SURGICAL 
DISEASES OF WOMEN 
BY 
ROMAINE J. CURTISS, M.D. 
OF JOLIET, ILL. CLINICAL CASES OF SURGICAL DISEASES 
OF 
WOMEN. 
BY 
ROMAINE J. CURTISS, M.D. 
OF JOLIET, ILL. 
REPRINTED FROM THE MEDICAL AND SURGICAL REPORTER, JANUARY 28, 1882 
vaginal injections of hot water were used daily 
for about two weeks, and sesquioxide of iron 
was given internally. 
On the fourth day before the operation a laxa- 
tive was given, which was repeated daily, the 
last dose being given the evening before. The 
intestines were as empty as they could be made, 
which plan is most decidedly a great improve- 
ment over the old one of giving a cathartic only 
the day before the operation. At six o’clock in 
the morning two grains of opium were given, and 
at nine o’clock the operation was performed. 
The patient took ether very kindly, and when 
under its influence I removed the cicatricial tis- 
sue and as much of the vaginal mucous mem- 
brane as was deemed necessary. The rent in the 
septum was so great that the apex of the denuda- 
tion in the mucous membrane was well up in the 
cul de sac behind the cervix. During this part 
of the operation the bleeding was excessive, sev- 
eral vessels being cut, and the capillary bleeding 
being greater than was expected after the pro- 
longed use of hot water. I have since learned 
enough to know that the sesquioxide of iron con- 
tributed to this result, as it inhibits the vaso- 
motor contractors, and I have lately used it in 
angina with better success than is given by nitrite 
of amyl. To control the bleeding, hot water was 
used by one of the assistants, at first with a 
sponge, and then with a syringe. The two phy 
sicians who assisted in the operation and I, soon 
learned to keep a stream of hot water following 
the cut of the scissors ; but for this the opera- 
tion would have been almost impossible. The 
Bestoration of the Perineum. 
Cask 1.—Mrs. , aged twenty-six years. 
Three years before I saw her, this lady was 
delivered of a hydrocephalic child—a still 
birth. The feet presented, and forceps were 
applied to the head, effecting its delivery, with 
the result of producing a complete laceration of 
the perineal body, and of the septum through 
the sphincters. From date of the injury this lady 
experienced the usual sequent miseries of this 
injury. She had no voluntary control over the 
sphincter function of the bowel, and had pro- 
lapse of the bladder. She was confined to the 
house, and generally to the bed. During this 
time she lost weight and color, and began to 
cough, and had chills and night sweats. Her 
mother having died at an early age with con- 
sumption, this disease was reasonably feared by 
the patient and her friends, in her own case. I 
was called to see her on account of her lung 
disease, and found a condition of her right lung 
which, I believed, indicated fibrous phthisis. 
She told me nothing about her injury until the 
fact was developed by inquiries relating to the 
uterine organs. On examination, I found the 
condition as stated. I advised the patient to 
have the perineum restored by operation, and 
afterward to take a trip to Colorado, for her 
lungs, to which she and her friends assented. 
In the surgical treatment of this case I followed 
the method practiced and advised by Dr. T. H. 
Emmett in his truly great work on gynaecology. 
As a preparation, locally, for the operation, 4 
surface denuded was unusually large, and eight 
silver sutures were used. The first suture was 
placed in that relation to the sphincter which in- 
sures its union, and which was demonstrated by 
Dr. Emmett, and is difficult to explain without 
the aid of the diagram given in his book. 
The last suture was inserted through the vulva 
and passed through the mucous membrane above 
the denuded surface, which drew the membrane 
over the vaginal portion of the surfaces where 
union was hoped for. The placing of the lower 
and upper sutures in this manner, with the ob- 
ject of placing the torn edges of the sphincter in 
apposition in one case, and of protecting the 
uniting surface from the septic influence of vagi- 
nal biological ashes in the other, are certainly 
strokes of a gynaecological genius. 
On the sixth day after operation the two mid- 
dle sutures were removed; the remainder were 
removed on the twelfth day, and the union was 
perfect. Injections were given, to render the 
contents of bowels soluble, and they were 
moved without injury. During the twelve days, 
one-half a grain of opium was given daily, which 
was sufficient to prevent any action of the bowels, 
and vaginal douches, carbolized, were also used 
daily, and the urine drawn twice a day, great 
care being used to avoid getting any urine into 
the wound. 
The general health of the patient began to 
mend as soon as she was out of bed. She gained 
flesh, got a good color, and went to Colorado for 
six months. The lung disease was subdued, so 
far as any active manifestation goes. It is now 
three years since the operation was made ; the 
lady during this time has again become a mother, 
with very little injury to the perineum, and her 
health is good. 
Case. 2.—Mrs. —, was aged twenty two years 
when she was delivered of her first child. Her 
accoucheur was a member of the hybrid, homoeo- 
pathic, “ new school ” of medicine. The peri- 
neal body, as a result of this labor, was torn 
through, as well as the external sphincter 
muscle. The sequences of the injury were : A 
limited control over the sphincter function, and 
prolapse of the uterus, the cervix of which was 
somewhat lacerated. The patient attributed her 
misfortune eiitirely to the fact that her physician 
during the bearing down pains kept straining the 
perineum backward with his fingers. On ques- 
tioning her, I learned that she was delivered 
while lying on her left side, with thighs flexed, 
which position, combined with the efforts of her 
physician, were certainly proper antecedents to 
such a calamity. 
I wish here to contribute a mite toward the 
literature of management of the perineum during 
labor. It is obvious that the perineum serves a pur- 
pose in the mechanism of labor, and other things 
being equal, does not require the support so much 
talked about in the text books. The benefit of 
such support—pressure with the hand—having 
the effect to aid the perineum in giving the head a 
forward direction, describing a curve around the 
pubis. It is apparent that if this direction of 
the head is maintained there is so much less 
danger to the perineum. The course of the head 
through the pelvis, in the direction of the curve 
of Carus, is in great part due to the anatomical 
conformity of the pelvis; but the office of the 
perineum is to continue the course of the head 
in the circle of which the curve of Carus is a 
segment, and the opposing force to this perineal 
force is the pubis. It is, then, a deduction from 
these facts, that support of the perineum means 
aiding the perineum to continue the course of 
the head in the direction of a circle which is 
continuous with the curve of the pelvis. It is a 
further deduction, that straining the perineum in 
the opposite direction directly interferes with the 
mechanism of labor, and as directly endangers 
the perineum. Another factor in the support of 
the perineum is the position of the parturient 
woman. It may easily be demonstrated that the 
woman, when the head is describing the curve 
around the pubis, should lie with her thighs ex- 
tended. If the finger of the accoucheur be in- 
serted between the head of the child and the 
perineum, and the woman’s thighs are flexed, 
the tension of the perineum is felt to be greater 
than when the thighs are extended, other things 
being equal. If this demonstration proves any- 
thing, it is, that flexure of the thighs upon the 
abdomen increases the curve of Carus very nota- 
bly in that portion of its course bounded by the 
perineum, and that flexion of the thighs during 
delivery of the head and shoulders directly in- 
creases the danger to the perineum. I have 
never attended a parturient woman who suffered 
rupture of the perineal body to any notable ex- 
tent, which fact I attribute to the reason that I 
discovered the facts as given, relating to flexion 
of the thighs and tension of the perineum, in the 
third case of labor which I attended, sixteen years 
ago—a primipara, thirty-eight years of age, dur- 
ing whose labor the head remained two hours in 
a position which partially distended the peri- 
neum. This discovery, I suppose, has been made 
by many physicians, but I never happened to see 
the record of it. 
In this case the operation for restoration of the 5 
perineum was made bv the older method. In- 
stead of cutting away the cicatricial tissue and 
the mucous membrane, the epithelial tissue only 
was removed and the silk quill suture used. The 
union was not as complete as in Ease 1. To all 
appearance, as manifest to touch, the peri- 
neal body was intact; but a communication 
existed between the vagina and external peri- 
neum, along which water could find its way when 
injected into the vagina. The patient, however, 
was cured, by the operation, of the prolapsus and 
the inconvenience relating to the bowel. 
Restoration of Cervix. 
Case 3.—Mrs. —, when I saw her, in Febru- 
ary, 1880, was forty-two years old and the mother 
of five children, the youngest seven years of age. 
This lady is a native of England, and her physi- 
cian in London was the famous Dr. Richardson. 
I was called to see this patient on account of an 
attack of menorrhagia. I made no examination, 
as the proposition to do so was thought by her to 
be unnecessary, as she stated these attacks had 
been repeating themselves at intervals during the 
last two years, and she thought they were due to 
approaching change of life. I prescribed large hot 
water vaginal injections and a preparation of ergot 
and digitalis, to be taken in a decoction of cinna- 
mon. 
In two weeks I saw patient again, and was 
obliged to use the tampon. I discovered, by 
digital examination at this time, that she had a 
complete laceration of cervix. I found it neces- 
sary to tampon vagina several days, and learned 
by repeated examinations that the cervix was 
split entirely, and its lateral halves were, so far 
as could be determined by touch, continuous 
with the vaginal walls. I confess that I was 
nonplussed by the case as felt at first, for, 
sliding my finger up the vaginal wall, I would 
find no evidence of a cervix, or Douglas cul de 
sac, but my finger would pass up into the cavity 
of the uterus, which fitted it like a cup thimble. 
I had never seen a laceration so extensive, and 
was unprepared to know the meaning of the 
tactile sensation. I became satisfied, however, 
what the condition of things must be, and in a 
few days, the bleeding having ceased, I made an 
examination with Sim’s speculum, and found 
that I could see the fundus uteri, as well as feel 
it, there being no external or internal os. With 
two hooks I brought the halves of the cervix 
from, apparently, out of the vaginal walls, and 
drawing them together the form of the uterus 
could be seen. The perineal body was also 
lacerated, and the fundus of the uterus—the in- 
side of it—was about three inches above the vulva. 
I explained the nature of things to the patient, 
who remarked that Dr. Richardson said she was 
ruptured, and had proposed an operation to re- 
lieve her before she left London. The cervical 
mucous membrane was congested, and pricking 
it let out an abundance of gelatinous substance. 
I told the patient that her life depended on the 
restoration of the cervix, and two months were 
occupied in the preparatory treatment and un- 
avoidable delays. The treatment consisted in 
administration of ergot, digitalis, and dialysed 
iron ; a daily vaginal douche of a gallon of hot 
water, and application every third day of com- 
pound tinct. of iodine to the cervical membrane 
and uterine cavity. There were frequent and 
severe hemorrhages during this period of prepa- 
ration, and for twenty days, in the aggregate, I 
was obliged to use the tampon. A notable fea- 
ture of this treatment was the hot water injec- 
tions, which were performed with the ordinary 
Davidson’8 syringe, using one gallon of water at 
once, and which was, of course, injected directly 
into the uterine cavity, without a symptom of 
the usual uterine colic which follows sometimes 
the advent of a small quantity of water into the 
uterus. There was apparently no more sensation, 
in character or degree, in this patient’s uterus 
than was afforded by the vaginal walls. The 
patient could distinguish her menstrual hemor- 
rhage from other paroxysms of bleeding by the 
backache and other sympathetic pains, and the 
operation was appointed on the fifth day after 
accession of menses, providing the flow could be 
stopped. At next menstruation she was tam- 
poned, as usual, and seven days passed before 
she was ready. At this time a physician sent 
her word that he could cure her without an 
operation, and in consequence the operation 
was delayed until ten days before the time for 
her next menstrual period. The operation was 
made as Emmett directs: the cicatricial and mu- 
cous membrane being removed, leaving a space 
for the cervical canal, the two halves were 
brought together, and eight silver sutures were 
used. On the fourth day after the operation 
she began to flow, which I supposed would 
destroy the hoped-for result of the operation. 
The flow continued about six days. I left the 
sutures in place fourteen days, hoping union 
might occur, when the patient had an attack o f 
winter cholera, which came on at night, was very 
severe, and when I reached her she was col- 
lapsed, almost pulseless, and was, to all appear- 
ances, a hopeless case. Her family and friends 
were around her in the attitude of mourners, and 
I never saw so pale and exsanguined a surface 6 
as she presented. I gave her, hypodermically, 
morphia sulph. gr. i and atropia sulph. gr. 
the remedy which I relied on for winter cholera. 
She began within an hour to rally, and recovered 
from the attack. She was plied with beef ex- 
tract and brandy until the eighteenth day from 
date of operation, when I removed the sutures, 
fully expecting to see the parts separate, but to 
my great surprise the union was perfect. At her 
next menstruation the patient declared she was 
“ more natural than she had been at any time 
since she was twenty years old.” She has been 
healthy ever since and has gained thirty pounds 
in weight. The uterus occupies the normal 
position in the pelvis, notwithstanding the peri- 
neal body is gone. 
Case 4.—Mrs. —, was married at the age of 
thirty-eight years. She was small in stature, 
light in weight, had always been a subject of neur- 
asthenia, with neuralgic manifestations, but never 
had any of the zymotic diseases, or acute sick- 
ness, and yet says she never had a well day. 
Within a year after her marriage this lady was 
delivered of a ten pound boy, by aid of forceps, 
and the cervix was completely lacerated. In this 
case the split was not midway in the cervix, but 
the anterior portion was about half the thickness 
of the posterior. The two sides rolled out, after 
the manner of a celery root when split in the 
axis of its length. The laceration extended up- 
ward on the external surface of the cervix to its 
junction with the vaginal walls, and internally 
extended through the internal os. The sequences 
of this injury were entirely referred to the ner- 
vous system, and the only discomfort was neural- 
gia, which appeared to extend throughout the 
whole sensory nervous system connected with the 
pelvis. The pain was nearly constant, and con- 
fined her to bed. Sleep could only be procured 
after great exhaustion from wakefulness and 
suffering, or by chloral. At the end of the sec- 
ond month the cervix was restored by the same 
method as in the previous case, but without an 
untoward symptom. The sutures were removed 
on the tenth day and the union was found per- 
fect. The restoration of the cervix cured the 
pelvic neuralgia, and her general health is much 
better than before her marriage. 
Case 5.—Mrs. — was twenty-eight years old 
when she was delivered of her first child,by for- 
ceps, with the lamentable sequence of unilateral 
laceration of the cervix and complete rupture of 
the perineum. Her physician told her that 
the accident was due to the fact that the 
child had ho soft spot in its head. I suppose he 
referred to the condition of the fontanelles. He, ! 
however, immediately inserted silver sutures, 
and to all appearance the perineum was united, 
and the medical gentleman assured the patient 
that the like was never known before. I saw the 
case three months afterward. The patient was 
emaciated, had loss of appetite, indigestion, and 
the urine loaded with phosphates. She referred 
her local distress to the bladder, stating she not 
only had difficult micturition, but could not sit, 
except on one of the nates, or rather one hip, fre- 
quently changing from one side to the other,on ac- 
count of painful sensations produced in the blad- 
der. 
On examination, I found that the perineal 
body was not united, but there was a union of the 
integument of the perineum, which bridged 
across the chasm, and somewhat resembled the 
web of a goose’s foot. The uterus emitted a dis- 
charge of acrid, purulent matter, and was pro- 
lapsed, resting between the severed halves of 
the perineal body. To relieve the sensation of 
bladder distress I cut the bridge away with scis- 
sors, which allowed the patient to sit upright, by 
removing the tension from the integumentary 
perineum, and proceeded to prepare her for res- 
toration of cervix and perineal body. These 
operations were completed in due time, without 
misfortune or hindrance, and the patient recov- 
ered her health. She has since given birth to 
her second child,, during the labor for which the 
perineum remained intact. 
Case 6.—Mrs. —, when I saw her, was aged 
nineteen years; had been married three years ; 
and a year since gave birth to a child. Since 
then her health had materially deteriorated. She 
was subject to hystero- epilepsy, and was at times 
quite maniacal. There was a bellows murmur, 
heard loudest over the apex of the heart. She 
never had rheumatism She complained of an 
acrid vaginal discharge, which caused great irri- 
tation, and had been treated for ulceration of 
the cervix, without benefit. I detected a uni- 
lateral laceration of the cervix by digital ex- 
amination, there being so much vaginal in- 
flammation that I could not use a speculum. 
She was directed to use hot water vaginal 
douches, and returning in two weeks, a speculum 
examination was made, which verified the exist- 
ence of the laceration. The lacerated surfaces 
were secreting pus of an acrid character, which 
kept the vaginal mucous membrane in a condi- 
tion of inflammation. Topical applications of 
the comp, tinct. of iodine were made daily to the 
wound, and punctures with a sharp lancet as 
often, to let out the gelatinous matter. The parts 
appearing ready for the operation, the day was 7 
appointed, but while getting ready, owing to ex- 
citement, the patient had an attack of hystero- 
epilepsy, which postponed matters. This occurred 
the second time, when I adopted the strategic move 
of making the operation without foreknowledge 
on her part. The patient was placed, as usual 
during her local treatment, in Sim’s position. I 
quickly denuded the surface, but trouble began 
in patient’s head before I could insert the sutures. 
I took a cup pessary, and applying it over the 
cervix, packed the vagina with a cotton tampon, 
fixing thereby the stem of the pessary. The 
patient was accustomed to applications of cotton 
glyceroles, and with additional persuasion be- 
came quiet. The next day she was informed of 
the condition of matters, and remained quiet in 
bed. Every other day I removed and replaced 
the cotton tampon, carefully keeping the cup 
pessary in place by holding the stem. This pro- 
cedure was kept up for ten days, when I ventured 
to look at the cervix, and had no reason to be 
dissatisfied with the result. The surfaces were 
united. The patient was put on increasing doses 
of bromide of zinc, which, together with a change 
of climate, worked a cure.