive form of the disease." 464 DISEASES OF WOMEN. 1009. The passive form of menorrhagia is by far the most frequent; it varies in degree from a slight excess over the normal discharge to a profuse and rapidly debilitating hemorrhage. Men- _struation may occur at the regular intervals, or these may be shortened, the menses appearing at intervals of tAvo or three weeks ; the length of the menstrual Aoav may also be greatly increased. The symptoms are those of exhaustion and debility; the pulse is feeble, and occasionally quickened, the extremities cold, the face colorless, want of appetite, pain and weakness of the back, indisposition to exercise, etc. This variety is said to be almost always aocompanied with leucorrhea. 1010. Another species of menorrhagia that we might notice here, occurs at the commencement and close of menstruation, and generally results merely from uterine congestion. In the young female the first periods of menstruation may be accompanied by more or less menorrhagia, but after this the men-trual function will be physiologically performed, still the loss of blood at these times is very rarely such as to call for medical interference. It is not so, however, at the close of menstruation, the occurrence of menorrhagia at this time being both frequent and profuse. It may arise merely from uterine congestion, and in many cases this is probably the cause ; thus the menses may disappear for two or three periods, and. Avhen it does appear again, there is such a determination to the uterine organs that menorrhagia is the result. It may likeAvise occur at this period from the presence of malignant groAvths, and tumors, but apart from these, I believe, it is most frequently caused by inflammation either of the entire uterus, or more frequently of the cervix. On this point Dr. Bennet says: — "In nearly all the instances of very obstinate hemorrhage at the change of life which I meet Avith, I find on examination that the congestion and hemorrhage are kept up by inflammation and ulcerative disease. Indeed, som> of the very Avorst instances of protracted and severe hemorrhage that I have ever seen, have been cases of this description; and, what satisfac- torily proves that the inflammatory affection- is the cause of the continued hemorrhage, is, that Avhen it is cured the hemorrhage generally ceases. This is not, hoAvever, invariably the case. I MENORRHAGIA. 465 have occasionally met with females at the critical period of life, in whom the hemorrhage obstinately persisted after the removal of the inflammatory and ulcerative disease of the ceivix, which had probably in the first instance given rise to it. In several of these cases, however, time or dilatation of the cervix has subsequently proved that the hemorrhage did not proceed from a sound uterus. but Avas connected Avith the presence of a polypus, or of a fibrous tumor, so small and obscurely situated as not to have been recognized at first." 1011. Causes.—The causes of these varieties of menorrhagia are the same as those named in profuse menstruation. 1012. Diagnosis.—The fact that uterine hemorrhage exists can ahvays be ascertained from the patient, but, Avhether it does or does not arise from structural disease of the uterus, can only be known by a strict vnginal examination. This should ahvays be made if the hemorrhage does not yield to the use of the ordinary remedies, the various morbid conditions, capable of giving rise to uterine hemorrhage, have been already described, and the reader is referred to them for their distinctive marks. 1013. Treatment.—In active hemorrhage I like the action of Veratrum, associated with Ipecac, and folloAved by oil of Erigeron if necessary. I usually prescribe—R Tinct. Veratrum, gtt. x. to gtt. xx.; Tinct. Ipecac, gtt. xv.; Water, 3iv., a teaspoonful every fifteen minutes at first, increasing the distance between the doses when the patient feels nausea. This will sometimes be all that is necessary, with rest in the recumbent position, to stop the most alarming hemorrhage. If not, folloAv in a short time with five- drop doses of oil of Erigeron on sugar, or five-grain doses of Gallic Acid. In place of Veratrum the Lycopus maybe given in the proportion of gtt. xxx. to water 3 iv. Macrotys maybe added to the treatment when there is muscular pain and uterine tender- ness, and Viburnum when the pain is expu!sh7e like labor pains, Apocynum should be thought of Avhen there is the slightest ap- pearance of oedema, and Ergot if there is impairment of spinal innervation. The Hamamelis will also prove a valuable remedy, and should be thought of in anticipating the next menstrual pe- riod. It may be given in teaspoonful doses during the Aoaa7, and 30 466 DISEASES OF WOMEN. afterwards in doses of one-fourth teaspoonful four times a day. The Senecio and Aletris have proven useful during the inter-men- strual period, and even to correct the hemorrhage. If the hem- orrhage has been ushered in with a chill, it is well to follow the sedative with five-grain doses of Quinine, and singular as it may seem, the first dose will sometimes arrest the hemorrhage Avhen other means have failed. The triple phosphate of Quinia, Strych- nia and Iron, in the usual tonic doses, is an excellent remedy during the inter-menstrual period. Should the hemorrhage be alarming, cold may be applied to the abdomen and vulva, and the vagina plugged with sponge or linen cloths. During the menstrual interval the same course of treatment should be pursued as recommended for profuse menstruation in the plethoric; and should there be any inflammation of the uterus or its cervix. which may be the cause of this form, it should be ascertained and removed. 1014. In passive hemorrhage we may give the Carbo-veg., oil of Erigeron, Gallic Acid, tincture of oil of Cinnamon, Apocy- num, minute doses of Ipecac or Ergot, as heretofore recommended. I like the action of the first named, and Avhen the patient was pallid and almost bloodless, I wouldrather trust it than any other. The Hamamelis is especially the remedy when there is a sense of fullness with relaxation in the pelvis and perineum. The patient should be kept in the horizontal position, on a hard bed or mattress, the extremities kept Avarm by the use of hot bricks or bottles of hot Avater, but otherwise she should be kept cool. If the above measures are not sufficient to arrest the discharge, Ergot may be administered in doses of five grains and repeated every one or tAvo hours, or the tampon may be used, or the extremities may be ligated : this last measure will nearly ahvays prove effectual in checking the discharge until other means have had sufficient time to act. 1015. During the menstrual interval the means already men- tioned should be resorted to, to improve the general health, all causes tending to produce the disease should be avoided, especially such as tend to produce excitement of the genital organs. The directions of Dr. Ashwell in this disease, are to the point. He CHLOROSIS. 467 days: " Sexual intercourse and stimulants, mental excitement and physical effort, must be avoided for ten or tAvelve days before the periodical returns. When there are increasing pallor, oedema, threatened dropsies, softening of the cervix, and aggravated debility—sea air, or mild but nutritious diet, consisting of animal food and milk, or malt liquor, must be enjoined. Where there is universal coldness of surface, especially of the extremities, fric- tions, by stimulating embrocations, the flesh-brush, and horse-hair gloves, the wearing of flannel and Avorsted stockings, are indi- cated. The salt hip-bath, the local salt shower-bath, applied night and morning, by a common garden Avatering-pot, over the hypogastric and lumbar regions, are often advantageous. Nor is the injection of cold water, once or tAvice a day, into the rectum, to be neglected. Astringent vaginal injections are deservedly relied on, especially if carefully administered as already urged, during the intervals. Still, there are cases Avhere cold injections can not be borne. Local fullness, excitement, and pain follow their use; and sometimes I have attributed to their employment, an earlier and larger return of the hemorrhage. They are most beneficial where there is copious leucorrhea, and from the cure of this morbid secretion, good may generally be anticipated. It must be remembered, that the unmarried are liable to congestive menorrhagia, and I have often thought that their cure Avas more difficult and protracted, and their hemorrhages larger, than where many children had been borne; but on this point, I am not pre- pared to give a positive opinion." Chlorosis. 1016. Chlorosis, or green-sickness, is defined by Dr. Ashwell, to be: "A peculiar affection of the general health; in which debility, languor, and deranged stomachic functions are prominent symptoms ; most frequently occurring Avhen puberty is or ought to be established, although it may exist at any subsequent period, always characterized by anaemia of the system, and a yelloAvish, dirty-green pallor of the surface. When a disease of early vouth, almost invariably connected, either with entire absence of menstruation, or with a scanty, painful, and irregular performance 468 DISEASES OF WOMEN. of the function ; and if a disease of later life, in addition to these causes, it may have been preceded and produced by menorrhagia or leucorrhea." This disease is strictly a disease of the blood, and may arise in either male or female; it very rarely occurs in males, however, and when developed in the female, it is nearly ahvays associated with some derangement of the menstrual func- tion, hence it is considered by most authors to be a disease either dependent on derangement of the menstrual functions, or else that the blood-disease is primary, and the menstrual derangement the effect of it. In a large majority of cases, it occurs at or near the period of puberty, and it has thus been considered a disease peculiar to this period. 1017. Pathology.—As it is an admitted fact, that chlorosis is a disease of the blood-mass, we have to ascertain in what this con- sists—Avhat change the blood undergoes to produce this condition of the system, and then what influence the uterine organs have in producing this change. According to Becquerel and Rodier the blood of a healthy female consists of Avater 791.1 parts in 1000, solid constituents 208.9 parts in 1000. This 208.9 parts of solid constituents consists of: fibrine 2.2, corpuscles 127.2, albumen 70.5, fat 1.6, extractive and salts of serum 7.4. In chlorosis, all the constituents of the blood retain their normal proportion, with the exception of the red globules, which are diminished from their normal amount 127.2 to 70.50, or even as low as 27. With this diminution in the red globules, we may have a diminution in the entire quantity of the blood—there is not only poor blood [spanemia), but also deficiency of the blood (anosmia). Andral states: " That the quantity of blood in circulation may be so diminished, as no longer to penetrate the minute vessels of the cutaneous surface, in Avhich its place is supplied by a thin serous fluid; and after death, a deficiency or even total absence of blood is observed, not only in the large arteries, veins and right side of the heart, but likeAvise in the capillary system, Avhich is remark- ably pale and colorless. In these cases, the membranous and parenchymatous tissues, such as the brain, lungs, liver, kidneys, alimentary canal, and the parenchyma of the heart and muscles, arc also remarkably pale and cxsanguinous." The red globules CHLOROSIS. 469 of the blood appear to be that part on which its vivifying and calorific properties chiefly depend. This is proved by the fact, that when they exist in their normal proportion, the different functions of nutrition, secretion and excretion, are all normally performed; the body is well developed, the skin reddened, the color of the blood bright, etc.; while in persons in whom they are much below the normal standard, the functions of nutrition, secretion and excretion are inactive, the surface pale or sallow, the muscles flabby, etc. 1018. We have noAv to examine hoAv this diminution of the red globules is produced, and Avhat relation the uterine system has to this condition. In many cases of chlorosis it has been observed, that if at the age of puberty the catamenia did not become established, or, if established, that it had become suddenly checked, that the health began to deteriorate, and this condition of the blood was produced. " It might seem difficult," says Dr. Williams, " to understand how irregularity of the uterine function operates in producing this condition. That in many cases it is a cause, and not an effect of anaemia, is plain from the Avell-knoAvn fact that no signs of anaemia have occurred until cold, over- exertion, or mental excitement, or some circumstance has suddenly checked the Aoav of the catamenia; it has not returned ; and then the patient begins to lose color, and gradually to exhibit the anaemic state. In many cases, I have knoAvn this to occur in young females, Avho have previously suffered from acute rheuma- tism, implicating the heart. It Avould seem that, in these cases, some injury is done to the blood-particles, and to the poAvers by Avhich they are repaired; this is manifest, not only from the pallidity, but from the yelloAvish and almost greenish hue which the complexion sometimes presents, and which obviously depends on a discoloration of the textures by the altered blood, as in the neighborhood of a bruised part. In some of these cases of chlorosis, the appetite is depraved; there is such a complete disrelish for animal food and other nourishing articles, and such a craving for sour things, and even for matters destitute of nourish- ment, as chalk, cinders, etc., that it might be supposed that this perverted appetite is the cause of the anaemia, by deterring the 470 DISEASES OF WOMEN. patient from taking that food which is capable of making red blood; and undoubtedly such an appetite, when indulged, must contribute to this result; but it is not so constantly present as to be considered the chief cause." 1019. Again, the disease may partly depend upon a lesion of innervation, the uterus and ovaries being supplied with nerves from the sympathetic system, which also supply the organs of digestion and sanguification; a disease of the uterus and ovaries Avill affect the formation of the blood through the medium of the nerves. That this is the case in structural and functional disease of these organs can not be doubted, for in almost every variety of uterine disease we find that the digestive organs sympathize greatly Avith the diseased uterus or ovaries. In proof that this is one cause of the malady, Andral states that "it frequently happens, that by stimulating the nervous system of these chlorotic patients by the physical and moral emotions of matrimony, we produce a more natural complexion and color of the Avhole cutaneous surface, thus indicating a correspondent improvement in the process of sanguification ; and in proportion as the anaemia disappears under the influence of this new modification of the nervous system, the Avhole train of diseased action, the difficult respiration, constant sensation of uneasiness and listlessness, impaired digestion, gastralgia, vomiting, tympanitis, and limpid urine, together with all the strange nervous symptoms, which seemed dependant on some organic alterations of the solids, gradually subside and eventually vanish, as a fresh supply of blood is generated in the system. 1020. Causes.—The causes of chlorosis are all such as depress the vital poAvers of the system ; the special influence of derange- ment of the menstrual function has already been noticed. The primary cause of the menstrual derangement, and thus of chlorosis, may have been a delicate, feeble state of the constitution from childhood, the vital poAvers not being sufficient to perfect the development of the uterine system and its physiological function, menstruation; this may again react in the manner spoken of, upon the general health, and chlorosis is the result. It may also be produced by any exhausting discharge, as menorrhagia, profuse CHLOROSIS. 471 menstruation, leucorrhea, etc. Or by insufficient and innutritious food, croAvded and ill-ventilated apartments, residence in a damp, cold, or marshy locality, etc. 1021. Symptoms.—The symptoms of chlorosis are at first those of debility; the patient is Aveak and languid, dislikes to take exercise, and is easily fatigued ; she is not cheerful, but dull and listless; there is a habitual melancholy ; she loves solitude, and weeps without cause. The appetite is impaired and perverted, food is loathed, and innutritious substances desired, as chalk, dirt, etc. The boAvels are nearly ahvays constipated, the tongue is coated with a dirty white fur; there is flatulence, and all the symptoms of indigestion, sometimes tympanitis; the breath is offensive; there is usually more or less frequent headache, palpitation of the heart; the pulse is quick, weak and com- pressible. 1022. In the aggravated form of chlorosis, says Dr. AsliAvell, "Debility, languor, and listlessness, are more marked; depression is more complete ; the appetite is more morbid, Arith a desire for Blate-pencil, chalk, acids, pickles, and other things equally per- nicious. The complexion becomes still more characteristic: it is a yelloAvish, dirty green, and the lips, gums, conjunctiva, and the lining menibrane of the mouth are bloodless ; the tongue, too, is of a still paler Avhite, and being soft and flabby, it is easily indented by the teeth; the breath is offensive; there is nausea; sometimes vomiting, and frequent heartburn; the boAvels, though generally constipated, are occasionally in a state of irritable and painful diarrhea. There is acute and anomalous headache, attended by every variety of distressing sensation, such as heavy Aveight in the front or at the back of the head, vertigo, fixed and intense pain in one particular spot, paralytic feeling and neuralgia. There is a dark line underneath the eyes, about the alae of the nostrils and at the angles of the mouth ; the eyelids are dark and oedematous in the morning; the ankles and legs are frequently so at night; the cellular or soft tissues are flaccid, and the surface generally, especially of the upper and loAver extremities, is cold. If menstruation has continued up to this time, its intervals become more distant, the discharge itself is scanty 472 DISEASES OF WOMEN. continuing to Aoav only for a feAV hours, and in quality it is often serous and pale, and of offensive odor. There is sometimes a general dryness of surface; the skin is no longer resilient; there is a splitting and brittleness of the finger-nails; the hair loses its glossy brightness, falls off in large quantities, and alters in color. It is not uncommon in advanced chlorosis, for the abdomen to be full and painful; and Avithout decided phthisical complication, there may be slight, short cough, pain under the left mammae, and hysteria in a variety of forms. At this period, one or several symptoms being confirmed, so far mislead as to induce the belief that the lung, the brain, the liver, or the heart may be organically diseased. Such is the malady Avhen fully developed." 1023. Treatment.—In the treatment of chlorosis we have three prominent indications to fulfil: First, to remove any disease which may exist independently of the chlorotic condition, and which may, by its continuance, tend to keep it up. Second, to restore the blood to its normal condition, by the use of tonics and iron, nutritious diet, appropriate exercise, the use of the bath, etc., and Third, to stimulate the uterine organs to a performance of their natural functions. 1024. Diseases of the system existing in connection with chlorosis will have to be treated in the usual manner, having especial reference, however, to the debilitated condition of the system. Two of these, however, deserve special notice: disorders of the stomach and constipation of the bowels, or Avhat is of rare occurrence—diarrhea. We have already seen that the stomach is the first organ specially affected in this disorder, that the appetite was vitiated, that it was frequently accompanied Avith nausea and vomiting, that the tongue was coated, and the breath offensive. As a healthy condition of the stomach is of the first importance in the treatment of any disease, and especially of this, where the entire success of the means Ave adopt depend upon a normal absorption and assimilation of the remedies given, and a healthy performance of the digestive functions, so that Ave may restore the deficient elements of the blood; it becomes necessary that we have seme definite knowledge of the condition of this viscus in chlorosis. According to Dr. Budd, "the continued disturbance CHLOROSIS. 473 df the secreting function of the stomach seems to lead to an inflammatory, or a catarrhal state of the mucous membrane. The digestive poAver is greatly Aveakened, and, under the influence of unhealthy or decomposing mucus, the starchy principles of the food undergo fermentation in the stomach, by which large quanti- ties of lactic acid are formed. The undue acidity of the stomach, or the great disturbance of its secreting function, lessens the secretion of the liver, and the continuance of the disorder causes a salloAV appearance of the countenance." In many cases of chlorosis this condition of the stomach exists, and it is so promi- nently marked that it can hardly be mistaken. What is the remedy for this condition of the stomach? Can it be overcome by the use of tonics, iron, cathartics, and the various remedies recommended for chlorosis? It may; but, in my opinion, the easiest and surest Avay of restoring the tone of the stomach, is to' first remove the morbid secretions from it by an emetic, which will not only accomplish this, but will also stimulate the stomach to a normal performance of its functions, and modify, by the shock which it gives to the system, the abnormal nervous irritability. I may be wrong in estimating the proportion of cases in Avhich this condition of the stomach exists, but in all of the cases that I have seen, with but one exception, it Avas present. My use of emetics, in such cases, commenced as a dernier resort; in the first case I had employed the means recommended by authors for the disease, but the patient gradually declined under the use of them, the condition of the stomach Avas evident, and I determined, not- Avithstanding her weakness, to employ an emetic; the Compound PoAvder of Lobelia Avas administered in infusion in the usual man- ner, accompanied Avith copious draughts of Avarm water, free emesis occurred, and the quantity of decomposing nauseous mucus throAvn off of the stomach Avas astonishing. The immediate benefit derived from the emetic Avas surprising, at least it surprised me, as I Avas fearful of the result; in a few hours aftenvard, the patient expressed a desire for her supper, Avhich she had not done for three months before, and from this date, under the influence of mild tonics, the soluble preparations of iron, nutritious diet, and exercise, she rapidly regained her health. I have used emetics 474 DISEASES OF WOMEN. in several other cases of debility at this period with equal advantage; but in none but this in Avhich chlorosis was so well marked. The only account of the use of emetics in this disease that I have seen is by M. Colombat. He says: "Emetics, first proposed by Mercatus, (1554,) may be appropriate for cases in Avhich the disease is complicated Avith some gastric disorder. Buillon relates that all the remedies employed for the cure of the daughter of a goldsmith, aged eighteen years, and affected Avith chlorosis, proved unsuccessful; but he adds that the young patient Avas thrown from a carriage, Avhich gave her a great fright, and brought on abundant vomiting of bile; from that moment her appetite returned, her face resumed its natural color, and her health Avas perfectly restored in a short time." 1025. Constipation of the boAvels :s a very frequent condition in this disease, and it is of much importance that it should be overcome; the cause of the constipation is probably torpor of the boAvels, caused by deficient innervation. To remove this difficulty, the majority of authors recommend aloetic purgatives—aloes and some of the preparations of iron. But a much better remedy will be found in the Compound Tincture of Tamarac, or Bones' Bitters; this may be given in doses of a table spoonful three times a day, half an hour before eating, and if it should be necessary, its action may be assisted by the use of laxative enemas. 1026. Looking back over the experience of twenty years, I do not know but what I have given "the emetic" too strong a recommendation and too wide a use; and yet I let it remain as written for those intractable cases with foul tongue and breath, that will not yield to other means. In some cases the Sulphite of Soda, or Sulphurous Acid, or Chlorate of Potash, will rectify the wrong of the stomach. In others, minute doses of Podo- phyllin Avith Hydrastia will be indicated. Nux Vomica, and Ig- natia are the remedies when the special indications of nausea, sallow expressionless mouth and abdominal pain, or morning chills, cold extremities, and peculiar constrictive pain in the*epi- gastrium, are present. Graphites, Cuprum and Arsenic, are pos- sible remedies in these cases, the indications heretofore given CHLOROSIS. 475 being prominent. The compound Syrup of the triple phosphate of Quinia, Strychnia and Iron, will prove a good tonic and resto- rative, when there is an indication for Quinine. The compound syrup of the hypophosphites, or the hypophosphite of lime, when there is a tendency to aplastic deposits in cellular tissue, or dis- ease of the lungs. Our indigenous bitters vary in their medicinal action, and there is room for careful observation and selection of them here. I would especially name the Senecio and Aletris as worthy of trial. 1027. It should not he forgotten that chlorosis is dependent upon or associated with disease of the reproductive function or organs, and this should be carefully looked for. Non-appearance of the menstrual Aoav, suppression, and menorrhagia, may all be causes, and a right treatment to correct these wrongs will be ab- solutely necessary to success. Undue sexual excitement, from any cause, may prove sufficient to produce the disease. 1028. In regard to the hygienic treatment, I can not do better than to quote from M. Colombat. He says: " Whatever may have been the cause that has brought on chlorosis, Ave should remove the patient from all exposure to cold and humidity; she should breathe a dry, pure and moderately Avarm air, and it is because these conditions exist during the spring and autumn, that those seasons are most favorable to the cure of the disease. A dry, breezy situation, in a sunny exposure, ought to be recom- mended. Clothes, Avhich by the nature of their tissue, slightly irritate the skin, are to be preferred to any others. Flannel worn next to the skin, and especially alcoholic and aromatic frictions to the whole surface of the body, should likewise be proposed, with the vieAv of exciting the action of the capillary vessels, of invit- ing the blood into them, and promoting perspiration. The food must consist of roast meats, fresh eggs, farinaceous vegetables, ripe fruits, and bitter and aromatic plants; for example, succory and celery. As a drink during meals, we may employ with advantage, a mixture of chalybeate Avater with wine. Between the repasts, the patient may allay her thirst with some refreshing, slightly acidulated drink. Nevertheless, though a careful regimen ought to be strictly observed, it is not well to be too exclusive; if we meet with great reluctance in giving up the injurious 476 DISEASES OF WOMEN. articles which the patients desire, it would be necessary at first, to respect their longings, however strange they might seem, and even to satisfy them, unless they were directed to substances evidently hurtful. We should ahvays commence by regulating the meals, and by forbidding fruit, salad and all crude articles; we ought, moreover, to consult the digestive functions, and Avholly proscribe articles Avell knoAvn to be indigestible. 1029. " Whatever be the aversion to exercise felt by chlorotic persons, Ave ought invariably to insist upon its employment, regu- lating it, hoAvever, by the strength of the patient. Should the muscular debility be so great as to prevent her from Avalking, Ave must resort to mixed and passive exercises. Riding in a carriage, or still better, on horseback, especially if a man's saddle is used, in open and elevated places, where the air is pure, are proper modes of exercise, particularly if pleasant conversation can be added to the charms afforded by diversity of vieAvs and landscapes. Boating excursions, Avhich exert a favorable effect upon all the organs, and Avhich unite to all the advantages of exercise, that of being agreeable to young persons, and of producing a useful stimulation by the presence of individuals of the opposite sex; music, Avhich occasions a salutary excitation in lymphatic persons, and finally, sea-bathing, and SAvimming in running Avater, are different hygienic means, Avhich it is Avell to recommend to ner- vous, sad and melancholy women, and to those of great moral sensibility. Traveling can not be too strongly recommended to persons in Avhom the disease is kept up by acute sorrow, or by any moral affection whatever; the use of mineral waters taken at the springs, offers in this respect, incalculable advantages, not only from the medicinal action of the Avaters themselves, but also, because the patients enjoy at such places the various charms of a numerous and brilliant society, and attractions which are con- stantly changing. 1030. "The use of very tight corsets ought to be forbidden ; sleep should not be protracted beyond eight or nine hours, and care must be taken that the patient's bed is neither too Avarm nor too soft, because such beds often increase the feebleness and con- stipation of very sensitive Avomen, especially those in whom the HYSTERIA. 477 chlorotic state has been developed and maintained under the influence of disappointed love. We should forbid exciting drinks, wine, highly nutricious food, vivid emotions, the frequenting of balls and shows, the reading of highly-wrought romances, the examination of lascivious pictures, and lastly, we should, as far as possible, suppress all circumstances capable of disturbing the sensibility, or of exciting the passions too strongly." Hysteria. 1031. By the term hysteria, wTe understand a peculiar nervous affection not entirely confined to females, but in a large majority of cases seen in them, and generally the result of some structural or functional disease of the uterine organs. Dr. Condie states that he "has repeatedly seen all the phenomena characteristic of hysteria in the male subject. The fact of their recurrence in males is also stated by Sydenham, Louyr, Villermay, Georget, Ferriar, Frotten, Conolly, and others." We have to consider it, hoAvever, only as it occurs in females. 1032. Pathology.—Various opinions have been advanced in regard to the pathology of hysteria, and yet none of them appear so reasonable as the most ancient one, that it arises from some disease of the uterine system. If Ave examine the anatomy of the uterus and its appendages, Ave find that it is abundantly supplied with nerves from the hypogastric plexus of the sympa- thetic, and from the spermatic or ovarian plexus of the same system. It Avill also be noticed that the hypogastric plexus is not formed solely by branches from the sympathetic system, but that it likeAvise receives numerous small branches from the spinal nerves, and thus a connection is formed betAveen the uterus and spinal cord. As the uterine organs receive nerves from the sympathetic system, Avhich also supplies the organs of digestion, sanguification, and secretion, it is evident that disease affecting the uterus will also affect more or less the entire portion of the system supplied Avith those nerves, by sympathy. This fact is well proA7ed in almost all diseases of the uterine organs, the disease affecting in a marked degree the functions of digestion, assimilation, secretion, and excretion. The intimate connection 478 DISEASES OF WOMEN. existing betAveen the uterus and ovaries, through the medium of the nerves connecting the sympathetic system and the cerebro- spinal, and through the branches of the spinal nerves which pass through the hypogastric plexus to these organs, will account anatomically in part for the nervous irritability that is manifested. Dr. Carpenter says : " The clinical history of hysteria would lead us to suppose that the convulsive action depends rather upon some state of the blood Avhich alters its relation to the nervous tissue, as its exciting fluid, than upon any change in the nutritive supply which it affords as would induce a more permanent disorder in the system. Taking all the phenomena into account, there seems much reason to think that a general excitability of the nervous system, such as is only an exaggeration of that which is charac- teristic of the female sex, is induced by some defect of nutrition, comparatively permanent in its nature." This defect of nutrition may occur in tAvo ways; first, through nervous sympathy, as already mentioned, and second, through the circulation. It is supposed, and with much plausibility, that the constitution of the blood is affected by the condition of every tissue with which it comes in contact, so that if any diseased condition of the uterus exists, the circulation of blood through that organ, will change the condition of the entire circulating fluid. 1033. Symptoms.—I can not do better than to give the symp- toms of this singular and ever-varying malady as they are described by NeAvton and PoAvell. " Most of the disquieting feelings, strange and wayward fancies of nervous females arise from hysteria. A paroxysm is usually preceded by general uneasiness, anxiety and oppression; a sensa- tion of choking, or as if a ball Avere rising up from the abdomen into the throat, to which sensation the appellation of globus hysteri- cus has been given ; stiffness about the larynx, headache and cramps. M. George says : ' Hysteric patients in the hospital of the Salpetriere, are so Avell accustomed to take Avarning by these precursory symptoms, as never to be seized unexpectedly ; they go to bed, and are tied doAvn until the fit is over.' Sometimes the paroxysm ends here; but more generally the anxiety and sufferings increase, extreme depression of spirits, often Aveeping. HYSTERIA. 479 ensues; there is a painful sense of stiffness and coldness of the limbs; noise in the ears; vertigo; confusion, and to these rapidly succeed temporary loss of sense and consciousness, and of com- mand over the voluntary muscles, during which, the most vehement struggles are alternated with moments of repose. Occasionally, there is a tetanic rigidity of the muscles of the trunk or back, and the body is thrown up in the form of an arch, but the limbs are more generally contorted ; the patient often beats her breast, tears her hair, grinds the teeth, bites the tongue or lips, or other- wise injures herself. The assistants are often struck, bitten or scratched, and have vociferous epithets heaped on them; terrific screaming, sobbing, laughing and vacant staring may rapidly suc- ceed each other. During the struggling, the heart beats tumultu- ously, the countenance becomes flushed and swollen, and the breathing laborious. After a variable continuance of from a feAV minutes to some hours or even days, of repeated intervals of struggling and repose, as here described, the patient either falls asleep or gradually returns to a state of consciousness and her ordinary condition, save feelings of fatigue and soreness, which disappear in a feAV days. Such are the prominent features of the hysteric paroxysm ; but it varies greatly in intensity and duration. The convulsions may be severe, Avith lucid intervals, and of fre- quent occurrence for days, or a deep, quiet sleep or coma may fill up the intervals, from Avhich nothing can arouse the patient. In some women, the paroxysms return monthly, or at the men- strual Aoav ; in others, at variable intervals dependent on disturb- ances of the physical or mental equability. It is remarkable that plumpness of person, roseate hue of countenance, and general appearance of good health are not incompatible, but often attend the Avorst of sufferers from this affection through life, so faithfully is the nutritive function preserved amid the many and frequent storms of nervous functional derangement. 1034. " So variable are the protean shapes Avhich hysteria may assume, that there is scarcely an organ or its function that may not be invaded and the gravest maladies counterfeited, calculated to lead to errors in diagnosis and prognosis, compromising, if not 480 DISEASES OF WOMEN. the life and welfare of the patient, at least the reputation for close discernment of the practitioner. 1035. " Sudden, extreme, and anomalous symptoms should not be hastily pronounced upon at the bedside of the patient. Hysteric distention of the intestines by flatus has beep mistaken for pregnancy; hysteric hiccup, for that of approaching death ; hysteric colic, for acute peritonitis; hysteric stridulous breathing, for croup; hysteric cough, for hooping-cough; hysteric limpid urine, for diabetes; intense urinary irritation, for nephritis; interior irritation, for inflammation ; hysteric headache, for ence- phalitis; hysteric tenderness and SAvelling of the knee-joint, for Avhite SAvelling; hysteric coma, for apoplexy ; hysteric AvayAvard- ness, for mania, etc. 1036. " Diagnosis.—The suddenness of an attack of epilepsy, the cry, the fall, the distortion of the features, frothing at the mouth, livid turgescence of the face, small quantity of air admitted in inspiration, and the profound coma are sufficient to distinguish it from the hysteric paroxysm Avhich certainly similates epilepsy more than any other affection. The Avant of correspon- dence betAveen the violence of functional dsturbance and the symptoms of organic disease will generally guide in distinguishing hysteric imitations or counterfeits. The history of the individual will aid; examination of the spine also. 1037. " Causes.—Whatever impairs the constitution and in- creases the excitability of the nervous system, may become an exciting cause of hysteria. The anemic state favors its incursion; an irritable habit produced by errors in early physical training; early vicious practices; emotional and imaginative reading; spinal, uterine, or gastric irritation; strong and impassioned feelings; startling sights, sounds, or intelligence ; grief, jealousy, or unrequited loA7e. The ancient doctrine Avas that the uterus was the seat of the disease, but modern physicians regard it as seated in the nervous system or centers." 1038. Treatment.—The treatment of hysteria will be of two kinds: palliative treatment while the paroxysm is on, and treat- ment for the radical cure of the affection by removing any uterine HYSTERIA. 481 disease that exists; strengthening the digestive organs, and restoring the general health. 1039. If called to see a patient suffering under an attack of hysteria, it is recommended to administer anti-spasmodics, as Assafeetida, Valerian, Musk, Castor, Scutellaria, etc. These agents may prove very efficient at times, but I have never had any success with them. I have used the Tincture of Gelseminum, in all cases marked by flushed face, bright eyes, and contracted pupils—the dose of our strong tincture being five drops every fifteen to thirty minutes until the patient is relieved. The tinc- ture of Lobelia and Capsicum is the remedy when the pulse is oppressed and feeble, balf-teaspoonful every ten or fifteen minutes. until it nauseates the patient, or produces vomiting, and I have found in every instance that nausea or vomiting and hysteria Avere incompatibles. There can be no doubt that impressions produced upon the mind have great influence in checking these paroxysms or in keeping them off, and the Lobelia and Capsicum will be found to produce such a disagreeable impression on the patient, that rather than experience the effects of the medicine, if she is certain that it avill be given, she will resist, and that successfully, the approach of the paroxysm; at least this has been my experience. Sometimes it vs ill be impossible to administer anything, on account of the spasmodic closure of the jaAvs, but the medicine can generally be introduced into the corner of the mouth; if it can not be given this Avay, it may be injected into the rectum, using double the quantity of the medicine that Avould be given by the mouth. Sir Charles Clark recommended strongly the cold Avater douche; bringing the patient's head to the edge of the bed, he would pour on pitchersfull of cold Avater, until the paroxysms had ceased. In one case related by Dr. Watson, of a young lady, who for many days had been affected by trismus, so that she Avas unable to open her jaws, and could therefore neither speak nor eat, this treatment Avas adopted. Sir C. Clark being called in, recognized the nature of the affection. He had her placed with her head hanging over a tub by the side of the bed, and proceeded to pour pitchers of cold Avater on her face. Before he had emptied the second, the patient could scream and com' 31 182 DISEASES OF W 0 M E N . plain, giving very audible indications that she could open hei mouth. Dr. Watson says, "Although these patients get great relief by the treatment, they do not like it; and if they are con- vinced that it Avill be put in force, they Avill generally manage not to require it." 1040. The treatment after the paroxysms are over, must be conducted on general principles, any disease of the uter'ne organs existing must be removed, and the general health restored in the manner heretofore pointed out. In reference to the preventive treatment, Dr. Ashwell makes the following judicious remarks: " Where a tendency to the disease is evident, or where one or several decided hysteric seizures have occurred, it is evident that every prophylactic measure should be early and fully adopted. The remarks on the physical education of female youth already made, have a distinct reference to this important subject, and it can not be too strongly urged, that nature and common sense are the best arbiters in every matter relative to female health. Of all the influences capable of molding the female constitution, there are none so poAverful as light, air, food, and exercise; and certainly, in reference to the tAvo latter, nothing can be more at variance with propriety than our modern customs. It Avere easy to censure the Avay in Avhich female education is conducted, but it Avould be to little purpose, till such plans are adopted as shall insure a higher appreciation of physical health and vigor. Happily of late some degree of reformation is observable ; and the young ladies in our fashionable boarding-schools are beginning to realize its blessings. Animal food, and not farinacious puddings and slops ; wholesome malt liquor, instead of water, tea, or bad Avine ; run- ning, jumping, and vigorous play, are more occasionally heard of Avithout being condemned as fit only for the vulgar. By and by, it is to be hoped, that a sounder education will be built on these natural principles ; and instead of days and weeks deA7oted, as they now are, to music, absurd accomplishments, and romantic nonsense, some hours, at least, daily, or weekly, will be given up to history, general literature, and the economy of every-day life." DISEASES OF THE BREAST. 483 CHAPTER XV. DISEASES OF THE FEMALE BREASTS. BY PROF. R. S. NEWTON 1041. The space allowed to me precludes the idea that I should enter into a minute description of the minor affections of the female mammae. It is to those more terrible forms of disease of the breasts that I Avould call attention. There have been Avritten many very excellent and learned dissertations on the subject in hand, and at a first thought it Avould seem that nothing had been left unsaid which could throw light on the subject; yet all these fine essays, all the deep research, all the experiments and statistics of the books, in a practical point of vieAv, amount to but little. Physicians, with all their skill, and Avith a perfect knowledge of the experience and opinions of others, Avho have Avritten on this class of diseases, still have to endure the mortifying spectacle of the unchecked ravages of such affections, and their own inability to arrest their progress. It matters little Avhether we are able to give the rationale of the cure or not, if any one really can affect a cure of a reasonable proportion of the more malignant forms of disease, to which the female breast is liable, he will have done more for humanity than all the learned essayists who have Avritten on the subject. 1042. Having made this class of diseases a special study during the past sixteen years, and having had extensive opportunities to investigate the subject, I deem it my duty to offer to the pro- fession my opinions, Avhich, in many respects, Avill not differ from vieAvs advanced by others, but in other particulars the divergence Avill be very material. One of the simplest divisions of diseases of the breast is that of Mr. Syme, viz.: 1. Those in which there is merely derangement of its nutritive or sensitive action, causing simple enlargement, induration, and pain; 4S4 DISEASES OF WOMEN. 2. Those in which there is a collection of purulent fluid; 3. Those in which there is a morbid growth, limited to the part in which it originates ; and 4. Those in which the groAvth is of a malignant kind,—that is, tends to spread, ulcerate, or fungate, and affect the patient's constitution. 1043. But to comprehend the nature of the diseases to which the mammae are subject, we must understand their structure and functions. So far as its anatomy is concerned, we may learn something of its complicity from the statement of Sir Astley Cooper, that he had heard a good anatomist say, " The breast is so complicated that I can make nothing of it." 1044. The breasts are situated on the anterior portion of the chest, upon the lower part of the platysma myoides muscle, upon the anterior portion of the pectoralis major, upon the serratus major anticus and oblique externus abdominis, and usually cover the space from the third to the seventh rib. The breasts are essentially glands, and, when Avell developed, constitute the most beautiful apparatus in the body. In location and number they differ in different classes of animals, there being generally tAvo for each young one to be nourished by their milk. It has been often supposed, that the provision of a pair of breasts, as in the human female, Avas a provision of nature to supply nourishment for tAvins, when accidentally produced. This seems not to be the case, but to correspond Avith that common duplication of our organs, the natural provision for disease. If one eye is diseased, the other may serve the purposes of sight, and so, if one breast shall be the seat of disease—a very common occurrence—then the sound one will ansAver all the purposes for which the apparatus is intended. 1045. These glands are not situated on the chest so as to pro- ject the nipples directly forAvard, but rather laterally, so as to make the projecting nipple more convenient to the mouth of the child. Sir Astley Cooper has Avritten very elegantly of the adaptedness of the breast to the convenience of the child, and I Avould suggest to the student a careful examination of the subject, as he Avill be more likely to detect even a slight variation from the normal position, and Avhich will enable him to escape errors in DISEASES OF THE BREAST. 48j diagnosis. It is quite true that in those who have borne and nursed many children, the gland becomes pendulous, and the nipple may project forward Avithout any disease being present. And in some tribes, as the Avoman of South Africa, etc., this elongation and relaxtion of tissue is so great that the breast may be, and is often, throAvn over the shoulder, that the child may nurse as it is carried on the back of its mother. 1046. When vieAved as a mass, the mammary gland is a coni- form body, someAvhat globular, Avith its base rather" cupped to fit the bend of the ribs. The number in the human female is usually tAvo, but cases have been recorded in Avhich there Avere four, as Avas the case of a very respectable mother seen by Dr. Robert Lee and Sir Astley Cooper. [Cooper on the Breast, pp. 25 and 26.] But such cases are to be regarded as accidental developments. The mammary gland, in its structure, is not unlike that of the salivary and parotid glands, though on a more magnificent scale. It is made up of from fifteen to thirty lobes, varying in size from one-fourth to one inch in diameter, the size being greater as Ave approach the base of the gland. The lobes are again divided into smaller compartments, called lobules, and these again are sub- divided into ccecal vesicles. The ducts of excretion are thoroughly lined with a beautiful tessellated epithelium ; they all converge toAvard the nipple, upon which they open by a number of small apertures, ranging in number from ten to twenty. In their course they dilate into small ampulae, Avhich vary in capacity. 1047. The breast is divided anatomically into two parts, the internal and the external, both of which require careful study. Per- haps the true Avay to get a knoAvledge of the gland is to begin at its development, and end by giving its physiology. The mammary gland originates from the mucous layer of the epidermis, as a mere papillary projection, as early as the fourth or fifth month of foetal life. It soon develops into a complicated glandular struc- ture, very irregular at first, but which acquires symmetry as birth approaches. All its parts converge to form the mammilla, or nip- ple, Avhich is not, as is supposed by many, in the center of the glandular body, but nearest the abdominal margin, and also nearer the posterior than the anterior margin. Or, as Sir Astley Cooper 4S6 DISEASES OF WOMEN. says: " from one-half to three-quarters of an inch above the lower edge of the pectoralis major." The lactiferous canals, which are thrown nearly together in the virgin, separate and enlarge in the lactating Avoman, and hence the nipple is increased in size, in such as have nursed. It is also longer, and can never after be made to acquire the solidity of the virgin state. Imme- diately on the apex of the nipple, there is a small indentation, caused by the orifices of the lactiferous tubes. Before puberty the nipple is quite smooth, but it is afterward masked by small papillae, Avhich increase in size up to forty years of age. It acquires a Avrinkled aspect after the age of fifty, and in old Avomen has a Avarty appearance. The shape of the nipple is sometimes, but not ahvays, changed by nursing; in the virgin, it is a rounded cone, with the base or broad part resting on the breast, but in Avomen Avho have nursed many children, their order is reversed, or else occupies some medium place between the vir- gin state and the last-named condition. Its color is very various, passing through all the shades of red, and is often even of a very dark muddy color; generally, hoAvever, it loses much of its color as old age advances, and during utero-gestation, is possessed of a higher color than at other times. I desire to be minute in the description of the various parts of this gland, for no one is com- petent to judge of its pathological states, until he is well ac- quainted with its entire structure. 1048. In respect to the cuticle covering the gland, I need only notice that it is much more thin and delicate in women with fair skins and red hair, and is hence more apt to be a.braded by the mouth of the child. The nipple is generally darker than the rest of the breast, which is OAving to the rete mucosum, the character of which will be more fully explained presently. 1049. The areola or colored circle of skin which surrounds the nipple, has received a large share of attention, and as I deem an acquaintance Avith its characteristics of considerable importance, I shall feel Avarranted in also referring to it, at least briefly. The areola is but a spreading of the nipple, or a continuation of it, and. like the nipple, depends for its color upon the rete mucosum. In girls, before puberty, it is simply a colored circle around the DISEASES OF THE BREAST. 487 nipple, but after puberty, during gestation, and in lactating Avomen, it becomes more or less uneven, in consequence of the development of small tubercles, Avhich open on the surface, con- tain a mucous excretion, but have no connection with the lactiferous tubes ; in fact, they are not very different from the common seba- ceous glands of the skin. The color of the nipple and areola depend very much upon the condition of the uterine apparatus, and this is so true that its physical aspect has long been held as quite expressive of the condition of the uterus. Owing to the presence of erectile tissue, and the abundant supply of blood- vessels, the nipple may be erected as in the case of the male penis, and this erection may depend either upon a state of the genitals, or upon the passions. It is a knoAvn fact that there is a most intimate relation of sympathy betAveen the nipple and the uterus or the genitals, and that Avhen the latter are in a state of excitement, the nipple is more or less erected, and that there is an increased engorgement of blood in the nipple at such times, and hence, too, the color of the areola is then deeper. On the other hand, to illustrate the completeness of this sympathy, it may not be amiss to state that many females are so sensitive on the nipples, as to be at once excited by passion Avhen the nipple is touched or handled. Instinctively men recognize this law of inter-relation. It will be understood that the rete mucosum is but the coloring pigment which tinges the entire skin, and that it is the same in every respect as that deposited in the eye to confer color. The more abundantly blood be supplied, the more plenti- ful will be the pigment, and the darker the part so colored. 1050. The mammary gland is well supplied with blood-vessels, the chief arteries being the branches of the thoracica longa, exter- nal mammary, which, like the former, is a branch of the axillary artery, branches of the internal mammary artery, and another branch from the same. Outside of these principal branches, there are a number of less important branches ramifying through them, most of them reaching the nipple. The veins begin at the nipple in minute capillaries, and as they recede from it, unite in large trunks, entering the internal mammary and intercostal veins. 1051. The absorbents are very numerous and well distributed 188 DISEASES OF WOMEN. These have for their office the separation of the milk from the blood. The nerves of the mammary gland are the axillary and the sternal, or the posterior and anterior branches of the above nerves, so called from their distribution. The posterior consists of the third, fourth and fifth branches of the dorsal nerves, all of which reach the nipple. The anterior consists of the reflected branches of the fourth dorsal nerve. To these nerves the nipple is indebted for its extreme sensibility. There are many openings and a feAV stray fine hairs in the areola, but the orifices do not connect, as before stated, Avith the lactiferous tubes. 1052. The gland is in reality inclosed between two fascia, or a single fascia which has separated to accommodate the gland, and which may be traced to the ligamentous substance covering the sternum. From this fascia numerous fibrous processes are given off, which Sir A. Cooper calls ligamenta suspensoria, since by them the breast is suspended in its situation. They are firmly attached to the skin, and though admitting the gland to change position enough to resist violence, they still hold it firmly Avithin certain bounds. These ligamenta suspensoria distribute them- selves upon the posterior surface of the skin, adding greatly to its whiteness and solidity. They also pass out from the gland, enve- lope the lactiferous tubes, and by connecting with the interior cutis of the nipple, prevent its displacement from the gland. Between these ligaments, if such they may be called, Ave find folds of fat, which, acting as cushions, prevent the gland from sustaining injuries from bloAvs, etc. Indeed, these ligamenta sus- pensoria form a net-work, keeping all the parts together, and at the same time, increasing the secreting surface of the gland. The deeper-seated fascia sends its fibers in both directions—into the aponeurosis of the pectoralis major, and into the body of the gland, thus securing it to the body. 1053. The tubes of the mammary gland are both numerous and varied ; e. g., the straight tubes of the nipple, the areolar tubes or reservoirs, the mammary ducts, differing only in their disposition or size ; as a general remark, they enlarge as they pass from the nipple to the reservoirs. Along side of these tubes, we find the aiteries, equally distributed, and conferring on the tubes great DISEASES OF THE BREAST. 489 vascularity. The veins do not run parallel always, and are less branched, the functions of the parts requiring a greater influx than reflux current. The tubes are lined Avith a folded mucous membrane, which is highly vascular. It must be borne in mind, that most of these ducts are entirely separate and distinct from all others, a fact Avhich is easily determined by injection. 1054. The gland itself is a conglomerate structure of small glands, the interspaces, when not occupied with tubes, arteries, veins, or nerves, being filled with fat. The glandules vary in size from the head of a pin to that of a buck-shot, and when injected, are nearly round. 1055. Of the milk-cells, little need be said, since their charac- ter can not materially further the investigations of the pathologist. Into these milk-cells the milk is secreted from the blood, and of course, if not in a physiological condition, soon present us Avith a pathological state. The milk passes from these cells to the mam- mary tubes, and after reaching the areola, is deposited in the reservoirs ready for use. 1056. The axillary and internal mammary arteries furnish the gland, and though greatly distributed, it is only necessary to regard the above larger trunks, as the sources of supply. The veins of the breast empty into the axillary, the cephalic, the inter- costal, the internal mammary, the external jugular and subclavian. The veins of these glands are often engorged in certain diseased states, and some of the best surgeons have been in the habit of opening them, to alloAv the accumulated blood to escape. There is no doubt but it affords, as I have often witnessed, immediate relief, and I greatly prefer the operation to the more tedious one of using leeches to accomplish the same end. The same thing can, hoAvever, be accomplished with great certainty, by other treatment, as I shall have occasion hereafter to shoAv. 1057. I shall be sufficiently understood, if I say, that the breasts are literally permeated by absorbent vessels, or ducts, which, Avhen many unite, may sometimes make a tube as large as a small quill. Such a one is found on the inner side of the axil- lary vein, and betAveen the first rib and clavicle. These tubes are intimately connected with the blood-vessels, and with the 490 DISEASES OF WOMEN. glandules, etc. These absorbents are frequently diseased, and indeed, many of the more malignant forms of mammary disease may be traced to that source. 1058. The nerves of the breast are derived from the dorsal branch of the spinal column, and are so minute in their ramifica- tions that the anatomist can hardly promise himself success in tracing them. I need not attempt to trace the reflex nerves, for the labor Avould not be satisfactory, even though I had space at command. 1059. It is an interesting study to trace the effects of gestation and lactation on the breasts, and though the profession have a sort of general and indefinite knoAvledge on the subject, it must be admitted that too feAV entertain correct views on this point. To arrive at expertness in reading the phases through Avhich the breasts pass, requires a close and careful study of the organ in the living subject, Avhich modest women, before marriage, Avill not per- mit, and on others the circumstances are usually adverse. But before avc attempt to explain the nature of the changes Avhich are Avrought on the breast by gestation and lactation, it may be Avell to inquire how any such sympathy can exist betAveen the uterus and its appendages, and the breasts? It is presumed that no intelligent physician Avill deny that such sympathy exists, and hence I shall not here refer to the evidences upon Avhich the asser- tion is based. Any treatise Avhich is perfect should examine the uterine and mammary systems as constituting the same apparatus, but as this has not been done, I can only briefly show Avhy this should be so. 1060. The sympathy between the uterine appendages and the mammary glands, has been explained by supposing that the epi- gastric artery sent more blood to the internal mammary artery, and hence to the breast itself, during gestation than at any other times; and Avhile I admit that this is altogether probable, the manifestation betAveen the genitals and the breasts, or the mam- mary glands and the uterine appendages, is so instantaneous, as it were, that I think Ave must look to more rapid transmission of influences than such as can be conveyed by the circulation. This sympathy is entirely nervous, in the first place, and whatever DISEASES OF THE BREAST. 491 influence of a permanent nature is transmitted by the blood, is of a secondary character. The great sympathetic nerve, Avhose branches are incorporated with the dorsal nerves of the breast, is also largely distributed to the uterine appendages. It is to be understood that other parts of the system are also reached by the great sympathetic, and other parts, also, partake of the sympathy, but in a less marked degree. I have already stated that the nipple is furnished Avith erectile tissue, and hence Ave might expect it to be more prominently effected than other organs in Avhich no such tissue exists. Very many facts, illustrative of this sympathy, might be cited, but one, it seems to me is quite sufficient, i. e., advantage is taken of this sympathy, by the reckless and fear- less, to produce abortion by simple irritation of the nipple at certain periods of gestation. And Avhether Ave are enabled to give a satisfactory explanation of the phenomena or not, the mere fact stands undisputed, and Ave must base our conclusions on it. 1061. During gestation more blood is sent to the breasts, their color is darkened, and they become more solid, or even SAvell, and become quite painful. They are tender to the touch, and if it be in a first pregnancy, they at once undergo that evolution by which they are matured. The nipple enlarges, the areola becomes much darker, and the papillae become protuberent; in fact, the entire organ looks as though it Avere, as it is, engorged. The increase of the diameter of the areola is from one to tAvo inches. The increased darkness of the areola depends upon the more abundant supply of the rete mucosum, and by its being rendered more visible in consequence of the stretching of the skin, which is the necessary result of the enlargement of the gland. The areola will also be found thickened, in consequence of the development of the papillae. The glands and blood-vessels around the nipple, and on the body of the gland, will also be more prominent than before. 1062. After lactation has been established, all these indica- tions, except deepening of the color of the nipple and areola, are increased. In old age, the tubes of Avhich I have been speaking, become more or less ossified. I need not here enter into a descrip 492 DISEASES OF WOMEN. tion of those influences brought to bear oh the female breast about the time of the cessation of the catamenia, as I shall have occa- sion hereafter to treat this subject more in detail. I have given such facts as I conceive to be necessary in the proper study of the diseases of the breast, and to Avhich too little attention has been paid by surgeons. Perhaps no surgeon in America, of my age, has had more experience in treating the diseases of the female breast than myself, and certainly none have been more successful; which success I imagine to depend both upon my knoAvledge of the glands and the plans which I have adopted for the treatment of their diseases. From these considerations, I feel warranted in laying my experience before the profession, fully believing that when others are guided by the same principles that I have adopted, they will be equally successful. 1063. Numerous morbid specimens ought to be carefully examined, for I assure you that an intimate acquaintance with their appearance, structure, and physical characteristics, will be highly advantageous to you, both in determining the kind of diseased groAvth, and its mode of development. Were this not so, experience could never add to the success of a surgeon ; your knoAvledge of the general pathology of such groAvths would be all that Avould be requisite to enable you to treat them with entire success—a supposition which is not to be entertained. By com- paring together a great number of such morbid structures, Ave learn to recognize the peculiarities of each, and to detect those peculiarities in practice. If there is any science in surgery and medicine, of course it will be applied only when we understand the pathological states that are to be reduced to physiological conditions. There are certain forms of morbid structure, for the removal of Avhich there are specific agents, and nothing but care- ful examinations of those structures can enable you to diagnose them. 1064. If you shall have first examined these structures, and made yourselves perfectly familiar with their pathology, the strong presumption is that you will not commit those grave blunders which have so disgraced many honorable members of the profession. The necessity for thoroughly studyino- the chai- DISEASES OF THE BREAST. 493 acter of these growths, in all possible ways, will be sufficiently obvious by remembering that diseases of the breast may be properly divided into tAvo great classes, the curable and the incurable. The physician, who is entitled to be called scientific, never guesses at what he is to do ; if he does, he is a quack who strikes in the dark, and Avho is as apt to kill as to cure. I have bo frequently seen operations on the breast, which I novv know were unnecessary, that I feel it my duty to guard you against rashness in this respect. 1065. The diseases of the female breasts are exceedingly numerous, and are greatly modified in different constitutions. What would be a dangerous tumor in one case, and Avhich would require a prompt operation, wrould be simple in another, and require no operation. I need hardly call your attention to age and the general health, to impress this truth, and yet some surgeons, judging from the language of the books, and from what I have seen, act upon the principle that a tumor is a tumor, and must, in all cases, be removed. I venture to affirm, that one-half of the tumors of the breast which are called cancer, are not truly such, and in this opinion I do not stand alone. 1060. The causes Avhich give rise to these tumors are also so exceedingly varied, that the fair presumption is a variety of effects; opposite causes usually producing opposite effects. Sir Astley Cooper has drawn a delightful picture in his excellent AAork on the breasts, after having endeavored to impress upon the profession the great necessity of carefully manipulating the living tumor, and of scrutinously examining the morbid specimens on exhibition. He says: 1067. " The result of such knowledge is frequently the source of great security and happiness to a person afflicted with a disease in the breast, as well as of great satisfaction to the sur- geon. I have scarcely Avitnessed a stronger expression of delight than that which has illumined the features of a female — perhaps the mother of a large family dependent upon her for protection, education, and support — who, upon consulting the surgeon for some tumor in her bosom, and expecting to hear from him a con- firmation of the sentence she had pronounced upon heiself, 494 DISEASES OF WOMEN. receives, on the contrary, an assurance that her apprehensions are unfounded. Pale and trembling she enters the surgeon's apart- ment, and, baring her bosom, faintly articulates — Sir, I am come to consult you for a cancer in my breast;—and when, after a careful examination, the surgeon states, he has the pleasure of assuring her that the disease is not cancerous—that it has not thej character of malignancy—that it is not dangerous, and Avill not require an operation ; the sudden transition from apprehension to joy brightens her countenance with the smile of gratitude ; and the happiness of the moment can hardly be exceeded, Avhen she returns, Avith delighted affection, to the family from Avhich she had previously considered herself destined soon to be separated by death, Avith the alternative only of being saved by a dubious and painful operation." 1068. For the purpose I have in view, I shall adopt the very natural classification of affections of the breasts, Avhich is made by Birkett, viz.: 1. Diseases occurring before puberty; 2. Diseases occurring during the establishment of puberty; and 3. Diseases occurring after the establishment of puberty. 1069. It will be apparent that the diseases occurring in either of these periods Avill admit of a very Avide and diversified subdi- vision, each of Avhich Avill be examined in detail, as I progress Avith the general subject. It is difficult to determine at what precise age the earliest development of mammary disease occurs, but within a fevv days of birth. The mammary gland, or the rudi- mentary gland, begins to develop after the sixth month of foetal life, and, like any other gland, may at once become the subject of disease. Diseases occurring in the mammary glands before puberty, and especially Avhen the patient is still an infant or child, are mostly of an inflammatory character, and they vary only in the extent and termination of that inflammation. 1070. Within two or three days after birth, the mammae, or their rudiments, acquire a state of tumefaction, and soon there is observed, issuing from the papillae, a milk-like secretion, Avhich of itself, and independent of all other circumstances, is a demonstra- tive proof of the preexistence of the secreting gland. Many DISEASES OF THE BREAST. 495 mothers, exceedingly ignorant of the processes of nature, and over-careful, become very anxious to have this secretion removed, or to have the excretion stopped. To accomplish its stoppage, they resort to frictions, etc., and inflammation results as the consequence of such harsh treatment of the tender gland. The attention of the parent is first called to the part by the hardness, tumefaction, and tenderness which the child evinces Avhen it is touched. Noav all this is natural enough, and, if let alone for a feAV days, will cease of itself, and leave the parts in a healthy condition. It is true that in rare cases, the tumefaction may last for some days; the natural inflammation may assume a somewhat intense degree; but still, if it be let alone, it will resume its natural state in a short time. 1071. Nothing can be more irrational than to rub, squeeze, pinch or irritate so tender an apparatus as the developing mam- mary gland. Where this injudicious course is adopted, there may be extensive and acute inflammation, ending in abscess, in which event the assistance of the physician will be needed. The treatment must, in every case, be on general principles, modified by the tender age and constitution of the patient. The inflam- mation often extends beyond the glandular structure, as Avas the case with a child less than one month old, seen by Mr. Wagstaffe, in Avhich the inflammation extended from the upper part of the breast down the right side to the umbilicus. Where the attack is so severe as in this case, the inflammation spreads very rapidly over a large space. To bathe the inflamed surface with cooling lotions, and to poultice the abscess which may form, is about all the treatment that is required. 1072. Again, the tumefaction and pain may folloAv the cessation of hemorrhage from the vulva, as Avas observed by Barrier in a female infant only five days old. In this case there Avas but little attending inflammation, yet the case Avas interesting as another evidence of the very close sympathy existing between the mammae and the genitals. 1073. Birkett reports a case in which there Avas an abscess formed in the breast of a child three months old, and whose mother stated to Mr. Birkett that, unlike her other children, the 496 DISEASES OF WOMEN. breasts of this one had not had the usual milky discharge from the mammary gland; and in another case, where the child was sixteen months old, an abscess was present, and the breast SAvelled very much, in Avhich there was also a discharge from the vulva, showing that the genitals were in an irritated condition—another evidence of the sympathy of the parts. But however often we may be called to treat such tumefactions and swelling of the infantile breasts, we shall find the symptoms rapidly subsiding after the slightest attention; and that in no case do they end in serious lesions. 1074. When we approach nearer to puberty, the breasts become more subject to disease, and not unfrequently Ave shall find, that they then readily assume a form of malignancy which demands our utmost attention. And what adds to the difficulties attendant on their treatment, is the modesty of those thus afflicted, and their indisposition to permit examinations to be made, Avhile the disease is yet in its incipient stages. 1075. With the complete development of the ovaries, and the establishment of the catamenia, the mammary glands rapidly enlarge, and assume their perfect shape ; the areola deepens, and the nipple evolves into its natural prominence, of course not acquiring the size and shape Avhich it is afterward to attain. Changes thus occurring are perfectly natural, and do not com- monly give rise to disturbances Avhich require surgical attention; yet they sometimes do, and it is therefore incumbent on me to make some suggestions respecting those diseased conditions. 1076. We are to bear in mind that this natural period of female development varies Avith climate, habits and constitution. It may be stated to range from nine to sixteen years of a^e, and M. Bourgat Saint Hilaire relates the case of a little girl, born in Louisiana, on the 13th of December, 1837, having from birth well- formed breasts, and having the pubes covered with hair, as in a girl of fifteen. The catamenia appeared Avhen the child Avas three years of age, and continued to appear monthly, as in Avomen generally, after puberty has been fully established. The quantity of the catamenial discharge was as great as in Avomen fully developed ; the time of the discharge being usually four days DISEASES OF THE BREAST. 497 This is certainly an anomalous case, but none the less interesting as a fact. A similar case is reported in vol. 2, of the Medico- Chirurgical Transactions, by Sir Astley Cooper. This child Avas the daughter of a Avaterman at Lincoln. The catamenia appeared before she Avas three years old; at first occurring at long intervals, but becoming more regular as she acquired age. " The catame- nia," says Sir Astley, "exactly resembled that of most Avomen, except that it Avas rather of a darker color." The breasts Avere very full, being as large as those of most Avomen at tAventy years of age. Her pelvis Avas well developed, and the pubes covered with a light-colored hair. She did not seem to possess the sexual desire, and Avas not more modest than most children at her age. When six years of age she menstruated regularly every 21st day, the discharge lasting four days. She had frequent leucorrhea, and when in her seventh year, exhibited much more modesty than before. This girl had other sisters a\1io did not manifest any forwardness. Other cases have been recorded, but these are quite sufficient to sIioav that the breasts, in connection Avith the ovaries, may be developed at a very early age ; Avhile on the other hand, numerous cases are recorded where neither the ovaries nor the breasts were ever developed. 1077. Even at the early age of twelve, or at the period Avhen puberty is being established, the breasts may become the seat of cancer, and other malignant diseases, though such instances are not common, by any means. Mr. Bransby Cooper relates the case of a girl aged 13, on whom he found carcinoma medullae of the breasts, Avhich Avas removed, and Avho died, notAvithstanding the operation. Lyford reports a similar case in the London Lancet, and also refers to a specimen in the museum of St. BartholomeAv's Hospital, which was taken from a girl aged sixteen years. 1078. The diseases most apt to attack the mammary gland, at the period of puberty, are inflammation and its sequelae, and often ending in chronic abscess, which, if suffered to run on, may finally develop itself into malignant tumor. Girls, at the establishment of puberty, have most to fear from tubercular diseases of the lungs, mournful instances of Avhich we see almost daily. 498 DISEASES OF WOMEN. 1079. The surgeon Avho expects to master the treatment of diseases incident to the breasts, must not neglect to glean from every source all such information as Avill lead into an understand- ing of the basis of those pathological states Avhich form their development. He ought to examine with a microscope the com- posit cells of every morbid groAvth, the pus, the fibres, the blood- vessels, the tissues, and the chemical nature of the attendant secretions. 1080. As it will be to the diseases which affect the mammary glands after puberty, that I shall direct your attention more par- ticularly, I close this lecture by reminding you of some of the effects of common inflammation in the breasts. This has been divided, by Sir Astley Cooper, into three stages, Avhich he very appropriately terms adhesive, suppurative, and ulcerative. Ad- hesive inflammation produces a firm and very sensitive enlarge- ment, Avhich, in consequence of the tardiness of the dense fascial membrane in yielding to the enlargement, often occasions excru- tiating pain and suffering to the patient. The solidity of the swelled gland depends upon the engorgement of the interstices with the serous and fibrous portions of the blood. The blush of inflammation is Avell marked, and the throbbing quite sensible. Shiverings reveal the fact that the general system is influenced by the local inflammation. This shivering is succeeded by heat and copious perspiration. As the disease progresses the cuticle separates, ulceration is established in the cutis, and a discharge folloAvs. This process is completed in from one to three weeks— the disease running its course much more rapidly in some than in others. This kind of inflammation mostly attacks young mothers, and for obvious reasons. When Ave endeavor to arrest the first stage, we shall not often be compelled to treat the suppurative stage. Fomentations, and washings with cool lotions, will be found of great benefit, and a poultice, in Avhich there has been incorporated a large quantity of Veratrin, Avill be serviceable. Or, if the suppurative stage has been reached, then Ave must rely upon hop and poppy fomentations, and hyoscyamus poultices. The abscesses of the ulcerative stage are to be opened with the lancet, as soon as there is much evidence of accumulated matter, and DISEASES OF THE BREAST. 499 then the part is to be treated with poultices and fomentations— the minutia of which will be noticed hereafter. 1081. The limited space at my command, compels me to abbre- viate what I have to say in relation to the diseases of the breasts, to say nothing of those minor affections which frequently require medical or surgical interference. The acute inflammations Avhich are to be observed occasionally attacking the breasts, does not differ very materially from the same forms of inflammation Avhen observed elseAvhere, and if there be a difference, it is easily under- stood to result from the peculiar anatomical structure of the mammary gland. It is to be remarked, hoAvever, that the intimate relations which exist between the breasts and the uterus, and betAveen the uterus and the great nervous centers, may occasion by reflex or secondary actions, peculiar hysterial or nervous phe- nomena, which do not attend the acute inflammation of other localities. The acute sufferings attendant on inflammation of this gland arise from its peculiar sensitiveness; its perfect nervous connections, and in the treatment of common acute inflammation of the gland, we shall be compelled to induce an obtuseness of the nervous centers, as far as possible, to blunt the sensory ganglia. 1082. From peculiarity of structure, there is a great tendency to the confinement of the inflammation to a particular spot, Avhere Ave soon observe that the inflammation has passed through its adhesive stage, and has become hard, shining, and marked by a throbbing sensation, which may be regarded as more or less characteristic of the suppurative process. The general system has already partaken of the disturbance, and Ave witness the occurrence of tremors, shiverings, heat, and dryness of the cuticular surface, and, finally, profuse perspiration. Soon after, the cuticle sepa- rates, or splits into rugous cracks, and ulceration is at once established, the matter being discharged through the apertures or cracks in the cuticle. 1083. In any particular case, unless by remedies we may arrest the progress of the disease, all these stages will have been accom- plished in from two to three Aveeks. Individual peculiarities, arisincr from general irritability, the depth to which the abscess has 500 DISEASES OF WOMEN. formed, etc., will lengthen or shorten each case, but usually all the stages are completed in the course of three Aveeks, and after this, the Avhole tendency of the disease is to malignancy. Inflam- mation of this kind results from various causes, some of the most palpable of which I shall notice. When the child is first put to the breasts, its suction-efforts tend to draw an extraordinary Aoav of blood in the direction of the nipple. This is the case only Avhile the child draAvs before the milk begins to flow. All parts of the tissue thus become periodically injected by an unusual quantity of blood, which, not returning Avith equal facility, is left in the engorged tissues, where it becomes a source of irritation, and finally, consequently, of inflammation. Then, again, there is constant and violent exposure of the breasts to a cold air, after they had been snugly and warmly accommodated in the dress. At one moment, they are full, warm, and dry, and a few moments afterward, they are flaccid, cold and Avet, favoring great irregu- larities in the circulation, and thus maintaining a ready impressi- bility to every source of irritation. The disastrous practice of nurses and midAvives encouraging the use of stimulating drinks, and refusing the child the use of the breasts, before several days have elapsed, and when the callostrum corpuscles have become agglutinated, has given rise to many a mammary abscess, and no doubt the same practice has been to some extent encouraged by physicians. 1084. In treating the adhesive stage of this kind of inflamma- tion, Ave should endeavor to equalize the general circulation, to move the boAvels, stimulate the functions of the skin, by the free use of diaphoretics, and to brace the system by the free and judicious use of tonics, not forgetting the great value of Avarm fomentations to the breasts. The use of cathartics will often prove of great advantage by their revulsive efforts. If these means do not arrest the disease, and the second, or suppurative stage shall have been reached, then poultices of Poppy and Gelseminum should be applied, the breast being bathed in a decoction of Veratrum Viride, all of Avhich should be tepid. The internal administration of the folloAving pill, at the same time, will be found to be of great value: DISEASES OF THE BREAST. 501 I£ Gelsemin, gr. iii. Podophyllin, gr. ii. Sanguinarin, gr. i. Scutellarin, gr. iv. Make into six pills, and give one at morning, one at noon, and one at bed-time. If the bowels are already open, then omit the Podophyllin, and substitute in its place Quinine, iv. gr. 1085. In regard to the abscess which may have formed, let me here remark, that they ought to be opened in every instance, no matter Avhether they shall be deep or shallow. No possible harm can result to impede the cure, but, on the other hand, the use of an abscess-lancet will greatly relieve the immediate sufferings of the patient, and enable us to inject a very Aveak solution of Sesqui-Carbonate of Potash, or of Muriated Tincture of Iron into the abscess, which Avill very greatly facilitate adhesion, granula- tion, and restoration of the organ. Of course every opening should be made where the fluctuation is most distinct. The neglect of these abscesses and endeavors to discuss them Avhen once formed, is a prolific source of malignant mammary tumors. Sir Astley Cooper, in his excellent treatise on this subject, relates a case Avhere an ordinary milk-abscess, Avhich had been someAvhat neglected, degenerated into a true fungoid excrescence of the whole gland, Avhich finally destroyed the Avoman's life. After the abscess has been healed, if a peculiar hardness remain, as is often the case, then it should be an object to discuss such induration by the use of Iodine, etc. 1086. The child should not be allowed to suck the diseased breast, but the milk should be regularly draAvn by a glass tube prepared for the purpose; or else by the use of the breast-pump. The breast ought not to be squeezed or roughly used, as every. physician of much experience has seen a greater or less number of mammary ulcers which have arisen from such improper manipulation of the breasts. Abscesses of the mammary glands often arise from cracks and fissures on the nipple, rendering it unpleasant to have the child put to the breasts, and hence they are alloAved to become engorged Avith milk, which soon produces 502 DISEASES OF WOMEN. irritation and inflammation. This is particularly apt to be the case when one breast is sore, and both the mother and physician should be guarded against alloAving the milk to accumulate in the breast over and above the ordinary quantity, since the incidental distention woxild greatly favor, or give rise to inflammation— which, in every instance, is to be regarded as a symptom of a pathological state, requiring close and circumspect attention. 1087. Incidental to chronic inflammation, there is another ab- scess Avhich requires the most careful inspection, and as it is long in forming, it has been denominated the chronic abscess. It is distinguished from acute abscess, by the length of time in Avhich it is forming, by the little pain accompanying it, absence of heat and redness on the breust, and the want of rigors and those other constitutional disturbances which have been mentioned as being characteristic in acute abscess. For these reasons Ave are not led to suspect the formation of matter, and thus a malignant tumor is suffered to arise and progress Avith its ravages, Avhich, had the nature of the disease been clear from the first, would have been averted. Upon pressure over such abscesses, the patient is very sensitive, and if Ave examine closely, the presence of matter will be detected by fluctuation. Let it be borne in mind that there is ahvays more or less induration around the matter so formed, and hence we are liable to suppose that there is a tumor requiring excision. Sir Astley Cooper reports several cases Avhich had been sent to him of this nature, and Avhich had deceived those who sent them. In lancing such abscesses, or any others, the lancet should be put in so as not to cut the lactiferous tubes across—in other words, the blade should be put in parallel to the nipple, as the tubes run from the base towards the apex of the gland. It has been customary to give mercurials in this abscess, to alter the secretions; but it seems to me that no practice could be more injudicious. That Stillingia, combined Avith some of the more positive tonics are indicated, I do not deny; but generally a due attention to the functions of the kidneys, skin, liver, stomach, and the diet are all-sufficient, along Avith opening the abscess, to effect a cure. If, after the abscess has been opened sinuses form that refuse to heal, then stimulating injections arc DISEASES OF THE BREAST. 503 indicated, in order to produce that inflammation which the tissues Avere unable to set up. 1088. There is another abscess of the breasts Avhich seems to me to warrant some attention. I refer to what Sir Astley Cooper calls the Lactiferous SAvelling, which is nothing more nor less than a lactiferous aneurism—the excessive enlargement of a single milk tube. To enable the practitioner to recognize it at once, I beg to briefly describe it. The SAvelling is like a ridge running from the nipple toward the base of the gland. The woman complains of a feeling of great distention, which is almost insupportable, when the child attempts to suck, OAving to the increased Aoav of milk in the adjoining tubes. The breast is uncolored, but the cutaneous veins are greatly distended, while the fluctuation in the tumor is most distinct. 1089. When opened, little or nothing than milk is discharged, and if the opening is suffered to be closed, the tube is again soon similarly distended. If not opened by the surgeon, ulceration occurs, and an opening folloAvs near the nipple, Avhich can hardly be healed until the child has ceased to suck, and until milk is no longer secreted. The requisite treatment is apparent—puncture the tumor, and keep the child from the breast until milk is no longer secreted. Or if the child be yet very young, and it be desirable to retain the activity of both glands, open the abscess, making a free incision, and then inject a stimulating solution, so as to induce inflammation, during the progress of which, the breast may be artificially relieved of its milk, until adhesion has been completed. With all justice, this disease might be called Mammary Ranula, which it resembles in every respect, except that the one is produced b}7 an accumulation of saliva, and the other of milk. 1090. There are four kinds of watery tumors of the mammary glands. The first of these are mere sacs filled Avith serous fluid, and named by Sir Astley Cooper Cellulose Hydatids. This variety is distinguished by freedom from pain, enlargement of the breast, no fluctuation at first, but Avhich finally appears ; the breasts then grow more rapidly, and fluctuation can soon be detected in a number of places at one time; the cutaneous veins are varicose. 504 DISEASES OF WOMEN. and the breasts though many pounds heavier than usual—perhaps three or four times as large as common—are still free from pain; but a few patients complain of heat, and sometimes pain in the shoulder. The tumor moves easily on the pectoral surface, and is at the same time very pendulous. It may involve a part or the whole of the mammary gland. 1091. In its progress at one of the points of fluctuation, the breast inflames, ulcerates and opens, Avhen a glairy mucilaginous fluid, mixed Avith serum, is discharged. Other sacs, if there be more than one, go through the same process, forming sinuses, Avhich do not readily heal. The general health may be, and mostly is, good; nor do the adjacent structures seem to partake of the disease. The disease may progress, until so much fibrous structure has been formed, that the breast becomes one great tumor, which fills the patient and her friends with the apprehen- sion of cancer. These larger sacs contain smaller ones, and these again, yet smaller ones, giving the idea of cellular dropsy. They vary in size, of from one-tAventieth to half an inch in dia- meter, and rarely to one inch. The sacs are larger. The cysts are exceedingly vascular, the veins are engorged, and in opera- tions bleed profusely, Avhich disposition is manifested even after the tumor has been extirpated. There is no danger of confound- ing it with either of the abscesses already described, and Avhen the sac is opened, the surgeon is at once led to a knowledge of the complaint. Sometimes a true scirrhous tubercle will have hydatids associated, but then Ave shall find that there are also present those darting pains, excessive hardness, etc., characteristic of scirrhus. For the treatment of this complaint, there is required only a simple dissection of the sacs and the immediately surrounding indurations, Avhich usually effects a radical cure, with little or no further treatment, than a genial diet. Though the disease is not generally painful, there are some cases in which much uneasiness is felt from the first, as has been noticed by Cooper and others. These cases, however, seem to be excep- tions, and may generally be accounted for by idiosyncrasy, etc. 1092. The second form of hydatid disease is marked by the following peculiarities: the breast is enlarged; hardened by fibri- DISEASES OF THE BREAST. 505 nous effusion ; there are distributed through it various sacs con- taining serum, which fluctuate; from the inner wall of the sacs hang a number of polypous bodies which seem to float in the fluid contained in the sacs ; many of these bodies are detached and floating loosely in the serum of the sacs; they vary in size, the largest not larger than small beans; generally, they are ovoid, and when opened, are found to be composed of many lamina, as in the layers of an onion, and Avhich readily separate. This form is also characterized by the absence of pain. The best descrip- tion and plates of this form of disease is found in Cooper's work on the Breasts. When the disease has advanced, so as to require treatment, that ■will have to be surgical, the breast must be removed, inasmuch as the great mass of the gland is diseased. 1093. The third species of hydatid disease of the breast, is that Avhich has been called animal or globular. This form con- sists essentially of sacs filled Avith similar, but smaller sacs, filled with fluid, having no vascular connection with the surrounding parts. These hydatids are not confined to the breasts, but are often found in the liver, in the loAver part of the abdomen, in ovarian tumors, lungs, the brain, around the heart, etc. The hydatid is contained in a cyst, which is surrounded by a fibrinous effusion, the result of inflammation. This fibrinous matter is highly vascular, but the hydatids are not immediately connected thereAvith. Cooper describes these cysts as a " scrni-diaphanous bag, filled by a clear water, and it is uniformly smooth on the inner surface." Having no opening or inlet, it is nourished by absorption through the Avails of the cysts. They are self-propa- gating, for if Ave collect the fluid of a sac, Ave shall find it filled with miniature hydatids. They are animalcules, having a separate and independent existence, and propagate on their interior sur- face their OAvn species. They are sometimes found on the abdom- inal viscera Avith a mouth and tail added, and then receive their food through the mouth like other animals. Sir Astley Cooper regards them as the true link betAveen the A'egetable and animal kingdom. It is supposed to have been deposited Avherever found, from the blood, and acting as a foreign body, is soon inclosed by the adhesive process. 506 DISEASES OF WOMEN. 1094. The proper treatment is to make an incision in*:, the hydatid tumor, discharge the contents of the cysts, and then it readily heals, and, if the fluid should accumulate, a seaton may be passed through it, so as to set up sloughing. Perhaps it Avould be safer and more economical to inject the cyst, as soon as evacuated, Avith a solution of Sesqui-Carbonate of Potash, and thus insure a radical cure. The fourth form of Mammary Hydatids will be described further on. 1095. There is a tumor resulting from uterine sympathy, mostly found in females from seventeen to forty years of age, Avhich is denominated Chronic Mammary Tumor. It is mostly found in single or barren Avomen. It usually springs from the surface of the breast, and is therefore superficial and very movable; it is of slow growth, painless, generally, though sometimes gives rise to a sensation of rheumatic pain in the shoulder ; it is commonly more tender just prior to the recurrence of the monthly flow of the menses. 1096. These tumors seldom acquire a Aveight of more than four or five ounces, though they have been found weighing as much as one pound. They Avill exist for many years, then disappear altogether, and, therefore, are in no sense malignant. The tumor is of a conglomerate or lobular form, and the name of lobulated Mammary Tumor has been suggested by Cooper. Upon dissection one is led to think that the tumor is only an added number of lobules, Avithout the lactiferous tubes. It differs from malignant tumors of the breasts by the youth of the patient, generally, by the absence of pain, by the good health of the patient, the slow progress, its superficial situation, its extreme mobility, and lastly, its lobular character, which is at once revealed to the sense of touch. 1097. The pressure of stays, bloAVS, etc., encourage the devel- opment of the tumor, but the real cause is in the uterus. We shall, therefore, be at once led to the principles Avhich are to govern us in the treatment of the disease. Every function must be encouraged to normal action. The digestion, secretion and excretions must be inquired into; but, above all, the state of the uterus must claim special consideration. To the breast, over the DISEASES OF THE BREAST. 507 seat of the tumor, an iodine ointment plaster should be worn, unless there be considerable inflammation, in which case it will be best to employ cooling lotions and poultices of hops and bitter herbs. AVe must, however, not expect to induce their absorption while the uterus is the seat of irritation, inflammation, or ulcera- tion. The disease rarely requires an operation, and it will be our duty to make its character known to the patient, who is always alarmed as to the possibility of its terminating in cancer. Mar- riage is almost sure to cure it when it occurs in single Avomen, and a due attention to the uterus in those Avho are married is all that is required. But if the patient is determined to have it removed, no operation is more simple and certain to effect a radical cure, no possible danger attends the operation in any Avay, either imme- diately or remotely. 1098. In certain specific inflammations of the breasts, Gelatine is effused, Avhich becomes vascular from the surrounding parts. It resembles cartilage, and in it ossific matter, especially phos- phate of lime is deposited. These tumors have been described as Cartilaginous and Ossific tumors. The pain attending these tumors is very severe, the skin is Avarmer than natural, the tumor is very hard, and more painful before than after menstruation. The treatment is extirpation, as affording the only relief. 1099. Adipose tumors are frequently formed in and on the mammary gland. These tumors may groAV on the surface covered only by the skin, or they may be merely an enlargement of those fatty masses Avhich occupy the interspaces between the lobules. They can not be discussed, and the better plan is to remove the tumor at once, which may be readily done. Scrofulous swellings of the breasts are sometimes presented to the surgeon, but they are rare, and require no special treatment. 1100. Sir Astley Cooper describes an irritable tumor of the breasts, cases of Avhich I have seen myself in several instances, and it seldom or never occurs before puberty. When the complaint attacks the glandular structure, there is little or no swelling of the breasts, but one or more of the lobes become very tender to the touch, and when handled gives rise to pain, which does not subside for many hours. This pain affects the entire arm and shoulder, 508 DISEASES OF WOMEN. and generally prevents the patient from lying on that side when in bed. It may also affect that side of the body more or less. There are alternate sensations of heat and cold in the breasts; the pain is neuralgic, darting here and there along the nervous tracts—the stomach sympathizes, vomiting ensues, the pain is more acute before menstruation, there is no sign of inflammation, and the skin retains its natural color. Both breasts may be affected, or only one, or even a part of either one. This pain may continue for months' or years, and the plan of treatment must be constitutional. The breasts may be bathed in an infusion of Gelseminum, Poppy and Lobelia, while the Gelsemin or Vera- trin are given internally. 1101. But occasionally these symptoms are associated with a tumor, clearly defined, Avhich is exquisitively sensitive to the touch, and at intervals exceedingly painful, especially before men- struation. They vary in size, but do not usually become large. They may exist in this painful state for a great Avhile, Avhen the pain may cease, and the tumor finally disappear. The treatment must be constitutional—and so ordered as to lessen the nervous irritability of the patient. An operation is by no means admissi- ble, for the extraction of a tumor does not effect a cure; and more than one case has occurred where this has been clearly proven. I once, in my earlier practice, committed this mistake, and have known of similar errors in others. The mistake is a sad one, and Ave can not exercise too much care in diagnosing this as well as other similar affections of the breast. The space at my command prevents a further consideration of those minor affec- tions of the breasts, and I shall, therefore, close this article by presenting briefly some vieAvs of cancer of the breasts, in which the profession and the public are more immediately interested, as the disease in all its forms is a source of great dread, and gene- rally too often fatal in its effects. 1102. Carcinomatous or cancerous degeneration of the mam- mary glands has thus far baffled the skill of the medical pro- fession. It is true that here and there Ave sometimes hear of a surgeon avIio has had much success in the treatment of Cancer, but until recently, as the disease, exist where it might, DISEASES OF THE BREAST. 509 was considered incurable, it was thought disreputable to adapt its treatment as a specialty, and hence, too many physicians have neglected its proper study. For sixteen years I have made this form of disease a special study, Avhile I lurve not neglected my general surgical and medical practice, and I have constantly endeavored to teach the classes before Avhom I have lectured for the past ten years, all that I knew in relation thereto; I neither have, nor do I desire to make any secret of my knoAvledge in relation to the treatment of cancer, and I therefore repudiate the idea of being merely a " Cancer Doctor." I regard cancer as any other disease—one phase of the pathological states of man, and of which every physician should be informed. It Avould be just as unphilosophical to cease our endeavors to understand the nature of vomito, because Ave can not ahvays cure it, as to neglect the study of cancer, because the profession has acknoAvledged its inability to cure it. Such an admission is a disgrace, since Ave knoAv that in various parts of Europe and America, there are practitioners who do cure cancer in all its forms, and Avhat one can do another ought to try. I have treated several hundred cases from all parts of the country, and Avhile I have sometimes failed to effect cures, especially in the early years of my practice, I am proud to say that I have relieved, radically, hundreds Avho will sustain this declaration. There are few surgeons in America who have had so extensive a practice in the treatment of carci- nomatous disease as myself, and therefore, few, if any, in this country, have had more experience than myself. If I shall be instrumental in fixing the attention of the profession to the im- portance of this subject, I shall have been amply satisfied for the trouble of preparing this paper. AVhile I have hundreds of cases that might be detailed, my space is so circumscribed, that I shall be compelled to confine my remarks mostly to general principles. 1103. Carcinomatous tumors differ from every tissue found in the body, which, after proper development, gives rise to an ulcer, which in its extension destroys the surrounding parts. There is no difficulty in identifying carcinoma, since all the varieties depend upon constitutional peculiarities, the tissues 510 DISEASES OF WOMEN. which surround it, the stage of the disorder, etc. The anatomical revelations of cancer are so peculiar and distinct from all other tissues, remove every doubt as to its character. . 1104. There are five prominent forms of cancer of the breasts : Lobular carcinoma, intra-glandular carcinoma, encysted carcinoma, carcinoma of the nipple, and Cutaneous carcinoma. 1105. When carcinoma first begins to develop, one form is characterized by a stony hardness, to which the name carcinoma fibrosum is given; but Avhen the tumor is soft, imparting an elastic sensation, it is called carcinoma medullare, and all other forms are, at most, only varieties of these two. 1106. In every case, the tumor will have acquired some size before its presence is detected. AArhen examined, the tumor feels hard, or it will be perfectly movable beneath the skin. At this time it gives no pain, Avas accidentally discovered; the health is good; but after a few Aveeks, the lump has groAvn, lancinating pains are felt, and if the adipose tissues are thin, the skin is seen to be elevated by the tumor. It is still hard to the touch, and gives a sensation of roughness to the touch. If the groAvth shall noAv be removed, it Avill have a greyish-yelloAv tint, having a sort of peduncle by Avhich it Avas connected to the tissue of the gland. Fibrous lines, radiating from the tubercle, extend betAveen the subcutaneous adipose tissue toward the skin—the tubercle itself looking speckled in the center, owing to the remains of the ducts of the engorged gland tissue. 1107. After a few more Aveeks or months, the gland, Avhen again examined, will be found to have enlarged, it is more painful, and noAv adheres to the cutis, which, as Birkett says, may be " slightly puckered in." 1108. The adipose tissue covering it has noAv been most!} absorbed, and the attachment betAveen the tumor and skin is so perfect that one readily moves the other. On either side of the tumor the skin is much thicker than usual. Unless the tumor shall be removed, the skin becomes harder, and, finally, the Avhole gland has disappeared, to give place to the tumor. The surface of the breasts is hard and rough, while the skin looks as though it was ready to burst from its extreme tension. It is reddish. DISEASES OF THE BREAST. 511 shining, and looks as though it Avere very sensitive, which, strange to say, is not ahvays so. 1109. Another stage of development is soon established; the integuments begin to slough away, and an ulcer is at once established. Before this ulcer has been completely formed, small cutaneous eminences appear, the center of which decays, and is thrown off, leaving a little hole, which continues to enlarge, until it unites with others, and a large sloughing ulcer is formed. Or the ulcer may form by scaly cracks from Avhich an oozing takes place, and these cracks uniting, result in a foul ulcer. Sometimes the development seems to be suddenly arrested, but such an occurrence is at all times an unfavorable circumstance, since the disease is at Avork on new tissues, and suddenly avc find every symptom greatly aggravated. 1110. Soon after the attachment of the skin to the tumor, the axillary glands become affected; prickling of the skin in that region increases; oedema of the arm folioavs ; and great pain is felt from any motion involving the action of the thorae'e muscles, as in breathing, which is often very painful. A dull leaden hue characterizes the aspect of the patient; the countenance is uneasy and depressed; the strength fails; the scent nauseates her; she has pain in the bowels, and the patient sinks under her multiplied maladies. 1111. Carcinoma is rarely developed in the mammary gland before the age of tAventy-eight, though it is sometimes found as soon as the establishment of the function of menstruation, and some few cases are reported where it occurred in children. From 28 to 50 years it is very common. It is sometimes found in Avomen Avho have attained the age of 90 years. It may attack married or single women, those Avho are prolific or those who are sterile. Celibacy seems to favor the disease, notAvithstanding the figures of Dr. Lever to the contrary. For while the percentage in married is to its percentage in single women, as 85 to 6, Ave must remember that the percentage of married to single women is even greater. 1112. There is, evidently, a cancerous cachexia, but it is very difficult to describe it. It may be known only by experience, in 512 DISEASES OF WOMEN. Avhich it Avill be obsen7ed that such Avomen are those Avho are impressible to misfortune, and Avho have had much real or imagi- nary trouble. 1113. Those Avho have a strumous diathesis are most subject to cacoplastic deposits, but to point out any signs which Avould enable us to say that any woman Avas liable to or free from the horrors of carcinomatous disease, is out of the question, in our present state of knowledge. Cancer is a local manifestation of a consti- tutional dyscrasia, and Ave shall generally find, along with the earliest manifestations of the disease, defective nutrition. 1114. To be better enabled to comprehend the disease, its development has been divided into stages, Avhich, hoAvever, answers the purposes of convenience only inasmuch as the Avhole process is a degeneration from the outset, and the constant tendency is to a fatal termination. At first the tumor is found small and rolling like a stone under the integuments, and is generally situated on the peripheral extremity of a lobe. This new growth may be attached to the surface of the gland, betAveen it and the integu- ments, and under or in the subcutaneous adipose tissue. In this event, it is called extra-glandular; or Avhen it rises, as it some- times does, from the very center of the gland, it is called intra- glandular. In that event, it is situated immediately behind the •nipple and areola. When it becomes attached to the skin, it is said to have passed into the second stage. The adipose tissue has been displaced, the tumor extends right and left, and greedily contaminates the surrounding parts. AVhen the cutis begins to thicken, groAV red and glossy, the third stage is said to have been reached. AVhen the tumor becomes attached to the thoracic Avails, it is said to have entered on the fourth stage. In the first of these stages the patient complains of no pain, and this is so true, that she admits considerable manipulation Avithout the mani- festation of any uncommon sensitiveness. AVhen it happens to be in contact with the minute branches of the inter-costal nerves, it is more painful. The pain is of the lancinating kind, and is not confined to the gland. The pain, no doubt, arises from stretching the nervous filaments, and hence the pain is often referred to the sentient extremities of the nerve Avhose trunk had been thus DISEASES OF THE BREAST. 513 stretched. While the pain in some cases is not intolerable, in other instances it is excruciatingly severe. The external charac- teristics do not become clear until the third sta^e has been reached, when an oozing takes place from the cuticular surface, which, drying, forms a scab; in others, a fissure in the skin appears, which at first may, or may not, be attended with redness. At last, hoAvever, a redness surrounds the scab or fissure, as the case may be, the discharge is more copious, and soon the surface' begins to excoriate, which is evidently a result of carcinomatous contamination. 1115. The fourth stage is that of necrosis, more particularly. Development does not cease here; but the earlier developments die, and fall off. As noAv seen, the ulcer is a frightful, a gap- ing, and eroded sore, the edges of Avhich are elevated, with deeply excavated, and irregular surfaces, from Avhich there is poured out a most offensive ichor, Avhich is the debris of the decomposed carcinomatous tissue, mixed with serum, serous fluid,, and blood. The nipple is often depressed, a circumstance Avhich may arise from the elevation of the surrounding skin, or from the tension made on the tubes attached to it by the growth behind it. 1116. It Avould be desirable to determine, if possible, the pro- bable duration of the disease, but such an attempt Avould be futile. Sometimes death will take place in four months; again, it may last many years; but, from my experience, I should be led to say that the disease will run its course in three years, on an average. There is a fact connected Avith the second stage of carcinomatous growths of the breasts to which I must make some allusion. I refer to the implication of the axillary lymphatic glands, Avhich actually undergo an organic change, and while I do not profess an ability to give a rational explanation of the circum- stance, I must nevertheless remark, that I think the fact is an index to the constitutional management of the disease. The con- stitutional effects of these various stages must claim our attention briefly. Generally, Avhen the tumor appears about the "change of life," Ave shall be apt to learn that some common malaise has been experienced. The patient does not begin to feel ill until the second and third stages have been established. Her sleep Avill 33 514 DISEASES OF WOMEN. then be disturbed, she is duller than in ordinary health; she has nausea in the morning, and usually constipation all the time. All these symptoms are intensely aggravated during the fourth stage. The arm of the affected side swells, becomes oedematous, and painful on slight motion; the breathing is difficult and the patient is often constantly sick at the stomach. Racking pains are felt in the bones, jaundice supervenes, and great constipation is often experienced. 1117. Of the treatment I shall be brief, for I have already occupied my allotted space. It is universally admitted that the mere removal of the tumor Avith a knife will not effect a radical cure. If a cure is to be effected in this Avay, it is when the tumor is in its first stage, and a large part of the sound tissues sur- rounding it have been removed therewith. It is evident that no operation of any kind should be attempted until the constitution is in the best possible state—not until every function is in a state of activity. The disease is both constitutional and local, and in its treatment our remedies must be both general and special. For this reason, Avhrm a patient comes to me for treatment it is my first care to put her on a properly nutritious diet; to regulate the functions of the skin, liver, kidneys, etc., to effect which objects, of course a variety of remedial agents are to be employed. Comp. Syrup of Stillingia, Iodide of Potassium, and Prussiate of Iron are usually given, along with such other agents as may seem to be indicated, as narcotics in extreme irritability, stimulants in great depression, etc.; particularly should Ave look to the digestive functions, and Avhen we have removed the anemic habit of the patient, she is then ready for an operation. For the sake of econ- omy the patient is put under the influence of chloroform, and the entire diseased mass is at once removed with the knife, after which I usually cover the surface with some tonic escharotic, as Chloride of Zinc, which seems to act more rapidly and greedily on the car- cinomatous tissue. This is folloAved by poultices to slough the surface; and again, time after time, while a visible shred of the diseased tissue remains, this plan is followed, during which time the system is toned up to the highest pitch, and the functions are all closely watched. In this way, by the union of constitutional DISEASES OF THE BREAST. 515 and local treatment, if the constitutional stamina is good, we shall often, nay, if Ave proceed judicicusly, nearly always effect a cure. Nor is the cure temporary, as can be demonstrated by cases now in this city, Avhom I discharged ten or twelve years since. As every case will differ from the common type, we shall be com- pelled to vary our plan of treatment. What I have thus Avritten I know by experience, and I ask that attention to the subject which its great importance demands. The practice here given has been pursued by many who have witnessed my operations and attended my clinic lectures, and I am proud to say with great success. TREATMENT OF DISEASES OF THE BEEAST. Acute Inflammation.—Among the troubles of child-bearing there are none that are more annoying than diseases of the breast, and none, I am glad to say, more amenable to treatment. An early knowledge of the trouble, and prompt means for its relief, become necessary if we expect the greatest success, and the physician fails to do his duty that alloAvs disease to progress Avithout notice and treatment. It is especially to be observed that all rubbings of the breast, either before or after delivery, Avith the crude idea of " softening it," or "toughening it," are to be avoided. The application of Pond's Ext. of Hamamelis to the nipple and areola is permissible, and may sometimes be beneficial in lessening the irritability of the nipple; and the application to the breast may sometimes re- lieve irritation and lessen sensitiveness. But if consulted about sensitive breasts before delivery, we can not do better than to prescribe small doses of Phytolacca, and if necessary make a local application of the same. " Milk fever " is sometimes attended with irritation, fullness and engorgement of the breasts—" caking "—Avhich may go on to inflammation. The administration of— R Tinct. Aconite, gtt. v; Tinct. Phytolacca, gtt. xx ; Water, |iv., a teaspoonful every hour, will usually give prompt relief. In some cases the severe after- pains call for Macrotys, and it may be added to the mixture. Proper support, with sufficient freedom, should be looked to, 516 DISEASES OF WOMEN. and the ordinary corset Avith Avhale-bones making pressure upon, or sticking into the breast, avoided. It is possible to have an un- derwaist cut so as to fit the chest and the breasts, and give this support, and this should be named to the mother. It may also be made of such material as will give the required Avarmtb. AVith the first announcement of the symptoms of inflammation of the breast Ave put the patient upon the use of Phytolacca, either alone or with the sedative, Aconite, if there is vascular disturbance, Macrotys if associated Avith uterine tenderness and pain, Bryonia if tbei'e is costal pain and soreness, Iris if there is fullness of the thyroid, and other remedies as they may be indi- cated. It will not do to say that Phytolacca will cure all cases of inflammation of the breasts. Without other indications than mammary irritation and determination of blood, it is sufficient, but other lesions require other remedies. If, for instance, the lochial discharge Avas fetid, Ave would want chlorate of potash ; if the tongue was heavily coated and pallid, sulphite of soda, etc. In the commencement of mammary inflammation, I frequently paint the affected part Avith tinct. Veratrum or Veratrum and Aconite. It may be used in the full strength or diluted Avith one or two parts of glycerine or Avater. It is better to limit the appli- cation to a space not larger than three inches in diameter, and the mother or nurse should be cautioned against letting the lotion come in contact with the nipple, or the child's mouth come in contact Avith that portion of the breast to Avhich it has been applied. In other cases when the inflammation is not so active, Ave may use a lotion of equal parts of tinct. Phytolacca, glycerine and water ; or when there is evident congestion a portion of tinc- ture Belladonna may be added. Fomentations and poultices are to be avoided in the early stage for Avithout these Ave may reasonably expect resolution in a large number of cases, whilst if the breast is poulticed, suppuration is a common result. Even Avhen suppuration is unavoidable, it is best to use poultices Avith caution, or avoid them altogether, for the less suppuration Ave have the better it will be for the breast and the mother. I have continued the Aconite and Veratrum to the extent of relieving the acute suffering, and Phytolacca in the interim, through the entire process of suppuration, until the breast had healed. DISEASES OF THE BREAST. 517 If we use a poultice, nothing Avill be better than a strong infu- sion of Phytolacca (the fresh root if it can be obtained), thick- ened with Avbeat bran. In place of this, a simple flax-seed poul- tice Avill prove as good as anything, or a couple of folds of lint Avetted with Avarm Avater, and sprinkled with tincture of Stra- monium. AViLh the appearence of pus near the surface, determined by yellow discoloration, or by fluctuation, or the deep throbbing pain when the pus is deep-seated, it is best to give it an exit with the lancet. The suffering of the mother at this time is very severe, local applications do no good, and if narcotics are given the gen- eral health must suffer. The patient dreads the knife, it is true, and Ave dislike to use it, but it gives prompt relief like pulling a tooth, and if the physician has experimented Avith the scalpel until be can make a rapid and skillful incision the pain is not so very great. But save me from your bungling doctor, Avho holds bis knife unsteady, and saAvs through the tissues like an unskill- ful carver trying to find the joint of a fowl. If such a one should read this, I advise him to buy an old-fashioned spring lancet for his operation, and that Avill go quick. The incision should always be made in the direction of the milk ducts—from the nipple to the circumference of the breast, and never across them. This may seem a trivial matter to the be- ginner, but it is a most serious one to the patient, for the cross incision may obliterate the milk ducts, and cause disease with each successiA7e child. If the inflammation progresses steadily, and the breast is very large and heavy, its Aveight may be sufficient to continue the dis- ease, and occasion much suffering. I have already called atten- tion to the necessity of support for the healthy breast; the dis- eased breast requires it still more. A handkerchief may be so arranged around the neck, in the form of a sling, as to give a very good support, but it is better obtained by having a piece of stout muslin cut to fit the breast. Even this may not be suffi- cient, and Ave use adhesive strapping, not only to give support, but to compress the enfeebled tissues. I have seen prompt relief given by the application of strips Avhen the patient had formerly been suffering severely, and a termination by resolution or lim- ited suppuration, Avhen otherwise there Avould have been exten- 518 DISEASES OF WOMEN. sive destruction of tissue. The reader will recollect the treatment of orchitis by strapping, and will use the adhesive plaster here in the same way and for the same purpose. It must not be forgotten that Avhen pus has formed and the abscess opened, Ave arc not yet through with our case, nor the patient Avith her trouble. Other points of irritation, engorge- ment and inflammation may appear, and before the disease lias run its course the breast may be honeycombed with fistu'ous pipes from small abscesses. I do not think this is likely with the treatment named, and when the breast is eared for, but is rather due to neglect and want of knowledge. See that the breast has constant support; use the local application named to any point of irritation that shows itself; give Phytolacca internally, and use such means as may be necessary to restore the general health, and Ave Avill have an end to the disease, and a good condition of the breast. In some cases neither the abscesses nor fistulae have any incli- nation to heal, and the breast remains in a Very unpleasant con- dition. Here we must think of some local means that will free the breast from the diseased tissues, and stimulate the structures. At first I use a Avet dressing of—R Salicylic Acid, Borax, aa. 3j. to 3ij ; Water, Oj ; and even wash the abscesses out with it if ne- cessary. But if still more sluggish, with the debris of old tissues lining the abscess, there is nothing better than the injection of sesqui-carbonate of potash (saturated solution), followed by the dressing above named. Chronic Inflammation.—Chronic inflammation is usually the re- sult of the acute which has terminated in suppuration, as already described. If properly treated as above described, I do not think any inflammation will continue, though for some time there may be local indurations, and such adhesions maybe formed as Avill cause trouble Avhen the breast again comes into use. But if the old methods of poultices and frequent lancing is folloAved, we may not only have serious lesion of structure, but a condition of chronic inflammation continuing for years. Even in this case I have great faith in Phytolacca as a remedy, and administer it internally and apply it locally. Of course it is not the only remedy, as Ave may find use for any of those we have studied, if Ave carefully observe the indications. The breast should DISEASES OF THE BREAST. 619 always have a well adjusted support, and be protected against sudden changes of temperature and other causes of irritation. In some cases strapping will answer a good purpose. If there has been considerable deposit, the gland being greatly enlarged, and its circulation enfeebled, I would recommend the local application of the TJvedalia ointment, or one part of the tincture to four parts of water and Glycerine. The old Mayer's ointment proved an excellent application in some of these cases, and in some the ointment of iodide of lead was of service. With fistulae and the remains of old abscesses nothing is so good as the thorough injection of a saturated solution of sesqui-carbo- nate of potash, and a wet dressing of salicylic acid and borax. Disease of the Nipple.—"Sore Nipples" are among the unpleas- antnesses of child-bearing, and frequently give mother, nurse, and doctor a great deal of annoyance. This may be provided against in some cases, by care of the nipple and breasts the last Aveeks of pregnancy and when the child commences to nurse. The use of Pond's Hamamelis before confinement has been thought to harden the nipple, and prevent after trouble, but I prefer the lotion of borax and salicylic acid, or the tincture of Pentborum one part to glycerine and water five parts. The first symptoms of soreness of the nipple, or soreness of the mouth of the child, should be met by the administration of Phy- tolacca to the mother in the one ease, to the child und mother in the other. It is a little singular that the sore mouth of the child, shown by its crying when put to the breast, may be the very first intimation of the sore nipple Avhich is sure to follow, and the physician Avill be surprised to find how wide the range of Phyto- lacca is in these cases, and bow prompt and certain its action. Insist that the child be nursed at proper intervals of two to three hours, and that the breasts be drawn alternately, and not alloAved to be too greatly distended. If the nipple sinks in, and is difficult for the child to take hold of, use a good breast-pump to draw it out. But in all cases be sure that the nipple is properly dried after nursing, and covered with a fold of soft cloth when the breast is returned under the clothing. If I Avas asked for the very best Avash in these cases, I should answer, a lotion of borax, or borax and salicylic acid. I prescribe the first as folloAvs: R Borax, gr. x.; Glycerine, 3j., Rose Water, 520 DISEASES OF WOMEN. 3iij.. The second maybe used in the proportions already named. A very good prescription in some cases is—ft Chloral, 3J ; Glyce- rine, §j ; Rose Water, |iij.; used as above. There are many pre- scriptions for this purpose, but my experience has shown that in a multitude of prescriptions there is no Avisdom. Especially avoid all ointments or " salves," or anything containing fatty matter. If there is local ulceration, or painful and suppurating fissures, nitric acid Avith the pine pencil may be used to advantage, asso- ciated Avith the other treatment. I do not like nitrate of silver. But the remedy in a large majority of cases will be found in the lead nipple shield, which should be continually worn. It is easily made by beating out a piece of lead into a thin sheet, and then indenting it Avith a piece of wood formed to the size and shape of the nipple. It should be moulded so as to fit accurately, and the edges maybe trimmed so that it will extend over the breast an inch from the nipple. Being thin the weight is no objection, and it protects the nipple and is at the same time the very best remedy for the ulceration. Benign Growths.—The difficulties of diagnosis have already been named, and tbe fact that many benign growths are mistaken for cancer, and the breast removed in consequence. If the reader Avill bear in mind that the malignant or cancerous growth appro- priates tbe tissues of apart to its own use; that it is in facta degeneration of tbe tissue ; and that the benign growth is ahvays distinct from the natural tissues, an outgrowth from them, and never appropriated by them ; we will have the best grounds for a correct diagnosis. If Ave can determine that a tumor is separate from tbe glandular structure, movable on the wall of the chest, and that the skin moves freely over it, we have reason to believe that it is benign. This is strengthened if the surface of the growth is smooth, it is of equal consistence, and it is free from pain, ex- cept that which comes from pressure or Aveight. In some Avomen, from tbe age of 35 to 50 the breasts are so freed from the earlier deposits of fat, that tbe glandular structure is felt very distinctly, and Avhen well developed it may seem like a nodulated growth, or a series of these growths. I have seen three cases of this kind in Avhich women were frightened by the thought that they had cancer. In one case it was diagnosed as cancer by two physicians. DISEASES OF THE BREAST. 521 Having determined that our patient has a benign growth, the next question is as to its treatment. Local applications to the surface are absolutely of no use, and neither is internal treatment. If the tumor has a very slow growth, and does not give much annoyance by pressure, we let it alone. But if it is decided to remove it, Ave have a very simple operation. An incision is care- fully carried doAvn to tbe growth where it can best be reached, not dividing the milk ducts if possible to avoid it, and tbe growth then enucleated with tbe handle of tbe scalpel or with the finger. When tbe growth has a fibrous capsule and fluid contents, a care- less incision may cut through the capsule, discharging tbe con- tents, and make the operation a failure. If it is a simple growth, we may bring the parts together and have it heal by first intention ; but if we have reason to believe it is a recurrent fibroid, we are careful to remove the base from which the groAvth sprang, and leaving the Avound open heal it by suppuration. These operations about the breast are so simple that anyone can jierforni them Avith safety, if be studies his case well. Malignant Growths.—The evidence of malignancy is sometimes so clearly marked that no one can make a mistake; but at others it is very difficult to make a diagnosis. If the structure of the gland is very evidently being appropriated by the groAvth, it is cancer. This can almost ahvays be determined when it comes to tbe surface, and we witness the gradual change in the skin. The peculiar pain is also characteristic—twitching, sticking, darting, craAvling, always radiating from a common center to the circum- ference of the gland ; the gradual agglutination and adhesion of parts, until finally the groAvth is fixed ; its uneven surface, and unequal resistance to pressure; and finally the enlargement of tbe lymphatic glands of the axilla?, and the impairment of the general health—cancerous cachexia. Having diagnosed our case as one of cancer, we wish to deter- mine the best treatment. AVe have first to determine Avhether the groAvth shall be removed, or whether the treatment shall be palliative, and if it is decided to remove it, Ave wish to determine tbe best method. We will decide to remove the cancerous groAvth when the mam- mary gland is freely movable on the chest, and when there is no, 522 DISEASES OF WOMEN. or very little, engorgement of the axillary lymphatics. If the growth has formed an attachment to the pectoral muscles, it is an unpromising case, as it is when there is much disease of the lym- phatic glands, and the unpleasant waxy salloAvness of skin that marks the cancerous cachexia. Whether tbe cancer is open—sup- purating—or still covered by the integument, makes little differ- ence, but the more rapid its growth tbe more unfavorable tbe prognosis. Having determined to remove it, we must next choose tbe method. It the growth is entirely free, not having formed attach- ments to the muscles beloAV or tbe skin above, excision of tbe gland is decidedly preferable. If it has appropriated a portion of the skin, and is suppurating, Ave may still excise tbe breast, or we may remove it with chloride of zinc or arsenious acid. Hav- ing determined on excision of tbe breast as tbe better method, we explain to tbe friends that we select this because it is tbe speed- iest and least painful method, but that to prevent a return of the groAvth in tbe cicatrix, Ave heal it by suppuration, as an open Avound, and do not bring flaps of skin over it for speedy union, as generally practiced. There seems to be an antagonism betAveen the suppurative process and cancerous groAvth—the pus cells replacing the cancerous cells, so that this healing by suppuration becomes an important part of the treatment. Any one Avho has the least nerve and moderate skill with tbe knife, can perform this operation. Tbe breast is lifted with tbe hand, and a sweeping incision made around it, commencing next the axilla, and dividing the upper and interior part last, so that we may speedily take up the mammary arteries. Tbe gland is dissected from the pectoral muscles., and w7e leave no engorged tissue if we can avoid it. It is hardly necessary to say, that any enlarged lymphatics in the axilla should be removed, for if they are left the disease is sure tore-appear in tbe cicatrix or the axilla. For the first day avc use a simple Avater dressing, or add a small portion of borax and salicylic acid to it. Then we make our anti- septic dressing a little stronger, or in three or four days Ave may dress it with mild zinc ointment. EveryT day Avhen it is dressed we examine the surface carefully to see if there are any large or discolored granulations, or any sensitive points. If Ave find either Ave sprinkle tbe surface with finely powdered sulphate of zinc, or DISEASES OF THE BREAST. 523 apply tbe chloride of zinc paste to the spots, and burn them down. Thus Avith careful attention we see the Avound gradually close up by granulation, and at last a firm cicatrix is formed. Chloride of zinc is the escharotic in common use by Eclectic physicians, and may be so applied as to destroy tbe growth and effect a cure. I should prefer to use it in epithelial cancer, or when the growth being near tbe surface, had involved the skin, and Avhen it w7as still of moderate size. Our object here should be a rapid destruction of tbe diseased tissues, for not only is tbe application very painful, but it excites inflammation of adjacent tissues, and if Ave are timid in making the application, the excite- ment caused by it may cause the cancer to grow more rapidly than Ave destroy it. I prefer a paste made of—R Chloride of Zinc (crystals), Powd. Gum Arabic, aa 3ss.; Powd. Sanguinaria, sj.; rub it up in a mortar, and add water until it forms a paste. This is spread on plaster leather a fourth of an inch thick, and applied to the groAvth, pressing it into every interstice, if it is an open can- cer. The recommendation to push it as rapidly as possible an- swers all questions as to tbe frequency of application, and we only stop when we are sure of the entire destruction of the growth. If the pain becomes unbearable, the patient may be put' under the influence of chloroform, or we may use chloral internally, or a hypodermic injection of morphia. When Ave are satisfied the growth is removed, we endeavor to heal tbe wound by suppuration. A dressing of a solution of borax and salicylic acid, or of hydrate of chloral, |j. to water Oj., or of the mild zinc ointment, Avill usually serve our purpose well. Arsenic is said to give a painless cure, but this depends upon the strength in which it is used. The majority of tbe cancer recipes throughout the country contain arsenious acid as the active ingredient, and they are sometimes sold to verdant doctors at a high price. There is no doubt that some of these are very good, as arsenic is one of the agents known to destroy these parasitic growths. I think its combination with iron is one of tbe best forms, and I will give directions for the preparatiou I have usu- ally employed. Take of the bydrated sesqui-oxide of iron a sufficient quantity, throw it on a paper filter, and allow it to drain until the paste is of proper consistence. Then add lard one part to five of the iron, and Ave have the basis of our arsenical plaster. 524 DISEASES OF WOMEN. If now we have time, tbe groAvth is sIoav, and not vascular, we may add of arsenious acid, 3ij., to this iron ointment, |iv., and the application will be almost painless. But if it is necessary to de- stroy it more rapidly, we increase the proportion, until sometimes it is used one part to two or even equal parts. The ointment is used freely, and crowded into tbe open sore. the dressing being made every day; gradually the growth loses vitality, becomes hard as if charred, and finally has so separated from tbe sound tissue that it can be lifted with the dressing for- ceps. Then with a pair of scissors clip the connective fibres, tis- sue, vessels, and nerves, that may hold it, and it can be remoA7ed " roots and all." It will be noticed that by this method the growth is desiccated, and hardened into a mass, whilst by chloride of zinc it Avas melted down, and passed off as a species of pus. In this case it is best to heal the cavity by tbe dry process, in- stead of by suppuration as before, and to accomplish this Ave dust it at each dressing with a very finely powdered sulphate of iron. The general treatment of the cancerous cachexia will vary in different cases, tbe rule being to give tbe remedy indicated. I have seen most excellent results from the administration of iodide of potassium, where the patient had the pallid, leaden-colored tongue, and the blue gums,—the morbid process seeming to be arrested for the time being, and the growth diminishing in size. So also I have seen good results from the Phytolacca, when there was a tendency to glandular engorgement, and from arsenic Avhen there was epithelial disease. I have given Donovan's solution (in minute doses) with Phytolacca Avhen there was engorgement and tenderness of the superficial cellular tissue. Rhus has given good results when there was great burning in the cancerous ulcer and an ichorous discharge. Outside of the selection of these special remedies, avc may use the Hydrastis, Avhich has obtained quite a reputation with our Homoeopathic brethren as a specific to the disease. Or in place of this the Gallium Aparine maybe employed. Other than these Ave see that Avaste and excretion are free, and that digestion and blood-making are well performed. Among tbe tonics I will sug- gest the use of the syrup of the triple phosphate of quinia, strych- nia, and iron, as especially useful in restoring innervation, at the same time that it improves the appetite and digestion. DISEASES OF THE BREAST. 525 As a local application to palliate the disease, relieve pain, and cheek the rapidity of groAvth, Ave have seen that carbolic acid w7as best for mucous membranes, and tannic acid for the disease of the skin and other parts. Still carbolic acid may sometimes be used in cancer of the breast, the strength varying from a sat- urated solution to one part to four of glycerine, or still more di- lute. We use that strength which best relieves the pain, and checks growth. Tannic acid is used in saturated solution, either in glycerine or water. It is very freely soluble, and it is our object to so thor- oughly tan the tissues that growth Avill be next to impossible. If it acts kindly tbe pain Avill be mitigated, the discbarge greatly lessened, and tlie engorged tissues Avill be depleted of their fluids. Other than this, a saturated solution of borax and salicylic acid may be used as a dressing, or a solution of hydrate of chlo- ral 3j. to water Oj. These are both good dressings, relieving pain and lessening or destroying tbe fetor of the discharges. I do not like permanganate of potash so well, but it may some- times be used Avith advantage. INDEX. PAGE 79 Abdominal Manipulation, or hypogastric touch,.... 66 444 Abrasion of Cervix Uteri, 230 114 Abscess of Labia,........ 81 1085 of Breasts,........... 501 781 of the Ovary,......... 375 330 Pelvis,............... 169 960 Amenorrhea, . ........... 444 961 absent Menstruation,.. 444 967 Symptoms,............440 968 Causes,............... 447 969 Treatment,........... 447 973 suppressed Menstrua- tion, ............... 448 974 Symptoms,............ 448 977 Diagnosis,............ 449 978 Treatment,........... 4-50 1 Anatomy of the Female Or- gans of Generation,.... 33 749 Anteflexion of the Uterus, 3'12 749 Anteversion of the Uterus, 362 751 Causes,............... 363 752 Symptoms,............ 364 754 Diagnosis,............ 364 755 Treatment,............365 105 Aptlne of the Vulva,..... 79 49 Bladder, anatomy of,..... 56 188 removal ofCalcul us from 107 233 disease of, in Cystocele, 124 746 Bond's Instrument for Re- troverted Uterus,....... 360 1041 Breasts, Diseases of,......483 1044 Anatomy of,.......... 484 1080 Inflammation of,...... 498 (526, PAG2 f 1085 Breasts, Abscess of,....... 501 1087 Chronic Abscess of,.... 502 1088 Lactiferous Swelling of, 503 1090 Cellulose Hydatids of,.. 503 1095 Chronic Mammary Tu- mor, ............... 506 1100 Irritable Tumor of,___ 507 1102 Carcinoma, or Cancer of, 508 66 Broad Ligaments,........ 61 1102 Cancer of the Breast,___508 1103 Pathology,............ 509 1106 Symptoms,............ 510 1114 Diagnosis,...........512 1115 Prognosis,___........ 513 1117 Treatment, ........... 514 849 Cancer of the Ovary,..... 401 851 Symptoms, ........... 402 844 Diagnosis,........... 403 855 Treatment, ........... 403 480 Cancer of the Uterus,___ 249 481 Pathology,............ 250 487 Symptoms,............ 252 494 Diagnosis,............ 255 497 Prognosis,............ 257 498 Treatment,.......... 257 256 Cancer of the Vagina,.... 134 258 Diagnosis,............ 135 259 Prognosis,............ 135 260 Treatment,............ 136 650 Cannula, double, for tlie li- gation of Polypi,........314 Carcinoma of Uterus, See Cancer. 472 Cauliflower Excrescence of Cervix Uteri,.......... 243 INDEX. 527 475 476 477 478 479 440 462 478 469 499 261 473 Cauliflower Excrescence of Cervix Uteri—Pathology, 244 Symptoms............. YUi Diagnosis,............ 217 Prognosis, ........... 247 Treatment,............ 248 Excision of the Cervix Uteri in............ 248 433 Caustic in Inflammation of the Cervix Uteri,___223 in Hypertrophy of the Cervix Uteri,....... 217 in Ulceration of the Cervix Uteri,...... 238 in Cauliflower Excres- cence, .............. 248 in Corroding Ulcer,... 242 in Cancer Uteri,.....257 in Cancer Vagina,.... 136 590 Cellular Polypus,......... 292 408 Cervix Uteri Congestion,.. 209 410 Symptoms, ........... 209 413 Causes,............210 414 Treatment,........... 210 417 Inflammation of,...... 211 419 Causes, ............ 212 422 Symptoms,......... 214 426 Treatment,......... 218 434 results of Inflammation, 223 444 Erosion of,............ 230 446 Symptoms,......... 232 447 Treatment, .........232 436 Hypertrophy of,....... 225 437 Causes,............. 225 438 Symptoms,.........226 439 Treatment,......... 226 454 Ulceration of,......... 234 458 Symptoms,..........236 459 Treatment, .........236 479 Excision of,........... 248 856 Child-bed Fever,......... 404 1016 Chlorosis,................ 467 1017 Pathology,............ 468 1020 Causes,............... 470 1021 Symptoms,..........471 1 1023 9 408 410 413 414 634 573 74 464 465 466 468 469 945 232 100 71 104 164 192 296 327 343 399 663 691 772 955 1039 955 691 794 789 PAOB Chlorosis—Treatment,____ 472 Clitoris,................ j} 7 Congestion of Cervix Uteri, 209 Symptoms,............ 209 Causes,............... 210 Treatment,............ 210 Conception with the pre- sence of Polypus,.....308 Conception, blighted,..... 286 Constitutional eifects of Uterine Disease,........ 64 Corroding Ulcer of the Uterus,................ 240 Pathology,............ 240 Symptoms,............ 241 Diagnosis,........... 242 Treatment, ........... 242 Crural Phlebitis,......... 435 Cystocele Vaginal,....... 123 Discharges, examination of, 77 Diseases of Females, Path- ology of,............... f,3 Diagnosis of,......... 04 of the External Organs of Generation,...... 79 of the Urethra,........ 96 of the Vagina,........ 109 of the Perineum,...... 156 of the Pelvic Cellular Tissue,............. 168 Venereal,............. 177 of the Uterus,........ 206 Nervous,........... 321 Displacements,...... 333 of the Fallopian Tubes and Ovaries,........ 372 Functional diseases of, 441 of the Breasts,...... 483 Disorders of Menstruation, 441 Displacements of the Uterus, 333 Dropsy of the Fallopian Tubes,................. 373 Dropsy (encysted) of the Ovary,................ 877 528 INDEX. PAGE 559 Dropsy of the Uterus,.... 282 984 Dysmenorrhea,........... 453 985 Neuralgic,............ 453 986 Symptoms, ......... 454 987 Causes,............. 454 988 Treatment,........ 455 992 Inflammatory, ........ 457 993 Diagnosis,.......... 457 994 Treatment,......... 458 995 Mechanical,..........458 996 Treatment,......... 469 653 Ecraseur of Chasaignac,.. 316 980 Electricity in Amenorrhea, 451 721 in Prolapsus Uteri, ... 348 961 Emansio Mensium,.... 444 1024 Emetics in Chlorosis, .... 473 983 Emmenagogues in Ame- norrhea, ............... 452 849 ^ Encephaloid Cancer of the Ovary,................ 401 122 Encysted Tumor of Labia,. 83 124 Diagnosis,.......... 84 126 Treatment, ........ 84 253 of the Vagina,........ 133 789 Dropsy of the Ovary,.. 377 725 Episcraphia,............. 350 444 Erosion of Cervix Uteri,.. 239 446 Symptoms,............ 232 447 Treatment,............ 232 479 Excision of Cervix Uteri,. 248 126 of Encysted Tumor of Labia,.............. 84 130 of Oozing Tumor,..... 86 658 of Uterine Polypi,--- 318 184 of Vascular Tumor of Meatus Urinarius,.. 104 151 of Warty Tumors of Vulva,............. 92 472 Excrescence, Cauliflower,. 243 1 External Organs of Genera- tion, Anatomy of,...... 33 104 Diseases of,........... 79 770 Extirpation of the Uterus, 372 832 in Ovarian Dropsy... 392 PAGS \ 41 Fallopian Tubes, Anatomy of,.................... 54 774 Abscess of,........... 373 774 Dropsy of,............ 37c 772 Inflammation of,...... 878 774 Obliteration of,....... 373 578 False Conception,........ 286 856 Fever, Puerperal,.........404 631 Fibrous Polypus,......... 305 848 Fibrous Tumors of the Ova- ries, ................. 401 586 of the Uterus,........291 587 Pathological Anatomy of,................. 291 599 Metamorphosis and Dis- eases of,........... 296 612 Symptoms of non-pedi- culated, .......... 300 « 622 Diagnosis,........302 625 Treatment,......... 303 631 Symptoms of Pedicu- lated, ............ 305 037 Diagnosis,.......... 310 646 Prognosis,.......... 312 647 Treatment,......... 312 648 by Ligation,........ 312 653 by the Ecraseur,.... 315 657 by Torsion,......... 318 658 by Excision,........ 318 662 by the use of Caustic, 320 264 Fistula Vesico-Vaginal,.. 137 265 Causes,.............. 137 268 Diagnosis,............ 138 269 Treatment,........... 139 271 Palliative method,..... 140 272 Desault's method,..... 140 273 Cauterization,......... 141 276 Suture,............... 143 283 Special Instruments for the Approximation of the edges,.......... 147 2^4 Anaplasty, ........... 147 286 Fistula Recto-Vaginal,___ 149 289 Treatment............ 150 292 Case of Prof. Freeman,. 151 INDEX. 529 PAGE 340 Fistula Vesico-Uterine,.... 173 341 Utero-intestinal,....... 175 342 Recto-vesical,......... 175 574 Fleshy Mole of Uterus,... 287 956 Fluor Albus,............. 442 955 Functional diseases of Ute- rus, ................... 441 4 Genital Organs, anatomy of,.................... 34 344 Gonorrhea,............... 177 345 different varieties of,.. 178 348 Symptoms,...........178 355 Diagnosis, ............ 182 958 Treatment, .......... 183 650 Gooch's Cannula,......... 314 448 Granular Inflammation of Cervix Uteri,.......... 232 1016 Green Sickness,........ . 314 490 Hemorrhage in Cancer Uteri,.............. in Cauliflower Excres- cence, .............. in Corroding Ulcer,.... in Inversion of the Uterus,.......... Uterine from Polypus,. Venous from Vulva,... 154 Hernia Vulvar,.......... 156 Vaginal, ............. 559 Hydrometra,............. 660 Varieties, ............ Causes, .............. Symptoms, ........... Diagnosis,............ Treatment, ........... 577 Hydatids Uterine,------- 12 Hymen,.................. 196 Persistent,............ 193 Imperforate,.......... 199 Treatment, ........ 436 Hypertrophy of CervixUteri, 436 Causes,............... 438 Symptoms, ........... 475 467 760 635 143 662 663 665 567 254 247 242 868 308 90 93 94 282 282 283 283 284 285 288 38 110 109 110 225 225 226 PAGB 1 438 Hypertrophy of Cervix Uteri—Treatment,...... 226 1031 Hysteria,................ 477 1032 Pathology............. 477 1033 Symptoms,............ 478 1036 Diagnosis,............ 480 1037 Causes,...............480 1038 Treatment ............ 480 508 Hysteritis, ...............262 509 Acute,................ 262 518 Chronic,.............. 266 527 Internal, ............. 270 866 Puerperal,............409 133 Imperforate Hymen,...... 109 4:!6 Induration of Cervix Uteri, 225 104 Inflammation of the Vulva, superficial,.......... 79 110 Phlegmonous,....... 80 169 of the Urethra,....... 98 210 of the Vagina, acute.. 115 218 Chronic,............ 118 827 of cellular tissue of Pel- vis, ................ 168 344 Gonorrhea, ........... 177 417 of the Cervix Uteri,... 211 419 Causes,.............212 422 Symptoms,.......... 214 426 Treatment, ......... 218 434 results of,.......... 223 508 of the Uterus,........ 262 509 Acute, ............. 262 518 Chronic,............ 266 527 Internal........... 270 866 Puerperal, ......... 409 772 of the Fallopian Tubes. 373 776 of the Ovaries,........ 374 877 of the Peritoneum..... 412 873 of the Veins and Lym- phatics, ............ 410 757 Inversion of the Uterus... 305 759 Causes, .............. 206 760 Symptoms, ........... 268 763 Diagnosis,............ 36S 764 Treatment, ........... 869 530 INDEX. PAGE | ? 665 Irritable Uterus,......... 322 GOG Diagnosis,............ 323 670 Treatment,............ 324 157 IUhing of the Vulva,..... 94 6 Labia Majora,............ 35 117 Labia, cohesion of,....... 82 122 Encysted Tumors of,.. 83 115 Oldema of,........... 82 127 Oozing Tumor of,..... 85 138 Thrombus, or Sangui- neous Tumor of,..... 88 134 Varices of,............ 86 296 Laceration of Perineum,.. 156 296 History,.............. 156 298 Causes,............... 157 299 Means of Prevention,.. 158 801 Consequences of,...... 159 302 Treatment,___....... 159 306 operation of Mr. Baker Brown,............. 161 307 Contra-indications to operating,.......... 161 308 Time of operating,___ 162 810 Instruments required,. 162 312 Mode of operating,___ 163 814 Division of the Sphinc- ter Ani,............ 164 315 Insertion of the Quill Sutures,............ 164 316 Insertion of the Inter- rupted Sutures,......165 319 Operation in recent cases,.............. 166 320 After-treatment,...... 166 956 Leucorrhea,.............. 442 423 from Cervical Canal,.. 215 527 Uterine,.............. 270 218 Vaginal,.............. 118 648 Ligature in Polypus Uteri, 312 151 in Warty Tumors of Vulva,............. 92 184 in Vascular Tumor of Meatus Urinarius,.. 104 772 in Inverted Uterus ... 372 PAOI 65 Ligaments of the Uterus,. 61 66 broad,................ 61 67 round,................ 62 1041 Mammary, diseases of,.... 483 1080 Inflammation of,......498 1085 Abscess of,........... 501 1087 Chronic Abscess of,.... 502 1088 Lactiferous swelling of, 503 1090 Cellulose Hydatids of,. 503 1095 Chronic Tumor of,___506 1100 Irritable Tumor of,___507 1102 Cancer of,............ 508 11 Meatus Urinarius,........ 38 180 Vascular Tumor of,... 104 995 Mechanical Dysmenorrhea, 458 999 Menorrhagia, with the dis- charge of the normal menstrual fluid, ...... 460 1000 Symptoms,............ 460 1001 Causes,............... 461 1002 Treatment,............ 461 1007 with the discharge of blood directly from the uterine vessels,.. 462 1008 Symptoms,.......... 462 1011 Causes,............. 465 1012 Diagnosis,.......... 465 1013 Treatment,.......... 465 961 Menses, Abscesses of,..... 444 973 Suppressed,........... 448 961 Menstruation, absent, .... 444 973 Suppressed,...........448 999 Excessive,...........400 984 Painful,.............. 453 975 Vicarious,............449 944 Milk-leg,................ 435 571 Moles,................... 286 574 Fleshy,............... 287 577 Vesicular,............ 288 580 Symptoms,............ 289 583 Diagnosis,............ 290 584 Treatment,............ 290 5 Mons Veneris,............ 84 INDEX. 531 PAGE If 985 Neuralgic Dysmenorrhea,. 453 986 Symptoms,............ 448 987 Causes,............... 449 988 Treatment,............ 450 663 Nervous affections of the Uterus,................ 321 8 Nymphae,................ 36 177 Occlusion of the Urethra,. 103 179 Treatment,............ 103 198 of the Vagina,........ 113 199 Treatment,.......... 114 115 GDdema of the Labia,..... 82 121 Inflammatory,......... 83 127 Oozing Tumor of Labium, . 85 130 Treatment,............. 85 457 Os Uteri, ulceration of,.... 235 423 Dilatation of, in Inflam- mation, ............. 214 43 Ovaries, ... ............. 55 776 Inflammation of, ..... 374 778 Causes,............ 374 779 Symptoms,.......... 374 781 Terminations,...... 375 783 Diagnosis,.......... 376 784 Treatment,.......... 376 881 Puerperal,..........413 847 Tumors of,............ 401 848 Fibroid Tumors of,--- 401 849 Cancer of,............ 401 851 Symptoms,.......... 402 854 Diagnosis,.......... 403 855 Treatment,..........403 789 Ovarian Dropsy,.......... 377 790 Pathology,............ 378 792 Simple Cysts,......... 378 794 Multilocular, or Prolifer- ous Cysts,.......... 379 796 Structure............ 380 799 Contents,........... 382 800 Symptoms........... 382 803 Diagnosis,.......... 383 813 Treatment,..........385 816 by Compression and Pal- pation, ............. 385 PAGE 816 Ovarian Dropsy—by Tap- ping, ............... 386 819 Tapping with Pressure, 388 820 Tapping and Injection of Iodine,.........388 826 Artificial Oviduct,..... 389 830 Excision of a portion of the Cyst,............ 391 832 Extirpation,...........392 832 Ovariotomy,. ............ 392 833 reasons for and against, 392 838 conditions rendering it justifiable,.......... 394 839 preparations for the ope- ration, ............. 395 840 mode of operating,.....396 843 dangers to be apprehend- ed after,............ 399 776 Ovaritis,................. 374 70 Pathology, Uterine,...... 63 62 Pelvic Fascia,............ 60 330 Pelvic Abscess,........... 169 327 Cellulitis,............. 168 327 History,.............. 108 329 Causes,............... 168 330 Terminations,......... 169 331 Duration,............. 170 332 Symptoms,............ 170 333 Diagnosis,............ 171 334 Treatment,............ 171 338 Fistulous passages re- maining after,...... 173 340 Cases of,.............. 173 52 Perineum,................ 58 296 Perineum, Laceration of,.. 156 877 Peritonitis, Puerperal,.... 412 714 Pessaries,................ 343 944 Phlebitis, Crural, ........435 873 Uterine,.............. 410 944 Phlegmasia Dolens,....... 435 945 Pathology of,.......... 436 946 Symptoms,.......... 437 950 Diagnosis,.......... 439 951 Treatment,..........439 532 INDEX. 110 Phlegmonous Inflammation of Labia,........... 80 111 Causes,............... 80 112 Diagnosis,............ 80 113 Treatment,............ 81 550 Physometra,............. 279 554 Symptoms,............281 556 Diagnosis,............ 281 557 Treatment,............ 282 631 Polypus Uteri—Symptoms,. 305 637 Diagnosis,............ 310 646 Prognosis,............ 312 647 Treatment,............ 312 648 by Ligation,........... 312 653 by the Ecraseur,...... 315 657 by Torsion,........... 318 658 by Excision,.......... 318 662 by the use of Caustic,.. 320 693 Procidentia Uteri,........ 334 693 Prolapse of the Uterus,... 334 697 Causes,............... 334 703 Symptoms,............ 339 709 Diagnosis,............ 340 710 Treatment,............ 341 711 by rest in the horizontal position,............ 341 712 by Astringent Injections, 341 714 Pessaries,............. 343 718 Rational Method,...... 346 721 Galvanism,........... 348 724 Perineal Supporter,--- 349 725 Episcraphia,.......... 350 231 Prolapse of Vagina,...... 122 232 Prolapsus Vesicae,........ 123 157 Pruritus of Vulva,........ 94 158 Symptoms,............ 94 i60 Treatment,............ 95 856 Puerperal Fever,......... 404 858 Causes,............... 404 864 Pathological Anatomy,. 407 866 Puerperal Endometritis, 409 873 Inflammation of Veins & Lymphatics of Uterus, 410 877 Inflammation of the Peritoneum,......... 412 PAGB If 881 Puerperal Fever—Puerpiral Ovaritis,........... 413 885 Pathological changes in other portions of the system,............ 414 904 Secondary terminations, 420 907 Symptoms,............ 121 908 Symptoms of the Inflam- matory form,........ 421 913 Symptoms of the Ty- phoid form,....... 423 921 Diagnosis,..........426 926 Prognosis,.......... 428 927 Treatment, ......... 428 286 Recto-Vaginal Fistula,___149 289 Treatment,............ 150 292 Case of Prof. Freeman, 151 240 Rectocele,............... 128 727 Retroflexion of Uterus,___350 727 Retroversion of Uterus,... 350 729 Causes,............... 352 730 Symptoms,........... 352 735 Diagnosis,............ 355 738 Treatment,............ 356 676 Rheumatism of Uterus,... 326 677 Causes,............... 327 678 Symptoms,............ 327 683 Influence on the progress of Pregnancy,.......329 684 Influence on Labor,.. . 330 686 Diagnosis,.......... 331 687 Treatment, ......... 331 85 Ricord's Speculum,....... 71 296 Rupture of Perineum,.... 156 293 of Vagina,............ 154 138 Sanguineous Tumor of the Labia,.............. 88 140 Diagnosis,............ 89 141 Treatment,............ 89 849 Scirrhus of the Ovary,___401 489 of the Uterus,......... 249 100 Secretions, examination of, 77 88 Simpson's Uterine Sound,. 72 index. 533 PAGE 84 Speculum, use of,......... 70 85 Ricord's, ............. 71 85 Ferguson's,........... 71 175 Stricture of the Urethra,.. 102 176 Treatment,............ 102 202 Stricture of the Vagina,... 113 205 Treatment,............ 114 364 Syphilis,................ 186 366 Stages of,............. 188 369 Inoculation,........ .. 189 370 Simple Chancre, ...... 190 371 Indurated, or Hunterian Chancre,......____ 190 372 Phagedenic Chancre,... 191 377 Secondary Symptoms,.. 192 382 Syphilitic Vegetations,. 197 383 Mucous Tubercles,..... 198 385 Diagnosis,............ 198 388 Treatment of Primary,. 200 392 Treatment of Secondary, 203 816 Tapping in Ovarian Dropsy, 386 819 with Pressure,......... 388 820 with Injection of Iodine, 388 138 Thrombus, or Sanguineous Tumor of the Labia,... 88 140 Diagnosis,............ 89 141 Treatment,............ 89 657 Torsion for removal of Polypi,............... 318 80 Touch, as a means of Diag- nosis,................, 67 60 Transversus Perinaei,..... 60 55 Triangular Ligament,.... 59 122 Tumors, Encysted, of the Labia,.............. 83 127 Oozing of the Labia,... 85 138 Sanguineous of the La- bia, ................ 88 148 Warty, of the Vulva,.. 92 180 Vascular, of the Meatus Urinarius,.......... 104 253 of the Vagina,........ 133 586 Fibroid, of the Uterus,. 291 612 Non-pediculated,...... 300 PAGi 531 Tumors—Pediculated (Poly- pi,) ................ 305 847 of the Ovary,......... 401 550 Tympanitis, Uterine,...... 279 464 Ulcer, Corroding,......... 240 454 Ulceration of the Cervix Uteri,.............. 234 458 Symptoms,............ 236 459 Treatment,............ 236 49 Urethra,................. 56 188 Dilatation of, for remo- val of Calculi,...... 107 168 Inflammation of,....... 98 180 Tumors at orifice of,... 104 175 Stricture of,........... 102 185 Foreign bodies in,..... 106 168 Urethritis,............... 98 169 Symptoms,............ 98 170 Treatment,............ 99 527 Uterine Leucorrhea,....... 270 559 Dropsy,.............. 282 873 Phlebitis,...........410 88 Sound, ............... 72 550 Tympanitis,___I...... 279 23 Uterus, Anatomy of,...... 43 749 Anteflexion of,........ 362 749 Anteversion of,....... 362 480 Cancer of,............249 480 Carcinoma of,......... 249 472 Cauliflower Excrescence of,................. 243 404 Corroding Ulcer of,--- 240 399 Diseases of the,....... 206 691 Displacements of the,.. 333 559 Dropsy of the,.........282 771 Extirpation of the,.... 372 586 Fibroid Tumors of,___291 508 Inflammation of,......262 509 Acute,............. 262 518 Chronic,............ 266 527 Internal,........... 270 757 Inversion of,.......... 365 665 Irritable, .. ........ 322 571 Moles and Hydatids of, 286 534 INDEX. 631 693 727 727 676 Uterus, Polypus of,........ 305 Prolapse of,........... 334 Retroflexion of,........ 350 Retroversion of,...... 350 Rheumatism of,........ 326 192 Vagina, Diseases of,...... 256 Cancer of,............. 210 Inflammation of,...... 210\ Acute,.............. 218 Chronic,........... 192-198 Occlusion of the,...... 231 Prolapse of,........... the Anterior Wall,.. the Posterior Wall,.. Entire Circumference, Laceration of,......... Stricture of,......... Tumors of,............ 232 Vaginal Cystocele,........ 233 Symptoms,............ 234 Diagnosis,............ 235 Treatment,............ 80-84 Vaginal Examination,___ 218 Leucorrhea, ........... 240 Rectocele,............. 241 Causes,............. 242 Symptoms,.......... 244 Diagnosis,.......... 245 Treatment....... 232 240 249 293 202 253 210 Vaginitis, Acute,...... 212 Causes,.......... 213 Diagnosis,........ 214 Treatment,....... 218 Chronic,........... 221 Symptoms,....... 223 Diagnosis,....... 224 Treatment,....... 134 Varices of the Labia,.. 135 Causes,............ 136 Treatment,......... 577 Vesicular Mole,....... 264 Vesico-Vaginal Fistula, 265 Causes............. 109 134 115 115 118 109 122 123 128 131 154 113 133 123 123 124 124 67 118 128 129 129 130 130 115 116 116 117 118 118 119 120 86 87 87 288 137 137 PA03 If 266 Vesico-Vaginal Fis-tula— Diagnosis............. 138 269 Treatment,..........139 271 Palliative Method,..... 140 272 Desault's Method,..... 140 273 Cauterization,......... 141 276 Suture,............... 143 283 Special Instruments for Approximation of the1 Edges,.............. 147 284 Anaplasty,............ 147 340 Vesico-Uterine Fistula,... 173 873 Veins of Uterus, Inflamma- tion of,...............410 10 Vestibule,................ 38 975 Vicarious Menstruation,.. 440 104 Vulva Superficial, Inflam- mation of,.......... 79 105 Appearances,......... 79 106 Causes,............... 79 107 Treatment, ........... 79 110 Phlegmonous Inflamma- tion of,........... 80 111 Causes,............ 80 112 Diagnosis,.......... 80 113 Treatment,........... 81 143 Venous Hemorrhage from 90 148 AVarty Tumors of,..... 92 149 Symptoms, ......... 92 150 Causes, ..___...... 92 151 Treatment,.......... 92 157 Pruritus of,........... 94 158 Symptoms,......... 94 160 Treatment,........ 95 122 Tumors of the,........ 83 154 Vulvar En terocele,........ 93 155 Treatment,............ 93 148 Warty Tumors of the Vulva, 92 149 Symptoms,.......... 92 150 Causes,............. 92 151 Treatment,.......... 92 253 of the Vagina,........ 133 956 Whites,.................. 442 A. i / / / NL.H 005fl003fl 7 m ^ - *$$?& *3£\vr f*.-v'~ **• * -i** >!•" *&_ £« +\ •>' -*l!L- >1>M NLM005800387