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" " Paper " - - - -75 Five Volumes or more taken at one time, Cloth, each, 1.00 " " " << " " Paper, " .60 POSTAGE PREPAID. DISEASES OF WOMEN. Clinical Lectures. By Lombe Atthill, M.D. Fifth Edition. Revised and partly Rewritten. With Illustrations. 342 pages. HEADACHES; Their Nature, Causes and Treatment. 4$y,MM, Henry Day, m.d., author of "A Systematic Treatise on Diseases of Children." Third Edition. With Colored Plates and other Illustrations. 322 pages. THE PRACTICE OF MEDICINE. A Handbook for Physicians and Students. B/ M. Charteris, m.d. With Microscopic and other Illus- trations. 366 pages. DISEASES OF THE STOMACH, and the Varieties of Dyspepsia. With Diagnosis and Treatment. By S. O. Habershon, m.d. Third Revised Elition. 324 pages. THE RENAL, URINARY AND REPRODUCTIVE ORGANS; Their Functional Diseases. With a Review of Urinary Pathology. By D. Campbell Black, m d. 300 pages. THE LAWS OF THERAPEUTICS, or The Science and Art of Medi cine. By Joseph Kidd, m d. 196 pages. 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CLINICAL LECTURES LOMBE ATTHILL, M.D., CONSULTING OBSTETRIC SURGEON TO THE ADELAIDE HOSPITAL, EX-PRESIDENT OF THE DUBLIN OBSTETRICAL SOCIETY, ETC. FIFTH EDITION, REVISED AND PARTLY RE-WRITTEN, WITH ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 WALNUT STREET. 1882. WP \6 8.7- PREFACE TO THE FIFTH EDITION. In issuing a Fifth Edition of my Lectures I have only to repeat that I have endeavored to furnish to Practitioners and Students, "■ within the limits of a moderate-sized volume, such an account of the Diseases Peculiar to Women, verified by my personal experi- ence, as would meet their wants." The size of the present volume is not, therefore, materially enlarged. My reasons for deciding on this course will be found in the Preface to the last Edition, which is annexed. The whole AVork has, however, been carefully revised, and the chapter of Chronic Endometritis for the most part rewritten ; while some omissions which existed in the former Editions have been rectified. LOMBE ATTHILL. Rotunda Hospital, Dublin, July, 1878. /S^^' PREFACE TO THE FOURTH EDITION. After much consideration I have decided on presenting this Edition of my Lectures to the profession in an unaltered form. A large edition has gone out of print in less than a year and a half, and while gratified, as every author must be, at such a result, I am deeply impressed with the responsibility thereby entailed. It is impossible that a fourth edition of any Medical work can be reached without its influencing to a considerable extent the manage- ment of the diseases of which it treats, and the author should weigh well not alone the views and statements he puts forward, but also the omissions he makes. These Lectures have been characterized by a reviewer in the Edinburgh Medical Journal as "a very imperfect compendium of the diseases of women." This charge would have some truth in it had the volume been put forward as a complete treatise on gyne- cology. Such it did not profess to be, but still it affords to students and practitioners information on all "the Diseases Peculiar to Women" which fairly come within the limits of a work on these subjects. The criticism is not, however, devoid of weight, and I yiii PREFACE. have been urged, by "enlarging the scope " of this volume, at once to render for the future such a criticism impossible, enhance my reputation as an author, and add to the value of the work. After much hesitation, I have decided against following the ad- vice thus in good faith tendered. By "enlarging the scope" of the work is meant the discussing in extenso not alone the pathology and treatment of uterine and ovarian disease, but also the describing in detail all the numerous operations now falling within the province of the obstetric surgeon, including ovariotomy and that for the cure of vesico-vaginal fistula. The task would not, indeed, be a very serious one, for my difficulty has been, while omitting all that was superfluous, to convey in language as clear and concise as possible all that seemed to me to be essential for my purpose. But while admitting the force of the first two reasons, I much doubt if by " enlarging the scope " of the volume I would add to its usefulness. The object I had in view, in which I am gratified by feeling I have in some degree succeeded, was not to supply practitioners and students with information already within their reach in rec- ognized manuals of surgery, but to furnish them, in the limits of a moderate-sized volume, with such an account of the Diseases Peculiar to Women, brought up to the standard of the most recent period, and verified by my personal experience, as would meet their wants, and tend to the more general diffusion of a knowledge of these common, but, unfortunately, much-neglected affections. PREFACE. IX I have endeavored, however, in the present Edition, to render the volume more worthy of the favorable reception accorded to it by a careful revision, and by the addition in many places of new matter, suggested by the experience obtained in the great field of observa- tion afforded me in this Hospital. LOMBE ATTHILL. Rotunda Hospital, Dublin, November, 1876. CONTENTS. o*«c LECTURE I. PAGE Introductory—Mode of examining patients—Use of Speculum- Uterine sound,..........15 LECTURE II. Leucorrhcea—Its characteristics, sources, causes and treatment—Vagin- itis—Vaginismus,..........31 LECTURE III. Menstruation—Amenorrhea—Causes of—Treatment of various forms of—Use of galvanic stem pessary,.......46 LECTURE IV. Dysmenorrhea—Varieties of—Cause of pain in—Treatment of, . . 60 LECTURE V. Menorrhagia — Causes of—Subinvolution — Treatment of— Uterine porte-caustique—Plugging vagina,.......79 LECTURE VI. Menorrhagia (continued)—Granular ulceration of cervix—Granular condition of cavity—Mode of dilating cervix—Sea-tangle tents— Use of nitric acid—Curette, ........97 LECTURE VII. Polypus—Mucous, cystic and fibrous—Operations for removal of— Steel wire—Author's Ecraseur—Fibrinous and placental polypi, . 113 LECTURE VIII. Fibrous tumors — Definition of—Sub-peritoneal—Sub-mucous and intramural varieties—Treatment—Influence of pregnancy—Spon- taneous cure, . .........132 XII CONTEXTS. LECTURE IX. PAGK Inflammation of the Cervix Uteri—Ulceration of—Treatment of, by local depletion, nitric acid, and styptic colloid—Pelvic cellulitis —Pelvic hematocele, . . . • • • • • .loo LECTURE X. Chronic Inflammation of Cervix—Induration of—Treatment by potassa fusa and by local depletion—Endometritis—Endocervicitis, . . 187 LECTURE XL Displacements of the Uterus—Retroflexion—Its causes, symptoms, and treatment—Hodge's pessary—Value of local bloodletting—Ante- flexion—Prolapsus uteri—Retroversion, . . . . 212 LECTURE XII. Enlargements of the Uterus—Frequency of—Causes of, considered with reference to diagnosis, ......... 249 LECTURE XIII. Cancer—Varieties met with—Medullary and Epithelial—Symptoms— Cauliflower Excrescence—Amputation of Cervix—General Treat- ment, ..... ....... 261 LECTURE XIV. Ovarian cystic disease—Pathology—Unilocular, multilocular, and dermoid—Varieties—Symptoms—Diagnosis,..... 279 LECTURE XV. Ovarian disease (continued)—Effect on duration of life—Ovariotomy— Statistics of—Tapping cyst—Injection of cyst—Inflammation of the ovary, ...........296 LECTURE XVI. Uterine therapeutics—External applications—Hot and cold hip-baths —Use of Chapman's spinal hot water and ice bags—Wet bandages —Blisters—Iodine, .......... 306 LECTURE XVII. Uterine therapeutics (continued)—Applications to the vagina and uterus — Vaginal injections — Intra-uterine applications — Medicinal treatment,......... . .315 LIST OF ILLUSTRATIONS. FIGURE 1. Bi-valve Speculum,..... 2. Four-bladed Speculum, .... 3. Duck-bill Speculum, .... 4. Mode of Introducing Sound, . 5. Galvanic Stem Pessary, .... 6. Priestly's Dilator,..... 7. Savage's Metrotome, .... 8. Kuchenmeister's Scissors, 9. Greenhalgh's Metrotome, 10. " " ... 11. Greenhalgh's Expanding Intra-uterine Stem, 12. Intra-uterine Porte-caustique, . 13. Polypus—Sea-tangle in situ, to effect Dilatation, 14. Vulsellum,...... 15. Wire Ecraseur,..... 16. Ecraseur applied for removal of Polypus, 17. Dr. Atthill's Ecraseur, .... 18. Fibrous Tumor with Double Attachment, 19. Uterine Out-growth or Polypus, 20. Uterine Fibrous Tumor, 21. Extra-uterine Fibro-cystic Tumor, . 22. Intramural Fibroid of Cervix, 23. Intramural Fibrous Tumor, 24. Hall's Knife for Puncturing Cervix, 25. Retroversion of Uterus, . 26. Retroflexion of Uterus, .... 27. Hodge's Pessary,..... 28. Hodge's Pessary in situ, .... 29. Greenhalgh's Spring Pessaries, 30. Greenhalgh's Flexible Stem, . 31. Complete Prolapse of Uterus, . . . 32. Zwank's Pessary,..... 33. Apparatus for Vaginal Injections, . 34. Playfair's Probes,..... 35. Author's Canula for Intra-uterine Medication, CLINICAL LECTURES ON DISEASES PECULIAR TO WOMEN. LECTURE I Introductory Remarks—Mode of Examining Patients—Use of Speculum—Fergusson's—Bivalve—Duck-bill—Uterine Sound —Method of Introduction—Information to be obtained from its Use—Bimanual Method of Examination. Gentlemen : It is of course essential to the right treat- ment of any disease, that the condition of the affected organ should be carefully and scientifically investigated. To assert such a palpable truth seems almost absurd; yet when coming together as wo now do, to investigate the symptoms, and discuss the treatment, of the diseases of the female genital organs, it must be borne in mind, and I feel bound to im- press upon you the importance of the simple proposition I have laid down. Not a year passes that I do not meet with instances in which practitioners lose credit and character by neglecting, or being unable skilfully, to make the examina- tion necessary in the class of cases we are about to con- sider. What physician Avould dream of prescribing for a case of haemoptysis without previously ascertaining the con- dition of the thoracic viscera ? Yet many do not hesitate to 16 DISEASES OF WOMEN. undertake the treatment of a case in which hemorrhage from the uterus is present, without having the least idea whether the haemorrhage depends on the existence of granular ulcera- tion of the os and cervix uteri, on the presence of a polypus, of cancer, of that condition known as subinvolution of the uterus, or on some other less easily demonstrable causes. T therefore unhesitatingly lay it down as a rule, that in all cases presenting symptoms of uterine disease, a careful examina- tion of the pelvic viscera should be made. But let me at the same time earnestly impress on you the duty of con- ducting such an examination in a mode as little irksome as possible to the patient, and with all possible delicacy. Now, in nearly every case of uterine or vaginal disease, we require the aid of both touch and sight to enable us to arrive at a correct conclusion as to the condition of the affected organs. To use the speculum without a previous examina- tion by the finger and hand, is not only wrong, but it also fails to convey to us anything like an accurate knowledge of the case. Thus a patient suffers from leucorrhoea, with pelvic pain, and pains in the thigh. You make an examination with the speculum, and finding the os uteri healthy, mav hastily come to the conclusion that no abnormal condition of the genital organs exists, and perhaps assure the patient that the womb is healthy. But nevertheless she is dissatis- fied, for her sufferings continue, and by-and-by she consults another practitioner, who detects the existence of a retro- fleeted or anteflected uterus—a condition which an ocular inspection of the os uteri failed to recognize. I could easilv multiply examples, but let this one suffice to impress you with the necessity of making a manual examination before usino- the speculum. In speaking of a manual examination, I mean more than a digital examination of the vagina. I include also under DIGITAL EXAMINATION. 17 that term the investigation of the pelvic viscera through the alKlominal walls, and, if the symptoms seem to demand it, through the rectum also. I shall make a few remarks on the mode of conducting these investigations. First, then, as to the ordinary digital examination of the vagina and uterus. The patient is to be placed on her left side, with the head low and bent well forward, taking care, too, that she doc not rest upon her elbow; the knees should h-2 well drawn up, and the hips pushed out to the edge of the couch. These preliminaries effected, the index finger, pre- viously well greased,* should be introduced slowly upwards, in the axis of the outlet of the pelvis, the tip of the finger being kept in contact with the posterior wall of the vagina. By adopting this course the finger reaches the posterior cul fie .sac of the vagina, and by carrying it from this point round the cervix uteri, we are enabled at once to ascertain the con- dition of the lower segment of the uterus. Thus we learn whether it be movable or fixed, whether it be of the normal size and shape, or, on the other hand, elongated or hypertro- phied. Then, by drawing the finger down along its surface, you reach the os uteri and discover its state; whether it be patulous, with everted lips, or small and contracted. While thus engaged in investigating the condition of the uterus, vou should not fail to attend to that of the vagina, and satisfy yourself whether it be of the natural temperature and mois- ture, or unduly hot and dry. But there is more yet to be as- certained before vou have gained all the information possible for a digital examination,—the position of the uterus itself is to * For this purpose a compound of purified soft soap, three parts; glycer- in, one part, and carbolic acid, five grains to the ounce, answers admirably. It washes off ea;ily, is a deodorizer and disinfectant, and does not damage clothes or any other article on which it falls as oil and grease do. 2 18 DISEASES OF WOMEN. be made out, for the organ may be retroflected or anteflected, or possibly under certain circumstances, completely retroverted. As a rule, you should not be able to feel the body of the unimpregnated uterus through the posterior cul de sac of the vagina. If, therefore, on sweeping the finger round the cervix posteriorly, you feel a firm globular mass above, you can at once pronounce that the organ is in an abnormal condition. Then immediately follows the question which you are called upon to solve ; namely, on what does this enlargement de- pend ? But I must defer the consideration of this question to a future lecture ; for a mere digital examination, though of importance, is frequently insufficient to enable us to decide this point; and in a large number of eases you must not re- main content with it, or you will fall into grave errors. To make your examination complete, you must have recourse to the use both of the speculum and of the uterine sound. I name them in the order in which, as a rule, they should be used. You see on the' table three kinds of speeulums. All of them are admirable instruments, and, as I am about to ex- plain to you, each possesses some certain advantages which the other wants, and certain disadvantages which renders the use sometimes of one, and sometimes of another preferable. It is, therefore, essential that you should be acquainted with the re- spective merits of each. There are, no doubt, numerous-other kinds; but for ordinary purposes these are sufficient, and for general use, I, without hesitation, recommend the one known as Fergusson's. It is, as you are aware, a glass cylinder sil- vered externally. This, again, is protected by a laver of gutta- percha, which answers the double purpose of affording a verv smooth surface and serving as a protection to the vagina should the glass by any mischance crack or break. Through a full- sized one of these speeulums you can see the parts verv dis- BIVALVE SPECULUM. 19 tinetly; it also possesses this great advantage, that it is unin- jured by the action of acids, a class of remedial agents which are frequently used in the treatment of uterine disease. It is not, however, so easily introduced as either of the other speeu- lums which I exhibit. If, therefore, the vagina be narrow, or if much inflammation be present, the attempt to use a full- sized one will give so much pain that you will have to desist, and should you, with the view of avoiding this, have recourse to a smaller one, you will find much difficulty in bringing the os into view; even when you succeed in doing so, the portion of the cervix exposed to view will be of such limited extent as often to afford but little information. Still the number of cases in which it is inapplicable will be comparatively few. When, from the narrowness of the orifice of the vagina, or from the amount of inflammation present, you find Fergus- son's speculum to be unsuitable, I recommend you to make use of a plated bivalve, such a one as this (Fig. 1). Fig. 1. Bivalve Speculum. It is verv easily introduced, but does not reflect the light nearly so well as the glass one does, and moreover the lateral 20 DISEASES OF WOMEN". folds of the vagina fall, to a considerable degree, into the space between the blades when they are expanded, and intercept your view. To remedy the latter objection, Dr. Graily Hew- Fig. 2. Four-bladed Speculum. itt has introduced a four-bladed speculum (Fig. 2), which in several respects is superior to any other expanding speculum. This speculum, which, from its shape, is known as the duck- bill speculum (Fig. 3), affords one advantage which neither of the others possess; namely, it permits you to see the os uteri, and at the same time to touch it—a matter of the greatest im- portance in many cases. We therefore use it when introducing sea-tangle or sponge tents into the cervix uteri; or when, hav- ing withdrawn these, we proceed to examine the condition of, or to make applications to, the canal of the cervix or bodv of the uterus, and also in the case of all operations about the vagina or uterus. Its disadvantages are that the forcible drawing back of the perinaeum, which is necessary to permit the os uteri to be seen, causes pain; while if the instrument be not held very steady, the os slips out of view. Secondly that it is absolutely necessary to have an assistant present to take charge of it; and thirdly, that difficulty is often expe- INTRODUCTION OF SPECULUM. 21 rienced in keeping the anterior wall of the vagina from inter- cepting the view, unless, indeed, you seize the os with a hook or vulsellum—the reason for, and the mode of, doing which, I shall explain on a future occasion. Fig. 3. Duck-bill Speculum. I shall now give a few directions as to the mode of intro- ducing the speculum; for, if the instrument is used in a bungling, unhandy way, not only will the patient be caused much unnecessary pain, but you will also most likely leave an unfavorable impression on her mind as to your skill; I therefore feel that I am not wasting time in dwelling on these minutiae. First, then, you should dip your speculum into warm water to bring it up to the temperature of the body, and oil it; then the patient lying on the left side with her hips well out, you should, with the index and middle finger of the left hand, raise and draw up the right labium and nympha, while with the thumb and index finger of the right hand you hold the speculum, and bring its points to the orifice of the vagina. You should at the same time, with the middle finger of that hand, depress the soft parts on the left side; for if this be not done, and if the labia or nympha? be turned in be- 22 DISEASES OF WOMEN. fore the edge of the speculum, the patient will be caused much unnecessary pain which a little care would have obviated. When once the point of the speculum has fairly entered within the vagina, its further introduction is a matter of no difficulty ; but still it is very possible for a person inexperi- enced in its use to fail in bringing the os uteri into view; therefore, you should be careful to keep the point of the in- strument pressed well back against the posterior wall of the vagina, for the os uteri should look downward and backward, so that by keeping the point of the instrument in the direction I have indicated, the os should without difficulty come into view. If this be not the case the speculum should be with- drawn a little way, and its direction slightly altered, when the desired object will most likely be attained. The foregoing di- rections hold equally good whether you use Fergusson's, or the expanding speculum ; for though the latter, on account of its shape, is introduced with greater facility, yet it is not easier with it to bring the os into viewr; indeed the reverse is the case. The duck-bill speculum requires special directions for its use. The following are those given by the inventor, Dr. Marion Sims, and should be carefully attended to whenever this speculum is used : " The thighs are flexed at right angles with the pelvis, the patient lying in a semi-prone position on her left side, her left hand being drawn backwards under her, and kept in that posttion; the chest rotated forward, bringing the sternum very nearly in contact with the table or couch, the head resting on the parietal bone ; the head must not be flexed on the sternum nor the right shoulder elevated; the patient is thus rolled over on the front, making a left lateral semi-prone position. The nurse or assistant at her back, pulls up the right side of the nates with the left hand, while the sUroCOU introduces the speculum, elevates the perinaaum, and gives the VAGINAL EXAMINATION. 23 instrument into the hand of the assistant, who holds it firmly in the desired position." These directions are admirable, and should be strictly attended to. When with either speculum you have exposed the os uteri you are able to judge of its state. You see first of all what may be the condition of the lips ; if they are covered with healthy mucous membrane, and present the normal light mother-o'-pearl colored appearance, or whether they be con- gested, abraded, or in a state of granular ulceration, bleeding on the slightest touch; you see also whether the os be a small opening, free from discharge, or whether it be patulous, and plugged with a string of thick, glairy mucus, the sure indica- tion of an unhealthy condition of the cervical canal. Then, while withdrawing your speculum, you have an opportunity of satisfying yourself as to the condition of the vaginal mucous membrane; thus by touch and sight you are enabled to pro- nounce with positive certainty as to the state of the os, of the lower segment of the cervix uteri, and of the vagina; but, should you stop here, you will in many cases have tailed in your duty. Many a sufferer has been told, after having sub- mitted to such an examination, that the womb was perfectly healthy, because the os and cervix appeared to be free from disease, and has consequently been looked upon as a complain- ing hypochondriac by her friends, while in reality she was a suflering invalid—the physician having failed to detect the actual ailment, either because he omitted to carry his investi- gation further, or because he was ignorant how to do so. For nivself I lay down the following rule, which I advise you to pursue, in the investigation of all cases of uterine disease which come under your observation: 1st. To make a digital examination of the vagina and cervix uteri; 2d. If that fails in satisfying me as to the cause of the patient's suffering, then 24 DISEASES OF WOMEN. to use the speculum; and 3d. If still in doubt, to introduce the uterine sound, unless its use be clearly contraindieated. You are aware that the sound is an instrument of compara- • tively recent invention; still it is surprising how little it is used, and how few appreciate its merits. I look on it as one of the most useful, and at the same time, if carefully and judiciously handled, safest of obstetric instruments. In my own practice I am indebted to it for mast important informa- tion which could not have been obtained by any other means, and this too without having ever known it to produce the most trifling injury. Doubtless I am aware, that if roughly and unskilfully handled, or used in an improper case, the most serious consequences may follow its introduction ; but the same may be said of the catheter, or indeed of any other instrument requiring skill. I again repeat, that if carefully used and skilfully handled, it is a harmless instrument, and may be em- ployed with perfect safety. Before explaining the mode of introducing the sound, I wish to call your attention to the instrument itself. It is, as you see, a metallic staff, not unlike the sound used by surgeons for examining the bladder in the male. The best are made of copper, plated. The advantage which they possess is that you are able to bend them at pleasure; a matter of no small im- portance, as you arc frequently obliged to alter the curve when flexions of the uterus exist. At a distance of two and a quarter inches from the extremity of the instrument there is a little knob, which marks the depth to which it should usually penetrate into the uterine cavity, and at this point you observe the instrument is curved, so that it may pass in a direction cor- responding with the axis of the uterine cavity. The entire length of the instrument is marked at intervals of an inch by notches, which enable you at once to decide to what depth the instrument has penetrated; for when withdrawing it, if vou INTRODUCTION OF SOUND. 2o keep the point of your finger on the notch nearest to the os, you can with the aid of the figures marked on the handle, see at a glance what the depth of the uterine cavity may be. It is not a matter of any great difficulty to introduce the sound into the cavity of the uterus; still it requires tact and Mode of Introducing Sound. practice, just as the use of the catheter does. The following directions will aid you in obtaining the requisite skill: Hold- ing the sound in the left hand, I recommend you to introduce the index finger of the right into the vagina, and keeping its tip in close contact with the os uteri, guide the point of the sound up to the os, slipping it along the inner surface of the finger, the concavity of the instrument being turned towards the rectum (Fig. 4). 26 DISEASES OF WOMEN. A little manipulation and gentle pressure will now make it enter the canal of the cervix. This being fairly accomplished, a fact you can always be sure of because your finger is still in contact with the os, you are to rotate the handle of the sound, a manoeuvre exactly similar to that practiced by surgeons when introducing the catheter in the male, and termed the " tour de maitre." This has the effect of changing the direc- tion of the point of the instrument, which will now look up- wards and forwards in the direction of the axis of the uterus; steady but very gentle pressure should now be made, and the point will, in general, pass on without difficulty till it reach the os internum; here some slight obstruction is met with. This, if it occurs, should be overcome by gentle continuous pressure; force must not on any account be used, lest injury be done to the uterine walls. As the point of the instrument passes through the os internum, the patient nearly always com- plains of pain and sometimes of nausea; but, as a rule, this subsides in a few minutes. When it is severe and lasts, as it sometimes does for some hours, metritis or endometritis will be found to exist, and I have on one or two occasions known a patient to feel faint; this feeling, too, soon passed off, and was never sufficient to prevent my finishing the ex- amination; but it is well to tell your patient before you intro- duce the sound, that she may expect some pain, or at least a feeling of discomfort, similar to that experienced at the ap- proach of a menstrual period. In some instances an obstruction to the introduction of the instrument is met with low down in the cervical canal. This is not due to any contraction, but to the point of the sound becoming entangled in a fold of the mucous membrane, which in this portion of the intrauterine canal is not smooth but plaited. Should this occur, you must withdraw the point a little, and altering its direction somewhat, again press it on- UTERINE SOUND. 27 ward. This difficulty is more likely to occur when the os uteri is patulous, and the cervical canal relaxed from the effects of disease, than when it is in a healthy condition; but a little pa- tience and careful manipulation will always overcome the«e obstructions. I have dwelt at some length on the mode of in- troducing the sound, because the difficulties of the operation have been much exaggerated, and I am satisfied that they are mainly due to want of skill on the part of the operator. The method of using the sound which I have described is that which I always adopt; but there are other modes doubt- less equally as good. Thus Dr. Graily Hewitt, following the plan recommended by Sir J. Simpson, introduces the index finger of the left hand, guiding the sound along it up to the os uteri; while Dr. West recommends introducing two fingers of that hand for the purpose, the instrument being held in the right hand. But whichever method you adopt, you will speedily with a little practice become adepts, only remember, never use force; better far that you should never use the in- strument than that you should run the risk of injuring the uterus, and perhaps cause a fatal result, in doing by force what should only be accomplished by tact. But you will frequently meet with cases in which the use of the sound is entirely forbidden. Thus, if there be any possi- bility of pregnancy existing, it would be most improper to in- troduce it, and wait until you are satisfied on this point. In cases of cancer, too, and as a rule, during an attackof any form of acute inflammation, your own judgment will warn you against it. But with such exceptions as these, I can confidently recom- mend the sound as a safe and useful instrument. So high is my opinion of the value of the information to be obtained by the judicious use of the uterine sound, that I make it a rule to introduce it in all doubtful cases, unless its use is contraindi- cated bv the possible existence of pregnancy, or some equally 28 DISEASES OF WOMEN. valid cause; and I am satisfied that this will at no distant time be recognized by all well-informed obstetric practitioners as the established rule. Now as to the information to be obtained from its use. We learn three things which it would be impossible to ascertain by any other means. First, we determine with positive certainty what the depth of the cavity of the uterus is. If the sound pass beyond the nodule at the curve of the instrument, we know that the cavity is unduly elongated, and we can measure accurately the extent to which it is elongated. Secondly, we ascertain the position of the uterus, and determine whether it be in its normal position, or fixed anteriorly or posteriorly. Lastly, we learn whether the organ is fixed or movable, free or attached to any tumor, wThich we may detect exists in the pelvis. This is a matter of the greatest moment; for when we come to determine the all-important question as to the na- ture of some abdominal tumor, the sound, and the sound alone, enables us to decide whether the uterus is engaged in that tumor or not. But our means of obtaining information are not vet ex- hausted. Our examination hitherto has been carried on through the vagina. We have ascertained what the condition of the os uteri is. We have measured the depth of the intra- uterine canal with our sound. We are satisfied that the uterus has retained its natural position, or is displaced.- But wTe know nothing of the condition of the external or peritoneal surface of that organ. A fibrous tumor, for instance, of any conceiva- ble size, may be developed from any portion of the uterine wall, and yet the examination I have hitherto described may fail to detect it. Never omit, then, in all doubtful cases to pass the hand over the abdomen, and by the aid of both hands to satisfy yourself as to the shape and size of the uterus. This method, termed by Dr. Marion Sims the bimanual method BI MA NTAL EX A MIN ATION. 29 often affords valuable information. To carry it out, pressure is made with the left hand over the pubes, while the index finger of the right is kept in contact with the cervix uteri; the patient lying on her back, should be made to expire deeply, and, at this moment, the fingers of the left hand should be pressed firmly down into the pelvis, immediately over the pubes, while the index finger presses the uterus upward from the vagina. It will thus, to use Dr. Sims's words, "be easy to measure the size and shape of the body of the womb, for it will be held firmly between the fingers of the two hands, and its outline and irregularities will be ascertained with as much nicety as if it were outside the body." In thin subjects the re- sults here enumerated can be attained; but in fat or very mus- cular women we sometimes fail in our efforts to feel the uterus at all through the abdominal parietes. Still, even with these exceptions, the bimanual method of examination is often of great value. 1 have already told you, that in order to arrive at an accu- rate diagnosis, it is generally necessary to make a digital ex- amination of the condition of the uterus and vagina, and to use both the speculum and the uterine sound. But in many cases the latter two modes are not only unnecessary, but posi- tively forbidden. Thus, if on introducing the finger into the vagina, you can detect cancer of the os uteri, the introduction of the speculum becomes unnecessary, and may be injurious, while the use of the sound is altogether prohibited ; or if, on using the speculum, we find the os and cervix uteri in a state of ulceration, the symptoms the patient is suffering from will probably be accounted for, and the introduction of the sound into the uterine cavity is uncalled for, and should therefore be avoided. So your examination in all cases is to be progressive, the finger always being used in the first instance. Any depar- ture from this course I deprecate strongly. 30 DISEASES OF WOMEN. Further, in a certain number of cases it is necessary to in- troduce the index finger into the rectum, in order to decide certain points which your previous examination failed in deter- mining. Thus, with the finger in the rectum and the sound in the uterus, you can ascertain whether a tumor lying in the posterior cul de sac is attached to the uterus or not. In like manner, the sound being introduced into the bladder and the finger in the rectum, the absence of the uterus may be detected, or an inverted uterus distinguished from a polypus. I have now, gentlemen, described very briefly the mode in which you are to investigate cases of supposed uterine disease. But without a knowledge of what is thus to be learned, the examination itself will be useless. In my future lectures, I will call attention to the symptoms of, and the mode of treatment adapted to, the various forms of uterine disease, as suitable cases for their illustration may from time to time jjresent themselves. LECTURE II. Leucorrikea—Definition op—Characteristics of—Sources op— Vaginal—Cervical—Uterine—Vaginitis—Causes of—Treat- ment—ClitoridectomY—Vaginismus. It is a matter of much regret that the nomenclature of the diseases peculiar to women is so vague and indefinite; terms which in reality only express a symptom, the result of very various pathological conditions, being commonly used as indic- ative of a special disease. Thus we hear it said that a patient is suflering from "leucorrheea," or it maybe from " nienor- rhagia," while in point of fact these terms should only convey the idea of a prominent symptom. To-day I propose to call your attention to the subject of leucorrheea; a word which literally means a white discharge, and for which the popular svnonvm is " the whites." It is a symptom met in connection with affections diflering widely the one from the other, while the discharge itself varies greatly in color, in consistence, and even in chemical properties. It is so essential that you should bear in mind that although, as I have stated, leucorrheea means a white discharge, the term is to be understood in a relative sense as opposed to a red sanguineous one, and that it includes all non-haemorrhagic vaginal discharges. Thus very frequently it is of a light cream color, sometimes of a yellow, or again of a greenish tinge. In its natural healthy condition, the vagina, while moist, should not secrete any appreciable discharge; but hardly any 32 DISEASES OF WOMEN. departure from a perfectly healthy state of either the vagina or uterus ever takes place without leucorrheea in some of its forms being present. You cannot have failed to remark, gentlemen, the extreme frequency of this symptom among the patients who have presented themselves here, and yet you have seen that the affections from which they have suffered were various. But before reminding you of the different abnormal conditions on which, as I have from time to time pointed out, these dis- charges depend, I must briefly enumerate the main character- istics they present, and the sources from which they proceed. As already mentioned, the term leucorrheea includes a great variety of non-hsemorrhagic discharges. It very commonly presents itself as a profuse mucous discharge, inordorous and light in color, or again as a thick creamy fluid, coating the whole surface of the vagina, and flowing into the speculum as you introduce it; then you have seen it so evidently purulent that, as I have pointed out, it was impossible to say whether it was the result of gonorrhceal infection or not; in other pa- tients it presented a curdled appearance, or lastly, was seen as a thick, tenacious, glairy secretion, issuing from and filling up the os uteri. Now it is quite evident that these various forms of leucorrheea must not only depend on different causes, but must also be secreted by different jiarts of the genital canal. Accordingly, we find vaginal leucorrheea, cervical leucorrheea, and uterine leucorrheea, to exist as three distinct affections. The discharge, when proceeding from the vagina, is gener- ally a light-colored creamy-looking fluid, unless acute vaginitis be present, when it may become almost purulent • it is some- times secreted from the whole surface of the vacrina but more frequently, especially in children, proceeds mainly from the vulvo-vaginal glands. Again, in some forms of erosion of the cervix uteri, the discharge is profuse and semi-purulent. That poured out by the cervical glands is very different in character • LEUCORRHCEA. 33 the glands situated in this part of the uterus are very numer- ous, and when inflamed secrete a copious, tenacious, albumin- ous fluid, closely resembling in appearance the white of egg ; this discharge is so remarkable and so pathognomonic of dis- ease of the cervical canal, as to be unmistakable. Lastly, you may have leucorrheea proceeding from the interior of the cavity of the uterus itself. The occurrence of this form of leucorrheea is less easily recognizable than any of the others, but of its existence as the results of a special affection I entertain no doubt; it is com- paratively seldom that any discharge other than the glairy mucus secreted by the cervical glands, is seen to issue from the os uteri, but there is ample evidence to show that a copious discharge is, under certain circumstances, poured out from the mucous membrane lining the body of the uterus. This mem- brane at each menstrual period undergoes a great change, fitting it for the reception of the impregnated ovum, should such reach it—a change aptly termed by Dr. Aveling* "Nidation" —or, conception failing to occur, a process of degeneration takes place, and it is expelled in minute portions, or sometimes, though rarely, as a perfect sac. This great and frequently re- curring change in its condition predisposes to the occurrence of disease; in addition to which there is also to be taken into consideration the vast alterations which occur in it during pregnancy, and subsequent to delivery or abortion. As a mat- ter of fact we find that the approach of menstruation is in most women ushered in by the appearance of a white, mucous dis- charge, which there can be but little doubt, is mainly secreted by this membrane; therefore that a similar discharge should present itself when it is the seat of disease, is to be expected. The discharge issuing from this source is often not to be dis- * Obstetrical Journal of Great Britain and Ireland, No. XVI, July, 1874. 3 34 DISEASES OF WOMEN. tinguished from that secreted in the vagina, with which it be- comes mingled; but while the latter has an acid, the uterine discharge has an alkaline reaction, and it is the mingling to- gether of these two fluids of opposite reactions that gives rise to the curdled appearance sometimes seen in the vagina. The causes of leucorrheea may be either constitutional or local. Anything which debilitates the constitution is liable to be accompanied by the appearance of a white discharge; thus it is seldom absent when lactation has been unduly prolonged; or if a woman be debilitated by profuse menorrhagia she is nearly certain to be further weakened by the occurrence of leucorrheea in the intervals between the menstrual periods. Again, it is met with in delicate girls, especially those of a leucophlegmatic temperament, in whom there exists a tendency to phthisis, and not infrequently in them it is the precursor, if not the cause, of the lung disease. Dr. Bennet, who for sev- eral years was engaged in practice at Mentone, a favorite resort, as you are aware, for consumptives, remarked that great im- provement frequently took place in the condition of many pa- tients threatened with phthisis in whom leucorrheea existed, on that discharge being checked by appropriate treatment; an observation capable of easy explanation, if we bear in mind how exhausting must be the effect of a profuse discharge so rich in albumen as leucorrheea is. In cases which come under either of the heads I have al- luded to, namely, debility arising from over-lactation, or from the effects of a weakly strumous constitution, our treatment must be twofold; in the first place to endeavor to check the debilitating discharge, and then to invigorate the constitution and improve the general health. With the view of effecting the former, you will order the use of astringent vaginal injec- tions, those of alum or sulphate of zinc are the best, from two VAGINAL LEUCORRHCEA. 35 to four drachms of either salt being dissolved in a quart of tepid water. This quantity should be injected twice a day into the vagina by means of an ordinary syphon syringe, and at the same time you should by change of air, when possible, by the adoption of a generous diet, and by the judicious ad- ministration of tonics, of which the preparations of iron are especially appropriate, endeavor to improve the patient's gen- eral health. But other cases of leucorrheea are met with less amenable to treatment than these—namely, those which de- pend on the existence of visceral disease, such as that of the liver or kidney, cases in which special treatment can do no good, and therefore is to be avoided. It would be tedious and unprofitable, however, for me to enumerate all the constitu- tional causes which predispose to the occurrence of leucorrheea. I may briefly sum up this part of the subject by saying, that any disease which debilitates and enfeebles the health, is likely to be sooner or later accompanied by leucorrheea. But in addition to the cases depending on disease of other organs, or of the system at large, we constantly meet with leucorrheea as a symptom of local disease, and of none more frequently than that of inflammation of the vagina itself, or vaginitis as it is termed. You have seen over and over again examples of this. The mucous membrane lining the vagina, in common with that of all other parts of the body, is liable to inflammation of both an acute and chronic character; the latter, however, is much the more common. AVe have recently had under treat- ment two well-marked instances of acute vaginitis, one in a vouns: woman, J. McC----. She stated that she had been married for four years but had never been pregnant. .She complained of burning pain in the vagina, of pain in the back, and of scalding in making water. On examining her, the entire 36 DISEASES OF WOMEN. length of the vagina was seen to be of a bright scarlet color; it was tender to the touch, the introduction of a small specu- lum, and even of the finger, giving great pain. As the speculum was being introduced, we saw a copious discharge of a greenish-yellow color to pour into it. The mucous membrane covering the os uteri was bright pink, the cervix itself being evidently congested. Now these cases of acute vaginitis are rare, and I always look on them with suspicion; accordingly I questioned this patient closely as to the possibility of her having contracted gonorrhoea; she said it was impossible; but be the cause as it may, we had here to deal with a case of acute inflammation of the mucous membrane of the vagina, and I treated it as I would similar inflammation occurring in any other part of the body. If an oculist meets with a case of acute ophthalmia, h'e endeavors, in the first instance, to arrest the progress of the inflammation by local bloodletting; I advocate the same practice in acute va- ginitis. You may remember that in this case I punctured the cervix freely and encouraged the bleeding, and ordered her saline purgatives, but I did not, in the first instance, make any application to the vagina. Caustics or astringents used at this stage would only have done harm. In the case I am re- ferring to I purged the patient freely, and punctured the cer- vix at intervals of a few days, on each occasion abstracting a good deal of blood, and when the acuteness of the inflamma- tion had subsided, applied to the vagina a solution of nitrate of silver, ten grains to the ounce, and subsequently a stronger one.. At the end of two months this young woman returned, havino- in the interval become pregnant. Now had this woman been in hospital instead of attending as an out-patient, I should in addition to the local abstraction of blood by puncturino- or by leeches and the exhibition of purgatives, have prescribed warm SUBACUTE VAGINITIS. 37 hip-baths, or directed hot-water* vaginal injections, to be used at least twice daily, which would not only have expedited the (aire, but also have alleviated the woman's sufferings, and these are the means I recommend you to adopt in your future practice. The foregoing case afforded a good example of the difficulty of deciding between simple acute inflammation of the vagina and that depending on gonorrheeal infection. I must avow that I know of no means of distinguishing with any cer- tainty between the two. Another mode of treatment, of the greatest value, is by the application of glycerin. A roll of cotton-wool, or of wadding, with a strong thread attached to facilitate removal, is to be saturated with glycerin ; this is to be then introduced into the vagina through a speculum, and left in situ for twenty-four hours. The glycerin, by its affinity for water, produces a copious serous discharge which, in a marked degree relieves the congestion that exists. In a future lecture, however, I will refer at greater length to the local use of glycerin in uterine affections.f I have already said that cases of acute vaginitis are of in- frequent occurrence; but, though acute vaginitis is not very often seen, subacute inflammation of the vagina, accompanied by leucorrheea, is common enough, and is the cause of much suffering. The pruritus, the burning pain in the vagina, the frequent desire to micturate, and the scalding on doing so, though not so severe as in cases such as the one I have just de- tailed, are often constant and most distressing. The causes of * For directions as to the mode of carrying out this treatment, see Lec- ture XVII. f It is occasionally desirable to instruct patients how to carry out this method themselves. For this purpose a vulcanite repositor has been sug- gested by Dr. Clement Godson, which answers the purpose very well. It is made by Arnold & Sons, West Smithfield. 38 DISEASES OF WOMEN. these attacks are various: you meet them sometimes in young healthy women, who generally attribute them to cold, but they are seen more frequently in married women;, in whom, in addi- tion to the causes named, I am inclined sometimes to attribute their occurrence to the .effect of too frequent sexual intercourse, of intercourse occurring too soon after a menstrual period, or before the vagina has regained its normal condition after de- livery. There is one form of subacute vaginitis which gives rise to very distressing symptoms; in it we see apthous-looking patches on various parts of the vagina. I have invariably re- marked that this condition of the vagina is accompanied by most distressing pruritus; not that prurit us does not occur in cases of vaginitis in which these apthse do not exist, for on the contrary, pruritus is a very common accompaniment of every form of vaginitis, but it is most marked, and nearly if not always present in conjunction with them. And here let me impress on you the uselessness of attempting to treat itching about the vulva, without first ascertaining what the condition of the vagina and uterus may be; for you will seldom fail to discover, either that inflammation of the mucous membrane exists, or that the cervix uteri is congested or abraded, and till these be cured, all your efforts to relieve the pruritus perma- nently will fail. If vaginitis alone exist, you will, .with the view of attaining this object, and at the same time of checking the pruritus which it causes, use in the first instance soothing applications and then astringent ones. Of the former none can compare with infusion of tobacco. It should be made by infusing from half a drachm to a drachm of the unmanufac- tured leaf in a pint of boiling water. The infusion thus pre- pared should be injected into the vagina twice a dav. It is necessary, however, to exercise some caution in using it, for if the orifice of the vagina be very narrow, some of the infusion TREATMENT OF VAGINITIS. 39 may be retained in that canal, and nausea and vomiting result from its absorption into the system. An infusion of hops, made by infusing an ounce of hops in a quart of boiling water is another very soothing remedy. It may be employed without the risk of the occurrence of the unpleasant symptoms which occasionally follow the use of the infusion of tobacco; infusion of linseed also forms an excellent and soothing lotion. AVhen the acute symptoms have abated, the addition of borax, in the proportion of a drachm to the pint, adds greatly to the efficacy of either of these infusions, or a solution of borax in tepid water may, if preferred, be employed. Very often, indeed, great good may be effected by injecting the vagina with plain warm water, provided it be done efficiently ; but I must refer to this subject again.* The itching in these cases is sometimes almost intolerable.f To relieve this most distressing symptom, I am in the habit of recommending the patient, after she has syringed or sponged herself with warm water, to place between the labia a piece of lint or pledget of cotton soaked in a lotion composed of car- bolic acid, ten grains; acetate of morphia, eight grains; dilute hydrocyanic acid, two drachms; glycerin, four drachms; and water to four ounces. Sometimes when the vagina is exces- sively tender, medicated pessaries containing acetate of lead or tannin do good; but I do not think that any kind of pessary can be relied on. Dr. Greenhalgh recommends their being made with glycerin and gelatin, and containing whatever medical substance may be desired; such doubtless possess the advantages of not producing the disagreeable greasy discharge, which those made in the ordinary way do. * See Lecture XVII. f It should be borne in mind that pruritus is sometimes a prominent symptom in cases of diabetes. 40 DISEASES OF WOMEN. You will often find that vaginitis is associated with a weakly state of the constitution, and that you are called on to admin- ister tonics; of these the mineral acids seem especially useful. But it does not follow that because you cure the vaginitis the leucorrheea will disappear. Sometimes it continues when all symptoms of inflammation have subsided, and then you can use freely and with great advantage, as injections, solutions of alum, two drachms, or of sulphate of zinc, one drachm to the pint; but often all our efforts fail to check entirely the dis- charge, and it becomes chronic or disappears only after a long interval. Before leaving the subject of vaginitis, let me cau- tion you against pronouncing every little blush of redness that may be seen on the vagina to be inflammatory, or of attribut- ing all the symptoms the patient may complain of to that af- fection. In nearly every case of leucorrheea the discharge is much more profuse immediately after the menstrual period has termi- nated, and occasionally it seems to take the place of the latter, which is then suppressed. In these latter cases the leucorrheea is profuse at the date when menstruation ought to occur, and lessens considerably, or nearly disappears, for a time correspond- ing to the interval between the ordinary periods. This is likely to occur when the patient is debilitated by prolonged lactation, or by the existence of some constitutional disease. A white discharge, accompanied occasionally by a good deal of vascularity and irritation of the orifice of the vagina, is also not unfrequently met with in unhealthy strumous children • and this has sometimes given rise to a suspicion that the child had been injured by an attempt at sexual intercourse. You must exercise great caution in such cases in o-iving an opinion • but, unless strong confirmatory evidence existsa showino- that an attempt at penetration has been made, I would have you slow in encouraging the idea. You may have recently seen an ex- TREATMENT OF VAGINITIS. 41 ample of such a case in the children's ward; the little pa- tient was but six years old. Cleanliness and a nutritious diet, with the exhibition of iron, speedily improved her condition. I also passed a camel's-hair pencil saturated in a solution of nitrate of silver, up the vagina every four days, and she was soon quite well. You must also bear in mind, that irritation about the vulva may be kept up in children by the presence of worms in the rectum. Even in adults the possibility of leu- corrluea depending on irritation existing in the rectum must not be overlooked. Thus among our extern patients you re- cently saw a young woman in whom vaginitis was kept up by the presence of tapeworm. Hitherto I have spoken only with reference to discharges of purely vaginal origin; we have besides, however, not only cervical but uterine leucorrhica. It is also nearly certain that in some forms of disease of the Fallopian tubes, a discharge is secreted which finds its way into the uterus and thence to the vagina, but it is very difficult, if not impossible, to diagnose the existence of Fallopian disease during life. You are all aware of the appearance which cervical leucor- rheea presents, I have called your attention to it so frequently. In its healthy condition the cervix uteri secretes a transparent viscid fluid in sti'-h small quantities as not in general to attract any attention, or be observed when the speculum is introduced; but, when the cervical canal becomes the seat of inflammation, this secretiou becomes not only much more profuse, but also very thick and tenacious, blocking up the os uteri, and hang- ing out of it as a rope of viscid mucus which it is almost im- possible to wipe away. Cervical leucorrheea, or as it is some- times called, "cervical catarrh," is an effectual bar to preg- nancy, in this contrastino: with other forms of leucorrheea which do not necessarily cause sterility. The condition of the cervix giving origin to cervical leucor- 4 42 DISEASES OF WOMEN. rhoea is one very difficult to cure; to do so .you must treat the whole extent of the cervical canal, and this can seldom be ac- complished without applying to its whole length a strong caustic, such as the fuming nitric acid, which I prefer to any other; the application of the solution of nitrate of silver, and even of the solid nitrate itself, will seldom be sufficient. If the case be not of very old standing, the introduction of one of the solid zinc points, as suggested by Dr. Braxton Hicks, often does good. You have seen me apply them several times with success; they cause a good deal of local irritation, and give some pain, but this soon passes off. The chance of this occurring may, however, be much lessened, by placing a roll of cotton saturated with glycerin, in contact with the os uteri, after the zinc point has been introduced. At present, how- ever, I can only glance at the treatment of this most obstinate affection; I shall return to it again, when the subject of dis- ease of the cervix uteri comes before us. I have already stated that leucorrheea may proceed from the interior of the body of the uterus; the diagnosis of this form is less easily made than that of the others. Its presence is gen- erally accompanied by a greater or less amount of pain, which is not necessarily present in either of the other forms. The reason of this is easily understood, for uterine leucorrheea is, I believe, nearly always the result of disease of the lining mem- brane of the womb. AVhen leucorrheea is vicarious with, or, as already stated, takes the place of, the regular menstrual discharge, it probably proceeds from the interior of the uterus. Though I have never been able to verify it by a post-mortem examination, I believe that the thin clear discharge sometimes seen issuing from the os uteri proceeds from the cavity of the uterus. Perhaps the present is the most suitable time I shall find for alluding to a practice, unfortunately of not very rare occur- CERVICAL LEUCORRHCEA. 43 rence, which, while, it destroys the health of the body, if per- sisted in, impairs in no less degree the powers of the mind, and which is nearly always accompanied by leucorrheea—I allude to masturbation. I do not believe all I have heard as to its great frequency, but that it is practiced by many females is too true. In some, I have no doubt, it has been the result of uterine disease, the habit having been contracted accidentally in the first instance, in the efforts to procure alleviation from the irritation which so often exists about the orifice of the vagina; but, be the cause what it may, it is soon accompanied by vaginitis and endo-cervicitis, manifested by the presence of the well-known, glairy, cervical discharge. Beware, howr- ever, of charging a patient with being addicted to this degrad- ing habit, because suspicious symptoms present themselves; the dilated pupil, the downcast look, the uncontrollable excite- ment which a vaginal examination causes, generally tell the tale; added to this, there is often a severe lancinating pain complained of immediately over the pubes, and in several cases I have noticed that vomiting at night has been a prominent symptom. The habit if carried to any extent also gives rise to vaginitis and even to endo-metritis of an obstinate form, as well as to serious constitutional symptoms, of which menor- rhagia is probably the most common. These distressing cases can be cured by moral means alone; local treatment is useless, and generally injurious, for it attracts the patient's attention to the genital organs, the very thing we should be most anxious to avoid. The administration of bromide of potassium in thirty grain doses is, however, sometimes beneficial. I cannot find words sufficiently strong to condemn, as I wrould, the bar- barous habit of mutilating the patient by the removal of the clitoris. This operation is as useless as it is disgusting; for there is no truth in the idea that in the clitoris alone is seated the nervous expansion which subserves the sexual orgasm. 44 DISEASES OF WOMEN. There is a condition of the vagina, or, to speak more cor- rectly, of the orifice of the vagina, to which the term vaginis- mus is applied, the result apparently of some irritation of the nerves supplying the sphincter, or constrictor vaginse muscle, and which sometimes causes much distress. Any attempt at sexual intercourse, even at introduction of the finger, produc- ing spasmodic closure of the canal. In some cases this condi- tion is evidently the result of inflammation, and can only be relieved by the use of soothing applications, such as those al- ready recommended in cases of ordinary vaginitis. In addi- tion to these means, Dr. Barnes recommends that the patient should wear a cylindrical vaginal pessary made of india-rubber, which is to be inflated with air after its introduction; this acts beneficially by keeping apart the irritable and inflamed walls of the vagina, and moreover, according to Dr. Barnes, by the " mechanical support it affords to the vaginal walls, subdues the morbid contractility of the muscular tissue." In other cases, however, no inflammation exists, except it may have been produced by attempts to forcibly overcome the spasm. Dr. Marion Sims is of opinion, that under such circum- stances the hymen itself is the seat of the excessive irritability, and he has succeeded in perfectly curing several patients by dissecting out the hymeneal membrane, and afterwards dilat- ing the vagina by means of glass dilators (Uterine Surgery, page 335). Vaginismus, in an aggravated form, is not of fre- quent occurrence, but cases exhibiting minor degrees of spasm are met with in practice from time to time. But you must be careful not to confound vaginismus with those not uncommon cases in which sexual intercourse is simply painful, a condition termed by Dr. Barnes " Dyspareunia." This condition, in the majority of cases, depends on inflamma- tion of the vagina or cervix uteri, but occasionally its causes MUCOUS TUMORS. 45 are obscure, and baffle, or for a long time resist, our efforts to effect a cure. I may here allude to a trifling, though very troublesome affection, not unfrequently met with in females, and which is often accompanied by a leucorrhoeal discharge, namely, trie occurrence of little vascular mucous tumors, growing round the orifice of the urethra. These frequently give rise to consider- able irritation, and even actual pain, the passage of the urine over their surface sometimes causing much suffering. Their removal sometimes gives trouble. Caustics generally fail, while considerable bleeding has followed attempts to extirpate them. The late Dr. Beatty was in the habit of passing a liga- ture of fine iron or silver wire round them with AVilde's snare for aural polypi and twisting them off; but the means most likely to be followed by permanent cure, wrill be found to con- sist in cauterizing them freely by means of the galvanic or thermo-cautery. LECTURE III. Menstruation—Amenorrhea—Causes of—Local and Constitu- tional—Treatment of Various Forms—Use of Galvanic Stem Pessary—Medical Agents. By menstruation, as you are aware, is understood that pe- riodic sanguineous discharge which occurs in the human female at regular intervals of about four weeks. Its first appearance in the majority of girls takes place in their fourteenth or fif- teenth year, but it may be, and frequently is, deferred to a much later period without the health being impaired. The discharge itself is blood mixed with mucus, and with shreds of the mu- cous membrane lining the body of the uterus. The blood pro- ceeds from the uterus, as has been proved beyond all possi- bility of doubt; for, in cases of inversion of the uterus, the blood has in several instances been seen to flow from the everted surface; but, although the discharge proceeds from the uterus, the function depends on the ovaries, both for the stimu- lus necessary for its first appearance, subsequent regular re- currence, and due performance. These organs, as you have learned elsewhere, become congested as the period approaches, and finally extrude the mature ovum, while the uterus, par- ticipating in the same condition, assumes a state of activity; the membrane which lines its cavity becomes thickened and affords a favorable nidus to the ovum should it be fecundated • or that failing to occur, it becomes disintegrated and is cast off with an escape of blood in a sufficient quantity to relieve the MENSTRUATION. 47 congestion which has temporarily existed. The most careless observer must see how slight a cause may disturb the equilib- rium which nature designs to be maintained during the per- formance of this nicely-adjusted function, and how a chill or other suddenly acting cause, by checking the menstrual dis- charge, may lay the seeds of uterine disease. As already stated, the majority of females commence to menstruate during their fourteenth or fifteenth year; in many, however, the discharge does not show itself till a much later age. The interval which elapses between each period varies a good deal in different women; it should not, however, be less than twenty-one, or exceed twenty-eight days; the duration of the period, too, varies much; in some extending over but two or three, in others continuing for six or seven days; if these limits be exceeded menstruation cannot be looked upon as being strictly normal, though instances are met with in which a considerable departure from the foregoing standard occurs, and yet the health in no way suffers. The reproductive powers of the female cease with the cessation of menstruation, which occurs at a date even more irregular than does the first appear- ance of the flow, and this period, termed by some "the change of life," by others the " climacteric period," is a time marked by a special tendency to the development of disease. The departures from normal healthy menstruation are nu- merous. Menstruation may be scanty or profuse; it may occur only after long intervals, or return after the lapse of but a few days; it may be painful, or, finally, not appear at all. The latter condition is probably the rarest. Amenorrhcea, taken in the limited sense of total absence or suppression of menstruation (the suppression of menstruation during preg- nancy being of course excluded), is not by any means so fre- quently met with, as are the other forms of derangement of the menstrual function; but, if taken in the more extended 48 DISEASES OF WOMEN. sense of greatly diminished menstruation, it comes commonly enough under our notice, and it is in this latter sense that we must consider the subject. Cases of amenorrhcea naturally divide themselves into two classes, namely, those in which menstruation has never oc- curred, or, if at all, in a very imperfect manner; and those in which the function once normally performed, now appears ir- regularly and with a scanty flow, or has ceased entirely. Each of these, again, must be subdivided into two other classes, as the amenorrhcea depends on local or constitutional causes. It is self-evident that for the due appearance of the discharge, no less than for its regular return, both the ovaries and the uterus must be in a normal state; for, though poured out from the inner surface of the latter, the stimulus essential to produce menstruation must proceed from the ovaries. If, therefore, the ovaries be absent, diseased, or imperfectly developed, or if the uterus be wanting or rudimentary, the discharge will not appear at all, or at best, as a mere sign. There is generally much difficulty in deciding whether the ovaries are at fault or not; if the patient be well formed, if the breasts have become full and round, and if, in addition, the symptoms known as the " menstrual molimina " show themselves, we may conclude that it is not from any fault in the ovaries that the non-appear- ance of the discharge depends. These symptoms, in addition to numerous vague nervous sensations, consist of pain in and ful- ness of the mamma?, which sometimes become swollen and hard • of pain in the ovarian region; weary aching across the loins and down the thighs; of flushings and headaches, and some- times of nausea. If all these symptoms be wanting there is strong reason to suspect that the absence of menstruation de- pends on some abnormal condition of the ovaries • but what that condition may be, can seldom be known during life. In the majority of cases in which the absence of the men- AMENORRHEA. 49 strual molimina leads us to suspect that the ovaries are absent or defective, the patient's general contour is imperfect and the stature stunted; but this is not by any means necessarily so. There is a woman at present attending our out-patient depart- ment, whose ease I called your attention to the other day. She is well-formed, aged about thirty, and has been married for about four years. Menstruation occurs, she tells you, only at intervals of three months or upwards, and she adds, that until after marriage she menstruated altogether but some half-dozen times, at intervals of at least twelve months. Sexual inter- course in her case has evidently acted as an ovarian stimulus, inducing the flow to appear after shorter intervals and in in- creased quantities; she has never been pregnant. I am of the opinion that in this case the ovaries, although present, are in a state of imperfect development. I should add that the vagina and uterus are in all respects normal. Again, the uterus may be entirely wanting or only in a rudi- mentary condition. No case in which the uterus was altogether wanting has presented itself at this hospital since my connec- tion with it, but I must nevertheless refer to the subject. Cases occur in which all the symptoms constituting the menstrual molimina are present, and in which consequently we may fairly conclude that the ovaries are normal, and yet menstruation does not follow. In some of these the uterus has been proved to be entirely absent. The diagnosis on this point is not diffi- cult to make, for if a silver catheter be introduced into the bladder and the finger into the rectum, the presence or absence of the uterus can be determined with certainty. But though cases in which the uterus is altogether wanting are rare, instances of an imperfect or rudimentary condition of the orted " menstrua- tion, I have noticed several times in connection with chronic endometritis and thickening of the cervix. A very good ex- ample of this is afforded in the case of a patient at present under treatment in the pay ward. She is a nurse-tender, and was admitted complaining of severe pain in back and thi«-h AMENORRHCEA. 57 which incapacitated her from following her occupation; there is some erosion of the lips of the os; the uterus is heavy and anteverted, and the cervix greatly thickened. Unless in her case we can cure this condition of the uterus, menstruation will not again follow its normal course. ('ases of amenorrhcea depending upon constitutional causes are of more frequent occurrence than those of local origin. A"ou must all be aware that suppression of menstruation, or its appearance as a mere sign, is often an early and ominous symptom in cases of incipient phthisis, and frequently it is the symptom for which we are consulted. Let me here repeat the warning I have so often given you, when such cases have presented themselves, not to yield to the solicitations of the patient, or of her friends, to attempt to restore the function by the exhibition of stimulating emmenagogues; the attempt would be vain and the result disastrous both to your character and to the patient's health. Females almost invariably look on suppression of menstruation as the cause of their ill-health, and will express day after day the certainty they feel that health would be restored if the discharge could be made to re- appear, an assertion often true if only read conversely ; the reappearance of the discharge indicating that health had im- proved, but not being the cause of that improvement. Thus some women menstruate regularly when resident in certain lo- calities, but never when compelled to leave them. I saw some time since a lady who was quite regular during a two years' residence at Falmouth, though for a long time previous to her going there menstruation had been entirely suppressed. Busi- ness matters compelled her to revisit Ireland, the amenorrhcea soon became habitual; symptoms of phthisis rapidly devel- oped themselves, and she died in a few months of consump- tion. Need I add that in such • cases the lung disease, not the amenorrhcea, is the condition calling for treatment. 5 58 DISEASES OF WOMEN. All other forms of organic diseases come under the same category, as being frequently the causes of amenorrhcea ; but it is not my province to enter on the treatment of these, and the enumeration of them would be tedious. One constitu- tional disease, however, of which amenorrhcea is a prominent symptom, calls for special notice; I mean ansemia, including under that term chlorosis. In it, as you are aware, the patient presents a sickly yellowish-green color. She complains of pain in the back, of lassitude, and often of headache; nearly always the appetite is bad and the taste depraved ; the bowels are con- stipated, and the tongue generally furred. These cases are un- fortunately too common among our town population, especially among those poor women who work hour after hour from early morning till late at night, earning a miserable pittance with the needle. With them we can do but little; country air and a generous diet would soon work wonders for them, but the remedy is beyond their reach. In many, however, some good can be effected by the exhibition of tonics, and es- pecially of iron, a remedy which above all others is here indi- cated. As constipation is nearly always present, you should combine aloes with it; this greatly enhances its activity; two grains of the sulphate of iron, Avith a quarter or half a grain of extract of aloes, three times a day, sometimes acts like a charm. Another medicine of the highest value is strychnia; five drops of the liquor strychnia, which is equivalent to the one-' twenty-fourth of a grain of the alkaloid, gradually increased to ten drops, three times a day, alone or in combination with the tincture of the perchloride of iron, sometimes produces the most beneficial results; but I think it is more suitable to those cases in which simple debility rather than a chlorotic condition is present. Strychnia, I believe, acts as a powerful stimulus to the ovaries, as Avell as a general tonic. AMENORRHCEA. 59 When no anaemia is present, and Avhere the indication seems to be rather to stimulate the ovaries and uterus, I have found the combination of five drops of the tincture of iodine and five of the solution of strychnia, productive of much benefit. I shall allude to but one other constitutional cause of amen- orrhcea. It is one of not very infrequent occurrence. I mean a plethoric condition of the system. In such Avomen the com- plexion is high, the pulse strong; they suffer much from flush- ing and headache, especially at the time menstruation ought to occur. In such cases active outdoor exercise, a moderately ab- stemious diet, and the exhibition of the acid saline purgative already recommended in cases of local congestion, Avill gener- ally produce good results. We should aim at establishing periodicity, and selecting the time in each month Avhen the oc- currence of the molimina indicate that menstruation ought to occur, apply two or three leeches to the inside of the thighs or to the Arerv \rerge of the anus, thus relieving the local conges- tion, and thereby favoring the chance of the natural Aoav ap- pearing ; or, if the patient be married, puncture the cervix and abstract the blood directly from the uterus itself. LECTURE IV. Dysmenorrhea—Definition — Membrane thrown off during— Spasmodic—Inflammatory—Cause of Pain in—Typical Case of—Treatment of—Mechanical—Surgical. Intimately connected Avith the subject of amenorrhcea, is that of painful menstruation, or dysmenorrheea, as it is termed; a subject the pathology of Avhich is still far from being clearly understood. Menstruation, like all the other functions of the body, to be perfectly normal should be painless; but in point of fact, the majority of Avomen suffer more or less pain and discomfort be- fore the appearance of, or during the flow, Avhile in many the sufferings are very severe. In dysmenorrheea, as a general rule, the pain commences about tAventy-four hours before the discharge appears, increasing in severity as the period ap- proaches, sometimes becoming so intense that the patient cannot move about, but is compelled to lie down, and even to roll in agony on the bed; occasionally, too, nausea and even vomit- ing, occur. In due time the discharge appears, and then in many instances relief is obtained; sometimes, however, the pain lasts during the Avhole period, or becomes paroxysmal; again, not very unfrequently clots, and sometimes shreds, are ex- pelled per vaginam, and instances are recorded in which large pieces of membrane, and even a perfect cast of the entire cavity of the uterus, have thus come aAvay during attacks of painful menstruation. This dysmenorrhceal membrane is an DYSAIEXORRHCEA. 61 exfoliation of the mucous membrane lining the cavity of the uterus, Avhich is cast off as a perfect sac, instead of being de- tached in shreds. Its expulsion has on some occasions given rise to the suspicion of pregnancy ; a suspicion Avhich a care- ful examination of the bag will speedily dissipate, as of course all trace of an ovum Avill be Avanting. J Authors differ greatly as to the nature of the causes produc- ing painful menstruation; no theory has of late years been so prominently brought forward, or so Avarmly advocated as the mechanical one. Mechanical dysmenorrheea, and obstructive dysmenorrheea, are terms you aa ill hear constantly made use of. Noav, Avhile admitting that mechanical obstruction to the exit of the menstrual discharge occurs, I doubt that it is as frequently a cause of painful menstruation as is generally stated; nor can I admit the correctness of the axiom laid down by Dr. Marion Sims, " that there can be no dysmenorrheea properly speaking, unless there be some mechanical obstacle to the egress of the flow, at some point between the os internum and the os externum, or throughout the Avhole cervical canal."* Such an unqualified assertion made by a Avriter of such ac- knowledged Aveight, is calculated to produce much mischief, by inducing surgeons to have recourse to operative interference for the relief of dysmennorhoea, which in many cases may be wholly unnecessary. For practical purposes I think it sufficient to class cases of dysmenorrheea under four heads, namely : 1st. Spasmodic; 2d. Ovarian; 3d. Inflammatory; and 4th. Mechanical dysmen- orrheea. In spasmodic dysmenorrheea the pain, as in most of the other forms, precedes the appearance of the discharge. In the ma- jority of cases it is met with, either in delicate girls of feeble * Uterine Surgery, p. 143. 62 diseases of women. constitution and leucophlegmatic temperament, or, again, in women of full habit, especially if they lead an inactive life. I have pointed out to you from time to time, numerous exam- ples of this form of painful menstruation in seamstresses, and in poorly-fed overAvorked servants. In these cases the flow is in general scanty, and its appearance does not bring any marked relief, the pain continuing more or less during the whole of the period; it is not, hoAvever, always equally severe, but is paroxysmal, being less so Avhile the patient is Avarm, but becoming aggraATated by the least exposure to cold. This form of dysmenorrheea is by some Avriters described as neural- gic ; its true nature, however, is very obscure, but its attacks can almost Avith certainty be cut short by the administration of sedatiATes and antispasmodics; and these are the remedies you should prescribe. I generally give a pill containing half a grain of opium, one of Indian hemp, and two of camphor, at bedtime—a combination Avhich seldom fails to give at least temporary relief; or if for any reason opium is objectionable, I substitute for it two grains of the extract of conium. In some cases the hypodermic injection of a solution of morphia and atropia* affords relief, Avhen opium administered by the mouth or by the rectum has failed. When the attacks have become habitual, and the patient is consequently obliged to have recourse regularly to the use of medicines to obtain relief, I usually direct her to have by her, a mixture containing two drachms of tincture of Indian hemp, two drachms of the liquor opii sedativus, tAvo drachms of the compound tincture of chloroform, and water sufficient to make * The following is the formula I use in such cases : Acetate of morphia, four grains; solution of atropia, four drops; water, two drachms—ten drops of this contain one-third of a grain of morphia, the largest dose which should be administered on the first occasion. It is safer to inject a small quantity at first, and repeat the dose if necessary. ovarian dysmenorrhea. 63 a six-ounce mixture; of this she should take a tablespoonful every two hours. Sometimes five grains of lupulin, taken in the form of a pill, thrice a day, from the time the first symp- tom of the approaching paroxysm is perceived, will staA'e off the attack altogether. The patient should also take a warm hip-bath even- night at bedtime for a week before the ex- pected recurrence of the menstrual period, and if preA'ented by the pain from sleeping, have a full dose of the hydrate of chloral. This treatment is, however, only palliative, and as the cause generally lies in some fault of the constitution, or system at large, our object should be to correct that condition by treatment carried out during the interval betAveen the men- strual periods. If you can detect symptoms of imperfect di- gestion, their removal is sometimes followed by relief of the dysmenorrheea ; while if the patient be anaemic, the exhibition of iron, or sometimes of arsenic, is of the greatest use. I am convinced, however, that many cases of spasmodic dysmenor- rhea are due to congestion of the lining membrane of the uterus, and that this is specially the case in Avomen of full habit, who lead indolent lives, and in Avhom great benefit fol- lows from the adoption of more abstemious diet, and more ac- tive habits, together with occasional use of saline purgatives. In OA'arian dysmenorrhea, the ovaries are engaged more than the uterus, though the latter organ frequently participates in the abnormal congestion. In it, the paroxysm is preceded by pain in the ovarian regions, and by a feeling of tension, often amounting to acute pain, in the mammae, and sometimes by headache. The attacks may sometimes be averted by the use of saline purgatives taken immediately before their antici- pated return ; if the case be of any standing, the administra- tion of the bromide of potassium or of ammonium, in twenty to thirty grain do,-es, three times a day for a week before, each menstrual period, together Avith warm hip-baths at bedtime 64 diseases of women. should be had recourse to. This treatment, or that of a simi- lar character, directed to relieve or prevent the ovarian conges- tion, will generally prove successful. Inflammatory dysmenorrheea is a common affection, and the sufferings due to it are often very acute ; the pain, hoAvever, is generally, although not always, relieved by the appearance of the menstrual flow; a fact capable of easy explanation, for the loss of blood relieves the congestion Avhich exists, just as it Avould a similar condition in any other part of the body. In this form, the uterus, or at least its lining membrane, is in a state of chronic inflammation ; sometimes also there is asso- ciated Avith it an unhealthy condition of the cervical canal; sexual intercourse is often painful in consequence of extreme sensibility of the cer\Tix, a not uncommon result of chronic in- flammation of that part of the Avomb. In the spasmodic form of dysmenorrheea the pain is nearly always referred to the back, or to the lower portion of the abdomen. In inflamma- tory dysmenorrheea, on the other hand, it is often most intense above the pubes, and is sometimes felt along the edge of the false ribs, generally on the left side, shooting up to the shoulder, and doAvn to the ovary on that side. Noav to Avhat is all this suffering due? Are Ave to believe, as is held by many, that it is caused by retention of the men- strual discharge and consequent distension of the uterus by fluid ? a result supposed to be due to the closure of the os in- ternum by the swelling of the mucous membrane, which oc- curs in consequence of the venous congestion always present at the commencement of each menstrual period. That this may be a cause of painful menstruation I admit, but that it is a very frequent one I much doubt, The history of the following case is very instructive, and bears on the point under consideration. The patient, a lady, aged twenty-eight, who had borne five children, the youngest but fifteen months old, came under my INFLAAIMATORY DYSMENORRHCEA. 65 care some time ago; her suffering dated back several years, during which time she had been twice confined. For two or three days before the menstrual period, Avhich always recurred regularly, she suffered from pain over the uterus, shooting up under the left breast and round to the back. This Avas very severe during the first day of the flow, then it gradually sub- sided, and she enjoyed comparative ease for a time. Sexual intercourse had been for a long time attended with pain. She did not complain of the introduction of the finger into the va- gina, but the moment it touched the cer\rix, she cried out, stat- ing, however, that the pain this caused Avas quite different from that experienced at the menstrual period. The sound passed Avith the greatest facility through the os internum, but though there was no obstruction to its passage, the moment it reached that point, she suffered the greatest agony, and while pre\Tious to the examination she had been free from discomfort, she, at this instant, experienced a severe paroxysm of pain, similar to that from which she suffered so much during the menstrual period. Now this case throws some light on at least one variety of inflammatory dysmenorrheea. Xo obstruction existed here, yet menstruation Avas excessiATely painful, and paroxysms of pain, exactly similar to that suffered during menstruation, Averts caused by the passage of the sound through the os inter- num. I believe that this patient Avas the subject of chronic endometritis; that the loAver portion of the cavity and the os internum Avas specially engaged; that Avhen the uterus became congested, as it does at each monthly period, this inflammatory condition being necessarily aggraA^ated, caused the acute pain from Avhich she suffered, and that this was relieved, Avhen the flow set in, as other congestions are relieved, by local deple- tion. I think further, that the sufferings experienced by many women at each catamenial period are not mechanical, but are due to congestion of the portion of the lining membrane of the 6 66 DISEASES OF WOMEN. uterus indicated, the congestion occurring at the menstrual period, rendering acutely sensitive a part Avhich, though in an unhealthy state, Avas not before the seat of pain. It is quite possible, and indeed very probable, that the swelling and thick- ening of the mucous membrane, which takes place Avhen this congestion occurs, may in numerous cases be sufficient to close the os internum, and thus actually oppose a mechanical obstruc- tion to the exit of the menstrual discharge ; but I cannot concur in the commonly held idea, that it is the general cause of painful menstruation, or agree Avith Dr. Marion Sims, who says " that if there be much pain either preceding its eruption or during the flow, there Avill generally be a physical condition to account for it, and this will be of a nature to obstruct mechanically the egress of the fluid from the caA^ity of the Avomb. The obstruc- tion may be the result of inflammation and attendant tumes- cence of the cervical mucous membrane, Avhereby this canal be- comes narroAved merely by the tumefaction of its lining coat; but by far the most frequent cause of obstruction is purely anatomical and mechanical." Noav in the case I have just alluded to, the canal of the cervix Avas so patulous that I do not think it possible the lin- ing membrane could SAvell to such an extent as to close the passage; and if the patient's sufferings were in this case due to mechanical causes, Avhy should the passage of the sound repro- duce so exactly the pain of the menstrual period? In my opinion it Avas caused by the os internum being in an unhealthy condition, and that therefore anything Avhich increased the ex- isting irritation, whether that were the passage of the sound, or the congestion consequent on the approach of' the menstrual period, equally caused pain; in fine, Avhile admitting the mechanical theory as serving to explain the symptoms pre- sented in a certain proportion of cases of dysmenorrheea I deny that it does so in the majority. INFLAMMATORY DYSMENORRHCEA. 67 The occurrence of congestion and inflammation causing dys- menorrhea is of course Avell known, and in the foregoing re- marks I merely desire to point out that in my opinion the seat of pain is in such cases at, or immediately beyond, the junc- tion of the body Avith the cer\ux uteri; that the cause of the pain in many instances is endometritis, and that it is not neces- sarily due to any actual obstruction to the exit of the menstrual discharge. I may add that in the case just alluded to, local depletion and the subsequent application of the fuming nitric acid perfectly cured the dysmenorrheea. The treatment of inflammatory dysmenorrheea includes three indications. 1st. Removal of all causes keeping up the existing irrita- tion. Foremost among these is the abstinence from sexual in- tercourse; for not only does the act itself generally cause pain, and therefore must be injurious, but the occurrence of concep- tion is to be specially avoided, for till the patient is cured, abortion is A'ery liable to occur, to be folloAved by aggraATation of her symptoms. Riding on horseback, fatiguing Avalks, or even household occupations Avhich necessitate much standing, should be giAren up, Avhile the occurrence of constipation is to be carefully guarded against. 2d. Relief of the uterine congestion. By local depletion, either by means of leeches applied before the menstrual period, or by puncturing the cervix uteri and encouraging the bleed- ing—this latter treatment you have seen me carry out re- peatedly Avith considerable benefit. It is not suitable in the cases of young unmarried girls, as it necessitates the use of the speculum. In them leeches should be applied to the inside of the thighs, or to the A-crge of the anus, but in married women to the cervix uteri itself; mild purgatives should also be ad- ministered from time to time. When by these means you have succeeded in relieving the congestion of the uterus, considerable 68 DISEASES OF WOMEN. benefit will be derived from blisters applied over the sacrum, or to the abdomen a little above the pubes. 3d. Excitement of healthy action in the uterine mucous membrane. If the case be of long standing, and that the symptoms though relieved, do not entirely disappear, shoAving that a certain amount of endometritis still exists, I recommend you to cauterize the cervical canal, and sometimes even the whole interior of the uterus, with carbolic acid, or, in many cases, better still, Avith strong nitric acid. I shall on a future occasion explain to you the mode of carrying out this safe, and indeed painless treatment.* I have met Avith but little benefit from the exhibition of medicines in inflammatory dysmenorrheea. Where ovarian excitement exists, bromide of potassium, in tAventy or thirty grain doses, three times a day, does good; the bichloride of j mercury in small doses, and continued for a considerable time, i has been recommended by several writers; for myself I must say it has disappointed my expectations. Purgatives, espe- cially the saline, seem to me the only medicines capable of pro- i ducing real benefit; these, to do good, should be exhibited just before the menstrual period. It remains for us to consider those forms of dysmenorrheea which depend on mechanical causes. Of these there are three A'arieties, namely, those in which the cervical canal is so flexed as to obstruct the escape of the menstrual discharge; secondly, those in Avhich inflammation or congestion of the lining mem- brane exists to such an extent, as to cause temporary inclosure of the canal or of the os internum ; and thirdly, those in Avhom from some congenital malformation or acquired cause, the os internum or the cervical canal throughout its entire length is permanently narrow and constricted. To this last mav be * See Lecture XVII. MECHANICAL DYSMENORRHCEA. ■ 69 added those cases in Avhich fibrous tumors are met in connec- tion with and often causing dysmenorrheea. Painful, or difficult menstruation, is frequently observed in women in whom the uterus is flexed; but though flexions of the uterus may, and certainly do, interfere Avith the exit of the menstrual flow, they seldom do so unless the flexion be com- plicated by the existence of chronic inflammation, or the pres- ence of a fibroid. In such cases we should certainly endeavTor to relieve the flexion, and see if by replacing the fundus in its normal position, and supporting it there by a pessary, Ave can relieve the patient before having recourse to surgical means. Cases of dysmenorrheea are not unfrequently met Avith in women who, although married, are sterile, and in whom flexions of the uterus exist, menstruation prior to marriage having been a painless function. In the majority of these cases I believe the flexion to have been congenital, and that marriage to them Avas a positive eATil; producing congestion in a malformed organ, and giving rise in turn to a long train of distressing symptoms. In these cases the uterus is generally anteflectcd, and division of the cervix becomes essential to their successful treatment. I have already so fully explained my ATieAvs as to the chief cause of the dysmenorrheea in cases of inflammatory swelling of the lining membrane of the uterus, that I have but to re- peat that, though not in my opinion of frequent occurrence, cases are met with in Avhich the os internum, or some portion of the cervical canal, becomes so narrowed in consequence of the tumefaction of the parts, as to present a mechanical im- pediment to the discharge of the menses. In such cases, if the treatment I have already recommended fail, I haA^e no hesitation in having recourse to surgical measures Avith the vieAv of procuring relief; indeed it is obvious that an opera- tion which divides the cervix, so freely as does that introduced 70 DISEASES OF AVOAIEN. Fig. 6. ;: by Sir James Simpson, must be calculated to give perma- nent relief to the congested organ. I only say again that the operation should not be had recourse to till other means have failed. I may here take the opportunity of saying once for all, that I object to the use of any of the means which have been suggested for the purpose of dilating the cervix in the treatment of dysmenorrheea. Several cases of severe inflammation, and even of death, are recorded as having followed such an attempt. Moreover, this mode of treatment, whether carried out by means of metallic dilators or by sea-tangle bougies, is in other respects also objec- tionable. It is slow, painful, and most uncertain in its results; for the cervix after a time nearly invariably contracts, and the patient relapses into her former unsatisfactory state. Of all the instruments devised for the purpose, Priestly's Dilator (Fig. 6) is probably the best. I have used it in cases in which difficulty occurred in getting a sea-tangle tent through a very narrow os internum; but even then, I only expanded the dilator to a very trifling extent. Now I never employ it. A contracted os, looking almost like a pinhole, and leading up to a narrow cervix uteri, is not unfrequently seen; this condition is almost invariably asso- ciated with sterility, and very often with dysmenorrheea also. You saw last week a very good example of this in the case of the young Avoman who sought relief for the latter affection. Menstruation is with her both painful and scanty ; the os uteri is so small as hardly to admit the point of a probe; and there can be no doubt but that the cervical canal is unduly Dr. Priestly's Dilator. USE OF STEM PESSARY. 71 contracted. I think such cases as hers are fair subjects for operation, for no other treatment will be productive of per- manent benefit; but beware of holding out hopes to your pa- tient, that by submitting to the operation she will gain more than relief from the suffering caused by the dysmenorrheea. When the operation has been performed simply for the cure of sterility, it has in general, as far as my experience goes, re- sulted in disappointment; in other Avords, division of the cervix is in my opinion a legitimate proceeding, if performed with the Ariew of curing dysmenorrheea, but it is seldom justi- fied in cases of simple sterility ; because the narroAV os and contracted cervical canal are not the cause of the sterility, but merely an index of some congenital condition or defect in the uterus itself which hinders conception. What that defective condition may be Ave may not be able to decide. But the patient I haAre just alluded to is averse to under- going any operation, and I have, therefore, introduced a slender and short-stemmed galvanic pessarv. She has Avorn it for three weeks, and it has already been productive of marked benefit; for she tells you, that during the menstrual period which has just passed, she Avas free from pain, and that the flow continued for five instead of two days.* You saAv that I had some difficulty in introducing it, mainly because the uterus is slightly anteflected. I had accordingly to expose the oswith the duck-bill speculum, then to seize and draw doAvn the cervix with a fine hook, and while the Avomb Avas thus fixed, slip in the stem of the pessary. You must ahvays adopt this method when difficulty occurs in the introduction of these instruments. * This patient continued for some time to derive relief from wearing the pessarv, but on removing it all her bad symptoms returned ; therefore, after the lapse of many months, I decided on dividing the cervix. The opera- tion proved successful. 72 DISEASES OF WOMEN. I have knoAvn much good to result in such cases as the fore- going from this simple treatment; it is at least Avorth trying before advising that an operation should be performed. The use of the stem pessary is also sometimes indicated, Avhere painful menstruation exists, with either retroflexion or anteflexion of the uterus; for the stem not only renders the canal patulous, but, by straightening the cervix, favors the escape of the discharge. Unfortunately a certain amount of endometritis commonly exists in such cases, and this frequently preA'ents the stem being tolerated. To meet this difficulty, Dr. Greenhalgh has invented a soft, flexible stem pessary,* made of india-rubber, that can sometimes be worn with comfort when a rigid one could not be borne. But a large percentage of the cases we meet with in prac- tice derive no permanent benefit Avhatever from any form of palliative treatment, nor can any favorable result be antici- pated, because some portion of the cervical canal, either at the os internum, or throughout its entire length, is contracted. In some patients the cervix is conical, and terminates in a A-ery small circular os uteri, " the pinhole " os uteri, as it is termed, the cervical canal being generally much contracted. Dr. Barnes is of opinion, that in such cases the obstruction is mainly due to the small size of the os itself: he consequently rests satisfied with an operation Avhich divides the cer\Tix, but does not di- vide the os internum. I much doubt, hoAve\Ter, if the os in- ternum is eArer of its normal size Avhere the os externum and cervical canal are contracted. Certainly the exceptions to this being the rule must be rare. I, therefore, in all cases, divide the os internum as Avell as the os externum and vaginal por- tion of the cervix. Noav, Avith respect to the operation itself, Ave are indebted * Manufactured by Arnold & Sons, 34 West Smithfield, London. DIVISION OF CERVIX. 73 Fig. 7. for its introduction to Sir J. Simpson, Avho for a time prac- ticed it very extensively, though I believe that before his death his vieAvs on this point were considerably modified, and that he did not perform it nearly so frequently as he had done at an earlier period of his career. His method of performing the operation Avas by passing an instrument termed a bistourie cache" through the canal of the cervix, and within the os in- ternum. It contained but one blade, Avhich, Avhen the instrument had penetrated to the requisite depth, Avas made to protrude, the extent of the protrusion being regulated by a screw. The incision commenced at the os internum, and as the instrument Avas Avith- draAvn it incised gradually and more deeply the substance of the cervix, until it divided the ATaginal portion quite through; the in- strument had then to be turned, re-intro- duced, and the other side diAided in like manner. This re-introduction is very objec- tionable, and consequently various knives (metrotomes) have been invented Avith the view of obviating it. Those proposed by Dr. Savage and Dr. Greenhalgh are both good instruments. I generally use the former (Fig. 7). It is furnished Avith two blades, the cutting edge of each being directed out- wards ; and as the back of each blade, when the instrument is closed, projects beyond the cutting edge of its felloAV, Avhich it thus overlaps, its introduction into the cervix can be safely effected. It is sometimes necessary to dilate the cervical canal a little before this step can be effected; one piece of sea-tangle Dr. Savage's Me- trotome. 74 DISEASES OF AVOMEN. will, however, open the canal sufficiently for the purpose. Hav- ing exposed the os by means of the duck-bill speculum and seized one lip with a hook, so as to steady the uterus, you proceed to introduce the metrotome, taking care fig- s. that it does not pass unnecessarily far into the uterus; the blades are then expanded, laterally, sloAvly, and only to the limited extent previously de- cided on, and which is regulated by means of the screw affixed to the han- dle of the instrument; for if this pre- caution be neglected you will divide the os internum too deeply; a pro- ceeding which may cause alarming haemorrhage, and is nearly certain to be followed subsequently by such great eversion of the lips of the Avomb, as to leave the neck patulous and gaping to an excessive degree. This condi- tion exists in a patient at present un- der my care, who was operated on by Sir J. Simpson many years ago. The metrotome, the blades being kept ex- panded, is now Avithdrawn; I think Kuchenmeister-s Scissors. it better not to divide the vaginal portion of the cervix with them, but to complete this part of the operation subsequently by means of the scissors (Fig. 8). With this object, the longer blade, which terminates in a probe-pointed extremity, is introduced into the cervical canal and through the os internum, the other blade is applied later- ally, to the vaginal portion of the cervix; the part included between them is then to be divided by the closure of the blades. DIVISION OF CERVIX. 75 Fig 10. Fig. 9. When one side of the cervix has been divided the blades have to be turned, and the other side divided in a similar manner. My reasons for completing the operation in the manner described are, that to enable the blades of the metrotome to cut through the vaginal portion of the cervix, they must be expanded to a degree Avhich, without great care, may permit of their in- cising the os internum to a dangerous extent; Avhile even Avhen so expanded, a sufficient division of the lower segment of the cervix is not always made, and, moreover, the risk of hemorrhage occurring is much lessened, if not indeed altogether avoided, by following the method I adopt. Dr. Greenhalgh's metrotome (Fig. 9) is preferred by many. It was, I believe, the first bilaterally cutting metrotome invented, and is very ingeniously constructed. By it the entire operation is completed at once. It is easy of introduction, cuts laterally outwards, and the extent of the incision can be regulated Avith great nicety. Dr. Marion Sims varies the opera- tion by dividing first one, and then the other side, of the vaginal portion of the cervix with a pair of bent, narrow- bladed scissors ; he then presses a nar- roAV-bladed knife through the os inter- num, and cuts from within outwards. The operation of dividing the cervix uteri is not absolutely devoid of danger, and it has, though not in my practice, Blades ex- been foliowed by fatal results. But I panded. J have known very alarming haemorrhage to occur both at the time, and also some hours subsequently. Dr. Green- halgh's Metro- trotome closed. 76 DISEASES OF AVOAIEN. Fig. 11. You should, therefore, be ahvays prepared for this contin- gency, and be provided Avith a solution of the perchloride of iron in glycerin. With this I was formerly in the habit of invariably brushing OArer the divided surface. I have now given up the practice, because I find if the operation be performed in the man- ner I describe, there is little if any risk of haemorrhage; but should haemorrhage occur, a pledget of cotton saturated Avith it should be inserted into the cervix, and the vagina then plugged. The operation itself seldom causes pain, and, if the woman be healthy, the chance of inflammation following is not great; still extreme care should be taken to guard against such occurring, and she should be kept in bed several days. There is often a great tendency in the incisions to unite; to prevent this, Dr. Coglan suggested the insertion of a thin roll of lead; this ansAvers the purpose very Avell. It is sometimes necessary to introduce and leave in the cervix an expanding spring stem, as suggested by Dr. Greenhalgh (Fig. 11). Dr. ££%£*£.. Gra% Hewitt recommends, with the view of preventing contraction, and at the same time of keeping the canal straight, that the patient wear for some time subsequently an ebony stem pessary, a proceeding which in many cases would doubtless be useful. But in general these precautions may be dispensed Avith. I prefer, in the few cases in which I find anything of the kind necessary, to introduce one of Greenhalgh's flexible stem pessaries, but, as a rule, I content myself with passing the uterine sound almost daily for at least tAVO or three Aveeks subsequent to the operation, and at inter- DIVISION OF CERVIX. 77 A'als for some time longer. I find this to be usually sufficient to prevent the divided surfaces from uniting. Although I have Avarned you against-performing the opera- tion of dividing the cervix uteri unnecessarily, I feel equally bound to impress on you the necessity of carrying it out Avhen- ever suitable cases occur in your practice. It is not merely that by doing so you afford your patient the best chance of escaping from constantly recurring pain, although that alone in many cases is a sufficient reason for having recourse to so safe an operation, but, moreover, long-continued dysmenorrheea is likely to produce very graA'e consequences. Sterility, metri- tis, and endometritis terminating in permanent enlargement of the uterus, and perhaps giA'ing rise, in addition to other dis- tressing symptoms, to the occurrence of profuse menorrhagia, may follow, until the patient, Avorn out by long-continued suf- fering, becomes a confirmed invalid, or sinks into a state of morose despondency. Such most likely would have been the result in the case of the young girl, M. W., on Avhom you saAV me recently operate. Her sufferings, for several days at each menstrual period, Avere extreme; she Avould roll on the floor in agony, and this had been the case since the first appearance of the catamenia, three years previously. On examining her I found the cervix uteri to be abnormally small, and appar- ently imperfectly developed. Much difficulty Avas experienced in introducing the sound, so contracted Avas the cervical canal; and indeed it required the exercise of some skill to detect the os uteri, it was so exceedingly small. We found it necessary to dilate the cervical canal in this case, with a tent of sea- tangle, before attempting to introduce the metrotome. The result of the operation has been very satisfactory, for the girl has ever since enjoyed freedom from the excruciating pain she had previously periodically suffered. I should add that I had tried the effect of a stem pessary with her before having re- 78 DISEASES OF WOMEN. course to the operation, but she could not tolerate its pres- ence. I have hitherto spoken of the operation of division of the cervix Avith reference to those cases only in Avhich the cervical canal though contracted is straight. I recommend a different operation when the uterus is anteflected, namely, the division of the posterior Avail of the cervix only. This procedure, in the class of cases now under consideration, is strongly urged by Dr. Marion Sims, of New York, and after an extended trial I unhesitatingly confirm his experience of its being far the most satisfactory in its results. In performing this opera- tion the steps are reversed, the cervix being exposed, and the anterior lip fixed by means of a tenaculum; the probe-pointed blade of Kuchenmeister's scissors (Fig. 8) is introduced into the cervical canal, and the posterior Avail is divided up to the os internum. The os internum is then to be divided to a limited extent, by a knife Avith a very narroAV blade, the parts being kept from healing, as in the other operation, by the daily introduction of the uterine sound. I cannot speak too highly of this operation in cases of endometritis, occurring in nulliparous Avomen in Avhom congenital anteflexion exists, giving rise, as is nearly inA7ariably the case, to dysmenorrheea; but I shall have to recur to this subject when speaking of the treatment of endometritis. LECTURE V. Menorrhagia—Definition—Causes of—Constitutional and Local —SvBINA'OLUTION—TREATMENT OF—UTERINE Po-RTECAUSTIQUE— Plugging Vagina. I propose to-day, gentlemen, to draw your attention to the subject of menorrhagia; one of the greatest importance, both on account of its frequency and of the serious consequences which follow its occurrence. The term " Menorrhagia" strictly speaking, means profuse menstruation; the ordinary menstrual period being prolonged, or the quantity of blood lost during a menstrual period of average duration being in excess of what is normal. In gen- eral both these conditions are present, the period being pro- longed, and the quantity of blood lost being excessive; but we not unfrequently meet Avith cases in Avhich a discharge of blood takes place from the uterus during the interval between the menstrual periods; to such attacks of haemorrhage the term " Metrorrhagia " is by some applied. Let me first of all impress on you that menorrhagia is not a disease ; it is only a symptom of a diseased condition, Avhe- ther it be of the system at large, or of the organs of genera- tion. It is, therefore, incumbent on you, in dealing Avith every case of menorrhagia Avhich may come under your observation, to endeaA'or to determine, before you attempt to treat it, on what that symptom depends. I know of no affection in the treatment of Avhich professional character is so frequently 80 DISEASES OF WOMEN. lost, from Avant of due care in attending to this important point. Thus, within the last feAV days I was consulted by a lady Avho for three years had been the subject of profuse menor- rhagia, during the whole of which period she had been under the care of a surgeon in extensive practice. He had prescribed iron and astringents in various form Avithout benefit, but he never once made, or even suggested, a vaginal examination. I found that the menorrhagia depended on the presence of a large intra-uterine polypus; but the discovery of the cause was in this case made too late. She sank from sheer exhaus- tion, and died before the polypus could be removed; had the diagnosis been made but a few months earlier, a valuable life would have been saAed. Noav the causes on which Menorrhagia may depend are twofold—constitutional and local. I shall speak briefly of the former class first, and subsequently enter at length into the consideration of the latter, as being those Avhich are more immediately Avithin the province of the obstetric physician. The general constitutional causes Avhich predispose to menor- rhagia are not very numerous, nor is their influence very dis- tinctly marked. The folloAving are the most common: (L) Debility arising from any cause, but more especially if the result of prolonged lactation is, I think, the constitutional cause on which menorrhagia most frequently depends. In such cases it often assumes a very aggraA^atel form. Thus a delicate Avoman continues to nurse, although menstruation has reappeared, and the patient, Aveakened by the double drain, rapidly loses health and strength. In such cases, if nursing be given up altogether and tonics be administered, of Avhi.-h strychnia alone or combined Avith iron, is generally the most useful, a rapid improvement in the general health, and a CAUSES OF MENORRHAGIA. 81 marked diminution in the quantity lost at each monthly period, often follows. (2.) Profuse menstruation is seen in young women of full habit but of lymphatic temperament. I haATe met Avith sev- eral well-marked instances of this; in one especially the ten- dency to menorrhagia Avas so great and so difficult to restrain, that on more than one occasion I feared that as a last resource I should be compelled to plug the vagina. This patient was quite a young girl, who looked the picture of health. In her case, the only remedy which seemed to exert any decided in- fluence in cheeking the great loss was the application of Dr. Chapman's hot-Avatcr bags to the spine—a mode of treatment wel 1 Avorthy of a trial. (3.) Again, as age advances and the climacteric period of life approaches, women are liable to menorrhagia, sometimes of a very aggravated character. Not unfrequently some months elapse without the normal discharge appearing, and then it comes on so profusely as to give rise to the suspicion that preg- nancy had existed and had terminated by abortion. The same train of symptoms is not very unfrequently met Avith in re- cently married Avomen; from the non-appearance of the cata- menia at the regular period, they naturally believe themselves pregnant, till after the lapse of some Aveeks, they are undeceived I »y the return of menstruation in an aggravated form; in both eases, the cause is probably the same—namely, temporary con- gestion of the uterus, and probably, of the ovaries. The ad- ministration of mild saline purgatives, and in the former class of cases, if the attacks recur, the exhibition of ergot and strychnia Avill generally check the excessiAre loss, or prevent its recurrence. (4.) Disease of the heart is sometimes attended by menor- rhagia. This e\Tidently depends on congestion, the results of 82 DISEASES OF WOMEN. the retardation of the return of the blood to the right side of the heart, and occasionally the loss of blood in these cases seems to give temporary relief. A good example of menorrhagia de- pending on this cause, Avas seen in the case of a woman, long under observation in this hospital, who for years labored under mitral obstruction, and in Avhom the attacks of profuse men- struation sometimes assumed an alarming aspect. (5.) Analogous in nature to the last-mentioned class, are those cases Avhich depend on chronic hepatic disease, or hepatic congestion. HoAvever, as alluded to in another lecture, hepatic congestion may cause a diminution, rather than an increased floAV, of the menstrual discharge. (6.) Menorrhagia, too, is met in connection Avith that form of renal mischief knoAvn as Bright's disease, due to the blood being in this disease deprived of its albumen, and con- sequently in a condition favorable to exudation through the Avails of the capillaries; but all these affections fall Avithin the province of my colleagues rather than of mine, and I must therefore leave you to learn from them the mode in Avhich menorrhagia depending on these causes should be treated. The local conditions causing profuse menstruation are nu- merous and very important; they are: 1. Subinvolution of the uterus. 2. Granular erosion of the os and cervix uteri. 3. Inflammation and congestion of the membrane lining the cavity of the uterus, and a granular condition of that mem- brane. 4. Retention within the uterus of a portion of the placenta of the foetal membranes. 5. Congestion of the uterus and ovaries. 6. Polypus of the uterus. 7. Fibrous tumors of the uterus. 8. Inversion of the uterus. CAUSES OF MENORRHAGIA. 83 This is a long list, and yet the lesions enumerated in it are all, with the exception of inversion, of frequent occurrence, and all frequently cause menorrhagia. Indeed I think Ave should add cancer to the list. Some authors, no douht, object to can- cer being considered as a cause of profuse menstruation, and in the majority of the cases of this terrible disease, the dis- charge to Avhich it sooner or later gives origin, is not in any Avay connected with menstruation, and therefore to term it menorrhagia is incorrect; but in other cases, especially in those of epithelioma, menstruation is, in the first instance, augmented, and the term is then correctly applied. I think therefore that it is better to speak of cancer as a possible cause of menor- rhagia. I shall noAV proceed to call your attention to each of the foregoing conditions somewhat more in detail. Subinvolution of the uterus is a far more common cause of menorrhagia than is generally supposed; indeed, in married Avomen, or in those avIio haA^e been at any time pregnant, pro- fuse menstruation is probably more frequently dependent on this condition than on any other. When Ave speak of subinvolution of the uterus, we mean that the process by which the Avomb regains its original size subsequently to delivery, or abortion, has been from some cause retarded or arrested; this process has been termed involution, and when it is incomplete Ave talk of the uterus as being in a condition of imperfect involution, or more commonly, of sub- in Arolution. The involution of the uterus should be completed Avithin a few Aveeks after the date of delivery. It is one of the most remarkable phenomena Avhich occur in the human body. The uterus, immediately before the expulsion of the foetus, meas- ures about fourteen inches in length, and weighs tAventy-five ounces, often indeed, even more. Immediately after its size is diminished to considerably less than one-half its former bulk, 84 DISEASES OF WOMEN. its Aveight being proportionally reduced ; Avhile, if the process proceed regularly and unchecked by any cause, the womb will, after the lapse of five or six Aveeks, be less than three inches in length, and Aveigh but tAVO ounces. The first step in this process is, that the supply of blood to the uterus is checked and the circulation of blood through that organ interrupted, by the contraction of the muscular fibres of the uterus, a pro- cess Avhich commences the moment labor terminates, and goes on in a more or less painless manner for some days subse- quently ; Avhile at the same time fatty degeneration and disin- tegration of tissue, on the one hand, and absorption on the other, rapidly complete the Avork of reducing the uterus to its normal size, and restoring its compactness of tissue. But you can easily understand that numerous causes may in- terrupt this process; thus in Aveakly, debilitated Avomen, the uterine contractions may not be sufficiently poAverful to check the blood supply, consequently the nutrition of the organ may continue almost as active as previous to delivery, and accord- ingly the uterus Avill remain in a state which may be con- sidered as one of permanent hypertrophy. Instances of this are Arery numerous. A similar result may follow in a healthy, muscular Avoman if she leave the recumbent posture too soon after delivery, and, as many of the loAver orders do, return to her ordinary occupations, long before the uterus has regained its normal size. Again, peLic inflammation in any of its varieties is a common cause ; interrupting, and often arresting, the iiiArolution of the uterus. Subinvolution may folloAV on abortion, even Avhen it occurs in the early months of preg- nancy, a fact you should not overlook; indeed my experience leads me to think it is more likely to occur after abortion than after labor at the full term. But from Avhatever cause arising, subinvolution sooner or later gives rise to very trouble- some and distressing symptoms of which menorrhagia is the SUBINVOLUTION OF THE UTERUS. 85 most prominent and alarming, the one, too, for the relief of Avhich Ave are most frequently consulted. I cannot better exemplify this affection, than by calling your attention to the case of C. D., who is still in hospital. She is forty- three years of age, has had six children. Her health has never been good since the birth of the last, ten years ago, shortly after Avhich she noticed that menstruation Avas much more profuse than formerly; for a long time back each period had lasted for not less than ten or twelve days, returning after an interval of only a fortnight. On admission she complained of debility, of great pain in her back, of irritability of the bladder, and conse- quent straining and tenesmus, she also suffered from profuse leu- corrheea. The effects of this long-continued drain was manifest in her appearance ; you must haATe remarked how perfectly ex- sanguine she was. I expressed the opinion from the history of the case, dating as it did from immediately after labor, that the menorrhagia would probably be found to depend on subinvo- lution, and that the irritation of the bladder Avas reflex, de- pending on an unhealthy condition of the mucous membrane lining the uterus, Avhich Avould probably be found to be rough and granular ; this opinion Avas confirmed by the fact, that the os and cervix uteri Avere healthy, Avhile the sound proved that the cavity of the uterus was elongated to the extent of about three inches. I shall by and by refer to the treatment you saw me adopt in the case; for the present it is sufficient to say, that she Avill leaATe the hospital in a day or two, after a stay of but three Aveeks, cured of an affection of ten years' stand- ing. But the mischief resulting from imperfect involution of the uterus does not end here, for this abnormal state of the Avomb predisposes to the occurrence of that unhealthy condition 86 DISEASES OF WOMEN. knoAvn as granular erosion of the os and cervix uteri, a condi- tion which greatly augments the tendency to menorrhagia; thus the two causes Avhich I have placed at the head of the list may be present in the same patient. The case of M. F., recently under our observation, afforded a Avell-marked instance of this. She has had twelve children, and is now forty-eight years of age. She stated, that ever since the date of the last confinement, six years ago, menstruation had gradually be- come more profuse, the flow continuing for a longer time than usual, the interval between the periods being correspondingly shortened. During the interval she suffered from profuse leu- corrheea, and Avas, as a result, greatly debilitated. On examining her, extensive abrasion of the vaginal por- tion of the cervix uteri Avas found to exist, the os was patulous, the lips everted, and the mucous membrane lining the cervical canal could be seen in a thickened, highly Avascular condition; the uterine sound penetrated to the depth of three and a half inches. This patient, too, Avas discharged after a residence of a few Aveeks in the hospital, perfectly cured. She occasionally appears among the out-patients, but not from any return of the menorrhagia. I treated both these cases alike, with most marked success, by the application to the interior of the uterus of the fuming nitric acid, in a manner I shall hereafter explain at length. In the foregoing case, subinvolution Avas manifestly the pri- mary cause of the menorrhagia, the erosion being altogether secondary; but often subinvolution exists alone or, on the other hand, erosion may exist alone, either condition being fully sufficient to give origin to severe menorrhagia. As an instance of the former, the folloAving serves for an example: F. L., set. tAventy-four, a delicate young woman, of lymphatic temperament, married about a year, had always menstruated profusely, especially if she took walking exercise, or exerted SUBINVOLUTION OF THE UTERUS. 87 herself during the Aoav. She became pregnant after the occur- rence of the second menstrual period, subsequent to her mar- riage, but, having imprudently taken a long and fatiguing walk, aborted at the eighth week. The two subsequent men- strual periods Avere so profuse as to reduce her to a state of ex- treme debility. Ergot, gallic acid, and numerous other as- tringents were administered, but they failed to check the haemorrhage. On examining her, I found the uterus consid- erably elongated, the sound passing to the depth of more than three inches ; there Avas not any abrasion of the lips of the os uteri. The history of the case being altogether against the supposition of the existence of a polypus, I came to the con- elusion that the menorrhagia depended on subinvolution ; in fact, that the uterus had ncvTer regained its normal size and tone since the miscarriage which had taken place two months previously. I therefore decided on carrying out a plan of treatment, the Aralue of which you have had, in the wards of this hospital, repeated opportunities of judging, I mean, the introduction up to the fundus of the uterus of ten grains of the solid nitrate of siLer, Avhich is left to dissolve there. This I accordingly did. It produced considerable pain, which lasted for five or six hours, but no further unpleasant results folloAA^ed. I confined the patient to bed for three days, and then allowed her to go about. Menstruation appeared at the regular time, and Avas moderate in quantity. She became pregnant imme- diately after, and went to the full term of utero-gestation. I wish to call your attention to this case, first, as illustrating the occurrence of subinvolution as a result of abortion; a fact, which, though mentioned by Sir J. Simpson, has been overlooked by many ; next, as shoAving that dangerous haemor- rhage may result from this condition of the uterus; and, thirdly, as proving the excellent results Avhich follow the treat- ment I adopted. This point I wish specially to impress on DISEASES OF WOMEN. Fig. 12. you. You will find that ergot, gallic acid, and indeed all other medicines, will frequently fail to check menorrhagia de- pending on subinvolution, and that you must have recourse to treatment directed to the uterus itself. You must stimulate the organ to set up that healthy action by Avhich it regains its normal size after pregnancy has ter- minated, a process to Avhich, as I have already told you, the term " involution " is applied. AVith this vieAV, I unhesitatingly advocate, in suitable cases, the adoption of the treatment I practiced in this case. The mode of carrying it out is simple. You introduce the instrument, Avhich I now exhibit (Fig. 12), into the uterus, just as you Avould an ordinary uterine sound. It is Sir James Simpson's " Uterine Portecaustique." It consists, as you see, of a holloAV silver tube, in size and shape closely resembling a sound, and containing a flexible stilette which fits it accu- rately. As soon as you are satisfied that the point of the instrument has reached the fundus of the uterus, yon AvithdraAv the stilette, and push up by means of it, through the tube, a piece of solid nitrate of silver, reduced to the requisite size and weight, until it is fairly lodged in the cavity of the uterus. In doing this there is but one caution requisite, namely, that as soon as the piece of nitrate of silver has reached the extremity of the portecaustique, and before it is finally pushed out of the instrument (a point you can always be certain of by observing how much of the stilette remains still unintroduced), you should withdraw the instrument to the extent of about half an inch; for, if this precaution be not observed, it is possible that the nitrate of silver might be forced into the substance of 9 Uterine Porte- cauotique. TREATMENT OF SUBINVOLUTION. 89 the uterine wall, instead of being left free in its caATity, an accident which, though possible, is very unlikely to occur. I have dAvelt at some length on this plan of treatment, be- cause I am satisfied that its value is far from being fully ap- preciated. It is looked upon by many practitioners as heroic and dangerous. I have practiced it freely for several years, and I believe it to be both simple and safe. I do not say that it is always sufficient, and that a cure must always result, but in my hands it has been productive of marked success, and in no single instance have I knoAvn it produce serious symptoms. That pelvic cellulitis may, under certain circumstances, follow the introduction of the solid nitrate of silver into the uterus is quite possible, and I should not at any time be surprised at its occurrence; but the fear of this would never deter me from carrying out the treatment, for an attack of cellulitis is of much less importance than the continuance of profuse menorrhagia. Although I have seen cellulitis follow the use of apparently milder astringent applications, it has not as yet occurred in my practice after the introduction of the solid nitrate of silver. This treatment is no novelty. Dr. Evory Kennedy, many years ago, was in the habit of passing solid nitrate of silver into the cavity of the uterus; but he did not allow it to re- main there. Subsequently, Sir J. Simpson introduced the method I now adA'ocate, and invented the portecaustique. In the case I have related, I was asked to see the patient just as the flow, which had continued for nearly a fortnight, ceased to appear, and as a full trial had been given to the or- dinary method of treatment without result, and the woman being in such a debilitated condition that a return of the haemorrhage might be productive of very serious consequences, I seized the opportunity to carry out the treatment just de- tailed. Had I, hoAvever, seen her at an earlier period, I should at once hav^e stopped the loss of blood by plugging the vagina. 8 90 DISEASES OF WOMEN. This is a mode of arresting the haemorrhage, which, if properly carried out, is ahvays safe, and, as a temporary means, effica- cious. You have seen me practice it repeatedly in our wards. Of course, in an emergency, a sponge or a pocket-handkerchief will ansAver the purpose ; but, when it can be obtained, nothing does so Avell as common cotton Avadding. It should be cut in strips, the full length of the sheet, and two inches Avide, the paper to Avhich the wadding adheres being left attached. These strips should then be introduced one by one, through a specu- lum, a piece of tape or twine being attached to those first in- troduced, for the purpose of facilitating removal, the ends of the string being left outside the vulva. As many strips of the Avadding as the vagina will contain are in this manner to be introduced, from four to six being usually required, according to the capacity of the vagina. As the strips of wadding are introduced the speculum should be gradually withdrawn, and, Avhen finally removed, the finger should be passed into the vagina and the Avadding firmly pressed together, when, if it be found that the vagina is not fully distended with the plug, more cotton should be introduced. If this precaution be not adopted, blood is very likely to ooze out betAveen the sides of the vagina and the plug. Another very good plug is formed by twisting cotton-Avool into a rope, and introducing it in the same manner. The plug thus formed is easily withdrawn, for if the ends of the strips last inserted be laid hold of by a pair of dressing- forceps, which are then to be rotated so as to coil the strips round them, each piece can be extracted in succession without its breaking, Avhile the ones first introduced are withdrawn by means of the strings attached to them. Any substance left in the vagina rapidly becomes very offen- sive ; but this can be in a great degree remedied by smearing the wadding or cotton freely with glycerin. The plug should MODE OF PLUGGING VAGINA. 91 in all eases be withdrawn after the lapse of tAventy-four hours; to be replaced for a similar period if the haemorrhage continues. Should you be unable to obtain Avadding, cotton or toAv will answer the purpose very avcII. You must, however, be careful to attach a string to each of the rolls first introduced, and to keep the ends outside the ATuhTa, or you Avill experience some difficulty in removing the plug. This treatment is equally efficacious in restraining haemorrhage depending on any of the causes I have enumerated as giving origin to menorrhagia, and should always be practiced in severe cases. In hospital practice, where I have the aid of an assistant, I prefer using the duck-bill speculum Avhen plugging; but, while its use certainly facilitates the introduction of the plug, the shape in which it is usually made renders its removal, when once the vagina has been filled with the cotton or Avad- ding, a matter of difficulty. In cases of emergency, where no speculum is at hand, one may be extemporized by introducing the handle of a spoon into the vagina, and with it drawing back the perinaeum, or the index and middle finger of the left hand may be introduced and made use of to dilate the orifice of the A'agina; for if this be not done by some means, the in- troduction of the plug is not only a matter of difficulty, but Avill cause the patient much pain. Dr. Greenhalgh, instead of using sponge or cotton, employs three India-rubber balls, which are made in three different sizes and covered with spongio-piline; one of these is introduced, collapsed, into the Aagina, and then inflated to the required extent; they are easily introduced and removed, and are worn without discom- fort. Dr. Barnes advocates plugging the os uteri itself Avith sea-tangle or sponge-tents, in preference to filling the vagina with the plug. Doubtless his method is the most efficacious, but the difficulty of effecting it will render its general use unpopular. 92 DISEASES OF WOMEN. You are not, hoAvever, to infer that all cases of subinvolu- tion are to be treated on one stereotyped plan, and that in every case you must have recourse to the introduction of the solid nitrate of silver. Many cases will yield to milder though slower methods, especially those in Avhich the muscular tissue of the uterus, being in a very relaxed condition, permits the organ to remain in a.state of extreme engorgement; under such circumstances, the frequent abstraction of small quanti- ties of blood from the Avomb (which should be effected by puncturing the cervix), and the administration of strychnia or ergot, with or without the addition of iron or digitalis as the patient's condition may indicate, will often prove eminently useful. The abstraction of blood by relieving the engorge- ment, permits the contraction of the muscular fibres of the uterus and favors the action of the ergot and strychnia on them. The case of Mrs. M., Avho for some time past has been a regu- lar attendant at the out-patient department, affords a good ex- ample of this treatment. She has had six children, and her illness dates from a miscarriage which occurred four years ago. She has not been pregnant since, but has suffered from severe pains in the back and loins. Menstruation has gradually be- come more and more profuse, and now lasts for fourteen days. On examining her, the uterus AA'as found to be much enlarged, the sound penetrating to the depth of three and a half inches; it was also retroflected, and the cervix was soft and engorged. As this patient Avould not agree to come into hospital, it Avas necessary to select a mode of treatment which would not inter- fere with her attending to her ordinary household duties. I accordingly, on May 20th, punctured the cervix with Dr. Hall's lancet-shaped knife; it bled freely. On May 23d, she stated that she felt weak, but much easier, and I introduced a Hodge's pessary to support the retroflexed uterus. From that date, for several Aveeks, blood was regularly abstracted from TREATMENT OF SUBINVOLUTION. 93 the cervix by puncturing it, and her condition gradually im- proved. On the 24th of July, I made a note that the catame- nial period, which had just terminated, had lasted but seven days, and that the Aoav Avas moderate in quantity, the pain in the back much less seA^ere, and that she felt considerably stronger. During the Avhole of this period she had been taking — ten drops of the tincture of the perchloride of iron, three of the liquor strychniae, and twenty of the liquor ergotae, three times __ a day. On the 22d of August she reported that another period had just passed, and that it had only lasted three days; the uterus A\ras noAv of its normal depth. The simple treatment practiced in this case was eminently successful. The uterus returned to its normal size and menstruation became regular. Doubtless, the treatment extended over four months ; but it was carried out under the most unfavorable conditions, for this poor woman continued to perform all her usual household duties, washing, cooking, etc., for her family during the whole time. Had I been able to enforce rest in the recumbent posi- tion, her improvement Avould have been much more rapid. In the foregoing case no application Avas made to the interior of the uterus, but in the great majority of cases such is neces- sary, both because the mucous membrane lining the cavity of the uterus is generally in an unhealthy condition, and also be- cause the application of a caustic to the interior of the uterus - stimulates the organ to contract. Dr. Playfair advocates for this purpose the use of carbolic acid. I have given this agent an extended trial, and consider it, for general use, superior to perhaps any other.' In old-standing cases, or Avhere the lining membrane of the uterus is in a granular condition, carbolic acid is insufficient, and it will be necessary to apply the solid nitrate of silver or the fuming nitric acid. The latter is the agent I generally employ in such cases, applying it through a 94 DISEASES OF WOMEN. platinum canula.* The use of carbolic acid, or indeed of any other intra-uterine application, should not supersede the local abstraction of blood; on the contrary, I recommend you to carry out both methods at the same time; first applying the caustic and then puncturing the cervix before the speculum is AvithdraAvn. Carbolic acid has this advantage over solid nitrate of silver or nitric acid, that its use does not necessitate the con- finement of the patient to bed. It may be applied Avith safety in the case of hospital out-patients, or pri\Tate patients, Avhom it may be necessary to treat at your own houses. As I do not wish to have to refer again to subinvolution, I must diverge for a moment from the subject of menorrhagia, to say, that though profuse menstruation is nearly ahvays an early and common symptom of subinvolution of the uterus, there may be exceptions to this rule, as the following case proves: A young married woman was admitted into one of our hospitals during the past summer for Avhat Avas supposed to be an ovarian tumor. She had been confined about three months previously of her third child. Haemorrhage had followed de- livery. She also appeared to have been subsequently attacked by some form of pehTic inflammation. She recovered slowly and had not been able to nurse. The lochia ceased to appear during the attack alluded to, and menstruation had not occurred since delivery. On passing the hand ovrer the abdomen, a large moArable tumor could be easily felt lying to the left side; it was very painful to the touch. After a feAv days this woman was discharged from hospital, her case being considered unsuit- able for any kind of surgical interference. As, however, she continued to suffer much distress, she presented herself anion"- the out-patients here, when a careful examination, made with * For directions as to the mode of applying these agents, see Lecture XVII. TREATMENT OF SUBINVOLUTION. 95 the aid of the uterine sound, proved the tumor to be the uterus, much enlarged and elongated; in fact, it Avas a case of subin- volution, with temporary suppression of menstruation. I ad- mitted her into hospital, and introduced ten grains of nitrate of silver into the uterine cavity in the manner already de- scribed. This, as usual, caused some pain for a feAV hours, but it had the desired effect. It stimulated the uterus to set / up the process of involution which the attack of inflammation had arrested, and in a couple of Aveeks she was discharged, the uterus having almost regained its normal size. AVhen admitted, the sound penetrated to the depth of five inches into the uterus. Although the mode of treatment I have just detailed, and which you have seen repeatedly carried out in this hospital, is one on which you can rely for the cure of menorrhagia de- __ pending on subinvolution, I am far from desiring you to sup- pose that I advocate its use in all cases. On the contrary, in general I first try milder treatment. That which I generally adopt in the less severe forms, of which so many examples occur among the extern patients, is the application of a strong solution of carbolic acid (two parts of acid to one of spirit), to --■ the intra-uterine surface, carrying it up to the fundus by means of one of Playfair's probes.* With this, if congestion exists, I generally couple local depletion, administering at the same time such medicines as are known to exert an influence on the uterus. Of these ergot is the most reliable ; if the patient be anaemic, I frequently give ten drops of tincture of the per- chloride of iron, Avith the addition, in some cases, of three or four drops of the liq. strychniae three times a day, in an ounce of the infusion of ergot. The addition of ten drops of tinc- ture of digitalis when the heart's action is very rapid is often * For directions see Lecture XVII. 96 DISEASES OF WOMEN. beneficial. If, on the other hand, symptoms are present indi- cating the existence of ovarian congestion, I substitute the bro- mide of potassium for the iron in the mixture.. In some cases, arsenic in four-drop doses, taken on a crumb of bread after meals, produces good results. The administration of these medicines should be continued for several Aveeks. LECTUEE VI. Menorrhagia Continued—Granular Erosion of Cervix Uteri— Treatment of—Granular Condition of Cavity—Treatment of—Mode of Dilating Cervix—Sponge Tents—Sea-Tangle— Barnes's Dilators—Use of Nitric Acid—Curette—Ketained Placenta after Abortion. In my last lecture I dwelt at some length on the subject of subinvolution of the uterus, as bearing on that of menor- rhagia which is frequently associated with it, and I mentioned that this abnormal condition of the uterus predisposed to the occurrence of erosion of the cervix; but erosion is often met Avith independent of subinvolution, and is by itself capable of giving origin to profuse menstruation. Mere abrasion of the lips of the os uteri is not sufficient to produce menorrhagia, but an unhealthy spongy condition of the cervix is met with, Avhich bleeds on the slightest touch, the surface being granular, the os patulous, and the lips everted, a condition quite capable of originating severe menorrhagia. Thus I recently saw a young married woman, who had never been pregnant, who stated that she had become greatly debili- tated by the excessive loss which occurred at each menstrual period. Ergot and astringents had been freely administered, and she had been ordered to inject into the vagina, lotions con- taining alum and zinc; but this treatment produced no good effect. A vaginal examination proved the existence of exten- sive granular disease of the os and cervix uteri. Now, in se- vere cases, such as the one I am referring to, you may rest 98 DISEASES OF WOMEN. satisfied that the unhealthy condition of the mucous membrane extends at least as high as the os internum, and that you will fail to effect a cure unless your treatment reach every portion of the diseased tissue; therefore, with a view of permitting the necessary applications to be made to the whole extent of the cervical canal, I commenced my treatment by introducing tAVO tents of compressed sea-tangle, two pieces being sufficient for the object I had in vieAV, Avhich Avas not to open the uterus to such an extent as to enable me to examine its cavity, but only to permit me to treat the entire of the cervical canal. I left these pieces in situ for twenty-four hours, and on withdrawing them, after the lapse of that time, I cauterized freely the whole of the diseased surface with fuming nitric acid. This did not cause any pain. On examining the os uteri a few days subse- quently, I found it in a much healthier condition; the menor- rhagia never returned, and although a considerable time elapsed before the uterus regained a perfectly healthy state, still the progress of the case was rapid and the cure perfect, the only treatment subsequently necessary being the occasional applica- tion of a tAventy-grain solution of nitrate of silver to the os uteri, and, at a later period, of small blisters OATer the sacrum; finally, not the slightest trace of the erosion remained, and menstruation became in all respects normal. The foregoing case illustrates the mode of treatment Avhich, as a rule, I adopt. Of course, it is not always necessary to dilate the cervix uteri. If the case be recent, and you can satisfy yourself that the unhealthy condition of the mucous membrane does not extend very high, the use of the solid ni- trate of silver, or brushing the part lightly over Avith nitric acid, may be sufficient; but in the more severe forms of the disease such treatment will prove to be merely palliate, and the only effectual means will be found to consist in Avhat I have advocated, or in the use of agents even more potent than GRANULAR CONDITION OF CAVITY. 99 the fuming nitric acid, which, though it acts rapidly, produces a vTery superficial slough. In not a few cases recourse must be had to the potassa c. calce, or to the actual cautery.* I be- lieve that not a little of the opprobrium which rests on ob- stetric practitioners for the length of time over which their treatment extends, is due to excessive timidity, and to the use of inefficient remedies. A condition very analogous to that which Ave can see in the cervical canal, occurs also in the interior of the Avomb, as the result of congestion and inflammation of the lining membrane of that cavity; a fact which is often overlooked. Indeed, the majority of systematic writers altogether omit mention of it. Dr. Tanner, in his excellent work on the Practice of Medi- cine, mentions the " existence of an unhealthy pulpy condi- tion of the mucous coat" of the uterus as a cause of menor- rhagia. My OAvn experience leads me to conclude that while a " pulpy" condition is rare, chronic disease, producing a rough, granular state of the mucous membrane lining the cavity of the uterus and giving origin to menorrhagia, is far from being uncommon. This condition I believe to be in many respects analogous to that so commonly met with in the eyelid, and you will fail to cure the menorrhagia which it causes, until you have destroyed the granulations on the mu- cous membrane and restored it to a healthy state, just as you Mould fail to relieve the ophthalmia depending on granular lids, until you have cured the palpebral affection. I may here take the opportunity of laying down a rule, which I advise you invariably to adopt, namely, whenever you meet with a case of menorrhagia in an otherwise healthy woman, which a careful vaginal examination proves not to depend on erosion of the os and cervix uteri, on an extra-uterine polypus, on cancer, * Sue Lecture XVII. 100 DISEASES OF WOMEN. or some other evident cause, that you should dilate the cervix and os internum with the vieAV of determining what the condi- tion of the interior of the womb may be. This I hold to be your manifest duty. I cannot refrain from quoting the judicious remarks of Dr. Tanner with reference to this subject. He says, speaking of menorrhagia, vol. ii, p. 301: " When a woman suffers from repeated attacks of uterine haemorrhage, which can only be partially or temporarily relieved by rest, nourishing food, and proper astringents, we may be sure that there is some organic disease of the ovaries or uterus; and though the cervix and body feel healthy to the touch, we can be certain that the bleeding is due to some actual disease; that it is not functional." And further on, after enumerating what these causes may be, he adds: "There is only one plan of treatment which can be adopted with a reasonable hope of success, and that is to dilate the os and cervix thoroughly, so as to permit the removal of the source of evil." I fully indorse these observations. There are tAvo methods still practiced of accomplishing dila- tation of the cervix uteri, the one being with sponge-tents, the other by means of sea-tangle. The former can be made of any required size; it is merely necessary to cut a fine clean sponge into pieces, conical in shape, and of various sizes and lengths; for you should always be provided with several tents of differ- ent sizes before commencing the process of dilatation. You should then wrap each piece as tightly as possible with fine twine, commencing at the narrow extremity and winding it on till it reaches the thick end. The pieces of sponge are next to be immersed in a strong solution of gum arabic, and left in it till thoroughly saturated, and then hung up to dry slowly. Before these are used the surface should, after the removal of the tAvine, be rubbed smooth. A small-sized tent is to be first in- serted, a larger one being introduced on its removal, after the SEA-TANGLE TENTS. 101 lapse of from six to twelve hours, and the process repeated until the cervix is sufficiently dilated. I iioav seldom use sponge-tents; they are troublesome to prepare, give rise to a very fetid discharge, and are further objectionable, because the mucous membrane lining the cervix sinks into the cells of the sponge, and is consequently lacerated as the tent is AvithdraAvn, and the risk of inflammation occur- ring is thereby greatly increased. Besides, sponge-tents, from their conical shape, necessarily dilate the os externum the most, often beyond what is required ; Avhile the os internum may not be opened even moderately. In fine, in my opinion, sponge- tents should never be used if sea-tangle can be obtained. Tents made of this substance, technically called laminaria digitata, have been in use for some years for the purpose of dilating the cervix. The method first adopted was to intro- duce one, which, after the lapse of some hours, Avas Avithdrawn, and another of greater calibre introduced in its place, the pro- cess being repeated till the os internum Avas sufficiently dilated. This process Avas necessarily very tedious, besides being objec- tionable in other points of view. It is noAV given up, and a modification of it, introduced by Dr. Kidd of this city, adopted in its place. Dr. Kidd's method possesses these three great ad- vantages,—it is comparatively rapid; is cleanly; and lastly, and most important of all, it dilates the canal equally throughout its whole length, except in some cases of rigidity of the os in- ternum, to which Ijshall allude presently. Having decided to dilate the cervix, the first step is to ex- pose the os uteri by means of the duck-bill speculum, next to seize the anterior lip Avith a tenaculum, and Avith it to draAV doAvn and steady the uterus, as shown in Fig. 13. You should previously measure the depth of the uterus, and have ready several pieces of sea-tangle bougies, each piece being nearly the length of the uterine cavity. These you noAV proceed to intro- 102 DISEASES OF WOMEN. duce; the main difficulty is in the introduction of the first piece, the difficulty being greatly increased if the uterus be retro or anteflected. When either of these conditions exist, you had better first introduce the uterine sound, and slipping in" some pieces of sea-tangle beside it, withdraw the sound. Short lengths not being so easily manipulated as long ones, I some- Fir,. 13. Polypus (Case of M.D.) Sea-tangle in Situ to effect Dilatation. times, Avhen difficulty occurs, take an entire bougie and pass it through the os internum as you would the sound, and then slip pieces of the proper length in beside it; for when one piece has been inserted, it straightens the uterus and serves as a guide to the others. When several pieces have been intro- duced, you can AvithdraAV the long one, or if, before passing it in, you nick it round at a point corresponding Avith the length of the other pieces, you may be able to break it off, and so avoid the trouble of withdrawing it and substituting another SPONGE-TENTS. 103 length in its place. The number of pieces you should insert varies in each case. If the patient have never been pregnant and the cervix is rigid, you will not be able to get in more than two or three; but, if she have borne children, and if the cervix be relaxed, you may succeed in introducing double that number, or even more, without difficulty. If a small number only have been introduced, it is better to AvithdraAV them after the lapse of nine or ten hours, and in- troduce a larger number; but if seven or eight pieces have bsen inserted, they may be left for twenty-four hours before any further steps be taken. The sea-tangle gradually absorbs moisture from the vagina and uterus, and swells, and by so doing forcibly dilates the cervix. This, of course, causes pain, which, hoAvever, is seldom very severe, and generally passes off after a feAv hours. If it continue, I usually direct a mor- phia suppository to be introduced into the rectum, or twenty grains of the hydrate of chloral to be administered at bedtime. Dr. Grailly Hewitt, who still advocates the use of the sponge-tents in preference to the sea-tangle, states, as an ob- jection to the latter, that they are liable to slip out. This cer- tainly is true, if you use the short tents Avhich are sold in boxes, but if you use pieces of bougie of the length already specified, and take care that they pass nearly lip to the fundus, there is very little chance of their being expelled; I have even on two or three occasions experienced some difficulty in remov- ing them. This has been the case when the os internum was so rigid that it prevented the sea-tangle expanding as freely at that point as it did in the cavity of the uterus and in the cer- vical canal; the pieces of tangle being thus constricted in the middle, it Avas necessary to press the index finger of the left hand firmly against the lip of the os uteri, while, Avith a pair of long forceps held in the right hand, one piece was seized and slowly extracted. These are the cases in Avhich, as just 104 DISEASES OF WOMEN. mentioned, the whole extent of the canal is not equally dilated; then fresh pieces of the tangle must be introduced, and time given to allow of their expansion before proceeding to explore the interior of the uterus. You will, hoAvever, from time to time, meet with cases in which, although the sea-tangle has expanded to its fullest extent, still from the size of the tumor, or some other cause, the os internum is not as large as you would desire. Under such circumstances, I usually complete the process by the introduction of one of Dr. Barnes's dilators. These are india-rubber bags, of a someAvhat hour-glass, or rather fiddle shape. They are made of three different sizes. One end terminates in a long slender tube, the extremity of which is furnished Avith 'a stop-cock. The dilator is intro- duced in a flaccid state into the uterus on the point of a staff or sound, or held and compressed between the blades of a pair of long slender forceps, the terminal bulging part being carried by them through the os internum; Avater is then to be gradu- ally forced in through the tube just alluded to, and the dilator left in for an hour or tAvo; by that time it will generally be found to have distended the canal to a considerable extent. The peculiar shape of the dilator prevents it, when once it has been distended, from slipping out of the uterus. Dr. Barnes originally introduced these bags into practice for the purpose of dilating the os uteri in cases in which it Avas desirable to induce premature labor, a purpose Avhich they often serve admirably; but their use is now further extended, and we employ them occasionally for the purpose of completing the dilatation of the cervix in the unimpregnated uterus. You have had frequent opportunities of seeing the process I have described carried out, and must have noticed the entire absence of unpleasant symptoms, after a proceeding so appar- ently seArere as the forcible dilatation of the cervix uteri. I have therefore no hesitation in recommending you to adopt INTRA-UTERINE EXAMINATION. 105 this course in your future practice, as being one which you have seen productive of such good results in this hospital. I have never, in my OAvn practice, met Avith an instance in which unpleasant symptoms followed the attempt to dilate the cervix uteri with Laminaria tents; but I am far from throw- ing doubt on the accuracy of the statements of others, who have recorded the occurrence of alarming symptoms, or even of death, as consequent on this procedure, and I am prepared for the possible occurrence of such, for cases occur from time to time in Avhich the most trifling exciting cause will be folloAved by serious symptoms; but, as a rule, I believe when these arise, either during the processes, or in consequence of the dila- tation, they do so because unsuitable cases haAre been selected. Therefore, to guard as far as possible against unpleasant re- sults, I lay down for myself the following rules, Avhich I rec- ommend to you for your guidance : 1. Never to dilate the cervix uteri for the cure of dysmenor- rheea or sterility, depending on a narrow cervical canal or conical cervix. 2. Never to dilate where a large and dense intramural fibroid presses on, and partially obliterates the cervical canal. The knife is much safer in these cases. 3. Never to continue the process for more than forty-eight hours. If the cervix be not sufficiently open then, operative interference should be postponed for some weeks. If you attend strictly to these rules, you will have little to fear in carrying out the process. Of course, if the patient suffer unduly, or that symptoms of inflammation shoAV them- selves, it will be your duty to AvithdraAV the pieces Avithout de- lay, and for "the time at least to give up all attempts to dilate the cervix. I have noAV explained the way in which dilatation of the cervix is to be accomplished. It remains for me to direct 9 106 DISEASES OF WOMEN. your attention to the mode in Avhich you are to proceed when, having withdraAvn the sea-tangle or sponge tents, you desire to clear up any doubt Avhich exists, and satisfy yourself as to the cause of menorrhagia. We have, in the vast majority of cases, to rely for this pur- pose on the sense of touch alone, and must accordingly pass the index finger fairly through the os internum, till the tip reaches the very fundus.* To accomplish this by no means easy matter, it is necessary in the first instance, to draw down and fix the Avomb; this you effect by seizing the anterior lip of the os uteri Avith a vulsellum, Avhich you intrust to an as- sistant to hold, while the fundus should be at the same time pressed down by your left hand, or better still, by that of another assistant; the finger, well oiled, is now introduced slowly through the os internum and SAvept round the entire cavity of the uterus. You will thus detect the existence of a polypus or a tumor, no matter how small, should either be present, while the educated finger will recognize the rough uneven feel which the mucous membrane, if in an unhealthy granular condition, conveys to the touch. I have already expressed my opinion, that this condition of the interior of the uterus is probably due to subacute inflam- mation. This view I believe to be correct; but be the cause what it may, the mode of treatment should be the same, and * My friend, Dr. Cruise, who has paid special attention to the use of the endoscope, has on several occasions made an examination of the interior of the uterus with that instrument, and is of opinion that in most cases this can be done satisfactorily. In confirmation of which statement I may refer you to Dr. Cruise's paper, in the Dublin Journal of Medical Science, vol. lxxviii, for May, 1865, page 333; also to a case recorded by Hayden, in vol. lxxx, of the same periodical, p. 497 ; to a paper on Granular Endome- tritis, by Dr. Churchill, in vol. i, of the British Medical Journal, p. 2; and to an Essay on the Endoscopic Examination of the Cavity of the Uterus, by Dr. Pontaleoni, of Nice, in the Medical Press and Circular, July 14th, 1869. APPLICATION OF NITRIC ACID. 107 that is to destroy these so-called granulations, " and endeavor to excite healthy action in the diseased part." AVith this object, I invariably make use of the strong nitric acid, applying it with extreme freedom to the interior of the uterus. In such cases it is necessary to reach the entire of the diseased surface. I apply the acid by means of a thin layer of cotton, Avrapped firmly round a platinum rod; if that is not at hand, an iron Avire or the stilette of an ordinary catheter will do. The os is brought into vuew by the aid of the duck-bill speculum, which protects the posterior wall from any risk of injury, its concavity being smeared with lard to preArent the acid from corroding it, AAmile the anterior Avail is guarded by the vulsellum with which the lip is still firmly held ; the Avire armed with the cotton saturated with the acid is then passed boldly through the di- lated cervix, sAvept round the entire interior of the womb, and withdrawn Avith a view of protecting the lips of the os uteri and cervical canal from the action of the acid. I am in the habit of using a vulcanite tube, tAVO inches in length, and one- third of an inch in diameter at its loAver extremity. This should be passed up to the os internum, and the acid applied through it, or a glass tube may be used for the purpose. The cervix having been previously freely dilated, this can be done without any trouble.* In eases where the disease is of old standing, and the haemor- rhage has been severe, I repeat the application, passing the stilette, armed with a fresh piece of cotton, saturated with the acid, a second or even a third time up to the fundus, so as to insure the thorough cauterization of the Avhole inner surface of the uterus. As soon as the cauterization has been effected, and the tube withdrawn, a piece of cotton, soaked in water, should be at once applied to the os, to prevent the vagina being injured by any acid discharge which might issue from * See Lecture XVII. 108 DISEASES OF WOMEN. the uterus, and then the lip being freed from the grasp of the vulsellum, and the speculum Avithdrawn, the patient is to be placed in bed. The subsequent treatment is very simple. Should the pa- tient suffer pain, which she seldom does to any great degree, I order a morphia suppository to be introduced into the rectum, but in the majority of cases this is unnecessary. Indeed, much less pain is caused by this application than by the introduc- tion of the solid nitrate of silver, though the latter Avould seem the milder treatment of the two. This immunity from pain after application of the acid is very remarkable. I have only once found it necessary to dilate the uterus a second time for the cure of these cases, but it may be necessary to apply the acid again, if after the lapse of some time men- struation continue to be profuse, a platinum or small vulcanite canula being always introduced, and the acid or other caustic carried up to the fundus through it ;* after one or two appli- cations of the nitric acid, carbolic acid may generally be sub- stituted for it. You can doubtless recall to mind several cases which have been treated by this method during the past session. The following one, at present in the house, serves as an example: J. C, a married woman, aet. twenty-eight, admitted 26th November. She has never been pregnant. Menstruation regular, till within the last few months, Avhen she observed the flow to become much more profuse than formerly, and to last for a greater number of days. Latterly, the interval be- tween each period has been but a fortnight. She has suffered, and continues to suffer greatly, from severe pain over the left ovary and in the back. On making an examination per vagi- nam, the os was found to be relaxed and patulous, the sound penetrated to the depth of nearly three inches, and the fundus * Fig. 34, Lecture XVII. USE OF CURETTE. 109 appeared to be slightly enlarged. The existence of a small polypus or fibrous tumor being deemed possible, dilatation of the cervix Avas decided on ; fi\re lengths of compressed sea- tangle Avere introduced on the morning of the 3d December, but, on Avithdrawing them next morning, the os internum Avas found still too contracted to admit of the passage of the finger; Barnes's small-sized dilator Avas consequently introduced and maintained in the cervix for a couple of hours. On its re- moval, I Avas able to introduce the finger, and to reach the fundus, but neither polypus nor tumor could be detected in the uterus. The inner surface, hoAvever, Avas felt to be rough and uneATen; the entire of this surface Avas freely cauterized Avith fuming nitric acid. This patient Avas subsequently dis- charged cured. Such is the treatment I nearly invariably adopt, circum- stances, of course, occasionally requiring me to modify it. Were the patient in a very feeble, debilitated condition, I should endeavor, in the first instance, to improve her health, restraining the menorrhagia by plugging, by alum injections, or by hot-Avater bags applied to the spine, or, if the cervical canal be patulous, perhaps by the injection of hot Avater at a temperature of 110° ; but this treatment Avould be altogether palliative, and I should as soon as possible have recourse to the radical plan I have just advocated. In many cases, hoAV- eArer, of the affection of Avhich I am speaking it is altogether unnecessary to dilate the cervix, for Avhen satisfied as to the nature of the case you can apply nitric acid or any other agent you may select, through my canula,* Avithout subjecting your patient to that painful process, Avhich is not often needed ex- cept Avhen the diagnosis is doubtful. Tavo other modes of treatment haA^e been practiced to which it is right I should call your attention ; namely, injection into * 8ee Lecture XVII. 110 DISEASES OF AVOMEN. the uterus of astringent or caustic fluids, and scraping of the inner surface of the uterus with an instrument called the curette. I do not think the former of these modes of treat- ment either safe or satisfactory. Inflammation of a serious, and evTen fatal character, has folloAved the injection of fluids into the cavity of the uterus; and I look on it as a hazardous practice. If any of you, gentlemen, should be induced to try it hereafter, let me recommend you, in the first instance, to di- late the cervix, so that the injected fluid may have a ready means of exit. As to the curette, its use is, in many cases, a valuable ad- junct to our treatment, but it cannot be relied on alone. This instrument is intended to detach any soft bodies Avhich may exist in the interior of the Avomb; in plain English, the ob- ject is to scrape off its lining membrane, and if this has to be done almost at random, it is evidently uncertain Avhether it effects the object in A7ieAV or not. Recamier himself, who in- vented it, adATocates the cauterizing of the interior of the uterus Avith nitrate of silver after the curette has been Avithdrawn— a clear proof that the use of the instrument eA^en in his oavii hands proved inefficient. There are just tAvo cases in Avhich, in my opinion, the use of the curette is justifiable, namely, for the removal of a small polypus the size of a pea or bean, Avhich it is difficult to seize Avith the forceps for the purpose of twisting off, and in those instances, in which, as the result of long-standing disease, the mucous membrane becomes dis- organized, and granulations form of such considerable size that it is doubtful whether nitric acid Avill be sufficiently poAverful to destroy them; then their removal by means of the curette, previous to the free application of the acid, is justifiable. But in both cases the cervix should have been previously dilated, and the instrument, if possible, guided along the finger to the TREATMENT OF MENORRHAGIA. Ill required point. I use the instrument known as Marion Sims's curette. The retention of a portion of the placenta or of the foetal membranes is too Avell knoAvn a cause of uterine haemorrhage to need more than a brief notice. Not long; since Ave had in hospital a case where riiis occurred, and to which I Avish to call your attention. This woman Avas the mother of five children. Early in February she had a miscarriage, at about the fifth month of pregnancy. There Avas considerable haemorrhage at the time; the discharge did not entirely disappear for four or five Aveeks. After an interval of about a fortnight, a red dis- charge, Avhich she supposed to be the regular menstrual Aoav, appeared, and continued, with short intervals, till the 1st of May, Avhen she came under my care. On examining her, I found the uterus to be much enlarged, the sound penetrating to the depth of four inches. The large size of the uterus, and the freedom Avith which the sound rotated in the cavity, in- duced me to suppose that it contained a tumor of some kind, and I determined to explore the interior. I accordingly di- lated the cervix, and on passing my finger through the os in- ternum, detected Avhat appeared to be a polypus attached by a slender pedicle to the uterine Avail. I seized it Avith a vulsel- lum, and using A'ery slight traction, extracted Avhat proved to be a portion of placenta, which had been retained in utero for nearly three months, giving rise to the symptoms I have de- tailed. Profuse menstruation, occurring at irregular intervals, is not unfrequently noticed in women approaching the climac- teric period, and sometimes assumes an alarming character. The causes of these attacks are sometimes obscure, but in many instances they depend on congestion of the ovaries or uterus, or on hyperemia of both these organs. They are most likely to occur in women, who, as is often the case at this period of 112 DISEASES OF WOMEN. life, fall into flesh; the attacks are frequently preceded by a feeling of much discomfort, by headaches, and sometimes by tenderness on pressure of the ovaries. During the period the excessive loss is best checked by rest, the application of Chap- man's hot-water bags to the sacrum, and by the exhibition of ergot. But our main efforts should be directed to avert a re- currence of the attack. With this view, the bromide of potas- sium or ammonium may be administered, in thirty-grain doses, for some days prior to that on Avhich the Aoav is expected. Not unfrequently, hoAvever, although the patient looks stout, and even plethoric, she feels weak, and complains of fatigue on the least exertion, the pulse is feeble, the heart's action Aveak; therefore, in the intervals between each period, you should at- tend carefully to the general health, see that the diet be nutri- tious and unstimulating, that open air exercise be taken, Avhile you Avill at the same time administer tonics, of which arsenic, iron, strychnia, and digitalis, are pre-eminently useful. From what I have told you as to the causes on which menor- rhagia depends, you will understand why it is that astringents, and haemostatics administered by the mouth, are so frequently ineffectual in checking the haemorrhage. You are not, how- ever, to suppose that they are useless. On the contrary, they are frequently productive of much benefit, and generally are A-aluable adjuncts to our surgical treatmeut. In cases of pro- fuse menstruation depending on subinvolution, ergot is of great value. I usually prescribe it in the form of the infusion, ad- ministering Avith it, if, as is commonly the case, symptoms of ovarian irritation exist, the bromide of potassium in full doses; or if a patient be anaemic, ten drops of the tincture of the per- chloride of iron, from three to five drops of the solution of strychnia to each dose of ergot, and am satisfied that the addi- tion of the latter drug increased in a marked degree the pecu- liar action of ergot on the uterus. I have also tried this com- TREATMENT OF MENORRHAGIA. 113 bination Avith advantage in cases of post-partum haemorrhage. You haA'e had an example of its effects in the case of the pa- tient, who was admitted for profuse haemorrhage, coming on three weeks after abortion at the fourth month, which I be- lieved to have been kept up by the retention of the placenta, and may have remarked that each dose of the ergot and strychnia Avas folloAved by sharp uterine pains, resulting in the expulsion of the placenta. I recommend you to try this in your future practice. Gallic acid, too, alone, or in combination Avith ergot, is an admirable medicine, and often produces excel- lent effects. I usually giAre ten-grain doses of both. The minerial acids and acetate of lead are extensively prescribed in cases of menorrhagia. They are, however, very unreliable agents. 10 LECTURE VII. Polypus—Varieties of—Mucous—Fibrous—Symptoms of—Opera- tion for Removal of—Adaantages of Steel Wire—Modifi- cation of Gooch's Canulje—Fibrinous and Placental Polypi. In the preceding lecture, I have spoken of those forms of menorrhagia Avhich depend on, or are caused by, an abnormal or diseased condition of the uterus or of its lining membrane; to-day, I have to call your attention to an affection as impor- tant as any of the preceding, one, too, of frequent occurrence, and Avhich almost invariably gives rise to profuse menstruation. I allude to polypus, which may be defined as the result of an hypertrophy of some portion of the uterine substance, Avhich, taking the form of an outgroAvth, becomes in time a distinct tumor attached to the wall of the uterus, either by a base of considerable extent, or more frequently, by a well-defined pedicle. These growths are met Avith of all sizes and shapes, sometimes as little stunted bodies only the size of a pea or small bean; sometimes as large tumors occupying the entire cavity of the uterus, enlarged to the size that organ should be at the fourth or fifth month of pregnancy; but more commonly they are seen of intermediate size. Occasionally the uterus seems to resent the presence of a polypus which has been developed within its cavity, and by contractions, similar to those of labor, expels it, and thus causes it to assume the form of an extra-uterine tumor; a pro- cess Avhich is evidently nature's attempt, often a successful one, MUCOUS POLYPUS. 115 to effect a cure. AVhen this takes place, and an intra-uterine polypus expelled from the uterus reaches the vagina, the haemorrhage it has given rise to is usually checked, or may possibly cease altogether. But, in addition to those of intra- uterine origin, polypi may grow from the cervical canal, just within the os uteri, or spring from the vaginal surface of the uterus. Numerous Ararieties of polypi are described by authors, but for practical purposes they may be classed under tAvo heads, namely, the mucous and the fibrous. The mucous polypus may spring from any portion of the mucous surface of the uterus; but its favorite seat seems to be the cenucal canal, and it may not unfrequently be seen pro- jecting from the mouth of the Avomb, as a small tumor of a bright pink color, Avhich bleeds on the slightest touch. These groAvths, Avhen of cervical origin, seldom attain a large sizS. The largest of this Arariety Avhich has come under my observation occurred in a AAoman, the Avife of a cabman. I saAV her about tAventy-four hours after deliArery, and found a polypus, of the size of an orange, hanging partially out of the A-agina. It Avas attached by a long and very slender pedicle to the cervix uteri, the point of attachment being just inside the os. The mkhvife Avho attended this Avoman assured me that her labor had been in all respects easy and natural, and that she did not detect the polypus till after the expulsion of the placenta. Its vitality had evidently been destroyed by the pressure to Avhich it had been subjected during the passage of the child's head through the vagina; for Avhen I saAV it, it al- ready exhibited signs of decomposition. This patient stated that having lifted a heavy Aveight when in the third month of preg- nancy she felt something give Avay internally, and immediately afterAvards perceived a tumor at the vulva. Profuse haemor- rhage folloAved, Avhich, hoAvever, soon subsided, and the tumor 116 DISEASES OF AVOMEN. receded. During the remainder of pregnancy she enjoyed good health, and, excepting that Avhen fatigued, she noticed some- thing appear at the vulva, she was not conscious of the exist- ence of anything abnormal. A polypus of such size as this springing from the cervical canal, is, however, rare. Another example of mucous polypus occurred in one of our out-patients, an unmarried woman, aged tAventy-four. Per- sistent haemorrhage, which all astringents failed to check, com- pelled me to make a vaginal examination, and I discoA'ered one of these polypi, nearly an inch and a quarter in length, but not much thicker than an ordinary quill, hanging out of the os uteri. In the great majority of instances, hoAveATer, the mucous polypus does not attain a fourth of that size. These small ones are nearly entirely composed of a soft gelatinous structure. They are highly vascular, and often give rise to severe haemorrhage quite out of proportion to the size of the tumor. They are generally attached to the canal of the cervix by a slender pedicle, and their vitality is very easily destroyed. It is not at all uncommon to meet Avith several small mucous polypi in the same patient; occasionally they are of a denser texture, a greater proportion of fibro-cellular tissue entering into their structure, and Avhen this is the case, they are more likely to attain a large size. Once detected, the removal of these mucous poylpi of cer- vical origin are a matter of great ease. This can be effected - either by torsion, or by means of a pair of curved scissors ; or better still, by snaring them Avith a loop of thin iron Avire, severing the attachment either by twisting it or by using an ecraseur. Doubtless, it seems almost unnecessary to use an ecraseur to remove so small a body, but it is by no means easy to twist off these little groAvths; it is often imperfectly done, and the consequence is the operation has to be repeated, and thereby much suffering entailed on the patient. I nowahvavs MUCOUS POLYPI. 117 use a Avire for the purpose of removing them; indeed I have seen such profuse haemorrhage folloAv the excision of eATen a very small polypus, that I do not think I shall eA^er again use a knife or pair of scissors for the purpose. In all cases, their point of origin should be cauterized Avith nitric acid. AVhen they project from the os uteri, this is all that has to be done, but sometimes they lie higher up in the cervical canal, and then you ha\Te to dilate the canal before you can reach them. This proceeding may of itself be sufficient to effect a cure, for so readily are they destroyed by pressure, that instances are not of infrequent occurrence, in Avhich haemorrhage himng led the phvsician to dilate the ceiwix in order to explore the uterus, he has, Avhen this dilatation was effected, found no morbid structure, the sea-tangle having destroyed by its pressure the polvpus to Avhich the haemorrhage Avas due. The fact of a polypus not being discovered in any particular case is, there- fore, no proof that one may not have existed. But mucous polypi are occasionally met Avith springing from the fundus of the uterus; then their removal is a matter of more difficulty, for the uterus must be dilated throughout its Avhole extent, the polypus seized, its attachment seATered, and nitric acid freely applied to the interior of the Avomb. Here is a specimen of a mucous polypus Avhich I recently re- moved from a patient in this hospital; it is very large, being as vou may see, the size of a goose's egg. The patient from Avhom this polvpus Avas removed is unmarried, aged tAventy-six years. A vear and a half ago she presented herself among our out- patients, and stated that of late menstruation had become so profuse as to debilitate her greatly. This, with some leucor- rhassed Avith ease up to the base of the polypus; they are then to be separated, and Avhile one is held firmly, the other is carried round the pedicle. This can always be accom- plished Avhen a silk or hempen liga- ture is used, but it is Aery difficult indeed, to carry a stiff Avire round a large tumor Avith them. HoAvever, I have done it, and cases from time to time occur in which this method proves very useful. Having once got the Avire round the tumor, the canula; are to be passed through the open- ings (c, c) in the extremity of the ecraseur ; the ecraseur is then to be pushed up, guided by the canula?, till it conies in contact with the pedi- cle of the polypus, the canulae can then be AvithdraAvn, and the Avire attached to the ecraseur at d and e, the operation is completed as if Ave Avere using an ordinary Avire ecraseur. This is, in point of fact, an adaptation of the canulae of Gooch to the ecraseur. Dr. Atthill's Ecraseur. 126 DISEASES OF AVOMEN. There has no greater advance been made in uterine surgery than in the treatment of intra-uterine polypus. Before the method of dilating the cervix uteri Avas introduced, it Avas im- possible to diagnose their presence with any degree of accuracy. We might .suspect their existence from the occurrence of haem- orrhage, and of uterine leucorrheea, but nothing more; now, to use Dr. Marion Sims's language, " We can determine Avith the minute'st accuracy not only their presence, but the size, shape, position, relations, and attachments of all such tumors," and, by means, of the Ecraseur, remoAye them in a short time Avith- out pain to the patient, who is under the influence of chloro- form, and Avithout any great risk to her life. But a fibrous polypus may spring from the vaginal portion of the cervix, as Avell as from the interior of the uterus; its removal is then comparatively an easy matter; for, unless the bulk be very great, the chain or Avire of an Ecraseur can be carried round it without much difficulty, and its separation accomplished in a feAV minutes. These polypi, as Avell as those of intra-uterine origin, which, having been expelled from the womb, have become vaginal, do not bleed so freely as those contained Avithin the uterus. Dr. McClintock, in his Avork On Diseases of Women, relates a striking example of this. He remoAred an enormous fibrous polypus, Avhich weighed thirty-four ounces, from the vagina of a Avoman aged fifty, and yet for tAvo years previously she had not had any red dis- charge. Here is a specimen of a remarkable form of fibrous poly- pus. You see it has a double attachment to the uterus. This patient Avas admitted into hospital suffering from profuse men- struation. On making a Aaginal examination, a large, firm, smooth tumor AA'as found projecting through the os uteri into the vagina. Anteriorly, and rather to the right side, this FIBROUS POEYPUS. 127 tumor could be traced up to the os, Avith the anterior lip of Avhich it Avas continuous, and presented the character of a ses- sile polypus springing from the margin of the os uteri and loAver segment of the cervical canal. The finger, passed up ov-er the posterior surface of the polypus, could not reach the upper margin of its attachment. The sound penetrated to the dis- tance of nearly three inches beyond the furthest point the finger could reach in this direction. The patient havung been etherized, the tumor Avas draAvn doAvn by means of a A'ulsellum, and, Avith some difficulty, I succeeded in carrying a steel wire, attached to a long ecraseur, over the posterior surface of the polypus. The Avire, however, broke before constriction had proceeded to any great extent, the attachment being evidently very dense and thick. A strong annealed wire was now in like manner carried over the tumor, but Avith no better success—it also broke ; and a third attempt, with a Aery strong steel Avire (piano string), resulted in the breaking of the ecraseur. The attempt to remove the tumor with the ecraseur having thus failed, I determined to detach it, if possible, by means of a pair of curved scissors. This proved to be a matter of much difficulty, the tissue being ex- tremely dense ; but, after the expenditure of considerable time, I succeeded in cutting through the portion attached to the an- terior lip. HoAvever, when this was accomplished, I Avas dis- appointed at finding that the true pedicle had not yet been reached, but that the tumor sprang from a point in the uterine Avail much higher up. The severance of the anterior attach- ment having given more room, and the tumor being Avell drawn down by means of the vulsellum, I at once proceeded to complete the operation. This was accomplished partially with the scissors and partly Avith a scalpel. Considerable htemorrhage folloAved, to restrain which I applied the actual 128 DISEASES OF WOMEN. Fig. 18. cautery, freely, to the bleeding surface ; but as it still continued, a pledget of cotton saturated Avith perchloride of iron in glycerin Avas inserted Avithin the os uteri, and the vagina plugged Avith cotton AAradding. Some hours subsequently, violent and incessant vomiting set in. This I attributed to the irritation caused by the pressure of the plug, for on re- moving it the vomiting ceased. No further unpleasant symptoms fol- loAved, and the patient made a rapid and good recovery. The tumor, on examination, proved to be a fibrous polypus. It Aveighed half a pound, its greatest circumfer- ence Avas seATen inches, that of the true pedicle, four inches. The most re- markable point connected with the case AAras that the polypus had tAvo attachments. It appeared to have been doubled back on itself, the point of the tumor having become so firmly and evenly united to the right side.of the os uteri, that it Avas con- tinuous with it. This condition is represented in the annexed Avood cut (Fig. 18). This union, I presume, must have oc- curred as the result of some inflammatory attack Avhich took place Avhen the point of the tumor had reached the os uteri, and that as the tumor subsequently greAV, the descent of the point being arrested by its union to the lip of the uterus, the central portion Avas forced dowmvards, and thus became the most depending part. The length of the polypus, AAmen in utei-o, measured from its pedicle to the most depending point, Avas fhre inches, but, Avhen removed and unfolded, it measured seven and a half inches. Fibrous Tumor with Double Attachment. FIBRINOUS POLYPI. 129 This Avoman was in a very anaemic condition, and the heart's action extremely feeble. These circumstances induced me to select ether as the anaesthetic to be employed, and the result Avas very satisfactory. There Avas no excitement, struggling, or vomiting. The pulse never failed, nor, during the whole of the long period she Avas under its influence—for the opera- tion occupied an hour and a quarter—Avas it necessary to Avith- draAV it. The sickness Avhich subsequently followed, I do not attribute, for the reason already stated, to the effects of the ether. In addition to the tAvo classes of polypi I have just spoken of, and Avhich are undoubtedly outgrowths from some portion of the uterine substance, two others are recognized by patholo- gists, to Avhich I must allude. The one is termed the fibrin- ous, and is looked upon by some authorities as the result of abortion. " The embryo having been extruded, the remains of the ovum left behind, form, with the extravasated blood, the foundation of a fibrinous polypus;" others believe these tumors to be " metamorphosed and adherent coagula of retained menstrual blood." Next, the possibility of the remains of the placenta being capable of giving rise to polypoid bodies in the uterus has also been advocated, especially by Dr. Stadfeldt, of Copenhagen, from a translation of avIiosc paper by Dr. W. D. Moore, in the Dublin Quarterly Journal, for NoATember, 1863,1 have quoted the foregoing extracts, the perusal of Avhich Avill amply repay anv of vou who may desire to become better acquainted Avith this subject. Dr. Stadfeldt does not believe that those small portions of the afterbirth which nearly ahvays remain after the placenta has been detached, and Avhich usually come away Avith the lochia, are capable, even if retained, of giving origin to " placental polypi," but only when portions, varying in size " from that of a Avalnut to that of a goose-egg or larger, and 11 130 DISEASES OF AVOMEN. Avhich contain one or more cotyledons of the placenta," are left behind, and remain firmly attached to the uterine Avail. Ably adduced, hoAve ver, as are the arguments of Dr. Stadfeldt, I am not satisfied that his views are borne out by the facts brought fonvard in support of them. They amount to this: that in four cases large portions of the placenta were found after death adherent to the uterus inAvomen recently delivered; the longest interval which elapsed betAveen delivery and death being but four weeks; in his other cases but a feAv days intetwened. With similar instances every obstetric physician is familiar. In the case related at the conclusion of my last lecture, I removed a portion of the placenta Avhich had been retained in the womb for nearly ten Aveeks after delivery, and Avhich doubtless Avas during that time gradually being loosened from its attachment to the uterine Avail, and its connection Avas prob- ably only completely severed by the traction I made use of. That it Avas still connected Avith the uterus Ave may, I think, safely infer from the fact that the mass Avas'not in any degree decomposed; but the persistence of vitality in a portion of placenta adherent to the iiterus is a very different thing from its development into a polypus. I may here allude to those soft, pearl-colored bodies which are occasionally met with in the cervix uteri, and Avhich are sometimes, though incorrectly, termed cystic polypi. They are composed of an albuminous, gelatinous fluid inclosed in a delicate membrane. They appear sometimes to be simplv en- larged or hypertrophied Nabothian glands, but are occasion- ally neAV groAvths. I pointed out to you an example of the latter form in one of the out-patients a feAv days ago, in whom a polypus grew from the lip of the os uteri; it was the size of, and not very dissimilar in appearance to, a grape, and had not caused hemorrhage. When I attempted to seize it with the forceps, it broke, and discharged its contents. I cauterized FIBRINOUS POLYPI. 131 its point of attachment freely Avith nitric acid, and Avhen the Avoman presented herself again, after the lapse of a feAv days, no trace of this little polypus remained. In none of the cases which have come under my obserA-ation have they been of greater size than a hazel-nut or grape, nor am I aware of any instance in Avhich they were attached high up in the uterus. They nearly invariably groAV from some portion of the cervical canal, and are ahvays sessile, that is, grow directly from their point of origin Avithout the intervention of a pedicle; two or more may, and frequently do, occur at the same time. When once detected, they are easily destroyed, either by pressure or by torsion. If situated within the cervical canal, they gener- ally give origin to a glairy discharge, and nearly always cause haemorrhage. LECTURE VIII. Fibrous Tumors—Definition of—Varieties of—Subperitoneal— Submucous—Intramural—Enucleation—Intra-uterine Injec- tions—Influence of Pregnancy—Spontaneous Cures. I shall proceed to-day, gentlemen, to direct your attention to the subject of fibrous tumors of the uterus, a» subject of even greater importance than that of polypus, which Avas last under our consideration, and unfortunately oftener beyond the reach of surgical interference. ' A fibrous tumor may be defined as, a groAvth composed of tissue, identical in structure with that of the uterine wall, but " disconnected" from it, being in general surrounded by a capsule of dense fibro-cellular tissue, Avhich " is peculiarly dry and loose, so that when one cuts on the tumor it almost of itself escapes from its cavity" (Paget, Surgical Pathology). This fact of the fibrous tumor of the uterus being by means of its capsule disconnected from the surrounding tissue, distinguishes it from the ordinary fibrous polypus; a distinction Avhich often cannot be made during life. The annexed Avoodcuts, copied from Paget, illustrate the difference betAveen these two groAvths; the one (Fig. 19) being a section of a uterine outgroAvth or polypus, the other (Fig. 20) of a uterine fibrous tumor, the former being " continuous," but the latter " discontinuous," Avith the substance of the uterus, although both in outward ap- pearance are Aery similar. FIBROUS TUAJOR. 133 It Avould be quite impossible in the brief limits of a clinical lecture to enter at any length into the pathology of a subject so extensive as that of fibrous tumors of the uterus. I can only glance at a few of the leading characteristics, referring such of you as desire further information on this interesting subject to the works of Paget, West, McClintock, Matthews, Duncan, and others. Fibrous tumors are met Avith of all sizes, from that of a Fig. 19. Fig. 20. Uterine Outgrowths. Uterine Fibrous Tumor. (After Paget.) grain of shot upAVards; those of large size being by no means of unfrequent occurrence, Avhile eases are on record, in Avhich they have attained a size greater than that of the Uterus at the full term of pregnancy, and a AVeight of seventy pounds, or even more. Again, they may be solitary, but usually two or more are present in the same patient; they may spring from the peritoneal surface of the uterus, and can be felt through the abdominal Avail; they may groAV from the submucous tissue of the uterus, or, finally, be developed within the Avails of the organ. Consequently, fibrous tumors are spoken of as belong- ing to one of three classes, namely, subperitoneal, submucous, and intramural, according as they are found to groAV in one or other of the situations I have designated. The extra-uterine and subperitoneal being in general beyond 134 DISEASES OF AVOMEN. the reach of treatment, must be dismissed after a brief notice. They A*ary in size and appearance in even a greater degree than either of the other varieties; sometimes being numerous, small in size, and sessile, giving the surface of the uterus a nodulated appearance; or, on the other hand, attached by a pedicle which is sometimes short and thick, as shoAvn in Fig. 21, or at other times, so long and slender as to permit the tumor to float, as it Avere, free in the abdominal cavity, and finally eAren dissever itself from all connection with the Avomb, and possibly become Fig. 21. Subperitoneal Fibro-cystic Tumor. attached to some other portion of the peritoneal surface. When subperitoneal fibroids are pedunculated they sometimes descend into the pelvis, and then, by their pressure on the neighboring organs, give rise to most distressing symptoms. When this occurs, the patient's sufferings are sometimes Arery severe, inces- sant desire to micturate, or total inability to pass Avater, beino- frequently experienced. Of course, it is impossible to -give re- lief unless the tumor be raised from its position and replaced above the brim. This is ahvays a matter of great difficulty, FIBUOUS TUMORS. 135 sometimes an impossibility. The tumor invariably lies in the posterior cul de .stic, betAveen the rectum and the uterus, occu- pying much the same position which the impregnated uterus does Avhen rctroverted. With the vieAV of raising it above the brim, Dr. Kidd has adapted to such cases the method sug- gested by the late Dr. Halpin, of Cavan, for restoring the uterus to its normal position Avhen rctroverted during preg- nancy. He introduces one of Barnes's largest-sized india- rubber bags into the rectum, and gradually distends it Avith water by means of a syringe, Avhile, at the same time, steady pressure is made Avith the finger on the tumor through the vagi- nal Avail. In this Avay you will occasionally succeed in rais- ing the tumor, and making it slip up into the false pelvis, un- less indeed the ease be of long standing, and it be bound doAvn by adhesions ; should such exist, your efforts Avill be not only useless, but injurious. Subperitoneal fibrous tumors do not necessarily give origin to menorrhagia; indeed, as a rule, they do not seem to influence menstruation at all. Thus, in the case delineated in Fig. 21, the catamenia Avere quite regular. These tumors also gener- ally spring from the posterior surface of the uterus or from the fundus. This, however, is far from being ahvays so ; for, in the patient from whom the drawing (Fig. 21) was made, the tumor grew from the anterior wall. This case Avas interesting too, as affording an example of that form of the disease termed jibro-ey.stic, in which a cyst is developed within the structure of the solid tumor. The patient was under the care of my friend, the late Dr. Morgan, in Mercer's Hospital, through Avhose kindness I had an opportunity of seeing her. She appeared to be about thirty- live years of age, was married, but had never been pregnant. She stated that two years ago she detected a small, hard mova- ble tumor in the left iliac region; that a year subsequently she 136 DISEASES OF AVOMEN. perceived Avhat she supposed to be another distinct tumor in the right side; the latter was, hoAvever, but a projecting por- tion of one large central groAvth, Avhich had steadily increased till she had attained the size of a woman near the full term of pregnancy, but she did not think that for the last few months she had become larger. Menstruation appeared regularly at intervals of three Aveeks; fluctuation Avas everywhere very dis- tinct, and there Avas universal dulness on percussion. On making a vaginal examination, the tumor could be easily felt blocking up the brim of the pelvis. The anterior lip of the os uteri, which Avas greatly hypertrophied, projected into the vagina, the uterus lying quite behind the tumor. The diagnosis of the uterine cystic disease was made, and all idea of surgical interference was given up. This patient subsequently died of an attack of acute peritonitis, and we had an opportunity of veri- fying our diagnosis. The tumor, Avhich was of enormous size, consisted mainly of an immense cyst; it sprang from the ante- rior and upper surface of the uterus, being connected to it by a short, thick pedicle. The woodcut, Avhich accurately repre- sents both the size, shape, and position of the tumor, Avas taken from a drawing made by my friend and former pupil, Dr. Hamilton Moor head. The submucous, pedunculated, fibrous tumor is, prior to its removal, in no way distinguishable from and is to be treated in a manner identical Avith the ordinary fibrous polypus of which I have already spoken. I shall not, therefore, allude to it any further, but shall proceed to the consideration of the third, and most important variety of these tumors. Intramural, or as they are sometimes termed, parietal or in^ terstitial fibrous tumors, are of frequent occurrence. They differ from the subperitoneal in tAvo important features^ namely, that they nearly ahvays cause menorrhagia, and almost as invariably pain, frequently of a very severe character, Avhich FIBROUS TUMORS. 137 is aggraA'ated on the approach of each menstrual period, Avhile their presence induces enlargement of the uterus, an effect not usually produced, at least to a marked degree, by the subperi- toneal ATariety. Thus, in the case just alluded to, though the tumor weighed upwards of eleven pounds, and Avas at lea^t twenty-five inches in circumference, the uterus Avas of nearh7 its normal size and shape; Avhile the presence of even a Arery small intramural tumor has been knoAvn so to stimulate the Avomb, that it has grown to a length of five or six inches, Avhile its Avails haA'c attained a thickness of an inch or more. Dr. West, in his Avork on Diseases of Women, mentions a case illus- trative of this fact. The groAvth of an intramural fibrous tumor is sometimes very slow. In a case at present under my observation, and in Avhich the womb has attained a length of five inches, no ap- preciable change has taken place during a period of several years. On the other hand, the tumor sometimes steadily in- creases in size, and then one of the three results must occur— either, it will bulge out the peritoneal surface of the uterus, and possibly may become a subperitoneal tumor; or it may continue to groAV in the substance of the uterus, the Avhole of the organ enlarging as the tumor increases ; or it may project into the uterine caA'ity carrying before it a covering of the muscular tissue of that organ. It is easy to conceive hoAv this latter process, if continued, may result in the formation of an intra-uterine tumor, connected Avith the Avail by a pedicle, consisting; of muscular tissue continuous Avith that of the uterus and of the mucous membrane covering it; and that this pedicle may in time elongate, and as it lengthens become more slender, till finally it passes out of the uterus ; or eA^en, the pedicle giving way, may be expelled from the vagina. 2s early all writers, Avith the exception of Dr. Matthews Duncan, admit the possibility of such an occurrence. He thinks that the 12 138 DISEASES OF AVOMEN. uterine Avail never elongates before the true intramural tumor, but that the tumor is expelled bare into the uterine cavity, enucleation of the tumor, a process to Avhich I shall have to refer by and by, having taken place spontaneously. How- ever, one thing is quite certain, that these growths frequently present themselves as Avell-defined tumors projecting into the cavity of the uterus. Here is a specimen of a tumor so circumstanced ; you see that it is connected to the uterine Avail by a very extensive attachment, the circumference of the base being greater than that of any other portion of the tumor. It Avas taken from the body of a patient who recently died in hospital. She Avas a married AAToman, aged fifty-three. About five years ago she ceased to menstruate, but after a considerable interval, again observed a sanguineous discharge to appear. This at first re- curred with tolerable regularity, then gradually became more and more profuse, till finally it was continuous. Some months ago, she perceived a tumor in the abdomen, AA'hich at one point, on the left side, Avas extremely tender to the touch ; she also experienced constant pain in, and was unable to lie on, that side. When admitted into hospital she was in a very anaemic condition. On passing the hand over the abdomen, a large tumor could be felt lying rather to the left side, Avhich, as I have al- ready mentioned, was at one point very tender to the touch. On making a vaginal examination, this tumor proved to be the uterus greatly enlarged. The sound passed to the depth of five inches. I at once proceeded to dilate the cervix with sea-tangle, on AvithdraAving which, this large tumor Avas de- tected projecting into, and filling up the whole cavity of, the uterus. The pattent's condition rendered it absolutely neces- sary that its removal should be immediately attempted. I en- deavored to accomplish this Avith Marion Sims's intra-uterine FIBROUS TUMORS. 139 ecraseur, but, as stated in a former lecture, I found that in- strument quite unsuitable for the purpose. I then tried an ordinary wire e*craseur, and succeeded in ensnaring the tumor, but the Avire (an iron one) broke. Three times I succeeded in encircling the tumor Avith the Avire, but the strain to Avhich it was subjected Avas too great, and on each occasion it broke. As the patient Avas noAV much exhausted I desisted from any further attempt; besides, I hoped that the great pressure to Avhich it had been subjected, might have been sufficient to de- stroy the vitality of the tumor and that it Avould slough off. Matters Avent on Aery Avell for three days; indeed on the third day she expressed herself as being quite Avell. There Avas not any haemorrhage; she had no pain on pressure, and the pulse Avas quiet; but, on the night of the fourth day, she Avas sud- denly seized Avith a violent rigor, complained of intense pain over the abdomen, sank into a state of low, muttering delirium, and finally died comatose. On opening the abdomen after death hardly any trace of peritoneal inflammation presented itself, but on raising the omentum, that point on the fundus of the uterus which, as previously noticed, had been so exeesshTely tender to the touch, was found to be in a condition of actual mortification. On opening the uterus this enormous tumor Avas seen; it was nearly five inches in length, and its base Avhere the ligature had surrounded it, measured nine inches in circumference. This case fairly illustrates the risk which must be incurred in the attempt to remove fibroids haAnng extenshre attachments to the AArall of the uterus by means of the ecraseur; the mor- tality attending the operation, in such cases, being, as far as my experience goes, very high indeed. The body is the usual seat of intramural fibroids, but they may be developed in any part of the uterine wall. Thus I recently removed one Avhich Avas imbedded in the anterior lip 140 DISEASES OF AVOA1EN. of the os. The patient Avas an unmarried Avoman, aged about thirty. She stated that for some months past she had suffered much discomfort from a sense of Aveight and fulness in the vagina, and that recently she perceived a tumor protrude from the vagina, which receded Avhen she lay doAvn, but always re- appeared Avhen she Avalked about. Menstruation continued perfectly normal. On examination, an ovoid mass, of the size of a hen's egg, Fig. 22. Intramural Fibroid of Cervix. Avas seen projecting from the vagina, its long diameter being parallel with the vulva. The protrusion consisted of the anterior lip of the uterus, Avhich Avas elongated and thickened; the uterus itself being drawn doAvn by the weight of the tumor FIBROUS TUMORS. 141 till it rested on the perinaeum, the os uteri being close to the vulva. The condition of the parts is correctly represented in the annexed Avoodeut (Fig. 22). The diagnosis of a fibrous tumor imbedded in the anterior lip of the uterus having been made, I determined to amputate the elongated portion of the cervix, electing to do so by means of the galvanic knife, hoping by that method to lessen the risk of haemorrhage, Avhich the thickened and hypertrophied condi- tion of the part led me to think Avould be likely to occur—an opinion which the eArcnt verified. The apparatus employed was Grenet's. The galvanic knife consisted of a loop of plati- num Avire about half an inch in length, connected by means of the ordinary wire conductors Avith the battery. The cervix measured three and a half inches in circumfer- ence at the point selected for amputation. The great thickness of the tissue to be divided, and its extreme denseness, rendered the operation very tedious. The cauterization was sufficient to prevent any serious haemorrhage occurring; still tAvo arteries had to be ligated. On subsequent examination, the amputated lip was found to contain a perfect fibrous tumor inclosed in its capsule. In general, howeATer, fibrous tumors appear as mere protu- berances, bulging out of the uterine wall, as is sIioavu in Fig. 23. Such tumors as these cannot be removed Avith an ecraseur, and yet you cannot leave them alone, for health is undermined, and life itself frequently endangered by the haemorrhage aris- ing from their presence. The treatment to be adopted in such eases necessarily divides itself into the palliative, and the radi- cal ; the former consists in restraining the profuse Aoav, Avhich occurs at each menstrual period, by plugging the vagina, as recommended in a former lecture, and by the administration of haemostatics, such as gallic acid, alum, etc., Avhile ergot, alone or in combination with perchloride of iron, is often useful, But 142 DISEASES OF AVOMEN. this plan of treatment is irksome to the patient, and can only be looked on as a means of delaying the fatal result, Avhich, if the haemorrhage continue, ere long must folloAv unless more energetic means be adopted. Medicines without number have been administered Avith the vieAV of causing the absorption of fibrous tumors of the Avomb. I have tried fully and freely most if not all of them, and be- lieve them to be of no use. It would be Avaste of time for me Fig. 23. Intramural Fibrous Tumor (after Sims). to go through the long list of drugs Avhich have been recom- mended in these cases. I do not Avish to deter you from trying them in your future practice; they will probably do no harm, but I think I can promise that they Avill effect little good. For myself, I have lost all faith in the resolvent powers of medi- cines in the disease at present under consideration. The very limited good produced by medicines has induced obstetric surgeons to adopt energetic measures for the treatment of intramural fibroids; no less than six methods ha vino-been recommended and practiced Avith the vieAV to the radical cure FIBROUS TUMORS. 143 of these imbedded fibrous tumors. They are: 1st. Incision of the cervix uteri. 2d. Incision of the tumor. 3d. Incision into the tumor and destruction of a portion of its tissue, a process to Avhich the term gouging has been applied. 4th. Enuclea- tion of the tumor. 5th. Avulsion, or the forcible tearing aAAay of the tumor from its attachment. 6th. The formation of a slough in the tumor and intervening portion of the Avail of the uterus, produced by the use of the actual cautery. The treatment by incision of the os is founded on a theory of the late Mr. Baker BroAvn's, according to Avhich " the di- vision of the os and cervix uteri, permits the fibres of the body of the uterus to contract upon the contained tumor, and thereby to compress the ATessels and prevent haemorrhage." Whether this be the true explanation or not, one thing is quite certain, that the operation is occasionally folloAved by good results, and in the case of very large tumors, Avhich are contained Avithin the uterus, and Avhen the cervix is thin and spread over them, it is fully justified. The incision of the tumor has been practiced by Dr. Atlee, in America, by Dr. Tracy, of Melbourne, and others, with success—a success Avhich is probably due to the fact that the vitality of these tumors is nearly, if not altogether, destroyed bv the incisions having divided their capsules; for the fibrous growth itself is endoAved with but a ATery Ioav degree of vitality. I have on several occasions incised these tumors Avith the effect of moderating the haemorrhage for a time, but it is an opera- tion that cannot be relied on. Enucleation, that is the cutting doAvn on, and dhdsion of the capsule, the tumor being then seized and turned out of its cap- sule, is an operation suggested by a consideration of one of the processes by Avhich nature occasionally effects a spontaneous cure; the capsule and investing covering of the tumor becom- ing thinned at one point by a process of absorption, the con- 144 DISEASES OF AVOMEN. tained tumor is then pushed out by the contractile power of the uterus, and so finally expelled. Enucleation is advocated by Dr. MattheAvs Duncan, with his usual ability. He also practices the operation of aArulsion, that is the seizure of the tumor with a strong vulsellum, and forcible aArulsion of it from its attachment. Avulsion is adopted by Dr. Duncan in cases in Avhich spon- taneous enucleation has already partially begun, or Avhere that process, having been artificially commenced, has advanced to a certain extent. He considers it to be the proper practice in those cases of fibrous tumors in which the patient's life is in great danger, and which medical treatment is unable to avert. In the folloAving case I successfully practiced avmlsion, enu- cleation of the tumor having been preATiously effected: C. S., set. 40, a" widow; admitted into the Rotunda Hospital, June 8th, 1877. She stated that she has had two children, and al- Avays enjoyed good health till the birth of her last, sixteen years ago, after Avhich she observed the menstrual periods to become profuse, and occasionally to re-occur twice in the month. Of late the intervals became longer, but the loss continued as profuse and as Aveakening as ever, and Avas accompanied by great pain. In March last the haemorrhage Avas so profuse that she Avas confined to bed for five Aveeks, and has suffered ever since from excessive Aveakness and pain in the back and above the pubes. She also suffers from a constant leucorrhceal discharge of a yelloAV color and fetid odor. On passing the hand over the abdomen, a large tumor of very dense structure could be felt rising out of the pelvis and reaching to Avithin an inch of the umbilicus; this, on a bi- manual examination, proved to be uterine. The sound passed to the depth of nearly seven inches; the os uteri Avas patulous, and through it the finger reached a globular tumor, apparently imbedded in the uterine Avail. ENUCLEATION. 145 The diagnosis of intramural fibroid Avas made. It being eATident that this Avoman Avould soon sink from the combined effects of uterine haemorrhage and profuse leucor- rhceal discharge, I decided on attempting the removal of the tumor. June 25th. As a preliminary step, the patient being brought under the influence of chloroform, the cervix was di- vided freely on both sides by means of Kuchenmeister's scis- sors; no haemorrhage folloAved. She Avas then ordered the folloAving mixture : R. Liq. ferri perchloridi,......gij. Liq. ergotse (B. P.),......^iv. Inf. ergotse an,.......^ viij An ounce three times a day. July 13th. Being again brought under the influence of chloroform the tumor Avas seized Avith a strong A'ulsellum, and its base, easily reached through the now patulous ceiwix, Avas with a knife freed from its attachment to the uterine AA'all, to the extent of nearly two inches; an ineision diA'iding the cap- sule Avas also made into the tumor on its anterior surface in a direction perpendicular to its base. A moderate amount of blood only Avas lost, and it was not found necessary to have recourse, either to the plug, or the use of the perchloride of iron. After a lapse of a couple of days the patient Avas again put on the ergot mixture already mentioned, Avith this remarkable result, that Avhereas Avhen previously administered it did not seem to produce any effect, now the same medicine brought on powerful uterine action; each dose produced this effect Avithin half an hour of its being taken, and the pains continued for four or five hours. Indeed, such extreme suffering was pro- duced, that the patient absolutely refused to continue the mciii- 146 DISEASES OF AVOAIEN. cine. This remarkable difference in the action of the ergot was probably due to the fact that, the capsule of the tumor be- ing divided, the tumor Avas noAV, as it were, a foreign body in the uterine cavity, AA'hereas previously it had formed part of the uterine wall. 27th. A large section of the tumor has passed through the os uteri, and the rim of the os can be felt grasping the centre of the half-expelled tumor. August 10th. The pains ha\Te ceased for the past day or tAvo, and the ergot no longer induces uterine action. On ex- amination, the tumor is found to occupy the position of the foetal head in the second stage of labor; the os uteri can no longer be felt. In fact, the tumor has been expelled from the uterus, and is only attached to the fundus by a comparatively small base, and is virtually " enucleated." No haemorrhage Avhatever had occurred since the operation of July 13th. There is, hoAve\Ter, a very copious vaginal dis- charge, broAvnish in color, constantly present. The patient did not suffer any pain, but complained of great debility. It being evident that nature would do no more, and it being impossible to leave the patient in her present state, the removal of the tumor by avulsion Avas decided on. The patient Avas accordingly brought under the influence of ether, and the pro- jecting portion of the tumor being seized Avith a strong vul- sellum, traction was employed, the left hand of the operator being introduced between the tumor and the pelvic Avail, and the detachment of the tumor aided by the fingers of that hand. The tumor was thus finally torn from its attachments, and completely removed. The cavity was now sponged out and plugged with pledgets of lint saturateed in a solution of ferri perchlor. (1 in 3.) The haemorrhage during the operation was inconsiderable. The tumor, which was of an irregular ovoid shape, Aveighed EROOT HYPODERMICALLY. 147 13| oz., and measured fhre inches in length in its longest di- ameter. This patient made a rapid recovery. There are less heroic modes of treatment, I Avould haAre you bear in mind, and under certain circumstances practice, before having recourse to surgical measures. One is the injection, after previous dilatation, of tincture of iodine, or of the liquor of the perchloride of iron, into the uterine cavity. This prac- tice is warmly advocated by Dr. Bouth, of London, and, if the cervix and os internum be first dilated, so that the injec- tion may have a free and rapid exit, I do not think that it is likely to be folloAAred by unpleasant symptoms. My friend Dr. McClintock informs me that he has recently injected tincture of iodine Avith marked success, in the case of a lady, Avhom I had an opportunity of seeing Avith him, and in Avhom alarmingly profuse menstruation, Avhich he ascertained to be dependent on the presence of a large fibroid, occurred from time to time. Dr. Matthews Duncan has recorded two cases in Avhich he successfully restrained dangerous haemorrhage, depending on the existence of a tumor in the uterus, by the injection, in each case, of one drachm of tlie liquor ferri perchloridi dil., by means of a IioIIoav sound, into the caATity of the womb. In his cases the cervix does not seem to have been dilated, a pre- caution I should ahvays adopt. The hypodermic injection of ergot has, for some years past, been extensively practiced for the control of various forms of hemorrhage, and Avith considerable success; latterly the same treatment has been adopted Avith the aucav of check- ing post-partum haemorrhage Avith equally good results, the main objection to its use being, that troublesome sores are apt to form at the site of the operation. Dr. Hildebrandt* * Gazette Ilebdoniadaire de Medeeine et de Chirurgie, vol. ix, page 443. 148 DISEASES OF AVOMEN. has published the particulars of numerous cases in Avhich he has practiced the subcutaneous injection of ergot in the treat- ment of fibrous tumors of the uterus. He comes to the con- clusion that ergot thus used is a poAverful agent. In one case, a tumor Avhich reached above the umbilicus disappeared ; in a second, a tumor, extending as high as the false ribs, descended beloAV the umbilicus, and in four other cases, in Avhich the treatment Avas otherAvise less complete, there was an ameliora- tion of the general and local condition. According to him, ergot thus employed rectified menstruation in almost all the cases, rendering its recurrence regular, less profuse, and above all, less painful. It is true, as Dr. Hildebrandt remarks, that it is not easy to state precisely how the ergot acts; but he adds that it is A^ery likely that, as a result of the contractions pro- duced by the ergot in the nutritive ATessels of the tumor, and in consequence of the compression exercised in all directions by the contractions of the uterine walls, the nutrition of the tumor is impeded, and that in time fatty degeneration and absorption folloAv. It is probable that intramural tumors are more easily acted on than subperitoneal. Dr. Hildebrandt's formula is: Watery extract of ergot, three parts; glycerin, seven parts; and distilled Avater, seAren parts. Such a solution is better, in his opinion, than an alcoholic one, as its use does not produce so much pain, and is not so liable to be folloAved by the forma- tion of abscesses. He recommends that the injection should be made in the loAver segment of the abdominal Avails, betAveen the umbilicus and pubis, and says, that after the operation the patient may be alloAved to walk home. There is no doubt but that an aqueous solution is less liable to be followed by un- pleasant consequences than a spirituous one. I at first adopted Dr. Hildebrandt's formula, and injected from three to five drops of the liquid extract of ergot on each occasion. En- couraged by his experience I injected, as you may remember, ERGOT HYPODERMICALLY. 149 about three minims of the liquid extract of ergot under the skin of the abdomen, in two of our out-patients a feAv days since, and alloAved them to AAralk home. Both suffered severely ; one Avas confined to bed for three days subsequently, so intense was the pain she experienced, and so considerable the inflamma- tion Avhich ensued. I should not recommend you to employ the hypodermic injection of ergot, unless the patient could re- main at rest. But I have no hesitation in saying that the addition of glyc- erin is most injudicious. Since I haATe ceased to add it to the solution I have not had any unpleasant results. I have given the hypodermic injection of ergot a full and fair trial, both in hospital and private practice. The details of the following cases Avill enable you to judge for yourselves as to the results Avhich may be expected from this mode of treat- ing uterine fibroids. They are doubtless too feAv in number to lead to any definite conclusion, but I think they establish tAvo facts: 1st. That the hypodermic injection of ergot is most ef- ficacious in restraining uterine haemorrhage depending on the presence of a fibroid; and, 2dly, that the treatment is not al- together unobjectionable. In three of my cases troublesome abscesses formed, sooner or later, in two of the patients giA7ing rise to considerable constitutional disturbance, Avhile in a fourth I Avas obliged to abandon the treatment in consequence of the excessive pain following the injection. It is Avorthy of special notice, however, that since I omitted the glycerin no abscess or sore folloAved the injection. Case I.—M----, aged 41, suffered from very profuse men- struation, the periods being inArariably ushered in by such in- tense pain that for a long time previous to her admission into hospital she had been in the habit of taking large doses of opium nightly. On admission, a tumor, as large as the foetal head at full term, could easily be felt in the abdomen. The 150 DISEASES OF AVOMEN. sound penetrated to the depth of 4^ inches, and after a care- ful examination, the diagnosis of fibrous tumor of the uterus was made. As the case seemed a very suitable one in Avhich to try the effects of the hypodermic injection of ergot, I at once commenced this treatment, using for the purpose the extract urn ergotce liquidum (B. P.) in proportion of three parts of the ex- tract to seven of glycerin and seven of Avater, this being the formula recommended by Professor Hildebrandt. The first injection of tAventy minims of the solution just named, contain- ing about TTjjniss. of the ergot, was made on the 1st November, during a very profuse menstrual period. In about three hours it markedly checked the Aoav, but the pain caused was so intense that I did not venture to repeat the injection for seA'eral days ; the floAV, I should add, entirely ceased on the second day after the injection. On this occasion, and on all the subsequent ones, the fluid Avas injected behind the great trochanter, the needle being made to penetrate into the substance of the glutaeus mus- cle, on either side alternately, to the depth of upAvards of half an inch, previous experience having proved to me the correct- ness of the observation made by Dr. Keating in The American Journal of Medical Science, that the tendency to inflammation occurring after the injection of ergot is much lessened by pass- ing the needle through the cellular tissue into the substance of the muscle. The second injection Avas made on the 9th NoArember, and the third on the 16th. From that date the injections Avere re- peated on every second or third day, and once or tAvice on two days in succession, according to the intensity and duration of the pain produced by the operation, until fifteen injections had been given. Tavo abscesses then formed on the site of the two last injections, and these became so very painful and trouble- some that the treatment had to be discontinued for three Aveeks. The effects hitherto observed Avere these: 1st. Very intense ERGOT HYPODERMICALLY. 151 and long-continued pain ahvays folloAATed the injection. The duration of the pain was from five to tAvehre hours, after the lapse of Avhich time it gradually subsided, leaving her greatly exhausted. She Avas unable to sleep during its continuance. I Avas therefore obliged, except on tAvo occasions, to alloAV at least forty-eight hours to elapse betAveen the injections. 2dly. The duration of the eatamenial period, which on admission had been fourteen days, Avas, on the recurrence of the first period after, the ergot had been injected, reduced to four days; on the second to tAvo days, and on the third to one day. 3dly. The periods Avere rendered free from pain; formerly, the pain at these times had been very intense. It is necessary to add that the tAvo last injections Avere not made in accordance Avith the rule I had laid doAvn, namely, that the needle should penetrate deeply into the substance of the muscle, for during my absence the needle Avas introduced on one occasion over the head of the femur, and, on the other occasion, very near the crest of the ilium. It Avas not until the 5th of January, 1874, that the abscesses and sinuses resulting from the injection of the ergot had suffi- ciently healed to permit a resumption of the treatment. On recommencing I resolved to employ a different preparation of ergot, and accordingly procured some of " Wiggers's pure er- gotin." This, instead of being a liquid, is a granular substance, and very insoluble; I injected two grains of it on the 5th. The catamenia had appeared two days previously; the flow lasted four daA^s Avithout pain. I consider this satisfactory state, hoAV- ever, as due to the previous treatment. On the 10th, having passed the sound into the uterus, the Aoav returned and con- tinued for four days more; and again, after an interval of but four days, the discharge reappeared, continuing for six days, the hypodermic injection being repeated daily. On the 2d of 152 DISEASES OF WOMEN. February I made the following note : " The hypodermic injec- tion of the Wiggers ergotin did not cause any pain, but it seems to be inefficacious, for the metrorrhagia has returned." I now decided on trying Bonjean's ergotin; this is a thick fluid, easily mixable Avith water. I injected TTj^iy of it dis- solved in trgxx of water. This caused some pain; less, how- ever, than that produced by the English preparation. The injections were, from this date, continued regularly, rrgy of er- gotin being injected ewery second day. March 11th. Catamenia came on after tAventy days' interval, accompanied Avith intense pain, Avhich was only relieved by the hypodermic injection of morphia. The Aoav ceased on the sev- enth day. I believe Bonjean's ergotin to be less efficacious than the English preparation, but on the other hand to be much less irritating. Shortly after the last date this patient was compelled to re- turn home. She resides in a very remote part of Ireland, and I have been unable to learn anything of her present state. Case II.—This case is of little practical value, excepting so far as it illustrates the difficulty of carrying out the treatment of fibrous tumors by the hypodermic injection of ergot. A. M----, aged twenty-five, a pale, unhealthy-looking woman, six months married, presented herself among the out-patients of the Adelaide Hospital. She stated that of late she Avas hardly ever free from profuse and Aveakening haemorrhage. Her appearance fully confirmed this statement; she Avas evidently anaemic and in very bad health. On examination, a large interstitial fibroid was diagnosed. In her case I commenced treatment by inject- ing TTgjv of Bonjean's ergotin, dissolved in fifteen minims of water. The fifth injection, however, Avas followed by the for- mation of a very painful and troublesome abscess, and on re- covering from it she left the hospital; nothing Avould induce her to permit the injection to be repeated. I think it probable ERGOT HYPODERMIOALLY. 153 that the rapidity Avith which abscesses formed in this case may be accounted for by the fact that the Avoman was evidently ill-fed, and in a thoroughly bad state of health. Case III.—An unmarried lady, aged 48, came under my care in February, 1874, at the termination of a very profuse menstrual period. She stated that eight years previously, she had detected a tumor in the abdomen, which had gradually increased to its present size. Menstruation had, for many years, been profuse, becoming markedly so during the last tAvo years, with occasional haemorrhagic discharges during the intervals, never, hoAvever, until recently, of sufficient severity as to cause alarm. She had ahvays been more or less of an invalid, and was, moreover, the subject of Avell-marked cardiac disease. The tumor was very large—it reached nearly to the umbilicus. The sound penetrated to the depth of five inches. The diag- nosis of fibrous tumor was made. When I saw her first she was in a state of great danger. The excessive loss of blood had reduced her to a condition of extreme debility. She fainted constantly; the pulse was small, feeble, and intermit- tent. Under treatment she gradually improved; but being convinced that a recurrence of the profuse loss would probably prove fatal, I determined to try the effects of the hypodermic injection of ergot, not, however, Avithout considerable hesitation, for, in her debilitated state, I dreaded the formation of ab- scesses, Avhich my previous experience had shoAvn me were so prone to occur. I should add, that at this time the periods recurred at inter- A'als of not more than fourteen days, and that during this interval, she Avas seldom free from a slight red discharge. The first injection of two grains of Bonjean's ergotin Avas made on the 20th February, the same formula being used as in the former case. The needle Avas inserted behind the great trochanter, and made to penetrate to the depth of at least an 13 154 DISEASES OF WOMEN. inch. No pain folloAved. From that date to the 20th of March, the injection of the Bonjean's ergotin was continued with tolerable regularity on every second day; occasional in- termissions, hoAvever, occurred, Avhen, from a feeling of exces- sive debility, arising generally from the heart's action being more than usually irregular, she seemed unable to bear the pain, trifling though it Avas. Five grains of the ergotin Avere, during this period, injected on each occasion. The haemor- rhage returned on the 20th March, so very profusely, that I Avas obliged to plug the vagina; the interval had, however, lengthened a little. After an interval of three Aveeks, I recommenced the injec- tions. When it had been employed for some days, one im- provement in her condition Avas noticed; the slight red discharge, which had never been absent for more than a few hours together, ceased to appear; the interval betAveen the periods also Avas prolonged, the Aoav not appearing on this occasion till the 8th of May, an interval of a Avhole month. The loss on the 10th Avas very heaA'y, but the period lasted only fhTe days. This result I looked upon as most satisfactory, but at this juncture, the seat of the last injection inflamed, and after much suffering, an abscess formed, and though opened in good time, a troublesome fistulous sore resulted, which healed up very sloAvly. The treatment, therefore, Avas necessarily suspended. On the 22d she unfortunately caught cold, and suffered from an attack of rheumatic fever. This attack greatly reduced her strength, and shortly after she died rather suddenly, Avith the symptoms usually attending the formation of a clot in the pulmonary artery. There can be no doubt but that the injec- tion of Bonjean's ergotin in this case Avas productive of marked good. The sanguineous discharge, Avhich had been for a very long time constantly present, disappeared; the interval be- CHANGES IN FIBROUS TUMORS. 155 tween the periods lengthened from fourteen to tAventy-four days, and the periods themselves became correspondingly shortened; but, notwithstanding every possible precaution, an abscess formed. The results so far obtained discouraged me greatly, and for « a time I discontinued treating fibroids by the hypodermic injection of ergot, but Dr. Hildebrandt's further published statements as to his continued success induced me to give it another trial. I resolved, hoAA'eVer, to omit the glycerin from the solution, and to use the extract urn ergotce liquidum, B.P., dissolved in Avater alone, and since doing so, 1 have not been once troubled by the formation of abscesses and sores, Avhich in my former cases had ghTen rise to such pain and suffering. The following is a brief abstract of some of the cases I have recently treated : Case IV.—Mrs. ----, a AvidoAv, aged 38, mver pregnant, the subject of a large intramural fibroid; suffered from sense of weight, prolonged but not profuse menstruation, and an intramenstrual Aoav, lasting for two or three days. I injected trgv of the cxt. ergotce liq. Avith TT£x of water, twice a week, for fifteen weeks, Avith the folhnving results: total cessation of the intramenstrual discharge of blood, and shortening of the menstrual period by about thirty-six hours, no pain folloAving the injection, either in the tumor or at the seat of the injection, Avhich was made behind the trochanter, in each side, alternately. Case V.—A married Avonlan, neATer pregnant, the subject of a large intra-uterine tumor; menstruation recurred at intervals of fourteen days, lasted for ten days or longer; is blanched, amende, and very feeble. Ergot injected six times, at intervals of two days; pain ex- perienced at seat of the first injection, but not subsequently; menstrual flow did not come till after an interval of tAventy- 156 DISEASES OF AA'OMEN. four days, and lasted but six days; on its cessation, dilated uterus and removed an intra-uterine fibrous polypus. Case VI.—M. G----,aet. 48, unmarried, admitted 6th Janu- ary, in a state of extreme anaemia, pallid and exsanguine, the result of long-continued uterine haemorrhage; she Avas the subject of a huge intramural fibroid, very hard in texture, and easily felt through the abdominal parietes. It reached to within an inch of the umbilicus, and dipped deep into the pelvis. Menstruation lasted usually for fourteen days, and in fact she has, during the past year, been seldom free from a red discharge. She Avas also in constant pain. January 14th, rryy of the liquid extract of ergot, and rrgx of Avater, were injected into the substance of the glutaeus muscle; this was repeated on the 17th and 20th of January; she felt- pain in the uterine tumor in about an hour after the injection had been made. From this latter date, the ergot was injected every second day, and noAV she stated that severe pain com- menced in the tumor immediately after the injection, and lasted for five or six hours. But little pain or soreness was felt at the seat of injection, Avhich Avas made into the substance of the muscle on each aide, alternately, the needle ahvays pene- trating to the depth of an inch or more. A menstrual period commenced on the 22d January, and lasted to the 28th. 7th February. Severe pain experienced in back and stomach, folloAved by vomiting, relieved by hypodermic injection of morphia; injection of ergot suspended. 9th. Injection of ergot resumed. 13^ March. Since last date the injection of ergot has been practiced regularly every second day; great pain referred to the rectum now experienced after defecation; catamenia appeared on the 18th, after an interval of three Aveeks; is stronger, and were it not for the great pain, Avould be decidedly better. CHANGES IN FIBROUS TUMORS. 157 To have gr. 4 iodoform in a suppository each night, TTgvij of ergot to be injected daily, with TTgvij of Avater. ISth. Iodoform suppository has been of much use in relieving the pain experienced in the rectum, also that felt in tumor; it gives as much relief as a morphia suppository, and does not cause sickness. 3c? April. Menstruation appeared on the 1st, lasted only two days; tumor seems smaller. 21.s/ May. Menstrual period just over, lasted four days; now experiences incessant pain of the most Avearying character, some- times agonizing, demanding the repeated administration of morphia hypodermically; appetite quite gone, confined alto- gether to bed from the pain. The injection of ergot had been now carried on continuously for more than four months, and upAvards of sixty injections had been given, but though the haemorrhage had been controlled, the patient's condition Avas in no AAray improved, and I reluc- tantly abandoned the treatment. The result Avas that the haemorrhage returned with such violence as to necessitate plug- ging the vagina; all this time, hoAvever, she Avas free from the least tendency to the formation of sores or abscesses at the site of the injections, and this, although more than sixty had been given. The conclusions to be deduced from the foregoing cases are these: 1. That Wiggers's pure ergotin is inert, and useless for the purpose of hypodermic injection. 2. That Bonjean's ergotin, hypodermically injected, exerts a marked effect on cases of uterine fibroids, lessening the amount of blood lost and shortening the periods, but that its use is liable to be folloAved by the formation of abscesses. 3. That the extract urn ergotce liquid urn, B.P., is still more efficient in checking uterine haemorrhage, occurring in these 158 DISEASES OF AVOMEN. cases, but that its use sometimes causes severe pain, and that troublesome abscesses occasionally form at the site of the injec- tion, though these are not likely to occur unless glycerin be added to the solution. I should add that I have also tried the ergotin discs pre- pared by Messrs. Savory and Moore, but I do not think them to be at all as efficient as the liquid extract. From what I have already said, you will gather, that I am not an advocate for surgical interference in cases Avhere large uterine fibroids exist, if it can possibly be avoided. My rea- sons for arriving at this conclusion are twofold, namely, that the vast majority of such cases go on tolerably well for years, and that if by plugging the vagina, by the hypodermic injec- tion of ergot, or the use of other means, at our disposal, Ave can check profuse menstruation Avhen such exists, there is every probability of the patient's condition improving when she ar- rives at the climacteric period, and Avhen the uterine functions cease to be actively performed. But on the other hand, cases are from time to time met with, in which surgical interference is imperatively called for. That of M. B-----, whose case I have just been alluding to, is one of these. You remember, that by the hypodermic injection of ergot, Ave succeeded in re- straining the excessive menstrual flow, but that her condition did not improve; that she became more anaemic and weaker day by day, apparently as a result of the excessive pain from which she suffered, pain so intense, that the administration of morphia by the rectum or by the skin, was imperatively re- quired, not once but three or four times during each tAventy- four hours. Her appetite failed, she became daily more pallid, and if possible more emaciated ; life could not under such con- ditions endure very long. She begged, too, that something might be done, Avhich would afford a chance of relief from her sufferings, and expressed herself quite indifferent as to the re- CHANGES IN FIBROUS TUMORS. 159 suit, life having become unbearable to her. But any possible operation involved grave responsibility, as well as serious risk. We had to deal Avith a tumor Avhich extended to Avithin an inch of the umbilicus, and dipped doAvn deep into the pelvis. The os, Avhich Avas A'cry small, lay far back, and could only be reached with difficulty; the sound penetrated to the depth of five inches, proving that the whole uterus was implicated. The tumor itself Avas firm, and dense to a degree, and I Avas satisfied that to dilate the os uteri, and attempt the removal of the tumor through it, Avould be a futile as Avell as a dangerous proceeding. I, therefore, after much consideration, resolved to attempt its enucleation by the use of the actual cautery, ap- plied freely through a Avooden speculum to the anterior portion of the cervix, Avhich aviis stretched out over the *tumor, and projected so much in front of the os that it could be reached Avithout much difficulty. I decided on adopting this course in consequence of the satisfactory results of this treatment obtained by Dr. Greenhalgh, of London. The folloAving conditions are essential for success in such cases : 1st. That the tumor be intra- mural. 2d. That it extend doAvn to and hwolve the neck of the uterus. 3d. That it bulge out the neck, so that on intro- ducing the Avooden speculum, the portion of the neck selected can be easily reached by the cautery. All these conditions existed in the case now under our consideration. Accordingly, having placed the patient under the influence of chloroform, I introduced a full-sized Avooden speculum, and through it ap- plied the cautery, causing it to burroAV deeply into and through the texture of the cervix, till it penetrated into the substance of the tumor. I then placed in the vagina a pledget of lint, saturated with glycerin, and withdreAV the speculum. On recovering from the effects of the chloroform, the patient expressed herself as being freer from pain, and easier than she had been for a long time previously; this condition I pointed 160 DISEASES OF WOMEN. out to you, Avas probably due to the lessening of the extreme tension of the uterine tissue, which had so long existed, caused by the steady growth of the tumor Avithin its substance. On the separation of the slough the tumor could be felt through the opening formed in the Avail of the uterus, like a foetal head inside a rigid os uteri. I noAV divided Avith a knife the portion of the uterine Avail intervening betAveen the open- ing made by the cautery and the canal of the uterus, thus lay- ing bare the surface of the tumor to a considerable extent. The results obtained Avere tAVofold, namely, relief from intense pain, and diminution of the amount lost at the menstrual period, for the period just past Avas by no means excessive. The condition of the patient, too, has greatly improved. At present there is a great tendency in the opening to close altogether. Though so far the results have been good, no approach to a cure has in this case been as yet made. I have noAV given you an outline of the pathology and treat- ment of the various forms of fibrous tumors, but there yet remain tAvo interesting and important phases of their history, to Avhich I must allude before concluding the subject; the one the increase and subseqent decrease in their size, Avhich is some- times observed; the other, their occasional absorption, trans- formation, or even elimination. All fibrous tumors, especially the submucous, Avhen they hang into the cavity of the uterus, are liable to become (Edem- atous, and to this cause many of the recorded cases of enlarge- ment, and subsequent decrease in their size, is referable. But in addition to this cause, menstruation and pregnancy undoubt- edly influence both the condition and size of these growths. In many cases a fibrous tumor, which ordinarily is produc- tive of no discomfort to the patient, becomes at each menstrual period the seat of pain. This is a fact I have several times noticed. That actual increase in bulk should also occur at CHANGES IN FIBROUS TUMORS. 161 the epoch is easily understood. The folloAving case, illustrating this, is recorded by Dr. Ernest Lambert of Paris :* "Age of patient, thirty-eight; for ten years past a tumor appeared before each menstrual epoch, disappearing in turn to reappear again; for a year past it ceased to disappear, and had become the seat of severe pain." After death, a large fibrous tumor Avas found groAving from the anterior surface of the uterus. From the same author I quote the two following instructhTe cases: The first is on the authority of M. Depaul, avIio relates that having been summoned to a patient at a distance from Paris, he found three physicians in attendance on a primipara, supposed to be three months pregnant. She had suffered for some time past great difficulty both in passing Avaterand in defecation, and for four days previous to M. Depaul seeing her, had been unable to empty either the bladder or rectum ; even the catheter could not be passed except Avith great difficulty. She suffered from the most powerful expulsive pains, and her agony Avas A*ery great. M. Depaul recognized the existence of a large fibrous tumor, Avhich filled the pelvis; the patient's state Avas one of great danger. AVith difficulty he reached the os uteri, intro- duced a sound and brought on premature labor. The next day a foetus, " flattened like a sheet of cardboard," Avas expelled; in a short time this tumor had decreased to a third of its for- mer size, and at the end of four months AAras not larger than a small apple ; it Avas situated in the anterior Avail of the uterus, near the neck. The second case Avas that of a Avoman, aet. forty-four, Avho had given birth to se\Teral children; she was admitted into hospital on the 21st of March, 1869. The membranes had ruptured before her admission, and the feet of the child Avere * Etudes sur les Grossesses Compliquees de Mvomes Uterine, Par le Dr. Ernest J. Lambert. Paris, 1870. 14 162 DISEASES OF AVOMEN. in the vagina. The child Avas extracted alive, and in a feAv minutes the placenta Avas expelled. On placing the hand on the abdomen shortly after, a tumor as large as a child's head was felt at the fundus of the uterus; supposing that it Avas a case of twins a vaginal examination was made, but no foetus could be felt. As the placenta had come aAvay, and as there was not any haemorrhage, it Avas not deemed right to explore the interior of the uterus, but the hand laid on the abdomen easily detected the presence of a tumor as large as the head of a foetus at the eighth month of pregnancy; beloAV this large tumor a smaller one could be felt, Avhich Avas supposed at first to be the elboAV of the child ; careful auscultation, hoAvever, failed to detect the sounds of the foetal heart; the diagnosis seemed very obscure. The Avoman declared that there Avas no cause for anxiety, as she had these tumors after each confinement, and that they always disappeared in a short time. The next day the large tumor Avas unchanged, but in place of the sharp pro- jecting tumor, a globular one of smaller size existed ; two days later, the large one only could be felt. She died of fever . on the 12th of April, twenty-three days after delivery. On making a post-mortem examination, two fibrous tumors were discovered, the larger the size of a hazelnut, the other still smaller. Dr. Lambert concludes by saying, " We saAV in this case a Avoman, in Avhom at the moment of her accouchement there existed in the parietes of the uterus, tumors, of Avhich one had the volume of the head of a foetus at the eighth month ; these tumors could be as clearly made out as if they had been laid bare, for the abdominal Avails Avere very thin and flaccid, and the autopsy discovered, but tAvo little fibrous tumors, of Avhich the largest was but the size of a nut." It Avould be quite foreign to the scope of these lectures for me to enter on the subject of the influence Avhich fibrous tumors exercise on pregnancy, but the two cases just quoted, clearly prove, that CHANGES IN FIBROUS TUMORS. 163 pregnancy stimulates them to a very dangerous degree; and this knowledge should certainly induce us to warn any Avoman in Avhom they exist, should she consult us on the subject, that marriage ought not to be thought of. Fibrous tumors, Avhen left to themselves, not unfrequently undergo changes Avhich may not only alter their character, but also result in an actual cure. One of the most remarkable of these changes is the development of cavities, or cysts, in their substance. These are especially likely to form in tumors, the texture of Avhich is loose. According to Sir J. Paget, this may be due either to a local softening and liquefaction of por- tions of the tumor, with effusion of fluid in the part affected, in Avhich case the caATities are irregular and without distinct parietes ; or they may be true cysts, their ca\rities being lined by a membrane. In either case they may be small and numer- ous, or of such great magnitude as to be mistaken for, and treated as, ovarian cysts ; a very serious mistake indeed, and one unfortunately too often made. I shall, hoAveArer, havre more to say Avith reference to this point Avhen I come to speak of OATarian tumors, and shall therefore defer making any fur- ther remark on this part of the subject for the present. But nature also makes an effort, and not unfrequently a successful one, to effect a cure in these cases. Dr. McClintock has pointed out fhre methods by Avhich this result may be at- tained—namely, by, 1st, absorption; 2d, calcareous transfor- mation ; 3d, detachment; 4th, sloughing or disintegration ; 5th, expulsion by the uterine contractions. Examples of absorp- tion have been frequently recorded, and are sufficiently numer- ous to induce us to postpone surgical interference, if the symp- toms be not urgent, and especially if the patient be near the climacteric period. I have tAvo such cases at present under observation. In one, menstruation, which for several years past has been \*ery profuse, is now at the age of forty-nine 164 DISEASES OF WOMEN. become much more moderate in quantity ; this patient refused to submit to any local treatment. Cases are met with, in Avhich calcareous deposits have been formed in the substance of fibrous tumors, and it is possible that the process may extend to the entire tumor. Here is a specimen of such which I removed after death from the body of an old woman, Avho died of pneumonia in the Adelaide Hospital. Detachment and separation is most likely to occur in cases of the submucous variety, for in the intramural the formation of a long pedicle is very unlikely, and according to Dr. Mat- theAvs Duncan, never does take place, and unless this happens, the spontaneous detachment is a very unlikely occurrence. But, on the other hand, in the case of the imbedded intra- mural tumor, a cure sometimes results by a process of slough- ing, which either gradually breaks up the groAvth, or, if that process be confined to its muscular and mucous coats, frees the tumor and permits its spontaneous enucleation. Expulsion is but a variety of the curative process last spoken of; the uterus nearly always makes an attempt to expel any substance which is formed within its cavity, consequently polypi and fibrous tumors are, as a matter of fact, frequently extruded by its contractions; but in the case of the latter, the expulsion seems to be of but doubtful occurrence, unless as the final stage of the process of spontaneous enucleation just spoken of. I have purposely avoided, at present, entering into the ques- tion of the differential diagnosis of fibrous tumors, because I think I shall treat this part of the subject with greater advan- tage Avhen considering that of ovarian disease, Avith which alone it is likely to be confounded, for to mistake a fibrous tumor for pregnancy, is hardly possible; the size and shape may in- deed resemble that of the pregnant uterus, but the sIoav increase EXPULSION OF FIBROIDS. 165 in its size, and the occurrence of menorrhagia, should alone in most cases, suffice to prevent error. There is one symptom, hoAvever, often present in a fibrous tumor, Avhich may mislead the careless observer, and that is the occurrence of a bruit de soujflet. It is of but little value as a diagnostic sign, and I merely mention it to put you on your guard, lest you should be misled by its occurrence to suppose pregnancy existed. You must not, hoAvever, forget that pregnancy is not incom- patible Avith the presence of a fibrous tumor, and a Arery seri- ous complication it is. LECTURE IX. Inflammation of the Cervix Uteri—Ulceration of—Symptoms of—Treatment of by Local Depletion, Nitric Acid—Pelvic Cellulitis—Pelvic Hematocele. The great frequency with which inflammatory affections of the unimpregnated uterus occur, resulting, as they do in some of the most distressing and intractable ailments to which women are liable, renders the subject of inflammation of the womb, to which I propose to call your attention to-day, one of great importance. The cavity of the uterus is divided into tAvo parts by the os internum; the upper part, that of the body, is triangular in shape, and lined by a mucous membrane, Avhich, according to the researches of Dr. John Williams,* becomes thickened at the approach of each menstrual period, then appears to undergo a process of fatty degeneration and rapid decay, and finally is disintegrated and cast off, forming, with blood and mucus, the menstrual discharge. It is of a light-gray color, and smooth on the surface. The loAver part, commonly designated the cervical canal, is circular, bulging in its centre, and contracted at each extremity. It, too, is lined Avith mucous membrane, continuous with that of the body, but differing from it in being thinner, and in being arranged in transverse folds, which form the arbor vitce, the interstices between Avhich conceal numerous * Obstetrical Journal, No. XVII, p. 324. INFEAMMATION OF OER\TIX. 167 mucous follicles, and glands. Both these portions may simul- taneously be the seat of disease, or one may be attacked inde- pendently of the other. When speaking to you on the subject of menstruation, I pointed out the important part Avhich the mucous membrane lining the cavity of the uterus played in the performance of that function; Iioav easily the discharge which at the catame- nial epoch it pours out, might be checked, and the ill results to be anticipated from such an occurrence. But, in addition to affections folloAving on interrupted or suppressed menstruation, an unhealthy condition of both the body and cervix is likely to occur as the result of abortion, or of imperfect recovery after labor at the full term, Avhen the involution of the uterus being retarded, that organ remains enlarged and congested, a condition most favorable to the occurrence of inflammation. Other causes too, not so clearly traceable, produce congestion and inflammation of the cervix, and, as frequently, of the body of the uterus. Inflammation of the cervix is never of a very acute charac- ter, but the cases avc meet Avith in practice vary greatly in intensity. The more acute form has two Avell-marked stages. In the one, actiATe congestion of the part exists, manifested by great \Tascularity of the mucous membrane coA'ering the vaginal portion of the organ, Avhich becomes of a bright pink color, and by engorgement and tumefaction of the substance of the cervix, Avhich, however, feels soft and elastic to the touch. In the other, the mucous membrane, being denuded of its epithelial covering, presents the appearance of an irregular, abraded sur- face of a deep-red hue, which pours out a profuse muco-purulent discharge, and is studded with numerous papillae. The os uteri is patulous, and its lips everted, Avhile the cervical canal is blocked up by a thick, tenacious discharge, secreted by the cervical glands. This, in appearance, resembles the Avhite of 168 DISEASES OF AVOMEN. egg, and is ahvays pathognomonic of endo-cerv'c.d inflam- mation. If you succeed in removing it, and get a glimpse at the membrane lining the interior of the cervix, you will find it also to be of a bright-red color; Ave seldom see a case in the very early stage of the disease, the symptoms rarely being sufficiently severe to induce the patient to seek medical aid. But in general, ere long, the inflammation extends to the cer- vical canal, and then, her sufferings being increased, she applies for relief. We have, at present, in the house, a Avell-marked example of inflammation of the neck of the Avomb, in the first stage, occurring in an unmarried Avoman. The mucous membrane covering the cervix is smooth, nor does abrasion at any point, exist; the os uteri is patulous, and a copious, transparent, tena- cious discharge issues from the cervical canal, proving that its lining membrane participates in the disease. Xoav contrast the appearances presented in this case, Avith those you saAV in the patient occupying the opposite bed. S. B., set. thirty-four, has had two children; her illness dates from the birth of the last, tAvo years ago. The cervix is greatly thickened and indurated ; its ATaginal portion, Avhich is of a deep-red color, instead of being smooth and even as in the other, is covered OATer Avith little red papillae, which bleed on being touched, while a copious muco-purulent discharge, that has to be wiped aAvay before the parts can be seen, exudes from its Avhole surface. The os uteri is \rery patulous, and is plugged with a mass of tenacious, opaque mucus, Avhich, Avhen removed, after much trouble, discloses a cervical canal, Avhose lining membrane is seen to be congested, and covered Avith large vas- cular elevations. Here you have an example of the second stage of cervical inflammation; the substance of the cervix is thickened as in the former case, but, in addition, induration exists, and the mucous membrane is denuded of its epithelium. INFLAMMATION OF CERArIX. 169 The surface thus exposed is covered Avith granular-looking eleA'ations, Avhich, indeed, have sometimes been mistaken for granulations; they are not, howeA'er, new groAvths at all, but merely the papillae which abound in this situation, hypertro- phied by the existence of the surrounding inflammation. Finally, you have a profuse muco-purulent discharge secreted from the diseased surface, the roughened condition of the mucous membrane Avith its enlarged and prominent papillae secreting a muco-purulent discharge, being a secondary con- dition, the result of the preAdously existing inflammation. The case I have just been alluding to affords also an excel- lent illustration of the condition termed " ulceration " of the cervix; a term the accuracy of which has been Avarmly dis- puted. Dr. Bennet defends its use, and, on the authority of Petit, defines ulceration as " a solution of continuity from Avhich is secreted pus, or a puriform, sanious, or other matter."* But, as Ave usually associate the idea of ulceration Avith a loss of substance of greater extent than that produced by the mere removal of the epithelium, I am inclined to agree with the vieAV held by Dr. Farre, that the term ulceration should only be applied to cases in Avhich the loss of substance extends deeper. HoAvever, if Dr. Farre's definition be strictly adhered to Avhen speaking of affections of the uterus, examples of ul- ceration of that organ Avill prove to be very rare. I have never seen a single instance of true ulceration of the cervix uteri, as defined by him, unconnected Avith specific disease; indeed, I do not believe that such occurs. All this, hoAveATer, is a mere dispute about a term, and, although it is not strictly correct, still the Avord ulceration continues to be frequently applied to the condition avc are considering.f * " Inflammation of the Uterus," page 82. f An admirable summary of the arguments for and against the theory of ulceration will be found in Dr. Grailv Hewitt's work "On Diseases of Women." 170 DISEASES OF AVOMEN. But, cases less severe than the one of Avhich I have been speaking constantly occur. In some there is mere abrasion of the vaginal surface of the cervix, a circle of limited extent sur- rounding the os uteri appearing red and abraded, a condition Avhich terminates abruptly just inside the os; or, you may have cases intermediate in severity, in Avhich the vaginal portion of the cervix being denuded of its epithelial covering, presents an irregular surface of a deep-red color studded with the hyper- trophied papillae I have already spoken of, the cervical canal, hoAvever, not being implicated in the disease. Such a surface as that Avhich I have last endeavored to describe, almost invari- ably secretes a copious purulent discharge, and, in addition, there is usually a certain amount of vaginitis present. You had an excellent example of this in the case of Mrs. H., in Avhom the discharge was so profuse and AATeakening that it Avas for its cure she sought relief. The milder forms of abrasion of the cervix are not of them- selves of any great importance; they seldom give rise to dis- tressing symptoms, nor do they necessarily cause sterility, even when as severe as in the case of Mrs. H., for she became preg- nant long before the abrasion Avas cured ; but then the mucous membrane of the vaginal portion of the cervix alone Avas en- gaged. It is quite otherwise when that lining the cervical canal is implicated, for in that case the os becomes patulous, its lips are everted, and a copious viscid discharge is invariably poured out by the cervical glands ; this completely fills up the os, and is seen hanging from it as a rope of thick, semi-opaque mucus. Such a discharge is an effectual bar to conception, and is pathognomonic of cervical disease; whenever you see it you may at once pronounce that the patient is suffering from inflammation of the mucous membrane lining that canal. Per- haps the best name for this condition is endocervicitis, by many, hoAvever, it is termed cervical catarrh. In it, the lining mem- INFLAMMATION OF CERVIX. 171 brane, being congested, is of a deep-red color; subsequently, hypertrophy takes place, and the rugae become prominent, Avhile its surface is covered with numerous vascular papillae. When this stage is reached, not only is the os patulous, but the cervical canal is relaxed throughout its entire length, as high at least as the os internum. If you proceed to introduce a sound in a case such as I am describing, you will probably find it a matter of considerable difficulty. This difficulty is caused by the point of the instru- ment becoming entangled, first in one, and then in another, of the folds of the hypertrophied mucous membrane, and it is only after the lapse of some time and the exercise of much patience that these difficulties can be overcome and the cavity of the uterus reached. Some drops of blood are nearly cer- tain to folloAv the Avithdrawal of the sound, which should not occur Avhen the lining membrane of the cervical canal is in a healthy condition. In addition to these local changes symptoms of a general character are imrariably present; thus, the patient is nearly sure to complain of backache, and of pain and tenderness on pressure over the OArary, especially on the left side; pain, too, is frequently complained of along the edge of the false ribs. When this is severe, and particularly if it becomes aggravated at the approach of the catamenial period, I look on it as indi- cating that the disease has extended up to the os internum. Then, irritability of the bladder and often distressing pruritus are frequently present; and, after a time, menstruation is very likely to become profuse and Aveakening—indeed, not unfre- quently it is for the cure of the menorrhagia that Ave are con- sulted. This Avas so in the case of Mrs. B., to Avhom I alluded when speaking of menorrhagia, and of several others whom from time to time Ave have had in hospital. A A*erv instructive case Avas that of the young married 172 DISEASES OF AVOMEN. woman, Mrs.-----. Her illness commenced soon after mar- riage ; she did not suffer much pain, but latterly had hardly ever been free from a sanguineous discharge; there was also profuse leucorrheea present. Before coming under my obser- vation she had taken various astringents without benefit. The cause of the failure of this treatment Avas apparent, for on making a digital examination the cervix felt as soft as apiece of sponge, and on looking at it through the speculum, it presented an ap- pearance Avhich I can only compare to that of a large raspberry. The slightest touch Avas folloAved by copious bleeding. You saAV that, with the ATiew of checking the haemorrhage, I brushed over the surface with the saturated solution of perchloride of iron in glycerin ; this answered that purpose effectually ; sub- sequently, as you may remember, I repeatedly applied the fum- ing nitric acid, and the part gradually assumed a more healthy appearance. She Avas discharged cured, but not till after the lapse of many weeks. I was inclined to attribute the condi- tion of the cervix in this case to excessive sexual intercourse in a young Avoman of delicate constitution. In the foregoing outline I have endeavored to trace the prog- ress of a case commencing in inflammatory congestion of the substance of the cervix, in which the mucous membrane cover- ing its vaginal aspect, participating in the disease, becomes after a time abraded; that lining the cervical canal also being im- plicated. This is a very common course for the affection to folloAv, and an example of it is afforded in the patient to Avhose case I have just draAvn your attention. It is, hoAvever, far from being the invariable one; for, without doubt, inflamma- tion in many cases first attacks the cervical mucous membrane, ulceration of its A\aginal surface folloAving; the inflammation and consequent induration sloAvly extending into the substance of the cervix. But Ave may have cervical catarrh, indicating the existence INFLAMMATION OF CERArIX. 173 of inflammation of that canal, Avhile the mucous membrane covering the lips of the uterus remain perfectly healthy. When this condition exists, Ave generally find that the case is one of long standing, and that it has crept on sloAvly and insidiously, the patient dating back the commencement of her illness many years. I shall refer to this condition again by and by. Your treatment of eases of inflammation of the cervix uteri must be guided by the stage Avhich the disease has reached, and the form Avhich it has assumed, as well as by the patient's state of health. We seldom see the acute form till the stage of ulceration has been reached. It is too commonly the cus- tom to treat all such cases on one method, namely, by apply- ing nitrate of silver, either solid or in solution, to the surface of the cervix—a treatment in general altogether insufficient, and sometimes positively injurious. Bear in mind that you are dealing with inflammation, or, at least, the congestion of the organ, and it is rational that your first step should be to relieve that congestion by local bloodletting. There are two Avays of effecting this ; the one by the application of leeches, the other, by incising or puncturing the cervix. Leeching is a very troublesome and tedious process, as Avell as most un- certain in its results; at one time you cannot get the leeches to take at all, or at most not more than one or two, at another they Avill bite freely, and, perhaps, in spite of all the care you can take, Avill fasten on the vagina, and profuse bleeding may folloAv. I have seen such profuse bleeding folloAv the appli- cation of leeches as to compel me to plug the vagina; I there- fore noAV, as a rule, rely on the other method, and practice it very much in the same Avay as recommended by Dr. Hall, of Brighton, in the Lancet for the 3d September, 1870. Merely scarifying the surface of the cervix is not sufficient, especially in a case of a very chronic nature and accompanied by induration; I therefore always puncture the vaginal portion of 174 DISEASES OF WOMEN. the cervix, tolerably deeply, in two or three places. The depth to which I make the point of the knife penetrate varies from ^ to \ of an inch, according as the cervix is soft and Aras- cular, or firm and indurated; for in the former case it bleeds very freely, in the latter it is sometimes difficult to obtain a sufficient quantity of blood. Dr. Hall has had a knife specially made for the purpose by Coxeter (Fig. 24), but I often use a long, straight-backed bis- toury, terminating in a very sharp point Avhich, if the former is not at hand, ansAvers very Avell. One great advantage of this plan of treatment consists in the ease and rapidity Avith Avhich it can be performed. Having exposed the cervix, Avith an ordinary speculum, you make two or three punctures rapidly, and then allow the requisite quantity of blood to flow through the speculum, on AvithdraAving which, the bleeding, unless the part be very vascular, generally ceases ; the opera- tion seldom causes pain, if it does, it subsides in a few minutes. You can practice this treatment Avith equal facility in the wards of the hospital, in the extern de- partment, in your own study, or at the houses of your patients. You have seen how extensively I have carried out this system of local depletion, and hoAv often consider- able relief has folloAved its use. Of course, it is not invariably successful. I have found it productive of benefit even in cases of chronic inflammation of the cervix, although the induration then so constantly present often prevents our obtaining a sufficient quantity of blood. My rule, then, in nearly all cases of inflammation of the cervix uteri is, first to relieve the congestion by puncturing the part. I only omit this Avhen menorrhagia depending on a LOCAL DEPLETION. 175 granular condition of the cerA'ix is present; for should such exist, depletion is in general unnecessary and appears some- times to be injurious. Your object, in that case, should be to check at once the Aveakening discharge. This is best effected by applying freely to the diseased surface the strong nitric acid or a saturated solution of the perchloride of iron in glycerin, Avhich is much less irritating than either the tincture or the liquor, and is generally sufficient, if applied freely, to check temporarily the bleeding. To apply it, you should ahvays ex- pose the cervix with one of Fergusson's glass speeulums, and make your applications through it. HoAvever, this proceeding is but palliative, and as in all severe cases the membrane lining the interior of the cervix is implicated in the disease, it is es- sential to treat every portion of the unhealthy surface of that canal. In the majority of cases the cervical canal is relaxed, and the os uteri so patulous that this can be effected Avithout difficulty. If this be not so, I sometimes introduce one or tAvo lengths of the compressed sea-tangle, taking care that they pass through the os internum ; on AvithdraAving these my usual treatment has been to apply the strong nitric acid, freely to the whole interior of the cervical canal, in the manner recom- mended in a preA'ious lecture. This Avas the course adopted in the case of the Avoman S. B., of Avhom Ave have been speak- ing. I confined her to bed for three or four days subsequently, and then treated the still unhealthy surface by the application of a solution of tannic acid in glycerin of the strength of ten grains to the ounce. I strongly recommend the use of this application in cases of abrasion and inflammation of the cervix after local depletion has been practiced; it is especially useful if vaginitis be present. Saturate a pledget of cotton in the glycerin, pouring about half a drachm of it into the palm of the hand, and soaking it up Avith the cotton. Repeat this process several times till the cotton is thoroughly saturated, and then, 176 DISEASES OF WOMEN. attaching a piece of string to facilitate its remoA^al, introduce it up to the os uteri through the speculum and leave it there for tAventy-four hours; the patient can withdraw it herself by means of the string. This treatment is often productive of great benefit; the tannin acts as an astringent, Avhile the glyc- erin produces a copious watery discharge. The result of this combined action is, that the surface of the cervix, on the Avith- drawal of the cotton, looks paler and altogether much cleaner and healthier. If much irritation exist in the vagina, omit the tannin and use plain glycerin, as it relieves the vaginal con- gestion more effectually than Avhen it contains an astringent. It was from Dr. Marion Sims's excellent Avork on Uterine Surgery that I first learned the great value of glycerin in the treatment of uterine disease, and I daily appreciate it more. Remember, however, that glycerin must be very freely used; I commonly employ from half an ounce to an ounce for a single application. The quantity Avhich even a small pledget of cotton will absorb is surprisingly large. If the nitric acid be freely applied to the whole length of the cervical canal, and the unhealthy surface be subsequently dressed with the glycerin of tannin, you Avill in many instances effect a cure in the course of a feAv Aveeks. We had an ex- ample of this in the patient alluded to. If the surface be in- dolent, it may be necessary to apply to it occasionally, a solu- tion of nitrate of silver, of the strength of from thirty to forty grains to the ounce. In cases of less severity, I sometimes use, instead of the nitric acid, the zinc points introduced into practice by Dr. Braxton Hicks ; or, if the nitric acid has failed to effect a cure, I introduce them subsequently; they are often productive of great benefit, especially Avhen no induration exists. They cause, hoAvever, a good deal of pain and considerable local irritation. From time to time you will meet with cases in which the FSE OF GLYCERIN. 177 various modes of treatment I haAre recommended, including the repeated application of the fuming nitric acid, will fail to effect a cure : this is likely to occur Avhen the entire substance of the cervix is implicated ; Avhen both the mucous membrane lining its canal and that coA'ering its vaginal aspect, being in an un- healthy condition, are studded with vascular papillae, and at the same time, the cervix itself is greatly engorged, and fre- quently, in my opinion, also (edematous. Menorrhagia Avas present in all the cases of this form of uterine disease Avhich haAT come under my observation ; all of them, too, Avere of considerable standing. Take as an example the case of Mrs.-----, Avho has only been recently discharged from hospital; her illness commenced three and a half years ago, and appears to have had its origin in a Avell-marked attack of inflammation ; for she suffered at the time from acute pain OATer the left OArary, Avhich only yielded to the application of leeches and other antiphlogistic treatment. Latterly, she experienced much pain before each menstrual period, while the Aoav became very profuse and lasted for seven or eight days. The uterus proATed on examination to be consid- erably enlarged, and was also anteflected; the ceiwix Avas elon- gated, tumefied and engorged; its \raginal surface Avas covered Avith large, highly vascular granulations, from Avhich the haem- orrhage eAudently proceeded ; a similar condition existed in the cervical canal. I therefore dilated it, and applied the strong nitric acid, freely, to the diseased surface, but I was disap- pointed in the result. The next menstrual period Avas so pro- fuse that I had to plug the A'agina, and, though I applied the nitric acid repeatedly, she improA^ed \-ery sIoavIv indeed. I now determined to have recourse to potassa fusa, and to destroy with it, if possible, the whole of the diseased surface. When- e\rer this caustic is used, it should be applied through a glass speculum and rubbed freely against the part, till you are sat- 15 178 DISEASES OF AVOMEN. isfied that the tissues have been destroyed to a considerable depth; a pledget of cotton saturated in vinegar should be pre- viously inserted betAveen the loAver lip of the os uteri and the edge of the speculum, so as to neutralize any of the potash which may escape, and Avhich Avould otherwise irritate the vagina; that canal should also, as a further precaution, be washed out with vinegar immediately after the application. In this case I cauterized not only the exposed surface of the cervix in the manner described, but I also passed the stick of caustic potash to the depth of at least half an inch into the ■cer- vical canal; this proceeding did not cause much pain. The only local treatment I subsequently adopted, was placing in the vagina daily, pledgets of cotton saturated Avith glycerin. Of course I confined the patient to bed for several days. The slough was Avorn off in less than a Aveek. The surface thus exposed presented a very healthy appearance and healed up rapidly, so that at the expiration of about three Aveeks I was able to allow the patient to return home cured. In these severe cases, the total destruction of the diseased surface by caustic potash is by far the most effectual means at our disposal; and if care be taken to limit the application to the cervix, and if the vagina be washed out freely immediately afterwards with vinegar, no injury to that canal nor any un- pleasant consequences need be feared. The milder cases of abrasion of the cervix will generally yield to the use of nitrate of silver. Tincture of iodine some- times seems to agree, but I do not rely on it. I have, how- ever, noticed that its use seems sometimes to allay the backache from which the subjects of uterine diseases suffer so much. I also use a saturated solution of carbolic acid in spirit, and in mild cases it answers very Avell. In concluding my remarks on the treatment of the more acute forms of cervical inflammation, especially when, as nearly PELVIC CELLULITIS. 179 always is the case, the disease implicates the membrane lining its canal, I must repeat that you haATe to deal Avith a most troublesome, and often an intractable, affection, and one Avhich can only be cured by active and energetic measures. I stated just now, that that peculiar form of abdominal inflam- mation knoAvn as pelvic cellulitis may occur in patients suffering from chronic disease of the uterus. In one case it evidently folloAved on the application of the tincture of the perchloride of iron to the cervix, used with the view of checking profuse menorrhagia; it may, however, be caused by the application of any caustic. Exposure to cold is, hoAvever, by far the most common cause, and is specially likely to induce an attack on Avomen recently confined, or who have recently aborted. Cel- lulitis, too, is liable to occur after operations about the uterus. The term parametritis is by some authors preferred to that of pelvic cellulitis. In my opinion this is unfortunate. I quite agree Avith Dr. Fordvce Barker in thinking that the former is not warranted either "by precedent or analogous usage," and I greatly prefer the term pelvic cellulitis, by Avhich is meant inflammation of the cellular tissue around and in the neighbor- hood of the uterus, or occurring in any part of the pelvis. It is right, hoAveA'er, that you should bear in mind that parame- tritis is synonymous Avith pelvic cellulitis, as is also perimetritis with pelvic peritonitis. As avc have at present a case of this affection in the house, I shall take the opportunity of calling your attention to the subject. This patient was admitted in a very anaemic con- dition, having lost a great quantity of blood. She stated that she had aborted three Aveeks previously, and on examining her, it was evident that the haemorrhage Avas kept up by the reten- tion of a portion of the placenta. I plugged the A'agina, and directed her to Iuia-c thirty drops of the liquor ergotae and three of the solution of strychnia every third hour. This produced 180 DISEASES OF WOMEN. sharp uterine action, and on AvithdraAving the plug, after the lapse of twelve hours, the placenta was found in the A'agina, and the haemorrhage immediately ceased. Three days subse- quently she had a rigor, and complained of sharp pain in the region of the uterus ; pressure over the abdomen, hoAvever, caused comparatively but little distress. Vomiting soon after set in, and for the next forty-eight hours Avas incessant; indeed this distressing symptom did not entirely cease for five days. The pulse Avas very quick, as it ahvays is in these cases. On making a vaginal examination immediately after the rigor had occurred, nothing could be detected, but the vagina felt hot, and she complained of the pressure of the finger causing pain. On repeating the examination, after the lapse of twenty-four hours, the uterus was found to be immovable, being fixed by a firm hard SAvelling, Avhich extended all round it. This in the posterior cul-de-sac assumed the form of a well-defined tumor, which pressed against the rectum, and thus explained a symptom she noAV complained of, namely, a constant desire to defecate; all her attempts, hoAvever, to do so proved useless. Now, what has occurred here is, that inflammation, Avhich has resulted in the rapid effusion of serum, has attacked the cellu- lar tissue situated around the uterus and Avithin the folds of the peritoneum. In this case there are three points worthy of your special attention ; namely, the hardness of the swelling- as felt through the vagina; the pressure on the rectum which this SAvelling caused; and the distressing A'omiting from Avhich she suffered. The hardness is due to the infiltration of fluid into the cellular tissue surrounding the uterus. This effusion may be circum- scribed, so as to form a well-defined tumor, or be general, as in the present case; its hardness, and the rapidity of its forma- tion, being its distinctive features. The pressure Avhich the SAvelling exercises on the rectum PELVIC CELLULITIS. 181 often causes much distress, and may, by totally obstructing the boAvels, eATen prove fatal. Let me impress on you the necessity in such cases of avoiding the exhibition of purgatives. The obstruction is mechanical, and cannot be OArercome by exciting the peristaltic action of the boAvels. On the contrary, it is your duty to quiet that action by the exhibition of opiates. This Avas the treatment adopted in the case at present in the house. She took half a grain of opium every third hour, AA'hile enemata of tepid Avater Avere administered twice daily, Avith the vieAV of aiding the descent of any fecal matter Avhich might be im- pacted in the loAver part of the boAArel. The opium, hoAvever, had no effect in checking the distressing vomiting, I therefore tried the subcutaneous injection of morphia, and Avith great success; the injection of one-sixth of a grain always quieted her stomach for two or three hours. Now this is a fact Avorth bearing in mind. Vomiting frequently folloAvs the subcu- taneous injection of morphia, but I haAre several times seen it check reflex irritation of the stomach depending on uterine disease. Vomiting is a frequent, I Avas almost going to say in\rariable, accompaniment of peh'ic cellulitis. This, I believe, is usually due to the endometritis Avhich generally coexists. In the case at present in hospital, the treatment adopted, in addition to the subcutaneous injection of morphia, Avas keeping the abdomen constantly awered Avith Avarm linseed meal poul- tices, and the internal exhibition of opium and of hydrocyanic acid. Food could not for several days be retained on the stomach. She had milk and lime-Avater, and milk and soda- water in small quantities, frequently, and also beef tea; the latter Avas also administered per rectum. She is noAV sloAvly recovering; the case w ill terminate by resolution. The tendency of pelvic cellulitis is to recovery; it is always a tedious disease, but by carefully sustaining the patient's strength with unstimulating nourishment, and by the avoid- 182 DISEASES OF WOMEN. ance of loAvering treatment, such as the exhibition of mercury, the patient generally recovers. In some cases resolution takes place, the sAArelling being slowly absorbed, but sometimes it ter- minates in the formation of an abscess, Avhich may discharge into the rectum, into the bladder or vagina, or open externally. The chief danger consists in the risk, Avhich ahvays exists, of the inflammation extending to the peritoneum. A little care will enable you to discriminate between peritonitis and an at- tack of cellulitis; pressure is in the latter much better borne than in the former, while a vaginal examination if carefully made will in general set the question at rest, by detecting the existence of a firm, hard swelling, the uterus being fixed. The patient Avhose case I have just referred to suffered from an acute attack, but more commonly the disease creeps on insidiously, and its existence may for a long time escape notice ; a careful ATaginal examination should, therefore, in all cases be instituted. As an example of this latter form the case of another patient, J. S-----, is instructive. She Avas admitted suffering from very profuse and Aveakening menorrhagia, and as the cause was not apparent, the uterus Avas dilated, and the intra-uterine mucous membrane found to be in a state of granular degeneration. For the cure of this nitric acid was applied. No pain folloAved, and at the end of a week the patient was convalescent. But on being alloAved to get up, she exposed herself to cold, and an attack of sharp fever followed, accompanied by pain referred to the pelvis. After a time a hard swelling could be felt pos- teriorly and laterally fixing the uterus. She Avas treated by the exhibition of sedatives, rest, Avarm baths, etc.; the pain subsided, but the swelling round the uterus remained, and after a lapse of six Aveeks a copious discharge of matter per rectum proved that suppuration had taken place, and that the abscess had burst into the boAvels. Her convalescence was tedious, but she was finally discharged cured. This fortunate result does PELVIC HEMATOCELE. 183 not, hoAveArer, al ways occur. In not a feAv instances the patient is run down by hectic, and the case terminates fatally, notAvith- standing our best efforts to save life. There is one affection, of more rare occurrence, Avith Avhich pelvic cellulitis is specially liable to be confounded: I allude to those cases in which an effusion of blood takes place into the pehdc cavity. To this the term of pjelvic hcvmatocele is applied. In considering this affection it is necessary to bear in mind that the effusion of blood is not the disease, it is ahvays the result of some lesion or abnormal condition, and though the extravasated blood may become a source of danger to the pa- tient, it is only a secondary, not a primary cause. Blood may be poured out into the pelvic peritoneum in one of three Avavs. 1st. It may escape from the Fallopian tubes during, or im- mediately before, the occurrence of a menstrual period. 2d. It may be poured out from a ruptured bloodvessel in the OATary, Fallopian tube, or broad ligament. 3d. It may be due to the rupture of the cyst in cases of extra-uterine fcetation. For the occurrence of an escape of blood from the Fallopian tubes, it is, I think, necessary to suppose that some obstruction must exist to the exit of the menstrual discharge—a conical cervix and contracted cervical canal, acute anteflexion of the body or the presence of a tumor pressing on or blocking up the os internum, Avould be such. It is also extremely probable Avhen a reflux of blood takes place along the Fallopian tubes, that the exudation of the menstrual blood from the lining mem- brane of the uterus is both rapid and copious. The diagnosis of pelvic haematocele is often very difficult, and is specially so in the form under consideration. The blood almost invariably gravitates into the recto-uterine cul-de-sac, 184 DISEASES OF WOMEN. consequently a swelling is formed there, but unless the loss has been so considerable as to produce a shock, the patient may not at first seek for medical advice. After a time, however, the extravasated blood excites inflammation, and then Ave have a patient with all the symptoms of pelvic inflammation, in whom also a well-defined SAvelling exists, occupying the posterior cul-de-sac of the peritoneum, the uterus being forced upwards against the pubes. I feel confident that attacks of pelvic cellu- litis and pelvic peritonitis occurring at or near a menstrual period, are not unfrequently pronounced to be haematocele, the tAvo former being of frequent occurrence, the latter rare. To form a correct opinion, a careful consideration of the history of the case, as well as of the symptoms which present themselves, is essential. In haematocele the access of the attack is sudden. The patient, without any premonitory symptom, is attacked with pain, and may become faint and cold; after a time there is reaction, to be folloAved probably by the symptoms of pelvic peritonitis; at the same time a vaginal examination will detect a tumor behind the uterus, Avhich, at first soft, becomes grad- ually harder, this hardening being due to the coagulation of the blood. In pelvic cellulitis this train of symptoms is reversed. The patient most probably will experience those premonitory of an ordinary febrile attack, namely, a chill, or even a rigor, fol- lowed subsequently by an accession of pain, and the gradual formation of a hard swelling round the uterus. This SAvelling is from the first hard and unyielding, Avhereas in haematocele the tumor, at first soft, gradually becomes harder. The fore- going remarks refer more especially to that form of haemato- cele due to the escape of blood from the Fallopian tubes, and which I believe to be of very infrequent occurrence. When it is due to the rupture of a bloodvessel in the ovary or Fallo- pian tube, the symptoms are likely to be much more severe PELA'IC HEMATOCELE. 185 and marked, namely, sudden collapse, coldness of the extremi- ties, and those symptoms Avhich usually announce a severe shock. When such occur, Avith the simultaneous formation of a SAA^elling behind the uterus, the diagnosis can hardly be doubtful, Avhile if a Avoiuan in Avhom the symptoms of preg- nancy exist is seized Avith sudden pain of an acute character, and that a SAvelling is detected behind the uterus, the proba- bility of extra-uterine testation, Avith rupture of the cyst, is ob- ATious, and this conjecture Avould be strengthened, if, in addition, the sensation of something having gh-en Avay be experienced by the patient. Haematocele occurring as a result of extra-uterine testation, or due to the rupture of a bloodvessel in the ovary, generally terminates fatally, and the treatment must depend on the nature of the symptoms. If collapse be present, the ordinary means employed to counteract this must be had recourse to, and among these the hypodermic injection of ether should not be omitted, half a drachm or more being injected into the fleshy part of the thigh, and repeated at short intervals of time. Care, hoAvever, must be taken not to induce exccsshTe reaction, or the haemorrhage might recur. Pain, generally very in- tense, is also under such circumstances iiiArariably present, and demands the free administration of opium. But these cases, though so alarming, are not those Avhich demand exercise of the greatest skill; it is those cases Avhose iiiA'asion is less marked, and Avhose course is sIoav, Avhich often tax our judg- ment to the utmost; possibly the tumor may gradually diminish in size, and as the symptoms of inflammation subside, may dis- appear, absorption having taken place, but it is quite as likely that the tumor may become softer, that fluctuation may be detected, that the temperature may again rise, and Ave become convinced that suppuration is about to take place. With these changes the danger of septicaemia becomes imminent. 16 186 DISEASES OF WOMEN. Under such circumstances the puncturing of the tumor sometimes becomes a necessity, but it should not be undertaken unless the symptoms become urgent, and that no hope of the fluid discharging itself through the rectum or vagina remains. If the operation be decided on, an aspirator should in the first instance be employed, and the entrance of air into the cyst, if possible, carefully preA^ented, but often the contents are too solid to be thus evacuated, and a free incision into the posterior cul-de-sac of the peritoneum may become unavoidable. For- tunately these cases are very rare, and of those Avhich do occur, comparatively few demand surgical interference. LECTURE X. Chronic Inflammation of the Cervix Uteri—Induration of Cervix — Treatment of, by Potassa Fvsa ; by Local Deple- tion—Endometritis—Endocervicitis. In my last lecture, I gave you an outline of the history and treatment of the more acute forms of inflammation of the cer- vix terminating in congestion and thickening of the mucous membrane lining its canal, and of the follicles Avith which that membrane is studded, while its A-aginal portion, denuded of its epithelial coat, is covered Avith numerous Avascular papillae; these little bodies, projecting as they do, from a rough and abraded surface, and secreting a copious muco-purulent dis- charge, haA'ing been sometimes mistaken for granulations. The term ulceration, is often applied to the condition I have described: a term, the correctness of Avhich is Aery doubtful, there being no excavation, and but little loss of substance, while the discharge is merely the ordinary product of inflam- mation of a mucous membrane. I shall noAV proceed to direct your attention to those still more common cases of, Avhat Ave must call, chronic inflamma- tion of the cervix. In it vou haA'e considerable thickening and induration of the Avhole substance of the cervix, Avhich feels hard, and frequently is A'ery sensitive to the touch. A vaginal examination or the introduction of a speculum causes considerable pain, Avhile sexual intercourse may, for the same reason, be unbearable. We frequently find this condition 188 DISEASES OF WOMEN. associated with flexions of the uterus; Avhen these occur, the fundus generally participates in the senshaVe condition of the cenux. On exposing the cervix with a speculum, its surface will frequently be found to present its normal appearance. If any abrasion exists, it will generally be confined to a narroAV rim surrounding the os uteri, AArhich is frequently patulous, and, in women avIio have borne many children, sometimes nodu- lated and irregular, this condition being apparently due to the slight lacerations Avhich may haA-e taken place during labor. In addition, you not unfrequently have the glairy discharge issuing from the lips of the os uteri, Avhich is pathognomonic of disease of the cervical canal. These cases of chronic inflam- mation and induration of the cervix, Avith little or no abrasion of the mucous membrane, are met with constantly, especially among Avomen of the loAver class, Avho leave the recumbent posture and engage in their ordinary a\rqcations a feAv days subsequent to delh'ery or abortion. But it is far from being restricted to them ; you will meet Avith numerous examples of it in the upper classes also. I do not think that there is any affection more distressing than chronic inflammation of the cervix. The pain in the back, the OArarian pain, and the pain felt along the inside of the thigh, is often even more severe than that experienced in the acute form. The unfortunate patient nevTer seems to lose it even for a day, Avhile it is sure to become aggravated by fatigue, by exposure to cold, and by the approach of each menstrual period. In addition, irritation of the bladder, manifested by frequent desire to micturate, often becomes a very troublesome and distressing symptom. This symptom, as pointed out by Dr. Churchill, is one, common, no doubt, to other affections of the uterus, but I think I have observed it more frequently in conjunction with chronic inflammation of the cervix than with CHRONIC INFLAMMATION OF THE CERVIX. 189 any other; unless, indeed, it be when anteflexion of the organ exists. In fine, though not likely, in itself, to shorten life, chronic inflammation of the uterus often renders the patient little better than a confirmed invalid, and makes life itself a burden. The constant distress, and even actual pain, Avhich patients suffer when laboring under chronic inflammation of the cervix, frequently gives rise to the suspicion of the existence of cancer; but the mobility of the uterus, the absence of haemorrhage, and of a fetid discharge, Avill generalh' enable you to assure your patient, that, though likely to be for a long time a sufferer, she is not laboring under malignant disease. The induration, too, resulting from chronic inflammation of the cervix, is A-ery different from that caused by the deposit of cancerous matter, the surface in the former being smooth, in the latter, nearly always irregular, and frequently presenting, at one point, a sharp, AArell-defined edge, indicative of the existence of cancer- ous ulceration. I haAe knoAvn the nodulated condition of the lips of the uterus, Avhich is sometimes met Avith in Avomen Avho haATe borne many children, and in Avhom the ceiwix has become indurated, to be mistaken for malignant disease; but these irregular projections, surrounding, as they do, the os uteri, are Aery different in feel from those produced by cancer. The induration which takes place in cases of chronic inflammation of the cervix is, according to Dr. Bennet, due to the effusion of plastic lymph in the tissue of the cervix. I have already noticed that the occurrence of extensive abrasion of the ATaginal surface of the cervix is comparatively rare in these cases; it is not easy to explain this circumstance. I am, however, inclined to think that the access of the disease is so a cry sIoav, that, Avhile lymph is gradually deposited in the tissues of the cervix, the mucous membrane escapes being inplicated; it is different, hoAvever, Avith respect to the lining 190 DISEASES OF WOMEN. membrane of the cervical canal, Avhich is frequently engaged to a greater or less degree; it is not vascular and engorged as in the more acute forms, but thickened and hypertrophied. In fact, whilst in the acute form, you have a soft, tumefied cerA'ix, its surface denuded of epithelium, and secreting a copi- ous muco-purulent discharge, the cerA'ieal canal participating in the disease, and menstruation at the same time being nearly always profuse, you haATe in the chronic form, a hard, indu- rated cervix, frequently covered Avith an apparently healthy mucous membrane, Avhile a copious glairy discharge, indicative of chronic inflammation of its lining membrane, is seen to issue from the cervical canal, menstruation being almost invariably diminished in quantity. These cases have long been the op- probrium of obstetric physicians, Avhile their extreme frequency give them an importance which the direct effects they exercise on the duration of life do not Avarrant. The modes of treatment suggested for the cure of this affec- tion have been very numerous. Nitrate of silver, nitric acid, the nitrate of mercury, and iodine haAre been all repeatedly tried with the like result, and that generally is,—failure. Equally inefficacious, as far as the local disease is concerned, but probably more injurious to the general health, have been the long courses of the iodide of potassium, and of the bichlor- ide of mercury, to Avhich such patients have been subjected. In my opinion, medicines are nearly useless in this disease. The failure of all ordinary means, induced the late Sir James Simpspn to try Avhat good could be effected by the employment of potassa fusa, applied directly to the indurated cervix, Avith the vieAV, "partly of destroying the indurated tissues by direct decomposition, and partly to soften down the remainder by new inflammatory action." He found it " far more manage- able, speedy, and certain than any other method." I have myself, used the potassa fusa with success, and I have neA'er CHRONIC cervicitis. 191 seen any unpleasant consequences resulting from its application. I do not, hoAvever, rely on it in cases of chronic inflammation of the cervix ; still I do not hesitate to use it, should the means I usually employ fail to effect good results. I have already (page 177) explained to you the mode in AA'hich this poAverful caustic should be applied, and the precau- tions you should ttdopt to prevent its injuring the vagina, and therefore need not repeat them here. I may, howe\'er, add that Avhen much induration exists, one application Avill sel- dom be sufficient, and that it may be necessary to apply the caustic a second or even a third time, after the lapse of tAvo or three weeks. Another valuable means in the treatment of these cases con- sists in the application to the hypertrophied cervix of the actual cautery; but, instead of a metal rod heated red-hot, I noAV generally use ignited charcoal pencils, specially prepared for the purpose. On another occasion* I shall give you full direc- tions as to the preparation and mode of using these. Dr. Greenhalgh treats such cases as these I now speak of by the application of iodized cotton to the cervix. The cotton is first uniformly saturated with glycerin; a strong solution of iodine is then added and equally diffused under pressure in a closed vessel; twenty per cent of iodine may thus be combined with the cotton.f The size or Aveight of the pledget of cotton to be used is, therefore, determined by the quantity of iodine re- quired. A pledget of the requisite size is placed in contact with the cervix, and outside this a roll of cotton saturated Avith glycerin ; strings are attached to these to enable the patient to remove them when necessary. The iodized cotton doubtless * See Lecture XVII. f The iodized cotton can be had of Messrs. Savory & Moore, 143 New Bond Street, London; or of Graham & Co., 30 Westmoreland Street, Dub- lin. 192 DISEASES OF WOMEN. exerts a marked influence on the cervix, and many cases derive considerable benefit from its use; but I find, on the other hand, that not a feAv patients are unable to tolerate the strong taste of iodine Avhich is perceived in the mouth in a very feAv min- utes after its application, and remains for a long time. In some patients, too, it produces considerable irritation of the vagina, though in the great majority of cases the glycerin pre- vents this occurring. I find that much relief can be obtained by repeatedly punc- turing the cendx and abstracting blood by this means locally. Let me call your attention to some of the cases Avhich have re- cently been treated in this manner in our extern department. M. W., five years married, has never been pregnant. For two years past she has suffered constantly from pain over the left ovary, from pain along the edge of the false ribs on that side, and from backache, always more severely before and during each menstrual period ; the flow has greatly diminished in quantity, and is still progresshrely lessening; the cervix Avas elongated, indurated, thickened and very tender to the touch; copious cervical catarrh was also present. The diagnosis Avas obviously chronic inflammation and induration of the cervix uteri Avith inflammatory hypertrophy of the mucous membrane lining the cervical canal. The cervix was punctured, and the operation repeated at intervals of a AAreek; the pain steadily decreased in severity, and after the lapse of six Aveeks she had obtained such relief that she considered herself to be perfectly well; no other treatment was adopted. This patient Avas not cured, for, like most persons of her class, she could not be in- duced to continue her attendance when once the urgent symp- toms Avere relieved. Here is another example in which the same treatment Avas adopted: Mrs. W., set. forty, had one child nineteen years ago, never pregnant since. Catamenia regular till seven months LOCAL DEPLETION. 193 ago, since then they haA'e appeared but tAviee, the last time being three months ago. Complained of backache and pain in right side, shooting doAvn into hip ; she also suffered from profuse leucorrheea. Cervix in a state exactly similar Avith Avhat I pointed out to you as existing in the last case. She first presented herself on the 22d of April. On that day I punctured the cervix, Avhich bled freely. May 2d. Again extracted blood by puncturing cervix ; states that she menstru- ated two days after last visit. May 13th. Much freer from pain; cervix again punctured. This Avas repeated Aveekly, until the 20th of June. On that day, I find the folloAving entry in my note-book: Is much easier; has menstruated Avithout pain. June 27th. Quite free from pain; cervix still indurated but no longer tender to the touch. Here Avas a woman in Avhom, previous to the adoption of local depletion, menstruation was irregular, scanty and painful, Avhile she suf- fered constantly from distressing pain both in the back and side. You have seen the benefit she has derived from this treatment. But I should only Aveary you by detailing the particulars of the numerous cases I have treated in this manner. Most of vou have seen them and are capable of judging of the effects for yourselves: I cannot, hoAvever help alluding to that of one Avoman, Avhose sufferings Avere extreme. J. D., ret. thirty, married seven years, has never been preg- nant ; for the past year has suffered from, constant and severe pain in the left groin, also over left ovary, and above the pubes. Bladder extremely irritable, micturition painful, catamenia very scanty and irregular, sometimes not appearing at all for several months; uterus Ioav in pelvis and very tender to the touch, fundus ret reflected. Sexual intercourse has become so painful that she cannot uoav permit it at all. On the occasion of her first visit, on the 12th of February, I ordered her to 194 DISEASES OF WOMEN. have a saline purgative, and introduced a small-sized Hodge's pessary, hoping that the support it Avould give the retroflected womb might afford some relief. In this I was disappointed; the organ Avas too tender to admit of the instrument being worn for any length of time, and I had to remove it after the lapse of three days. For the four following months, she pre- sented herself at least once a Aveek in the out-patients' room, but her condition did not improve, indeed she became worse, and she often could not straighten herself, so great Avas the pain she suffered. During this period I tried every possible form of medical treatment Avithout effect. On the 20th June I decided on puncturing the cervix, and from that she steadily improved. I repeated the operation at intervals of five or six days. After a few Aveeks she Avas so much easier that she only attended about once a month. On each occasion the treatment was repeated Avith marked benefit. Menstruation, though scanty, appeared at regular intervals, and she Avas so much better as to be able to resume her regular occupation—that of Avorking in a market garden. She presented herself the other day, after an interval of three months. She then stated that the menstrual Aoav noAV appears regularly, that she suffers but little pain, and can permit sexual intercourse. The uterus is still retroflected and will, I believe, ahvays remain so, but it is not painful to the touch. It is Avell Avorth your AAdiile bearing this case in mind. Previous to practicing local depletion, I had, for four months, tried every other means of treatment I could think of, Avithout effecting the least good. You all have seen the benefit resulting from that finally adopted. This case is instructive too in another point of vieAV as proving that the patient's sufferings Avere due to the state of chronic inflamma- tion Avhich was present, and not to the retrofleetion. I have hitherto spoken only of inflammation of the cervix uteri and of the lining membrane of its canal, but the body CHRONIC ENDOMETRITIS. 195 also is liable to be affected in a similar manner, and cases of chronic metritis and of endometritis are \-ery common. I Avish you to understand, that Avhen I speak of endome- tritis I refer to inflammation of the interior of the body of the uterus only, that is of the part lying above the os internum. This term is used by some, I think, erroneously, so as to in- clude inflammation of the canal of the cervix also. Inflam- mation of this latter portion should be spoken of as endocer- vicitis, a term made use of by Dr. Marion Sims, and Avhich I prefer as being more definite than any other. Endometritis, formerly looked on as a rare affection, is, now that its symptoms are better knoAvn, recognized as a disease of frequent occurrence. It is met Avith in AAromen Avho haATe never been pregnant, and not seldom even in virgins; it also occurs frequently as a result of imperfect hwolution of the uterus, and in aggravated cases may terminate in complete disorgani- zation of the intra-uterine mucous membrane. Such extreme eases are, hoAveArer, rare. All cases of chronic endometritis naturally divide them- selves into tAvo classes, namely, those Avhich occur in Avomen Avho have borne children, and those Avho never have been preg- nant. The course, symptoms, and treatment of these two classes are essentially different. I Avill speak first of the dis- ease as it occurs in those aat1io have borne children. In the great majority of such cases the patient's attention Avill be attracted to her condition by the occurrence of derange- ment of the menstrual function, Avhich generally in the first instance, at least, becomes profuse, and often painful; leucor- rheea, too, is generally present. On proceeding to examine the patient the cervix Avill be found to be thickened, the os patulous, perhaps the lips everted, and possibly in a state of granular erosion, Avhile a copious dis- charge, thick, opaque, and tenacious, issues from it; the cer- 196 DISEASES OF AVOMEN. Adcal canal also is patulous, and the sound Avill pass Avith ease through the relaxed os internum. Nevertheless its introduc- tion often causes pain, either at the os internum, or Avhen its point reaches the fundus. If the sound causes pain as it passes through the os internum, menstruation is, I believe, ahvays painful; but if the extreme sensitiveness is confined to the fundus, this may not be so. Dr. Routh is of opinion that in some instances that portion of the endometrium situated be- tween the openings of the Fallopian tubes on either side may alone be diseased, and he terms this " fundal endometritis." I much doubt, hoAvever, if the affection be ever limited to so circumscribed an area. As the disease progresses the mucous membrane lining the body of the uterus becomes disorganized. This is manifested, as already pointed out, by derangement of the menstrual func- tion, which becomes painful, or profuse, or both, and it is not till this stage is reached that, as a rule, the patient seeks medi- cal aid; doubtless she Avill in general complain of pain in the back, of a feeling of weight in the pelvis, and perhaps of a bearing-down sensation, but Avhen contrasted with the disease as it occurs in the unmarried or sterile Avoman, endometritis in the AA^oman Avho has borne children produces comparath'ely little discomfort, and except Avhen the patient is run doAvn by profuse or constantly recurring haemorrhages, comparatively little constitutional disturbance. Here is a typical case: Mrs.-----, aged 25, gave birth to her first and only child three years ago. She nursed but a feAv months, and then, menstruation recurring normally, she weaned the child. Shortly after her husband became ill, and for many months she tended him by day and night, not- withstanding Avhich her general health continued tolerably good, and it Avas not till after the lapse of quite a year that the occurrence of repeated attacks of profuse menstruation, latterly CHRONIC ENDOMETRITIS. 197 accompanied by acute pain, compelled her to seek relief. In her ease the os uteri Avas very patulous, and the cervical canal blocked up by a mass of thick, semi-purulent mucus. When the point of the sound reached the os internum she complained of sharp pain. I treated this patient by the application of carbolic acid to the fundus, applying it twice a Aveek for about tAvo months. The first menstrual period after the commence- ment of this treatment Avas perfectly painless, but Avas A'ery profuse, and lasted for seven days; the next Avas equally pain- less, and Avas over in four days. Since then the function has been perfectly normal, and the uterine catarrh has disappeared. The treatment just mentioned Avill often prove efficacious, provided the case be of recent origin ; but if of long standing, and if copious uterine catarrh or menorrhagia be present, more active treatment is called for. In all cases Avhere much tenderness on pressure exists, local bloodletting should first be practiced ; this is a rule from Avhich 1 make feAv exceptions. Local bloodletting relieves the pain to a considerable degree, and certainly faATors the ac- tion of other treatment, whether that be medicines administered by the mouth, or applications made directly to the diseased surface. Local depletion is a Aery old practice of recognized value. It has, hoAvever, fallen into disuse, apparently because, Avhen carried out bv means of leeches, it is troublesome, and, more- OArer, is often attended Avith unpleasant consequences. Some- times the leeches Avill not bite, at other times they will fasten on the vagina and give rise to bleeding, alarming in quantity and difficult to stop. Sometimes, too, notwithstanding every precaution, a leech Avill make its Avay into the os uteri. AYhen this has occurred to myself, as it has on tAvo occasions, the leech returned soon, but a patient assured me that on one occa- sion a leech remained in utero for tAveh'e hours, and gaA'e rise 198 DISEASES OF WOMEN. to no small anxiety. For these reasons the application of leeches to the cervix is unsatisfactory ; but I am decidedly of opinion that, as a preliminary treatment, local depletion is most valuable. I practice it, as you are aware, by puncturing the cervix. If the cervix be soft and spongy it must be done cautiously; one or two punctures, one-eighth of an inch in depth, will generally be folloAved by sufficiently free bleeding; if not, deeper ones should be made, and if the cervix be indurated, the point of the knife must be made to penetrate a considerable depth. The quantity of blood taken can thus be regulated with nicety; but a few minutes are occupied in the operation, and no pain is caused. The bleeding generally ceases the moment the speculum is AvithdraAvn; if it should not, a pledget of cotton must be placed in the vagina, and left in situ for a few hours; but it is very rarely indeed that even this is necessary. Local depletion does not produce as beneficial results in cases of corporal endometritis as it does in cases of cervical congestion; the benefit, therefore, resulting from the practice will be in an exact ratio to the amount of cervical disease which may exist. Local depiction is, hoAvever, in cases of endometritis, but a preliminary step; it is invariably necessary to adopt treatment which will act directly on the diseased surface—that is, on the mucous membrane lining the body of the uterus. There are three methods of making applications to the in- terior of the uterus: one is by injecting fluids into its cavity; another, the introduction of a piece of solid caustic into it by means of Simpson's intra-uterine porte-caustique ; and a-third is the passing up to the fundus, of a stillette armed with a layer of cotton, saturated Avith nitric acid, carbolic acid, or some other active agent. The first of these methods I have neArer tried, as it is a prac- CHRONIC ENDOMETRITIS. 199 tice not free from danger; and not alone that, but also much less certain and satisfactory in its results than either of the others. The second I have frequently practiced, in cases of imper- fect involution of the uterus. Where no inflammation exists its effects are most excellent; but it is not, so far as my ex- perience goes, a satisfactory method of treating any form of endometritis. The application of strong caustics to the interior of the uterus, of Avhich, in my opinion, the fuming nitric acid is by far the best, is a practice noAV extensively carried out, not only in this city, but also in America. HoAvever, some practitioners have still a great dread of ap- plying powerful caustics to the interior of the uterus, a fear which is totally groundless. Nitric acid seldom causes any pain Avhatever, if properly applied ;* in this respect its appli- cation differs entirely from the injection of even Aveak solu- tions of caustics into the uterus, grave symptoms, and even death, having followed the latter practice. Therefore, while I advocate the use of nitric acid and of the solid nitrate of silver as safe applications to the interior of the uterus, I strongly object to the intra-uterine injection of any fluid in the treatment of the class of cases under consideration. Of numerous cases of endometritis, in the treatment of which I used nitric acid, I shall give very briefly the details of the folloAving. The patient was a widow, and her last child had been born twenty years ago. Of late menstruation had become profuse, and Avas attended with very severe pain. She also suffered from constant pain in the left side, felt most intensely at a point midway between the spine and crest of the ilium. This pain, at first experienced only at each menstrual * For directions as to the mode of using nitric acid, see Lecture XV 200 DISEASES OF AVOMEN. period, became, after a time, constant, being aggravated in in- tensity during the periods, sometimes, indeed, becoming at those times absolutely intolerable; there Avas also tenderness over the right OATary. The uterus Avas tender to the touch, enlarged, retroflected. The introduction of the sound caused much pain, and some blood folloAAred its AvithdraAval. The cervix was SAVollen and much engorged. To relieve this condition I punctured it. It bled freely, and, hoping to lessen the ovarian congestion, I directed twenty-five grains of the bro- mide of potassium to be taken thrice daily. This treatment was continued in for some time, blood being extracted locally at intervals of five days. The result Avas that the cervical en- gorgement Avas removed, menstruation became someAvhat less profuse, and the 0A7arian pain much mitigated in severity; but, treatment having been discontinued for a short time, the Avhole train of bad symptoms returned; and I became comnnced that no permanent relief would be obtained unless I treated the interior of the uterus directly. I accordingly explained' my vieAvs as to the nature of her case to this lady, and to her son, himself a surgeon.. She consented to undergo any treatment which promised relief from her sufferings. I commenced by dilating the cervical canal so freely that I passed my finger through the os internum and up to the fundus of the uterus. As I had anticipated, I detected a rough granular condition of its lining membrane; the lip of the uterus aatis then seized Avith a vulsellum and drawn doAvn, and a Avire armed Avith a roll of cotton, thoroughly saturated with the fuming nitric acid, Avas passed up to the fundus and retained there for some seconds ; this Avas done twice, so as to secure a thorough cau- terization of the Avhole interior of the uterus. No pain fol- loAved. I kept this lady in bed for some days as a precaution, but no other treatment was adopted. The next period came on a little before its time, and Avas profuse, but attended Avith CHRONIC ENDOMETRITIS. 201 less pain. Since then her condition has steadily improved; the periods noAV last but three or four days, and are almost painless. This lady had been treated in various Avays, Avithout benefit, before she came under my care. I may here remark, that if nitric acid be applied shortly before a menstrual period, that period is likely to be profuse; but this by no means indi- cates that the treatment is a failure, the subsequent ones, as in the present instance, frequently becoming normal. To guard against misapprehension, I think it right to add that, in advocating the method of treating endometritis, prac- ticed in this ease, I must be understood to refer only to cases in Avhich menorrhagia, purulent discharges, or profuse uterine catarrh exist, or to cases in Avhich other means haA'e, on a full and fair trial, failed to effect a cure. This case occurred before I commenced to use my platinum canula.* I noAV but seldom find it necessary to dilate the cervix in cases of endometritis, but apply the acid through the canula ; a method which saArcs the patient much suffering, and, if carefully carried out, is very efficacious. WheneArer endometritis exists for any considerable length of time the mucous membrane lining the caA'ity of the uterus is thickened, and likely to become covered with numerous eleva- tions, sometimes minute, sometimes so large as to be distinctly felt bv the finger introduced through the cervix. It is generally necessary to remove these with the curette, and subsequently to apply nitric acid. The occurrence of this condition, I have already dAA'elt on, Avhen speaking of menorrhagia, to which it nearly invariably gives origin. We have recently had in our Avards, a Avell- marked example of this, the particulars of Avhich I have de- tailed in a former lecture (Lecture V). The patient suffered * See Lecture XVII. 17 202 DISEASES OF WOMEN. from such irritability of the bladder, that for years past she had been obliged, eATen during the night, to micturate at least every hour. This AAas her most distressing symptom, but of even more importance Avas the menorrhagia, which had gone on increasing in severity for ten years, and had rendered her perfectly exsanguine. In this case, I dilated the cervix, passed my finger up to the fundus, and found the lining membrane of the cavity to be in a roughened, granular condition. I cau- terized the interior of the uterus freely Avith the strong nitric acid, and had the satisfaction of seeing her completely relieved from the vesical irritation, and of discharging her, after the lapse of a few weeks, perfectly cured, also of the menorrhagia from which she had so long suffered. But, as already mentioned, you frequently have endometritis associated Avith endocervicitis, and, as the latter is the most obvious, all the symptoms may possibly be referred to it, and the existence of the former overlooked. Consequently you may be surprised to find, when you have cured the cervical affection, that the patient's sufferings are not alleviated. Dr. Marion Sims points out this, in his work on Uterine Surgery, and I am able to confirm the accuracy of his observations. Endometritis occurring in virgins, or in women who have neATer been pregnant, runs a very different course. In the great majority of cases, these will seek medical aid, either for the cure of sterility, or, more generally, Avith the Ariew of pro- curing relief from the sufferings which they experience at each menstrual period. I will first trace a case as it occurs in a married AA'oman. She, on being questioned, will, as a rule, tell you that prior to marriage, menstruation had been normal, or, at least attended Avith but little suffering ; that after mar- riage, the function gradually became more painful, and that this increased in intensity till she was compelled to seek relief. CHRON10 ENDOMETRITIS. 203 On making a A'aginal examination, we will find the cervix uteri to be elongated, probably SAVollen, and congested, fre- quently too, indeed I think in the majority of cases, anteflexion of the fundus Avill be found to exist, occasionally it is retro- flected, the os uteri is small and annular, and frequently Ave Avill be able to see a clear and slightly A'iscid discharge to exude from it. Noav the pathology and causation of these cases is, I think} this: they always occur in Avomen in Avhom either the cerArical canal is contracted, and the cervix conical, or in Avhom con- genital anteflexion of the uterus exists; the canal, narroAV though it be, sufficed before marriage, to permit Avithout diffi- culty, the exit of the menstrual discharge, but under the influ- ence of the excitement caused by sexual intercourse, a greater quantity of blood flows towards the uterus and o\-aries; the mucous membrane lining the cavitv and cervix becomes unduly SAVollen and A'ascular, and as a result, an increased amount of blood is, at the menstrual period, poured out into the cavity of the uterus; the swollen condition of the mucous membrane at the os internum and in the cervical canal, renders the originally narroAV passage almost impermeable, the menstrual flow is retarded, and, as a result, the blood coagulates in the distended caA'ity, and thus becomes Arirtuallv a foreign body. It excites the uterus to contract, and after much suffering, it is expelled ; relief then for a time is obtained, but the same process recurs OA^er and OA'er again, and in time permanent irritation of the intra-uterine mucous membrane is excited. And now the pa- tient's sufferings are not confined to the menstrual period alone, for, in consequence of the unhealthy condition of the intra- uterine mucous membrane, its secretion is increased in quantity and altered in character; it becomes viscid, and exudes slowly from the uterus. Often its exit is impeded to such a degree that it distend.- the cavity, inducing permanent dilatation, and 204 DISEASES OF AVOMEN. often hypertrophy of the Avhole organ, aggravating the pre- viously existing irritation of the lining membrane, and causing great distress and pain to the patient. If these cases are neglected, the Avhole system suffers; the ovaries are specially liable to be implicated; the irritation set up in the uterus, seems to be propagated to them ; they become enlarged, painful to the touch, and the source of great suffer- ing; the bladder often sympathizes, and the patient suffers from irritability of that viscus; then reflex irritations manifest themsehres; the breasts become painful, the appetite fails, and often there is nausea and even vomiting; in a word, chronic endometritis in a nulliparous Avoman is a most serious affection, causing the greatest sufferings, and undermining health, not rapidly, indeed, but surely, while sterility is an invariable result. Unfortunately, too, it is a most obstinate affection. If the case be of old standing, the hope of doing much for the patient is but small; if, hoAvever, it has not gone on too long, the prospect of effecting a cure is good, but to do this, it is essential to bear in mind the pathology>of the disease, the basis of Avhich is, that the conical cervix and contracted canal, coupled with anteflexion, Avhen this exists, pre Agents the menstrual discharges and viscid secretions of the diseased lining membrane from obtaining easy exit. The first step, then, toAvards effecting a cure, is to insure the free escape of the contents of the uterus. There is but one means of effecting this: the cervix must be divided. I lay this doAvn as a rule from Avhich there are few exceptions, that it is almost impossible to cure chronic endometritis in the nulliparous female, Avhen the cervix is conical, and its canal contracted, unless the cervix be divided, and this I believe to be absolutely true Avhen the affection coexists Avith either anteflexion or retroflexion. I ha\^e tried CHRONIC ENDOMETRITIS. 205 every other possible method, including the free use of nitric acid, after dilatation of the cervical canal, to find my patient after the lapse of a feAv months in no way improved. The folloAving affords a striking example of this. It is interest- ing, too, from the fact of its being the first case in Avhich I divided the cervix for the cure of endometritis, my previous operations ha\ring always been for the relief of painful menstruation. Mrs.-----, aged 36, married ten years, came under my care four years ago. She stated that previous to marriage she had ahvavs enjoyed good health, but that some months subsequently she suffered from a severe attack of pain in the region of the uterus. This after a time subsided, but from that date she never Avas perfectly free from suffering, till of late, though naturally of very active habits, she had been compelled to give up taking exercise nearly altogether; for years, too, she had been off and on under medical treatment, Avithout ever obtain- ing permanent benefit. She suffered from constant headaches ; these occasionally Avere very severe, from indigestion, flatulence, and constipation. She was unable to Avalk, for on attempting to do so she was ahvays seized Avith pain, referred to a point corresponding to the fundus of the uterus. This pain lasted for some time, then she would obtain relief, and immediately after invariably perceived a copious viscid discharge to exude from the vagina. These at- tacks of pain and subsequent leucorrhceal discharge occurred even Avhen she kept quiet, though then the intervals between them were considerable. Walking, however, always brought them on. I subsequently satisfied myself that these attacks of pain were due to the efforts of the uterus to expel the copious secretion Avhich collected in it. On making a vaginal examination I found that the cervix was conical, and the os so small that I could not introduce an 206 DISEASES OF AVOMEN. ordinary sound, but had to use a fine probe; the fundus was large and heavy, and slightly painful to the touch; there was no abrasion; but, though pressure Avith the fingers on the fundus caused but little pain, sexual intercourse Avas always producth^e of suffering. I decided on treating this case by applying nitric acid to the fundus, but as this Avas impossible in the contracted state of the cervical canal, I introduced a length of No. 3 sea-tangle bougie into the uterus, and after the lapse of twenty-four hours Avas, on Avithdrawing it, enabled to introduce a platinum canula, and through it apply the fuming nitric acid. The result Avas for the time very satisfactory. She improved wonderfully, and lost most of her distressing symptoms, and I saAV no more of her for four months, when she again consulted me, saying that she AAas as bad as eArer, and on making a vaginal examination, I found that she had relapsed into her former condition; the os uteri AAras as small, and the catarrh as copious as eArer. On considering this case, I became convinced that till I gave free exit to the pent-up viscid discharge no permanent benefit would folloAv, and, believing that division of the cervix would alone effect this, proposed the operation to her. She at once agreed to submit to it, and I accordingly performed it, dividing the cervix bi-laterally, in the manner described in a previous lec- ture. The result has been most satisfactory. She recovered without any drawback; has ever since steadily improved, and now, after the lapse of several years, is quite free from suffer- ing, is able to take long walks, and leads a most active life. After the divided surfaces have healed, and that no danger of exciting inflammation exists, it is generally necessary to apply carbolic acid, or some other caustic, up to the fundus; in fact, I always keep the patient under observation for some weeks subsequent to the operation. The length of time dur- ing which it is necessary to continue intra-uterine medication CHRONIC ENDOMETRITIS. 207 subsequently, must depend on the previous duration of the disease, as Avell as on the scArerity of the symptoms. In the case just related I applied carbolic acid seAreral times to the fundus, subsequent to the operation. In this case the patient has remained sterile; indeed, I had no hope that conception Avould folloAv in her on the cure of the endometritis, the disease Avas of too long standing. As a rule, I object to perform the operation of dividing the cervix, simply Avith the A'ieAv of remo\ring sterility; conception doubtless sometimes does occur after the operation, not because the cervix is rendered patulous, but because the membrane lining the in- terior of the uterus being rendered healthy, conception becomes possible. The folloAving case is an example of this: Mrs. K-----, aged 26. Had resided in India eArer since her marriage, five years ago; never has become pregnant. Menstruation Avas normal, and nearly painless. She suffers, hoAvever, constantly from backache1, and much discomfort in the left OA'arian region; is quite unable to take exercise, as walking brings on pain. She Avas specially anxious to have a family, and returned from India, and sought advice, more Avith the vieAV of having sterility remoA^ed, than for the relief of her sufferings. On examining her I found the cervix to be conical and the fundus acutely anteflected; there Avas also a good deal of uterine catarrh. The probe passed to the depth of nearly three inches. As this case Avas by no means a severe one, and evidently not of long standing, I decided on endeavoring to avoid dividing the cervix, and accordingly introduced an ante- version pessarv, punctured the cervix, applied carbolic acid to the fundus, gave bromide of potassium in full dose, and found the patient's condition steadily to improATe. All her symptoms subsided; the flexion, hoAvever, remained unaltered. After a time I sent her to Ems, Avhere she remained for some weeks, and returned in a very satisfactory state. Her husband, who, 208 DISEASES OF AVOMEN. during this time, had remained in India, noAV joined her, and they travelled about for a couple of months. On returning to Dublin, just a month before they Avere to start for India, she called on me, and said she had again of late begun to suffer as much as ever, and on examining her I found her to be in exactly the same condition as Avhen I had first seen her five months before. I at once told her that all she had done had been useless, and that there was no chance of a cure except she submitted to have the cervix dh-ided. She readily consented. I divided the posterior wall of the cervix only, this being the operation I always perform in cases of anteflexion. She sailed for India in four Aveeks from the date of the operation, soon after be- came pregnant, went to the full term of utero-gestation, and gave birth to a healthy child. I have given these tAvo cases in detail because they sIioav how useless any attempt to cure endometritis in sterile Avomen is, unless as a preliminary step, free exit is afforded to the dis- charge, Avhich invariably collects to a greater or less extent in the cavity of the uterus. And if I haA^e succeeded in impress- ing this fact on your minds, your failures in your future prac- tice will be lessened very considerably. The course and symptoms of endometritis in virgins do not vary in any great degree from those in the nulliparous married Avoman, the most prominent and perhaps the commonest symp- tom being dysmenorrheea, the discharge in many instances becoming scanty; in a feAv the menstrual function is normal, but these are the exceptions, Avhile the general health suffers even more than in the latter class; and, should the patient unfortunately marry, her sufferings are intensified. The cause of the attack is often obscure; it may be the result of over fatigue, but in the majority of cases I believe cold to be the exciting cause. CHRONIC ENDOMETRITIS. 209 I know of no affection so difficult to treat efficiently as chronic endometritis occurring in a virgin, and to make mat- ters Avorse, it is generally met Avith in girls of Aveakly, often of a strumous constitution. Occasionally it Avill yield to the application of carbolic acid to the fundus, coupled Avith Avarm hip-baths, local depletion, and attention to the general health ; but in by far the greater number of cases it will prove to be associated with a conical cervix, and probably an anteflected uterus, and if this be so, the only hope of cure, in my opinion, rests on the performance of the operation of dhuding the cervix, and the subsequent treatment of the unhealthy mucous mem- brane by the application of carbolic acid, or some similar agent. I haAre hitherto spoken only of disease of the mucous mem- brane lining the cavity of the uterus ; but the parenchyma also is frequently the seat of disease, being specially liable to con- gestion, Avhich often terminates in permanent hypertrophy and enlargement of the whole organ. To this condition the term chronic metritis is generally applied. I agree, hoAvever, Avith Dr. T. Gaillard Thomas, that " diffuse interstitial hypertrophy " conveys a more correct idea of the pathology of the affection I am now speaking of, consisting as it does in an increased Aoav of blood to the part and subsequent static congestion, Avith in- creased growth both of the connective tissue and of the mus- cular fibres of the uterus, that of the former being greatly in excess. Chronic metritis as thus defined is a very common affection. It is met coexisting Avith, often apparently the result of endo- metritis; the inflammation at first confined to the mucous membrane gradually extending to the substance of the uterus, the bloodvessels of which become engorged, while the muscular structure is softened, SAVollen, and, in my opinion, frequently infiltrated Avith serum to such an extent as to produce Avell- 18 210 DISEASES OF WOMEN. marked oedema of the organ, especially of the cervix. In fact, I have satisfied myself that the great size Avhich the uterus at- tains in many eases is due mainly to the serous effusion Avhich has taken place into its muscular tissue. In addition to those cases in which metritis appears to be due to an extension of dis- ease from the intra-uterine mucous membrane, Ave haAX1 it with- out doubt depending on the irritation caused by the develop- ment and groAvth of uterine fibroids. In tAvo cases Avhich oc- curred in my own practice, I Avas called upon to treat a very intractable form of metritis. Both patients Avere for a long time under obseiwation, and in both intramural fibroids Avere finally proved to exist. Both patients Avere unmarried. In other cases the affection seems to be of comparatiATely passi\re origin, often the result of imperfect involution of the uterus subsequent to delivery, Avhich, favoring or actually causing permanent fulness of the blood\7essels, is the first step in a process AArhich ends in the structural changes already described. On Avhatever cause depending for its primary oia'gin, me- tritis Avhen once developed is a very distressing affection, and one most difficult of cure. That form Avhich is connected Avith the growth of a fibroid may be dismissed Avith a feAv Avords. Small intramural fibroids are most difficult to detect, their very existence may not even be suspected ; time alone unravels the mystery Avhen the tumor has attained a size AA'hich enables it to be recognized ; but in metritis due to other causes, much may be done to alleviate the patient's sufferings. Where endometritis exists it is obviously necessary that every effort should be made to restore the mucous membrane to a healthy condition; till this is done no progress will be made towards the cure of the other affection. In these cases intra-uterine medication must be used Avith great caution for under such conditions the application of nitric acid or other strong caustic to the interior of the Avomb may be folloAved by CHRONIC ENDOMETRITIS. 211 injurious results. It is here that local depletion by leeching or puncturing the cervix is eminently beneficial, especially so in those cases Avhere oedema exists. Blisters applied abo\Te the pubes or to the sacrum are also of great use, Avhile where induration exists, repeated applications of the actual cautery promise the best results. Postural treatment, that is enjoining absolute rest, the shoulders being on a levrel Avith the pelvis, is an important element in the successful treatment of some of these cases, but is a method very difficult to carry out. Vaginal douches of hot Avater, if properly carried out, are capable of affording great relief, often of actually facilitating a cure; they should be administered* at a temperature of about 105°, and be continued for a considerable time twice daily. Counter-irritation, kept up by the application of a succession of small blisters above the pubes, is often productive of marked relief, but to be of use they have to be repeated frequently, and it is often difficult to induce patients to perseA7ere Avith them ; you may therefore be obliged to substitute for them the daily application of iodine. But in truth chronic metritis often proves a most intractable affection ; its tendency is to terminate in hypertrophy and induration of the Avhole, or at least of the body of the uterus. When this stage is reached, benefit fre- quently follows from a visit to Ems or Kreuznach; but the stay at either place should, to be of use, be a prolonged one. * See Lecture XVII. 212 DISEASES OF AVOMEN. LECTURE XL Displacements of the Uterus—Retroflexion—Causes, Symptoms, and Treatment of—Hodge's Pessarv—Retroversion—Ante- flexion—Prolapsus Uteri. The healthy, unimpregnated uterus is an organ of great mobility. Its connection Avith the pelvic walls by means of the broad ligaments, which are merely folds of the peritoneum, is so very lax, that it can without difficulty be inclined either anteriorly or posteriorly; they no doubt oppose a certain amount of resistance to its lateral motions, but very little to its movements in other directions, while the round ligaments, Avhich do materially aid in supporting it, frequently prove to be incapable of offering any effectual opposition to the descent much less to inclinations of the womb in either an anterior or posterior direction. In young Avomen who have not borne children, the muscular structure of the vagina, forming, as it does, a firm tube into which the cervix uteri is inserted, aids materially in supporting the Avomb ; but in women in whom that canal becomes relaxed from the effects of frequent par- turition, or of disease, local or constitutional, the support af- forded by it is in a great measure wanting, and the organ may sink directly doAvn; the tendency to such a displacement be- comes greatly aggravated, should the Avomb, as is frequently the case, be from any cause enlarged and heavy. But common as descent of the uterus is, the other displacements to Avhich the organ is liable are still more so. Hardly a day passes in which we do not meet with examples among the extern patients of RETROFLEXION. 213 flexions of the Avomb either backAvards or forwards. I shall call your attention to these first, and afterwards return to the consideration of prolapse. The Avomb, then, may be bent on itself either in a posterior or anterior direction, and to these flexions the terms " retro- flexion " and " anteflexion " are respecth7ely applied. Now it is of importance that you should clearly understand what is meant by these terms. Some Avriters, and among them the late Sir J. Simpson, used the words " retroversion " and " retro- flexion " as synonymous, but in reality they indicate two very Fig. 25. Retroversion of the Gravid Uterus. different affections, for retroversion signifies a turning back of the entire uterus, and is applicable to that change of position to Avhich the gravid womb is liable Avhen the fundus lies in the sacral 1io11oaat, the os being forced up behind the pubes, a con- dition rarely seen unconnected with pregnancy; whereas by retroflexion, on the other hand, is to be understood a bending back of the fundus alone, the os remaining very nearly in its 214 DISEASES OF WOMEN. natural position; while in cases of anteflexion, the fundus is in like manner bent forAvards. Retroflexion, which is perhaps the most common displace- ment to Avhich the uterus is liable, may be met with at nearly Fig. 26. Retroflexion of the Uterus. every period of life from puberty onAvards. It is, hoAvever, rare in youth and in advanced age, the great majority of cases occurring during that period of life in Avhich the uterine system is in the state of its greatest activity, namely, betAveen the ages of tAventy and forty years. It is besides an affection, the ex- istence of Avhich is very liable to be overlooked; this being due rather to the fact that the symptoms to which it gives rise have often but little apparent reference to the uterus, than to any difficulty in detecting it Avhen once our suspicions are aroused. When we consider the position of the uterus in the pelvis Avith the bladder, an organ capable of such immense disten- RETROFLEXION. 215 sion, placed in its immediate front and frequently exercising a pressure backwards, and Avhen Ave remember that many Avomen from mere habit, or from motives of delicacy, oftentimes pass many hours Avithout emptying that viscus, Ave can readily un- derstand the frequent occurrence of this displacement. But though the distended bladder may thus be the agent in direct- ing the uterus backAvards, it is but a secondary cause; the uterus itself must be at the time in an abnormal condition, for otherwise it Avould regain its proper position Avhenever the bladder became flaccid. Retroflexion is generally, in my opinion, produced gradually, and is the result of affections Avhich increase the bulk and weight- of the uterus, and more especially of its fundus. It is not, hoAvevrer, necessary that the increase should be confined to the fundus, though, if that be the case, the danger of retroflexion occurring is much increased; for if the bulk of the entire uterus be augmented this may still take place, because not only is there a force acting from before, directing the fundus downAvards and backAvards, but also be- cause there is no resistance from behind to counteract that ten- dency. The muscular tissue of the uterus is in all these cases in a relaxed condition. Were this not so, I do not believe that the uterus could bend. We, hoAvever, frequently meet Avith cases in which, Avhile retroflexion obviously exists, the uterus certainly is not enlarged or increased in weight; but this is capable of explanation if Ave bear in mind that, Avhen the uterus is bent on itself at an angle, the circulation must be seriously interfered Avith. Congestion doubtless at first occurs, but subsequently, if the case be neg- lected, atrophy of the organ may after a long interval result. In time the original cause of the affection may cease to exist; but the uterus does not necessarily on that account regain its normal position, for not only may the fundus be bound down by adhesions formed on its peritoneal surface, but also a pro- 216 DISEASES OF WOMEN. cess of absorption and consequent thinning, may take place at the point of flexion, especially on the loAver or concave surface, so that even Avhen no adhesions exists, permanent restoration of the uterus to its normal position is impossible; this fact en- ables us to understand the unsatisfactory results which often folloAv treatment adopted for the cure of cases of old standing. Without doubt, too, the affections may in a few cases be con- genital. The causes producing the condition likely to result in retro- flexion may be reduced to three classes, namely: 1st. Congestion, frequently terminating in chronic inflamma- tion of the uterus, and hypertrophy of that organ. 2d. Subin\rolution of the uterus, after labor or abortion. 3d. Tumors of the uterus. But in addition to those cases, in Avhich we can trace the flexion to the existence of one of the conditions here enumerated, we occasionally meet with others, the origin of Avhich is so ob- scure, as to prevent our being able to decide as to the mode of their occurrence. Congestion of the uterus is a common cause of retroflexion, and one frequently overlooked. It is met Avith in two very different classes of females, namely, those Avho lead a very ac- tive life; and again, in those of Aveakly constitution and seden- tary habits, such as needlewomen and teachers. Thus young Avomen of active habits, Avho from necessity or for pleasure, walk, ride, or garden much, or Avho folloAv employments or amusements necessitating much standing, will sometimes con- tinue to pursue these duties or amusements during the cata- menial periods; the result is that the organ remains congested for an undue length of time, and a condition favorable to chronic inflammation is produced. The folloAving case illustrates this form of the disease: M. F., set. tAventy-five, unmarried, has ahvays lhTed a very RETROFLEXION. 217 active life, and, till Avithin a comparatiArely recent period, en- joyed excellent health. About three years ago having been compelled to undertake the superintendence of a large farm, she undenvent great fatigue, generally spending from eight to tAvclve hours each day in the open air, either on foot or on horseback, and never relaxing her exertions even during her menstrual periods. At first she suffered from a sense of ful- ness and Aveight in the loAver part of the abdomen, but to these symptoms she paid no attention. At about the end of a year she percciATed, for the first time, a neAv train of symptoms. She now experienced difficulty in passing Avater, and Avas obliged to strain in doing so. After a little time her bufferings Avere further increased by difficulty experienced in defecation. The boAvels Avere not actually constipated but their action caused great pain, and the faeces Avhen passed Avere as small as those of a little child. The catamenia appeared regularly but in diminished quantities. I felt in this case, as I ahvays do Avhen the patient is unmarried, great reluctance to make a Anginal examination, but her sufferings Avere so great, and treatment directed to other organs had so entirely failed to afford relief, that I deemed it absolutely necessary to ascertain the condition of the uterus, and on examining I discovered that organ to be much enlarged, tender to the touch, and completely retroflected, its fundus occupying the IioIIoav of the sacrum, and pressing against the rectum; this explained one of her symptoms, namely, the difficulty experienced in defecation, the irritation of the bladder being evidently reflex. With the vieAV of re- taining the uterus in its normal position, I introduced a Hodge's pessarv. The fundus was raised without difficulty, but the pessary first used proved to be too large, and caused so much pain that, after the lapse of a few hours, it had to be removed. On a subsequent day, hoAvever, I introduced a smaller one. This ansAvered admirably, and she experienced such relief that 218 DISEASES OF AVOMEN. she Avas able to return home, and has since folloAved her ordi- nary occupations. In this case the retroflected uterus AAras in a state of chronic inflammation, and to this condition her greatest sufferings Avere due. In the folloAving case, however, no in- flammation Avas present. The uterus Avas simply congested, and a very different train of symptoms manifested themselves A schoolmistress, set. twenty-one, had suffered for more than a year from occasional attacks of A'omiting, which for the last three months had become incessant. She had been treated in various Avays, but Avithout benefit, and at the time I saw her in consultation Avith my colleague, Dr. Little, under Avhose care she had been, rejected everything she swalloAved. She eATen vomited lime-AArater and milk, and this though only one spoon- ful had been given at a time and at regular intervals, no other food of any kind being alloAved. In like manner she had been fed on beef tea exclushTely, a spoonful only being given at in- ter Arals of fifteen minutes. The food thus taken Avould be re- tained for a time, till some ounces had been SAvalloAved, then the Avhole Avould be rejected. Nevertheless she had not be- come actually emaciated, and she only complained of debility, and pain in the pit of the stomach and in the back. The cata- menia appeared at regular intervals, but in much smaller quan- tities than formerly. On examining the abdomen, tenderness on pressure Avas detected over the left ovary, and to that spot four leeches Avere applied. The effect Avas marked. The same afternoon the stomach retained some beef tea, that being the first food retained for several Aveeks. The vomiting, hoAvever, did not entirely cease, but still occurred once or tAvice a day, nearly ahvays in the morning. Being noAV satisfied that this symptom depended on some reflex irritation, Ave decided on making a vaginal examination, and I Avas somewhat surprised to find the uterus completely retroflected. The fundus was enlarged and occupied the holloAv of the sacrum. It Avas easily RETROFLEXION. 219 raised to its normal position, and to retain it there, I intro- duced a Hodge's pessary of small size. This Avas, from the A*ery first, borne Avithout inconA7enience, and from the time it Avas introduced the ATomiting entirely ceased. The catamenia subsequently appeared in much larger quantities. I remoATed the pessary after it had been worn for three months. Since then there has been no return of her distressing symptoms, and I understand that she is noAV married. Both these patients Avere unmarried women, in both con- gestion of the uterus occurred, Avhich in one had reached, in the other Avas slowly assuming the form of chronic inflamma- tion; when this happens the patient's sufferings are ahvays greatly aggraA'ated. She Avill tell you that, in addition to pain in the back, she suffers from severe lancinating pains over the pubes, in the groin, and shooting doAvn along the course of the crural nerve. Change of posture, or any motion, aggravates this pain, Avhich sometimes becomes so severe as to render walking a matter of great difficulty. Dr. Graily Hewitt has recently described this condition, and applied to it the term of " uterine lameness." Often too in these cases, the bladder sympathizes, and a constant desire to micturate Avears out the patient; touching the fundus of the uterus causes pain sometimes of a very se\Tere character. Sexual intercourse, therefore, becomes so painful and distressing as to be actually impossible. It is this form of the affection Avhich most imperatively calls for our interference, for it gives rise to great distress, and often lays the seeds of unhappiness in married life. The folloAving case exemplifies the distress Avhich exists in cases of retroflexion Avhen aggraA'ated by the occurrence of chronic inflammation of the uterus. S. B., aet. twenty-eight, had been married for eight years. Not long after marriage, when in the fourth month of pregnancy, she fell downstairs 220 DISEASES OF AVOMEN. and was much hurt. As the result of this accident she aborted. For a year folloAving she continued in a miserable state, the pain in her back and in the region of the uterus being so severe that she Avas seldom able to leave her bed. The catamenia Avere scanty and irregular. She Avas at length induced to go to Edinburgh, and place herself under the care of the late Sir J. Simpson. He incised the cervix uteri, and introduced a stem pessary. Severe inflammation folloAved and the instru- ment had to be removed. From this attack she recovered, and returned home feeling somewhat better, but soon relapsed into a condition even Avorse than before. She now experienced a distressing feeling of Aveight in the neighborhood of the rectum; this Avas greatly increased at each menstrual period, which, hoAvever, recurred regularly, the discharge being very scanty and its appearance ahvays ushered in by severe pain. At length she became a confirmed invalid. Walking caused such suffering that she dared not attempt even to cross the room. On examining her I found the uterus A\ras completely retro- flected, the fundus, Avhich occupied the IioIIoav of the sacrum, being very tender to the touch. The os Avas gaping, freely ad- mitting the tip of the finger, and a copious discharge of semi- purulent fluid exuded from it. I leeched the cervix on three occasions, and when the tenderness of fundus Avas lessened, in- troduced one of Hodge's pessaries, which she Avore Avithout incon- venience. Her condition has since steadily improved. Men- struation noAV lasts for two or three days, and she is able to per- form her usual household duties. She still continues to wear the pessary. In this case as AA^ell as in the foregoing one, menstrua- tion though not entirely suppressed had become very scanty. The reverse will be found to be nearly invariably present Avhen the flexion depends on other causes. You doubtless remember my having pointed out the fact that not unfrequently after labor or abortion, the uterus from RETROFLEXION. 221 various causes fails to regain its natural size, and remains un- duly enlarged ; to this condition the term " subinvolution " is applied. When this is the ease the organ is peculialy liable to flexions, for not only is its fundus unduly heaArv, but the mus- cular fibres also are relaxed, consequently the natural rigidity of the organ is in a great degree Avanting. When retroflexion occurs as a sequence of subinA'olution, it gives rise to very grave symptoms, the most prominent of Avhich is menorrhagia. Indeed it is frequently for the relief of this that we are con- sulted. We have recently had in our Avards a good example of this form of the affection. The patient Avas admitted suffering from menorrhagia; she stated that three months after the date of her last confinement, menstruation came on very profusely and lasted for six Aveeks, and that at each subsequent period the loss had been considerable. On examination the uterus Avas found to be retroflected, the whole organ being also enlarged; but it Avas not tender to the touch, nor Avas sexual intercourse painful, and the introduction of the uterine sound caused no distress. You see at once Iioav strongly this case contrasts Avith the ones previously detailed. Here is another, the particulars of Avhich I have recorded in my note-book. A lady gave birth after a difficult labor to a still-born child, about five months previous to my seeing her. Considerable haemorrhage followed delivery,'and her convalescence had been very slow. Subse- quently she suffered from profuse menstruation, had gone to the seaside and been treated by the administration of tonics, but Avithout effect. On examining her, I found the uterus com- pletely retroflected and much enlarged. The case was clearly one of subinvolution of the uterus and subsequent retroflexion. This lady did not suffer any pain. She complained of the debility consequent on the menorrhagia and of nothing else. There is no doubt but that the presence of a tumor im- 222 DISEASES OF WOMEN. bedded in the wall, or contained Avithin the cavity of the uterus, may predispose to its flexion; or again, by bulging out one AA^all it may simulate a flexion, although in point of fact the axis of the uterus remains unchanged. This Avas so in the patient Avhose case is illustrated by the woodcut, Fig. 13, page 102. The uterus in her case appeared to be anteflected, but in reality the anterior Avail had merely yielded to the pressure exerted by the polypus as it increased in size. In like manner fibrous tumors, if situated on the peritoneal surface, may pos- sibly, by their Aveight, draAV the fundus of the uterus doAvn- Avards. Care therefore is needed to discriminate betAveen a retro- or anteflected uterus and an intramural or intra-uterine tumor bulging the Avail outAvards, or an extra-uterine fibroid projecting from its surface. It is only by means of the uterine sound that you can clear up this point. From the details of the cases to Avhich I have called your attention, you will see that the symptoms they presented varied much ; still, as I shall presently notice, they had some Avell- marked points, common at least to all the cases falling under one of the heads into Avhich I have divided them. If you refer to most of the works on diseases of women, you Avill find the symptoms of retroflexion of the uterus stated to be a " sense of Aveight" in the pelvis, " pain in the back," or " shooting doAvn the thighs," etc.; symptoms Avhich are com- mon to nearly every form of uterine disease, and, therefore, worthless as a diagnostic mark; Avhile with respect to the state of the menstrual function, no attempt is made to apply to it any definite rule. Thus Sir J. Simpson, in the first volume of his Obstetric Works, says that he has found the " catamenial discharge to be the most oppositely affected, occasionally in the Avay of menorrhagia, sometimes of dysmenorrheea." Again, Dr. Churchill says, " Menstruation may be profuse or painful or both." I cannot but think that this apparent contradiction RETROFLEXION. 223 in the description of symptoms, is due mainly to the A\ant of careful discrimination betAveen tAvo classes of cases, depending on totally different conditions of the same organ. Doubtless there is not any one symptom on Avhich AA7e can rely as indicating the existence of retroflexion of the uterus; and I do not remember in my oavii practice a single case in which, prior to making a ATaginal examination, I had sufficient grounds for concluding that this displacement existed, though I often surmised, and as a subsequent examination proA'ed, correctly, that such Avas the case. Thus, in the first of the cases Avhich I have detailed, the most prominent symptoms Avere irritation of the bladder and difficulty in defecation; in the fourth, they were pains over the ovary and total inability to walk ; Avhile in the second regurgitant vomiting alone Avas complained of. Another case presented an example of uterine lameness, and in her the uterus Avas so tender to the touch, that sexual intercourse Avas impossible. In these cases, hoAvever, differing as they do in other respects, the menstrual function was similarly affected, being in all much diminished in quan- tity. In tAvo other cases, on the contrary, menorrhagia Avas the sole symptom Avhich attracted the patient's attention. And, again, in a case recently under obsoiwation, although menstrua- tion Avas profuse and Aveakening, the prominent symptom Avas paroxysms of intense pain. But though the result produced— namely, retroflexion—was in all these cases the same, the causes giving rise to that result Avas different. Thus, in those in which menstruation Avas diminished, the retroflexion Avas the result of congestion, terminating in chronic inflammation and sloAvly produced hypertrophy. In the others, Avhere menorrhagia ex- isted, it followed on subinvolution, the catamenial discharge beino-diminished or increased according as the flexion depended on one or other of the causes named. I have already noticed the occurrence of vomiting as having 224 DISEASES OF AVOMEN. been the prominent symptom in one case. This of course was due to reflex irritation; but the stomach is not the only organ liable to sympathize with the uterus Avhen it is retroflected; the mamma? may also be affected. Thus, I recently Avas con- sulted by a married lady, mainly for the purpose of deciding Avhether she Avas pregnant or not. She stated that four years previously she had given birth to a living child, and that sub- sequently she had been several times pregnant, but on each occasion had miscarried at the end of the third month. She supposed that she Avas noAV again pregnant, because she suffered from incessant nausea, Avhile at the same time her breasts had become enlarged, painful, and distended Avith milk; but still she was in doubt, because the catamenia appeared not only regularly, but in increased quantity. I speedily satisfied my- self that she Avas not pregnant. The uterus AAas retroflected. It was manifestly a case of subinvolution terminating in retro- flexion. In this case a pessary aa as at first badly borne, though finally one Avas introduced which ansAvered admirably. From the consideration of the foregoing cases, I think we may fairly draw the folloAving conclusions: 1st, That retroflexion of the uterus is a common affection, and that it is met Avith both in married and unmarried females. 2d. That it is generally a secondary, not a primary affection. 3d. That when it is due to congestion, or chronic inflamma- tion of the uterus, terminating in hypertrophy, the catamenia are diminished in quantity and frequently painful. 4th. But that when retroflexion is the result of subinvolu- tion of the uterus folloAving labor or abortion, the eatamenial discharge is, at least in the first instance, increased in quantity, sometimes even to an alarming degree. 5th. That in addition to the symptoms common to all forms of uterine disease, namely, pain in the back, sense of weight, etc., Ave not unfrequently have, Avhere the uterus is retroflected TREATMENT OF RETROFLEXION. 225 difficulty in defecation, and in some cases reflex irritation of the bladder, stomach, and breasts, "occurring noAV in the order of frequency given. It is seldom that much difficulty is experienced in recognizing a retroflected uterus; you feel a tumor in the recto-Anginal cul- de-sac, Avhich you can in most cases raise by making pressure on it with the finger; and in doing so you can generally satisfy yourself that it is the fundus of the uterus, the cervix of which lies in its natural position; but the use of the sound will decide the question; for, if the uterus be retroflected, the instrument Avill pass Avith its concavity towards the sacrum; and Avhen introduced you can in most eases, by giving the handle of the instrument a half turn, raise the retroflected fundus to its nor- mal position, thereby causing the tumor to disappear. It will, however, drop back as soon as the sound is withdrawn, unless it be supported by means of a pessary. Great difference of opinion exists among practitioners as to the best mode of treating cases of retroflexion. Dr. Meadows Avould endeavor to cure the inflammatory condition, Avhich is the chief cause of the patient's sufferings, before having re- course to mechanical treatment, I think, however, that Avhere a pessarv can be borne, the restoration of the organ to, and the supporting of it in, its proper position, Avill materially aid us in our efforts to effect a cure. The instrument that I generally use for the purpose of supporting the retroflected Avomb, is the modification of the ring pessary, known as Hodge's lever pessarv; it is oblong in shape, and has a double curve (Fig. 27). When introduced it should lie in the position shoAvn in the engraving (Fig. 28). Those made of vulcanized india- rubber, on Avhich the secretions of the vagina take no effect, are the best instruments. I prefer them Avith transverse bars; the cervix projects through the space behind the posterior one of these. Dr. Greenhalgh has suggested a useful modification 19 226 DISEASES OF AVOMEN. in the construction of these little instruments; he has them made of copper Avire eased in india-rubber tubing, the Avire, Fig. 27. Hodge's Pessary.* however, is wanting at the loAver or Avide end, the india-rubber alone extending across that part. This is a double advantage, Fig 2S. Hodge's Pessary in Situ. * These pessaries as generally sold, and as figured in the woodcut, are not sufficiently curved in their upper third, and their value as a lever is conse- quently materially lessened. • greenhalgh's spring pessaries. 227 the yielding band of india-rubber adapts itself to the parts, and never, by its pressure, irritates the neck of the bladder, Avhich the rigid instruments sometimes do, and moreover it permits the sides of the pessary to be approximated during its intro- duction, a matter of no small importance in many cases Avhere the orifice of the vagina is narroAV, while the elasticity of the Avire expands the pessary to its original Avidth as soon as it is fairly Avithin the vagina. I have repeatedly seen these " spring pessaries" worn Avith comfort by patients Avho could not tolerate the rigid ones. Instead of transverse bars Dr. Greenhalgh's haA-e bands of india-rubber running across them. He recom- mends that in the treatment of those troublesome cases in Avhich prolapse of the anterior Avail of the Aragina exists, large-sized pessaries be Avorn, in Avhich these transverse bands extend doAvn the entire length of the instrument, as is shown in the annexed engraving (Fig. 29). I do not, hoAvever, approve of Fk;. 29. Greenhalgh's Spring Pessaries. these bands, for I find that after a short time they stretch and yield, and, moreover, becoming coated Avith mucus, often cause a very disagreeable discharge. WhateATer instrument you select, care must always he taken to see that it be of suitable size and length : for if one be in- troduced which is too long, it Avill cause much discomfort, and 228 DISEASES OF WOMEN. perhaps actual pain ; while, if the instrument be too small it Avill slip out; you must, therefore, have a number of these pessaries of various sizes by you, and remember, that the \Tagina varies greatly in size in different Avromen. A properly fitting pessary generally affords immediate relief to the patient, and may be left in situ for several Aveeks, or even months. I ahvays, hoAvever, recommend patients to have it remoA7ed after the lapse of ten or twelve Aveeks, and not to have it replaced for a feAv days. By adopting this precaution, all danger of unpleasant consequences folloAving its use will be obviated. Sometimes, hoAvever, Hodge's pessary, e\Ten if properly shaped, fails to raise the retroflected fundus sufficiently, and you Avill from time to time meet with cases in Avhich it becomes necessary to straighten the uterus by the introduction of a stem within its cavitv. The use of stem pessaries are specially use- ful when dysmenorrheea is present in connection Avith retro- flexion. Stems are very liable to slip out of the uterus. To obviate this tendency Dr. Chambers recommends the use of a vulcanite instrument, the stem of Avhich is split and expands after being introduced into the uterus. This instrument is self-retaining, and when it can be borne often proves useful. Dr. Green- halgh's flexible pessary, Fig. 30, is, hoAvever, in my opinion, superior to any other. The stem consists of india-rubber tubing, admitting an ordinary sound, which must be passed into it when the stem is being introduced. Xear the upper extremity is a bulb Avith four slits in it, through which the secretions of the cavity escape ; the loAver extremity termi- nates in a shield. Dr. Greenhalgh urges in its favor that " being of soft material it adapts itself better to the canal, is not liable to slip out, or to inflict injury, and can be Avorn without interfering Avith marital relations." An ordinary vulcanite or galvanic stem pessary can in gen- FLEXIBLE STEM PESSARY. 229 eral be retained in-situ by the subsequent introduction of a Hodge's pessary, or if that fail, of an ordinary box-Avood disk. Stem pessaries, of Avhatever kind employed, should never be left in the uterus for a longer period than a month, without removal, and their use should be avoided when possible. Fig. 30. Greenhalgh's Flexible Stem. Should, hoAvever, the uterus be so tender to the touch that the pessary cannot be worn without causing discomfort, you must endeavor first to relieATe the tenderness by the use of the vaginal douche, or by local depletion, practiced either by puncturing the cervix or by leeching it. Indeed Dr. Hall con- siders repeated bloodletting, effected by puncturing the cervix, sufficient alone for the cure of flexions. This assertion is, hoAv- eA'er, too general; it is occasionally, but not generally sufficient. I use it as an adjunct; supporting the fundus by means of a pessary, and at the same time endeaA^oring to bring the organ 230 DISEASES OF AVOMEN. back to its normal condition by local depletion, practiced at intervals of a feAv days. In fine, treatment directed to remove the cause of the flexion should be carried out, Avhile the uterus should, if possible, be retained in its normal position by me- chanical means. In conclusion, I Avould urge on you the necessity of bearing in mind that cases of retroflexion are frequently met Avith Avhich seem to cause neither distress, nor even inconvenience, to the patient, and that such cases should not on any account be interfered Avith. I must now briefly direct your attention to retroATersion of the uterus: BetroArersion of the uterus is not, at least in its com- plete form, a displacement of freq uent occurrence; doubtless partial retroArersion, by Avhich is to be understood that condition in which the fundus inclines more or less backAvards, the Avhole organ lying in a sloping direction across the pelvis, the os being still, howeATer, its lowest point, is not very rare; but this par- tial version of the Avomb seldom giA'es rise to distressing symp- toms, and consequently, as a rule, escapes notice. But true, complete retroversion is of infrequent occurrence. But al- though this displacement is comparatively rare, still it is an affection of great importance, not only from the gravity of the symptoms it gives rise to, and the serious and even fatal con- sequences Avhich may result from its occurrence, but also be- cause of the frequent errors of diagnosis made in relation to it. In retroversion the uterus, as the name indicates, is turned completely backwards, the os uteri looking upAvards and for- Avards, the fundus lying in the holloAV of the sacrum, and some- times almost on the perinamm. It is of importance that you should bear in mind the differ- ence betAveen retroversion and retroflexion of the uterus. In the former the Avhole organ is, as I have explained, turned over; in the latter it is flexed, or bent at a point usually cor- RETROA'ERSION. 231 responding to the os internum. The diagrams, Figs. 25 and 26, pages 213 and 214, will coiwey to you a correct idea of these tAvo very different distinct affections, Avhich, hoAArever, are frequently spoken of as identical, or at most as differing only in degree. Retroversion, at all times a rare affection, is still more rarely met with unconnected Avith pregnancy. It generally occurs about the end of the third month of pregnancy, and the first symptom it gives rise to, almost invariably, is retention of urine. You will be asked to see a Avoman in the third or fourth month of pregnane)-, who will tell you that she is un- able to pass Avater, and on examination you Avill find the bladder to be distended Avith urine. On emptying it, you will on a further examination find that a globular body occupies the holloAV of the sacrum, and that the os uteri is high up be- hind the pubes, possibly altogether beyond your reach; at the same time, a bimanual examination aa ill prove the uterus to be absent from its normal position. But possibly the patient may tell vou, as in the case at present under our observation, that she is able to pass Avater; nay more, " that it is always com- ing." This is a statement Avhich constantly misleads inex- perienced practitioners; the dribbling of urine is under such circumstances but the overfloAV of an over-distended bladder, and if you fail to recognize this, and promptly to empty the bladder, vour patient's life will be endangered, possibly lost. She mav die of peritonitis, or of unemic poisoning, or the mu- cous membrane of the bladder may become softened and sub- sequently gangrenous, and death ensue. The causes producing retroversion of the uterus are various. Frequently the displacement appears to take place suddenly. A pregnant Avoman makes an effort such as that requisite to lift a heavy Aveight, and immediately experiences some pelvic distress. By-and-by she finds that micturition is impossible, 232 DISEASES OF WOMEN. and on examination retroArersion is found to exist. The con- clusion is that the displacement took place on the moment. I doubt if this explanation is ever perfectly correct. Most probably the uterus had been, ever since, probably before the occurrence of pregnancy, lying in an abnormal position, namely, more or less across the pelvis, and that the sudden muscular effort, the bladder being at the time distended, merely com- pleted the displacement Avhich had previously been in gradual progress. The subsequent retention of urine is the result of two causes—one, that the posterior wall of the bladder is draAvn down by the uterus, to Avhich it is attached; the other, that the neck of the uterus presses upon the urethra, and thus obstructs the flow of urine. But in some cases the patient cannot assign any cause for the production of the distressing symptoms from which she suffers. There may have been a gradually increasing difficulty in evacuating the contents of the bladder, till finally that cannot be effected at all, or at most, but partially, only a very small quantity of urine being Aoided at a time. What has occurred under such circumstances may possibly be this: the patient, previous to her becoming preg- nant, may have been the subject of retroflexion of the uterus; pregnancy occurring, the fundus of the uterus, as it enlarges, instead of rising, sinks gradually loAver, drawing doAvn with it the posterior wall of the bladder, the flexion in time being thus converted into a Arersion. This, however is, I believe, of ATery rare occurrence. I have on the contrary, frequently known patients, the subjects of retroflexion of the uterus, to become pregnant, and have observed that as utero-gestation advanced, the fundus gradually rose, and finally assumed its normal shape and position. Dr. Barnes believes that this is effected by the gradual enlargement of the fundus upAvards, there being no obstacle to its growth in that direction, and that thus, in time, the pelvic portion is partially " draivn out of its lodgment." RETROVERSION. 233 Cases of retroversion of the gravid uterus usually terminate in one of three Avays: 1. The uterus may be raised above the promontory of the sacrum and utero-gestation proceed normally; 2. xVbortion may occur; or, 3. Death may ensue. I shall here detail for you the particulars of the case of the patient at present in hospital, as she is likely to afford an ex- ample of the first and most favorable termination of this dis- placement, and it will also, I think, impress on you deeply, the importance of being able to recognize the affection, for this woman had been under treatment for some time before she came under my care, Avithout the true nature of her case being suspected. A. M., a married AAroman, and the mother of five children, Avas admitted into hospital, evidently suffering great pain. She stated that she had a "tumor" in the abdomen, which had existed ten or tAvehe days, during the Avhole of Avhich period she had been in constant pain. For some time previous to the formation of this "tumor," she had, she said, experienced a good deal of discomfort, or rather distress, Avhich was greatly increased by a constant desire to pass Avater, her efforts to do so being but partially successful, only a very small quantity of urine being voided at a time. Latterly, hoAvever, her condi- tion had undergone a great change; there Avas noAV inconti- nence of urine, or, to use her OAvn Avords, "it was constantly coming from her;" nevertheless, her sufferings Avere, if possible, more intense than ever. On passing the hand over the abdo- men, a Avell-defined tumor could be felt above the pubes, pressure on Avhich caused great pain. A Anginal examination detected another tumor lying in the hollow of the sacrum, and almost resting on the perinseum. The os uteri Avas absent from its normal situation, lay high up behind the pubes, and could 20 234 DISEASES OF WOMEN. not be reached Avithout the greatest difficulty. On questioning her she stated that, though a married Avoman, she did not think she was pregnant, but, on being pressed on this point, admitted that she had not menstruated for at least ten or twelve weeks. On proceeding to pass a catheter she objected, stating that this had been done the day before, and that she Avas told that there was no water in the bladder. HoAveA^er, being satisfied that this statement must be incorrect, I persisted, using for the pur- pose an ordinary Xo. 9 gum-elastic catheter, and dreAV off about two quarts of turbid, highly ammoniacal urine. The diagnosis AAas now clear, and a careful examination verified my previous impression that I had to deal Avith a case of com- plete retro ATersion of the gray id uterus. And yet this patient had been under the care of a Avell-informed medical man for more than a week before I saAV her, but he neAer suspected the real nature of the case, and told me himself that she passed water regularly. The thorough emptying of the bladder Avas folloAved by much pain, and fearing that peritonitis might supervene, I desisted for a time, after one ineffectual attempt, from any further effort at replacing the uterus in its normal position, and Avith the view of allaying the pain Avhich she suffered, administered half a grain of morphia, in the form of a suppository. After the lapse of eight hours, I found her in a comparatively satisfactory condition. She had slept, and the pain had nearly altogether subsided. The bladder Avas noAV again emptied, and the patient being placed in the ordinary obstetric posture, on her left side, I proceeded to endeavor to raise the uterus. For this purpose I introduced two fingers of the right hand into the vagina, and made steady pressure on the fundus, directing it upAvards and rather to one side. Such of you as Avere present Avill remember the stress I laid on the apparently trifling point of making the pressure laterally, instead of directly upwards: RETROVERSION. 235 by so doing the promontory of the sacrum, which often opposes a serious obstacle to the ascent of the fundus, is avoided. In the present instance the effort I made, as described, was at- tended Avith complete success ; the fundus, yielding to the steady pressure, slipped above the brim, and remained there; the pa- tient experienced great relief, and has since progressed favor- ably. The catheter was, hoAvever, used regularly night and morning for some days subsequently, for though the patient could pass Avater, she Avas unable to empty the bladder, and it Avas very desirable that no accumulation should be permitted to occur. This precaution, namely, that the catheter be passed tAvice a day in all cases in Avhich retention has continued for a considerable time should neATer be omitted, otherwise the bladder may not recover its tone. The subsequent history of this patient presents no point of interest; pregnancy is proceed- ing normally, and there is reason to suppose that she will go to her full time. This fortunate termination is not, hoAvever, to be frequently expected; in the great majority of cases in Avhich retroArersion of the gravid uterus takes place, abortion occurs either as a direct consequence of the accident or as a result of the treat- ment necessary to effect reposition; therefore, be always careful to give a guarded prognosis. Thus, not long since I was urgently requested to visit a lady Avho, in the tAvelfth week of pregnancy, suddenly discovered that she Avas unable to pass water. I found her in great agony, having for some hours endeavored ineffectually to relieve herself. She stated that she had always enjoyed the most perfect health; that on the morn- ing of the day on which I saw her she had been engaged su- perintending some domestic arrangements, during the progress of which she had assisted in raising a heavy box to a consid- erable height; that at the moment of making this effort she became conscious of " something giving way inside " her; but, 236 DISEASES OF AVOMEN. as at the time she did not experience any discomfort, she thought no more about it, till after the lapse of some hours, being de- sirous to pass Avater, she discovered that she Avas unable to do so. By-and-by her sufferings from this cause became severe, and she sent for me. I at once recognized the nature of the case, emptied the bladder, and endeaArored to raise the uterus, Avhich I found to be retroverted, above the brim, but my efforts were ineffectual. In this case I passed the catheter morning and evening, on each occasion of doing so, endeavoring by pressure on the fundus to replace the uterus in its normal posi- tion, and on the sixth attempt, that is, at the.end of three days, succeeded, after which the patient seemed to go on well for a time, but after the lapse of ten days, a sharp dash of haemor- rhage occurred, and she aborted. My belief is that in this case the force necessarily exerted in replacing the fundus, and not the accident itself, Avas the cause of the abortion. But abortion is not the result most to be dreaded—death may possibly folloAv. One fatal case occurred in my own prac- tice. This patient Avas further advanced in pregnancy than either of those just alluded to, before her sufferings induced her to seek relief. It Avas her first pregnancy, and she was unable in any Avay to account for the displacement. The symptoms appeared to have developed themselves very gradually, and the difficulty of micturition to have been progressive, till finally it became impossible. As well as could be ascertained she was, when I saw her, in the sixteenth week of pregnancy; the whole of the abdomen was very tender to the touch, and the retroflected uterus nearly filled up the true pelvis; the greatest difficulty Avas experienced in raising the fundus. This was mainly due to the size of the uterus; but I am also of opinion that the uterus was bound doAvn by adhesions. Abortion oc- curred within twenty-four hours after the reposition of the fundus had been effected, and she died in a feAv davs. I am retroversion. 237 of opinion that this may have been a case of congenital retro- flexion, Avhich under the influence of pregnancy, AAras, as pre- A'iously explained, converted into one of retroversion. The adhesions Avere of recent origin; probably local subacute peri- tonitis existed previous to the raising of the fundus, and that this subsequently spread over the Avhole abdomen and proAred rapidly fatal. In the treatment of retroversion of the graAnd uterus, two indications are plainly indicated, one being to keep the bladder empty, the other to restore the uterus to its normal position. The former should ahvays be effected by means of a long gum- elastic catheter, for an ordinary silver female catheter Avill often in these cases fail to reach the bladder, so greatly is the urethra elongated and displaced. The bladder being emptied, it is generally advisable to attempt reposition at once, unless, as in the case first narrated, great pain is caused by doing so, under which circumstances it is Aviser to alloAV some hours first to elapse, care being taken to pass the catheter at short intervals. In the majority of cases, especially if pregnancy has not ad- vanced beyond the tAvelfth or thirteenth Aveek, steady pressure exerted by means of tAvo fingers introduced into the vagina, Avill be successful in raising the fundus, care being taken to make the pressure rather to one side, so as to avoid the prom- ontory of the sacrum. Occasionally, hoAvever, you Avill fail to effect reposition by this means. When this is so, you will sometimes succeed by introducing one of Dr. Barnes's india- rubber bags into the rectum,* distending it Avith Avater, Avhile pressure is still exerted by the fingers in the vagina. If these efforts fail in raising the fundus above the brim, no resource remains but to bring on abortion. This, under the circum- stances, is best effected by introducing a catheter or sound into * This method was, I believe, first suggested by the late Dr. Halpin, of Cavan. 238 DISEASES OF AVOMEN. the uterus, and, if possible, rupturing the membranes, but sometimes in consequence of the os uteri having been forced up *behind the pubes, the introduction of a catheter or sound is impossible, and then as a last resource, an effort should be made to lessen the size of the uterus by tapping it through the rectum by means of a fine trocar or aspirator. This has been done several times successfully; the liquor amnii having been evacuated through the trocar, abortion followed, the patient subsequently recovering; but in all cases of retroversion, the tendency to abortion is great, and occasionally peritonitis supervenes. Bear in mind that in addition to abortion, the possible occurrence of peritonitis is to be dreaded, and death may ensue from this cause. Retroversion, therefore, of the gravid uterus is always to be looked on as an accident of a very serious nature. But supposing you have succeeded in raising the fundus, the patient will still, under the most favorable circumstances, need care for a considerrble time. It is essential to attend to the state of the bladder, and to pass the catheter at stated intervals, till satisfied that the organ has regained its tone, and you must watch lest the fundus of the uterus fall down again into the pelvis. To lessen the risk of this occurring, and also with a view of counteracting the tendency to abortion, you should for some time confine the patient strictly to the recumbent pos- ture. As the uterus enlarges, the risk of a relapse lessens, and after a time becomes impossible, but the tendency to abortion for a long time continues, and in a comparatively small per- centage of cases, does the patient reach the full time of preg- nancy. Before concluding my remarks on this subject, I must say a few words on the question of diagnosis. In all the cases Avhich have come under my observation in Avhich an error in diagnosis had been made, no sufficient examination appeared to have been RETROVERSION. 239 instituted; thus with respect to the patient whose case I am specially alluding to, the fact that she was suffering from re- tention of urine Avas not recognized, although the enormously distended bladder could be easily felt above the pubes. This negligence is quite inexcusable. But it is just possible that an ovarian or other tumor occupying Douglas's space might be mistaken for a retroverted uterus, even though an examination had been instituted, especially if it were large enough to press against the urethra and thus obstruct the Aoav of urine; but in such a case the symptoms of pregnancy will probably be Avant- ing, and moreover, a careful examination will detect the uterus, which, under such circumstances, Avould probably have been forced up aboAre the pubes, lying anterior to the tumor. Any other tumor, such as that caused by the sudden escape of blood into the recto-ATaginal cul-de-sac, may in like manner cause some perplexity. All doubts, however, will be dispelled if on emptying the bladder, the uterus is found lying anterior to the tumor. Excusable errors, in diagnosis, then, in cases of retro- version of the gravid uterus, are possible, but Avith ordinary care, such should rarely, if ever occur. But the uterus, as mentioned at the commencement of this lecture, may be displaced in other directions besides backAvards; thus the fundus may be thrown fonvard toAvards the pubes. Anteflexion, as this displacement is termed, is a very common and troublesome affection, and less amenable to treatment than retroflexion. In the great majority of instances, I belieATe anteflexion to be a congenital malformation. It is astonishing Iioav frequently it is met Avith in sterile Avomen, and hoAV commonly it is asso- ciated Avith painful menstruation; if the patient does not seek medical advice for the cure of sterility, or to procure relief from suffering at each menstrual period, the affection may altogether escape notice. And if it gives rise to no discomfort, is best 240 DISEASES OF AVOMEN. left alone. If, hoAvever, as is so commonly the case, dysmen- orrheea be present, that must be treated on the principles rec- ommended in a preceding lecture. I may, however, here remark that pessaries, no matter Avhat their shape or form, though they may give temporary relief, never, in my opinion, in cases of anteflexion effect any permanent good. Sometimes, however, anteflexion is a secondary affection, the result of congestion, chronic metritis, or subinvolution. In these cases, if congestion or inflammation be present, I puncture the cervix just as in cases of retroflexion, and this treatment alone often affords marked relief. As an example, you haAre the case of H. E. She is an unmarried Avoman, aged 30, of full habit and leucophlegmatic temperament; recently she had under- gone much fatigue. She complained of severe pain, Avhich she referred to a point immediately above the pubes, but suffered even more from a most distressing sensation, " as if," to use her own words, "something AAas going to fall out of her." On examining her, the uterus, which was very Ioav in the pelvis, proved to be completely anteverted, the os lay in the hollow of the sacrum, the fundus behind the pubes. The sound pen- etrated to the depth of three inches. The cervix AA^as much en- gorged, evidently the enlargement and subsequent displace- ment of the uterus Avas the result.of congestion. I punctured the cervix, which bled freely, at intervals of a feAv days, administered mild saline purgatives, and enjoined rest in the recumbent posture. This patient obtained-'speedy relief from the distressing symptoms she experienced. Menstruation be- came normal, and the uterus, without my having recourse to any mechanical support, regained its normal position. But then this case was one of recent origin, and to that cause Ave may attribute the patient's rapid improvement, for when these affections become chronic, additional measures are necessary. The fundus should, if possible, be raised to its normal position, PROLAPSE. 241 and retained in it. The former is in general easily effected by means of the uterine sound; the latter is a matter of much difficulty. When it can be tolerated, I prefer for this purpose a stem pessary, made of ebony, flexible india-rubber, or alu- minium. Dr. Graily HeAvitt has invented a cradle pessary for the purpose of supporting the anteflected uterus. It sometimes proves very useful, but as often fails to act beneficially; Dr. Greenhalgh uses flexible india-rubber stem pessaries, Avhich being soft, do not cause much irritation, and are no impediment to connection. They are to be had from Arnold & Sons, West Smithfield, London. But in truth, anteflexion of the uterus often baffles our utmost efforts, and in a considerable proportion of cases Ave are able to effect but little good. Prolapse of the uterus is another displacement of frequent occurrence, productive of great discomfort, and in aggravated cases, of actual suffering, but it is by no means so common as is supposed. Great numbers of Avomen, especially of the poorer classes, who present themselves among the extern patients, state that " the Avomb is coming doAvn," but on examination, the uterus is found to be in nearly its normal position, the sensation of dragging and bearing doAvn, being due to a relaxed condition of the anterior Avail of the vagina, Avhich often pro- trudes slightly beyond the vulva, and is mistaken by the patient for the Avomb itself. When this proceeds to any extent, the prolapsed part contains a portion of the posterior wall of the bladder, and constitutes the affection known as cystocele. Prolapse may be partial or complete; by the former Ave understand a protrusion of the cervix to a greater or less extent beyond the vulva; by the latter, the rarer form of complete extrusion of the Avhole uterus. When this occurs the vagina is everted, a portion of the bladder, and sometimes of the rectum also, being drawn doAvn with it. In cases of old standing, when the prolapse is complete, the mass hanging 242 DISEASES OF AVOMEN. outside the vulva is frequently enormous; in them the surface of the tumor, especially in the neighborhood of the os uteri, is covered Avith extensive patches of ulceration, while the mucous membrane of the vagina is so altered by exposure and the ef- fects of friction as to resemble true skin. The annexed wood- cut illustrates this condition (Fig. 31). The patient from whom the drawing Avas made, Avas under the care of my friend, Dr. McClintock, in the Rotunda Hospital; the prolapse Avas of twenty-five years' standing. Details of the case Avill be found in Dr. McClintock's Avork on Diseases of Women, p. 59. These aggravated cases are not, hoAvever, of very frequent occurrence; more commonly Avhen the patient stands for any length of time a portion of the cerATix protrudes, receding Avhen she assumes the recumbent posture. If, hoAvever, the case be neglected, the protrusion is sure to become gradually larger, and may in time remain permanently outside the vuhTa. Prolapse is always a very troublesome affection, the tendency of which also is to become slowly Avorse; judicious treatment, hoAvever, often affects much good ; absolute rest in the recum- bent posture, especially if the legs at the foot of the couch or bed be tilted up about a foot, is always of great use, the more so as congestion is generally present. But this postural treat- ment is but palliative. Xumerous kinds of pessaries have been invented with the AueAV of supporting the uterus and retaining it in its proper position. The best for general purposes is Hodge's, the same as I recommend in cases of retroflexion. You should in cases of prolapse choose a wide one with transverse bars ; they pre- vent the anterior Avail of the vagina from coming down, and as this is the part which first protrudes, it is important to sup- port it. Another pessary in general use is the disk of box- Avood, or vulcanized india-rubber; those made of the latter are much to be preferred. Globular ones are also employed, PROLAPSE. 243 but I dislike them very much; they are difficult to remove, and sometimes, as occurred Avith the patient AAre had here the other day, can only be extracted with the aid of a blade of the forceps. ZAArank's pessary was introduced long ago for the re- lief of procidentia; but, though excellent in principle, it pos- sessed many disadvantages on account of its manner of con- Fig. 3'. Complete Procidentia, with extensive Ulceration of the Os and Vagina, (after McClintoclc). struction. Dr. Godson, of St. BartholomeAv's Hospital, has produced a modified form in Avhich these objections are materi- ally lessened; it is sIioavii in the accompanying Avoodcut (Fig. 32). The Avings are made of vulcanite, and are intended to rest laterally, one on either side of the vagina, on the soft parts AA'hich form the floor of the pelvis; they are introduced par- allel to one another, and then made to expand by bringing the metal feet together, Avhich instantly lock. 244 DISEASES OF AVOMEN. In order to remove the pessary these feet, are pulled apart by the finger and thumb. It is intended that the instrument should prevent the womb from coming out, just as a truss relieves a hernia, and *^' Fig. 32. d' when lying down the one is no more necessary than the other; the pessary should therefore be removed every night and re- placed in the morning. The patient can be taught how to manage its introduction and extraction; it is therefore a form of pessary Avhich cannot lead to the serious consequences likely to follow from being left in the vagina for a length of time, as is sometimes the case with others which are not under the control of the patient. If, hoAA'ever, the prolapse be large, or the perinseum much relaxed, or if it has been destroyed by laceration occurring during labor, no matter Avhat pessary you use, it will be forced out by PROLAPSE. 245 the pressure constantly exerted on it. In such cases, unless you narrow the vagina by operative means, you can do but little for your patient. Such an operation, originally suggested by Dr. Marshall Hall, has been modified and improved by Dr. Marion Sims. He removes the mucous membrane in the form of a V from the anterior wall of the vagina, the apex being near the neck of the bladder, and the tAvo arms extended up on either side of the cervix uteri. These denuded surfaces he then brings together by Avire sutures, passed transversely, thus including a longitudinal fold of the vagina; this has the effect of narroAV- ing that canal considerably. In some of his more recent operations Dr. Sims united*the base of the Y by a transverse dissection ( Uterine Surgery, p. 311). This is the best opera- tion that can be performed, and holds out the greatest promise of a radical cure. But I must refer you to the Avork from which I have just quoted for further information on this point, as it is impossible for me at present to enter fully into the subject. If there be great deficiency of the perinseum, or if prolapse of the rectum (Reetocele) exist, it may be necessary subsequently to perforin an operation similar in principle, but differing in de- tails, on the posterior Avails of the vagina. This proceeding is advocated by Mr. Baker Brown. The first of these operations has for its object the narrowing of the vaginal canal, the latter the restoration of the perinseum. But neither of these operations have any direct influence on the uterus itself, Avhich is often enlarged to a great degree. This enlargement in many eases is confined to the vaginal por- tion of the cervix, Avhich becomes greatly elongated ; Avhile in not a feAv there is little if any descent of the uterus itself. You saw a Avell-marked example of this in the Avoman Avho presented herself among the extern patients the other day. 246 DISEASES OF AVOMEN. She is an overworked needleAvoman, and tells you she sits seAving for fourteen or fifteen hours daily. She suffers from partial prolapse of the uterus with great elongation of the cervix, the vaginal portion measuring at least two inches in length. She is unmarried. The perinseum is perfect and the vagina narroAV; therefore, in her case, neither of the opera- tions just mentioned is applicable, but, on the other hand, in her you Avould effect much good by amputating the cervix. I have urged this on her several times, but she is unAvilling to submit to the operation ; probably the inconvenience and dis- tress which she suffers will by-and-by compel her to do so. The operation of amputation of the cervix is a simple one; the hypertrophied part can be removed Avithout difficulty by means of an ecraseur. Great care, hoAvever, is necessary in preventing any portion of the Avail of the vagina getting under the Avire or chain ; for if this point be not attended to it is pos- sible that a fold of the peritoneum, or, as occurred in a case recently recorded, a portion of the posterior Avail of the bladder may be drawn in and removed, and thus giAre rise to Arery serious and possibly fatal consequences. However, before having re- course to any operation, you should in all cases try palliative means. It is sometimes astonishing hoAV much can be done by postural treatment, by astringent injections, and by the judi- cious use of pessaries. One other form of displacement of the uterus requires men- tion, fortunately it is a rare one ; I allude to inversion. As a rule, this displacement occurs immediately after delivery, and if detected then, is generally capable of being reduced without any great difficulty ; but should the accident be overlooked, and the process of involution far advanced, the case assumes a very serious aspect. It is to such cases as these that I noAV refer. The treatment of the recent form you will learn Avhen you come to study practical midAvifery, INVERSION. 247 The prominent symptom present in cases of chronic inversion of the uterus, is hsemorrhage. On proceeding to examine the patient Avith a vieAV of determining the cause on Avhich this symptom depends, a tumor of variable size and smooth on the surface, will be detected projecting through the os into the va- gina. This tumor may possibly be mistaken for a polypus, but a careful examination Avill enable you to arrive at a correct diagnosis. If the case be one of inversion, the sound, Avhich you should invariably use in such eases, cannot be introduced, its progress being arrested by the inverted Avail of the uterus, while Avere the tumor a polypus, having its origin from the inner surface of the uterus, the sound would probably penetrate to a considerable depth. At the same time, the bimanual method of examination Avill prove the fundus to be absent from its normal position, a fact which can, if necessary, be confirmed by the introduction of a finger into the rectum, the sound or a silver catheter being at the same time passed into the bladder, when if in Aversion have occurred the absence of the fundus from its normal position, Avill be proved by the fact that the sound can be distinctly felt Avithout the intervention of any solid body. In all cases of inversion of the uterus, I am of opinion that an attempt should be made to reduce the displacement by means of taxis carefully and judiciously applied; either directly, the hand being introduced into the vagina, or by the steady and continuous pressure exerted by an india-rubber bag placed in the vagina and retained there, when inflated, by means of a bandage; or by first one and then another of these methods. But very great care must always be exercised Avhenever taxis is tried, otherwise the most serious consequences may follow the attempt. Chloroform, in all such cases, should be freely administered. Should taxis fail, J)r, Barnes advocates incision of either side 248 DISEASES OF WOMEN. of the cervix. He directs you to " draw down the uterine tu- mor by means of a loop of tape slung round the body, so as to puf> the neck of the tumor upon the stretch; then Avith a bis- toury make a longitudinal incision about half an inch long and a quarter of an inch deep, on either side into the constricting os, then re-apply the elastic pressure. Xext day, try the taxis, and re-apply the elastic pressure if necessary" (Obstetric Op- erations, p. 449). Should taxis, steadily, carefully, and re- peatedly tried, fail to reduce the inversion, no means remain at our disposal save amputation of the inverted fundus. This, if attempted, should be performed Avith an ecraseur. It is an operation attended with considerable risk, and therefore it should- not be undertaken unless demanded by the presence of urgent symptoms. It is astonishing how often steady, continuous pressure, ex- erted in the manner described, will prove successful; but it is not sufficient that the fundus be returned Avithin the os uteri. It is essentially necessary to take precautions to insure the complete restoration of the fundus to its normal shape, other- wise the case may be only converted from one of complete into one of partial inversion, a change hardly likely to be for the better. It is therefore advisable, if the finger be not long enough, to pass some round, smooth body into the uterus, to prove that the restoration has been perfect, the bimanual method of examination being besides invariably practiced to confirm this. ENLARGEMENT OF THE AVOMB. 249 LECTURE XII. Enlargements of the Uterus—Frequency of—Causes of, consid- ered WITH REFERENCE TO DIAGNOSIS. You must haATe noticed the extreme frequency with which I use the uterine sound. Indeed, I may say that I im'ariably employ it in the examination of all cases presenting symptoms of uterine disease, unless its introduction is contraindicated by the existence of some special cause. My reason for doing so is this, that in a very large proportion of such cases, I find the uterus enlarged and elongated. The sound enables me to ascertain whether this is the case or not; should it be so, it immediately becomes my duty to endeavror to decide as to the cause on Avhich that abnormal condition depends. I think, therefore, by directing your attention to some of the causes producing enlargements of the uterus, I shall aid you consid- erably in forming a correct diagnosis in many cases of uterine disease; for while the subject of flexions of the uterus has of late years been investigated Avith great care, and has attracted quite as much attention as it deserves, the condition I am referring to, though intimately connected Avith, often indeed the cause of these flexions, has been comparatively little noticed. It is not surprising that the old writers should have over- looked this condition, for it is only of recent years that Ave pos- sess the means of investigating them, and of ascertaining Avith any approach to accuracy, Avhether, in a given case, the uterus Avas of its normal size or shape, or enlarged and elongated. Xoav, however, matters are completely altered; by means of 21 250 DISEASES OF AVOMEN. the uterine sound we can, in the great majority of instances, measure accurately the depth of the cavity of the uterus; and at the same time, the bimanual method of examination enables us to satisfy ourselves Avhether or not the uterine Avails are thickened and hypertrophied. Enlargement of the Avomb is met with in a very large per- centage of those cases in Avhich that organ is affected. Nor is this a matter of surprise when Ave remember the changes the uterus undergoes. In the virgin state, but a couple of inches in length, and an ounce or so in Aveight, it becomes, under the in- fluence of pregnancy, deAreloped into a large organ capable of containing the full-grown foetus, and weighing several pounds; consequently any circumstance which retards or preArents the return of the uterus to its normal size after delivery, may pro- duce, as is noAV well knoAvn, a condition Avhich often results in permanent enlargement, a condition to Avhich, as I have already explained, the term "subim^olution" is applied. But, in ad- dition to these great changes, the result of pregnancy, the uterus every month, as each eatamenial period comes round, increases in Aveight, and probably someAvhat in size; if from any accident or imprudence the natural Aoav is then checked, this temporary increase may become permanent, an accident which I am satisfied is far from being of unfrequent occur- rence. Here, then, at the outset, are two palpable causes of enlargement of the uterus. We meet, however, Avith eases of enlargement of the uterus which cannot be referred to either of these classes. Women who have never been pregnant, and never have had any de- rangement of, or departure from healthy menstruation, and Avomen Avho have conceived, have subsequently enjoyed unin- terrupted good health for years during which pregnancy un- doubtedly did not take place nor yet any derangement of men- struation occur, occasionally begin to suffer from symptoms ENLARGEMENT OF THE WOMB. 251 referable to the uterus, and on examination, that organ is found to be enlarged. This, in such cases, may depend on inflamma- tion of the substance of the uterus, either of an acute or chronic character; on hypertrophy of the muscular and areolar tissue of the uterus; on the presence of fibrous tumors developed in the AAralls of the uterus, and also, as all are aware, on the exist- ence of intra-uterine tumors of any kind, whether they be polypi, fibrous, or cancerous tumors. But it is not my inten- tion here to enter at all on the subject of either uterine polypi or uterine tumors, except Avith reference to the question of diagnosis. I also purposely omit all reference to the actual existence of pregnancy, or to the retention of any of the prod- ucts of conception in the uterus, as being foreign to the sub- ject to Avhich I Avish especially to direct attention. To recapitulate, Ave meet Avith enlargement of the uterus as the result of— 1st. Subinvolution of the uterus after labor or abortion. 2d. Congestion of the uterus from suppression and retarda- tion of menstruation. 3d. Acute inflammation of the uterus, or possibly of its peri- toneal coArering. 4th. Chronic inflammation of the uterus. 5th. Hypertrophy of the uterus. 6th. The stimulus given to the uterus by the development in its walls of fibrous tumors. 7th. The existence of intra-uterine tumors. 1. Subinvolution of the uterus is noAV a Avell-knoAvn cause of uterine enlargement. There is no doubt but it is most likely to occur in those cases in Avhich any form of inflamma- tory attack, Avhether it be peritonitis, metritis, or cellulitis, takes place subsequent to delivery. This fact has been pointed out by several writers. If, then, a patient has suffered from any such attack, the possible effect of it in retarding the normal 252 DISEASES OF AVOMEN. reduction in the size of the uterus, Avhich should take place within a few Aveeks subsequent to delivery, must be borne in mind, and Ave should, in such cases, carefully Avatch for any symptom indicating the presence of this condition. As a nearly invariable rule, profuse menstruation is the first and most prominent symptom indicating the existence of enlarge- ment of the uterus depending on subinvolution; a symptom capable of being easily explained, when we bear in mind the fact, that not only is there under such circumstances an undue amount of blood contained in the enlarged uterine veins, but also, that the relaxed condition of the muscular tissue of the uterus favors the exudation of blood. Profuse menstruation does not always occur immediately; sometimes ' months first elapse; but ere long, menstruation becomes profuse, and, on instituting an examination, the sound reA'eals the true state of the case by proving that the uterus is abnormally elongated. The depth of the uterine cavity in cases of subinvolution varies greatly in such cases. It seldom exceeds three and a half inches, but I met Avith one instance in Avhich it measured up- wards of five inches. 2. The occurrence of enlargement of the uterus from any cause suddenly checking menstruation, I believe to be by no means rare, but opportunities of proving this do not fre- quently occur; for if an unmarried woman complains of fulness and pain in the head, of pain in the back, and of a sense of Aveight in the pelvis, and states that menstruation has been checked by exposure to cold or by some other obvious cause, we are probably satisfied that uterine congestion exists; but we are not justified in making a vaginal examination, unless that, after a protracted trial, general treatment fails to relieve her. Again, if a married Avoman exhibits the same train of symptoms, the possibility of pregnancy precludes the use of the sound. Recently, hoAvever, I had an opportunity of veri- ENLARGEMENT OF THE AVOMB. 253 fying the fact. A widoAV, the mother of thirteen children, in Avhom menstruation had been irregular for three years, had in June last, after a long interval, a return of the discharge. It ceased suddenly, and she suffered great discomfort from a dis- tressing sensation of weight and bearing down in the pelvis, and of fulness and pain in the head. In her case the uterus Avas three inches in depth, Avhile all the symptoms rapidly sub- sided under treatment. It may be objected that, in this case, we Avere ignorant as to Avhat might have been the condition of the uterus preAuously ; but here Avas a woman in the enjoyment of good health, suddenly attacked, after the abrupt checking of menstruation, with distressing symptoms, in Avhom the uterus Avas proved to be enlarged, and who Avas relieved of those symptoms and of that condition by treatment. Is it not then fair to reason that the enlargement was a temporary con- dition, the result of uterine congestion, itself caused by the sudden checking of menstruation ? 3. All modern Avriters agree that acute inflammation may produce enlargement of the uterus, and I believe that this may be the case, wdiether the patient suffers from peritonitis, me- tritis, or pelvic cellulitis. Of the two latter I have no doubt. Of enlargement of the uterus as the result of peritonitis, I had no experience till very recently, but the following case throws some light on the subject: Mrs. K., set. 33, was admitted into the Adelaide Hospital suffering from menorrhagia and great pehdc distress. Her last child Avas born fourteen months previous to admission. She stated that four weeks after her confinement, having been exposed to cold, she Avas attacked Avith severe pain OA^er the Avhole abdomen. The pain, after a time, became localized in the left iliac fossa, and by degrees, nearly entirely disappeared. At the expiration of two months from the date of this attack menstruation came on very profusely, and lasted for six Aveeks. 254 DISEASES OF AVOMEN. She iioav obtained medical advice, and Avas treated for ulcera- tion of the os uteri; but although the menorrhagia Avas in some degree checked, the pain from which she suffered again became very severe. On admission into hospital the uterus wTas found to be retroflected, and a certain amount of granular erosion ex- isted ; menstruation was profuse. The uterus was enlarged to a trifling extent. The use of a pessary and other appropriate treatment speedily improAred the condition of the Avomb, and she returned home apparently cured. At intervals, however, she still suffered attacks of abdominal pain. But she again caught cold, and Avas re-admitted into hospital laboring under a Avell-marked attack of subacute peritonitis. Leeches, fomen- tations, and the exhibition of opium relieAred her. During the course of this attack I twice measured the depth of the uterus, and found that it had increased in length by nearly an inch. She did not menstruate during this attack. 4. Chronic inflammation of the uterus being of more fre- quent occurrence than the acute form is a more common cause of enlargement. Such cases are constantly coming under ob- servation. They are frequently found in connection Avith re- troflexion of the uterus. In these cases menstruation is gener- ally diminished, unless, indeed, a granular condition of the in- tra-uterine mucous membrane also exist; but this is not the form of uterine disease in which that condition is most likely to occur. The amount of elongation, too, in these cases is seldom great, the depth of the uterus seldom exceeding three inches. 5. Xext I shall call your attention briefly to that condition, which, for lack of a better name, I term hypertrophy of the uterus. I mean to include under this head those cases in which the Avhole of the uterus, or sonie portion of it, sloAvly and im- perceptibly increases in size. Sometimes the cervix alone is implicated, that portion of the organ becoming elongated and ENLARGEMENT OF THE AVOMB. 255 thickened, or the body alone may be affected, while in other oases the body and cerxix are equally engaged, and become thickened, enlarged, and frequently painful, the pain being ap- parently due either to hypersesthesia of the nerves of the uterus, or to the pressure exercised on them by the hypertrophied tissue by Avhich they are surrounded. In these cases menstruation, as a rule, is but little altered in its character; sometimes it is slightly diminished in quantity and not unfrequently becomes painful, but I do not remember meeting Avith a case in which menorrhagia Avas present. The pathology of this form of uterine enlargement is very obscure; the fibres composing the muscular tissue of the uterus appear to be elongated and thickened, Avhile there is also hy- pertrophy of the areolar tissue. Both conditions may lmre their origin in a Ioav form of inflammation Avhich at the time escaped observation; but avc cannot in the present state of our knoAvledge say why in a certain case the cervix uteri elongates and enlarges till by its Arery size and Aveight it irritates and causes distress, while, at the same time, the body and fundus of the uterus participating in the unhealthy condition of the eeiwix become heaATy and elongated, and in another case seem to remain in their normal condition. Excessive indulgence in sexual intercourse has been set doAvn as a cause of enlargement and hypertrophy of the cervix, but I doubt this much. A case of hypertrophy of the cervix, occurring in an un- married Avoman, has recently come under my obserA^ation. She is a dressmaker, set. 28, an industrious Avoman, sitting at Avork for upAvards of tAvelve hours a day. She complained of weight in the pelvis and of bearing doAvn. She also suffered from the most obstinate constipation. Menstruation Avas regular, but generally accompanied by pain. On making an examination the os uteri was found to rest on the peinseum ; the cervix was elongated and thickened, and the fundus slightly enlarged. 256 DISEASES OF AVOMEN. This woman would not come into hospital, and consequently I have had no opportunity of trying the effects of treatment, from Avhich, in truth, I would anticipate but little benefit. Any person Avho has read MM. Bernautz and Goupil's Avork on Diseases of Women, published by the Xew Sydenham So- ciety, Avill at once see that the condition I am noAV referring to is very similar, if not analogous, to that termed by M. Hu- guier, " allongement hypertrophique " of the uterus; a condi- tion which he divides into tAvo classes, namely, subvaginal and supra-vaginal, a division the actual value of Avhich I do not highly appreciate. I am inclined to the opinion that, although we may have enlargement of the body of the uterus without the cervix being engaged, the cervix is never enlarged for any length of time, Avithout the supra-vaginal portion of the organ becoming implicated in the disease. I also believe that not a few of the cases recorded by M. Huguier Avere cases of subin- volution of the uterus folloAving delivery, and not of the con- dition which I haAre termed hypertrophy. But, in addition to these cases of hypertrophy with elonga- tion of the cervix or of the body of the uterus, or of both, we meet with cases in which there is no elongation, but the very reverse. We sometimes find the cervix shortened, drawn up, as it Avere, into the body of the uterus, sometimes disappearing altogether. In such instances the body of the uterus assumes a globular form. This form of enlargement giAres rise to con- siderable distress, and it seems specially to cause intractable irritation of the bladder. In one case, Avhich was for years occasionally under my observation, this symptom was the prominent one, and that for Avhich the patient sought relief. There is no form of uterine disease in which so little can be effected by treatment as that to Avhich I am iioav referring. If the body of the uterus be engaged, it seems nearly useless. If, hoAvever, we are satisfied that the cervix only is affected, ampu- ALLONGEMENT HYPERTROPHIQUE. 257 tot ion may be resorted to Avith advantage ; or possibly local depletion and subsequently the repeated application of Dr. Greenhalgh's iodized cotton may effect some good. 6. It remains for me to allude, and I shall do so very briefly, to that form of uterine enlargement in which the organ is stimu- lated, and increases in size, from the presence of a fibrous tu- mor imbedded in, or growing from, some portion of its Avails. Cases are recorded in Avhich a fibrous tumor of A'ery small size, perhaps not larger than a nut, so stimulated the uterus that it increased to five or six times it* normal size, the cavity too be- ing proportionately elongated. These cases are most perplex- ing, a post-mortem examination alone being capable of reveal- ing their true nature. Fortunately they are not of frequent occurrence. In the great majority of instances a fibrous tumor sooner or later Avill bulge into the cavity of the uterus, or pro- ject out on the peritoneal surface. In either case the tendency of disease is to render menstruation more profuse; Avhile in that form of enlargement depending on hypertrophy .of the fibrous tissue of the uterus, and which is the only form liable to be confounded Avith the one noAV under consideration, men- struation, if interfered Avith at all, is more likely to be di- minished than increased. The subject of fibrous tumors of the uterus does not come Avithin the scope of the present lecture. I Avish, hoAvcAer, to draw attention to those cases, of by no means unfrequent occurrence, Avhere enormous fibrous groAvths exist, in Avhich the Avomb is imbedded and almost lost. These cases ha\re OATer and OArer again been mistaken for ovarian tumors, a mistake AA'hich the use of the uterine sound should enable us to aAroid. It tells us not only Avhat is the length of the uterine cavitv, but also Avhether the uterus is free or imbedded in the tumor. Xow, as to diagnosis. I haATe already stated that the sound and that alone enables us to decide as to Avhether the cavity of 258 DISEASES OF AVOMEN. the uterus be elongated or not, but it affords us no clue as to the cause of the enlargement. A few general rules, hoAArever, if they do not enable us to give a positive diagnosis, will at least facilitate materially our decision as to the nature of any case. Thus, if we meet Avith an enlarged uterus in a Avoman wTho has aborted or been delivered at the full time, even though several months have elapsed, the probability is in favor of the enlargement being dependent on subinvolution, and this opinion Avill be confirmed if menorrhagia be present, as is nearly al- ways the case, at least Avhen the affection is of recent origin. Again metritis, pelvic cellulitis, or peritonitis, if present or of recent occurrence, are fully sufficient to account for this condi- tion of the uterus, and it should be ahvays borne in mind that it does not folloAv that the enlargement Avill disappear Avith the subsidence of the inflammation; in other cases Ave should as- certain if menstruation has been checked or suppressed, and if symptoms referable to the uterus have folloAved on this; or if again,, pain in the back and over the pubes Avas first noticed, menstruation being subsequently lessened or suppressed. In the former case we are likely to find that the enlargement de- pends on congestion, in the latter on chronic inflammation. It is of no small importance in deciding on the cause to Avhich en- largement is due, to note the condition of the menstrual func- tion, for that Avill often, in doubtful cases, materially aid our diagnosis; thus if the enlargement be the result of chronic in- flammation, it Avill most probably be lessened in quantity; if to subinvolution, the flow Avill be augmented. Then, again, if there be menorrhagia in cases of enlarged uterus, unconnected with any of the causes noticed, Ave may expect to meet with intra-uterine polypus, or fibrous tumors, and it aa ill be our duty to clear up the doubt which exists, by dilating the cervix and exploring the interior of the uterus. As I have called your attention to the subject of enlarge- TREATMENT OF ENLARGEMENT. 259 ment of the uterus Avith the hope that I may aid you in ar- riving at a correct diagnosis in cases in which that condition exists, I shall not enter at any length into their treatment; that of subinA'olution AAras fully discussed on a previous occasion (Lecture Y), and I must refer you to Avhat Avas then said on the subject. In cases of enlargement folloAving sudden suppression of menstruation, the administration of saline purgatives, and subsequently of the bromide and iodide of potassium, con- jointly in full doses, Avill generally, if the case be recent, prove sufficient; but should it haA^e been neglected in the early stages, it will probably pass into the condition of chronic in- flammation, a condition over Avhich medicines possess little in- fluence. The prolonged use of the perchloride of mercury, in doses of -2'cth of a grain three times a day, has been recom- mended in these cases. I have seen, I think, more benefit re- sult from local depletion by puncturing the cervix uteri, than from anything else, and it is a mode of treatment deserving a fair trial. To be of use it must be repeated frequently at in- ' tervals of about five days. The application to the \rerge of the anus, of two or three leeches, immediately after the termination of a menstrual period, where menorrhagia is present in connec- tion Avith a relaxed and engorged uterus, also often proves bene- ficial. In cases Avhere the uterus has become enlarged and hardened, as the result of chronic inflammation, the use of the waters of Ems or Kreuznach seems sometimes to haATe a very beneficial effect, and if the patient's means are such as to admit of her visiting either place, a trial should be made. As to hyper- trophy of the uterus, treatment is seldom likely to effect good. In cases of enlargement of the uterus from inflammation of an acute character, I believe that rest, the exhibition of opium, 260 DISEASES OF WOMEN. and the application of warm poultices over the abdomen are the means upon which Ave should most rely. Depletion, if practiced at all, should be in a limited degree by a few leeches externally. Mercury I consider to be not only useless, but actually deleterious. CANCER OF THE UTERUS. 261 LECTURE XIII. Cancer of the Uterus—Pathology of—Varieties met with in the Uterus—Medullary and Epithelial Cancer—Symptoms — hemorrhage—ija1n—fetid discharge—cauliflower ex- CRESCENCE—Amputation of Cervix—General Treatment. I propose to-day, gentlemen, to call your attention to the subject of cancer of the womb; of Avhich disease, unfortunately, we have had several examples recently. You must not suppose that the subject is unimportant because the disease is in all probability not susceptible of cure, for you can sometimes pro- long life, and ahvays alleviate suffering; besides it is of great importance that you should be capable of recognizing the ex- istence of cancer, and of being able to pronounce that a disease Avhich may simulate it is not malignant. The idea of cancer is ever present to the minds of women, and few of them suffer from any chronic ailment, the symptoms of Avhich are referable to the uterus, without fearing that they are the subjects of that dreadful disease, and are sure to question their medical atten- dant closely. I need not delay in pointing out hoAV injurious it Avould be to your character Avere you to pronounce a Avoman to have cancer, who labored under such a comparatively inno- cent disease as inflammatory hypertrophy of the cervix uteri. Or hoAV lamentable Avould be the consequences, were you to assure your patient that nothing serious Avas Avrong Avith her Avhen death Avas inevitable. Yet both these mistakes are fre- quently made; mistakes for Avhich there is but little excuse. 262 DISEASES OF AVOMEN. Cancer of the womb is most frequently met Avith in Avomen who have passed, or at least attained middle age; but this rule must be received Avith great reservation. Women under thirty are not unfrequently attacked Avith it, and it is important that you should bear this in mind, lest, misled by the youth of your patient, you should give a favorable prognosis in what is really a hopeless case. Still it is in the decade betAveen forty and fifty that the greatest proneness to the disease manifests itself, fifty per cent, of all the cases occurring betAveen these ages. This, you are all aAvare, coincides Avith the period at which what is termed " the change of life" in woman takes place, when menstruation and the other functions of the repro- ductive system cease. There is no disease the symptoms of Avhich are so uncertain as those which usher in cancer of the uterus ; very frequently indeed, it develops itself so insidiously that the patient's atten- tion is only attracted to what she supposed to be a very recent malady, when in reality our first examination proves the dis- ease to be far advanced towards its fatal termination. The patient, Mrs. S., in No. 6 Avard, is a striking example of this fact. She believed herself to have been in good health up to the 4th of last month, when haemorrhage set in; but this is impossible, for the entire of the vaginal portion of the cervix is already destroyed, the uterus is firmly fixed by the deposit of cancerous matter in the surrounding tissues, and a gaping opening, surrounded by a jagged, indurated, and ulcerated mass, is all that is left of the tower segment of the uterus. Her end cannot be far distant. Yet it is but a month since her atten- tion was first attracted to her condition. Now, gentlemen, I must take it for granted that you all know something of the pathology of cancer. This is a part of the subject AAliich I cannot (hvell on at any length in a clinical lecture—I shall only say, lest I should have any hearers who CANCER OF THE UTERUS. 263 are altogether ignorant of the subject, that this dreaded disease consists primarily of the deposit or more properly of the de- velopment of an abnormal material in tissues hitherto healthy, and Avhich, consisting in a great degree of cells of a peculiar formation has a great tendency to invade neighboring struc- tures, and at a later period to take on a process of destructiAre ulceration. Dr. West, adopting the Avords of Miiller, defines cancer to be " those growths Avhich destroy the natural struc- ture of all tissues, Avhich are constitutional from their Arery commencement, or become so in the natural process of their development, and Avhich, Avhen once they have infected the constitution, if extirpated, invariably return, and conduct the person Avho is affected by them, to inevitable destruction." But, in truth, the origin of these groAvths is a puzzle to patholo- gists. Of the various forms of cancer, tAvo only are as a rule met Avith in the uterus, namely : 1st, the medullary, and 2d, the epithelial. Instances no doubt of true scirrhus, or hard cancer, and of colloid, or gummy cancer, are recorded, but they are exceed- ingly rare, and Ave may for the present set their consideration aside; the more so as, Avith the exception of the greater slow- ness of progress, there is not any essential difference betAveen the course of these tAvo varieties and that of the medullary form. As already stated, the first step in the production of the dis- ease is the groAvth of the cancerous matter in the substance of the healthy organ ; and I may here remark that it is in the vaginal portion of the cervix uteri that this nearly invariably occurs. Why this should be is not clear, but such is the fact. In a feAv rare instances, hoAvever, the body or fundus is the seat of the disease. Medullary cancer appears in general first to attack the sub- 264 DISEASES OF AVOMEN. mucous tissue of the vaginal portion of the cervix, and subse- quently extend to its muscular structure. "Very soon the ad- jacent parts become implicated. Cancerous matter is deposited between the uterus and the bladder anteriorly, and the rectum posteriorly, and in consequence the cerATix becomes fixed and immovable. By and by the mucous membrane at some point gives way, and an ulcerated surface is formed. The feeling communicated to the finger by this ulcer is unmistakable. It is hard, irregular, Avith sharp edges, and generally bleeds on the slightest touch. The ulceration extends Avith considerable rapidity ; occasionally, indeed, granulations arise on its surface, and at one point an attempt may be made at cicatrization ; but this soon gives way, the granulations disappear, and the dis- ease spreads as before. When this stage is reached, Ave generally find a most char- acteristic discharge present. It is dark in color, profuse, and fetid. Sometimes the fetor is so strong and unmistakable that it is possible to diagnose the disease from the smell alone, even before we make any examination; but this is not always so. The patient Avhose case I have alluded to is an example of this latter condition ; for though the disease is in such an advanced state, she has but little discharge and that by no means fetid. Haemorrhage, too, if not previously present, is noAV nearly sure to occur, and it is very probable that the decomposition of clots of blood Avithin the uterus may be one, though not the sole, cause of the fetid character of the discharge. The disease is all this time spreading upwards, and engaging the body of the uterus, and sometimes cancerous masses pro- ject into its cavity, Avhile, at the same time the vagina, also nearly invariably becomes involved. Sometimes, the posterior wall being affected, the disease extends backwards till the rec- tum becomes implicated ; but, more commonly, it is the ante- rior wall Avhich is chiefly engaged. CANCER OF THE UTERUS. 265 When life is prolonged beyond this stage, the ulceration may destroy not only the muscular structure of the vagina, but also the adjacent AATalls of the bladder or rectum, or eATen of both. And then to the sufferings previously experienced, are added the miseries incidental to ATesico- or recto-vaginal fistula. Under such circumstances death is brought about by a process of gradual exhaustion; more frequently, however, the patient sinks at an earlier stage from the effects of the constantly re- curring haemorrhage. The folloAving accurate description of the post-mortem appearances usually met with in cases of cancer is given by Mr. H. Arnott, in vol. xxi, of the Transactions of the Pathological Society of London : " It will be noted that in nearly every case the seat of disease is the same. The os and cervix are more or less completely destroyed, and the foul ulcer resulting includes the upper part of the vagina. In more se- vere cases the floor of the bladder is invaded, and perhaps freely perforated, Avhilst even the rectum may be opened into the vagina, the uterus itself being sometimes almost Avholly con- sumed in the general haAToc. In one remarkable case the os and cervix remained Avhilst the Avhole body of the uterus Avas destroyed by cancer." The pelvic glands are frequently the seat of secondary cancerous deposit, Avhile in not a feAv the ovary and even more distant organs, including the heart and lungs, may become implicated in the disease. Now, with respect to epithelial cancer, Avhich is the other form so commonly met Avith in the uterus. It differs from the medullary in this, that it is generally deAreloped as an out- groAvth, or excrescence from the cervix uteri. In general it seems first to appear as a tubercle, this increases rapidly, after a time it becomes fissured, and branches out, so as to form a soft irregular mass, commonly called, from its resemblance to the vegetable of that name, " caulifloAver excrescence ;" a resem- blance, however, Avhich is frequently Avanting. The discharge 266 DISEASES of avomen. arising from this is very profuse and watery, but is not gener- ally so fetid as that proceeding from the medullary form. The groAvth often attains a considerable size, sometimes form- ing a mass completely filling the vagina, and Avhich, from be- ing very vascular, is invariably accompanied by haemorrhage. Epithelial cancer occasionally attacks the vagina as a pri- mary disease. We have had tAvo examples of this recently in hospital; in one, the superficial ulceration extended to the very vulva, and the patient sank Avorn out by pain and re- peated though trifling attacks of haemorrhage. In her case the entire surface of the vagina Avas constantly covered with a dark, pultaceous slough. The other Avas admitted for profuse haemorrhage AAdiich threatened life. This was found to pro- ceed from a spot on the anterior wall of the vagina, not larger than a split pea; it was hard to the touch, and had a puckered appearance. In a third case, a large mass of epithelial cancer grew from the posterior part of one labium. Having thus ghTen you an outline of the course which can- cer usually runs, I must refer to the symptoms it gives origin to. In the early stages at least they are most vague and un- certain. To such an extent, indeed, is this the case, that Ave not unfrequently meet Avith instances in Avhich the entire of the lower portion of the cervix uteri has been destroyed by the ravages of disease, and yet the existence of cancer has never for a moment been suspected either by the sufferer herself or by her friends. The patient to Avhom I have already referred af- fords a Avell-marked example of this. She is a married Avoman, aet. fifty, has given birth to tAvelve children, and has had two miscarriages. Six years ago she ceased to menstruate, and was perfectly free from any symptom of uterine disease up to the 6th of December, when she noticed a discharge which resem- bled in all respects natural menstruation, being red in color free from smell, moderate in quantity, and not accompanied by CANCER OF THE UTERUS. 267 pain. The appearance of this discharge did not cause her any anxiety, and she continued apparently to enjoy her usual good health till three Aveeks ago, Avhen (on the 4th of January) she Avas suddenly attacked Avith profuse haemorrhage, Avhich has not as yet entirely ceased. At no time has there been any fetid discharge, nor did she suffer pain, except a dull back- ache, apparent the result of debility. But, on making a vagi- nal examination, Ave found the uterus fixed by the deposit of a large quantity of cancerous matter in the tissues surrounding the organ, Avhile the loAver portion of the cervix Avas already destroyed by the process of ulceration, and a Avide, gaping, ir- regular opening, led up to the body of the uterus. Noav, this case is very instructive—it shows hoAV insidious the disease may be. Not only is there an extensive deposit of cancerous matter, but a considerable portion of the uterus has been destroyed by ulceration, and yet till three Aveeks ago she presented no symp- tom of disease, except a slight colored discharge, Avhich ap- peared four Aveeks previously, and Avhich she believed to be a return of normal menstruation. Moreover, it sIioavs that you mav have extensive cancerous ulceration Avithout its being ac- companied either by pain, fetid discharge, or any appearance of cancerous cachexia. . But cases of cancer usually present all these symptoms in a greater or less degree. You Avill there- fore be correct in considering haemorrhage, fetid discharge, pain and cancerous cachexia as being the symptoms of cancer of the uterus, though none of them are necessarily present, I shall say a feAv Avords on each. First, with respect to haemorrhage; it is the most common and most important of them all; it is also the one Avhich, as in the present instance, is generally first noticed. If the pa- tient has not ceased to menstruate, she will probably tell you that her attention had been attracted by observing the cata- menia to become much more profuse, and to last a longer time 268 DISEASES OF AVOMEN. than formerly; then, that the discharge has commenced to ap- pear irregularly, returning at intervals of a feAv days, till finally it is almost continuous. If, on the other hand, she has passed the " climacteric " period of life, the first symptom most prob- ably Avill be—as A\Tas the case Avith the patient first alluded to— the sudden appearance of haemorrhage, Avhich is occasionally profuse. Sometimes haemorrhage occurs before any ulceration has taken place; this is especially likely if menstruation have not previously ceased; but it is after ulceration has occurred that it, as a rule, becomes so prominent, and often so alarming a symptom. Cases, hoAveATer, are met Avith in Avhich it is not present at all; they are, hoAvever, rare. It may not be an early, or a prominent symptom, but seldom, indeed, is it al- together Avanting. In general, as the disease advances and the ulceration spreads, the bleeding becomes more profuse, some- times in the form of a continuous draining, more frequently as Avell-marked attacks of haemorrhage, occurring at short inter- vals, often alarming, and threatening life itself, sometimes even proving fatal, though much more frequently the patient dies from the exhaustion consequent on the frequent losses of blood. Pain.—Of the symptoms indicative of cancer, pain is the most fallacious. Cancer, in its early stage, is, Avithout doubt, in general, a painless disease. This statement is, I am aAvare, directly at variance with preconceived notions. Women inva- riably associate the idea of pain Avith the existence of cancer, and belive the absence of suffering to be impossible; this is, however, a popular error. I have but to refer to Mrs. S., the patient to Avhose case I am specially calling your attention, as a proof of this. Here is a Avoman dying of cancer, and yet she is entirely free from pain; I fear, hoAvever, that her prospect of this immunity from suffering continuing to the last is very doubtful, for as the disease progresses, pain is seldom absent; SYMPTOMS OF CANCER. 269 frequently, indeed, it becomes almost unbearable, so terrible are the paroxysms, so excruciating the agony. Bear in mind, hoAveArer, that this applies to the stage of ulceration only. This absence of pain forms one of the chief diagnostic marks betAveen chronic inflammation of the cervix and cancer in its early stages. When you meet Avith a patient who has for a lengthened period suffered from pain referred to the back, to the uterine, and especially to the ovarian regions, shooting doAvn along the inside of the thighs, and Avho on examination proves to have a thickened, indurated cerA'ix, the uterus being movable, the probability is, that this is due to chronic inflam- matory hypertrophy, and not to malignant disease. But, as already mentioned, the immunity from suffering generally ceases after ulceration has taken place; we find, too, that the attacks of haemorrhage often come on during severe paroxysms of pain, and seem to relieve them, leading to the supposition that the pain is due to some form of congestion, for Avere it not so, the haemorrhage could hardly bring relief, as undoubtedly it often does. Be this as it may, the fact re- mains, that the terrible sufferings in the second stage of the disease present a marked contrast to the immunity experienced in the first; and though there may be occasional instances in Avhich pain is absent even to the last, they are unfortunately rare. Fetid Discharge.—This, too, is a symptom of variable oc- currence; ordinarily a discharge accompanies the early stage of malignant uterine disease, but not to an extent sufficient to alarm the patient; as changes in the cervix take place, hoAv- ever, and an open cancerous ulcer is formed, the discharge assumes a different character, it becomes more profuse, dark- colored, and fetid. In many instances this odor is so marked, that Avithout asking a question or making an examination, the experienced physician can pronounce the patient to be suffering 270 DISEASES OF WOMEN. from malignant disease. Sometimes the fetor is intolerable, and the profuseness and acridity of the discharge so great, as to add materially to the patient's suffering by giving rise to painful excoriations. In epithelial cancer, the discharge is more watery and seldom so fetid as in the medullary form. The cases of caulifloAver excrescence Avhich have been for some time past in our AA'ards, differ in many respects from that of Mrs. S., who afforded us an illustration of the medullary form. One patient, E. K., aged only twenty-three, is five years married, but has neArer been pregnant. She states that she was quite well till about two months ago, Avhen menstrua- tion became suddenly profuse; shortly afterwards she percehred a fetid Avatery discharge appear in the intervals between each period. She suffered from severe left side pain of a paroxys- mal character, Avhich became aggravated before each attack of haemorrhage, and also from diarrhoea. On examining her after admission, the Avhole of the upper third of the vagina Avas found to be occupied by a large mass of epithelial cancer; the disease had also extended to the anterior wall of the vagina. Her case was hopeless; Ave could but relieve her pain by sub- cutaneous injections of morphia, and check the discharge by astringent lotions, and by the exhibition of gallic acid, acetate of lead, opium, etc. She died shortly after. In another case I at first entertained hopes of being able to save, or at least to prolong life. This patient Avas a young Avoman, aged twenty-eight, mar- ried, and the mother of one child, who, at the period of her admission into hospital, was four years old; in the interval which had elapsed since its birth she had had three miscarriages, the last occurring twelve months prior to her admission. Her health had been very good up to October last, Avhen she re- marked for the first time, a sanguineous discharge, which appeared in the interval betAveen two regular menstruation CAULIFLOAVER EXCRESCENCE. 271 periods. It only lasted three or four days, and then ceased, but reappeared at irregular intervals during the next four months, nevrer lasting more than a feAv days; and as her gen- eral health continued good, she paid no attention to it. In March last this discharge became more profuse, and AA'hen ad- mitted into the hospital on the 16th of April, she Avas in a A*erv anaemic condition. She complained of Aveakness and of pain in the back, but of nothing else. The discharge, Avhich Avas very profuse, Avas of a sanguineous, Avatery charac- ter, and not very fetid. On making a vaginal examination, a cancerous mass, about the size of a lien's egg, Avas found, groAving mainly from the posterior lip of the os uteri; the anterior lip Avas also engaged, but in a less degree. The Aragina Avas not implicated in the disease, the uterus Avas moAT- able, and on passing the finger upAvard, the cervix uteri appeared to be perfectly healthy. I therefore thought it to be one of those cases in Avhich it Avould be justifiable to give the patient a chance of prolonging life by operation, and deter- mined to attempt the amputation of the entire of the cervix uteri above the diseased portion. This Avas done accordingly with the ecraseur. Much difficulty was experienced in getting the Avire round the cervix, the mass being large and filling up the vagina. However, after some little manipulation, I suc- ceeded in encircling the cervix above the growth, but the mo- ment I attempted to constrict the cervix by tightening the wire, the apparently healthy tissue yielded, the Avire of the ecraseur became entangled and imbedded in a mass of soft cancer, and I found it impossible to remove the entire of the cervix. We succeeded, hoAvever, in getting away a large portion, and the stump Avas then freely cauterized Avith strong nitric acid. The patient experienced no pain subsequently, and she improved greatly after the operation; the haemorrhage entirely ceased ; she put up flesh, and Avas discharged after a feAv Aveeks. I 272 DISEASES OF WOMEN. Avas aAvare at the time that this improvement could only be temporary, and I was not, therefore, surprised Avhen the poor AA-oman again sought admission, after the lapse of about six months, to find that she Avas in a hopeless condition, dying rapidly ; she expired a few days subsequently. On making a post-mortem examination, the body of the uterus Avas found to be perfectly healthy. The cavity did not exhibit the slightest trace of disease; it Avas entirely confined to the loAArer portion of the cervix, from Avhich the cancerous mass could be seen groAving. The vagina, Avhich had not been affected Avhen she Avas first admitted, Avas also noAV engaged. This case presented four points of interest. First, it showed at Avhat a very early age this form of cancer may attack the uterus. Secondly, it illustrated the possibility of hereditary taint, for she stated that her mother and tAvo of her OAvn sisters had died of uterine cancer. Thirdly, it shoAved in Avhat an insidious manner epithelial cancer may come on. When she Avas admitted, she Avas in a nearly hopeless state, and yet be- lieved herself to have been ill but for a feAv Aveeks, and com- plained only of Aveakness. Lastly, as to the operation. It proved how very unpromising it is. However, this Avas a case in Avhich it Avas justifiable, and the Avoman's life was cer- tainly prolonged by it. In a third case the operation of amputating the cervix promised very satisfactory results. The patient, a married Avoman, aged forty, Avas sent into hospital for the relief of what was supposed to be incontinence of urine. Neither the Avoman herself, nor the surgeon Avho had seen her, had any idea that she Avas the subject of uterine disease. She Avas free from pain, and merely complained of Aveakness, and of a con- stant Avatery discharge, which saturated her linen, and which she supposed to be urine. HoAveA^er, on making a Anginal examination a large mass, evidently a malignant groAvth, was AMPUTATION OF CERA^IX. 273 found springing from the lips of the os uteri. On passing the finger beyond this, apparently healthy tissue could be felt. I, therefore, determined to remo\re the Avhole cervix without fur- ther delay. The cerAux was easily encircled with an iron wire, but so Arery dense Avas the tissue to be divided, that this broke. HoAvever, by substituting for it a strong steel Avire, I Avas en- abled to diA'ide the cerATix. Considerable haemorrhage folloAved, Avhich Avas restrained by the application of the perchloride of iron. ThisAAToman made a rapid recoA^ery, and Avas discharged a feAv Aveeks ago, apparently cured, for the whole of the dis- eased mass Avas removed; a section of the divided surface ex- amined under the microscope exhibiting no trace of cancer cells. This case was instructi\7e from the almost total absence of symp- toms. Our hopes of effecting a permanent cure proved, hoAV- ever, in this case also, to be fallacious. After the lapse of a year this patient presented herself again. She stated that for months after the operation she had enjoyed good health, but that of late her abdomen had begun to enlarge, and pain of an intense character to be always present. On examination the uterus appeared to be healthy, and nothing definite could be made out to account for her great sufferings. Her condition, hoAvtwer, rapidly became Avorse, and she died Avithin a month in the greatest agony. On a post-mortem examination being made, death Avas proved to haA~e been due to the groAvth of an enormous mass of soft, jellylike substance, Avhich filled up the whole of the right inguinal region, and which was evidently of a malignant character; the uterus Avas healthy. Here the dis- ease had Avithout doubt been eradicated from the uterus, the organ first attacked, but only to reappear, and in another local- ity, in different and aggravated form. Still, by the operation life had been prolonged for quite a year. As a commentary on this case, the folloAving extract from Dr. Grail}- Hewitt's work is very appropriate: "As a palli- 23 274 DISEASES OF AVOMEN. ative measure frequently, as a curative measure occasionally, amputation of the cervix uteri (in such cases) is a valuable operation; it may possibly prevent a fatal result altogether; it Avill almost certainly postpone that fatal result even Avhen inevitable. The bleeding and a copious exhaustive discharge are at once arrested, and for a time the source of danger is re- moved." I can add nothing to this passage; and though in cases in which extirpation is out of the question, I shall con- tinue to use nitric acid or caustic potash as I have hitherto done; or try the acid nitrate of mercury, as suggested by Dr. Baker, of NeAv York; or e\ren, perhaps, that rather unmanage- able remedy, bromine, Avhich, according to Dr. Routh, "not only arrests the disease locally, but also the cachexia which accompanies it;" still, where it can be performed, extirpation is decidedly to be preferred. I use the Avord extirpation ad- visedly. In the cases just narrated, amputation of the cervix uteri was the operation performed. But Dr. Marion Sims has recently introduced a neAV one, Avhich promises good results. Instead of amputating the cervix, an operation Avhich in many cases fails to remoAre more than a portion of the diseased mass, he boldly folloAvs the disease right up into the uterus, removing by means of curette first, and then by scissors and knife, not only every portion of the diseased mass, but also the indurated gristly tissue subjacent to it, the dissection being carried up in some instances beyond the os internum, necessarily a portion of the uterine wall is also removed. This bold operation is, if carefully performed, quite safe; doubtless it is very tedious, but the bleeding is not great. I have performed it twice, but as the patients are still under treatment, I can give no definite opinion as to the final result, but I believe Dr. Sims AArhen he says, that though cure in cases of cancer is seldom to be hoped for, from the liability of the disease to recur in another or the same organ, still that the operation gives much greater hopes CANCER OF UTERUS. 275 of success than mere amputation, and that as a matter of fact he has patients under his observation for tAvo or three years Avithout there being as yet any recurrence of the disease. In order to perform this operation efficiently, it is necessary to procure the knife invented by Dr. Sims for the purpose. My first operation Avas performed Avith an ordinary knife, and it Avas not satisfactory. I then obtained from M. Collin, Maison Charriere, Paris, Dr. Sims's knife; it is a beautiful and in- genious instrument; the blade can be fixed at any angle, and my second operation performed Avith it was all that could be desired; the dissection, Avhich occupied nearly an hour, reached beyond the os internum; the large gaping y\ shaped caA'ity Avhich represented the canal of the cervix Avas then filled with cotton previously saturated Avith the Liq. ferri perchloridi fort., and partially dried. This was left in situ for some days till it loosened of itself, and came aAvay Avith the fluid used in syring- ing the vagina. After it had been removed, the cavity, some- Avhat contracted by this time, Avas again packed Avith cotton saturated Avith a strong solution of the chloride of zinc, and partially dried. This application caused, as it ahvays does, much irritation, and some pain. The cotton Avas left in the cavitv for four days, and on its remoATal no further treatment was adopted. The cavity contracted rapidly, and the present condition of the patient is promising. I look upon this opera- tion as a most important improvement in uterine surgery. I haATe hitherto spoken of cancer as being a disease of the cervix uteri, and in the very great majority of instances this is true; but even to this rule there are exceptions, though they are very rare. The only example of it Avhich has come to my knoAvledge, was one brought under the notice of the Patho- logical Society by my colleague, Dr. James Little. Neither the rectum, bladder, vagina, or cervix uteri were invaded by the disease, but the whole of the body of the uterus seemed to 276 DISEASES OF AVOMEN. have been converted into a mass of encephaloid cancer, and yet had a speculum been introduced in this case, the os would have been found small, and Avithout any appearance of disease. With respect to such cases as these I have only to say, that, impotent as Ave generally are for good Avhen cancer attacks the cervix, we are utterly poAverless when the disease originates in the body of the womb. When speaking of chronic inflammation of the cervix uteri, I mentioned that the induration which it produces has been mistaken for that Avhich results from cancer. I think I shall best enable you to form a correct diagnosis between these two affections by folloAving the example of Dr. West (Diseases of Women, p. 384), and arranging the symptoms of both in a tabular manner, so that you may the better be able to com- pare them. IN CHRONIC INFLAMMATION OF CERVIX. The history of the case is always chronic, often dating back several years. Pain—always present; generally more severe over left ovary than else- where. Menstruation scanty and frequently painful. Digital examination—Cervix feels hard to the touch, but smooth; pres- sure with the finger causes pain. Uterus—Movable. Vagina—Not implicated. Discharge—Inodorous and muco- purulent. IN CANCER. History — Symptoms seldom no- ticed till within a comparatively re- cent period. Pain — Seldom felt in the early stages ; most severe in the back. Menstruation—If patient be young will be increased; if advanced in life, haemorrhage may be the first symptom noticed. Digital examination—Cervix indu- rated, uneven and nodulated; pres- sure does not cause pain. Uterus—Fixed. Vagina frequently implicated. Discharge—Generally fetid. TREATAfENT OF CANCER. 277 HaAring given an outline of the ordinary course which med- ullary cancer of the uterus folloAvs, and dwelt on its leading features and symptoms, I must in conclusion allude to the treat- ment. Unfortunately we can seldom do more than alleviate the most prominent symptoms. With the A'ieAV of deadening the pain, opium in some shape or form must be our main re- liance ; chloral will often fail, if the sufferings be excessive, eA'en to produce sleep. Opium is best administered either per rectum, in the form of suppositories, or by being injected sub- cutaneously, commencing with gr. \ or \ of morphia. No doubt the subcutaneous injection of morphia acts more rapidly, and its effects last longer than those of opium administered in any other manner, Avhile it is, I think, less deleterious in its after consequences. Of astringents administered with a A'ieAV of checking the haemorrhage, gallic acid is, probably, the best. If the bleeding be A'ery seA'ere you may be compelled to plug the vagina; but I prefer in these cases, endetworing to stop it by the direct application to the cervix of a pledget of cotton saturated Avith a strong solution of the perchloride of iron in glycerin. To lessen the fetor of the discharge, you had better add half an ounce of the solution of the permanganate of potash to a pint of tepid Avater, and direct this quantity to be throAvn up the vagina at least tAvice a day; or you ma)- employ for the same purpose a AAreak solution of carbolic acid. For conveni- ence you may order an ounce of carbolic acid to be dissoh7ed in eight ounces of Avater, a tablespoonful of Avhich is to be added to half a pint of tepid Avater for injection into the vagina. Another lotion AA'hich is sometime useful both in allaying the pain and lessening the discharge, is a solution of nitrate of sih'er of the strength of ten grains to the ounce—two or three ounces of this should be injected at a time. Of internal reme- dies, arsenic and iron are the only ones Avhich Avill effect any 278 DISEASES OF WOMEN. good ; indeed I confine myself nearly altogether to the admin- istration of the latter, and of its A-arious preparations I prefer either the tincture of the perchloride, or, if the stomach be irri- table, the ammonio-citrate. The diet should of course be nour- ishing, but unstimulating. In cases of cauliflower excrescence there is ahvays the chance, if the case is seen early, of your being able to prolong life by amputating the cervix, or better still, by performing Dr. Marion Sims's operation Avhich I have just described, or possibly of destroying the groAvth by repeated applications of caustic potash. I effected the latter in the case of a Avoman aged nearly sixty; but the disease returned after the lapse of a few months, and then proved fatal. Indeed, no matter Avhat treatment be adopted, you should ahvays let it be clearly understood that the result is very doubtful. OVARIAN CYSTIC DISEASE. 279 LECTURE XIV. Ovarian Cystic Disease—Pathology—Unilocular, Multilocular, and Dermoid Varieties—Symptoms—Diagnosis. As I have performed the operation of ovariotomy twice in our wards within a comparatively recent period, one of the patients being still in hospital, I do not think it likely that I shall have a better opportunity than the present of drawing your attention to the subject of ovarian disease. The affections to Avhich these organs are liable have, till Avithin the last feAv years, been looked upon as almost incurable; but iioav, as you are all aAvare, the extirpation of one or both ovaries Avhen in a state of disease, is performed with great frequency, and although the result is most uncertain, and though patients doubtless die from the effects of the operation Avho might otherwise live for years, still the number of Avomen whom its performance has restored to perfect health is so great, that it steadily increases in professional favor. The affection to Avhich I shall first direct your attention, is that knoAvn as cystic disease of the ovary, by Avhich term is understood the development of a cyst, or sac, or of seAreral cysts within or adjacent to the ovary, Avhich are filled Avith a fluid, or semifluid substance produced in their interior. The devel- opment of cysts in the ovary is of very frequent occurrence. They are met with of all sizes, from that of a pea, to that of a large sac capable of containing many gallons of fluid. Patholo- gists admit that the ovarian cyst may be in the first instance 280 DISEASES OF WOMEN. the mere dilatation of a Graafian vesicle, this question having been A'irtually settled by Rokitansky's discoA'ery of an ovule Avithin one of these diseased cysts. As the cyst groAvs all trace of its origin is lost, and the sac thus formed, becoming dis- tended Avith fluid, gives origin to the simplest form of ovarian dropsy, to which, from there being but one cyst present,the term "unilocular" is applied.* But very generally more than one cyst is developed, several of the Graafian vesicles becoming simultaneously affected. In the early stages Ave may have a cluster of small cysts, none of them perhaps larger than a cur- rant ; then, after a time, one or tAvo of these seem to take on a condition of active life, and to become rapidly developed, SAvell- ing and increasing, till they attain a large size, Avhile the others remain stationary or increase sIoavIv. To this aggregation of the cysts, the term "multilocular" is applied; the multilocu- lar tumor is much more frequently met Avith than the uni- locular. The contents of these cysts Arary in as great a degree as do their appearance. The unilocular generally contain a light straav-colored. fluid, very like serum in chemical qualities. Sometimes, hoAvever, it is turbid and ropy, and occasionally seems to contain blood. In the multilocular, the contents of the cysts even in the same ovary vary much; in some they are similar to that just described; in others, they consist of a thick gelatinous-looking mass, Avhich is sometimes black and tenacious. Again, the Avails of contiguous cysts, containing fluids essentially different, may be absorbed under the influ- ence of pressure, and the contents becoming commingled, we have then a fluid, partly thick and tenacious, and partly aque- ous. But in addition to this groAvth by the amalgamation of * According to Mr. Lawson Tait unilocular tumors are not of ovarian but of parovarian origin. COMPOUND CYSTS. 281 contiguous cysts, there is yet another and very important pro- cess by Avhich these cysts increase, that is, by the development Avithin the parent cyst, of numerous other cysts. These, accord- ing to Dr. Hodgkin, Avhose observations have been confirmed by Sir J. Paget, may be either sessile or pedunculated, and may cluster in Avarty-looking masses on the inner surface ot the sac. Thus by the growth of the older cyst, and the rapid formation of the neAV, the ovarian tumor sometimes enlarges Avith an alarming rapidity, and then the disease generally proves fatal in a \Tery brief space of time. But ovarian tu- mors are seldom made up of these fluid-containing cysts alone. We frequently also find a considerable amount of so-called solid matter present; this solid matter is produced at the same time as the cyst; sometimes it is small in quantity, sometimes in bulk it exceeds that of the fluid contained in the cyst, and it may form a tumor of enormous magnitude. These partly cystic, partly solid tumors, to which the term "compound" is usually attached, are probably the most com- mon form of ovarian disease. Solid matter exists in them under various forms. One, Avhich has been described by Mr. Spencer Wells as being identical in structure with the adenoid groAvths found in connection Avith the mammary gland, has been called by him Adenoma of the ovary. Another remark- able one was long looked upon as malignant, a view now proved to be erroneous; it is termed Alveolar, and is likened by Dr. Farre to a sponge, the cells of Avhich are filled Avith a jelly-like substance. Other varieties of solid material are also met with in these cases of compound ovarian tumors > but it Avould be impossible for me to enter with any degree of mi- nuteness into pathological details, for I desire in these lectures to confine myself as strictly as possible to the clinical aspect of the diseases of Avhich I treat, and therefore must refer you to the writings of Paget and Farre, or to the admirable systematic 24 282 DISEASES OF AVOMEN. works of Graily Hewitt, West, Gaillard Thomas, Barnes, and others, for further information on the points Avhich I feel com- pelled to omit. There is, hoAvever, one other variety of ovarian cyst, which I must notice briefly; namely, that which contains hair, plates of bone, or fat, and in which even rudimentary teeth have been found, Avith or without any fluid being present. These tumors seldom obtain any large size, and may remain indolent for years; on the other hand, they sometimes inflame, sup- purate, and finally may cause death. These dermoid cysts, as they are termed, are a puzzle to pathologists; the fact that they sometimes are found in very young children negatives the idea of their being the product of conception ; Avhile it is equally difficult to admit, as some have suggested, that they may be the imperfect development of an ovum, Avhich has been impregnated, but Avhich by some accident has become enveloped in the tissue of another more adA'anced ovum; in truth, hoAvever, this matter is as yet a complete mystery. Having thus given you a brief outline of the pathology of ovarian tumors, I shall next call your attention to the con- sideration of what is of even greater importance to the prac- tical physician, namely, their symptoms and diagnosis; the latter a matter of often the greatest difficulty, an error in Avhich may entail the most serious consequences, jeopardizing, and even sacrificing life itself. First, I shall give you a brief outline of the tAvo cases recently under treatment here: One patient, Margaret McD., Avas unmarried, aged thirty. She stated that her health had been ahvays good till about ten weeks previous to her admission, Avhen, on recovering from a sharp feverish attack, the result of cold, she perceived that her clothes had become too tight for her, and since then she in- creased rapidly in size—so much so as to have become the CASES OF OVARIOTOMY. 283 object of unjust suspicion; indeed, she subsequently stated that it Avas in consequence of the annoyance she experienced from it being reported that she Avas pregnant that she sought medical aid, coming for this purpose from a remote country district. Her general health Avas good; she complained only of thirst and of a frequent desire to micturate; her appetite aa;is fair, menstruation normal, nutrition good. She measured, on admission, 39 inches round the abdomen, at the umbilicus ; fluctuation Avas distinct all OA'er the abdo- men, Avhich AA7as dull on percussion anteriorly from the pubes to about an inch above the umbilicus, but resonant in both flanks; the uterus Avas normal in size, shape, and position; the A'agina Avas narrow, and the hymen perfect. She Avas low- spirited and desponding, and while absolutely refusing to con- sent to an operation, urged that something should be done for her. Therefore, Avith a view of gratifying this Avish, I tapped her on the 6th April, and drew off 256 ozs. of a dark and someAvhat gelatinous fluid. After the tapping the circumfer- ence of the abdomen Avas reduced to 29 inches. She subse- quently suffered no inconvenience, and after a short stay in hospital Avas discharged. She returned again on the 8th June, Avhen the circumference of the abdomen was 35 inches. From that date it continued steadily to increase till the 12th August, Avhen she expressed her Avillingness to undergo any operation AA'hich Avould promise relief from her intolerable condition. Before the operation the diagnosis of a unilocular ovarian cyst, Avith but little solid matter, was made. On the morning of the operation she had, at 6 a.m., a light breakfast, consisting of a cup of tea and a little dry toast; and at 8 a.m. an egg, beaten up Avith half an ounce of brandy, was given. The boAvels Avere freed by means of an enema, and at 10 a.m. she Avas placed on the table, clothed in a flannel jacket, draAvers, etc. Ether Avas the anaesthetic selected, Avhich was 284 DISEASES OF AVOMEN. administered by means of Dr. Richardson's inhaler, AA'hich acted most satisfactorily. The patient Avas difficult to narco- tize, and before she Avas thoroughly under the influence of the ether, vomited—the egg, taken quite tAvo hours previously, be- ing rejected undigested—a circumstance Avhich deterred me from giving one on the next occasion. She A'omited also three times during the progress of the operation, and several times subse- quently. An incision, not quite five inches in length, was made in the median line; the cyst Avas AA'ithout difficulty exposed; a sound passed round its surface proved it to be quite free from adhe- sions ; Spencer Wells's trocar was then plunged into it, and the contents evacuated, without one drop of fluid escaping into the abdomen; the cyst was drawn out, some little difficulty being experienced in extracting the solid portion, which was of about the size of a man's fist; the pedicle was secured by means of Spencer Wells's clamp, and after being divided Avas seared with the actual cautery ; the edges of the incision were then brought together Avith carbolized catgut sutures, and the abdomen sup- ported in the usual manner, Avith broad strips of adhesive plaster and a flannel roller. The patient Avas then put to bed, no anodyne being given, nor any stimulant administered. The operation occupying, from the commencement of the incision till the wound Avas closed, in all about tAventy-five minutes. At 11 a.m. the pulse Avas 88. She remained in a state of semi- unconsciousness till noon, Avhen she Avoke up and spoke. Pulse 80. She vomited soon after. To have small pieces of ice at short intervals, and nothing else. 3 p.m.—Catheter passed; stomach sick, Avith retching subsequently; has dozed a good deal; to have nothing but ice. 11 p.m.—No sickness for some hours; to have a tablespoonful of soda Avater and milk iced every fifteen minutes, if not asleep, and ice ad lib. She re- covered rapidly. The second case was that of Mrs. M., aged tAventy-eight, CASES OF OVARIOTOMY. 285 married tAvo years; she had given birth to a child just tAvelve months previous to admission. Her labor had been easy, and convalescence good. Was attended by a mkhvife, who re- marked, after delivery, that the abdomen was larger than it ought to be. She did not mind this at the time, but a feAv AA'eeks subsequently observed that she " AA'as greatly SAvelled," the Avhole abdomen being uniformly enlarged. A day or two after this she Avas attacked Avith pain in the right inguinal re- gion. This subsided in four or fhTe days, but ever after she suffered a good deal of pain at each menstrual period. These attacks of pain, hoAvever, did not confine her to bed. From this time she steadily increased in size, the increase being sometimes so rapid as to be noticeable from day to day, at other times so gradual as to be almost imperceptible. Her health continued fairly good. She, hoAvever, lost flesh; but were it not for the weight and incom'enience which her size caused, Avould not have sought medical aid. On admission, though very thin, she aahs not emaciated; her health Avas apparently good, and complexion clear; she Avas very cheerful, and, Avithout hesitation, at once expressed her readiness to undergo the operation of ovariotomy—the nature and risk of which Avere clearly explained to her and her husband. The circumference of the abdomen Avas at this time, at the umbilicus, 34 inches ; from umbilicus to right anterior spinous process measured nine inches; to left, nine and a half inches ; ensiform cartilage to pubes (symphysis), twelve inches. The abdominal Avails being A7ery thin, fluctuation Avas everywhere distinctly perceptible. There Avas dulness on percussion over front of abdomen to Avithin three inches of ensiform cartilage ; both flanks resonant, The diagnosis of a unilocular ovarian cyst Avas made. The operation Avas performed at 10 a.m., the boAvels having 286 DISEASES OF AVOMEN. been freed by means of an aperient pill taken at night, and an enema administered in the morning. A light breakfast of tea and dry toast Avas given at 6 a.m., and a little beef tea at 8 o'clock. Ether was the anaesthetic selected, administered by means of Dr. Richardson's apparatus.. The incision, as in the former case, was commenced about an inch beloAV the umbilicus, and was in the first instance about three and a half inches in length. The abdominal wall Avas so very thin that after the skin had been divided the greatest care Avas exercised. The need of this was soon manifested, for after the dissection had proceeded to but a limited depth, so thin and attenuated Avas the abdominal Avail, and so intimately adherent and matted together were the subjacent structures, that it Avas impossible to say with certainty whether the peritoneum was laid open or not; layer after layer of thin tissue was carefully divided on a broad director, inserted with much difficulty under each layer, till at last I ascertained that I Avas thus dis- secting the actual Avails of the cyst itself, the Avhole anterior surface of Avhich Avas intimately and inseparably attached to the abdominal Avail. Failing to separate the cyst from its attachment to the ab- dominal Avail below the umbilicus, I enlarged the incision up- wards to Avithin an inch of the ensiform cartilage, hoping thus to reach the free edge of the cyst, but in vain. All attempts to separate the adhesions Avere fruitless, so dense and intimate Avere they, and at this juncture, in an effort to break them doAvn forcibly, the cyst ruptured, and the contents rapidly eA'acuated through the rent, much of the fluid escaping into the abdominal cavity. A brief consultation was noAV held, and so desperate did the case appear that one of my colleagues strongly urced the abandonment of the operation. However, it Avas decided to make one more effort. I enlarged the open- ing into the cyst, and inserting my hand into it, reached the CASES OF OA'ARIOTOMY. 287 bottom, and grasping the AA'all at its lowest point, succeeded in iiiA'erting the sae, draAving it through the opening I had made, and finally, Avith considerable difficulty, in breaking doAvn from behind the dense adhesions Avhich had before baffled me, and removing the entire cyst. The pedicle was noAV secured Avith a clamp, and, after being dh'ided, seared Avith the actual cautery. During the tedious and difficult processes described, very little blood Avas lost; a large quantity of the contents of the cyst had, hoAveA7er, escaped into the cavity of the abdomen; in fact, the pelvis Avas nearly full of it, and it Avas necessary to remove all of this by sponging. This occupied a long time, but Avas thoroughly accomplished ; no fluid being left in the abdomen. The Avound Avas then closed, as in the previous case, by means of catgut ligatures, but in consequence of the escape of the contents of the cyst into the abdominal cavitv, I deemed it wise to insert a drainage-tube, bringing it out above the clamp, its free extremity being secured by adhesive plaster to the outside of the right thigh of the patient. The operation lasted one hour and twenty minutes. The patient A7omited three times during the operation, and twice afterwards. On being placed in bed, there was no appearance of collapse; the pulse Avas good, about 85; neither stimulant or opiate Avas administered, and she Avas alloAA'ed nothing Avhatever, except ice, for the first eight hours. During the whole day she Avas drowsy, dozing a good deal; the catheter was passed eA'erv fourth hour. 7 p.al—Pulse, 104; temperature, 101.2°; com- plains of thirst; a good deal of sanguineous discharge through the drainage-tube; to have half an ounce of beef tea every second hour, and ice ad lib. I shall not AA'eary you Avith the details of the subsequent treatment of these cases, but merely state that her recovery too AA*as excellent. 288 DISEASES OF AVOMEN. Although these tAvo cases had the same favorable termina- tion, they presented features very markedly different. In the first the tumor Avas not only of the simplest kind, but was free from adhesion, and Avas removed Avithout the escape of one drop of fluid into the abdomen. In the second case the dense adhesions Avhich existed anteriorly rendered the removal of the cyst by the ordinary method impossible, and it Avas only by inverting the sac, and breaking the adhesions doAvn from be- hind, that this Avas finally accomplished. In consequence of the rupture of the cyst, the pelvis Avas filled Avith the fluid it had contained, and all this had to be removed by sponging, a process Avhich occupied a long time; but notwithstanding these adverse circumstances, the patient made an excellent and rapid recovery. In neither of these cases Avas any drug Avhatever adminis- tered, nor Avas any stimulant alloAved; but, on the other hand, the greatest care was taken Avith regard to diet, ice alone being alloAved for the first feAv hours, and subsequently beef tea and milk in very small quantities and at stated intervals. To this strict regimen, I belieA'e, much of the favorable issue of these two cases was due. The greatest care Avas also taken to insure the best possible sanitary conditions, and no person Avas alloAved to enter the ward subsequent to the operation, except the nurse who had charge of the case, and two pupils, Avho, not resident in the hospital, gave their Avhole time for the first feAv days to watch the patients. The general symptoms Avhich usher in ovarian disease, as you see from details of the foregoing cases, are very vague and uncertain. The patient may, and indeed probably does, com- plain of a considerable amount of discomfort in the ovarian region, before being conscious of any actual ailment, but, as a rule, the first thing that attracts her attention, is the discoA'ery of a tumor, or at least a fulness, generally in one side of the CASES OF OVARIOTOMY. 289 abdomen, which gradually increases in size. But often, even Avhen it has reached a considerable size, the patient does not pay any attention to her state, or seek medical aid till the disease is far advanced. In addition to the symptoms enumerated, there are often various others present referable to pressure on the neighboring viscera, such as irritation of the bladder, or interference Avith defecation; but these are ahvays A7ague, and valueless for the purpose of diagnosis. More definite and more important are the paroxysmal attacks of pain from Avhich the patient not un- frequently suffers. These may be due to the tension of some of the folds of the peritoneum, but they are far more frequently caused by transitory attacks of local peritonitis, and, as a result, we often find intimate adhesions formed Avith the surrounding structures, especially Avith the omentum. Such adhesions add greatly to the difficulty, as well as to the risk, of operations undertaken for the extirpation of these tumors. In the vast majority of cases, hoAvever, the disease has advanced to a stage, in Avhich either a Avell-defined tumor, or distinct fluctuation, or both, exist in the abdomen, before Ave are called on to give a diagnosis as to the nature of the disease from Avhich the patient suffers. This was so in both the cases recently in this hospital —in both, large tumors existed for a long time prior to their seeking medical aid. When this stage has been reached, the general health nearly invariably suffers to a greater or less degree. In the patient on Avhose case I am specially commenting, it Avas merely to the extent of loss of flesh, Avhile in others there is great emaciation accompanied by dyspnoea, the result of the size of the tumor, also loss of appetite, and a long train of secondary symptoms. Menstruation may continue to be normally performed; this AA'as so in the patient Avhose case we are considering, but in many it becomes irregular as the disease progresses, or is alto- 290 DISEASES OF WOMEN. gether suppressed. When the latter occurs, the patient, if she be married, naturally attributes the increased size of the abdo- men to pregnancy, and even in unmarried women, as happened in the well-knovra case of a lady of rank, the unjust suspicion of pregnancy, and its attendant disgrace, has been attached to the sufferer; an injustice Avhich the exercise of but a moderate amount of skill should have prevented. The leading features of a case of ovarian cystic disease then, are these: we have a tumor of variable size, the gradual growth of Avhich has generally been traced by the patient. The sur- face, in the case of the unilocular tumor, is smooth and even, Avhile in the multilocular, the separate cysts impart a lobulated, irregular feel, to the hand passed over the abdomen. Fluc- tuation is generally distinct in the former, and can be felt everywhere over the surface. In the latter, this is only the case here and there, or it may be detected in but one situation, while Ave can also nearly invariably make out at some point, a firm hard mass, indicative of the existence of solid matter. The whole of the anterior surface of the abdomen is, in the case of either form of ovarian disease, dull on percussion, the intestines being forced back behind the tumor. A vaginal examination, which should be made in all cases, will prove Avhether the uterus is of its natural size and shape; frequently, hoAvever, that organ is displaced, being drawn upwards and anteflected, but this is far from being inA'ariably the case. The conditions or affections Avith Avhich cystic disease may be confounded are numerous. Ascites, especially if complicated with the existence of an enlarged spleen, tumors of the omen- tum, cancerous tumors in various situations, and extra-uterine fcetation, have been mistaken for ovarian disease; but errors of diagnosis are specially liable to occur in cases of fibro-cystic disease of the uterus. Of twenty-three cases recorded by Mr. Clay, in Avhich ovariotomy had been attempted, but in Avhich OVARIAN DISEASE. 291 the operation Avas abandoned in consequence of the disease proving not to be ovarian, twelve AArere uterine; in two no trace of a tumor Avhatever could be found. While the enlargement of the abdomen from the presence of an ovarian tumor Avhen menstruation is absent may easily ghre rise to the idea of pregnancy, it seems hardly possible that an unimpregnated uterus could be mistaken for an OA'arian tumor; yet this mistake has been made, and in order to guard against the recurrence of a similar error, you should invariably seek for the usual signs and symptoms of pregnancy, some, or all of Avhich, Avill be sure to be present in a more or less marked degree. A careful A'aginal examination will prove the uterus itself, and not the ovary, to be the seat of the enlargement. This is one of those cases in Avhich the practice of ballottement may possibly be useful; you must, Iioavca'ci', always bear in mind, that pregnancy is not incompatible with the existence of disease of at least one ovary. The diagnosis betAveen ascites and OA'arian dropsy, is not in general difficult. It is Avith the simple unilocular form that the question is most likely to arise. The history of the case often aids us materially in forming our opinion, for the patient is frequently able to tell you that the swelling commenced by the gradual enlargement of a small tumor, Avhich, first felt in one or other iliac region, continued to increase till it extended across the abdomen, a history which Avould be incompatible with the idea of ascites. In ovarian dropsy also, there is al- most inA'ariably dulness on percussion over the Avhole front of the abdomen; the very reverse of this occurs in ascites, for in that disease the intestines almost invariably float, and are con- sequently in contact with the anterior abdominal Avail, there- fore percussion yields a resonant sound. Fluctuation too in as- cites is most clearly felt laterally, in the lumbar regions, that 292 DISEASES OF WOMEN. being the point at Avhich it is likely to be wanting in a case of ovarian dropsy. I cannot, hoAvever, go further into these details, much less would it be possible, even if it were desirable, for me to enter on the consideration of the differential diagnosis betAveen ova- rian cystic disease and that of all the other affections with Avhich it may possibly be confounded, and I must content myself Avith having laid before you the distinctive features of the former. Your other clinical teachers Avill explain to you those of the others, and you must weigh for yourselves the rela- tive value to be assigned to each symptom, Avhen called upon to decide as to the nature of the affection from Avhich the patient suffers. But it is essential before passing from the "subject of diagnosis, that I should point out to you the principal distinc- tive features Avhich exist between OA7arian disease and fibro- cystic degeneration of the uterus; first, because both diseases are strictly within the limits assigned to the gynaecologist; and secondly, because the latter is that Avhich is specially liable to be mistaken for the former, and indeed so closely simulates it as sometimes to mislead the most careful observer. I have in a previous lecture given you an outline of the leading features of fibro-cystic disease of the uterus, and I think I shall best aid you noAV, by throwing these into contrast with those of ovarian disease, so as to present them to you in a tabular view; premising, hoAvever, that there is not one of the symptoms enumerated Avhich is not liable to great variation, and that therefore, the most extreme caution must be exercised in forming an opinion based on them. I should also add, that I am iioav speaking only Avith reference to tumors of consid- erable size and Avhich extend entirely, or very nearly, across the whole abdomen. DIAGNOSIS OF OA'ARIAN DISEASE. 293 OVARIAN CYSTIC DISEASE. May occur at any age, but proba- bly more frequent before the age of thirty-six than after it. Of 281 cases recorded by Mr. Clay, and of which the ages were known, 168 were under thirty-six, 68 of these were aged between seventeen and twenty-five UTERINE FIBRO-CA'STIC DISEASE. Rarely met with in early life ; of twenty-three cases recorded by Mr. Clay, in which the operation was abandoned in consequence of the dis- ease being extra-ovarian, thirty-four was the age of the youngest patient. Previous history often throws light on the diagnosis, a tumor being fre- quently felt at first in one or other iliac region, which gradually ex- tended across the abdomen. Such a history unlikely to occur, growth usually more central. Growth of tumor comparatively rapid. Growth comparatively slow. Menstruation sometimes normal, Menstruation profuse, if tumor be but frequently irregular, and as the intramural or submucous, normal if disease progresses is liable to be sup- subperitoneal. pressed ; profuse menstruation of rare occurrence. Uterus of its normal size, fre- quently drawn upwards, so as to be difficult to reach, movable, unless bound down by adhesions and some- times anteflected. Uterus elongated if tumor be in its substance or interior. Sound often passing for a considerable distance into its cavity ; when tumor is rotated sound moves with it. Tumor becomes softer as it in- Time not likely to alter consistence creases in size. of tumor. Urine voided without difficulty. Difficulty in passing water occa- sionally experienced from pressure on bladder and urethra. Generally health always suffers G eneral health does not suffer, un- more or less, sometimes to a great less menorrhagia be present. degree. 291 DISEASES OF WOMEN. If care be taken to Aveigh each of the distinctive features here enumerated, the risk of making a serious error in diag- nosis will be greatly lessened. Above all, let me impress on you the necessity of using the uterine sound. It affords us the most important aid in forming our diagnosis. In the great majority of cases of large fibroids, Avhether solid or fibro-cystic, the uterus is either imbedded in, or so firmly attached to the tumor, that it cannot be movTed independently of it; a point Avhich can generally be ascertained, by inserting the finger into the rectum and keeping it there, Avhile the sound previously passed into the uterus is rotated gently. And again the sound should be held steadily, Avhile an assistant endeavors Avith both hands, to rotate the tumor itself. These are methods of manipu- lation Avhich often enable us to decide Avhether the uterus is attached to the tumor or not. Still even here error is possible; for, if a fibrous tumor spring from the uterus by a moderately long pedicle, or eA'en by one as short as that shoAvn in Fig. 21, p. 134, we may be able to move the uterus to such an extent as to lead to the conclusion that it is free; and on the other hand it is possible, that in a case of ovarian disease, the uterus might be so bound doAvn by adhesions as to be immovable. Some idea of the difficulty of diagnosing between fibrous tumors of the uterus Avhen in a state of cystic degeneration, and ovarian cystic disease, may be gathered from the folloAving case, recorded in volume xii of the Transactions of the Lon- don Obstetrical Society. The Avoman was aged thirty-six. An abdominal tumor had been discovered five years previously, which during the last six months had increased rapidly. On admission into hospital, a large tumor Avas felt which evidently contained no cyst large enough to Avarrant tapping, but Avhich did not feel so hard as a fibrous tumor of the uterus; no vascu- lar murmur Avas audible, and it appeared to move quite inde- I'IBRO-CYSTIC DISEASE. 295 pendently of a uterus of normal size. When the tumor Avas exposed, it proA'ed not to be OA'arian ; it sprang from the upper part of the posterior surface of the fundus uteri by a short pedicle. The tumor was removed, and Avas found to Aveigh thirty-four ounces, and was seventeen inches in diameter. The patient subsequently died. The fact of the tumor groAving almost from the very fundus of the uterus doubtless permitted that organ to have a greater amount of mobility than is usually met Avith in such cases, and Avhen I add that the operator Avas Mr. Spencer Wells, you will agree Avith me that no# means were omitted by that distinguished surgeon for arriving at a correct opinion as to the nature of the tumor. 296 DISEASES OF WOAIEN. LECTUKE XV. Ovarian Disease (continued)—Effect of ox Duration of Life— Ovariotomy—Statistics of—Tapping of Cyst—Injection of Cyst—Congestion and Inflammation of Ovary. We shall noAV assume that after having carefully weighed all the symptoms, you have made up your mind that the case you have been called to see is one of ovarian disease; it still, hoAvever, remains for you to consider Avhat its probable course Avill be, for on this point depends your future treatment. The most reliable data from Avhich Ave can form an estimate as to the probable duration of life in the cases of cystic disease of the ovary, are those supplied from the tables of Mr. Stafford Lee. Of 123 cases tabulated by him, nearly a third died Avithin a year, and rather more than one-half within two years from the date at Avhich the first reliable symptoms of the disease were noticed, a duration hardly longer than that of cancer, while but seATenteen lived for nine years or upAvards; of these seventeen, one surviA'ed for fifty years. From these tables Ave may fairly assume that the duration of life in cases of the dis- ease under consideration is unlikely on an aA-erage to exceed three or four years. As a rule, you may consider that the chance of life being prolonged, is in an in Averse ratio to the rapidity of the groAvth of the tumor; for if this be rapid, the patient will speedily be Avorn out, and die exhausted no less by the effects of the disease, than by the distress caused by the OA'ARIAN DISEASE. 297 size of the tumor itself, even should no intercurrent attack carry her off after a brief illness. The simple unilocular form seldom becomes dangerous to life, till the tumor, by its great size, interferes AA'ith respiration, and by its pressure impedes the abdominal viscera in the due performance of their functions. When this stage is reached, if, Avith the aucav of relieA'ing the patient's sufferings, we have recourse to tapping, Ave may actually accelerate the fatal ter- mination of the ease, the drain on the system caused by the refilling of the sac, increasing the previously existing exhaus- tion. The rupture of a cyst is another possible cause of death, but it certainly is not of very frequent occurrence. In all cases of ovarian disease, there is a great proneness to inflammation of the abdominal, and even of the thoracic A'iscera, and an attack Avhich AA'Ould in others be of no importance, be- comes, Avhen occurring in the patient suffering from OA'arian dropsy, a A'erv serious matter, and therefore not a few die of diseases not directly connected Avith the original malady, but which is not on that account the less chargeable with the result. The certain and speedy death, Avhich in the great majority of cases awaits the sufferer from ovarian disease, has decided surgeons to attempt its cure by the extirpation of the diseased organ ; the question, then, Avhich in each case has to be decided is, Avill the patient if left alone, haA'e a fair chance of being one of the fortunate tweh'e avIio, out of every 100, may be ex- pected to live for ten years or upAvard, or one of the eighty- eight who, if not operated on, must in a third of that time be consigned to their graves? In deciding on this momentous question, Ave should never for one moment lose sight of the fact, that there are but tAA'O possible terminations to operations for the extirpation of OA'arian tumors, the one being perfect recovery, the other speed}- death. The most important element in the calculation undoubtedly 25 298 DISEASES OF AVOMEN. is, the rapidity with Avhich the tumor is increasing in size; for if this be rapid, the case must soon terminate fatally. Thus, in one of the cases I am alluding to, the circumference of the abdomen increased four and a half inches in one month. This patient Ave may say Avith almost positive certainty, would have died under any circumstances in a very brief period, and there- fore the operation Avas called for; but if the increase be very sIoav, we should hesitate before sanctioning it. Again, the state of the patient's health will materially influence your judgment; if it be fairly good, and that she seems to suffer only from the ordinary effects caused by the presence of a large tumor in the abdomen, she will be in the most faA'orable state for the opera- tion. Of course, if the patient be laboring under any other form of organic disease likely to terminate fatally in a short time, ovariotomy is hardly justifiable; it would, hoAvever, be impossible to lay down an exact rule on this point. The presence of firm and extensive adhesions between the tumor and intestines or other abdominal viscera greatly in- crease the risk of a fatal termination; but the diagnosis of adhesions is very difficult, in some cases impossible to make. By grasping the integuments over the most prominent parts of the tumor and raising them up, and by endeavoring by careful manipulation to make them glide over its surface, a fair estimate may be formed as to Avhether they exist anteriorly or not; but Ave have no means of ascertaining Avhat may be the condition of the tumor posteriorly, and are therefore to a great degree necessarily in ignorance on this point. The repeated occurrence of attacks of sharp pain are, hoAvever, of import- ance ; if the patient has not suffered much from these, exten- sive adhesions are not likely to be met Avith ; but if paroxysms of pain have been frequently experienced, Ave may Avith con- fidence anticipate that they have formed. The simpler the tumor the greater chance there exists of a OA'ARIOTOMY. 299 favorable termination, and the larger amount of solid material the less hopeful is the case. You may take it as a general rule, that the further the tumor departs from the true cystic type, the more unfavorable the prognosis becomes. I am always unwilling to sanction the operation of ovariotomy Avhere the tumor is evidently nearly solid. But even under the most favorable circumstances the mor- tality in cases of ovariotomy is great; in the tables of results appended to the edition of KiAvisch's work On Diseases of the Ovaries, translated by Mr. Clay, of Birmingham, himself a suc- cessful operator, the results of 537 cases are recorded, 212 as successful, and 183 as terminating fatally, AA'hich may be con- sidered as implying that fifty-three per cent, recovered, and forty-seven per cent, died; but in the large number of 112 cases the operation had to be abandoned, either from the adhe- sions being too intimate to permit of the tumor being removed, from the disease being discovered to be extra-ovarian, or from partial excision only having been effected. Of these, fifty-five died, and this number must, in order to make the estimate as nearly as possible accurate, be added to the 183 fatal cases already mentioned. We are then to deduct from the 537 recorded cases, 87 in Avhich the operation AAas commenced but not carried out, but Avho nevertheless survived; this leaves 450 to be accounted for; of these, 212 were perfectly success- ful, and 238 terminated fatally; shoAving that nearly fifty-five per cent, of the cases operated upon resulted unfavorably. But though I quote these statistics and haA'e analyzed them for you, you must not accept them as being a fair index of the results of the operation at the present time, for the mor- tality has steadily decreased during the tAvelve years Avhich have elapsed since these tables Avere published. The errors in diagnosis are noAV comparatiA'cly few, cases unsuitable for opera- tion are rejected, while it is becoming rare to hear of the opera- 300 DISEASES of avomen. tion having to be abandoned. Still, making every alloAA'ance for improved diagnosis, and for greater care in the selection of cases, I do not think Ave can hope to raise the percentage of re- coveries permanently above sixty-five per cent. I am aAvare that a higher estimate than this of the success of the operation is made by others. Thus, Dr. Graily HeAvitt states that the recoveries are noAV from sixty-five to seventy-five per cent.; perhaps this may be true if errors in diagnosis be omitted, but this I consider it AA-ould be Avrong to do. The results of Mr. Spencer Wells's fourth series of one hundred cases of ovariotomy are still more favorable. Of 100 cases in Avhich the operation Avas completed, seventy-eight recovered, twenty-tAvo died, and thirteen other cases in Avhich the operation Avas commenced but not completed, or exploratory incisions only made, seven recovered, and six died. He shows that the mortality after ova- riotomy is in his practice steadily diminishing; of his first 100 cases, thirty-four died; of his second 100, twenty-eight died ; of his third 100, twenty-three died; of his fourth 100, tAventy-tAVO died. In his private practice he has of late lost but fourteen per cent. This is, indeed, as it was termed by Dr. West, "a splendid success;" still I cannot but feel that no small portion of this success is due not only to the dexterity of the operator, but to the skill Avhich he has exhibited in selecting suitable and rejecting unsuitable cases, a dexterity and skill Avhich all cannot hope to attain, and I fear that the average of all of the operations undertaken in Great Britain, will still show a con- siderably higher mortality than that here recorded. I am far from Avishing to discourage the operation in suitable cases, and am strongly of opinion that if greater discrimination in selec- tion be used, if the operation be performed earlier, and in patients free from symptoms of other diseases, that the results Avill be still more favorable, nor do I Avish to overlook the fact, that even if only sixty-five per cent, of our operations STATISTICS OF OVARIOTOMY. 301 prove successful, Ave restore to health more than fifty women out of each 100 cases, Avho would haA'e died in about three years, and this, after alloAAung for the full proportion avIio if not treated at all would have lived for a comparatively long period. I have hitherto spoken only of excision of the diseased ovary, an operation Avhich though long knoAvn, has only been extensively practiced Avithin the last feAv years; but tapping the cyst has been frequently performed, both as a palliative meas- ure and also as a first step towards a radical cure. With the former view it is practiced Avhenever the distension of the abdo- men is so great as to interfere Avith respiration. Under such circumstances it is always justifiable, but it is often productiA'e of but A'ery temporary relief, and sometimes only aggraA'ates the patient's condition, for if the cyst fills rapidly again as it generally does, the secretion of such a large quantity of fluid further Aveakens the already debilitated patient, and moreover tapping is sometimes followed by the rapid groAvth of other cysts Avhich seem to haA'e lain quiescent previously, their de- A'elopment having been apparently retarded by the pressure exercised on them by the fluid. Inflammation too may super- vene and terminate fatally, and lastly, bleeding of an alarming character has been knoAvn to occur, occasioned, by the trocar Avounding a large vessel. This may take place either into the cyst or into the abdominal caA'ity; but even Avhere no accident occurs, alarming prostration, and vomiting, have folloAved on the evacuation of the cyst, and in not a feAV cases fatal peri- tonitis has ensued; so that the operation, simple as it is, is not free from danger. According to Kiwisch, of 130 cases of tap- ping, twenty-two died in a feAV hours or days, tAventy-five more died Avithin six months, and he concludes by stating his convic- tion, that all these 130 patients had their lives shortened by the operation. 302 DISEASES OF AVOMEN. There have been cases no doubt recorded in Avhich after tap- ping, the cyst has shrivelled up and a permanent cure resulted, but they have been of such very rare occurrence as to hold out little inducement to us to folloAv the practice. Indeed I am not inclined to advise you to perform the operation of tapping except Avhen compelled to do so as a palliative measure. Dr. West advises that the operation of ovariotomy should not be performed till the cyst has been tapped. I cannot, however, concur Avith him on this point, but I admit that when the cyst is emptied and during the process of refilling, its rela- tions to the surrounding parts can be more readily made out, and also that the presence or absence of adhesions may per- haps be ascertained. Tapping also informs us whether the contents of the cyst be A'iscid or aqueous, Avhether the tumor be unilocular or multilocular, and may perhaps enable us to decide Avhat amount of solid matter is present. In obscure cases therefore, it is advisable to tap for the purpose of aiding us in forming our diagnosis. When for any reason you decide on tapping an ovarian cyst, I recommend you to have your patient in bed, and to let her lie on her right side, the abdomen being brought Avell over the edge of the bed. It is advisable to have a bandage round the patient, as is usual for tapping for ascites, Avhich is to be gradu- ally, but not unduly, tightened as the cyst is emptied. It is better to use a moderately large trocar. It is usual also to have an india-rubber tube attached to the canula, as suggested by Mr. Spencer Wells, through Avhich the fluid escapes into a vessel placed to receive it; should, however, the contents of the sac be viscid, this adds to the difficulty of its escape. If the canula becomes plugged, it will be necessary to pass a flexible catheter through it for the purpose of clearing the in- strument, a matter sometimes of some difficulty. After a cyst TAPPING. 303 has been emptied a moderately tight bandage should be kept round the abdomen and perfect rest enjoined for some days. Tapping, Avhen performed Avith a vieAV to a radical cure, is only preliminary to injecting the cyst with some stimulating fluid—iodine being that usually preferred ; the chief objection to the practice is, that it is only suitable to cases in Avhich the cyst is single, for if the tumor be multilocular no benefit is likely to folloAv. The results are under any circumstances very uncertain, sometimes none Avhatever have folloAved, Avhile in others the effects Avere most marked—prostration, A'omiting, and inflammatory symptoms—occasionally resulting in a cure of the disease, but sometimes terminating in death. The op- eration from its uncertain and sometimes fatal results is noAV seldom performed. I have not had any personal experience of it. You must have inferred from what I have said that medical treatment is useless in cases of OA'arian dropsy, excepting so far as the judicious administration of tonics is concerned, and I trust none of yon will ever be guilty of the folly, to use no harsher expression, of saliA'ating or blistering any patient you may meet Avith Avho is suffering from this disease. I have hitherto spoken only of cystic disease of the ovaries^ because it is by far the most common as Avell as most important form of disease to Avhich these organs are liable; but solid tumors of the ovary are also occasionally met Avith. I have never seen an example of this form of disease. Cancer too may attack these glands. I need hardly add that Avhen this occurs the case is beyond the reach of treatment. In addition to these affections which involve change in structure, the ovary may be attacked by inflammation. Acute ovaritis is very rare, but chronic inflammation, or at least con- gestion of the organ, is common enough. To this cause Ave may probably attribute the pain, Avhich in so many cases is ex- 304 DISEASES OF AVOMEN. perienced over the seat of the left ovary, and which is so in- variably present in Avomen suffering from many forms of uterine disease. This pain, Avhich is aggravated at each menstrual period, generally shoots down along the inside of the thigh ; in severe cases nausea is sometimes complained of, and even A'omiting may be present. The left ovary is the one by far the most frequently engaged; Avhy this should be so, I am quite unable to say, but it is a notable fact which probably you have all observed. Menstruation is occasionally affected, some- times becoming scanty and attended Avith pain, but on the other hand I am satisfied that a condition of ovarian irritation short of actual inflammation, but in Avhich there is probably a cer- tain amount of congestion present, is not an infrequent cause of menorrhagia. If from the occurrence of the symptoms enumerated you come to the conclusion that inflammation or congestion of the ovary exists, you will best relieve that con- dition by the application of a few leeches over the seat of the pain, or at the verge of the anus, by the exhibition of mild cathartics, and of full doses of the bromides of ammonium or potassium, and subsequently by blistering. We had a good example of chronic inflammation of the OA'ary in a young woman recently in the medical ward, Avhose prominent symp- tom Avas vomiting. I shall have to refer to her case again; at present I can only add that after the application of three or four leeches, the vomiting, Avhich had been persistent for weeks, was temporarily checked. You must not, however, suppose that every case of pain in the ovarian region is necessarily due to inflammation ; in by far the majority of these cases it is merely sympathetic, and is kept up by the existence of some uterine ailment. Subacute inflammation of the ovary is not of itself likely to be serious, but the constant pain Avhich the patient suffers is Aery Avearing, and exposure to cold and many other causes, OA'ARITIS. 305 may at any time aggravate it, and cause serious symptoms to arise from the inflammation extending to the peritoneum. The affection should therefore neArer be looked upon as being of no importance. In many cases of left side pain depending on OA'arian con- gestion, or irritation, I have found great benefit folloAv the in- unction twice a day over the affected part, of an ointment com- posed of equal parts of the Areratria and of the iodide of potassium ointments, to AA'hich, in some cases, I add a smaller proportion of the unguentum cantharidis. 2G 306 DISEASES OF AVOMEN. LECTURE XVI. Uterine Therapeutics—External Applications—Hot and Cold Hip-baths—Use of Chapman's Spinal Hot Water and Ice Bags —Wet Bandages—Blisters—Iodine. In previous lectures I have called attention to the most prom- inent features of those forms of uterine disease, which from time to time we have met Avith examples of; and in doing so, I have alluded to the treatment Avhich I considered most suit- able in each case. I think, hoAveA'er, I shall be doing you some service if I now devote one or two lectures to the consid- eration in greater detail of Avhat may be termed Uterine Thera- peutics ; a term which I must use in a very extended sense, so as to include not only medicines administered internally, but also the medicinal agents employed in the treatment of the dis- eases we have had under consideration, and the means by Avhich these remedies should be applied. I knoAV from my personal experience, that not a feAV even of those actually engaged in practice are still so imperfectly acquainted with this subject, that if called upon to give directions to patients suffering from uterine diseases as to the manner of carrying out the treatment prescribed, they will either be altogether unable to do so, or will direct its employment in an inefficient manner. In considering the subject of the treatment of uterine dis- ease, I shall direct your attention, first, to applications to the surface of the body; secondly, to those made directly to the A'agina, os uteri, or interior of the uterus; and, thirdly, to those HOT BATHS. 307 administered by the mouth or rectum, or by hypodermic injec- tion. Of external agents, none are of greater value, if judiciously employed, than baths. I am convinced, hoAvever, that much injury has been done to patients by directing them to use either hot or cold baths, in a mere empirical fashion, and Avithout duly Aveighing the effects they are likely to produce. I do not noAV mean to enter into the merits of sea-bathing, or of the ordinary tepid or hot bath, in Avhich the Avhole body is im- merse:!, but only of the cold and Avarin hip-bath, AA'hich, if judiciously employed, is frequently specially useful in the treat- ment of uterine disease. There exists a Arery strong popular prejudice in favor of the various forms of hot baths as a means of inducing menstrua- tion, if that function be suppressed or imperfectly performed; a prejudice not confined alone to females, but largely shared, and indeed encouraged, by many medical men. The common practice adopted in cases Avhere menstruation is suppressed, or Avhere the discharge, if appearing at all is scanty, is to immerse the feet, legs, and sometimes the pelvis in Avarm Avater, or mustard and Avater; a practice seldom folloAved by the intended results, but often on the contrary, proA'ing decidedly injurious. I can confidently adA'ise you frequently to adopt in such cases a directly opposite line of treatment; namely, to direct your patient to sit in a bath containing cold Avater of a depth suffi- cient to cover the pelvis, the legs and feet not being immersed in it, but kept Avarm, by being Avrapped in flannel, or by being plunged in a foot-pan full of hot water, care being also taken to keep the shoulders covered. The temperature of the Avater in the bath, and the length of time during AA'hich the patient should be directed to sit in it, must A'ary in each case. The Avater should not be too cold. A temperature of about 60° is probably the best. The bath should be taken at bedtime, and 308 DISEASES OF WOMEN. the patient should sit in it each night for a period, gradually increased if she can bear it, of from five to fifteen minutes. In summer obviously it can be borne longer than in Avinter. On leaA'ing the bath, she should be Avell rubbed Avith a coarse toAvel or sheet, and put instantly into bed. If chilly, a hot jar should be applied to the feet; should the patient, hoAvever, feel un- comfortable or chilly after the bath, either it should not be repeated, or the immersion should be for a much shorter time. Let me point out to you as an example a case recently treated here in this manner. A. M., aet. tAventy-five, unmarried, a servant, much confined to the house by her employment, had of late suffered greatly from headache, pain in the back, loss of appetite, and constipation. For months past the menstrual floAV had become gradually more and more scanty, till finally it ceased to appear altogether. There Avas not any symptom of constitutional disease, nor of local congestion or inflamma- tion. The boAvels being constipated, she Avas ordered pills con- taining aloes in combination with iron. This sufficed to keep the boAvels open, but the headache continued, and there Avas not any appearance of a return of the menstrual discharge. Strychnia AAas prescribed, still no improvement resulted. She Avas uoav directed to sit each night in cold Avater in the manner described, for ten days before the date at Avhich the Aoav Avas expected, and as a result avc had the satisfaction of finding the catamenia reappear, very scantily at first, it is true, but still in sufficient quantity to afford satisfactory proof that the treat- ment AA-as telling. The same course Avas adopted at the approach of the next menstrual period, and on that occasion the Aoav Avas much more profuse, and indeed in all respects more nearly normal than it had been for years, the patient's general health also improving in a marked degree. Bear in mind, hoAvever, that the cold hip-bath is not appli- cable to all cases in Avhich amenorrhcea is a prominent svmp- FSE OF COED BATH. 309 torn. You should neA'er employ it in any case in Avhich you have reason to suspect the existence of constitutional disease; or in patients of a A'erv feeble anaemic habit; but if you are careful in selecting fit cases, I can safely recommend your imi- tation of the practice you haA'e seen carried out in the case I have just drawn your attention to. The Avarm hip-bath is a not less valuable agent than the cold one, and is, moreoA'er, capable of being used Avith adA'an- tage in a greater variety of cases. You have seen me repeat- edly employ it in the treatment of patients suffering from endometritis. It is also useful in many cases of dysmenorrheea as an adjunct to other treatment. As in the case of the cold hip-bath, I recommend you to direct the Avarm bath to be taken at bedtime. The tempera- ture should not be high, not more than three or four degrees above that of the body, care being taken that it does not fall beloAV that fixed upon during the Avhole period of immersion, Avhich should be for about fifteen or tAA'cnty minutes. In cases of endometritis, Avhere much pain exists, I am in the habit of directing these baths to be taken every night for Aveeks together, except during the continuance of the menstrual Aoav. AYhen, hoAA'evcr, they are employed Avith the vieAV of relieving painful menstruation, they need only be taken for eight or ten days preceding the period. In these cases, too, I find that a some- what higher temperature (about 105°) is needed. We have vet another mode of employing heat and cold ex- ternally in the treatment of uterine disease ; namely, by means of Chapman's spinal bags. This is a method of very great value in the employment of these agents, and has besides the advantage of permitting their use Avithout much trouble or serious inconvenience to the patient; for Avhile the bath can only be employed Avith a(Wantage at bedtime, the spinal bag 310 DISEASES OF AA'OMEN. can be applied Avith facility at any hour in the day, and can be AA'orn, if necessary, Avhen the patient is dressed. I have for some years past employed the spinal hot water bag—1st, in the treatment of menorrhagia; 2d, for the relief of pelvic distress arising in course of uterine or ovarian dis- ease ; 3d, in some cases of dysmenorrhoea. I do not advise you to rely exclusively on the use of the hot-Avater bag in cases of menorrhagia; or to suspend other treatment while you em- ploy it, but to use it in conjunction with such additional reme- dies as you may deem fit. But this I can promise you, after A^ery prolonged and careful observation, that in many cases of profuse menstruation, epecially in patients of relaxed muscular tissue, or in those suffering from the effects of imperfect invo- lution of the uterus after deliA^ery, you will often succeed in restraining for the time the excessive loss, by applying to the lumbar vertebrae a ten-inch Chapman's spinal bag, filled Avith Avater at a temperature of about 105° Fahr., and this Avhen other means have failed. The size I have just named is the best for the purpose, and the bag should be Avorn for not less than two hours at a time. Chapman's bags are far superior to the ordinary hot-Avater ones, from the use of Avhich I have not derived any satisfactory result. Great benefit also folloAvs the use of the hot-water bag in cases of pain depending on the existence of almost any of the ordinary forms of uterine disease. FeAv patients labor under any of these affections without suffering from pain in the back, above the pubes, over one or other of the ovaries, or along the margin of the false ribs; and there are indeed few of these sufferers who do not derive relief from the judicious use of the hot-water spinal bag. Indeed, I have often Avondered that it is ordered so rarely. In like manner in cases of dysmenor- rheea, especially if they are of inflammatory or congestive origin, marked relief from present suffering often follows the A'ALUE OF SPINAL HOT-AVATER BAGS. 311 wearing of the hot-Avater spinal bag for tAvo hours at a time at intervals through the day. I say present relief, for I do not think its action exerted any permanent effects on any of the cases in Avhich I haA'e employed it. At present there are tAvo cases in the hospital in which I have practiced this treatment. One is that of Mrs. R-----; she has a large intramural fibroid, and suffers much from pain above the pubes shooting doAvn the inside of the thighs; this is specially severe just before the occurrence of each menstrual period. Her case is not one favorable for operation; she has derived the greatest relief from the hot-Avater spinal bag, and its use has also decidedly lessened the Aoav at the eatamenial periods, which usually is very profuse. The other patient, Mrs. D----, was admitted last Aveek in a very anaemic condi- tion. She has been drained by uterine haemorrhage, Avhich had lasted continuously for three Aveeks. So extreme is her debility, that I have not as yet ventured to dilate the cervix, as is necessary to enable us to ascertain with certainty the cause of this dreadful loss; I believe it aaIH prove to depend on a granular condition of the intra-uterine mucous membrane. In her case the application of the hot-water bag was at once followed by a diminution of the discharge, and time AAas thus afforded for the remedies administered internally to act. Pre- vious to its use she had taken ergot, iron, and quinine in full doses Avithout effeet. The treatment of uterine diseases by the application of cold to the spine, as best effected by means of Chapman's ice-bags, requires to be carried out Avith greater caution than that by means of the spinal hot-Avater bag. The latter, injudiciously applied, may be altogether useless, or even aggravate suffer- ing, but is not likely.to be injurious. The ice-bag, hoAvever, may, Avithout doubt, if used in unsuitable cases, prove decidedly so. I have found the ice-bag useful—1st, in certain cases of 312 DISEASES OF AVOMEN. amenorrhcea in which the cold hip-bath was not suitable; 2d, in relieving the sickness of pregnancy; 3d, in certain forms of disease in which severe pelvic and lumbar pains were ex- perienced, together Avith and apparently depending on the con- dition known as spinal irritation. Some females of feeble constitution are quite unfit for the prolonged immersion in cold water required for carrying out the treatment just recommended in certain forms of amenorrhcea; in such cases Chapman's spinal ice-bag may oftentimes be ap- plied with advantage over the sacrum and loAver lumbar spines. In the first instance it should not be used for more than fifteen minutes at a time. If well borne its application should be prolonged; but I consider it better to carry out this treatment by repeated applications of the ice-bag, made at intervals of some hours, than by prolonged application made once or twice a day. The same observations apply to this mode of treatment AA'hen practiced with the view of relieving the pain which, though referred to the uterus or OA'ary, appears to depend on spinal irritation. Without doubt the application of cold to the spine has sometimes a marked effect in lessening the distressing sickness experienced during pregnancy. Doubtless, too, it is a remedy which frequently fails to effect good ; but it is nevertheless a valuable one; let me, hoAvever, urge on you the necessity of caution, for I am by no means sure that it is not capable of producing abortion. There is one other method of relieving the suffering so constantly experienced in cases of uterine dis- ease by external means, which it is well to bear in mind, and which I urge on you not to despise because of its simplicity, or because it is recommended by a class of men whose practice is not in general worthy of imitation. I allude to the wet abdominal bandage. It is usually applied by dipping one- UTERINE THERAPEUTICS. 313 third of a calico bandage three yards long and half a yard wide in Avater; the Avet end is applied around the pelvis and the dry part rolled outside it so as to prevent the patient's sheets, or if Avorn in the daytime, as it can easily be, her clothes, from being Avet. This is specially useful in allaying pains depending on ovarian congestion or irritation, and, in- deed, is beneficial in all cases of uterine disease. My colleague, Dr. James Little, recommends the use of these bandages for the relief of habitual constipation, and it is a mode of treating this common and most troublesome affection AA'ell Avorthy of a trial. In such cases you must direct the bandage to be applied every night for a considerable time. Blisters are of great value in the treatment of many forms of uterine disease, especially in cases of chronic metritis or endometritis, Avhere the uterine Avails having become thickened and indurated no relief from suffering follows local bloodlet- ting, whether practiced by leeching or puncturing. In my opinion, blisters proA'e most useful Avhen applied frequently, at intervals of a feAv days; they should be of small size, about the circumference of a crown piece. I generally direct them to be placed alternately over the sacrum and above the pubes, or over the ovary if that be the chief seat of pain. The ap- plication of iodine is in some cases preferable to the use of blisters. It does not weaken the patient as blisters often do, and should therefore be employed Avith patients Avho may be in a debilitated condition. To produce any beneficial effects, its use must be continued for many Aveeks, and as the repeated application to the same spot of either the tincture or liniment of iodine, especially the latter, is apt to produce much irrita- tion, it is best to direct the iodine to be rubbed in over a lim- ited space only, and Avhen that spot becomes tender to apply it in a similar Avay to an adjoining part, so that without causing the patient much suffering the treatment may be carried on 314 DISEASES OF AVOMEN. continuously. To relieve the distressing backache so commonly present in these affections, you may sometimes employ with benefit a liniment composed of ten drachms of the compound camphor liniment Avith three of the tincture of aconite and three of chloroform, or an ointment composed of equal parts of veratria and iodide of potash ointments. This well rubbed in over the seat of pain often produces A'erv satisfactory results. But you will soon discoArer that all remedies applied to the surface of the body seldom effect more than transitory good. To effect a cure, your remedies must be applied directly to the diseased parts. In my next lecture I shall call your atten- tion to these means. HOT-AAATER VAGINAL INJECTIONS. 315 LECTURE XVII. Uterine Therapeutics (continued)—Applications to the Vagina and Uterus — Vaginal Injections — Intra-uterine Applica- tions—Medicinal Treatment. In my last lecture I directed your attention to those agents in the treatment of uterine and ovarian disease, Avhich are found useful Avhen applied to the cutaneous surface of the body; to-day I shall speak of that still more important class Avhich are applied directly to the vagina and uterus. Of these, lotions injected into the vagina are the commonest. Syringing the A'agina Avith Avater, or Avith medicated Auids is an old and popular remedy for nearly every form of uterine disease, and is one which, though often of great value if prop- erly performed and practiced in suitable cases, is as often utterly useless, and occasionally positively injurious. Thus, an elastic enema-bag, capable of holding from six to ten ounces, is commonly employed for the purpose: such an instrument is quite unsuitable. But occasionally a Avorse, be- cause a positively dangerous instrument, is employed; namely, a glass syringe, the end of which is perforated Avith fiA'e or six holes. Not long since I Avas requested to see a Avoman to Avhom such a syringe had been supplied. The glass being thin, the instrument broke in the vagina, and several pieces of broken glass remained in that canal, causing intense pain to the patient. By slowly and carefully introducing a Fergus- son's speculum, I Avas enabled to extract through it the frag- 316 DISEASES OF AVOMEN. ments of the syringe, and no serious consequences happily followed. Any syringe employed for the purpose of vaginal injections should be one capable of throAving up a continuous stream. Such syringes are commonly knoAvn as the " syphon syringe," or " Higginson's syringe." When using the syringe the patient should, if possible, lie on her back, the hip resting on a bed-pan which receives the fluid as it escapes from the vagina; but the majority of Avomen object to this plan, as it necessitates the presence of an assistant, and you are then obliged to permit the patient to inject the fiuid from a vessel placed in front of her, or in a foot-pan or bath over which she sits. This is a very inefficient method, for the Auid escapes from the vagina too rapidly, and does not distend that canal, as it is desirable it should. In cases Avhere there is not any urgent reason for the use of medicated lotions, it is often a good plan to direct the patient to use her syringe AA'hile sitting in a Avarm hip-bath. I have found this method very efficacious in allaying vaginal irritation. But very few patients can continue to use any of the ordi- nary syphon syringes for more than a few minutes at a time without fatigue; consequently, where it is our intention to inject a stream of water into the vagina for a length of time other means must be adopted. The use of hot-Avater vaginal injections, of a temperature of from 98° to 110° according to the nature of the case, are strongly advocated by Dr. Emmet, of New York ; and there is no doubt but that, Avhen properly administered, they are in many cases a very efficacious and valuable remedy; but to carry out this treatment aright four things are necessary: 1st. The quantity of hot Avater used on each occasion should be large; VAGINAL INJECTIONS. 317 2d. The temperature of the water should be kept up to an even standard; 3d. The stream should be continuous; 4th. The patient should lie in such a position as will permit some of the Avater to remain in the vagina, and consequently keep that canal more or less distended. To effect these objects I employ a very simple apparatus (Fig. 33).* It consists of a tin or zinc vessel, similar to that Fig. 33. Apparatus for Vaginal Injections. used for purposes of irrigation by surgeons, and capable of holding not less than tAvo gallons. At the side of this can, * Made by Fletcher & Phillipson, 10 Lower Baggot Street, Dublin. 318 DISEASES OF AA'OMEN. near the bottom, an india-rubber tube, six or eight feet in length, is attached, the free end of which is furnished Avith a stop-cook, and fitted with an ordinary gum-elastic vaginal tube about a foot in length. The other part of ths apparatus con- sists of a bed-pan, also made of zinc or tin, someAvhat similar in shape to the slipper bed-pan in common use, Avith an india- rubber tube affixed to a point near its bottom. The bed-pan should be at least six inches high in front, sloping gradually back to about tAvo behind, the posterior third should be cov- ered in and slightly holloAved, so as to alloAV the patient to lie on it without discomfort. In using this apparatus, the patient should lie on a hard couch, or better still, on a table, upon which a mattress, if necessary, can be spread. The precaution of requiring the patient Avhen using this arrangement to lie on a hard couch is essential, for if the pan be placed on anything yielding, such as a sofa or ordinary bed, the patient's Aveight aaHI sink it beloAV the leA'el of the surface, and consequently the AA'ater will not be carried off by the tube, but will overfioAV. The vessel containing the water should then be elevated some feet aboA-e the level of the couch on which the patient lies, Avhich can be done either by placing it on some article of furni- ture of sufficient height, or by hanging it from the wall. The extremity of the tube attached to the bed-pan being placed in any convenient vessel, the arrangement is complete. Any one can be taught how to regulate the temperature of the Avater, and to replenish the vessel containing it, if that be necessary, Avhile the patient herself can easily control its Aoav by means of the stop-cock affixed to the end of the vaginal tube; while the tube attached to the bed-pan carries off the water as it flows into it from the vagina, and thus obviates the necessity for repeatedly interrupting the douche by having to empty the pan, which Avould otherwise arise, thereby also greatly enhancing VAGINAL INJECTIONS. 319 the patient's comfort. Vaginal injections can, by this simple and cheap apparatus, be used Avith very little trouble. Having thus pointed out the method of syringing the vagina, it is further important that you should consider the tempera- ture of the fluid to be injected, the medicinal agents to be so employed, and their strength. As a rule, I recommend you not to inject any perfectly cold fluid into the Angina; doubtless perfectly cold Avater is a more tonic application, if I may use that expression, than Avarm could be; but the object of injections generally is to allay irritation, and not to give tone to the vaginal Avails; that Avill soon fol- Ioav as a result if you remove the local affection. Besides, I have seen very unpleasant and even serious consequences fol- low the injection of cold water into the vagina. Thus severe uterine colic, and intense pain above the pubes occurred as an immediate result in one case; and in another so grave were the symptoms that life AA'as endangered from an attack of pelvic cellulitis which folloAved the injection into the vagina of cold water, ordered with the aucav of checking profuse menstruation. I recommend you, then, to direct that the fluid employed be used at about blood heat, and Avhen vaginitis is present, at even a higher temperature. The medicinal agents employed for vaginal injections are very numerous. I, hoAvever, restrict myself to a feAv. I have so frequently found that solutions of alum and of the sulphate of zinc aggravate the patient's sufferings Avhen vaginitis Avas present, that I do not, in such eases, now employ either. They coagulate the albumen Avhich enters so largely into the compo- sition of leucorrhceal discharges, and, if you examine a patient any time Avithin tAventy-four hours after she has used an alum injection, you will find a number of hard masses in the vagina, formed by the coagulation of the discharge, Avhich often cause much discomfort. Borax is a better agent; but it too, some- 320 DISEASES OF AVOMEN. times causes irritation, though in a less degree. A drachm of borax to the pint of Avater is the strength I usually direct to be used. Where the object is to soothe and to allay irritation, an infusion of tobacco is an excellent remedy. Tobacco must, hoAvever, be used with caution. Some patients are peculiarly susceptible to its action; especially those in whom the orifice of the vagina being narroAV, some of the fluid is retained in the canal. Begin, therefore, by infusing fifteen grains of the un- manufactured leaf in a pint of boiling AA'ater. If this produces no unpleasant effect, increase the strength to thirty, or even sixty grains to the pint. In many cases the addition of a drachm of borax to each pint of the infusion greatly increases the effiacy of the treatment. Many patients, hoAA'eA'er, are unable to use the tobacco at all, as eA-en a very Aveak infusion causes nausea and faintness. When this is the case, or Avhere you fear to run the risk of causing any discomfort to the pa- tient, I recommend you to substitute for tobacco an infusion of hops, directing an ounce of the latter to be infused in a pint of boiling AA'ater, Avith or Avithout the addition of borax, as vou may deem advisable. Cases are, hoAA'ever, frequently met Avith Avhere no vaginal inflammation or even irritation exists, but Avhere a profuse and AA'eakening leucorrhceal discharge is constantly being poured out, Avhich it is necessary to check; here astringents, such as alum or zinc, in the proportion of sixty grains to the pint of J tepid water, often prove most useful. Should they irritate, you Avill frequently find the decoction of oak bark serviceable. Warn your patient, hoAvever, that the decoction of oak bark stains linen, for ladies Avill not be pleased to find their under- clothing or towels covered Avith ugly stains. This reminds me to give you a similar caution respecting the use of the solution of nitrate of silver. A feAv years ago this Avas almost the onlv A'AGINAL INJECTIONS. 321 remedy employed in the treatment of uterine disease. I can Avith confidence say that as an application in cases of disease of the body of the uterus or of the cervix, it is nearly useless. In eases of vaginitis it may be employed Avith advantage. It must be applied through a speculum, the surface of the vagina being brushed o\rer Avith a solution containing tAventy or thirty grains of the salt to an ounce of water. The application may be re- peated at intervals of tAvo or three days. I noAV seldom em- ploy the solution of nitrate of silver, as I look on its use in the majority of cases as a mistake, and I belieA'e I can obtain better results by other means. Of all the agents which are applied to the vagina for the relief of inflammation or congestion of that canal, glycerin, Avithout doubt, is one of the most valuable. A small roll of cotton-Avool Avill absorb five or six drachms of glycerin; you fasten to this a strong thread or piece of tAvine, introduce it through a speculum, and leave it in the vagina for tAvelve or eA'en tAventy-four hours, directing your patient to AvithdraAV it at the expiration of that time by means of the string Avhich is left hanging outside the vulva. Glycerin thus applied pro- duces a copious Avatery discharge, AA'hich has a marked effect on the mucous surfaces in immediate contact Avith it. Thus, after its application the A'agina and A'aginal aspect of the cervix uteri appear pale, and the copious discharge seldom fails to relieA'e, for the time at least, that distressing sense of heat Avhich is complained of in severe cases of A'aginitis. In less acute cases the addition of ten grains of tannic acid to the ounce of glycerin often proves useful, but if used before the acute symptoms subside, it may cause increased irritation. Be sure whenever you use glycerin to AA'arn your patient that she is to expect a copious discharge, othenvise the great Aoav Avhich often comes on almost immediately will cause much alarm. Medicated vaginal pessaries, containing a variety of medical 27 322 DISEASES OF WOMEN. agents, such as iodide of lead, mercury, tannin, belladonna, etc., are in common use. I can only say that I have never found them of real service, and consequently do not now em- ploy them. But many drugs may be administered Avith great advantage per anum in the shape of suppositories; this specially holds good Avith respect to iodoform. In many painful affec- tions, such as in some cases of fibroid tumors of the uterus, in which the sufferings are seA^ere, five grains of iodoform in a suppository introduced into the rectum gives great relief, and may with advantage be substituted for opium. It seems to act by relieving muscular spasm. Numerous medical agents are now employed in the treat- ment of disease of the cavity of the uterus. These may be used in the form of fluids, of solids, or of ointments. I men- tion them in what I consider to be the order of their value. With respect to fluids I give you one caution: do not inject them into the uterus. Such a method is fraught Avith great danger, and except that it is generally easy of execution, pos- sesses no advantage. The fluids most commonly employed in the treatment of intra-uterine diseases, are a saturated solution of carbolic acid, the tincture of the perchloride of iron, tincture of iodine, the pernitrate of mercury, chromic acid, and the fuming nitric acid. A solution of nitrate of silver is also sometimes used, but I believe it to be inefficacious. Carbolic acid is a mild, but not ahvays a painless applica- tion ; applied to the vaginal surface of the cervix it produces a very superficial slough, its effects passing off in tAventy-four hours. Applied to the interior of the uterus its effects are equally superficial and transitory. It is therefore useful in cases where you desire to apply a mild, stimulating caustic; but it is not suitable Avhen it is necessary to destroy the so- called granulations Avhich in severe cases cov6r the vao-inal APPLICATIONS OF CAUSTICS. 323 surface of the cervix and extend into its canal; nor Avhere an unhealthy condition of the mucous membrane lining the body of the uterus, the result of chronic endometritis, exists—a Fig. 34. Playfair's Probes.* condition which often gives rise to profuse menorrhagia. It is best applied by means of a flexible silver or copper probe, such as those suggested by Dr. Playfair (Fig. 34), round the end of which is Avrapped a layer of cotton; this can be passed into the uterus to the desired depth. When carried beyond the os internum the carbolic acid sometimes causes pain, Avhich, hoAvever, soon subsides. I generally introduce the probe tAA'ice, dipping it a second time in the solution before doing so, because the first application cauterizes the cervical canal only, but the second generally reaches the body. The perchloride of iron is an admirable styptic, and, as such, should be used when it is desirable to check uterine haemorrhage. You can apply it in the same manner as the carbolic acid ; but it is generally better to saturate a small roll of cotton with the tincture (or, as being less irritating, Avith a saturated solution of the perchloride in glycerin). Pass this up through a speculum, and place it in contact with the os uteri, and then, outside this, another and larger pledget of cotton Avell soaked Avith glycerin. Both these should be re- moved Avithin tAvelve hours of their application. I have seen a very deep slough produced in a case Avhere the cotton, * Made by Matthews Brothers, 27 Carey Street, London. 324 DISEASES OF AVOMEN. saturated Avith the perchloride, was accidentally left in the A'agina for tAvo days. AVhen it is desirable to check haemor- rhage depending on a granular condition of the cervix, or the existence of cancerous ulcerations, the perchloride of iron is a very valuable agent. Iodine has been used for the same purpose; it Avill sometimes ansAver, but is less certain in its effects. The pernitrate of mercury is a poAverful and active caustic. It has been recommended by some practitioners as an application.in cases of malignant disease. I neA'er employ it, because I be- lieve I have in nitric acid a caustic equally, if not more efficacious, and one, at the same time, much safer; for severe saliA'ation has folloAved the use of the pernitrate in persons susceptible to the peculiar action of mercury. Chromic and nitric acid are nearly identical in their action. The former is, hoAveA'er, in my opinion, more uncertain in its effects; it is also more irritating. I therefore prefer the nitric acid. Its application causes A'ery little, indeed, in general, no pain; produces but a superficial slough, and has a Avonderful effect in bringing about a healthy condition of the mucous membrane lining the body and cervix uteri. It also, in many instances, exerts a directly sedative influence, allaying the severe pain and vesical irritation so constantly present in cases of endometritis. Xo matter Avhich of these fluid caustics you may select cer- tain rules applicable to all should be borne in mind. In the first instance, local inflammation, indicated by tenderness of the uterus when touched, should, if present, be removed, or at least mitigated, by appropriate treatment before any of them be used. To effect this the cervix, if soft and engorged, should be punctured, or if enlarged and indurated, leeched. When it is desirable to carry the application up to the fundus, this should, if possible, be done through a canula or tube, Avith the double object of preventing the agent selected APPLICATION OF CAT'STICS. 325 from being Aveakened by admixture Avith the secretions during its passage through the cervical canal and by contact Avith its Avails, and also of protecting the healthy structures from the action of the caustic Avhich may be employed. For it must be borne in mind that the mucous membrane lining the cavity of the uterus may be, and often is, diseased, Avhile that lining the cervical canal is in a perfectly healthy condition. It is there- fore all-important that the healthy structures should be pro- tected from the action of the caustic. With the vieAv of effecting this object, I haA'e deA'ised an instrument of A'erv simple construction. It consists of a short tube or canula, made of platinum, and of a curved stilette, fitting the canula accurately, Avhich is fixed to a boxAvood handle. The easiest and most satisfactory methcd of using this instrument is by exposing the os uteri by means of a duck- bill speculum, and the cervix being fixed by a tenaculum, to introduce it into the uterus; but if you have not an assistant you will in general succeed in introducing it through a full- sized Fergusson's speculum. In either case, Avhen this is effected the stilette is to be AvithdraAvn, and the canula being held steady by means of a pair of long forceps, a copper, or better still, a platinum rod, round Avhich a layer of cotton Fig. 35. Author's Canula for Intra-uterine Medication.* avooI has been carefully rolled, dipped in the agent selected, is to be passed through the canula up to the fundus. * Manufactured by Fannin & Co., Grafton Street, Dublin. 326 DISEASES OF AVOMEN. There is seldom much difficulty experienced in introducing the canula, for generally in suitable cases the cervical canal is patulous. If this is not the case a single tent of sea-tangle in- troduced tweh^e hours before the application is made, will dilate the cervix sufficiently. A tAVofold advantage is gained by employing a canula such as I have recommended in the treatment of intra-uterine dis- ease. First, it enables you to convey the caustic up to the part to which you desire to apply it, without its being weakened by previous contact Avith the cendcal canal. Secondly, it pro- tects the latter from the action of the caustic, a matter some- times of importance if, as is often the case, the canal is healthy. Should it be desirable to apply the caustic to the cervical canal, that can be done after the canula is Avithdrawn. Now one word as to the details of this operation—if that be not too dignified a name for the proceeding—for you will fail in your attempt to carry out this method of cauterizing the in- terior of the uterus successfully unless you attend to various little points. The first is, that you take care to grasp firmly the little projecting ear of the canula Avith a pair of long forceps before you withdraw the stilette. If you do not do so, one of tAvo things will happen; either the canula will slip out of the cervix, or, if the os be patulous, as is frequently the case, it will disappear in toto within the cervical canal. Doubtless it Avill soon reappear; but it is not then ahvays easy to grasp it, and it will sometimes slip behind the speculum, or, if grasped, may be found full of mucus. By holding the canula firmly with the forceps these troubles will be avoided. In order to remedy this objection to the use of the instru- ment, I have had a vulcanite canula manufactured for me by the same makers, to Avhich a handle is attached, and Avhich in this respect resembles that figured in Dr. Barnes's recently pub- lished Avork on the Diseases of Women, but differs in being fur- USE OF ACTUAL CAUTERY. 327 nished Avith a stilette to facilitate introduction. It is, hoAvever, a clumsier instrument than the platinum one; but its price is not a third of the former. Next, and even more important, is the fixing of the cotton firmly on the end of the probe. DraAv out the cotton, moisten the tip of the rod, catch but a few fibres of the cotton at first, and roll the rest sloAvly and evenly on. This is better effected by rotating the rod than by rolling the cotton round it. If these directions be not attended to the cotton Avill wrinkle up as it passes through the canula and will render the passage of the rod impossible ; or, if loosely put on may be left behind in the uterus Avhen the rod is Avithdrawn. Neither of these accidents Avill ever occur if the directions I have giA'en be fol- lowed. These directions apply equally to all liquid caustics used for the purpose of intra-uterine medication, and the success of your treatment Avill depend very much on the dexterity with which you carry it out. If there be too much cotton rolled round the probe, or if it be too loosely rolled on, the rod will stick in the canula, and you will have to AvithdraAV it and re-introduce it; or if you take up too much of the caustic on the cotton it Avill trickle doAvn, and may cause a troublesome sore in the va- gina ; so that to carry out this method, simple though it be, skill is needed and must be acquired. Of the solid caustics, the nitrate of silver and sulphate of zinc are the only ones I use. These can be inserted through the canula I have described ; but better by means of Sir J. Simpson's portecaustique (Fig. 12, p. 88). By using it you can dispense Avith the speculum. Ten grains of the nitrate of silver or of the sulphate of zinc, the latter in the form of " zinc points," as suggested by Dr. Braxton Hicks, may be introduced through it up to the fundus, and left there to dissolve. Either of these caustics so used is liable to cause 328 DISEASES OF AVOMEN. pain, seldom, hoAveA'er, seA^ere in character; this too can be, in some degree at least, averted by placing a pledget of cotton saturated Avith glycerin in the vagina. I use both these agents occasionally, but less frequently than formerly, for since I have devised the means of applying the nitric acid Avithout previous dilatation to the interior of the uterus by means of the canula, the results have been so satisfactory that I uoav seldom resort to the use of the solid caustics. Of the use of ointments I have no personal experience; they are more difficult to apply than either the fluid or solid caustics named. Dr. Barnes, hoAvever, considers them to be often of great value in some cases. It is occasionally advisable to destroy the tissues of the cer- vix to a greater depth than can be effected by means of nitric acid. For this purpose two agents are employed, namely, caustic potash, or potassa c. calce, and the actual cautery: the former is eminently useful in those cases Avhere the lips of the os uteri are in a state of granular erosion, and you have seen me use it Avith the very best results. As I have in a previous lec- ture (Lecture IX) explained the mode of applying it, I shall not dAvell on it noAV further than to remind you that it must be used cautiously, and that the vagina must be protected from the action of the caustic by the insertion of a pledget of lint saturated Avith vinegar under the loAver edge of the cervix. The actual cautery is not much employed in this country, but in America its use is warmly advocated. Dr. Gaillard Thomas states that, according to his experience, " of all the means of counter-irritation for removing chronic parenchyma- tous congestion, and causing a diminution in the size of the uterus by stimulating absorption, this is the most efficient and least objectionable as to its consequences." He uses a small steel rod terminating in a disk not much larger that a split pea. This heated in a spirit-lamp he applies for ten or tAventv sec- USE OF ACTUAL CAUTERY. 329 onds to the cervix, so as to create a small slough, re-heating and re-applying the cautery so as to cauterize the cervix in two or three places, one at either side of the os uteri. Dr. Getchell, of Philadelphia, also advocates the use of the actual cautery in cases in Avhich the cervix uteri is hvpertro- phied and indurated ; but instead of a steel rod he employs char- coal sticks, made of nitrate of potash, tAventy grains ; charcoal, seven drachms; powdered acacia, one drachm; and water suffi- cient to make into a paste. This paste is to be formed into sticks of any required diameter and length. Dr. Getchell uses them of about the diameter of the little finger; the stick is to be held in the flame of a gas or spirit lamp for a feAv moments till converted into a live coal, and applied through a glass or wooden speculum. His directions are: "Take the caustic in the forceps and apply it about four or five lines from the os to the lip which is most hypertrophied. Noav, if you make slight pressure for a feAV seconds you Avill destroy tissue over a space of about the size of a three-cent piece, and of about two lines in depth; the pain is very slight. On Avithdrawing the cau- tery I sponge the part Avith cold AA'ater. I then introduce a pledget of lint saturated with glycerin, and keep the patient in bed for forty-eight hours." The actual cautery may be ap- plied once a month. I have tried these methods frequently, and can bear testimony to their efficacy; but I prefer Dr. Get- eliell's. I shall noAV make a feAv observations, respecting those drugs Avhich are most frequently employed in the treatment of uterine disease, premising that medicines haA'e but little influence on the uterus, and that, therefore, it is not surprising they effect but comparatively little good in the chronic diseases of that organ. My oavii experience leads me to the conclusion that those which haA'e any direct effect on the uterus do not exceed four or five in number. I have satisfied myself that ergot of rye, 330 DISEASKS OF AVOMEN. sulphate of quinine, strychnia, and arsenic exert a direct action on the uterus. I am not satisfied that any other medicine does. I do not mean to say that other medicines are not of use in the treatment of uterine disease, but I belieA'e that their action is only secondary. Thus, the administration of iron is often fol- loAved by marked benefit in many cases of old-standing uterine disease, but this improA^ement is only the result of imprcwed general health. Ergot is a drug Avhich, though long knoAvn, has but recently been fully recognized. At first used only in labor Avith the A'ieAv of stimulating the muscular fibres of the uterus and ex- citing them to increased action, it is now prescribed by physi- cians in cases of haemorrhage from the lungs and other viscera, sometimes even with very good results in the haemorrhage oc- curring from the boAvels in typhoid fever; but it is specially indicated in nearly all the forms of uterine haemorrhage. As- tringents are, in my opinion, nearly \ralueless in such cases. There is hardly a case of uterine haemorrhage or of menor- rhagia, unconnected Avith malignant disease of the uterus, in Avhich, from one cause or another, that organ is not enlarged, and its muscular tissue relaxed. Hence the value of ergot: it stimulates the muscular fibres of the uterus to contract, and thus checks the Aoav of blood. When administered for this purpose, ergot must be given in large doses and at short in- tervals. A drachm of the liquid extract, or an ounce of the infusion should be administered every third hour. In anaemic patients, the addition of ten drops of the tincture of the per- chloride of iron to each dose greatly enhances the efficiency of the medicine. Ergot may also be administered in cases of menorrhagia in the form of poAvder; ten grains of it, directed to be taken at short intervals, being the ordinary dose. One other mode of administering ergot deserves special no- tice. I allude to its hypodermic injection. It is thus em- KRKOT--QUININE. 331 ployed by physicians in many cases in Avhich haemorrhage oc- curs, unconnected Avith uterine disease; but it is specially useful in the treatment of menorrhagia depending on the presence of uterine fibroids. The recorded cases seem to proA7e that ergotin, that is the act'iA'e principle of ergot, injected snbcutaneously, not only arrests the profuse haemorrhage Avhich occurs in con- nection Avith these tumors, but has the effect of diminishing their volume. The draAvback to using it subcutaneously is that it is liable if not carefully used to produce great irritation at the point Avhere it is injected, the result frequently being the formation of troublesome though circumscribed abscesses. I generally inject ten to fifteen minims of the Ext. ergotae liq., B. P., Avith equal parts of Avater daily. In carrying out this treatment, the needle should be made to penetrate deeply into the muscular structures, the safest site for the injections being the glutaeus muscle. Xext to ergot, quinine is, perhaps, the most valuable agent at our disposal in the treatment of uterine haemorrhage depend- ing on a relaxed condition of the muscular tissue of the uterus, such as that AA'hich occurs in many cases of subinvolution. But vou must give it in large doses ; five grains or upAvards every four hours. I have also found quinine in full doses efficacious in cases of menorrhagia, Avhere ergot has failed. Thus, I have at present under my care, a lady, whose uterus is the seat of a subperitoneal fibroid, and she suffers from profuse menstrua- tion. I have tried Avith her in turn nearly every known remedy, and she finds greater benefit from quinine in seven- grain doses, Avith the addition of ten minims of the tincture of the perchloride of iron, than from any other drug. She is also one of those patients Avho has derived benefit from the use of the spinal hot-water bag. I do not rely as much on quinine in cases of menorrhagia as I do on ergot, but of this I am sat- 332 DISEASES OF WOMEN. isfied, that in some cases in AA'hich ergot produced no beneficial effects, the administration of quinine checked the haemorrhage. One other drug specially deserves notice Avith reference to its efficacy in certain forms of menorrhagia. I allude to arsenic. It seems, by diminishing the calibre of the capillary arteries, to check the exudation of blood from the inner sur- face of the uterus. 1 do not in general administer arsenic during a menstrual period, but direct it to be taken in the interval betAveen the periods. I belicA'e it to be of great use in those cases in Avhich the excessiA'e loss is met Avith in females of a leucophlegmatic temperament. Arsenic should be giA'en after meals, in gradually increased doses of from three to ten drops of the liquor arsenicalis, B. P. It is best administered in combination Avith a bitter, such as the com- pound tincture of gentian, or, if that be objectionable, Avith the compound tincture of chloroform. In several cases I haA'e found its efficacy increased by the addition of ten drops of the tincture of digitalis to each dose. That strychnia exerts a direct action on the uterus is, to my mind, clearly established. Added to ergot in cases of partu- rition, it greatly increases the efficacy of the latter drug, being specially useful Avhen post-partum haemorrhage is anticipated. It appears to have the poAvcr of increasing the tonic contrac- tion of the uterine fibres and of preventing their undue relax- ation Avhen the pain has subsided. Its use is contraindicated in all cases Avhere any inflammatory condition of the uterus or ovary exists. Strychnia is also specially useful in many forms of amenorrhcea Avhere it seems desirable to stimulate the uterus and OA-aries, and in such cases it is often prescribed Avith ad- vantage in combination Avith iron. It should be administered cautiously, commencing Avith tAvo or three drops of the liquor, the doses to be gradually increased to eight, or even ten drops, three times a day. I have, hoAvever, knoAvn even small doses MERCURY. 333 produce A-ery unpleasant symptoms; some patients being ap- parently very susceptible of the effects of this drug. Mercury seems beneficial in some forms of chronic uterine disease, especially in those in Avhich a Ioav form of chronic in- ( flammation exists, with thickening of the uterine AA'all and induration. It should be administered in small doses for a considerable length of time. The only preparation of mer- cury Avhich I employ in these cases is the perchloride, in doses of 2Vyth of a grain three times a day. If constipation exists it may be prescribed in the form of pills, each containing |th of the extract of belladonna, with Jth or ^th of a grain of the extract of aloes. I direct these pills to be taken continuously for many Aveeks. Bromide of potassium exerts a marked influence in certain forms of OA'arian irritation and congestion. In many Avomen the menstrual period is ushered in by seA'ere mammary pains, the breast becoming hard and full, pain being also expe- rienced in the OA'arian regions. In such cases thirty grains of the bromide of potassium, taken three times a day, often produce marked results. It is also sometimes useful in the vomiting of pregnancy, but it cannot be relied on. The same remark applies to its use in the reflex irritation of the stomach met Avith in some of the chronic forms of uterine and ovarian disease. I may here remark that the hypodermic injection of mor- phia occasionally controls the vomiting met Avith in pregnancy, or that Avhich sometimes folloAv severe cases of post-partum haemorrhage. The formula I iioav adopt for the solution to be injected subcutaneously is the folloAving : Acetatis morphia,.......gr. viii. Liquor, atropise,.......TtRxlviii. Glycerini,........"Kv. Aqu», . . . ..-..-.. . ■ • ad 3iv.—M. 331 DISEASES OF AVOMEX. Fifteen drops of this solution contain half a grain of the acetate of morphiae, and ^Q-th of a grain of sulphate of atropia. Indian hemp is a useful drug, and is often administered with benefit in cases of painful menstruation. Its use seems to be specially indicated in those forms of dysmenorrheea de- pending upon the presence of uterine fibroids, in which the pain experienced at the commencement of the menstrual periods is sometimes very seA'ere. Most patients bear this drug Avell, and derive much benefit from its use. The dose is from one- half to a grain of the extract, or from ten to fifteen drops of the tincture, every fourth hour; but with some it disagrees, producing dizziness and nausea, and in such its use must be discontinued. In some patients suffering from uterine disease, great irrita- bility of the bowels is a prominent symptom; these patients are generally in a condition urgently demanding the exhibition of tonics, Avhich, hoAvever, it is difficult to administer, as they often only increase the previously existing irritation of the gastro-intestinal mucous membrane. In such cases you Avill sometimes succeed by combining quinine Avith the carbonate of bismuth, administered in the form of powder; tAvo grains of the former with eight or ten of the latter, to be taken before meals. Most patients, hoAvever, laboring under uterine disease suffer from constipation of the boAvels, which is a source of great dis- comfort to them, and is also a most troublesome symptom to treat; the action of any strong purgative increasing their suf- ferings at the time, Avhile the dose must be repeated at short intervals, often too in augmented doses. In such cases enemata of cold water, taken regularly at the same hour daily, frequently ansAver the purpose of procuring a daily evacuation. Some patients cannot bear, hoAvever, the injection into the boAvels of cold water; Avhen this is the case it must be used tepid, but MERCURY. 335 its effects are then much less satisfactory. Over and over again patients have told me that enemata produced no effect; on in- quiry I found they used Avarm Avater, and on inducing them to try the injection cold, have knoAvn satisfactory results obtained. But many patients cannot or Avill not submit to this treatment; then you may try a pill containing a quarter of a grain of the extract of belladonna, and four grains of the compound rhubarb pill, to be taken regularly each night; or, if iron be indicated, you may combine the extract of aloes with the sulphate of iron, in doses of from one-quarter of a grain to tAvo grains of the former, Avith tAvo grains of the latter, to be taken as a pill three times a day, before meals. Very often the smaller doses named Avill prove quite sufficient if taken regularly. But the question of aperients is too extensive a subject for me to enter into at length. In conclusion, I shall only point out that in private practice the Pullna, Frederichshall, and Hunyadi Janos Avaters often agree very well. They should be taken before breakfast, and be warmed by adding a small quantity of hot Avater. INDEX. Abortion, a cause of subinvolu- tion, ......... Absorption of fibroids, . . . . Adenoma of the ovary, . . . . Allnnr/cment of the uterus, . Alveolar tumor of ovary, . \mennrrh'f the uterus, . . 212 Division of cervix,.....72 Douches, vaginal, . . . .211, 320 Dropsy, ovarian,......292 Duck-bill speculum,.....20 Dysmenorrheea,......60 cause of pain of,.....64 classification of cases of, . . 61 depending on endometritis, . 195 mechanical,......68 neuralgic,.......61 inflammatory,.....64 ovarian,.......63 spasmodic,.......61 Dyspareunia,.......44 Ecraseur, Dr. Atthill's, . . . 125 Dr. Hieks's,......122 Dr. Sims's.......125 Electricity in amenorrhcea, . . 63 Elongation of the cervix uteri, . 246 Endo-cervicitis,......170 Endo-metritis........195 Enemata,........334 Enlargements of the uterus, . . 249 diagnosis of,......257 treatment of,......259 Enucleation of fibrous tumors, . 143 Epithelial cancer.......263 Ergot in uterine therapeutics, . 330 Ergot, livpodermic injections of in fibroids,.....148, 331 Examination, bi-nianual, of ute- rus, ..........28 digital do.,......23 with speculum,.....18 sound,......24 Expulsion of fibrous tumors, . .164 Fergusson's speculum, ... 19 Fibrinous polypus,.....129 Fibro-cystic disease, . . . 134, 283 Fibrous polypus,......118 Fibrous tumors of uterus,. . . 130 absorption of,.....163 1 ND e x. 339 PAGE Fibrous tumors of uterus, avul- sion of,.......144 calcareous deposit of, . . . 164 changes in size of, ... . 160 in character of, ... . 163 cysts, development of, in, . 163 detachment of,.....163 effects of on uterus, . . . 256 enucleation of, . . . . . 144 ergotine hypodermically in, 147 expulsion of,......163 incision of,......143 influence of pregnancy on, . 160 injections in cases of, . . . 147 intra-inural,......136 sloughing of,......163 spontaneous cure of, . . . 164 sub-mucous,......136 sub-peritoneal,.....134 surgical treatment, .... 143 Flexions of the uterus, .... 213 Galvanic stem pessary, ... 55 Glycerine, in vaginitis, . . 39, 321 value of in uterine diseases, 176 Glycerine of tannic acid in cer- vicitis, .........176 Gonorrlnea........36 Gooch's canulae, Dr. Atthill's modification of,......125 Granular condition of cervix of uterus in menorrhagia, ... 97 in endo-inetritis, .... 202 Granular ulceration of cervix uteri,........97 Greenhalgh's stem pessary, 72, 228 spring do.,......227 India-rubber plugs, ... 91 iodized cotton,.....191 medicated pessaries, ... 39 metrotome,......75 Hematocele, pelvic, .... 183 Haemorrhage in cancer uteri, . . 267 in inversion of uterus, . . 247 in uterine polypi, .... 119 Hall's, Dr., mode of puncturing cervix,........174 Heart disease, a cause of menor- rhagia, ..... ... 81 Hepatic do. do. do. 82 PAGE Hewitt's, Dr., speculum, ... 20 Hicks', Dr., ecraseur. .... 122 zinc points, .... 176, 328 Hildebrandt, Dr., on hypodermic injection of ergotine, .... 147 Hops, infusion of, . . . • . . 320 Hot water, therapeutic uses of,........307, 316 Hodge's, Dr., pessary, .... 225 Hunyadi Janos water, .... 335 Hymen, imperforate, .... 51 Hypertrophy of cervix, .... 255 of the uterus,......255 Hvpertropque, allongement of, . 256 hypertrophy of,.....255 chronic,.......209 sub-acute,.......106 injection of fluids into, . . 109 inversion of,......246 involution of,.....83 prolapse of,......241 retroflexion of,.....213 subinvolution of, .... 83 Hypodermic injection of ergot, . 148 of morphia, .... 62, 333 Ice bags, spinal, in uterine dis- eases, .........311 Imperforate hymen,.....51 Indian hemp in dysmenorrheea, . 334 Induration of cervix uteri, . . 188 Inflammation of cervix, acute, . 167 chronic,....... . 178 Injections, hypodermic^ of er- got, ........148, 333 of morphia, . . .181, 334 intra-uterine, of iodine, . . 147 of liq. ferri perchlor., 144, 147 vaginal,.....38, 319 Intra-mural fibrous tumors, 136 treatment of,......141 Intra-uterine applica- tions, .....199, 201, 322 Iodine, injection of, into ovarian cyst, '. . . ......303 into uterine cavity, . . .147 into uterine diseases, . . . 313 Indoform,........314 Inversion of uterus,.....246 Involution, defective, .... 83 Iodized cotton,.......191 340 I X T> E X. PAGE Iron, perchlor. of, as a styptic, . 315 intra-uterine, injection of, in fibroids,.......147 Kreuznach, waters of, in chronic inflainmation of uterus, . . 259 Lameness, uterine,.....219 Laminaria digitata, tents of, . . 100 Leeches, application of, to cervix uteri,.........173 Left-side pain,.......305 Leucorrlm-a,.......31 causes of,.......34 cervical,.......41 due to polypus,.....119 infantile,.......40 uterine,........43 vaginal,.......32 injections in,.....319 Mamm.e, reflex irritation of, . . 225 Manual examination, .... 17 Masturbation,.......43 Medullary cancer,.....263 Menorrhagia,.......79 constitutional causes of, . . 80 local causes of,.....82 depending on cancer, . . . 267 depending on congestion of ovaries and uterus, . . .112 on endo-metritis, .... 196 on fibrous tumors, .... 137 on granular condition of ute- rus, ........99 on hyperaemia of ovaries, . Ill of cervix and os, . . 97 on inversion of uterus, . . 246 on polypus,......119 on retention of portion of placenta,......110 on retroflexion,.....223 on subinvolution, . . . .112 Menstruation,.......46 interrupted,......56 diminished, vide amenorrhea, 46 profuse, fide menorrhagia, . 79 suppressed, vide amenorrhcea, 46 suppression of, enlargement of uterus following, . . . 252 PAGE Mercury in uterine diseases, . 333 pernitrate of,......324 Metritis, chronic,......209 Metrorrhagia,.......79 Metrotome, Greenhalgh's, . . 75 Dr. Savage's,......73 Micturition, frequencv of, vide "bladder," ...'.... Morphia, hvpodermic injection of, ........118, 334 Multilocular ovarian cysts, . . 280 Nidation,........33 Nitrate of silver, solid, use of in subinvolution,......88 Nitric acid, application of to cavity in uterus, . . . 107, 325 Oakbark, injection of decoction of, . . .'.......32U CEdema of fibrous tumors, . . . 100 Ointments, intra-uterine applica- tion of,.........32« Os uteri, vide " Cervix," contraction of,.....7n Ovarian dropsy,......291 dysmenorrheea,.....63 Ovarian tumors, diagnosis of,. . 292 influence of on life, . . . 296 cause of death in, .... 297 symptoms of,......288 Ovaries, absence of,.....4m adenoma of,......281 alveolar, tumor of, .... 281 cystic, disease of, .... 279 dermoid, cyst of, .... 282 diagnosis of tumors of, . . 292 dropsy of the,.....279 inflainmation of,.....304 Ovariotomy,........298 cases of,.......282 Pain in cancer,......268 ovarian,.......;J,(j4 Pelvic, cellulitis,......179 haematocele,......183 Peritonitis, a cause of enlarge- ment of uterus,......253 Pessaries, flexible stem, . . 72, 228 galvanic,.......55 INDEX. 341 PAGE Pessaries. Greenhalgh's spring, . 226 medicated,.......39 Hodge's, Dr., lever, . . . 225 Zwank's, . . . 243 Phthisis, leucorrheea in, . . 34 Pills, purgative,......335 Placenta, retained, a cause of menorrhagia,......110 Placental polypus......129 Plugging of vagina,.....90 Polypus, definition of, .... 114 fibrinous........129 fibrous,........118 mucous,.......115 placental,........129 removal of,......116 symptoms of,......119 varieties of,......114 I'urtc-caustiqite, uterine, .... 88 Potassa fusa, application of in chronic cervicitis, . . . 177, 190 Pregnancy, diagnosis of, from ovarian tumors,......291 Pregnancy, influence of on fibrous tumors,"......- .100 sickness of, treatment of, 311, 334 Priestly's, Dr., dilator, . ... 70 Prolapsus uteri,......241 Pruritus vagina;,......38 Puncturing cervix, mode of, . . 174 Oi;inine in uterine haemorrhage, 331 Rectocele........245 Retroflexion of uterus, .... 213 causes of,.......216 diagnosis of,......22-) treatment of,......22-j Retroversion,.......230 Savaoe's, Dr., metrotome, . . 73 Scissors, Kuchenmeister's, ... 74 Sea-tangle tents, use of, . . . . 101 Simpson's, Sir James, porte-caus- tique,......_ • •_ • *s Sickness of pregnancy, spinal ice bags in,........;!H Silver, nitrate of, in subinvolu- tion, .........s'^ Sound, the uterine,.....24 PAGE Spinal bags,........311 Speculum, bi-valve,.....19 duck-bill,.......21 Fergusson's.......18 Hewitt's,.......20 introduction of,.....21 Sponge-tents,.......100 Steel-wire, advantages of, for ecraseur,........124 Sterility,.........41 due to cervical catarrh, . .170 Strychnia, action of on uterus, . 332 in amenorrhcea, .... 58, 332 Strychnia in uterine haemorrliage, 112 Subinvolution, causes of, . . . 83 menorrhagia, depending on, 83 retroflexion, a sequence of, . 221 treatment of,.....88, 92 Sub-peritoneal fibrous tumor, . .133 Tannic acid, glycerine of, in cervicitis,........176 Tapping in ovarian dropsy, . . 303 Taxis inversion of uterus, . . . 247 Tents, sea-tangle,......101 sponge,......• • 100 Tobacco, infusion of in vaginitis, 320 Tumors, fibrous,......132 fibro-cystic, . . . . 134, 163 ovarian,.......279 urethral,.......41 Ulceration of cervix uteri, . . 167 Unilocular ovarian cysts, . . . 286 Urethra, vascular tumor of, . . 41 Uterine diseases, course to be followed in examination of, . 23 Uterine lameness,......219 leucorrheea,......43 porte-caustique,.....88 sound,........24 therapeutics,......306 Uterus, absence of,.....49 anteflexion of,.....239 displacements of, . . . .212 enlargements of, .... 249 exploration of,.....105 fibro-cystic, disease of, . . 134 Uterus, fibrous tumors of, . . . 132 granular condition of cavity of,.......99, 202 342 INDEX. Vagina, absence of, . . aphthous condition of, atresia of, . cancer of, . . . closure of, . . . mode of plugging, shortening of, Vaginal injections, . Vaginismus, . . . Vaginitis, acute, . sub acute, . Vomiting, due to mastui to retroflexion, 38 bation, PAGE 48 37 51 261 i 51 90 50 319 44 35 37 43 218 Vomiting checked by morphia hypodermically,. . 181,333 by cold to spine, . . . .312 Water, cold, therapeutic uses of, 307 hot, do., do., ■ • • ,- 309, 303 application of to spine, . 309 vaginal injections of, . . 308 Whites, the,........31 Zinc points. Dr. Hicks's, . 176, 328 injections........319 Zwank's Pessary,......243 HANDBOOKS FOR PHYSICIANS.**5^ DISEASES PECULIAR TO WOMEN. CLINICAL LECTURES LOMBE ATTHILL, M.D., CONSULTING OBSTETRIC SURGEON TO THE ADELAIDE HOSPITAL, F.X-rRESIDENT OF THE DUKLIN OBSTETRICAL SOCIETY, ETC. FIFTH EDITION, REVISED AND PARTLY RE-WRITTEN, WITH ILLUSTRATIONS PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 WALNUT STREET. Price 75 cents each. I 2! 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