NLM D05fl00b7 b ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C NLM005800676 TREATISE ON THE DISEASES OF WOMEN FOR THE USE OF STUDENTS AND PRACTITIONERS BY J ALEXANDER J. C. SKENE, M. D. PROFESSOR OF GYNECOLOGY IN THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN, NEW YORK FORMERLY PROFESSOR OF GYNECOLOGY IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL GYNECOLOGIST TO THE LONG ISLAND COLLEGE HOSPITAL PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY, 1887 CORRESPONDING MEMBER OF THE BRITISH, BOSTON, AND DETROIT GYNECOLOGICAL SOCIETIES OF THE ROYAL SOCIETY OF MEDICAL AND NATURAL SCIENCES OF BRUSSELS AND OF THE LEIPZIG OBSTETRICAL SOCIETY FELLOW OF THE NEW YORK ACADEMY OF MEDICINE EX-PRESIDENT OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS EX-PRESIDENT OF THE NEW YORK OBSTETRICAL SOCIETY SECOND EDITION, REVISED AND ENLARGED WITH 251 ENGRAVINGS AND 9 CHROMO-LITHOGRAPES NEW YORK D. APPLETON AND COMPANY 1893 \NP £>^27t 1893 Copyright, 1888, 1892, By D. APPLETON AND COMPANY. TO THOMAS KEITH, M. D., LL. D., F. R. C. S. E,, THIS WORK IS DEDICATED AS A TRIDUTE TO HIS ACHIEVEMENTS IN SURGERY, HIS JUSTICE AND COURTESY TO THE MEDICAL PROFESSION OF AMERICA AND AS AN ACKNOWLEDGMENT OF HIS KINDNESS TO THE AUTHOR. PREFACE TO THE SECOND EDITION". The demand for a second edition of this work, and the fact that it is used as a text book in many of the leading medical schools, are very gratifying to the author, who takes this opportunity to thank the members of the medical profession for this evidence of their approbation. Every effort has been made to improve this edition by a thor- ough revision and the addition of much new material. isew chapters have been added on ectopic gestation, diseases and injuries of the ureters, vesical hernia and its surgical treatment, and the latest views of the author have been given in the discussion of laparotomy, ovaritis, and injuries of the cervix uteri and pel- vic floor. The publishers have, at great expense, produced a large number of new and handsome illustrations, and in every respect have made the work a perfect sample of their art. The Author. April 15, 1892. PREFACE. This book was written for the purpose of bringing together the fully matured and essential facts in the science and art of gyne- cology, so arranged as to meet the requirements of the student of medicine, and be convenient to the practitioner for reference. In the plan adopted, the diseases peculiar to women are, as far as possible, divided into three classes. The first class comprises those which occur between birth and puberty; the second, those between puberty and the menopause; and the third, those which come after the menopause. Each subject is briefly described, and histories of cases, typical and complicated, are given as illustrative of the disease or injury under consideration, together with the author's method of treat- ment. The number of illustrative cases given depends upon the practical importance of the subject and the ability to make it more plain by the use of illustrations. In carrying out this plan, the history of gynecology and the discussion of all unsettled questions have been omitted, as being at variance with the plan adopted. Credit has been given as far as possible to those who have made original discoveries, but a vast "number of original workers have been passed unnoticed for want of time and space even to name them. To the medical student, history has no value until he has mastered the rudiments of the science and the art, and the prac- titioner can find in the works of reference all the historical facte which he may seek. vi PREFACE. The author has ventured to give his own views and methods pertaining to practical matters, believing that while they may diifer to some extent from the general literature of the day, they "will be found reliable in practice and may be of interest to the spe- cialist. Marginal references have not been made, because all selections from the literature that have been incorporated in this work are those already well established and familiar to the gynecologist, and foot-notes only embarrass the reader who is seeking for the facts alone. Acknowledgments are due to my associates — Dr. J. H. Ray- mond, who has rendered valuable aid in the preparation of the work, and Dr. R. L. Dickinson, who has made the drawings for the original illustrations. The Author. TABLE OF CONTENTS. CHAPTER L- II.- III.- IV- V- VI.- VII.- VIII.- IX.- X.- XI.- XII.- XIIL- XIV- XV.- XVI. XVII. XVIIL- XIX.- XX.- XXI.- XXII.- XXIII.- XXIV- XXV.- XXVI.- XXVIL- XXVIII.- XXIX.- XXX.- XXXI.- XXXII.- -Methods of Observation ...... -Development of the Sexual Organs . . . . -Arrest of Development and Entire Absence of Functional Activity—Arrest of Development and Growth in the Later Stages of Evolution, and Consequent Imperfection of Function ..... -Flexions of the Uterus .... -Diseases of the External Organs of Generation -Diseases of the Vagina .... -Injuries to the Pelvic Floor from Parturition and Causes ...... -Fistula in Ano and Coccyodynia -Imflammatory Affections of the Uterus -Corporeal Endometritis .... -Subinvolution ..... -Sclerosis of the Uterus .... -Membranous Dysmenorrhea -Lacerations of the Cervix Uteri due to Parturition -Cicatrices of the Cervix Uteri and Vagina . -Inversion of the Uterus .... -Dislocations of the Uterus -Retroversion of the Uterus -Abuse of Pessaries .... -Hypertrophy of the Cervix Uteri -Fibroma of the Uterus .... -Malignant Disease of the Uterus -The Menopause ..... -Diseases of the Ovaries .... -Diseases of the Ovaries (continued) -Neoplasms of the Ovaries. -Cystic Tumors of the Ovaries—Symptomatology and Phys ical Signs ..•••• -Ovariotomy ...••• -Illustrative Cases of Ovarian Neoplasms -Diseases of the Fallopian Tubes -Pelvic Cellulitis . -Pelvic Peritonitis • PAGE 1 22 viii TABLE OF CONTENTS. XXXIII.—Pelvic Hematocele.......596 XXXIV.—Diseases of the Urinary Organs—Anatomy and Develop- ment of the Bladder and Urethra . XXXV.—Malformations of the Bladder and Urethra . XXXVI.—Function of the Bladder ..... XXXVII.—Functional Diseases of the Bladder . XXXVIII.—Functional Diseases of the Bladder (continued) XXXIX.—Methods of Exploration of the Bladder and Urethra XL.—Organic Diseases of the Bladder XLI.—Organic Diseases of the Bladder (continued)—Treatment of Cystitis — Croupous and Diphtheritic Cystitis — Cystitis with Epidermoid Concretions ..... XLII.—Non-Inflammatory Diseases of the Bladder—Dislocation of the Bladder ...... XLHI.—Foreign Bodies in the Bladder .... XLIV.—Rupture of the Bladder . XLV.—Neoplasms, Hyperplasia, and Atrophy of the Bladder XLVI.—Diseases of the Urethra and Urethral Glands XLV1I.—Dilatation, Dislocation, and Prolapsus of the Urethra XLVIII.—Stricture, Foreign Bodies, and Incomplete Fistula of the Urethra . . . . XLIX.—Diseases of the Glands of the Female Urethra L.—Vesical and Urethral Fistul^e . LI.—Diseases and Injuries of the Ureters . LII.—Ectopic Gestation ..... LIII,—Gynecology as related to Insanity in Women . INDEX TO ILLUSTRATIONS. FIG. 1. Examining table 2. Bimanual examination . 3. Sims's speculum 4. Cusco's bivalve speculum 5. Sims's position, seen from above 6. Nurse holding Sims's speculum 7. The movements of the speculum—first movement 8. —second movement 9- —third movement 10. Hunter's depressor 11. Sims's probe 12. Whalebone sound 13. Jenks's sound 14. Skene's curette 15. Hanks's dilator 16. Goodell's dilator 17. Sponge tents 18. Tupelo tents 18a. Ether inhaler 19. Miiller's ducts 20. Coalescence of ducts 21. Disappearance of septum 22. Appearance of fundus and cervix 23. Infantile uterus (Winckel) 24. Palma plicata . 25. Infantile uterus, antero-posterior section, scant invagination 26. Virgin uterus (Sappey)—anterior view 27. " " —median section 28. " " —transverse seetion 29. Double uterus and vagina (Eisenmann) 30. Uterus unicornis (Pole) 31. Uterus bicornis unicollis (Winckel) 32. Uterus bifundalis unicollis (Courty) 33. Uterus duplex (Cruveilhier) 34. Double uterus . 34a. Anteflexion of cervix—first variety 35. Anteflexion of body of uterus—second variety 36. Anteflexion of body and cervix—third variety 37. Operation for imperfect invagination ; the ineision 33_ « " " sutures in position X INDEX TO ILLUSTRATIONS. FIG. 39. Elliott's uterine adjuster 44. Stem pessary of Thomas 45. Extreme anteflexion . 46. Skene's hysterotome .... 47. External genitals of a woman who has borne childi 48. The superficial veins of the perinseum (Savage) 49. External genitals of a virgin . 50. Cribriform hymen .... 51. Annular hymen .... 52. Fimbriate hymen . 53. Rectum continuous with allantois (bladder) and duct of (Schroeder) . 54. The depression has extended inward (Schroeder) 55. The cloaca is dividing (Schroeder) 56. The perineal body is completely formed (Schroeder) 57. The upper part has contracted (Schroeder) . 58. Spurious hermaphroditism (Simpson) . 59. Length of vaginal walls 60. Triangular shape of the perineal body 61. Sims's vaginal dilator . 62. The levator ani (after Luschka) 63. The muscles of the pelvic floor (after Hart and Savage) 64. Diagrammatic sagittal section of the female pelvis 65. Complete laceration of the perinseum . 66. Sagging of the pelvic floor 67. Diagram of the sweep of the suture . 68-69. Sutures properly and improperly introduced 70. Peaslee's needle .... 71. Skene's tissue forceps .... 72. Emmet's curved scissors 73. Emmet's scissors .... 74. First step of perineorrhaphy, denudation begun 75. Second step, continuing the strip 76. Vivifying complete .... 77. Skene's needle-forceps .... 78. Stitch in place ..... 79. The stitches in place .... 80. Laceration with rectocele 81. Perineal body restored (profile view) . 82. Scissors for removing sutures . 83. Complete laceration of perinseum 84. do. operation; denudation complete 85. do. " rectal sutures . 86. do. " the remaining sutures placed 87. Haemorrhoid clamp .... 88. Hard-rubber rectal tube 89. The operation for fistula in ano 90. Mold of uterine cavity in the virgin (Guyon) . 91, « " " " multipara (Guyon) 92. Section of mucous membrane of uterus 93, " through corpus uteri of an infant 94. " " " " of a woman aged eighty-three Miiller PAGE 67 . 69 71 74 77 79 80 81 81 81 (vagina) 81 82 82 82 82 83 99 99 105 112 . 113 , , 115 119 123 128 129 129 138 . 138 , . 139 , 139 140 , , 141 141 . . 142 , , 142 143 143 145 Plate I Plate I Plate II Plate II 151 153 166 171 171 172 . 173 . 174 INDEX TO ILLUSTRATIONS. xi thev ar often Plate III Plate III Plate Iil 95. One of the median columns in the cervical canal (Courty) . 96. Section through the mucous membrane of cervix showing cystic degen eration ..... 97. Elongation of the cervix (Winckel) . 98. Hypertrophy of the body of uterus (Winckel) 99. General enlargement of uterus (Winckel) 100. Skene's instillation tube 101. Sims's curette ..... 102. The two sides of a half membrane from a multipar 103. Half a membrane from a virgin 104. A cast from a virgin .... 104a. Fragments of membrane in the condition in which expelled . . ... 104ft, 104c. A cast which might be taken for a product of conception 105. Bilateral laceration; unequal division of the cervix 106. Bilateral laceration, with thickening of the everted lips 107. Extensive multiple laceration 108. Multiple incomplete laceration 109. Incomplete bilateral laceration 110. " " " in section 111. Crescentic laceration 112. Skene's hawk-bill scissors 113. Denudation of cervix . 114. Skene's triangular needles 115. Counter-pressure instrument. 116. Sutures in place 117. Sutures tied .... 118. Removal of crescentic-shaped piece (seen in section) 119-120. Method of bringing the sides of the section together 121-122. Another method of closing the gap 123. Partial inversion (Thomas) . 124. Complete inversion (Thomas). 125. Polypus simulating partial inversion (Thomas) 126. Polypus simulating complete inversion (Thomas) 127. Byrne's method of reduction of inversion . 128. Cup pessary to exercise gradual pressure (Thomas) 129. Replacement of uterus by dilatation through abdomen (Thomas) 130. Section of pelvis, showing its inclination and the axis of the inlet 131. The normal range of the uterine axis (Van der Warker) . 132. Diagram of the uterine ligaments .... 133. Section of pelvis, with the slings of the uterus 134. Diagram of the uterus slung between the broad ligaments 135. The normal inclination of the pelvis and the transmission of force from above . 136. The three degrees of prolapsus 137. Prolapsus uteri with cystocele 138. The shallow pelvis with lessened inclination 139. Increased inclination of inlet 140. Uterus replaced, with pessary in position 141. Stern pessary, modification of Cutter's 142. The three degrees of retroversion 143. Retroversion of the second degree . of brim TAfiE 175 181 182 182 182 189 198 232 232 2:33 233 244 244 245 245 240 240 247 250 250 251 254 254 254 266 266 269 269 270 270 278 280 281 282 284 284 285 287 291 292 293 298 300 305 306 Xll INDEX TO ILLUSTRATIONS. PIG. 144. Retroversion with imperfect invagination of cervix 145. Apparent imperfect invagination . . ' . 146. The same uterus with its lips drawn back into place 147. The three steps in replacing the retroverted uterus by means of holders ....... 148. Albert Smith pessary ...... 149. Method of measuring the length of the pessary 150. Diagram of pessary in situ on looking through Sims's speculum 151. Slight invagination of cervix posteriorly with suitable pessary ■ 152. Decided invagination of cervix posteriorly fitted with a suitable 153. What the pessary does not do 154. How the pessary acts .... 155. Second step ; the uterus falls into the pessary 156. The knee-chest position 157. Fibroid on posterior wall of uterus simulating retroflexion 158. Prolapsed and adherent ovary simulating retroversion 159. Extreme retroflexion (Barnes) 160. Uterus with defective walls; the supra-vaginal portion of elongated (after Winckel) . 161. Stem of pessary ulcerating through cervix . 162. Stem cutting through body of uterus 163. High rectocele due to improper pessary 164. Displacement caused by a badly adjusted pessary 165. Hypertrophy of the cervix 166. The first step; splitting the cervix 167. The double flaps of the amputation 168. Diagram of the pieces removed 169. The sutures in place . 170. The sutures tied 171-172. Interstitial fibromata (Winckel) 173. Subperitoneal and submucous fibromata (Winckel). 174. Pedunculated submucous fibroid (Simpson) . 175-176. Enlargement due to subinvolution compared with that from of a fibroma (after Winckel) 177. Ecraseur ...... 178. Wall of uterus caught in ecraseur-wire and removed 179. Electrical action in a single cell 180. Law cell ...... 181. Milliamperemeter ..... 182. Rheostat ...... 183. Uterine electrode ..... 184. Cancer of both lips (Winckel) 185. The fundus uteri and ovaries seen through the pelvic brim 186. The ovary and its ligaments (Henle). 187. The ovarian, uterine, and vaginal arteries (Hyrtl) 188. Section of the ovary of a bitch (Waldeyer) . 189. Ovary displaced and bound down by adhesions 190. Left ovary, one large cyst (Farre) 191. Compound and proliferating cyst (Farre) 192. Multilocular cyst (Hooper) 193. Papillary cystoma of ovary (Winckel) 194. Dermoid cyst of ovary (Winckel) pessary the cervix is (His) PAGE 310 310 310 ponge- growth INDEX TO ILLUSTRATIONS. xiii 195. Fibroma affecting both ovaries (Winckel) 196, 197. Area of dullness in ovarian tumor and in ascites (Barnes) 198. Cautery clamp. 199. Keith's short compression-forceps 200. Keith's long compression-forceps 201. Keith's needle . 202. Keith's ligature-forceps 203. Keith's modification of Spencer Wells's clamp 204. Position of operator, assistants, and accessories in ovariotomy 205. Diagrammatic transverse section of the pelvis (Luschka). . /f!06. Pelvic abscess opening obliquely downward. VjJ07. Pelvic abscess opening obliquely upward 208. The pelvic peritonseum (Hodge) 209. The reflections and pouches of the pelvic peritoneum;(Hodge) 210. Retroverted uterus bound back by peritonitic adhesions (Winckel) 211. Subperitoneal pelvic hsematocele 212. Intra-peritoneal pelvic hsematocele .. 213. Diagram of the bladder to show corpus and. fundus 214. Base and neck of the bladder (Savage) 215. Urethra laid open with probes distending the glands (posterior wall di- vided) 216. Urethra laid open with probes in Skene's glands (anterior wall divided) 217. Transverse section of urethra with gland on either side 218. Longitudinal section of urethral glands 219. The meatus everted showing the mouths of the-glands 220. The relations of the ureters (Garrigues) 221. Extroversion of the bladder .... 222. Linear cicatrix ..... 223. Bladder covered by deep flaps 224. Diagram of the result of the operation- 225-227. Skene's endoscope .... 227a. Principal of the Nitze-Leiter cystoscope . 227b. " " " " 227c. Leiter cystoscope . 228. Skene's bivalve urethral speculum . 229. Fountain-syringe for washing bladder 230. Skene's instillation-tube . 231. Skene's urinal cup-pessary .... 232. Holt's catheter, with its modifications 233. Skene's modification of Goodman's self-retaining catheter 234. Retroversion of the gravid uterus (Schatz) . 235. Skene's pessary for prolapsus of the bladder 236. Pessary holding up the bladder 237. Modification of the retroversion pessary, used in prolapsus 238. Forward transposition of the uterus . 239. Retrocession of the uterus . 240. Skene's reflux catheter . 241. Skene's fissure probe and knife 242. Skene's urethral speculum . 243. Skene's modification of Folsom's nasal speculum . 244. Allen's polypus forceps 245. Blake's polypus snare . of the bladder 479 495 513 519* 519* 520 520 520 521 555 557 557 579 580 582 596 597 610 612 614 614 615 616 617 620 638 639 640 641 695 697 698 698 700 740 743 747 749 749 762 767 768 768 773 774 822 833 844 844 845 XIV INDEX TO ILLUSTRATIONS. FIG. 246. Dilatation of middle third of the urethra . 247. Skene's button-hole scissors . 248. Dislocation of upper third of urethra 249. Complete dislocation with dilatation 249a. Operation for prolapse and dilatation 249&. Growths at the mouths of the glands 250. Sims's tenaculum . 251. Operation for vesico-vaginal fistula; paring the edges 252. Sims's sponge-holder . 253. Emmet's needles . 254. Curved track of the needle . 255. Operation for vesico-vaginal fistula; the sutures in place 256. Two sutures tied . 257. Kelly's ureteral catheter . PAGE 852 860 861 862 Plate IV Plate IV 897 898 898 899 899 900 900 910 Plate I, Fig. 83. I, Fig. 84. II, Fig. 85. II, Fig. 86. Ill, Fig. 113. Ill, Fig. 116. Ill, Fig. 117. IV, Fig. 249a. IV, Fig. 2496. Complete laceration of perinseum. do. operation; denudation. do. " rectal sutures. . In short, does the general physiognomy indicate health or disease i All these interrogations are made by looking critically at the patient. There are so many questions to be answered in this con- nection, that one may find some difficulty in promptly remembering them ; but by constant practice the mind and eye can be trained to take advantage of a rule of observation employed by critical investi- gators in other arts, which is this: having a type of normal organi- zation in mind, the observer is able to scan a given case, and detect any deviation from that standard of healthy formation and appear- 4 DISEASES OF WOMEN. ance. The artist, in looking at a picture or statue, does not neces- sarily question every line of the drawing or form by itself, but his trained eye catches any defects that there may be in the work before him. The classification of facts is simply putting together those which are similar in character. The arrangement of material things in groups is familiar to all. A well-arranged library, in which all books pertaining to a given subject are placed side by side, is a fair illustration of this kind of classification. Facts and ideas can be arranged in the mind upon precisely the same principle. The ad- vantage of classification is that it aids comprehension and memory. By recalling one group of facts which have been associated in the mind, the rest will follow in easy and natural order. There are two methods of classifying the information contained in the clinical his- tory of a patient. One is to obtain all the facts possible, and then to arrange them in order. The other is to classify them at each step of the examination. The former method requires a mental grasp and tenacity which few possess, and therefore I would advise the latter. The information obtained by inspection may be classed under four heads: 1. The original character of the organization, whether perfect or imperfect in structure and function. 2. If imperfect, whether from imperfect development, causing lesions of form or lesions of structure, or from inherited or acquired disease, and inher- ited tendencies to disease, known as diathesis. 3. Evidences of dis- ease, expressed in the face, either acute or chronic. 4. The tem- perament ; which simply means the preponderance of a certain portion or portions of the organization. To illustrate the value of this process of general inspection of patients, the partial history of a case seen in private practice will suffice. A lady called to consult me regarding her son, a little fel- low seven years of age. After a very brief survey of the patient, I saw enough to satisfy me that he had recently had scarlatina, and that when a child he had suffered from sore eyes, and that his father had been subject to rheumatic pains in years gone by. The mother acknowledged that I was right in every particular. A glance at the boy showed that exfoliation of the cuticle, which occurs after scar- latina, was still going on; the face was pale and puffy, indicating commencing dropsy from acute nephritis, a sequel of the eruptive fever. I also noticed that he had a scar upon the cornea of each eye, the result of a former keratitis. The form of his nose and the character of his teeth indicated an inherited syphilis ; and from the METHODS OE OBSERVATION. 5 appearance of his mother and other facts known to me, I presumed that the father was the one who had transmitted the specific disease. The age of the patient should be ascertained, because that sug- gests the possible existence of the diseases which are likely to occur at certain periods of life. Care should be taken to compare the real and apparent age, in order to ascertain if the patient is prematurely old, or well preserved. This interrogation will also serve to keep in mind the fact that, in early life, acute diseases prevail, while degen- erations are usually limited to advanced life. It is important to know the social relations of a patient—that is, whether she is married or single. If married, she is liable to the diseases and accidents attendant upon child-bearing. If she has never been pregnant, her sterility may have resulted either from choice, or because of some defect in her organization. Women who are single are, by reason of that fact, limited in the range of diseases of their sexual organs, and this may be taken for granted unless evi- dence to the contrary is obtained. Having made a general inspection of a given case, and ascer- tained the age and social relations, an examination of the various portions of the body should next be made in systematic order. To do this conveniently, one group of organs or one system should be examined at a time. The various systems are classified as follows: THE NERVOUS, NUTRITIVE, MUSCULAR, AND SEXUAL SYSTEMS. The first three are subdivided as follows: The nervous has two grand divisions, the cerebro-spinal and organic. The nutritive has four subdivisions, the digestive, circulatory, lymphatic, and excre- tory ; and the third has the osseous and muscular. The present purpose is to outline the methods of investigating the sexual system, but, in order to do that successfully, it is necessary to be able to examine the whole body. No one can be a trustworthy specialist without having a thorough knowledge of the whole organi- zation. All the parts of the body are so bound together by mutual relations that one can not accurately diagnosticate the diseases of one portion without knowing the condition of all the others. On account of that fact I must refer to the principles upon which the examination is made of parts other than the sexual system. Briefly, it may be stated that the two principal subjects of in- quiry are the condition of the function and structure of the organs under examination. Perverted function of the cerebro-spinal divis- (J DISEASES OF WOMEN. ion of the nervous system is manifested through derangements of sensation and motion, and abnormal states of the organic nerves is indicated when nutrition is deranged, while the organs of nutrition are free from structural disease. The condition of the circulatory system is indicated by the color of the skin and mucous membranes, the character of the pulse, and the heart-sounds. The general nutrition may be estimated by the appetite for food, the excretions, and the state of the* tissues generally. These are meager hints, but, if kept in mind while examining cases in the de- partment of gynecology, will guard against the mistake of overlook- ing affections of the general system, which might modify or cause diseases of the sexual system. In applying the principles already hinted at in the investigations of special diseases of the sexual organs, we find that morbid action is manifested by symptoms and physical signs. The symptoms may be classed under three heads : First, deranged nerve-action; sec- ond, deranged functions of the organs affected ; and, third, modified locomotion. First Class (nerve-symptoms).—Pelvic pains not specially local- ized ; sacral pain; pain of certain pelvic organs; pains beginning in the pelvis and radiating to other parts of the body. Second Class.—Derangements of function, such as deranged men- struation ; sterility; abnormal discharges; deranged function of the bladder and rectum. Third Class.—Aggravation of any or all of the above-named symptoms, by standing, walking, or other muscular exercise. Keeping this classification in mind, questions will suggest them- selves, the answers to which will determine the presence or absence of these symptoms. One should know the symptoms which belong to a given disease, and then ascertain if they are present by asking questions of the patient. Correct testimony will more surely be ob- tained in this way than by depending upon the voluntary statements of the person examined. The following plan will be of service in obtaining the symp- toms referred to in the three classes given above : First, ask if the patient has pain and where it is located. Ascertain also if this pain is connected with any of the functions of the pelvic organs. Then obtain the history of the functions of the sexual organs, in the past and present. These facts can be obtained from the patient herself, aided perhaps by some one who knows her well. Some practice is necessary to acquire skill in taking testimony, the value of which depends largely upon the physician's ability to make the METHODS OF OBSERVATION. 7 patient answer his questions correctly. Such questions as the fol- lowing regarding the menstrual function should be asked : At what age was the menstrual function first established ? At what periods of time has it recurred ? How long does it continue each time' What are the quantity and character of the flow ? Is it attended with pain, and if so, where is the pain located, and at what time does it occur in relation to the menstrual flow ? Has menstruation always.- been attended with pain, or only for a limited period in the historj of that function ? And, finally, is menstruation attended with de rangements of any of the other functions of the body '\ From the answers to these questions two points can be decided: First, whether menstruation has been performed normally during the whole or part of the patient's menstrual period of life ; and, sec- ond, if any derangement of that function exists, whether it be in character, recurrence, duration, or quantity. Next in order comes the history of reproduction. Has the pa- tient had children, and if so, how many, and when ? Has she mis- carried ? If she has, at what period of gestation, and at what time in relation to birth of living children if she has had any'. Was there anything abnormal in her pregnancies, confinement, or recov- ery from labor; if so, what ? The answers to these questions will determine whether the present conditions date back to some of the diseases or accidents of pregnancy or parturition. If the history so far obtained indicates any disease or functional derangement of the sexual organs, and there is any accompanying affection of the general system, the question arises, regarding the relations which they sus- tain to one another. That question can frequently be settled by ascertaining which of the two affections, the local or general, ap- peared first. The one which precedes is frequently the cause of that which follows. Thus far we have been dealing wTith symptoms which, as a rule, reveal only derangements of function. They are but expressions of disease, and do not in all cases indicate the conditions of the organization which cause the derangement of function. This brings us to the final division of our subject, viz., the phys- ical signs of disease. These are the physical evidences of change of structure. There are exceptions to the general rule that these physical evidences are always present, but they are few in number, and therefore may be omitted in our general consideration of the subject. The changes of structure and organization in the sexual organs, which are expressed by physical signs, are as follows: 8 DISEASES OF WOMEN. Changes of position, form, size, consistence, composition, color or appearance, and degree of sensitiveness. The means of obtaining physical signs are the touch — single or bimanual—palpation, percussion, speculum, sound, probe, curette, exploring-needle, uterine dilator, and microscope. The art of employing these means next claims attention. EXAMINATION BY THE TOUCH. This examination is most conveniently practiced when the pa- tient is placed upon a suitable table. One that is thirty-three inches high, forty-three inches long, and twenty-three inches wide, having a projection on the right-hand corner upon which to rest the feet, answers better than any table or chair that I have ever seen. Fig. 1.—Examining table. (The upper part of the foot-rest folds down as the dotted lines show, and the support can be pushed in.) The patient should be placed upon the back, with the pelvis as near the end of the table as possible, permitting the heels to rest upon the table also, while the thighs are flexed upon the body and the legs upon the thighs. A sheet held by the edge in both hands is drawn over the limbs from the feet upward, at the same time that the skirts are pushed up out of the way. This protects the patient from exposure. In this examination the index-finger of the right hand is gener- ally employed, but both right and left should be educated, because it is sometimes difficult to examine that side of the pelvis which faces the back of the hand used. In critical cases, therefore, it may METHODS OF OBSERVATION. 9 be necessary to employ both hands, first one and then the other, in order to complete the examination. In the majority of cases it is requisite to employ is quite satisfactory in spare patients with lax abdominal muscles; but when the muscles are tense, and when the walls of the abdomen contain a thick layer of adipose tissue, the examiner will find great difficulty in practicing it. In such unfavorable conditions, when the diagnosis is obscure, much will be gained by using an anaesthetic. Examination of the pelvic organs through the rectum is of great value. In this method the touch is practiced in the same way as in that already described. There are other methods practiced, such as introducing two fin- gers into the vagina, the index and the middle ; and the introduction of the whole hand into the vagina or into the rectum. Simon's method is to first dilate the sphincter-ani muscle, and then pass the whole hand into the rectum as far up as need be. Extraordinary advantages have been claimed for this method, which brings all the pelvic organs within the grasp of the examiner; but it has proved to be dangerous, and, owing to the fact that pressure benumbs the hand, it is more difficult than it appears to be theoretically. It should not be practiced, except in rare cases in which it is of vital impor- tance to make an accurate diagnosis that can not otherwise be made. These methods are not without danger, and always do less or more violence to the parts, and are only practiced in rare and obscure cases, mostly those of tumors. Dilatation of the urethra sufficient to admit the finger has been practiced and advised for the purpose of 10 DISEASES OF WOMEN. aiding in the exploration of the pelvic organs, but the information gained in this way does not compensate for the suffering and danger ; hence the practice is rarely called for, and still more rarely admissible. Digital Touch by the Rectum.—This method is generally resorted to when some obscure, abnormal condition has been discovered by the vaginal touch. Much satisfactory information can be obtained in this way, especially regarding the posterior wall of the uterus, the ovaries, and the sac of Douglas. The bimanual method of practicing the rectal touch is the same as the vaginal. Pressure upon the hypogastrium with the external hand gives the conjoined aid, as in examining by the vagina. Vesico-Vaginal Examination.—In this method a sound is passed into the bladder while the finger is in the vagina. By this means certain states of the vagina, urethra, and bladder are investigated. Vesico-Rectal Examination.—This is the same as the vesico-vaginal except that the finger is introduced into the rectum. It is the more valuable of the two in exploring all that lies between the bladder and rectum. Palpation.—Whenever the touch discovers anything abnormal, as a tumor, an enlargement of the uterus, or products of inflamma- tion, additional information can be obtained by abdominal palpation. This is accomplished by manipulating the abdomen so as to outline the part in question, and to test its sensitiveness, mobility, and density. Both hands are usually employed in this examination. Percussion.—It is unnecessary to describe the manner of practicing percussion. Suffice it to say that percussion is practiced in exactly the same way in exploring the abdomen as it is in exploring the thorax, the object being to test the density of the abnormal part and outline its relations to the abdominal organs. Palpation and Percussion Conjoined.—This consists in resting the fingers of one hand at one point on the abdominal walls and making percussion at another point. Its chief object is to ascertain if there is fluid present; this is shown by fluctuation. There are three ways of accomplishing this: The first is to select points on the distended abdomen directly opposite one another, resting the fingers lightly at one part, and percussing at the other. This is known as the dia- metrical method. The second, the peripheral method, is to take points on a section of the abdomen and manipulate in the same way. The third consists in resting the fingers at one point and making pressure at the other, to see if the part is wholly movable or partially so. This differs from the others essentially in substituting inter- rupted pressure for percussion. METHODS OF OBSERVATION. 11 The Speculum.—This instrument is twofold in its use. It is one of the most important aids in the investigation of disease, and at the same time a necessary instru- ment in treat- ment. A great variety of spec- ula are used, but two answer all requirements. Sims's speculum and Cusco's bi- valve, slightly t_o t Fig. 3.—Sims's speculum. modified, answer every indication. In fact, Sims's speculum is all that is needed, ex- cept when an assistant or nurse can not be obtained to hold the specu- lum, then Cusco's may be employed with advantage in examining the cer vix uteri, and for the purpose of making applications thereto. In using Sims's speculum it is ne- cessary to have the patient upon the Fig. 4.—(Jusco s bivalve speculum. L r table already de- scribed, which should be near a window giving a good light. Oc- casionally it may be necessary to examine a patient upon the bed, but this is difficult, and should not be undertaken until the ex- aminer has acquired by practice great facility in the use of the instrument, and only then, when it is impracticable to place the pa- tient upon the table. The position of the patient should be on the left side, semi-prone, with the left arm behind the back, the head upon a low pillow, and near the right-hand side of the table, the limbs drawn up, the right limb above and in front of the left, and the pelvis at the end of the table on the left-hand side. Fig. 5 illustrates this position. In order to place the patient in this position, she should stand upon an ottoman or low chair, with her left side toward the end of the table. The skirts on the left side are then raised, and she is directed 12 DISEASES OF WOMEN. to sit down on the table; her left hand is placed behind the back, and she is made to lie down on the left side, inclining forward. The Fig. 5.—Sims's position, seen from above. Fig. 6.—Nurse holding Sims's speculum. limbs are at the same time drawn up and placed in proper position. The skirts are then pushed up on the right side, and at the same 22 METHODS OF OBSERVATION. 13 Nw^d ? time a sheet is drawn over the limbs and arranged so as to expose the labia only. The speculum is introduced by separating the labia with the fingers of the left hand, holding the instrument in the right hand by the handle ; the point of the blade is placed upon the posteri- or commissure, and, while backward pressure is made, the speculum is passed into the vagina. Care should be taken not to touch the meatus urinarius. The free blade is then grasped with the right hand by the nurse or assistant, while with the left she raises and supports the natis and labium on the upper or right side. The position of the one who holds the speculum should be with the left side toward the patient, the fingers of the right hand surrounding the blade, while the thumb rests in the inside of the blade. The elbow should rest against the side, as a point of purchase to give ability to make steady traction. The left arm should rest upon the right hip of the patient, while the hand supports the labium and natis to keep them out of the way (Fig. 6). Careful training is required to enable one to hold the speculum properly. The chief and essential requirement is to maintain the instrument for any desired length of time in the position in which the operator may choose to place it. The objects to be at- tained by the use of the speculum are, to distend the vulva by making traction upon the posterior commissure, and at the same time to draw the whole floor of the pelvis or perinseum backward toward the sacrum, away from the pelvic organs above, which, from the position of the patient, gravitate toward the abdomi- nal cavity. By these means the vagina is distended by atmospheric pressure, which gives space for the admission of light, and room for inspection or manipulation in operating. These facilities can be extend- ed by changing the position of the specu- lum in the following manner: The as- sistant who holds the instrument can, by rotating the hand, cause the point of the blade in the vagina to describe the arc of a circle (Fig. Y). By moving the hand forward, the blade is made to point backward r^ Fig. 7.—The movements of the speculum. First movement. Fig. 8. Second movement. 14 DISEASES OF WOMEN. Fig. 9.—The third movement. toward the rectum; and by moving the hand backward, the blade is caused to point forward (Fig. 8); and, finally, by raising or lower- ing the hand, the speculum is made to reflect the light upward or down- ward to either the upperorlower side of the vagina, according to the re- quirements of the examiner (Fig. 9). At the same time that all these changes of position are being made, the required traction upon the pe- rinseum can be maintained. In using the Cusco speculum, the position of the patient is the same as for examination by the touch. The labia are separated with the left hand, and the instru- ment introduced with the blades closed, the direction of introduction being downward and inward. When the speculum is in position the blades are separated. There is quite often difficulty in bringing the cervix into view through this instrument. This can usually be avoid- ed by getting the point of the posterior blade well under the cervix before separating the blades. This speculum is principally used in the treatment of the simpler diseases of the cervix uteri, when an as- sistant can not be procured to hold a Sims's speculum. As a means of investigation it is quite limited in its use. Hunter's Depressor.—This instrument is used to depress the anterior vaginal wall. It acts like the anterior blade of a bivalve speculum, and is a necessary companion to Sims's speculum. Of all the depressors, Hunter's I regard as the best. Fig. 10.—Hunter's depressor THE UTERINE SOUND AND PROBE. There are three kinds of sounds: Simpson's, which is made of hard metal, and maintains an unchangeable shape; Sims's, which is of soft metal, and can be bent or molded to any curve; and a third, which is elastic and bends on the slightest pressure, but by its elas- ticity regains its original shape. There are two varieties of the lat- ter : that made of elastic material like whalebone or rubber, and a metallic one, rendered elastic by a spiral arrangement in its mechan- ism, known as Jenks's. Simpson's sound is seldom used now, except METHODS OF OBSERVATION. 15 in a modified form. It is difficult to use, because its shape can not be adapted to different cases; and it is dangerous, from the fact that it will not bend to light pressure. Fig. 11.—Sims's probe. Sims's probe is made of soft copper or pure silver, both of which metals have the quality of being easily molded. It is like the ordi- nary probe used in general surgery, only longer and a little thicker, and is provided with a handle (Fig. 11). The probe which is most generally used, and the one which I prefer for ordinary use, is the same as Sims's, only thicker. It is stiff enough to sustain all requisite pressure, and yet can be easily G>."T\E.N\I\NU &^0. Fig. 12.—Whalebone sound. molded to any curve. In practice it is well to be provided with this one as well as that of Sims. The elastic probe is the same in form as Sims's, but is made of rubber, gum-elastic, or whalebone (Fig. 12). The sound of E. W. Jenks is hollow and spiral for a distance of two thirds from the pointed end. This spiral arrangement gives it flexibility. It is also graduated and provided with a sliding sheath which is very convenient in measuring the depth of the uterus, the ,/v 4__ ^ g.-\\oai\nu&<.co. Fig. 13.—Jenks's sound. arrangement being such that the examiner can run the sheath to- ward and away from him, the figures at the end of the sheath near- est the handle giving the measurement of the distance from the point to the distal end of the sheath (Fig. 13). The sound or probe should only be used after the position of the uterus has been ascertained by a digital examination, and its sensi- tiveness tested as far as that can be by the touch. It is very impor- tant to know the position of the uterus and its relations to the other organs, in order that the sound may be curved to suit the direction 16 DISEASES OF WOMEN. of the canal of the uterus, and to suggest the direction in which the instrument should be guided. There are two ways of probing the uterus: In the one, the patient is placed upon the back, and the fin- ger of the examiner is carried up to the os uteri; the sound is then guided along the finger until it enters the canal, when it is passed to the fundus, the handle being depressed to make the sound correspond to the direction of the canal of the uterus. The other way is to expose the uterus with Sims's speculum, and to pass the sound with the aid of the eye. This latter method is the easiest and safest, and gives at least as much information as the one first described. The vaginal walls being distended by the speculum, the instrument is free to accommodate itself to the direction of the canal of the uterus, and, aided by sight, the os uteri can be found at once. Safety in using the sound does not depend so much upon the touch which guides the instrument to the uterus as upon the hand that holds and passes it into that organ. There are few who acquire the perfection of touch to guide the sound into the unseen uterus without using force, which, though very slight, may cause mischief. In sounding or probing the uterus in any way, force should not be used. This rule should never be violated. The Sound and Palpation Combined.—In this method of examina- tion the sound is passed by touch, with the patient upon the back, and, while it is in the uterus, it is held with one hand; the other hand is placed upon the abdomen, and downward pressure made until the uterus is felt. The uterus is then moved by the sound, and the movements are detected by the hand upon the abdomen. The in- formation obtained in this way will be noted farther on. The Curette.—This instrument is used to explore the cavity of the uterus in order to detect any abnormal growths which may be there, and also to remove portions of such growth for inspection, in order to determine their character. The instrument best adapted to this purpose is made upon the principle of the Recamier curette. It is simply a scoop of small size with a stem of flexible copper or sil- ver, the object of this flexibility being to enable the investigator to bend or curve it to suit the position of the uterine canal, and also Fig. 14.—Skene's curette. that it may bend before doing any damage to the endometrium if undue force is inadvertently used (Fig. 14). The curette is introduced through a Sims's speculum in the same METHODS OF OBSERVATION. 1Y manner as the sound, and when once within the cavity of the uterus it is passed over the surfaces of the endometrium, and if any pro- jections are detected a portion can be scraped off and removed for inspection. The further use of the curette will be again described, in connection with the treatment of diseases of the uterus. The Aspirator.—This instrument is employed to investigate the contents or composition of tumors formed in the pelvis. When the question arises whether the tumor present is solid or fluid, and if fluid what the character of the fluid is, the use of the aspirator will determine. The aspirator used in general surgery answers well; still, a hypodermic syringe, larger than the usual size, and armed with a long, slightly curved needle, thick enough at the end nearest the syringe to give it strength to bear pressure, is more convenient. The method of using the exploring aspirator is as follows: The patient is placed upon the back, and the point of the needle is guided to the part to be examined, and is then thrust into the mass or tu- mor ; the piston is then drawn out, and the fluid, if any be pres- ent, is examined. Uterine Dilators.—When it is necessary, as occasionally happens, to dilate the cervical canal in order to explore the cavity of the uterus, resort must be had to some of the dilators. These are of two kinds: The first consists of graduated dilators, which can be passed in rapid succession, such as the dilators of Hanks (Fig. 15), and the instruments with expanding blades (Fig. 16). These are in- tended to produce rapid divulsion to the required extent. The other kind acts by the swelling of the material of which they are made. Of these tents the compressed sponge (Fig. IT), sea-tangle, and tupelo (Fig. 18) are in general use. It is seldom that tents are required for purposes of examination 3 18 DISEASES OF WOMEN. only; the dilators mentioned answer, as a rule. They act more promptly, and are less likely to cause after-trouble if dilatation is not carried to an extent which is seldom necessary for purposes of ex- amination. Tents are to be avoided if possible, because of the suffer- Fig. 17.—Sponge tents. Fig. 18.—Tupelo tents. ing they cause, and the danger of inflammation and blood-poisoning, both of which misfortunes have followed their use. They expand slowly, and cause irritation and pain, which must be endured for hours before they accomplish their work. Acting thus like foreign bodies and powerful irritants, they are not without danger. The dilators act more promptly, and are less likely to induce inflamma- tion, and, although they cause pain and irritation, these are of short duration. The Concave Mirror.—This is commonly known as the head-mirror, and is used in the practice of laryngoscopy. It is also of much use in speculum examinations when a good light can not be obtained. In emergencies occurring at night, the mirror enables the surgeon to use artificial light with perfect satisfaction. Placing a lamp by the side of the patient in front of the examiner, the light can be reflected into the vagina so as to expose the parts in a very perfect way. Facility in the use of this mirror should be acquired, as it is at times indispensable. The Microscope.—A careful scrutiny of the minute structure of pathological specimens is always necessary to complete diagnosis, hence the microscope should be placed high in the list of means for exact observation and investigation. All that need be done in this connection is to remind the reader of the fact. A knowledge of the microscope and its use must be obtained elsewhere. The prog- ress in microscopic investigation has been so great that many men in active practice have neither the time nor the ability to make their own microscopic investigations. When such is the case, the duty of the gynecologist clearly is to seek the aid of the microscopist that he may obtain through him the required information. METHODS OF OBSERVATION. 19 Anaesthesia.—There are certain cases that can not be examined without being anaesthetized. When there is great tenderness of the pelvic organs, and the abdominal muscles are in a condition of spasm, which render the examination wholly impossible or suffi- ciently unsatisfactory to leave a doubt in the mind, then ether should be given to the extent of complete anaesthesia. The relaxation which this affords simplifies all investigations in a very marked degree. In the investigation of the pelvic organs of insane women and in vir- gins who certainly require examination yet can not submit, the nitrous-oxide gas is of great value. It acts quickly and pleasantly, and has none of the effects during or after its administration which are so distressing to those of sound mind and horrifying to the insane. The mode of administering it is with the apparatus used by den- tal surgeons to whom we are indebted for perfecting the apparatus for giving this anaesthetic. The gas is condensed in a strong cylin- der which holds one hundred gallons. By a valve arrangement it is permitted to escape into a rubber bag, from which it is inhaled. The inhaler is an ingenious arrangement by which the act of inspi- ration opens a valve that permits the gas to be drawn from the bag, while the act of expiration closes the valve in the supply-tube, and opens another valve for the escape of the impure air. There is still another valve under the control of the operator, which admits air with the gas, so that when the patient is fully anaesthetized the gas can be diluted with air in sufficient quantity to keep up the anaesthesia. The cylinder of condensed gas and the inhaler are put up in a case convenient to carry. The mechanism of this apparatus can be more easily comprehended by examination than by descrip- tion, and a little practice will enable any one to use it. To be able to recognize the normal and pathological conditions which are revealed by the means described requires much practice. It greatly aids in obtaining that practice—in fact, it is quite neces- sary—to keep clearly in mind what to look for. In order to facilitate the memorizing of the objects to be investigated, I have arranged the signs under each of the various means of obtaining them as follows: Vaginal Touch.—Position, size, shape, and density of the uterus. Size and shape of the os externum. Presence or absence of discharge from cervix. Condition of vaginal walls, perineal body, and recto-uterine space. State of the rectum and lower portion of sac of Douglas. Position of the bladder and urethra as indicated through the an- terior vaginal wall. 20 DISEASES OF WOMEN. Presence or absence of fixation of pelvic organs; swelling or tu- mors in the sac of Douglas or broad ligaments. Tenderness at any part. Bimanual Touch,—Size, form, and position of the body of the uterus. Tenderness and mobility of the uterus and other organs and tissues. Position and state of the Fallopian tubes and ovaries. Condition of the bladder. Presence of neoplasms and their relation to the pelvic organs. Products of inflammation, their location and character. Rectal Touch.—Condition of the rectum, posterior surface of the uterus, broad ligaments, Fallopian tubes and ovaries, and utero- sacral ligaments. Vesico-rectal Touch.—Absence of the uterus from its normal position in inversion of the uterus, entire absence of the uterus; aid to diagnosis in women who are too fat to permit the bimanual examination. Vesico-vaginal Touch.—Changes in the position of the bladder and urethra. Results of disease in the vesico-vaginal septum. Palpation.—Form, size, and density of tumors or products of in- flammation felt through the abdominal walls. Percussion.—Density of morbid parts. Normal resonance. Relations of the above. Palpation and Percussion Conjoined.—Fluctuation, density, or elasticity of morbid parts. Speculum.—Appearance of mucous membrane of cervix uteri and vagina. Signs of inflammation of mucous membrane. Relations of the cervix to the vagina. Form of os externum. Character of secretions. Signs of injuries to the cervix and vagina. Nature of new growths suggested by their appearance. Sound and Probe.—Direction of the canal of the cervix and cav- ity of the body of the uterus, in relation to their normal position in the pelvis. Relation of the canal of the cervix and cavity of the body to each other. Straight, deflected, or tortuous state of the cavity of the uterus. Long and transverse diameters of the cavity of the uterus. METHODS OF OBSERVATION. 21 Caliber of the cervical canal, os externum, and os internum. Degree of sensitiveness or roughening of the different portions of the cavity of the uterus. Sound and Palpation Combined.—Displaced uterus may be raised up to meet the touch of the hand upon the abdomen for examina- tion. Mobility of the uterus with or without moving abnormal growths m the pelvis or lower portion of the abdomen. Curette.—Presence or absence of growths or tumors in the uterus. Removal of portions of growths from the cavity of the uterus for inspection. Aspiration.—Abstraction of fluid (encysted or otherwise) for in- spection. Dilators, tents, anaesthetics and head-mirror as aids with other means of exploration. Fig. 18a.—Ether-inhaler. Its principle is the same as that of the nitrous-oxide appara- tus. The reservoir, b, in which the ether is vaporized, is separated from the mouth- piece, a, by the long rubber tube. The valves, e, of the mouth-piece permit the expired air to escape without coming in contact with the ether-vapor. The valve, D, enables the anaesthetizer to administer pure air or pure ether, or any proportion of air and ether, f is the rubber tube and stop-cock by means of which the mouth- piece is blown up. c is a funnel through which the ether is passed, g is the joint uniting tube and inhaler. The advantages of the apparatus are that the ether-vapor is warmed, that reinspiration of expired air is avoided, and that the ether may be diluted with air to maintain the required anaesthesia. The stage of violent excite- ment caused by partial suffocation is avoided, and prolonged anaesthesia can be maintained without the slightest imperfection of aeration of the blood. CHAPTER II. DEVELOPMENT OF THE SEXUAL ORGANS. The Fallopian tubes, uterus, and vagina are developed from two primary elements known as Miiller's filaments. These filaments when first visible in the embryo are solid, and are situated on either side of the vertebral column, a little in front of and on the inner side of two other primary elements, the Wolffian bodies. The changes which take place in Miiller's filaments during the evolutions of de- velopment are as follows: From solid fibers, slightly enlarged and club-shaped at their upper ends, cavities are formed, and these be- come canals. Their lower ends approximate and coalesce, from below upward, less than half their length. This change, which takes place between the ends of the sixth and eighth weeks of foetal life, is repre- sented in Figs. 19 and 20. At this stage of develop- ment, Miiller's ducts are separated by a septum formed from their coalescent walls, so that the united portion shows a right and left cavity. These two cavities are soon converted into one, the septum disappearing from below upward throughout the whole of the united portion of the ducts. The lower single canal thus formed is the rudimentary vagina and uterus, while the two upper ends of Miiller's duets form the Fallopian tubes (Fig. 21). From this time to the fifth month there Fig. 19.—Muller's ducts. Fig. 20. —Coalescence of ducts. Fig. 21.—Disappearance of septum. Fig. 22. — Appearance fundus and cervix. of DEVELOPMENT OF THE SEXUAL ORGANS. 23 is an increase of tissue, especially in the upper portion of the canal, which renders the distinction between the vagina and uterus appar- ent. The upper ends of Miiller's ducts expand and become slightly fimbriated at their extremities. The upper portion of the uterus at this time is bifurcated and forms the two horns between which the fundus is subsequently developed. Fig. 22 shows the organs at this stage of development. In the sixth and seventh months the uterus increases in size, especially in the cervical portion, which at this stage is much larger than the body. There is also an increase of tissue between the horns of the uterus which renders their diverg- ence less marked. The rugose arrangement (palma plicata) of the rudimentary mucous membrane of the cavity of the uterus extends very nearly to the fundus, its folds running outward to the uterine orifices of the Fallopian tubes. Ele- vations appear in rows upon the mu- cous membrane of the vagina which are the rudiments from which the transverse folds are subsequently de- veloped. During the eighth and ninth months the thickness of the walls of the body of the uterus increases, the fundus becomes more prominent and rounded, but up to the time of birth the cervix is larger than the body of the uterus. At the time of birth the primary development of the uterus is complete, and it changes very little in form from that time until the period of puberty. The size and appearance of the infantile uterus are shown in Fig. 23. The cavity of the uter- us and the arrangement of its mucous membrane are represented by Fig. 21. Fig. 25 gives a side-view of the uterus and vagina, and shows their relations to each other. At this time the cervix pro- jects but little into the vagina. From the time of birth, when primary development is complete, up to the period of puberty, the uterus undergoes very lit- tle change except during the second den- tition. At that time the body increases in Fig. 25.—Infantile uterus, an- size becoming more nearly equal to the tero-posterior section, scant '. „. ° , t . t invagination. cervix. The palma plicata disappears Fig. 23.—Infan- tile uterus. Fig. 24. — Palma plicata extend- ing nearly to fundus. 21 DISEASES OF WOMEN. from the body of the uterus, excepting one longitudinal fold. The uterus gradually descends into the pelvic cavity and the cervix is projected down into the vagina a little farther. From this time no changes occur worthy of notice until puberty, when secondary de- velopment takes place. Secondary development consists in a general increase in the size of the uterus, especially in the body and fundus, which become much larger than the cervix. The length of the uterus is increased. The walls become thicker and firmer. The last trace of the palma pli- cata disappears from the mucous membrane of the cavity of the body, and the mucous membrane becomes thicker by the formation of its glandular tissues. In this way the uterus attains the shape and size of maturity. Together with the changes in size and form comes a change of position. The uterus descends into the pelvis and complete invagination of the cervix occurs. Fig. 26 shows the general appearance of the mature uterus in outline, and Figs. 27 and 28 represent the relations in which the cervix and vagina stand to each other. By comparing Figs. 23 and 25, which illustrate the infantile uterus, with Figs. 26 and 27 the difference between the results of primary and secondary develop- ment will be fully comprehended. DEVELOPMENT OF THE SEXUAL ORGANS. 25 MALFORMATIONS OF THE UTERUS. The malformations of the uterus are naturally divisible into two classes : those that occur during embryonic life, and those that occur at puberty, the period when secondary development takes place. The first class embraces the greatest variety. Nearly all of these malformations are due to arrest of development at different stages of that process. The malformations most frequently seen are the uterus Fig. 29.—Double uterus and vagina from a girl aged nineteen (Eisenmann): a, double vagi- nal orifice with double hymen. bipartis, uterus duplex, uterus unicornis, uterus bicornis, uterus bi- fundalis unicollis, and rudimentary uterus, generally known as ab- sence of the uterus. A very rare condition has been described as hypertrophy of the uterus, and classed with the malfonnations. It is really not a malformation, but a complete development of the 26 DISEASES OF WOMEN. uterus during infantile life. When the first evolution in the process of development—i. e., the union or coalescence of Miiller's ducts— Fig. 30.—Uterus unicornis from a young child, posterior aspect (Pole): b, right Fallopian tube; c, left Fallopian tube exceptionally present; d d, ovaries ; e, bladder (Courty). is arrested, and each duct grows by itself, the result is the uterus bipartis (Fig. 33). The uterus duplex is formed by the coalescence of the ducts, with arrest of absorption of the central wall. The development goes on, so that in time the whole organ is larger than the normal uterus, but it is divided into two by the central wall (Fig. 29). Uterus unicornis is produced by a complete arrest of development of one of the ducts at the part which should form one half of the body and fundus of the uterus (Fig. 30). The uterus bicornis occurs as the result of non-union of that part of the ducts which forms the Fig. 31.—Uterus bicornis unicollis (Winckel). body and fundus (Fig. 31). The uterus bifundalis unicollis is formed by the same error of development as that which produces the uterus bicornis and double uterus with the following difference : In the DEVELOPMENT OF THE SEXUAL ORGANS. uterus bifundalis (Fig. 32) the horns, though not united, are well de- veloped and present outlines more nearly like the normal body of the uterus and the septum formed by the union of the ducts at the part which forms the cervix. In this it differs from the uterus duplex (Fig. 33). Entire absence of the uterus is perhaps unknown, unless in monstrosities in whom the lower part of the trunk is wanting. Rudiment- ary uterus is seen occasionally. As most frequently found, there is a very small cervix slightly, if at all, invaginated, and in place of the body of the uterus one or two small solid masses are Fig. 32.—Uterus bifundalis unicollis. Fig. 33.—Uterus duplex (Cruveilhier). Left walls developed in consequence of pregnancy. found from a quarter to half an inch in thickness and about the same in length. The effect of these malformations as manifested during func- 28 DISEASES OF WOMEN. tional life is quite remarkable. In some there is not the slightest deviation from health in the function of the sexual organs. In others the results are very disastrous. This practically gives two classes of malformations according to the effect they have upon the health and usefulness of the subject. In the one class the malfor- mation does not materially affect the function of the uterus, while iu the other, the functional action is always imperfect—sometimes im- possible. The cases of simple deformity, in which there are suffi- cient development and growth of one or both elements of the uterus to make the organ functionally competent, have no ill effect upon the general usefulness and welfare of the individual. The follow- ing case will illustrate this : Double Uterus and Vagina.—A married lady, thirty-two years of age, who had borne three children and nursed them, called upon me for advice regarding a leucorrhcea which had troubled her since the birth of her last child. Her general health had always been ex- cellent. Upon making a digital examination, I found the vagina normal and also the cervix, excepting that one side of the cervix was closely united to the vaginal wall throughout its entire length. On the left side of the vagina high up I found a hard mass which was also noticed on making bimanual exploration. The first im- pression was that she had suffered from a pelvic cellulitis, and that the mass on the left side was the remains of its products. This idea was given up at once on finding that the patient gave no history of any pelvic inflammation. I then suspected that there might be a fibroid in the left side of the uterus, which, by extending the entire length of the cervix, had pushed the vaginal wall before it. A speculum examination revealed a ca- tarrh of the cervical canal. The uterus had the usual appearance of one that had borne children, and the cervix was normal in shape and position, except for the peculiar relations of the cervix and vagina on the left side, which were noticed during the examination with the touch. Just within the labium minus on the left side, a pe- culiar fold of the vaginal wall was noticed running transversely. On raising this fold with the point of the sound it was found to be a septum, and there was also discovered another vagina to the left of it. Using a smaller Sims's speculum to distend this vagina, I found the other cervix which had all the characteristics pertaining to a nul- lipara. The passage of a sound showed that the canal of the uterus on the left side was not quite so long as the one on the right. It was then clearly evident that the patient had a double uterus' and vagina, and that the right uterus had borne three children, while DEVELOPMENT OF THE SEXUAL ORGANS. 2(J the left uterus was a virgin one. She was attended in her confine- ments by three different physicians, none of whom made any refer- ence to this malformation, and it is fair to suppose that none of them discovered it. This case is of interest as showing the fact that some of the mal- formations do not in any way affect the function of the uterus nor the general health of the subject. When there is malformation, and the growth of the uterus falls so far short of the normal type that functional activity is impos- sible, the results are often very unfortunate. The nature of this class of cases bears such close resemblance to those in which there is arrest of secondary development at puberty, that they may be con- sidered together in the following chapter. A Unique Case of Double Uterus.—In this case I found a large uterus with a well-formed cervix, and directly in front of it a very much smaller uterus, the cervix of which was but slightly in- vaginated (Fig. 34). On my first exami- nation I made a diag- nosis of uterine fibro- ma. I thought that I could outline the tumor projecting from the uterine wall toward the bladder. Subsequently I noticed a free dis- charge of uterine leu- corrhcea issuing from a slight elevation on the vaginal wall in the median line, about an inch from the os ex- ternum of the larger Fig. 34.—Double uterus. uterus. I passed a sound through the small opening in the wall of the vagina, and found that it entered about an inch and three quarters, demonstrating that the supposed fibroid was a small uterus. I account for this strange malformation on the theory that, during development and after coalescence of Miiller's ducts, these rudiments made half a revolution, thus bringing one in front of the other. CHAPTEK III. ARREST OF DEVELOPMENT, AND ENTIRE ABSENCE OF FUNCTIONAL ACTIV- ITY__ARREST OF DEVELOPMENT AND GROWTH IN THE LATER STAGES OF EVOLUTION, AND THE CONSEQUENT IMPERFECTION OF FUNCTION. If absence of the uterus or a rudimentary state of its develop- ment is associated with absence or a rudimentary state of the ova- ries, there is no tendency to functional action, and the individual may not suffer in consequence. She simply remains an imperfect and undeveloped being. But when the ovaries are present and functionally active, there is generally a tendency to menstruate; and this tendency, unrelieved by a menstrual flow, is often attended with great derangement of the general health and much suffering. The first evidence of this malformation from arrest of develop- ment that comes to the notice of the physician is derangement of the menstrual function in some form, or its non-appearance at the proper age. On this account it will be well to discuss in a general wTay the nature and characteristics of menstruation before giving the history of its derangements, which arise from lesions of structure resulting from imperfections of development and growth. Menstruation has been the subject of so many speculations re- garding its physiology, that it would be unprofitable to enumerate them. Suffice it for our present purpose to state that when the uterus attains its normal development in a healthy subject it becomes pos- sessed of all the requisites necessary to the development of an ovum ; but when impregnation does not follow, the mucous membrane of the cavity of the body of the uterus undergoes degeneration, either wholly or in part, and is exfoliated in a granular state. This degen- eration and exfoliation, according to some observers, involve the whole membrane down to the muscular walls, while others claim that they only affect the epithelial layer. Be this as it may, there ap- pears to be a general agreement among the authorities of the present time that degeneration and exfoliation occur to an extent sufficient ARREST OF DEVELOPMENT. 31 to expose the smaller blood-vessels of the endometrium, and to so weaken their walls that they give way and haemorrhage follows. This menstrual flow is composed of blood from the vessels, with at least the debris of the degenerated and exfoliated epithelium. The flow, which lasts for days, subsides, the mucous membrane is renewed, and the same high state of anatomical completeness and functional capability is restored, when another menstruation takes place, and so this function is repeated over and over again, except when suspended during pregnancy or lactation, until the end of functional activity at forty-five years of age or thereabout. During the period of functional activity of the sexual organs, from puberty to the menopause, menstruation is an evidence of health, and is also essential to health. It is an index of the state of the sexual system and also of the general health of mature women. Hence its derangements constitute most valuable evidence of the presence of disease, while its normal recurrence is an evidence of health. In practice it is best to study this function by its character- istics, rather than by theories regarding its cause or the reasons for its existence. It is on this account necessary to comprehend its nat- ural history; therefore, I propose to give here a synopsis of the con- ditions of menstruation. The laws which govern this function of menstruation, as given in our text-books, are so varied by climate, personal peculiarities, and the conditions of life, that a general average pertaining to these laws is about all that can be obtained, and this can be used to very little advantage in practice. Fortunately, there are certain rules which apply to menstruation with great uniformity, and these should be clearly understood. The most important of these are the fol- lowing : 1. Menstruation should begin at puberty—i. e., when the woman is maturely developed, no matter what the age may be. Increase of size may take place by growth after puberty, but all the organs of the body should be completely defined, so far as form and structure are concerned, before the function of menstruation is taken up. 2. It should recur at regular intervals ; about every twenty-eight days is the average time. A regular periodicity is normal, but the duration of the periods often differs in different persons. 3. The discharge should always be fluid in consistence and san- guineous in color. 4. The flow should continue a definite length of time, the dura- tion depending upon the habit of each case; at least there should not be any great deviation from this rule. 32 DISEASES OF WOMEN. 5. The quantity should be about the same each time. There should be no deviation from the first rule. If the menses appear before development is complete, both in the sexual organs and the general system, it is an error which is either the result of disease or of the surroundings of the patient, and generally modifies unfavorably her future life unless it can be corrected. The same may be said regarding those who fail to menstruate when the devel- opment and growth of the body are completed. The other rules re- garding the recurrence, duration, quantity, and character of the men- strual flow, may vary in different women, but they should be uni- form and regular in each person. Whatever the habit may be that is established at puberty in a given case, that habit should be main- tained through life. Some women menstruate systematically from puberty until after bearing a child, then they take up a different order of menstruation in regard to all or some of the characteristics of that function. That is normal, but it is the only well-marked change in habit which is the same in health. Obedience to these laws of the menstrual function implies cer- tain conditions that are necessary to the fulfillment of these laws. These may be briefly stated as follows : 1. Maturity of development of all the organs, both of the general and sexual systems, and a fair degree of health of all. 2. A sufficient and well-regulated supply of normal blood to the sexual organs. 3. Normal structure and functional activity of the nerves which preside over the action of the sexual organs. 4. Conditions of life favorable to general health and reproduc- tion. This includes food, climate, society, and occupation. Allusion has already been made to absence of the uterus and also to its rudimentary states in which the menses never appear, and because of these marked anatomical defects and absence of function nothing can be done by the gynecologist in the way of improve- ment. There remain to be considered cases in which the conditions of menstruation are all present but in an imperfect degree, so that men- struation, although established, is performed imperfectly. ILLUSTRATIVE CASES. Uterus Unicornis; Imperfect Menstruation and the Results.—A woman, twenty-nine years of age, of healthy parents, above the average size, and well formed generally, had enjoyed excellent health until she was eighteen years of age. About that time her ARREST OF DEVELOPMENT. 33 mammary glands became well developed and she presented all the outward characteristics of woman physical and psychical. She then began to suffer at stated periods from backache, a sense of fullness in the pelvis, and slight leucorrhoea. In a day or two after these symptoms came on, and while they continued, she became heavy and sleepy, and had a feeling of fullness in the head and slight head- ache. These attacks lasted several days, when they passed off and again returned about every month. In the interval her health was good and she performed her duties as a domestic. Five months after the first time that these symptoms appeared, and while she was suf- fering from an attack, she had a slight menstrual flow, which lasted less than twenty-four hours, and appeared to alleviate her suffering. The next month her flow returned in the same way, but all her symp- toms were increased. From this time on her menstrual flow re- turned regularly, but did not increase in duration or quantity. At each recurring menstrual period her suffering increased in severity until she was obliged to give up her duties at such times. On one occasion when she was trying to do her work while suffering, she was exposed to cold and was seized with an inflammation—pelvic peritonitis, no doubt—and was taken to the hospital, where she re- mained for three months. During that time she took morphine lib- erally. From this time her suffering during the menstrual period was very great, sufficiently so to keep her in bed, and to require large doses of morphine to make life tolerable. Another attack of pelvic peritonitis came, and again she was sent to the hospital for treatment. She recovered from the acute attack, but her suffering at her periods was far greater than ever before. Epileptiform con- vulsions came with her pelvic pains, and were repeated frequently until the menstrual period passed by. For several years her time was spent between her home and the hospital, and in occasional efforts to do the duties of a house-servant. Condition when First Examined .—Raving obtained the above history from the patient, I observed that she still had all the evidence of fair general health, except that, from pain and the use of mor- phine, her nervous system was decidedly impaired. Physical Signs—The touch detected a very small cervix uteri which projected into the vagina only half an inch. The organs and tissues were fixed, and on the left side there was an irregular mass which felt like the products of a former pelvic peritonitis. On the right side the parts were less elastic than normal, and, owing to an exceedingly tense state of the abdominal muscles, the body of the uterus could not be felt, neither could the right ovary be positively 4 34 DISEASES OF WOMEN. made out. From the negative signs, however, I was able to satisfy myself that the right ovary was not enlarged, nor was the body of the uterus as large as it ought to be. The speculum revealed noth- ing of value, but, in using the sound through it, I could pass that in- strument into the cavity of the uterus. The canal of the cervix was an inch in length, and in its proper position as indicated by the sound. When the internal os was reached, the sound turned to the right and passed in that direction about an inch. This led me to suspect that the uterus was unicornis. To obtain further evidence, the speculum was removed, while the sound was left in the uterus. The patient was then placed upon the back, and, by the rectal and vaginal touch combined, the horn of the uterus above the vagina was reached. While making the combined touch, an assistant rocked the horn of the uterus with the sound, and I could then out- line it with the fingers. It was about an inch in its transverse, and only a little more in its long diameter. The upper end, which rep- resented the fundus, appeared to be slightly pointed in place of rounded, as is the fundus of the normal uterus. Treatment.—There was nothing in the case to give the slightest hope that she would derive benefit from any general treatment. The removal of the ovaries to stop the tendency to menstruation was the only indication apparent to my mind, and, owing to the old adhe- sions from the former pelvic peritonitis, the dangers of that opera- tion were fully appreciated. The case was explained to the patient and the friends who brought her for my advice, and they were left to choose between the removal of the ovaries, or no further care on my part. The patient, after thinking of the dangers and the pros- pects, became very anxious for the operation. Her argument was that she was tired of life, and that all her friends were tired of car- ing for her, and, if there was one chance in a thousand of being re- lieved, she longed for that chance. The operation was performed with great difficulty, owing to the adhesions. The right ovary was completely surrounded with inflam- matory products, and was found with much trouble. The left ovary was adherent at several points that were easily broken up. There was no trace of the left horn of the uterus, nor of the left Fallopian tube. The right ovary was located within one inch of the upper end of the right horn of the uterus, and there was no well-defined Fallopian tube on that side. Comments.—This case certainly illustrates fully the great suffer- ing that may arise from this degree of malformation. The presence of well-developed ovaries which excite a demand for menstruation, ARREST OF DEVELOPMENT. 35 associated with a uterus incapable of performing that function, is one of the most unfortunate conditions known to the gynecologist. It is evident, also, that the development of the one horn of the uterus sufficient to make a slight effort to menstruate only aggravated the difficulty. She would perhaps have been better had the uterus been absent altogether. Incidentally, I may remark that the absence of the tubes in this case is evidence against those who claim that they have a leading influence in causing menstruation. Rudimentary Uterus Bicornis; Entire Absence of Menstruation.— When first examined, this lady was thirty years old, below the aver- age size, but well formed, and presented, to outward appearances, all the characteristics of her sex. As a child she was rather small and delicate, but had good health. At the age of sixteen she passed through all the changes of form common to puberty, but never menstruated. When questioned regarding her health at that time, she remembered only that she occasionally had slight headache and indisposition, but whether these symptoms came periodically or not she did not know. At no time was her suffering sufficient to inter- rupt her school duties. She was married at eighteen, and, while she was affectionate and devoted as a wife, sexually she was perfectly negative. Without being very strong mentally or physically, she enjoyed good health, and only called upon me at the time she did because of some temporary irritation of the urethra which caused pain on urination. This gave me an opportunity to examine her pelvic organs. The external organs were normal, and the vagina also. The cervix uteri was not more than five eighths of an inch in diameter. The os externum was small but normal. In the location of the body of the uterus two small, oblong, bifurcated bodies were found continuous with the cervix. These bodies were about a quarter of an inch thick and about an inch long, as nearly as could be estimated by the bimanual examination. I regarded them as the rudimentary horns of the uterus, which were retroverted. Near the upper ends of the horns of the uterus, and a little outside of them, two other bodies were found which I presumed to be the ovaries. They were about half the size of a fully-developed ovary and of the usual form of that organ, except that they were not so flat from before backward, and appeared to be more dense than normal. It was evident that the development of the ovaries had progressed further than that of the uterus, because they were relatively much larger than the rudiments of the uterus. Owing to the fact that the patient was of small size, with non-resisting abdominal muscles and 36 DISEASES OF WOMEN. the rudiments of the uterus retroverted, the examination was easy, so that I feel some confidence in giving the physical signs and the diagnosis based upon them, believing that they are correct. Comments.—This case apparently shows that the ovaries were sufficiently developed to influence the changes which occur at pu- berty, but were so much under size that they were incapable of the highest functional activity, while the uterus was not only arrested in its development, but in its growth also ; hence menstruation, even in an imperfect way, was impossible. This case is placed in con- trast with the preceding one to show that when arrest of develop- ment and growth is such as to render functional action entirely impossible, a fair degree of health may still be maintained; while, on the other hand, if the development and growth of the ovaries are complete, and the uterus is developed sufficiently to make an im- perfect effort to menstruate, the health and usefulness of such a one is greatly impaired, and a life of suffering generally follows. Small Uterus from Arrested Growth; Scanty Menstruation im- proved by Treatment.—The patient was a young woman of full size and well formed, and of a sanguine, nervous temperament, and a remarkably good and well-cultivated mind. She had always enjoyed good health excepting when she was fourteen years old. At that time she was "working hard at school, and became run down." Rest soon restored her, and she began to menstruate at the age of fourteen years and six months. Her menses from that time returned regularly, but the flow was scanty and lasted only forty-eight hours. During the menstrual period, and for several days after it, she suf- fered from fullness of the head, restless nights, and a feeling of discomfort in the pelvis with general mental and physical indispo- sition. She continued in this way until she was mature, the time when she was first examined. By the touch the cervix uteri was found to be rather small, but well formed and in proper relations to the vagina. Owing to the rigid state of the abdominal muscles, the uterus could not be satisfactorily outlined by the bimanual touch. Using the sound through the speculum, the long diameter of the uterus was proved to be one and seven eighths inches; quite a small uterus for a woman of her size. Her general health was very good indeed, and she would not have sought immediate advice had it not been that she was engaged to be married, and was very anxious to be relieved from the ill feelings which came in connecticn with her scanty menstruation. Treatment.—AX her next period she was directed to take a tea- spoonful every three hours of the following mixture : Ammon. mur. ARREST OF DEVELOPMENT. 37 3 ij ; aquse camph., § ij, to begin as soon as she felt that the period was approaching, and to continue until six hours after the flow stopped. Not being used to medicine, she objected to it strongly, and during her subsequent periods she took a teaspoonf ul of liq. ammon. acetatis every three hours, commencing one day before the flow began and during its continuance. Immediately after the flow ceased, one or more fine punctures were made near the external os, which produced considerable bleeding. This was done to relieve, as far as possible, the congestion which lingered because it was not relieved by the menstrual flow. This was practiced after three pe- riods. At intervals of six days during the entire menstrual flow the canal of the cervix, including the internal os, was gently dilated with graduated sounds. This was done in the hope that it would stimulate the nutrition of the uterus. After the third month of treatment it was found that the men- strual flow had increased in quantity and continued for one day longer. A stem-pessary was then introduced, but it caused more irritation than was safe; so, after it had been worn for three days, it was removed, and not used again. From this time onward the treatment was limited to a mild con- stant electric current. One electrode was passed into the uterus, the other applied alternately over the sacrum and supra-pubic region. This was repeated every six days in the interval between the monthly periods. She continued to take the solution of acetate of ammonia at each period, but with what benefit is not known. At the end of eight months the uterus measured two inches and one eighth in its long diameter, and she menstruated between four and five days at each time, the flow being much more free and her unpleasant symp- toms having all disappeared. She was married then, and I lost sight of her for seven months, when she called to consult me regarding amenorrhoea, which had existed for two months and was due to pregnancy. I heard that subsequently she was confined, and was in quite good health. Undersized Uterus from Arrested Growth; Scanty Menstruation; Sterility; Incurable.—This woman was thirty years old when this history was obtained. She was of medium size, and had enjoyed fair health most of her life. During her girlhood she had to work very hard in a store, and often suffered at that time from fatigue. She developed slowly, and did not menstruate until seventeen years of age. During the first four years after puberty the menses lasted only two days and the flow was scanty. At twenty-two she was married, and placed in easier and more comfortable circumstances, 38 DISEASES OF WOMEN. and for about one year the menstrual flow lasted from two and one half to three days at each time. She then missed one period, and then the menses returned more freely than ever before, which made her believe she had had a miscarriage; but of this there was no proof. When she had been married two years she began to have pain of a dull, aching character in the region of the uterus during her menses. This pain became more marked as time advanced, and gradually the pain extended to the ovaries. These pains were never acute, and passed away entirely after menstruation ceased. At twenty-nine years of age she had sickness in her family and was overtaxed thereby, and her menses stopped for five months, but again returned. In the absence of the menses she had leucorrhcea, but not before nor since. Examination by the touch showed the uterus to be relatively long and narrow; the body was not much larger than the cervix. The long diameter as measured with the sound was two inches. There was slight tenderness on pressure over the ovaries. All the pelvic organs were in normal position. Her general health was about as good as it ever had been. Treatment.—Sodium bromide, gr. xxx, was given three times a day in Vichy water before meals during the menstrual period. This relieved the uterine and ovarian pain very much. Between the periods the hot-water douche was used until all pain had been relieved. The subsequent treatment was about the same as in the case last related, with the addition of more extensive dilatation of the cervical canal, and she also wore the intra-uterine stem-pessary for six weeks. She also took internally phosphates, iron, and strychnia in various forms, and for several months. At the end of seven months she was free from all pain during menstruation, but the flow was no freer, nor did it last any longer. The uterus had not in the least increased in size. She was dis- missed unimproved, so far as the growth of the uterus was con- cerned. Comments^—This and the preceding case are placed together to show the results of treatment. They demonstrate that the prospects of success in increasing the growth of the uterus depend very largely upon the age of the patient. The earlier in life that the treatment is begun, the more likelihood is there of success. Undersized Uterus, its Growth apparently being arrested by Pre- mature Sexual Nervous Excitation; Irregular and Painful Menstruation; all the Symptoms increased by Local Treatment.—This was a single woman, twenty-two years old, the daughter of wealthy and educated ARREST OF DEVELOPMENT. 39 parents. She was tall, spare, and of nervous temperament. Before puberty she acquired the habit of self-abuse while at school. While her general system was not developed, and while wTeak, irritable, dys- peptic, and subject to severe headaches she began to give evidences of puberty, and her menses first appeared at twelve years of age. From this time, up to the time of taking this history, she menstruated irregularly, the average time between the periods being five weeks, but often two, three, and on several occasions five months elapsed. The flow was usually normal in quantity, character, and duration, although the latter was variable. Pain in the back, pelvis, and lower portion of the abdomen always accompanied the menses, and was suf- ficiently severe to keep her in bed during that period. The severity of the pain was presumably not so great as the patient described. Her extreme sensitiveness inclined her to exaggerate her sufferings. Neither was the character of the pain so acute and localized as that which occurs in flexion of the uterus. Her general health was poor, slight mental or physical exercise fatigued her, and if she persisted she became so tired that she could not rest. Her sleep was disturbed by dreams that were not all dreams, and in the morning she felt quite exhausted. Before I saw her she had been treated locally and generally by several physicians, some of high standing in the profession, and others of questionable repute, and was invariably worse after being treated. An examination by touch revealed a small uterus slightly retro- verted, though that malposition was, I believe, temporary. The length of the uterine cavity measured with the sound was a fraction less than two inches. With the exception of extreme sensitiveness of the pelvic organs generally, there wTas no other abnormality found. Local treatment was tried for a short time, but it was found to be injurious. She was then given systematic occupation under the direction of a skilled attendant. Massage and careful dieting were also directed. Her days were fully occupied with short alternating periods of mental and physical exercise and rest. Every afternoon she took thirty grains of bromide of sodium, and during her men- strual periods thirty grains three times a day with eight drops of tincture of cannabis Indica. Laxatives were given to regulate the bowels, and tonics occasionally when specially required. It should be mentioned that she gave up her evil habit as soon as she was made to understand its ill effects. Under this general plan of treat- ment she improved in every respect. She still suffers at her monthly periods, and the menstrual function is still irregular. 40 DISEASES OF WOMEN. Comments.—This case is given as a representative of that class of cases of delayed or arrested growth of the uterus and the functional imperfection which is sure to follow, the primary cause of all being the premature excitation of the sexual organs. A sufficient number of these cases has been seen and studied to warrant the statement that when the habit of self-abuse is begun before puberty it often arrests the development or growth, or both, of the uterus, and the consequences are far more disastrous than the same practice when begun after puberty and completed growth. Closely associated with this subject is chlorosis, a condition in- volving menstrual derangements due to the same defect of the uterus, being associated with lesions of the general system. Chloro- sis is a condition which has usually been considered as a disease per se, but it appears to me to be rather a peculiar character of organiza- tion presenting invariably certain characteristics of structure which are unfavorable to high functional activity, and which predispose to certain forms of disease. Some authorities, French mostly, believe that chlorosis is a disease of the organic nervous system which appears at puberty and presents certain changes of nutrition, espe- cially in the character of the blood. There is certainly some reason for this view of the subject. The functions of the body which are under the direct control of the organic nerve-centers are perverted apparently by some obscure derangement of organic innervation, but this appears to come from some imperfection of the nervous system, perhaps mal-development, rather than from some well-defined dis- ease. The German pathologists hold that in chlorosis there is an arrest of growth of the circulatory and genital systems; the heart and blood-vessels being undersized and the sexual organs also. This certainly corresponds to the facts as observed clinically, and if to this be added that peculiar condition of the organic nervous sys- tem, which is undefined but- probably structural, a type of organiza- tion results which presents all the tangible characteristics of chlorosis. This is the conception which I have accepted regarding chlorosis, which may be defined as an organization in which the circulatory and the genital systems are below the normal type in point of devel- opment and growth, and in which there is a state of the organic nervous system which is also below the normal and incapable of exer- cising the highest functional activity. These constitutional conditions combine the features of a peculiar temperament and a diathesis • the temperament being so marked as to show a tendency to disease or diathesis. It would simplify the subject if the term chlorotic temperament were used to express this constitutional condition. ARREST OF DEVELOPMENT. 41 Viewing the subject from this standpoint, it is easy to understand that such an organization, while it might act under the most favor- able circumstances of life, would be incapable of sustaining the more complex functional activities of a mature and fully occupied life. It is easy to see, also, that a chlorotic subject, when called upon to take up the functions of reproduction, when thus ill-quali- fied to do so by reason of anatomical defects, would naturally tend to derangements of nutrition in the form of impaired appetite, labored digestion, and the anaemia, debility, and mental depression which naturally follow mal-nutrition. So, also, would the sexual sys- tem suffer because of the undersize of the uterus and, presumably in some cases, the ovaries also, together with the imperfect blood- supply which, sooner or later, comes from the mal-nutrition. This, I believe, to be the true state of the body known as chlorosis, and that all the phenomena manifested by such subjects are the outcome of their anatomical peculiarities. Whether this be the proper de- scription of chlorosis or not, it is the expression in brief of the prominent features of chlorotic subjects, and agrees with the facts observed in practice. The reason, I presume, for the different opin- ions held has grown out of the fact that some have accepted the mal-nutrition which is so often seen in the chlorotic, and the conse- quences thereof, as the disease itself; whereas these derangements of the nutritive and sexual systems are the outcome of the anatom- ical imperfections. The chief object in discussing the subject here is, because chlorotic women necessarily suffer from deranged and im- perfect menstruation, and they naturally fall into the care of the gynecologist, and without some definite idea of the nature of this affection its rational management would not be possible. From the very nature of chlorosis, it is clearly evident that the object of the therapeutist should be to aid in the development and growth of the subject while young, in the hope of overcoming the natural tendencies to these constitutional defects. After adolescence the most that the physician can accomplish is to overcome, as far as can be, the mal-nutrition and derangements of menstruation, which arise from the constitutional imperfections. Arrested Growth of the Uterus, associated with Small Circulatory Organs; Chlorosis.—This patient stated that when a girl she was of medium size and quite fleshy, and was said by her friends to look strong and healthy, but she was never able to endure much muscu- lar exercise. Her appetite and primary digestion had generally been good, yet she never required a large quantity of food, Her face was rather pale while a girl, and remained so. She never was in- 4:2 DISEASES OF WOMEN. clined to take active exercise, and, when obliged to do so, respira- tion was labored, and she soon became tired. At the age of fifteen she began to show the general form of womanhood, but did not menstruate until eight months later. From that time onward she menstruated regularly, but the flow lasted only three days, and was not at all free. On several occasions, when obliged to exert herself sufficiently to slightly lower her general health, the menstrual flow was almost colorless, and lasted only two days. At twenty-one she was married. Her general health remained as before, and she proved to be sterile. I saw her when she was twenty-eight years of age, seven years after being married. She then consulted me regarding her sterility. In general appearance she was a typical chlorotic subject. She was of medium height, quite fleshy, but not inordinately so; her hair was intermediate in color, being neither dark nor light—in fact, it might be said to be colorless; too light for a brunette, too dark for a blonde. If this dark shade had been removed, it would have been hair of a dark-flaxen color; the eyes were a gray-blue and very clear; the sclerotic coat pearly white; the skin remarkably smooth and white. The face was pale, with that greenish-yellow hue which must be seen to be fully appreciated. This color of the face differs from the yellow, dry skin of the cachectic subject, the pallor of anaemia, and the bronze of sunburn. Few blood-vessels were visible on the face or hands, and these were very small. The pulse was about eighty, but small, more like that of a child. The heart-sounds were very clear and distinct, but the impulse was weak. The area of cardiac dullness was apparently smaller than usual, but this was difficult to make out, owing to the mammary glands being large. At the time of my first examination she was feeling more than usually languid and weak because of indigestion and constipa- tion, which had troubled her for several weeks. Her tongue was coated, and her appetite poor. On walking up stairs quickly she suffered from " want of breath." If she stooped down and rose suddenly, she had vertigo. Toward night her ankles became slightly swollen. Her sleep was often disturbed by dreams. In dis- position she was a little sluggish, good-natured, and generally cheer- ful, with occasional attacks of mental depression, which occurred usually at the menstrual period. The pelvic organs were normal as regards general nutrition, except that the mucous membrane was anasmic. The position of the uterus was normal. The sound showed the cavity of the uterus to be a fraction under two inches in length. There was a slight leucor- ARREST OF DEVELOPMENT. 43 rhcea. The menses were regular, lasting from three to four days, until four months before she was first seen by me. During that time she had had a leucorrhoeal discharge at the menstrual period, but nothing more. Treatment.—Pil. hydrarg., gr. x ; pulv. ipecac, gr. j, were given at bedtime, followed by a saline laxative in the morning. After this, a teaspoonful of the following mixture was given, well diluted, before meals: Strychniae sulphatis, gr. ss; acid, hydrochlor., 3j; tinct. cardam. comp., ^ j I aquae font., § ij. This improved her appetite, and her strength increased. When she had finished the first mixture, the following was given: Ferri iodid., 3j; quiniae sulph., gr. x; ext. belladonnas, gr. ij, in pil. No. xx, one before each meal. These pills were taken with apparent benefit for three weeks, when they were stopped, and the following was ordered: Tinct. iodin., 3 ij ; potass, iodidi., 3 ss; syr. simp., 5 j j aquae font., 5 ij '■> one teaspoonful, after meals, in water. During the following six weeks she took the pills one week, and the next week the tincture of iodine mixture, alternating regularly. The menses appeared at the fifth month after they stopped, but were scanty, and lasted only two days. The appetite and digestion were improved, and the anaemia was less marked. She also felt much stronger. I then prescribed ferri pyrophos., 3 jss; stryclmise sulph., gr. ss; liq. potass, arsenit., 3 j ; tr. colomb., § j ; aquae font., § ij. Teaspoonful, in water, after meals. This mixture she continued to take for six weeks longer, omitting it occasionally for a few days. During the treatment she was relieved, as far as possible, from all care, took light exercise in the open air, and had a good supply of nutritious food in great vari- ety, being restricted only in the quantity of fluids, sugar, and fats that she took. The menses continued from this time onward to be regular, and the character and duration of the flow were the same as they had been in her best former health, but were not improved. I'Y>r several years, indeed up to the present time, which is now five years since she was first seen, she has been in fair health, but on several occasions, when she ventured to do more than usual, her digestion became deranged and her appetite poor. Anaemia has become more marked, and the menses have diminished, but she has promptly applied for treatment, and the use of tonics has restored her to her usual rather low standard of health. Comments.—This history shows that the patient was not cured of her chlorosis, but only relieved from intercurrent attacks of mal- nutrition and the consequent imperfect menstruation which she had. This is the history of the great majority of such cases when they 44 DISEASES OF WOMEN. come under observation and treatment after puberty. This shows that the whole character of the organization is below the highest standard, and hence there is a tendency to break down under ordi- nary taxation, and the physician can do no more than restore the patient to her usual degree of health. Chlorosis treated before Puberty, with apparently Good Results.— A school-girl, fourteen years old, large enough for her age, and un- usually fleshy, was brought to me on account of loss of appetite and constipation. There was no evidence of puberty, except that her breasts were large, but they were mostly made up of adipose tissue. Her general appearance, color of hair and eyes, small heart and blood-vessels, white skin, pale face, and disinclination to active exer- cise, indicated chlorosis. Nothing was lacking but the usual anaemia and peculiar color of the face to make the case a type of chlorosis. She was directed to give up some of her school duties and devote more time to systematic muscular exercise and out-of-door life, to abstain from fat meat, sugar, and butter, of all of which she was un- usually fond, and to live upon lean animal food, fish, eggs, oatmeal, fruit, and brown bread. To relieve her constipation I prescribed quin. sulph., 3j; ext. belladonnae, gr. ij ; ext. colocynth. comp., gr. x, in pil. No. xx; one immediately before each meal. At the end of two weeks the bowels were acting too freely. One pill, night and morning, before meals, was ordered. These answered for a time, but in three weeks it was found that one pill was all that was required, and at the end of two months from the time she came under treatment, pills were given up altogether. She was then put upon the following: ]j£ Hydrarg. chloridi corrosivi.....................gr. j. Liquor arsenici chloridi......................f 3 j- Tr. ferri chloridi, Acid, hydrochloric, dilu^i.................aa f 3 iv. Syrupi simplicis............................§ ij. Aquae..............................q. s. ad ? vj. M. Sig. : A dessertspoonful, well diluted, after each meal. This is known as the mixture of the four chlorides, and is said to have been first used by Tilt, of London, and was introduced to the profession of Philadelphia by the late Dr. A. H. Smith. This medicine was given for one month, then omitted for two weeks, and again taken for one month. After this, she was given iodide of iron in small doses for two months. In summer she was sent to the mountains, and encouraged to ramble in the open air, to drive, and occasionally ride on horseback. The diet that was first reco'm- ARREST OF DEVELOPMENT. 45 mended was continued, except that she occasionally indulged her fancy for sweets. Under this course of treatment she lost flesh, and grew taller and stronger. Her pulse was markedly improved, and her appetite con- tinued to be very good. At the age of fifteen years and three months she showed evidences of maturity, and simultaneously her appetite became somewhat capricious ; backache and headache occa- sionally troubled her, and she was at times depressed. The mixture of the chlorides was resumed and continued for one month. Her usual order of fife was continued, except that she did not ride on horseback, and was carefully guarded from overtaxation, mental and physical. The menses appeared and continued for four days normally, and were not attended with great pain. In six weeks the flow returned, and lasted the same length of time. From this on- ward for one year the menses were normal. After that, she went to a higher school, and tried to make up for lost time in her studies. During this time she was not seen, i. e., for about one year and four months. Then she called upon me, and the following history was obtained : Her appetite was capricious, and her bowels constipated; she had headache often; slept in a restless, dreamy way; had pain in the praecordial region and dorsal portion of the spine; was easily frightened, and had palpitation of the heart on taking exercise. The menses were delayed for two weeks, and when they returned the flow was scanty, and lasted only three days. At this time she had a more marked chlorotic appearance of the face than at any time before. The pills previously prescribed were given to keep the bowels regular, and the mixture of chlorides was given for one month, and after that she was given twenty minims of the sirup of the iodide of iron three times a day. The thought of falling behind in her studies grieved her so much, that she was placed under the care of a governess, who interested her in her studies but did not harass her. The menses became normal again, and she regained her general health, and has since continued well. She is at this time married, and the mother of one child. Comments.—It is not possible to prove that this patient would have become a well-defined chlorotic subject, but I am disposed to believe that she would, had she been neglected, as most of these cases are. In my clinical record I find several cases of this kind, and most of them have been greatly aided by care and medication similar to that used in the management of this case. The benefit of treatment has been most marked in those who came under care early in life. 46 DISEASES OF WOMEN. Those who had no treatment until after puberty, and were suffering from all the symptoms of typical cases were improved by treatment, so far as obtaining relief from deranged digestion and neuralgia, and to some extent from anaemia, but they still maintained their consti- tutional peculiarities, with a tendency to recurrence of the anaemia and menstrual derangements. In those who married early and bore children (a not unusual thing for those in whom chlorosis is not marked), there was a notice- able predisposition to albuminuria and puerperal convulsions. Such cases also tend to inertia of the uterus and post-partum haemorrhage. They very generally suffer from anaemia and nervous exhaustion dur- ing lactation. A Marked Case of Chlorosis, complicated with Gastric Derange- ment.—The patient was a domestic, twenty-three years of age, and presented all the characteristics of chlorosis in a typical degree. She had suffered repeatedly from amenorrhoea, but had always responded to tonics sufficiently to resume her duties in a few weeks. She was attacked with vomiting, her strength failed rapidly, and she was unable to leave her room for weeks. When she took food it gave her distress, until it was rejected. Sometimes food would be vomited after having been retained in the stomach nearly an hour, but it was not in any degree digested. Gastric ulcer was suspected, although she had never vomited blood. She was given peptonized milk as the only food. This she retained in increasing quantity, and gradually regained her usual health. Comments.—This case shows the strong characteristics of extreme anaemia in chlorotic patients. I believe that the stomach is unable to digest food because of the anaemia, and this causes the vomiting. In such cases the peptonized food is of the greatest possible value. Menstrual Derangements from Causes independent of the Sexual Organs.—This class of menstrual disorders is closely related, in the matter of diagnosis, to those deranged functions of the uterus due to anatomical lesions; hence the subject may apropriately be dis- cussed here. It is only necessary to call to mind all the condi- tions necessary to menstruation to see plainly that constitutional diseases, acute and chronic, as well as functional disturbances of the nervous system, would act unfavorably upon the functions of the genital system. As a general rule, any constitutional affec- tion which impairs nutrition and reduces strength very decidedly will affect menstruation. This is certainly the case when the gen- eral depression continues for any great length of time. The best ARREST OF DEVELOPMENT. 47 example of this Js seen in phthisis pulmonalis. In the advanced stages of this disease the menses usually stop altogether. The uterine function ceases under these circumstances, simply because the general system is unable to sustain it. In acute diseases, such as pneumonia or typhoid fever, menstruation may be interrupted for a period or two, but it usually reappears when the patient fully re- covers from the constitutional disease. On the other hand, in degen- erative diseases, such as organic diseases of the liver, lungs, heart, or kidneys, the menses often become irregular and scanty or profuse, and finally stop altogether during the remainder of the invalid's life. So, also, severe shocks or over-taxation from shock, exposure to cold, fear, grief, and extreme mental work, may cause the menses to temporarily cease. Again, either of the constitutional conditions referred to above may retard the first appearance of the menses if they are active at the period of puberty, even though the develop- ment and growth of the genital organs may not be arrested. Amenorrhoea, or delay of the advent of the menstrual function, is the rule when these causes exist. There are exceptions to this rule, as, for example, valvular lesions of the heart and cirrhosis of the liver, may cause menorrhagia, and nervous derangements may cause premature menstruation. The diagnosis in such cases is usually easy. By the time that the uterine function becomes deranged, the constitutional disease is so far advanced as to be easily recognized. One is greatly aided in diagnosis when the menses have for a time been regular, but become deranged without any disease of the sexual organs being present. When amenorrhoea occurs as the result of some constitutional disease that is incurable, the special interest of the gynecologist ends when the diagnosis is made, because no special treatment is of any avail. On the other hand, in menorrhagia, when due to chronic affections of the heart, liver, or kidneys, something may be accom- plished in the way of modifying the trouble, and thereby prolonging the life of the patient. Here also the management is general, not special, and hence does not come within the scope of the present work. Premature Menstruation from Deranged Conditions of Life and Deranged Innervation.—The rule that the menses should appear after the completion of development which occurs at puberty is violated in the cases now under discussion, because the uterine function is taken up before the general development is completed. In determining the question of premature menstruation it is necessary to ascertain whether the patient is sufficiently mature in development to render 4S DISEASES OF WOMEN. her capable of taking up this uterine function. #She may be old enough, but not developed enough in her general system. The causes of this too early appearance of the menses are various. It seems that opposite conditions of life produce the same results. Bad air, poor food, overwork, and impure social surroundings, have this ill effect; at least, cases frequently occur among those who are so poor that they fail to obtain all that is necessary to health. This fact regarding the premature activity of the sexual system appears to arise from a law in Nature, which is that all plants and animals placed in unfavorable environments devote more of their energies to reproduction than those that are more favorably situated. It would appear as if they appreciated their danger of being crowded out of existence, and hence struggle more vigorously to procreate. Viewing the subject in this light it may be said, to speak figurative- ly, that girls and plants while stunted by living in poor soil run to seed. The same premature menstruation occasionally occurs among those who are favorably situated in regard to the necessities of animal life. Those who have the means of supplying all their wants, real or imaginary, and lack intelligence and culture, which would enable them to profitably occupy their minds, suffer like the poor. This would indicate that the real cause of the sexual precocity was deranged innervation. Delay of the advent of menstruation occurs among those who are situated apparently like those just described. The girl wdio labors out-of-doors and develops great muscular strength may fail to menstruate until past the usual age. So, also, the same thing occurs to some who live in luxury. In such cases the cause is, no doubt, imperfect innervation. In the class first described attention is given to the genital system prematurely, while in the second class the social element of life is neglected. The general management of these patients consists in removing the cause, if possible, by placing them in such healthful surround- ings as will prevent the evil. This, however, is not always in the power of the physician, and he has to meet the wants of those really in suffering. When the menstrual function has been established, though prematurely, no effort should be made to stop it. Attention should be given wholly to building up the general system. The overworked should obtain rest and good food. The nervous system should have attention. The perverted mind-action should be cor- rected by wholesome brain-occupation. The indolent should be stimulated to greater activity. Society is desirable for those in ARREST OF DEVELOPMENT. 49 whom the menses are delayed, and quiet country life should be pre- scribed for those who have suffered from premature social excite- ment. ILLUSTRATIVE CASES. Premature Menstruation from Deranged Innervation, produced by Luxurious Surroundings and Over-Stimulation of the Nervous System. —The patient was an only daughter of wealthy parents, and was al- ways a bright child and greatly indulged by her family and friends. She was treated at home and at school more like a young ladv than a child, and was almost constantly in company. In the parlor and drawing-room she associated with her elders, and was devoted to the opera and theatre from the time she was big enough to visit such places of amusement. She often suffered from headaches and indi- gestion, and was always excitable mentally, and at times peevish and irritable. She menstruated first at eleven years quite freely, and the flow lasted four days. At this time she had all the ap- pearances of girlhood. The mammary glands were slightly de- veloped, but her form had not attained anything like maturity. From this time onward she menstruated regularly and normally. She was first seen during her first menstrual period, and then her parents were advised to change all her habits of life. She was taken to a quiet country home in summer, instead of a fashionable hotel at which she had previously passed her summers, and permitted to spend her time in the fields with her attendant, who wras a woman of good common sense and experienced in the proper care of chil- dren. All excitement was kept from her, and her habits of life made regular and natural. In winter she was permitted to attend school for half the time, and the rest of the day was devoted to draw- ing, reading, and gymnastic exercises. Abundance of sleep in the early part of the night was directed, and cold bathing every morn- ing. No medicine was given. Under this general management she grew in size quite rapidly, and by the time she was sixteen years old she was a well-developed young lady, and enjoyed very good health. Premature Menstruation occurring in a Poor, Ill-cared-for Girl, from the Lowest Grade of Society.—This patient, a hospital one, was ten years and five months old when she first menstruated. She lived in one of the poorest tenement regions of the city. Her father was a drunkard, and left his family to the care of the mother, who was a washer-woman. This girl lived by begging while very small, and when older worked in a tobacco-factory. She was thirteen years old when seen in the hospital, and had menstruated regularly from the age mentioned. Her general health was poor, very poor; she had 5 50 DISEASES OF WOMEN'. the appearance of an undersized, ill-fed, undeveloped girl, quite ignorant, and doubtless of low moral nature. She was in the hospi- tal to be treated for specific vaginitis. Delayed Menstruation in a Girl who was large, strong, and in good health.—The daughter of a poor farmer had spent most of her life in doing out-door farm-work. Iler food was milk, oatmeal, and potatoes. She was large, muscular, and full-blooded. Between six- teen and seventeen years of age she developed the characteristics of womanhood, but at the age of seventeen years and six months the menses had not appeared. She was then suffering from occasional headaches, backache, drowsiness, constipation, and general indisposi- tion. These symptoms, with delay in the appearance of the menses, caused her to seek advice. She was very muscular and fine-featured. The pulse was full and strong, the mammary glands well developed, and her figure was markedly of the female type. A teaspoonful of sulphate of magnesia and half a teaspoonful of table-salt in a goblet- ful of water were ordered every morning an hour before breakfast. The liberal use of animal food was directed. She was advised to take a vacation from her hard labor on the farm, and visit her rela- tions who were more comfortably situated. These directions were followed out for a month, with no effect, except to relieve her con- stipation. The saline mixture was stopped and the following or- dered: Quiniae sulph., 3i; ext. belladonnae, gr. ij; ext. aloes aq., gr. iv. Pil. no. xx : one before each meal. When the headache and general feelings of malaise returned, I prescribed spiritus ammon. arom., § ss ; aquae camph., § ijss — a dessertspoonful every three hours. At the end of two months, she began to menstruate. There was considerable pain accompanying the flow, which was rather dark in color. The pills were continued, but she was soon able to give up one a day, and then two, and finally cease taking them altogether. At each period, which recurred regularly, she took the ammonia and camphor mixture. Six months after her first men- struation she reported that she was regular and quite well. Delayed Menstruation in a Patient of Marked Phlegmatic Tem- perament and Indolent Habits.—The daughter of wealthy parents, of average height but quite stout, and presenting all the evidences of the phlegmatic temperament, was brought to me at the age of six- teen, because she had not menstruated. I learned that she lived well, slept much, and took but little exercise, mental or physical. She had all the appearance of having arrived at puberty, and for one year had had a slight leucorrhcea, but no menstrual flow. She was ordered to take lessons in horseback-riding, and to walk for half an ARREST OF DEVELOPMENT. 51 hour twice a day. A Turkish bath with thorough massage three times a week was also directed ; I prescribed potass, permanganat., gr. xxx, in pil. no. xxx: one three times a day, before meals. This treatment was continued for about three months, excepting that at the end of one month the pills were omitted for three weeks and again taken up, and continued until the end of the three months. At this time she menstruated, and continued to do so regularly after- ward. The flow was never very free, but it continued about five days each time. Irregular Menstruation from Deranged Innervation and Anaemia.— This patient was twenty-five years of age, of sanguine, nervous tem- perament, and had been in good health up to the time that she was nineteen. She menstruated first at fifteen, and continued to do so regularly, until the year that she graduated in school, when nineteen years old. During the latter half of her last year in school her menses became irregular, six weeks or two months in- tervening between the periods. At this time her health became much reduced, but after leaving school she improved generally, and the menses became regular. At twenty-four years of age she began to indulge to excess her love for music and painting, which had always been favorite studies with her. Dyspepsia and general debility fol- lowed, and the menses became again irregular. She first came under my care at twenty-five, and at that time the menses had been absent for three months. She was quite anaemic, and her nervous system much exhausted. She was ordered to give up her favorite studies, and devote herself to regaining her lost health. She was directed to take three regular meals a day, and in the forenoon a cup of beef- tea or a glass of milk, and in the afternoon extract of malt, or else peptonized milk and a glass of claret. Before her regular meals she was given tr. nucis vom., irt iij; vini ipecac, iri ij, in a wTine-glass of warm water. This improved her appetite. After meals she took a teaspoonful of the following: Tr. ferri chlor., 3 iij; liq- ar- senic, hydrochlor., 3 j ; spiritus limonis, 3 ss; syr. simp., § j ; aquae font.,5ij. This treatment was continued for three weeks, with the effect of improving her general condition, but the menses did not return. In place of the iron-mixture she was given the permangan- ate of potash pills, but without any apparent effect. Iron was again given, and the menses returned after she had been six weeks under treatment. She continued to be irregular, some five and six weeks between the periods, but, as her general health improved, the inter- menstrual periods became shorter, until the normal time was estab- lished. Altogether she was under observation for one year, and 52 DISEASES OF WOMEN. durino- most of that time she took tonics containing some form of iron. Citrate of iron and quinine, iodide of iron and whisky, po- tassio-tartrate of iron and wine, were the chief preparations given. Suppression of the Menses from Acute Derangement of Innervation. —A lady, twenty-one years of age, of excellent physique, who had menstruated with great regularity from the time that she was fifteen years of age, left home for the first time in her life to visit some friends in a far-distant city. On the day that her menses should have appeared, she was alone and not accustomed to traveling, and she became much excited over her journey, and was greatly fatigued when she reached her friends. She could not sleep on the cars, and her appetite left her almost altogether. I was called to her on the third day after she left home, and a few hours after her arrival. The menses had not appeared ; her head ached very acutely; her face was flushed; skin dry and pulse excited. The temperature was 100° Fahr. I ordered a hot foot-bath and the forehead bathed with alcohol, and prescribed ammon. bromid., gr. xv, tinct. aconit. rad., ui ij, every three hours in a small glass of Vichy water. She wTas kept quiet in bed. After taking three doses of the medicine, she slept fairly well during the night. Next morning her headache was almost gone; her pulse was quiet; flushing of the face less notice- able, and she had an appetite, but the menses had not come. I pre- scribed camph., gr. v ; ext. lupul., gr. x ; ext. valerian, gr., x : in cap- sul. No. x. One to be given every three hours during the day and following night if awake. She slept well in the night and next morning began to menstruate. Amenorrhoea from Chronic Derangements of Innervation.—This patient was twenty-four years of age, of good constitution, and had menstruated normally until six months before the taking of this his- tory. In that time she lost her mother, to whom she was greatly devoted. This prostrated her with grief, and about the same time her father suffered reverses in business, so that my patient, who had up to this time lived in luxury, was obliged to seek employment to support herself. From the death of her mother she failed to men- struate until nine months afterward. She was greatly depressed up to the time that she began treatment, and, although her general health was good, she was melancholy, and was greatly annoyed by her new occupation and changed social position. The amenorrhoea was a great source of anxiety to her, because some of her friends had told her that it was sure to lead to consumption. I fully assured her that she was in no danger, and that her recovery was certain. This alone was a decided tonic. ARREST OF DEVELOPMENT. 53 I ordered the following: Strychniae sulphatis, gr. ss ; tr. cannabis Indie, 3 ij; tr. card, comp., 5 j ; aquae font., § ij. Teaspoonful be- fore meals. This she continued for two weeks. I then ordered Parrish's compound sirup of phosphates, a teaspoonful, after meals, in water. This was taken regularly for three weeks, when the fol- lowing was given instead: Quin. sulph., 3ij; ext. valerian., 3j; ext. cannabis Indie, gr. v: in capsul. No. xxi. One before meals, and a glass of red wine after meals. This was continued for over a month. During this time she was induced to take more out-of-door exercise, and divert her mind by light amusements. General gym- nastic exercise was taken, but not systematically nor regularly. When this course of treatment had been employed she menstruated, and from this time on was regular and well. In general spirits she began to improve considerably before the menses returned, but after- ward her progress was rapid, and recovery complete. This case will suffice to illustrate this cause of amenorrhoea. Imperforate Hymen causing Non-appearance of the Menstrual Flow. —This affection should be classed with atresia of the vagina, but is given here because the history of such cases resembles delayed men- struation from some of the causes just given. This condition is usually unnoticed until puberty, when all the evidences of menstrua- tion appear except the flow, which is arrested by the imperforate, thickened hymen. The fluid which accumulates at each menstrual period distends the vagina first and then the uterus, the distention increasing at each period. Pelvic tenesmus, a feeling of distention of the vagina, and enlargement of the abdomen are the chief symp- toms and signs presented. In course of several months the suffering causes the patient to seek relief, when a diagnosis can be made by physical examination. The treatment is to evacuate the fluid by opening through the hymen. This is attended with great danger, owing to the tendency to inflam- mation and septicaemia. The fluid is dark, thick, and tarry in char- acter, and decomposes quickly on exposure to air. This and the irritation of the vagina and uterus may account for the tendency to inflammation and blood-poisoning. The method of treatment found, in past times, to be the safest was to make a small opening, evacuate very slowly, and subsequently enlarge the opening, or exsect the hymen entirely. Another method is to make a free incision with the incandescent knife of a thermo-cautery, evacuate rapidly, and wash out the uterus and vagina. This method has proved to be safer since the days of antiseptic surgery, and may be adopted. CHAPTER IV. FLEXIONS OF THE UTEKUS. I consider flexion of the uterus as a deformity, and it certain- ly belongs to that order of pathological conditions. The pathol- ogy, cause, symptoms, physical signs, and treatment of flexion, all differ from version, hence a clear distinction between the two should be made in order to avoid confusion. Anteflexion of the uterus is most frequently a congenital deform- ity, some arrest or derangement of development giving rise to the malformation. Occasionally it results from disease, inflammatory or degenerative, which weakens the uterus at a certain point and permits it to become bent upon itself. I shall limit myself to the consideration of flexion occurring as the result of these two causes, and shall purposely omit all deformities caused by pre-existing affec- tions, such as adhesions of the uterine body to other pelvic organs, tumors in the walls of the uterus which by their weight bend the uterus, and pressure of abdominal tumors which crowd the uterine body to either side. Whenever flexion is produced by some such antecedent disease, I prefer to consider it as a complication of the primary affection, rather than to discuss it as a distinct condition. The point of flexion is at the junction of the body and cervix. It may occur above or below that point, but only as a very unim- portant exception to the rule. The several forms of flexion I have denominated first, second, and third. The first is flexion of the body; the second, flexion of the cervix; and the third, flexion of both body and cervix. Taking the ground that flexion is a deformity, it may naturally be attributed to some defect of development; and in order to un- derstand the lesions of form and structure arising from arrest or derangement of development, it becomes necessary to restate the essential points in that process as relates to the uterus. At birth the uterus and vagina are joined in such a manner that FLEXIONS OF THE UTERUS. 55 the cervix uteri projects into the vagina but a very short distance, and about equally on the anterior and posterior walls of the vagina. After birth the uterus remains without change until puberty, ex- cept during the time of second dentition, when the palma plicata disappears from the body of the organ, with the exception of one fold which runs lengthwise. The body increases a little in size, so that the body and cervix become more nearly equal. At the same time the organ settles down into the pelvic cavity, and the cervix elongates and becomes more prominent in the vagina. At puberty the uterus undergoes secondary development. The organ increases in size, this being especially true of the body. Un- til puberty the uterus differs but little in shape from that of the new-born babe, which has been already described; but at the time when menstruation or functional activity of the reproductive organs is about to be established, it assumes the form and structure of the mature organ. Suffice it to say that, as the tissues are developed, they become denser, giving to the organ the firmness necessary to support it and keep it from bending in any direction by its own weight. There are two anatomical points bearing upon the subject now under consideration to which I desire to call particular attention: 1. The position or relations of the uterus to other pelvic organs at birth, during girlhood, and after puberty. 2. The relations of the cervix uteri and the vagina at the com- pletion of primary formation and after secondary development. The infantile pelvis is relatively narrower, deeper, and less curved than the adult; hence the canal formed by the uterus and vagina is straighter than after puberty. The small size of the infantile uterus, the thinness of its walls, and flaccid condition of its tissues, render it capable of bending forward or backward according to circumstances. This fact may account for the variety of opinions regarding the position of the uterus previous to puberty. At birth the uterus is high up in the pelvis, but settles down during the second dentition, as has been already stated, and forms with the vagina the arc of a smaller circle, having its concavity forward; hence the greater liability of the uterus to be anteflexed or anteverted during girl- hood, if it deviates at all; but, according to Klob, the uterus is neither bent forward nor backward until puberty. From the information obtained by the study of embryology and the anatomy of the reproductive organs, one must necessarily con- sider the uterus and vagina as forming one canal. The peculiar ar- rangement at the junction of these organs appears as if formed from 56 DISEASES OF WOMEN. an invagination, the upper part of the vagina receiving the dupli- cation of the uterus which forms the vaginal portion of the cervix. This invagination is very slight at birth, as may be seen by referring to any normal infantile uterus. The projecting portion of the cervix at this period is about equal, anteriorly and posteriorly. During the period of second dentition, when the uterus settles down, this portion of the cervix becomes more apparent still. It will also be observed that the posterior wall of the cervix projects a little farther than the anterior. At puberty, when the sexual organs undergo secondary development, invagination progresses still further, and the cervix and vagina assume the relation of adult maturity. It should be noted that the portion of the cervix which projects into the vagina is much longer posteriorly than anteriorly. This must neces- sarily be so, to some extent, from the fact that the uterus and vagina form an arc of a circle corresponding to the curve of the pelvis; but the difference is slightly greater than is necessary to make the curve form part of a circle. Perhaps it would be more correct to say that the junction of the cervix and vagina forms an obtuse angle. I am thus particular in describing these relations of the uterus and vagina, because I hope to show hereafter that arrest or derange- ment of the process of invagination of the cervix uteri has much to do in causing flexion. Anteflexion of the Uterus.—I prefer to consider anteflexion of the uterus a deformity, although it is usually called a displacement, because it certainly is a lesion of form rather than position. The pathology, cause, symptoms, physical signs, and treatment of flexion all differ from those of displacements of the uterus, hence the clearer that the distinction between the two can be made the better. The deformities which occur at puberty are perhaps more fre- quently lesions of size or quantity from arrest of growth than lesions of form from arrest of development. During secondary development the infantile uterus is transformed into that of the adult chiefly by the increase in the size of the body and fundus, and the dipping down of the cervix into the vagina. When these changes do not take place properly, especially if the invagination of the cervix is arrested, the uterus becomes flexed upon itself. Other causes of this malformation there are which will be again re- ferred to. Anteflexion of the uterus is usually a congenital deformity, caused by arrest of development occurring during the later stages of that process. It is inferred from the clinical history of flexion FLEXIONS OF THE UTERUS. 57 that it is congenital, but this is not perhaps strictly true of all the cases that occur as primary lesions. I presume that most frequently the malformation takes place during secondary development at puberty. Occasionally it comes from some pre-existing disease, in- flammatory or degenerative, which weakens the walls of the uterus at the junction of the body and cervix and permits it to become bent upon itself. Retroflexion often, perhaps generally, is devel- oped from retroversion, the one holding a causative relation to the other, but this form of acquired flexion will most conveniently come under the head of retroversion and its complications. Clinically considered in relation to causation there are two classes: the congenital, called so because it is usually first recognized at pu- berty ; and acquired, because it generally appears after puberty and follows some previous uterine disease either inflammatory, or a mal- nutrition which reduces the quantity of tissue at a given point, and permits the uterus to bend upon itself. Flexions from these two causes constitute a class by themselves, and therefore they alone will be treated of in this connection. Flexions occur in connection with other affections, such as adhesions of the body of the uterus to other pelvic organs; tumors in the walls of the uterus, which, by their weight, bend the uterus upon itself; and pressure from ab- dominal tumors which crowd the uterine body out of place; but flexion in such cases is only a complication of the affection which causes it, and does not belong to the subject of flexion as a primary lesion. Theoretically, the uterus might become flexed in either direction; but practically the forward and backward, anteflexion and retroflexion, are the only two forms that occur as uncom- plicated affections. The later- al flexions are, as a rule, sec- ondary to the diseases already mentioned. Anteflexion, which occurs as the result of imperfect de- velopment, and which is oc- casionally acquired from mal- nutrition, is by far the most common. There are three varie- ties of anteflexion: First, forward flexion of the cervix (Fig. 34); 5* Fig. 34a.—First variety; anteflexion of cervix. DISEASES OF WOMEN. Fig. 35.—Second variety; anteflexion of body of uterus. second, forward flexion of the body (Fig. 35); and, third, for- ward flexion of both body and cervix (Fig. 3f>). Pathology. — F'lexion of anv form necessitates some defect in the structure of the uterus. This constitutes one of the essential differ- ences between flexion and version, which latter is sim- ply an error of location without, necessarily, any change of structure of the uterus. The flexion is usu- ally at the junction of the body and cervix, the point corresponding to the inter- nal os. Flexion at any point in the body or cervix oc- curs only as an exception, which need not be noticed here. At the point of flexion the tissues of the uterine walls are deficient. On the side to which the organ is bent the wall is compressed and attenuated. On the other side the loss of tissue is not so marked, the thickness being but slightly diminished by the stretching. The sub- mucous, fibrous stratum of tissue, which is said to give firmness and support to the organ, is absent or deficient on the side to which the uterus is bent. The effect of flexion on the uterine canal is to produce constriction or occlusion of the internal os. The external os is sometimes more open than in health, owing to trac- tion being made on the pos- terior lip. The stricture thus formed gives rise to accumu- lation of the secretions of the uterine cavity, and to partial retention of the menstrual products. The circulation in the uterus, as will be Fig. 36.—Third variety; anteflexion of body and cervix. FLEXIONS OF THE UTERUS. 59 readily understood, is interfered with. The obstruction tends to keep up congestion, and this may eventually lead to oedema and a predis- position to endometritis and pelvic peritonitis. From all these causes derangement of function follows. The men- strual fluid, in place of escaping passively, is expelled, perhaps, by spasmodic contractions, attended with colicky pain. In other words, there is dysmenorrhcea. Sterility also exists in the majority of cases. These pathological conditions increase with time. The pressure at the point of flexion produces anaemia and atrophy of that part, and the intrinsic support of the uterus being thus diminished the flexion increases. Hence, the flexion of the first variety often progresses to the second and third. The anatomical appearances in flexion are well described in Xie- meyer's " Text-Book of Practical Medicine." I quote that portion which applies to anteflexion of the body of the uterus : " On autopsy, flexion of the uterus may be readily recognized, as part of the pos- terior wall of the body, instead of the fundus, forms the highest part of the uterus. Generally, we may restore the sunken fundus to its position, but it sinks back again to its former place when we let go of it. If we cut the uterus out of the body, and hold it erect by the vaginal portion, the fundus sinks down anteriorly; if it be held horizontally, it not infrequently holds its weight if the flexed side be upward, but it bends together if we reverse it." To this I would add that in the first variety the cervix projects into the vagina much farther on the posterior wall than on the anterior; indeed, in marked cases, the anterior lip of the cervix uteri is very little below a line corresponding to the point of union between the cervix and the an- terior vaginal wall. Natural History of Anteflexion.—Symptomatology.—Derangement of uterine function constitutes the principal point in the natural his- tory of flexion. Menstruation, from its first establishment, is often painful—there is dysmenorrhoea. The severity of the pain bears some relation to the extent of flexion. The greater the deformity the more marked is the pain, though there are exceptions to this rule. The character of the pain is of the greatest importance. It is inter- mittent, and always precedes the flow. When the flow begins, the pain either subsides or becomes much less. The pain closely resem- bles that which occurs in abortion in the early months of pregnancy. The reason, I presume, is that while the fluid is accumulating in the uterine cavity, pain is excited by distention; but the flow when once started, continues with less expulsive effort. Painful men- struation often occurs without flexion, but in such cases the pain GO DISEASES OF WOMEN. continues throughout the whole period, or during the early part of it, and is not relieved by dilatation of the cervix; while in flexion it precedes the flow, and is relieved temporarily by dilatation. This pain, at the commencement of menstruation, is the most prominent symptom in the history of flexion as it occurs in the young girl. The trouble tends to increase gradually. If the patient gets married, all the symptoms usually increase. Should she become pregnant, there is great liability to miscarriage during the early months. The effect of the pregnancy, however, in part at least, is to remove the deform- ity, even when miscarriage occurs, so that pregnancy is likely to occur again, and go on to full time, and the deformity is cured completely. Checking the menses by exposure to cold, or any cause which will produce hyperemia of the uterus, or endometritis, promptly increases the dysmenorrhea, and gives rise to new symptoms. Leucorrhcea, backache, local tenderness, deranged digestion, and nervous disturb- ances, are all added to the original symptoms. Sometimes in ante- flexion frequent micturition is a marked symptom. There are all varieties and degrees of prominence of the symp- toms in the natural history of flexion. The dysmenorrhcea which begins at puberty may continue, and increase but little through fife. This is most likely to be the case if the individual remains unmar- ried, and can avoid all the conditions which tend to aggravate uter- ine disease. On the other hand, the dysmenorrhcea may increase in severity during each succeeding menstruation, and after marriage become intolerable. In the intervals between the menstrual periods the patient in her early life is free from trouble, but eventually symptoms of uterine and vaginal inflammation are manifested. Constitutional derangements, especially of the nervous system, fol- low, and in time we have the broken-down, miserable patients, famil iar to all practitioners. Such patients often seek relief in the use of stimulants and opium, which only soothe for a time, but eventually aid in undermining the health and strength of the unfortunate suf- ferers. The subjects of flexion are very liable to pelvic peritonitis and diseases of the ovaries and Fallopian tubes, with all the suffering which these affections give rise to. Physical Signs.—Although the history alone might lead one with a tolerable degree of certainty to suspect the presence of flex- ion, the physical signs must be depended upon for an accurate diag- nosis. The physical signs of flexion arise from the changed relations of the body and cervix to each other. These signs are detected by the touch and the uterine probe. The touch may indicate that the FLEXIONS OF THE UTERUS. 61 cervix occupies its normal position, or it may be found to be retro- verted, which is its most frequent position in anteflexion. The os points toward the introitus in the same way that we find it in retro- version. The vaginal portion of the anterior wall of the cervix is much shorter than the posterior. Carrying the finger along the an- terior vaginal wall, the body of the uterus can usually be felt bend- ing forward. The bimanual examination reveals the deformed condition of the uterus in lean patients, wThose abdominal parietes are yielding; but in fleshy subjects with rigid abdominal muscles, very little can be learned by this mode of exploration. When rigidity of the parts is the obstacle to exploration, an anaesthetic may be used with great advantage, as practiced by Sir J. Y. Simpson. When the signs thus obtained point to flexion, the diagnosis should be confirmed by using the sound. Much trouble is often experienced in introducing this instrument. Indeed, it is impos- sible in extreme flexion to carry the sound into the uterus without first straightening the bend at the junction of the body and cervix. To do this, the cervix should be seized by a tenaculum, and gently drawn downward, while at the same time the fundus is pressed up- ward and backward. In this way the canal is partially straightened, and the sound can be introduced. There are cases where it is only necessary to curve the sound properly and manipulate with care, and the point of flexion can readily be passed. When the sound passes into the body of the uterus in the direction indicated by the touch, the diagnosis is complete. While there are many conditions which might present the signs of flexion as obtained by the touch, the combined testimony of the touch and sound are sufficient to make the diagnosis sure. Caus2 and 63. The normal elevation of the pelvic floor is illustrated by Fig. C>I. This position of the pelvic floor and the relations of the rectum and vagina should be noted because they become changed in most of the injuries of this structure. The muscles of the pelvic floor are surrounded by the deep and superficial fascia, which in some parts become ligamentous in char- acter ; for example, the ischio-perineal ligament—that dense portion of the fascia which stretches from one side to the other through the space between the rectum and vagina. This fascial structure accom- panying the muscles is characteristic of all muscular structures which have to afford continuous sustaining power, like the muscles of the back, of the neck, abdomen, and thigh. Function.—These anatomical facts regarding the floor of the pel- vis suggest that its functions are to sustain the rectum and vagina, and to aid in their functions. The arrangement of the muscles is such that they close by sphincteric action the terminal ends of the rectum and vagina, yet also permit the distention of their orifices during the acts of parturition and evacuation of the rectum. When pressure is made downward by any body in the rectum or vagina, the perineal muscles act to draw the orifices of these canals upward, and hence supply a resisting force to the downward pressure which effects dilatation of the vagina and rectum. This action of the mus- cles in resisting downward pressure is well demonstrated during par- turition. When the child's head presses upon the floor of the pel- INJURIES TO THE PELVIC FLOOR. 115 vis, the muscles, by retraction, distend the sphincter ani to a great extent. The dilatation of the vagina is produced by a more passive Fig. 64.—Diagrammatic sagittal section of the female pelvis, u, uterus; r, rectum ; s, symphysis; p, perineal body ; b, is beneath bladder. This is the position of the uterus when the bladder is moderately full. giving way to the forces above, and yet the muscles exert a well- defined power in retracting that portion of the pelvic floor. This function of the muscles should be noted because it enters into the mechanism of most of the injuries to be discussed. This brief statement regarding the function of the pelvic floor embodies the essential points in its chief offices. There remains something to be said regarding its relations to the pelvic organs. Up to the present time the attention given to this subject by gynecologists has been almost wholly confined to laceration of the so-called perineal body—an injury frequently seen, but not by any means the only one that occurs to these parts. This concentration of attention on one portion of the subject has given rise to great 116 DISEASES OF WOMEN. diversity of opinions regarding the function of the perineum and its relations to the displacements of the pelvic organs, one party to the controversy believing that the perineal body has much to do with sustaining the pelvic organs in position, the other holding that it has very little power in this respect. Without summing up at great length the arguments on both sides, the facts bearing on the practical side of the subject may be briefly stated. In all injuries of the pelvic floor which impair its supporting function to any extent, prolapsus of the pelvic organs will follow in time, except in three conditions: 1. When the injury is compensated for by the muscles (which still maintain their attachment to the vagina and rectum) drawing the remaining portion of the pelvic floor upward, forward, and toward the pubes, thereby closing the vaginal orifice and supporting the pelvic organs. 2. Where by reason of some intra-pelvic inflammation the organs have become fixed by adhesions; and, 3. Where the patient is abundantly supplied with adipose tissue, and takes very little active exercise. Excepting under the circumstances here named, prolapsus of the pelvic organs invariably occurs after important injuries of the pelvic floor. The displacement does not follow the injury immediately, but, as a rule, comes on slowly. This conclusion has been arrived at from a large number of clinical observations, and it helps to definite- ly settle the question regarding the value of the pelvic floor as a means of support for the pelvic organs. From these facts one may obtain the key to the differences of opinion which have been held by gynecologists regarding the functions of the pelvic floor. Those who believe that it plays a secondary part in maintaining the pelvic organs in position argue that there are anatomical structures which sustain the pelvic organs in place without aid from the pel- vic floor, and, in proof of this, point to the fact that the removal of the pelvic floor is not followed by displacement of the pelvic or- gans. This is often seen in cases in which lacerations sufficient to largely impair the function of the pelvic floor have existed for years m women in active life without the occurrence of prolapsus of the pelvic organs. And, more than all this, it is said, prolapsus of the pelvic organs occurs where there is no apparent injury of the pelvic floor-i. e., no laceration of the perineum. The falla- cies of this argument are that, although the pelvic organs are held m position by supports that are sufficient to resist ordinary taxation for a given time, they are not able to do so under ex- INJURIES TO THE PELVIC FLOOR. 117 traordinary pressure for any length of time unaided by the pelvic floor. Again, the cases cited in which prolapsus does not occur while the perineum is lacerated belong to one or another of the three ex- ceptional states which I have already given. And, finally, the cases in which there is prolapsus while the pelvic floor appears to be uninjured are, as a rule, cases of mistaken diag- nosis, the floor of the pelvis being really imperfect, although not apparently so on examination by the sense of sight alone. Some observers look for a laceration of the perineum by inspection of its mucous and tegurnentary surfaces, and, if injury to these surfaces is not found, they pronounce the pelvic floor perfect, while the fact is that laceration of the perineum in the median line is only one of many injuries of the pelvic floor which render it functionally imper- fect. But granting that the pelvic floor takes no part in supporting the pelvic organs under ordinary taxation, it certainly aids in doing so in case there is extraordinary downward pressure from lifting heavy weights, violent coughing, and the like. Again, when the pelvic floor is injured—say by laceration—and loses the power to support itself and the vagina and rectum, prolapsus, especially of the vagina, occurs. This causes a dragging upon the pelvic organs which in due time will cause them to descend. In view of these well- known facts, the most enthusiastic advocate of the independent sup- ports of the pelvic organs must admit that the pelvic floor is at least indirectly concerned in supporting the structures above it. Varieties.—The injuries of the pelvic floor usually seen in prac- tice are: 1. The various degrees of laceration of the perineum, i. e., in the median line of the pelvic floor. 2. Subcutaneous separation of the muscles of the pelvic floor at their junction in the median line, or so-called perineal body. 3. Laceration in the median line, and temporary loss of power in the remaining muscles from overdistention. 4. Laceration of the levator-ani muscle, occurring alone or accom- panied by the lesions already given. 5. Atrophy and permanent paralysis from injuries during partu- rition and other causes. 6. Loss of muscular motion caused by the products of former inflammation. The first of these, laceration in the median line of the pelvic floor, is the injury most frequently sustained during parturition. Several degrees of this injury are described by authors, but in re- us DISEASES OF WOMEN. gard to the pathology and treatment there are only two which, in fins connection, require attention: the one which extends through the muscles of the anterior portion of the pelvic floor-that is, from the vulva to the sphincter-ani muscle, and the other which extends through the sphincter-ani muscle and into the rectum. The former of these is the injury which is most frequently recognized, and is therefore presumed to occur most frequently, although this point is not vet settled. Certainly it is the least grave in its consequences if properly cared for, because it is the most easily remedied by surgical treatment. In its simplest form the laceration extends through the mucous membrane of the vagina, the integument, and the junction or union of the bulbo-cavernosus with the transversus-perinei muscle, a few fibers of the levator ani and the fascia, elastic and areolar tissues which constitute the perineal body. When this injury is uncomplicated with laceration of the muscles of the pelvic floor elsewhere than at the median line, the separated ends of the muscles involved in the rupture still retain their union with the divided side of the perineal body and with each other. This is very clearly shown by the fact that the bulbo-cavernosus, trans- versa perinei, and anterior fibers of the levator-ani muscles hold the separated sides of the perineal body and the posterior, uninjured portion of the pelvic floor upward. At the same time that the pos- terior portion of the pelvic floor is maintained at its normal eleva- tion, it is often brought forward to compensate for the loss of sup- port caused by the laceration (Fig. 65). This compensation does not occur in all cases, but usually does so unless there is damage done to the muscles other than at the median rupture alone. I have observed in some cases sufficient drawing forward to lessen the dis- tance between the meatus urinarius and anus very perceptibly. This is familiar to all who have studied the subject with a view to operat- ing, from the fact that, in order to estimate the depth of the lacera- tion, to determine how extensive the vivifying of tissue need be, it is necessary to retract the posterior portion of the pelvic floor with the finger or sound in order to press the rectum or anus backward into its place. This compensation prevents prolapsus of the pelvic organs for a long time, in some cases for many years, and is one rea- son why rupture of the perineal body is not always followed by pro- lapsus uteri. In this condition the vulva is not enlarged from dis- tention by the partially inverted vaginal walls, nor is the uterus necessarily displaced. Many such cases are seen among patients who seek relief for other affections, but have no symptoms which INJURIES TO THE PELVIC FLOOR. H9 can be traced to the laceration, except occasional pain in the scar tissue in the injured part. Case.—Mrs. H., aged forty, had had six children. During her first labor she says she was "torn," the child weighing thirteen Fig. 65.—Complete laceration of the perinaeum; anus drawn forward ; no rectocele. pounds. Of the perineal body a part of the anal sphincter alone re- mains ; but a little way up the posterior vaginal wall a thick, strong, muscular band crosses, which tightens about the examining finger and draws the anus forward. The uterus is in place, and there is no rectocele ; nor sagging of the pelvic floor ; nor are there symptoms. (See Fig. 05.) Rupture through the sphincter ani is the most unfortunate of all injuries of the pelvic floor, owing to the incontinence which follows. The unhappy subjects of this accident are debarred from taking 120 DISEASES OF WOMEN. much active exercise, and usually avoid society. Strange as it may appear, they do not all suffer from prolapsus of the pelvic organs; in fact, I think that prolapsus following this injury, to any great degree at least, is the exception. This is, no doubt, due to the fact that such patients are unable to do much walking or standing, and therefore the pelvic organs are not submitted to much downward pressure. It might be supposed that relief from this distressing con- dition would be sought before sufficient time had elapsed for prolap- sus to occur, but this is not always the case, for I have seen several such injuries of many years' standing, and yet there was very little displacement. There is indeed very little falling of the pelvic floor or of its divided sides. This is accounted for by the fact that the laceration extends through the greater portion of the pelvic floor, leaving little remaining to settle downward. In most cases the two halves of the floor are held well up in position by the muscles which are attached to them. When the laceration is through the sphinc- ter-ani muscle only, and does not extend upward into the anterior wall of the rectum and the posterior wall of the vagina, there is a little control of the rectum still retained. This retaining power is sometimes favored by a band of scar tis- sue, which lies between the upper fibers of the divided sphincter, and gives a fixed point toward which the muscle can contract in an imperfect way. There is usually prolapsus of the mucous membrane of the rectum in cases of long standing, and the prolapsus is almost always greater if the wall of the vagina and rectum are also lacer- ated to any great extent. The second form of injury mentioned in the classification is sub- cutaneous separation of the muscles of the pelvic floor at their junc- tion in the median line, or perineal body. The mucous membrane of the vagina and the skin covering the perineum remain normal, but the transversus-perinei muscles are torn apart in the median line. The bulbo-cavernosus muscles are separated from their inser- tion at the center of the perineum, and possibly some of the fibers of the levator-ani muscle are also lacerated. There is, in short, a complete laceration of the deeper structures of the perineum, the skin and mucous membrane alone remaining uninjured. The result of this injury is falling of the pelvic floor, and usually prolapsus of the pelvic organs. The function of the pelvic floor is destroyed as completely as in the injury first described. I believe that this condition has frequently been mistaken for functional imperfection of the perineum, or relaxation, as it has been called. The fact is, that it is a well-defined anatomical lesion, INJURIES TO THE PELVIC FLOOR. 121 which can be demonstrated quite easily by passing the finger into the vagina and pressing downward and outward. In this way the absence of the muscles, fascia, and connective tissue is discovered. It is found also by this examination that all muscular resistance is lost in the parts. Again, while the index-finger is in the vagina the parts anterior to the sphincter-ani muscle can be grasped between the finger and thumb, which will show that where the perineal body should be there is only skin and posterior vaginal wall. There is still another method of examination, and, perhaps the most critical one—that is, to pass one index-finger into the vagina and the other into the rectum, when it will be found that the only resisting mus- cular tissue felt between the two fingers is the sphincter ani. These examinations by the touch are quite sufficient; but, if fur- ther evidence is desired, it may be obtained by trying to excite con- traction of the muscles which act as a sphincter vagine. This can be done by the interrupted electric current, or by irritating the labia. In making a vaginal examination, every one has noticed how actively the muscles of the pelvic floor contract and close the introitus vagi- ne in the normal state; but in this injury no such contraction oc- curs, nor can it be produced by pricking the labia with a needle, or any such means used to excite reflex action. In case the levator-ani muscle remains intact, the posterior por- tion of the pelvic floor remains in its normal position, except that the end of the rectum may be displaced backward, but it rarely is, as a rule, because the vagina and uterus are not prolapsed. The coun- terpart of this lesion is often seen in cases that have been operated upon with the intention of restoring the pelvic floor or perineum, the operation having failed in its object. Union of the skin and mucous membrane is obtained, but the muscles are not united, and hence, although upon removing the sutures the result is pronounced to be perfect, and to the superficial observer appears to be so, the muscular function of the pelvic floor has not been restored, and the operation is, in fact, a complete failure. The third form of injury mentioned in the classification presents the same lesions as have been given in describing the two preceding forms. There is a laceration in the median line down to the sphinc- ter ani, and also an overstretching of the muscles, which give rise to sagging of the whole pelvic floor and backward displacement of the rectum. In some cases, in place of overstretching there is retraction of the ends of the torn muscles, so that they have no further connec- tion with the divided sides of the perineal body or with the sphinc- ter ani, and hence they can no longer sustain the pelvic floor even in 9* 122 DISEASES OF WOMEN. an imperfect way, as is observed in cases of simple laceration already described, in which compensation is made by the muscles drawing the posterior portion of the pelvic floor upward and forward. Evi- dence of this subcutaneous overdistention or retraction of the mus- cles and temporary paralysis is seen in a great many cases of partu- rition. Every obstetrician has observed the complete relaxation of the pelvic floor that so frequently follows delivery, even when there is no laceration of the integument. There is not only loss of mus- cular motion, but also loss of sensation in some cases. That this re- laxation is due in many cases to overdistention of the muscles with- out solution of continuity is probable from the fact that recovery is so rapid and complete. Still, in many cases the injury done to the muscles is sufficient to defy the natural recuperative powers, and remains permanent, if not relieved by surgical treatment. In many of the cases of this kind seen in practice the muscular insufficiency is doubtless caused by overdistention produced by pro- lapsus of the pelvic organs. As soon as the pelvic organs descend so as to make continuous pressure upon the pelvic floor, the muscles (impaired by the laceration in the median line) gradually give way, and finally lose their contractile power, either temporarily or perma- nently, according to the length of time that the prolapsus has ex- isted. It follows, then, that it is only when sagging of the pelvic floor is seen before any prolapsus of the pelvic organs has taken place that we can reasonably infer that the muscles were impaired at the time that the laceration occurred, and that the injury was more ex- tensive than the mere separation at the median line. The fourth injury is laceration of the levator-ani muscle with or without being accompanied with the injuries which have been de- scribed already. This is the most extensive injury which occurs, and is one of the most disastrous of all in its consequences ; and what gives it greater importance is the fact that it is not, so far as I know, commonly men- tioned in our literature. I am satisfied that this injury to the pelvic floor occurs frequently, but, fortunately, recovery occurs many times unaided by any special treatment. Still, there are many cases in which the injury is permanent, and can not be relieved by any treatment known at the present time. This condition may be associated with complete laceration in the median line, but usually is not. I pre- sume that the subcutaneous laceration of the muscles saves the super- ficial structures of the perineal body. When there is no laceration in the median line the tissues between the rectum and vagina appear to be normal; at least the distance from the anus to the posterior INJURIES TO THE PELVIC FLOOR. 123 commissure of the vagina is normal, but there is loss of contractile power in the parts. The whole pelvic floor, including the rectum, vagina, and lower part of the labia, projects downward below its normal elevation. This suggests the thought that subcutaneous lacer- ation of the transversus perinei generally takes place also, when the levator ani is injured. Fig. 6$ shows the downward displacement resulting from the injury to the muscles. This displacement can be demonstrated upon the subject by placing one finger upon the pubes and the other on the tip of the coccyx, and observing the extent to which the pelvic floor projects below these two points. Again, by placing the pa- tient upon the side and flexing the thighs at right angles with the trunk, the downward displacement becomes apparent. In the most pronounced cases the parts project downward almost on a line with the nates. The physical signs of this condition will be referred to again in connection with atrophy of the muscles, and the differential points will be noted. Atrophy, and the consequent paralysis from injuries during par- turition and other causes, occurs only in cases of long standing, and is, in fact, a secondary state re- sulting from laceration of the mus- cles or overdistention. It may follow any of the injuries already mentioned that have been long neglected, or in which unsuccessful efforts have been made to over- come the original injury. The muscles, having been torn or sepa- rated from their ligamentous attachments during parturition, become functionally inactive, and remain so until they undergo fatty degen- eration and are finally lost. These are usually neglected cases, but a like condition is seen when a surgical effort at restoration has been made which has resulted in union of the skin and mucous membrane without restoring the muscles. The same thing is pro- duced in another way. The pelvic floor sustains an injury, slight Fig. 66.—Sagging of the pelvic floor. The sweep from a to b denotes the sagging portion of the pelvic floor. The bulging posterior vaginal wall (rectocele) shows white between the labia. 121 DISEASES OF WOMEN. in itself, which is permitted to remain until prolapsus of the pel vie organs produces overdistention of the muscles, and maintains it so long that atrophy of the muscles takes place and permanent loss of the function of the pelvic floor follows. Other and rarer cases are seen in which atrophy of the muscles occurs as the result of long-continued overdistention. This I have seen in cases of paralysis caused by hypertrophic elongation of the cervix uteri and small fibroids in the uterus. In these cases there was no evi- dence that the floor had sustained any injury other than that pro- duced by the prolapsus. I am also personally convinced that pro- lapsus of the pelvic organs may be due to injuries of the uterine ligaments and upper pelvic fascia while the pelvic floor sustained no injury whatever until the prolapsed organ caused its overdistention. Again, habitual constipation will cause paralysis of the muscular tissues of the rectum, and also (to some extent, if not wholly) of the levator ani, and, if this continues long enough, atrophy and perma- nent paralysis will follow. If to this constipation prolapsus of the pelvic organs is added, and they both continue for a long time, per- manent insufficiency of the pelvic floor will occur from muscular atrophy. Finally, I presume (though I can not prove) that atrophy of the muscles occurs in very old women from no other cause than senile malnutrition. In this state of the parts other anatomical le- sions occur in nearly all cases. The fascia and elastic tissue are wanting, and the blood-vessels—notably the veins—become over- distended, giving a well-marked passive hyperemia. The vast differ- ence in the vascularity noticed in operating in different cases is accounted for in this way. The extent of prolapsus which occurs in this form of muscular insufficiency differs. In the most marked case that I have seen it was so great that the anus was nearly on a line with the nates while the patient was in Sims's position. The physical appearance of this affection has been already illustrated in connection with recent lacer- ations—the fourth injury described (see Fig. 66). The informa- tion obtained by inspection is usually sufficient for a diagnosis, but still further evidence can be obtained by the touch; this shows the lax, non-resistant state of the muscles, which, as already stated, can not be excited to contraction by irritation or the electric current. In the diagnosis of all these injuries, the all-important question is to determine whether the paralysis is due to overdistention of the muscles and is temporary only, or due to atrophy, and hence perma- nent. This can not always be settled at once and positively. If the tissues of the pelvic floor appear to the touch to be lacking muscular INJURIES TO THE PELVIC FLOOR. 125 fiber, and no muscular contraction can be induced by stimulation, it is presumptive evidence of muscular atrophy ; and yet it may be only a temporary loss of muscular power. It is necessary, then, to sup- port the pelvic floor and let the patient rest in the recumbent posi- tion to remove all downward pressure from the parts, and, by the use of astringents and electricity, endeavor to restore the muscular function sufficiently to prove that there is still muscular tissue pres- ent. If by such means the muscular function is even partially re- stored, the diagnosis is completed, and the indications for further treatment are established. It is then and only then that surgical treatment may be employed with the hope of obtaining complete recovery. Should all well-directed efforts fail to give evidence that the muscles still retain their true anatomical characteristics, it is use- less to hope for success in operating. Symptomatology.—The symptoms which are developed by injuries to the pelvic floor are not sufficiently diagnostic, or else they have not yet been sufficiently studied, to make them of decided value to the diagnostician. Patients express a feeling of want of support of the pelvic organs, or, as they express it, a dragging-down feeling, and some derangement of the functions of the rectum and bladder, but, as these symptoms occur in all the forms of injury named, and as they also in like manner occur in displacement of the pelvic organs, but little reliance can be placed upon them. When the function of the levator-ani muscle is lost from injury or atrophy, there is usually much difficulty in evacuating the rectum. This is, of course, most marked when the patient is constipated, but it is noticed also when the bowels are free, though to a less extent. When there has been a laceration in the median line the scar tissue is often tender to the touch, and occasionally causes some general nervous disturbance. The sensitiveness of this scar tissue is sometimes so great as to pro- duce reflex muscular contraction when touched while the patient is anesthetized. The admission and expulsion of air from the vagina (flatus vaginalis) is said to occur frequently in these injuries, and it is no doubt one of the most reliable symptoms of injuries of the pelvic floor, as it rarely occurs in any other condition. The last of the pathological states of this structure to be described is muscular rigidity produced by a previous inflammation, the prod- ucts of which have impaired the muscular tissue. This affection has been classed by authors under the head of rigid perineum, vaginismus, and spasmodic muscular contraction, but it belongs to a different pathological order of things. There are cases of rigidity or spasmodic contraction of the muscles due, perhaps, to 12G DISEASES OF WOMEN. hyperesthesia, but the condition under consideration is simply a rigid state of the muscles caused by the products of a former inflam- mation which have impaired the elasticity and motion of the muscles. The cases of that kind that I have seen have given a history of pel- vic inflammation—in two following scarlatina, in one from an injury sustained by falling upon the rail of a fence, and in another from a perirectal abscess. Ko difficulty was experienced in either case until after marriage, when it was found that coition was impossible. An ex- amination showed that the vagina was rigidly closed and the muscles of the pelvic floor could not be distended. All efforts to move them caused severe pain. In short, there was muscular anchylosis. The treatment for this affection commended in the books is to incise the pelvic floor from the vaginal orifice down to the sphincter-ani muscle, an operation entirely uncalled for and unsatisfactory in its results, as will be seen when we discuss the treatment. Causation.—The causes of these injuries are traumatic (excepting the last one described), that is, overdistention or stretching of the parts during parturition. The exceptions to this have already been mentioned, viz., long-continued overdistention from prolapsus of the pelvic organs, extreme constipation, and malnutrition in old age. There are, no doubt, certain states which predispose to these in- juries. Phlegmatic women who have failed to take exercise sufficient to develop these muscles are liable to lacerations during parturition. In such cases the muscles of the pelvic floor are poor in quality, and rupture easily under extreme pressure. The very opposite of this ap- parently predisposes to the same accidents. In vigorous muscular women the pelvic floor is often unyielding because of the great strength of its muscles. They resist the pressure of the child as it is forced against the pelvic floor by a powerful uterus, and, seemingly, rather than relax and stretch, their union at the median line gives way; it is in such cases that complete laceration in the first degree is most likely to occur. Again, in those in whom the pelvis is shal- low and wide in the straits, the child passes easily through the pelvic canal, when rather sudden, unrestrained pressure comes upon the parts and they are very liable to give way. In others still, either from habits of life or the position of the uterus in relation to the pelvis, the return circulation is retarded, the vessels become overdistended, and a deranged nutrition, with softening of the tissues of the pelvic floor, renders them easily torn. The immediate cause of lacerations—whether subcutaneous or complete—is distention during delivery. The tissues in the median line give way in the great majority of cases because the greatest INJURIES TO THE PELVIC FLOOR. 12V pressure is brought to bear at that point. That the laceration ex- tends to, but not through, the sphincter-ani muscle, as a rule, is no doubt due to the strength of this muscle. In fact, it is a matter of surprise that the sphincter is ever lacerated when its position is con- sidered in relation to the force brought to bear upon it. The only rational explanation of the laceration which I have been able to ob- tain from a careful clinical study of the matter is as follows: The transversus-perinei, levator-ani, and bulbo-cavernosus muscles are so strongly attached to the sphincter-ani muscles that, during de- livery, when the head distends the pelvic floor they hold the sphinc- ter ani upward and forward. If the size of the head is out of pro- portion to the distensibility of the pelvic floor, one of two injuries must occur: either the muscles attached to the sphincter must give way and permit the sphincter to recede downward and escape injury, or else the sphincter must be torn through. This effect of the other muscles upon the sphincter ani during delivery of the child's head can be seen by the way in which the sphincter ani is drawn upward until the anus is distended an inch or two. While the fetal head was unusually distending the pelvic floor, and while the hand was placed upon the parts to " support the perineum," I have felt, or fancied that I could feel, the muscles attached to the sphincter ani give way and permit the rectum to recede and escape injury. Regarding the causes of injuries to the levator-ani muscle, one has but to recall the phenomena of labor as related to it to under- stand how it may be freely lacerated in ordinary labor. It cer- tainly is as freely exposed to injury as the other muscles which we know are frequently lacerated subcutaneously. In delivery with forceps, the levator-ani muscle is frequently injured, I believe. AVhile the child's head is in the grasp of the forceps and during traction, I have noticed, by passing the finger into the rectum, that the levator ani was drawn so tightly over the edges of the blades of the forceps that it appeared as if it must be torn, and I feel sure that it often is. I am the more fully convinced of the truth of this by having carefully watched patients that I had delivered with for- ceps, and have found in some of them evidence of injury of the levator ani above its lower attachment. That evidence was obtained by finding, on subsequent vaginal examination, that the resistance of the levator muscle usually found was wanting, and also that there was prolapsus of the pelvic floor, and loss of contractility upon irri- tating the parts. Treat no nt.—The object in treating these injuries should be to restore the lacerated muscles by securing union of their severed 128 DISEASES OF WOMEN. fibers. In the ordinary or most commonly recognized injury, lacera- tion in the median line down to, but not through, the sphincter, the immediate treatment usually employed is to close the wound with sutures at once, or to cleanse the wound from blood-clots and coapt the parts, carefully bind the patient's limbs together, and trust that union may follow. The treatment by the immediate use of the suture will be made plain by the following : Primary Opercdion.—The wound, if seen when it occurs, is tri- angular, the base running parallel to the rectum and the apex being at the posterior part of the vulva. The sides of the wound come to- gether quite easily, and only require well-adjusted sutures to keep them in position. Much care is necessary in using the sutures. If they are imperfectly introduced they do harm by preventing the union which often takes place without surgical aid. If one is not accus- tomed to this simple operation of closing the wound with sutures, it would be infinitely better for the patient to trust to nature than to have the surgeon employ sutures in a bungling way. The sutures should be introduced as follows: The needle, held in the groove at right angles to the forceps, should be entered in the skin exactly at the edge of the wound, and as far down as the deepest part; it is then carried into the tissues and made to describe the arc of a circle and emerge at the margin of the mucous membrane of the vagina. The needle is again introduced on the opposite side and carried through as before, and brought out at the point in the skin opposite where it was first introduced. If this is properly done, the position of the suture in the tissue will be as represented in Fig. 67. The center lines repre- sent the sides of the wound and the dotted memhiwp- ^ne shows the suture, which describes a n circle, the point at which the suture is I tied and the opposite point of its cir- cumference being at the upper and lower angles of the wound. There are three advantages in using the suture in this way : First, the ends of the suture com- Fig. ^.-Diagram tf the sweep of {j]„ Qut ftt fche edgeg Qf ^ ^^ ^ the parts exactly together without the aid of superficial sutures; second, the curve which the suture takes deep under the tissues brings the central portions of the wound to gether, whereas, if the suture is passed straight through the tissues, the edges of the wound would curve inward, while the central parts would not meet. Fig. 68 shows the parts adjusted by a proper su- ture, while Fig. 69 shows the effect of the imperfect one. Again, INJURIES TO THE PELVIC FLOOR. 129 the suture running deep into the tissues gives additional surety of catching the ends of the muscles so as to reunite them; which is the chief object of the operation. In the pri- mary operation—i. e., the introduction of su- tures immediately after the injury occurs— , Peaslee's needle is easier to use than the or- dinary perineal needle. Fig. 70 shows the • instrument. This needle, with a handle, and an eye near the point, is armed with a thread fIGS- 68< 69.—Sutures proper- -, , ,, i,!,. lib an(l improperly introduced. and passed through the tissues as already described, and the end of the suture is passed under the thread in the needle; this is then withdrawn and brings one end of the suture into the tissues. The operation is repeated on the other side, which Fig. 70.—Peaslee's needle. completes the introduction of the suture. The only advantage of this needle is that it is easier to manage than the ordinary one It can only be used, however, in the primary operation. The silk suture properly prepared is by far the best for the immediate opera- tion. Silver wire, which at one time was the only suture which could be relied upon, has been superseded by others that are vastly superior for this purpose. It is impossible to keep the parts clean after confinement without causing pain while the ends of silver-wire sutures are projecting from the parts. The silk sutures save the patient much discomfort, and are not in the way of the means neces- sary to be used to keep the parts clean. This constitutes the whole primary treatment of injuries of the pelvic floor, as given in our text-books—a kind of management gen- erally sufficient in central lacerations, but that can have little influ- ence in restoring the other forms of injury. To secure the reunion of the muscles that have been lacerated subcutaneously, especially the levator ani, the parts should be well supported and kept at rest. If the pelvic floor is permitted to remain in its relaxed and displaced position there is but little chance of the lacerated muscles uniting, nor, in case they are simply overtaxed by distention, will they regain their tonicity promptly if left unaided by support. Especially is restoration likely to be prevented if the patient is permitted to as- sume the erect position too soon, and if, to increase the injurious effects of this unwise liberty, the uterus is crowded down into the 10 130 DISEASES OF WOMEN. pelvis by a compress and tight, bandage applied around the body. In all cases of injury in which concealed laceration of the muscles is suspected, the pelvic floor should be well supported with a compress and bandage fastened to the abdominal binder. By these means the severed ends of the muscular fibers are brought nearer together, so that they have a better chance to unite. An objection would natu- rally be raised to this treatment on the ground that it would obstruct the free flow of the lochia. This can be overcome by making the compress of absorbent cotton, antiseptic gauze, or marine lint, and draining the vagina with a drainage-tube or a strip of gauze or lint. I believe that in this way the vagina can be drained and kept as clean as it can be by occasional douching. In fact, I am inclined to think that the very frequent use of vaginal injections so generally employed in this age of antiseptic obstetrical practice often tends to retard the restoration of injuries of the pelvic floor. It is well, also, to let the patient rest upon either side after the first twelve or twenty-four hours. This position takes off all pressure from above, and favors the upward inclination of the pelvic floor. Great care should be taken to avoid distention of the bladder and rectum. Con- stipation after confinement is almost sure to prevent or, at least, retard recovery. By attending to these simple means much can be done toward preventing that incurable condition, permanent paraly- sis from atrophy. After convalescence from confinement, in case it is found that, although there is no complete loss of muscular action in any part of the pelvic floor, there is a muscular weakness shown by the impaired power of resistance to pressure, the supporting treatment, with judi- cious rest and exercise well regulated, should be kept up until strength is restored. The restoration of the function of the muscles, as already stated in speaking of general treatment, is the great object of all surgical operations for the relief of these injuries of the pelvic floor. It matters not how much tissue may be gathered together and united in the region of the perineal body, it will have no functional action if destitute of muscular tissue. The success of all surgical proced- ures depends upon the restoration of the muscles, elastic tissue, and fascia, and not the mere uniting of the tegumentary and areolar tissue. In this plastic operation, known as perineorrhaphy, or restoration of the perineum, much surgical skill is necessary in order to succeed. This is true of all operative surgery, and yet special care is necessary in this operation, because union by first intention must be secured INJURIES TO THE PELVIC FLOOR. 131 or else the operation will fail. In many operations in surgery, if the wound does not heal by first intention, union may be secured by granulation and a perfect result obtained; but in the operation under consideration, if the whole or any part fails to unite promptly, partial or complete failure is the result. This calls for the employ- ment of all known surgical means most favorable to prompt healing. On this account, then, some general considerations regarding plastic operations in gynecology will be in place before describing the methods of operating. What will follow on this subject will apply equally to all operations about the pelvic floor and pelvic organs, especially lacerations of the cervix uteri. The following may be given as the conditions necessary for the healing of the wounds in question : 1. A condition of the wound and of the general system favorable to the repair of injuries. 2. Perfect coaptation and retention of the parts to be united, and protection of the parts from extrinsic and offending agents during and after coaptation. If these conditions are all secured, success must of necessity fol- low. The management of wounds is not a matter of blind chance. The process of repair in living tissues is governed by definite laws which are always the same under identical circumstances. To ob- tain the conditions necessary to the fulfillment of these laws is often difficult and sometimes impossible; still, the nearer we come to all the requirements the more surely will the desired ends be accom- plished. The first of these conditions, viz., good general health, may be found wanting in many ways and degrees which are too familiar to require notice, but there are some of these which may be mentioned because they are very often overlooked—preoccupation of the sys- tem by some highly taxing function, like lactation, for example, and certain deranged states of the nervous system. These certainly have an important bearing upon the healing of wounds, although little if anything is said in our works on surgery regarding them. In fact, there is good reason for believing that enfeebled states of the nerv- ous system have much to do with retarding the healing of wounds, even when the general nutrition appears to be normal. We fre- quently hear surgeons say that patients recover from injuries much more promptly when they have courage and hope without fear; but exhausted and irritable states of the nervous system retard the pro- cess of repair, although the patient may be indifferent or perfectly satisfied in regard to recovery. 132 DISEASES OF WOMEN. Reorardino; the unfavorable conditions of the tissues generally met with, the following are the most important: Contusion*.—Contusions accompanying wounds caused by par- turition. Lacerated wounds of the pelvic organs often heal promptly if well coaptated immediately after they occur, but no such union should be expected in case the tissues are greatly contused. While this is true of the immediate treatment of wounds sustained during labor, it is pretty definitely settled that operation wounds made dur- ing the process of involution—that is, within four or six weeks after confinement—often fail to unite. From this we learn that while tissues are undergoing involution they are not in the best condition to heal; and also that, when involution is delayed beyond the usual time, treatment should be employed to complete the process before undertaking plastic operations. Scrupulous care is also required in preparing the tissues by mak- ing clean, accurate incisions which will give smooth surfaces to the parts to be united. Old scar tissue should also be removed from all wounds where union by first intention is desired. These are rules in surgery which are well known, but they are sometimes overlooked in practice. Hemorrhage.—Hemorrhage in these operations is often a source of difficulty and delay to the operator, but, worse than that, it is sometimes the cause of failure. In the vast majority of surgical operations all that is required of the surgeon is to arrest the hemor- rhage, by any of the ordinary means, in order to secure a good re- sult; but in the operations in question, if some kinds of styptics are used, they prevent union. Cases differ so very much in regard to hemorrhage that I have given much thought to the predisposing causes of this bleeding tendency, so marked in some patients. The hemorrhagic diathesis in its most typical form is generally found in men, but a less marked hemorrhagic tendency is common to many women, and these are very unpleasant subjects to operate upon. During the past few years it has been my misfortune to meet with quite a number of cases in which the bleeding tendency was noticeable. The cause of this in most of them, I think, was im- paired general health, due to exhausting conditions of life rather than to any congenital imperfection of the blood itself. Another very important element I have found to be mechanical interruption of the circulation, the pelvic organs becoming congested from re- tardation of the portal circulation, induced by hepatic disorders, sedentary habits, tight lacing, and so forth. The products of former pelvic inflammations, such as pelvic cellulitis, also tend to maintain INJURIES TO THE PELVIC FLOOR. 133 a hyperemic state of the pelvic organs; this we often find long after all evidence of active inflammation has subsided. The condition at the time also is often favorable for bleeding; the well-defined vas- cularity which exists in conditions such as imperfect involution in- sures hemorrhage in all operations undertaken during such unfavor- able states. The possible hemorrhage from such causes can be avoided by the proper selection and preparation of cases before oper- ating. The rule which should be followed in this matter is to secure the best possible state of the general health of the patient, and to reduce all hyperemic states of the pelvic organs as far as possible. This is generally possible to a great extent, because the object of plastic operations is to restore the organs to their original form and struct- ure, differing in this regard from many other operations in surgery which have for their object the removal of diseased parts. In carrying out this plan of treatment, however, there is one difficulty encountered in practice; when patients are ill and suffer- ing they will gladly accept any operation which promises them relief, but, when they are free from pain and have gained in health, they hesitate about undergoing any surgical treatment which is designed to keep them from suffering in the future. This, however, does not prevent the surgeon from advising that which is best. There are patients—fortunately very few—who have the hemorrhagic diathesis sufficiently marked to debar them from operations, and it is doubtful if any preparatory treatment will change this constitutional pecul- iarity. Such subjects should be let alone; to operate in these cases is dangerous, and almost always ends in failure. I have had three such cases in the past five years; two of them were operated upon before discovering their peculiarity, the result being depletion of the patients without any benefit from the operation, and the devel- opment of extreme caution on the part of the operator in selecting cases in future. The third case was diagnosticated earlier, and I declined to operate. The management of bleeding vessels in these operation wounds is of great importance. All hemorrhage should be arrested before bringing the parts together, because a slight oozing, which would do no harm in a wound to be treated by open dressing, may prevent union in wounds in which drainage should not be employed, or, at least, should not necessarily be required. This often requires an amount of time which the surgeon reluctantly bestows, but success in treating this class of wounds depends largely upon attention to this matter. Still more, the means used to arrest hemorrhage should 134 DISEASES OF WOMEN. be such as will not interfere with the process of healing. Hitherto the means employed have been ligation or torsion of the large vessels, and for minor bleeding the use of ice or cold water. More recent experience has pointed out objections to these means. Chilling the tissues by cold is injurious, it is said, and no doubt the statement is true. It has, fortunately, been found that hot water is more efficient in controlling hemorrhage, and its effects upon the tissues are not unfavorable—hence its use as a styptic in these operation wounds is strongly commended. Torsion is objectionable, because it is less certain to control bleeding than the ligature, and quite as liable to give rise to suppuration. In view of this fact, it may be said without doubt that the antiseptic ligature is the best means of controlling the vessels in these wounds. Regarding the material to be used as a ligature, it may be said that that which can be inclosed in the wound without giving subsequent trouble is the thing required. The prop- erly-prepared catgut ligature fulfills the indications. Some recent experience indicates that the Japanese ligature, made of whale-sinew, is the best, owing to its being absorbed with great facility. Occa- sionally, in deep lacerations, a small artery on each side may require to be ligated; the chief arterial bleeding, however, comes from the upper portion, the small vessels coming apparently from above down- ward in the areolar tissue, between the rectum and vagina. These sometimes bleed quite freely, and they are not controlled by tighten- ing the sutures, which arrest the hemorrhage at points lower down. Such vessels I control by passing a needle through the vaginal mu- cous membrane above the denuded surfaces, and thus carry a ligature under the bleeding vessels, tying it over the free surface, cheeking the bleeding on the principle of acupressure. The sutures can be left in position until the perineum has completely healed ; they can then be removed with the aid of the speculum. Occasionally it be- comes necessary to ligate some of these vessels which bleed persist- ently and can not be controlled in the way I have previously de- scribed ; it is then well to ligate them with a fine catgut ligature, the ends being cut off short and inclosed in the wound. In spite, however, of all precautions, secondary hemorrhage will occasionally occur after this operation. I have met with four such cases in my practice; in one of them it occurred on the seventh day after the operation. In all of them the bleeding took place from the upper or vaginal portion of the wound, the blood flowing into and widely distending the vagina before appearing externally. In my first case I was obliged to remove the sutures, empty the vagina of blood-clots, and ligate the bleeding vessels. This resulted INJURIES TO THE PELVIC FLOOR. 135 in spoiling my operation, for, although I reintroduced the sutures, union did not take place. This hemorrhage occurred on the sec- ond day. In my three subsequent cases I secured much better results. In- troducing a Sims's speculum on the anterior side of the vagina, I removed the clots and blood by sponging, and then, throwing light into the vagina by means of a concave reflector, I was able to see that the blood welled up from the upper portion of the wound. In place of pulling the edges of the wound apart and searching for the bleeding vessels, I passed a curved needle and ligature down and around the place where the bleeding came from, and was able, by tightening my ligature moderately, to control the bleeding entirely. These cases subsequently did well, and the result of the operation was good. Sutures.—The coaptation of the tissues by means of sutures re- quires more than a passing notice. The success which J. Marion-Sims obtained with the silver-wire suture led at once to its general use in gynecological operations. There is, however, good reason for believing that the results obtained by that great surgeon depended as much upon his skill in using sut- ures as upon the material which he used. To-day we know that it matters little whether silver-wire or pre- pared silk sutures are used, provided they are properly introduced. The silk selected should be braided, and not the twisted variety, for the reason that the braided silk retains wax much better, and does not unravel on being handled. The wax in the twisted silk breaks and separates from the silk, and the silk thereby becomes porous and will absorb blood-serum which readily decomposes. The reason why surgeons formerly failed in the operation for vesico-vaginal fistula, when they used silk, was because the organic matter, ab- sorbed by the unprepared silk, decomposed and caused septic inflam- mation. The braided silk, properly saturated with wax, overcomes this completely. The parts to be united should be brought together and held there without any straining upon the sutures. It is equally important to introduce the sutures so that they will prevent the in- curving of the undenuded edges of the parts to be united, and, finally, a sufficient number of sutures should be employed to secure uniform retaining pressure at all parts of the wound. These are facts which every one is supposed to know before en- gaging in surgery, but in practice a large number of failures are seen because of neglect in regard to them. The management of these wounds during the healing process 136 DISEASES OF WOMEN. differs somewhat from the modern treatment of wounds in gen- eral. Dressings.—The antiseptic dressings which surgeons use in some form or other are difficult of application in the operations for restor- ing the cervix uteri and perineum. So fully is this the case that some of our highest authorities on gynecology make no pretensions to using antiseptic treatment in such wounds, unless frequent bath- ing of the parts with water and carbolic acid may be called such. No doubt some of our best operators get good results with this kind of after-treatment, but it is more than probable that still better re- sults can be obtained by treatment more in accordance with the rules of antiseptic surgery. Viewed in the light of modern investigation, it appears that the frequent douching of wounds with carbolized water is a practice at least ten years behind the surgery of to-day. In treating wounds of the perineum there are many perplexing difficulties in the way of obtaining a proper antiseptic dressing. Here, also, the vaginal douche has been freely used, for the purpose, it is said, of removing vaginal secretions which might irritate the wound and prevent its healing. Such treatment is generally un- necessary, if not injurious. In all operations for repairing old injuries of the perineum it is better to first cure all uterine and vaginal dis- eases which give rise to abnormal discharges. That is the only sure way of protecting the operation wound from that source of disturb- ance. This, of course, can not be accomplished in the treatment of lacerations immediately after confinement. Then it becomes a very important question how to protect the perineal wound from the lochia. Various means have been suggested for this purpose, such as coating the vaginal surface of the wound with collodion, placing carbolized lint or borated cotton upon the inner portion of the wound, and, the most common of all, the frequent use of vaginal injections. It is hardly possible to say, at the present time, which is best. The collodion has not been tried often enough to speak positively regard- ing it. In using the lint or cotton there is danger of separating the edges of the wound, the very thing of all others to be avoided. Perhaps the best treatment, after carefully cleansing the parts and bringing them accurately together, is to let the wound alone for about two days, trusting that during this time it may become sufficiently protected, by a coating of fresh lymph, to resist the subsequent dis- charges. After the lochia begin to decompose, the frequent use of the vagina] douche is advisable, and should be continued until the union is completed. In the secondary operation for restoring the perineum, the vag- INJURIES TO THE PELVIC FLOOR. 137 inal portion of the wound may generally be left alone. It is pro- tected from the air by the anterior vaginal wall, which makes a suit- able dressing provided the uterus and vagina are in a normal condition, as they should be, before the operation is done. If suppuration takes place and pus is discharged into the vagina, it should be disposed of bv injections. The outer portion of the wound may also be left without dressing, but it is better to apply lint or cotton upon each side of the sutures; if silver wire is used, or if silk is employed, the lint can be placed over the wound and retained in place by keeping the limbs together. The advantage of this kind of dressing is that it absorbs any discharge that there may be. Perhaps the most important point of all in the management of such cases is to keep from dropping urine upon the wound. The most scrupulous care should be taken to close the end of the catheter in withdrawing it. If this is neglected, a few drops of urine will escape from the eye of the instrument, and, falling upon the wound, will cause trouble. The nurse should be carefully instructed to use the catheter in this way, and, to make doubly sure of cleanliness, a little absorbent cotton should be placed between the meatus urinarius and the wound every time the instrument is used. Notwithstanding all this care, suppuration will sometimes occur, and then the question arises how to manage this complication. If the suppuration is limited to the track of one suture, that one may be removed and the remaining ones trusted to keep the parts to- gether. It sometimes happens that a cellulitis which begins in the region of the sutures extends outward and ends in suppuration. This should be treated by a free incision and drainage, which may save the operation. On the other hand, if suppuration takes place between the surfaces to be united, there is very little hope of obtain- ing union at all by any kind of treatment. A partial or even com- plete success may be obtained in such cases if the suppurative process is detected early, and drainage from the lower edge of the wound is established. This can be effected by loosening one or more of the sutures, and then introducing carbolized silk thread or catgut to secure the free escape of the inflammatory products. DESCRIPTION" OF THE OPERATION FOR RUPTURE IN THE FIRST DEGREE. Velpeau, of Paris, was the surgeon who first operated for the restoration of the perineum. The first part of the operation consists in denuding the surfaces in* 138 DISEASES OF WOMEN. to be united. The extent to which this should be carried depends upon the character of the injury. If there is no prolapsus of the pelvic floor or of the posterior vaginal wall (see Fig. 66), it will suffice to denude the surfaces as far as the original laceration extended and no farther. This can be done by tracing the outline of the scar tis- sue formed by the healing after the laceration. This scar tissue con- tracts and brings the normal tissues toward each other so that the portion to be exsected, as indicated by the rule given here, appears to be very small and insufficient; but, when the scar tissue is re- moved, the skin and mucous membrane retract and make the denuded surface large enough—much larger, in fact, than the piece of tissue taken away. If more tissue is removed in such cases and good union is obtained, the introitus vagina? is made too small. When the sides of the laceration are drawn outward and the pel- vic floor is prolapsed, and the distance from the meatus urinarius to the anterior portion of the sphincter ani is increased to an abnormal degree (see Fig. 66), the denudation should be made high enough on either side to make sure, if possible, to unite the loose ends of the bulbo-cavernosus muscle. To do this the original scar tissue should not be taken as a guide in vivifying the parts. On the contrary, the vivifying should be carried upward on either side to within an inch or less of the lower side of the vestibule. In this condition there is usually prolapsus of the posterior vaginal wall, and when such is the case, the denudation should be carried upward nearly to the high- est point on the prolapsed portion of the vaginal wall. (See Fig. 67.) The instruments for denuding the parts are a number of sponges fixed in holders, a tissue forceps (see Fig. 71), and Emmet's curved scissors, four in number, two with lesser curves and two with greater. (See Figs. 72 and 73.) These instruments can not be described; they must be seen to be understood. INJURIES TO THE PELVIC FLOOR. 139 The method of operating is as follows: The patient is placed upon the operating-table in the lithotomy position; an assistant on Fig. 73.—Emmet's scissors. each side holds the limb of that side in the flexed position with one hand, while with the other he separates the labia to fully expose the parts; the operator, seat- ed in front of the patient, seizes the tissues with the forceps on the left side as high up as the denudation should extend, and with the scissors removes a strip at the junction of the skin and mucous membrane across to a corresponding point on the right. The end of the strip should be left attached, the other scissors taken, and the strip continued back to the left again. In this way the continuous strip may be taken out from one side to the other and back again until the whole surface is denuded. The three figures will give a 1 tetter idea of the mode of procedure than this de- scription. In case there is pro- lapsus of the vagina—and it is therefore necessary to carry the denudation high up on the vaginal wall—the scissors with the great- est curve should be used at that part of the procedure. When the whole surface has been denuded in the manner de- Fig. 74.—First step ; denudation begun. 140 DISEASES OF WOMEN. are scribed, it is necessary to make sure that the edges of the wound straight and alike on both sides, and that the surface is smooth. This can be accomplished by causing the assistants to put the parts upon the stretch, when careful sponging will show any irregularity which needs to be trimmed off. I5v passing the finger over the fresh surface, any scar tissue that remains can be detected by its density and resistance compared with the soft- ness and elasticity of the normal tissue. At this stage of the operation attention should be given to hemorrhage. If there are any spurt- ing vessels in the wound they should be controlled by suture or ligature. Fortunately, when such vessels are encountered, they are generally at the upper margin of the wound, and may be controlled by passing a fine suture through the mucous membrane of the vagina and under the vessel and then tying it tight enough to stop the bleeding. This has been already noticed under the head of general observations. Next in order comes the introduction of the sutures, and just here it may be stated that for all plastic operations I use silk sutures prepared as follows: The ordinary braided silk is immersed five or six hours in wax containing six per cent of carbolic acid and six per cent of salicylic acid. The wax is kept all the time at a tempera- ture high enough to liquefy it. This long immersion in the melted wax is necessary to thoroughly saturate the silk. When this is ac- complished, the silk is drawn through a carbolized sponge to remove any excess of the wax. It is then put on a reel which is placed in a close-stoppered bottle and kept until required. Xos. 5 and 7 are the Fig. 75.—Second step ; continuing the strip. INJURIES TO THE PELVIC FLOOR. 141 sizes used ; No. 7 for the lower suture and No. 5 for the upper ones. The needles employed are the ordinary darning needles found in the dry-goods stores, vary- ing in length from two inches and a quar- ter to one inch and a half. The larger nee- dles are armed with Xo. 7 thread and the smaller with No. 5. To manipulate these needles it is necessary to have a suitable forceps, and for this I have devised the instrument repre- sented by Fig. 77. It is a double forceps. The central portions of the two blades which form the han- dle are made of spring steel. The halves cross each other at about an inch from each end to form the jaws. At one end there are three grooves which receive the needle and hold it at an acute, obtuse, or right angle, whichever the operator may require. The other jaw, which closes over the grooved one, is file-faced, which Fig. 76. Vivifying complete; the vaginal sutures on one side are inserted. Fig. 77.—Needle-forceps. keeps the needle from slipping through the grooves when pressure is made upon it. The jaws of the other end are copper-faced and are used to grasp the point of the needle in drawing it through. The elastic spring of the handle portion opens the jaws at each end, the needle is introduced into the desired groove, the handle is 142 DISEASES OF WOMEN. Fig. 78. grasped, which closes the jaws and holds the needle perfectly immov- able, no matter how much pressure may be brought to bear upon it. When the jaws are closed there is a stop-catch that holds the two halves of the handle together and keeps a firm hold upon the needle. The needle is carried into the tissues while it is held by the grooved and file-faced jaw ; it is then unfastened by drawing back the catch, the forceps is reversed, and the point of the needle seized in the cop- per-faced jaws and withdrawn. The advantage of the copper-faced jaws is that they seize the point of the needle firmly enough to draw it through the tissues without injuring the point; a valuable feature in such an instrument. The sutures are introduced as follows: The needle —placed in the forceps at right angles to it—should be entered in the skin exactly at the edge of the wound at the lowest external angle of the denuded tissue. It is then passed outward deep into the tissues, then curved round in the tissues in front of the rectum and deep into the tissue of the other side, and made to emerge at a point corresponding to the one where it was entered. If this is properly done, no part of the suture will be seen. Its position in the tissues will be as represented in Fig. 78. The dotted line represents the suture which describes a cir- cle, and the straight line shows the sides JfP^'v:r^ of the wound as they are brought together where the suture is tied. Sometimes when the tissues are rigid it is difficult to introduce the first suture with one sweep of the nee- dle, It is then better tO pass the needle in Fig. 79.-The stitches in place; the vaginal sutures tied. INJURIES TO THE PELVIC FLOOR. 143 through half of the vivified portion, to draw it out and re-insert it at the same point, and to carry it around through the other side. If there is sufficient tissue between the base of the vivified part and the rectum, the second and third sutures may be introduced like the first—each one being passed at a higher point. The fourth suture (see Fig. 70) is introduced through the side. It is then carried through about three eighths of an inch of the vivified portion of the vaginal wall, and then passed through the other side. The last suture is passed through both sides, as shown in Fig. 81, the position of the sutures being viewed in profile. When more than five sutures are used, the fifth is passed like the fourth, only a little above it. Most operators in- troduce the in- dex-finger into the rectum, to guide the introduction and passing of the needle. This should not be done under any circumstances, be- cause, by so doing, the rectal wall is crowded forward, and is sure to be included in the suture, and, besides, it is a violation of the rules of antiseptic surgery to operate with dirty fingers. In many cases there is very little tissue left in the perineal body after the vivifying is completed. The muscular coat of the vaginal wall having become atrophied, or torn from its attachments to the floor of the pelvis, there is only the mucous membrane left, and, when that is removed in denuding the parts, the wall of the rectum is all that is left above the skin and sphincter-ani muscle. When such is the case, the first suture only should be carried through the tissue, as already described ; the others should be introduced as shown in Fig. 79. The great advantage of this is, that the sides of the wound are brought together in front of the rectum, the place where the perineal body should be. Furthermore, the sutures introduced in this way avoid the rectal wall—a very important desideratum, as we know from the fact that when any of the sutures are, intentionally or by accident, passed into the wall of the rectum, they cause much pain Fig. 80.—Laceration with rectocele. (The dotted line gives the normal location of perineal body.) Fig. HI.—Perineal body restored. (Profile view.) 144 DISEASES OF WOMEN. and rectal tenesmus, and greatly distress the patient, especially when the bowels move. When the sutures are all in place, the wound should be carefully cleansed of all blood-clots, and, if there is still some oozing of blood, traction should be made upon the sutures; if that controls the bleeding, the sutures should be tied in the ordinary way. While they are being tied the sides of the pelvic floor should be pushed up by the assistants, to bring the wound together. The after-treatment and other points, such as the removal of the sutures, will be brought out in the history of the following cases: Case of Central Laceration extending to the Sphincter Ani; Uncom- plicated.—The patient, a spare, small woman, had always been in good general health. She had been married nine years, and had one child eight years old. Her labor was easy and rapid, and her convalescence uninterrupted, excepting that she had a leucorrhoea which began after the lochia stopped, and continued until the time when she sought medical advice. Her menses returned ten months after her confinement and one month after her child was weaned. Six years after her confinement she overtaxed her strength, and then her leucorrhoea became more profuse, and she began to suffer from backache and slight pelvic tenesmus, especially upon standing or walking. She was slightly constipated, but in all other respects was well. She sought medical advice because of these symptoms and her sterility. An examination showed a laceration, but no other injury to the pelvic floor. The posterior and lateral parts of the floor were well sustained, and there was very little separation of the sides of the laceration. There was commencing prolapsus of the posterior vagi- nal wall, but so slight that it was only apparent upon separating the labia and causing the patient to cough or make downward pressure. The uterus was slightly below its normal elevation, but not changed in its axis. The leucorrhoea was due to a cervical catarrh, which promptly yielded to treatment. Five days after a menstrual period her bowels were freely moved in the morning by a dose of pulv. glycyrrhizse comp., given at bed- time the night before. On the following morning the bowels moved spontaneously, and, an hour later, an enema of borax and warm water was given to wash out the rectum. For breakfast she had a cup of coffee and a bowl of clear beef-soup. A large vaginal douche was used of borax and hot water to cleanse the parts thoroughly. At twelve, noon, she was anaesthetized with ether, and the operation was performed according to the method already described. The bleeding was easily controlled by the sutures. A small pledget of INJURIES TO THE PELVIC FLOOR. 145 marine lint Mas placed over the wound and the knees bandaged to- gether. Soon nausea followed, but no vomiting, and late in the even- ing she was comfortable, having only a feeling of slight burning in the region of the wound. She took a small cup of tea, and slept several hours during the night. ]N"ext day she had milk, soup, and gruel. The catheter was used for the first forty-eight hours, and after that, when necessary, she was rolled over upon her face, and, with a bed-pan placed under her, she urinated without further help. On the morning of the third day she took a Seidlitz powder, and at noon an enema of castile soap and water, which moved the bowels freely and easily. After this the bowels were moved daily with an enema and she had her usual food. The marine lint was kept upon the outside of the wound for five days, changing it daily. There was no discharge from the vagina or wound. There were no vaginal injections used, and the wound was not washed at any time. In fact, after the fifth day, she had no local treatment. On the eighth day the sutures were removed in the following way: She was placed in Sims's position on the bed; the nurse separated the nates, which exposed all the sutures without making any traction upon the parts; each suture was seized with a forceps, and, with the tenaculum blade of the scissors, one side of the thread was caught up and divided. Fig. 82 shows the scissors used for the removal of sutures. It answers the purpose well, and guards against clipping off both ends and leaving the suture in the tissues, an accident which not unfrequently happens. This method of removing the sutures is very much simpler than trying to remove them with the patient upon the back. The patient was kept in bed until the twelfth day after the opera- tion, but during that time she was permitted to change her position from the back to either side without help. On the thirteenth day she was permitted to sit in a chair, and on the fifteenth day she was allowed to begin to walk. Two months after the operation she was examined, and the space 11 146 DISEASES OF WOMEN between the rectum and vagina was found to be normal to the touch, i. e., the lines represented by the lower portion of the posterior vagi- nal wall and the outer surface of the pelvic floor, run- V ning from before backward, formed an angle as repro- ve sented in the accompanying diagram. \ Furthermore, when the introitus vaginae was re- \ tracted with a Sims's speculum and the instrument re- moved, the muscles promptly contracted and firmly closed the vagina, showing that the muscles had been restored. This I consider to be the only reliable evidence of the success of this operation. Laceration of the Pelvic Floor, Sphincter-Ani Muscle, and Recto- Vaginal Septum.—In this extensive injury, in which the laceration of the walls of the rectum and vagina extends upward beyond the internal sphmeter ani, it is necessary to restore the septum before operating upon the perimeum. As a rule, the laceration does not extend beyond the sphincters, and the parts can all be restored at one operation, but in the rare injury now under consideration, two separate operations are required. I will describe first the operation for restoration of the septum. The patient should be placed in the lithotomy position, and the anterior wall of the vagina elevated by a Sims's or bivalve speculum, which exposes the parts to be treated. The tissues on each side of the laceration are vivified well out on the vagina, in order to obtain a broad surface for coaptation. Only enough of the mucous membrane of the rectum is removed to dispose of the scar tissue that may be present. Silk sutures are introduced with a round-pointed, curved needle, such as Emmet uses for vesico-vaginal fistula. The needle should be introduced at the outer edge of the vivified surface of the vaginal mucous membrane, and be carried deep into the tissues, and should emerge just within the edges of the rectal mucous membrane. By referring to Fig. 86 in colored plate an idea may be obtained of the sutures in position, with this difference—that in this operation silk sutures are used, and are tied upon the vaginal side, whereas in the operation of restoring the sphincter-ani muscle and perinseum, catgut sutures are employed, and these are tied upon the rectal side. The introduction of the sutures is begun above, and each one tied when introduced. The sutures should be Xo. 3 silk, and not more than an eighth and a sixteenth of an inch apart. They should be removed on the eighth day, and one month allowed to elapse before the next opera- tion is performed, in order to give the parts a chance to become firmly united. PLATE I. FIG.84- R I. D DEI PLATE I. Operation for Laceration of the Perineum and Sphincter Ani. Figure 83. Page 147. The depressions on either side of the rectal wall show the ends of the sphincter ani. The rectum is drawn forward by the levator. Figure 84. Page 147. Denudation complete. INJUKIES TO THE PELVIC FLOOR. 147 OPERATION FOR THE RESTORATION OF THE SPHINCTER ANI AND PERINiETJM. It has been already stated that the chief object of all plastic operations upon the pelvic floor should be to restore the muscles that have been injured. This is pre-eminently so in the operation to be described, because the sphincter ani is the most difficult to restore, and the results of failure are so apparent that neither the surgeon nor patient can possibly believe that the operation is a suc- cess when it is not—a delusion often indulged in regarding the plas- tic operations to repair the lesser injuries of the pelvic floor. In order to comprehend the position and relations of the surfaces to be vivified, it must be borne in mind that when the sphincter ani is ruptured the severed ends are drawn outward and backward by the retraction of the muscle until they lie on either side nearly on a line with the posterior walls of the rectum. This may be better understood by referring to Fig. S3, colored plate. The depressions on either side of the anus are the ends of the muscle which are drawn down below the surface. The process of vivifying should be begun by seizing the end of the muscle on the patient's left. With the scissors a strip of tissue should be removed from that point around the tissues between the rectum and vagina, and downward and outward to and including the end of the muscle on the right. When this is done, it will sometimes be found that the softer tissues rise above the depressed end of the muscle, so that a fossa is formed on each side. Should this occur, more of the most prominent tissue should be removed. The denudation is then carried upward upon each side to the point where the laceration began. If there is much relaxation of the rectal and vaginal walls, the denudation may extend even higher on the sides. At this stage of the vivifying there are two broad denuded sur- faces (one on each side) connected by an isthmus formed by the recto-vagina] walls. In this septum all scar tissue should be cut away, and then the rectal and vaginal walls should be separated with the handle of a scalpel or blunt-pointed scissors. The object of this dis- section is to give a broader surface to be united, and to permit the vaginal wall to be raised up and attached to the inner side of the perineal body, as it is called. When the vivifying is completed, the parts appear as represented in Fig. 84, colored plate. There are or- dinarily two sets of sutures used, one to coaptate the rectal wall and sphincter-ani muscle, and the other to do the same for the perinseum. 148 DISEASES OF WOMEN. The rectal sutures are introduced first. I use No. 2 catgut and the curved Emmet needle. The needle is entered at the margin of the rectal mucous membrane on the patient's right side, and is carried upward and outward in the tissues about a quarter of an inch. It is then withdrawn, and entered on the left side, and brought out in a manner corresponding to the course which the needle traversed in the right side. This leaves the ends of the suture to be tied on the inside of the rectum. In introducing the first perineal suture, the point of the needle should be entered at the inner and lower point of the vivified sur- face, then carried outward around the end of the muscle, then in- ward through the rectovaginal wall, and finally around the other end of the muscle to a point directly opposite the one wdiere the needle was introduced. This requires skill and practice, and is often difficult; and I have found it easier to pass the needle around the ends of the muscle and bring it out in the median line, reintroduce it, and carry it around the other end of the muscle. The objection made to this method is that the central portion of the suture is ex- posed, but the suture is completely buried in the tissues when it is tied. Certainly it is better to introduce the first suture accurately in this way than to attempt the more difficult way and fail to get it right, a result usual to those who are not accustomed to this operation. The second suture may be introduced in the same way. The remain- ing sutures are employed in the way described in the operation for restoring the laceration in the first degree. Figs. 85 and 86, colored plate, show the sutures in place. Certain changes are necessary to be made in the details of the operation in those rare cases in which the laceration of the recto- vaginal septum has extended so high up that an operation for its restoration is necessary before restoring the sphincter-ani muscle and the perinseum. Another condition requiring similar treatment is found in cases in which the septum has been extensively lacerated, but has united by intervening scar tissue, which has to be removed to secure a perfect restoration. Under such circumstances, and also in cases in which the rectal and vaginal walls can not be separated by dissection, it is better to unite the vaginal wall in the median line by a special row of sutures running parallel to the axis of the vagina. In such cases three sets of sutures are necessary: One to unite the rectal wall, one to unite the perinaeum, and one to unite the vaginal wall. In performing this modified operation, I usually vivify the edges of the laceration of the septum the entire length and then introduce the rectal sutures and be- PLATE fl. Operation for Laceration of the Perineum and Sphincter Ani. Figure 85. Page 148. Sutures in the recto-vaginal septum introduced. Figure 86. Page 148. Sutures in the septum tied. The remaining sutures in place. 5 } 1 INJURIES TO THE PELVIC FLOOR. 149 fore tying them vivify all the rest of the parts to be united. The stitches are introduced into the vaginal wall and the perineal stitches placed last. The patient is put into Sims's position and the rectal sutures are tied. She is replaced upon the back and the vaginal sutures are tied, and lastly those in the pelvic floor. I have obtained the very best results from this method of opera- ting, and in suitable cases prefer it to all others. Further details of the operations will be brought out in the following history of cases: Typical Case of Laceration extending through the Sphincter Ani.— The patient was twenty-six years old when she was confined with her first child. The labor was tedious, and she was delivered, with forceps, of a very large child, which died during delivery. She made a rather slow recovery, owing to the extensive injury to the floor of the pelvis. Five months after confinement I saw her for the first time. She was then in very good health, but suffered pain in the region of the injury, especially when she walked, and she had very little control of the rectum. When constipated, she suffered very little; but, when the bowels were free and when there was flatulence, she was obliged to remain secluded. I found that the laceration involved the sphincter-ani muscle, and evidently had extended upward into the wall of the rectum and vagina; but union had taken place, by a little intervening scar tis- sue, down to the sphincter, or within a quarter of an inch of it. The muscles of the pelvic floor, excepting the sphincter and transver- sus perinaei, acted well, and held the divided sides well up. The end of the rectum was also drawn upward and forward, so that the distance from the vestibule to the posterior margin of the anus was less than normal. This brought the posterior wall of the vagina up to the anterior, so that the vagina was closed. It was only by plac- ing the finger in the rectum and pressing it backward that the full extent of the laceration became apparent. She was constipated, and her tongue slightly coated, at this time. Pil. hydrarg., gr. x, and pulv. ipecac, gr. j, were given at bedtime, and a wine-glass of Hun- yadi-Janos water an hour before breakfast next morning. This moved the bowels freely, and they were kept free for the subsequent two weeks with the following: Fluid extract of podophyllum.................... 3 j I Tincture of colocynth..............„............. 3 ij; Tincture of belladonna........................... 3 j ; Glycerin....................................... 5 ss- j Syrup of acacia and compound tincture of cardamom, of each....................................... ;§ j. 150 DISEASES OF AVOMEN. A teaspoonful of this noon and evening before meals. When this acted too freely, only one dose was given. During these two weeks the nurse passed the finger every day into the rectum and pressed the parts back toward the coccyx, main- taining the traction steadily for several minutes. This was done for the purpose of restoring the elasticity of the tissues, and also elon- gating the divided sphincter muscle as much as possible. Menstrua- tion then began, and no further local treatment wTas employed until after it stopped, when it was resumed. Four days after the menses ceased, the operation was performed in the prescribed way, silk sutures being used. For twenty-four hours before the operation, and for three days after, the patient had only fluid food—beef-tea, strained soups, whey, and water. After the third day, peptonized milk, strained oatmeal and barley gruels, and raw oysters were added to the diet list. There was sufficient pain during the first three days to require ten drops of liquor opii com p. to be taken every four hours. On the fourth day she suffered from flatulence, which was relieved by catheterizing the rectum, using a silver catheter; this had to be re- peated the following day. On the eighth day (and before the su- tures were removed) half an ounce of sulphate of magnesia in peppermint-water was given before breakfast and toward noon; when the patient felt the bowels inclined to move, half a pint of solution of ox-gall and water were used as an enema. When this had been retained about twenty minutes, the nurse assisted the evacuation of the bowels by making pressure upon each side of the wound opposite the first suture, and, with the index-finger of the other hand in the vagina, she made gentle and interrupted pressure downward and outward. In this way it was hoped that the rectum would be evacuated without disturbing the wound. There was not the slightest trace of haemorrhage, which gave reason for believing that no harm had been done. On the ninth day all the sutures were removed, and on the tenth day the bowels were moved in the same way as before. During all this time the catheter was used to draw the urine. After this the patient was permitted to urinate in the prone position. Every second day until the twentieth the bowels were moved, the same care being taken by the nurse to guard the wound during the evacuation. On the twentieth day the wound was carefully examined, and there was apparently perfect union throughout, including the mucous mem- brane. The function of all the muscles of the pelvic floor was re- stored, except that of the sphincter ani. The function of that mus- INJURIES TO THE PELVIC FLOOR. 151 cle was, however, sufficiently restored to give the rectum retaining power, but it did not act as a perfect sphincter muscle. WThen it acted, the contraction was not equally toward the center, but rather toward the point of rupture that had been restored. The posterior portion of the perineal body acted like a fixed point, toward which the muscle contracted. I am inclined to believe that this is the best result that can be obtained by this operation. After the new repara- tive tissue which is developed during healing has fully contracted, the function of the muscle becomes more nearly restored. Indeed, it is in many cases quite perfect so far as controlling the rectum is concerned, but it rarely, if ever, acts exactly as it did before injury —i. e., by a perfect concentric contraction. A Case illustrating Partial Failure of the Operation; a Second Operation completing the Cure.—The patient was thirty-five years old, and had had three children. The youngest was eighteen months old at the time when this history was taken. Her first labor, five years and a half ago, was complicated. The patient stated that the doctor in attendance said that there was a shoulder presentation, that the child was turned and delivered feet first, and that the forceps was used to deliver the after-coming head. From that time onward she had no control of the rectum, and the only way she was able to take care of herself was by being extremely constipated, the bowels never moving except in response to medicine, a dose of which she usually took about once every week. The extent of the injury was exactly like the case last given, excepting that there was union of a thin band of vaginal mucous membrane, which extended outward to the upper margin of the sphincter-ani muscle. There were also two ha^morrhoidal tumors, formed by hyperplasia of the rectal mucous membrane, located at each side of the anus. These haemorrhoids, which are not uncommon in this injury, were removed one month before the restoration of the lacerated parts was undertaken. The mode of operating was by seizing the tumors in a Pean forceps and making traction sufficient to raise the mucous membrane, then pass- ing the haemorrhoid-clamp (Fig. 87) beneath the forceps, and slowly Fig. 87.—Hemorrhoid clamp. 152 DISEASES OF WOMEN. constricting the pedicle by tightening the clamp. A ligature of prepared silk was applied to the pedicle under the clamp. The for- ceps and clamp were then removed, the tumor clipped off far enough outside of the ligature to prevent its slipping, and the stump touched with carbolic acid. The ligatures came off in less than a week, leav- ing a very minute spot to heal. She was then submitted to about the same preparatory treatment as in the last case related, and the operation was performed as before described. The diet was gruel and peptonized milk, with beef-tea. On the second day half an ounce of Rochelle salt was given, followed in three hours by an enema of half a pint of a solution of ox-gall, and, one hour later, a large ene- ma of soap-suds. This did not move the bowels ; on the following morning half an ounce of castor-oil was given, and in the afternoon the enema repeated as on the previous day; the enema came away, but the bowels did not move. The next day, she was ordered a mixture composed of a decoction of senna, one ounce to a pint of water, with one ounce of Rochelle salt. Of this, two ounces were given every hour until she had taken three doses. It produced a free evacuation, without causing pain in the wound or doing it any harm. The mixture was repeated in the same way with a like effect, and was again ordered a third time, but, by an oversight of the nurse (the case was in a general hospital), it was not given. Another mistake was made the following day, the nurse giving two drachms in place of two ounces of the medicine. On the eighth day after the operation the medicine was given correctly ; but, when the bowels were about to move, the nurse, who should have supported the parts, was absent, and the patient got out of bed to use the commode, and had a free movement, attended with pain and some bleeding. Up to this time the wound had progressed quite well in healing, but that unfortunate movement of the bowels, unaided by the nurse, tore the ends of the sphincter-ani muscle apart, and spoiled the operation to that extent. On the tenth day the sutures were removed. There was perfect union, excepting the ends of the muscle. The opera- tion was a complete failure, so far as its main object was concerned. She was kept in the hospital for two days more, when it was found that, although her bowels were easily kept regular—a great improve- ment on her former state—she had very little more control of the rectum than before the operation. Three months after this she was again persuaded to try to obtain relief, and she was placed under the care of a more competent nurse, who followed directions regarding preparatory treatment, including the manipulation daily of the sphincter ani, and at the end of a week INJURIES TO THE PELVIC FLOOR. 153 another operation was performed to restore the sphincter. The stretching of the muscle backward with the finger in the rectum as practiced by the nurse was more effectual than in cases in which the rupture is complete. The part of the pelvic floor which was restored by the operation gave some support to the severed ends of the sphinc- ter, so that when traction backward was made the muscle became considerably elongated ; and when the second operation was under- taken the parts were sufficiently relaxed to facilitate the necessary manipulations. The patient, well anaesthetized, was placed in Sims's position, a small speculum introduced into the rectum posteriorly, and traction made backward, while with a strong tenaculum, fixed in the margin of the anus anteriorly, the ends of the muscle and the intervening tissues were brought into view. The end of the muscle of the left side was seized in the tissue forceps and denudation made from the left to the right end of the muscle. The vivifying included both ends of the muscle and extended upward on the anterior rectal wall about half an inch. The sutures, three in number, were introduced in the same way as in the first operation. Some trouble was ex- perienced in curving the needle around through the tissues, but with the aid of an assistant, who passed his index-finger into the vagina and everted the rectum in front, all the sutures were accurately in- troduced. On the third day after the operation a dose of senna and salts was given in the morning, and at noon the bowels were moved in a rather novel way. An apparatus constructed upon the principle of that used by Professor Bigelow for expelling fragments of stone from the bladder was employed to wash out the contents of the rec- tum (Fig. 88). \. 88.—a is a hard-rubber rectal tube bifurcated at b c; B, which is the supply tube, is attached to a fountain syringe, and c connects with the evacuator, composed of a soft-rubber bulb, with an escape tube. In other words, it is a large reflux catheter with a rubber bulb in the escape tube for the purpose of facilitating the outflow. Two nurses use this instrument as follows: One passes the tube into the rectum, carefully making continuous pressure backward to avoid pressing upon the edges of the wound, while the other nurse, 154 DISEASES OF WOMEN. closing the escape tube and opening the stop in the fountain syringe, injects the solution of soap and water. When half a pint has been introduced, the supply is cut off and the evacuation tube opened. If the contents of the rectum do not flow out, the bulb is pressed and relaxed after the manner of using a Davidson's syringe. This process is repeated until the bowels are freely evacuated. The bow- els were moved in this way until the twelfth day (the sutures were removed on the ninth); after that the bowels were moved daily by the senna and salts. At the end of three weeks the restoration of the muscle was as perfect as could be, and the patient was dismissed with complete retaining power. This case illustrates the danger there is of the ends of the sphinc- ter muscle being torn apart when the bowels are moved. A skilled nurse, well used to the management of such cases, can do much to avoid this unfortunate accident, and yet when all care is exercised it will often happen. In order to avoid this, several ways have been tried. Keeping the bowels confined for ten or twelve days was the fashion for a long time. More recently some operators have kept the bowels free by laxatives that rendered the contents fluid and pro- cured an evacuation every day after the second day from the opera- tion. I have tried both, and now prefer the reflux-catheter evacuator when a nurse can be obtained who knows how to use it. When this is net possible, I prefer to keep the contents of the bowels solu- ble and to move them every second day—beginning on the third day after the operation. When union is obtained, excepting of the sphincter muscle, as in the case just related, and a second operation is performed, some op- erators prefer to begin de novo, dividing the united portion and then proceeding as in the primary operation. I much prefer to keep all that has been gained and to restore the sphincter in the way already described. I was first induced to adopt this method in a case that had been twice operated upon before it came to me with the result of restoring all but the sphincter. So much tissue had been removed that I dared not risk a possible complete failure, hence I attempted to restore the sphincter in the way just described, and with success. My second ease of this kind was one in which complete laceration occurred during labor; primary union, without sutures, of the peri- neal body took place, but not of the sphincter. Since then I have repeatedly operated successfully in such cases of partial failure in my own practice and that of others, INJURIES TO THE PELVIC FLOOR. 155 OPERATION FOR RESTORATION OF THE PELVIC FLOOR IN SUBCUTANEOUS LACERATION BETWEEN THE VAGINA AND RECTUM. This operation is the same as when the laceration involves the skin and mucous membrane also, excepting that the whole of the skin and mucous membrane occupying the position of the perineal body is removed. Before beginning the denudation the tissues in front of the sphincter should be seized between the thumb and finger. This will indicate the extent to which they should be removed., While the parts are thus held in the finger and thumb, or with a tissue forceps, the whole mass should be removed with one sweep of the curved scissors. After this is done, if there is still some loose tissue lying over the muscular structures below and on either side, it should be removed. The sutures are introduced as in the ordinary operation, special care being taken to pass the sutures deep into the muscular tissues, and to use plenty of them. At the present time I see accounts in the journals of restoring the perinseum with one su- ture. I have seen some of these so-called restorations, and found the results utterly useless. A Typical Case of Subcutaneous Laceration, belonging to the Sec- ond Class described in the Classification.—This patient was the wife of a physician; I give the history as I obtained it from her hus- band. The patient was thirty-three years of age, the mother of two chil- dren ; the first born on March 29, 1880, and lived eleven hours; sec- ond born September 9, 1881, now living; and one miscarriage since the operation in February, 1884. The first labor was tedious, lasting from Friday at 8 a. m. till Monday at 2 p. m.—seventy-eight hours, but accompanied with no after ill-effects of any note. In the second labor, though it was normal in duration, from its inception until the completion of the first stage it was observed that the presenting head was very low in the pelvis, resting upon the posterior wall of the vagina, while the cervix was directed toward the hollow of the sacrum, and was un- evenly dilated, the anterior lip being much thicker than the posteri- or. As the head descended toward the vulva the recto-vaginal tis- sues were pushed before it and extended beyond the vulva on the perinaeum. The anterior segment of the cervix, descending in front of the head and tightly grasping it, had to be pushed upward in the interval between the expulsive pains and held until complete exten- sion occurred and the delivery was completed. Xothing of note 156 DISEASES OF WOMEN. transpired during the lying-in period of sixteen days, excepting great difficulty in moving the bowels. Upon taking an upright position, it was found that the protrusion or prolapse which was noticed at the time of delivery was still pres- ent, and complaint was made of the feeling that tk everything was falling out" ; from this time onward defecation could only be accom- plished by pushing the protruding mass well back into the vagina. Her subsequent health was bad; rapid loss of flesh and strength fol- lowed ; nervous prostration, impaired digestion, and loss of appetite su- pervened, totally incapacitating her for her usual duties. One month after confinement she had a very painful attack of mastitis, which, however, did not go on to the stage of suppuration, but further pros- trated her, accompanied as it was by aphthae, ulceration of the cornea, facial neuralgia, etc. These sequelae, together wdth over-lactation, car- ried on for fourteen months, naturally first retarded and then pre- vented the proper involution of the pelvic organs ; and the prolapse of the recto-vaginal wall, dragging down the heavy uterus, caused constant distress, pain, and suffering, both physical and mental. Constipation of the most intractable kind now existed, and the bowels could only be evacuated by liquefying their contents with purgatives aided by enemas. Examination made twelve months after confinement revealed a slight prolapse of the anterior vaginal wall, bladder, and urethra, and extensive prolapse of the posterior wall, which caused the rectum to be drawn forward through the ostium, forming a sacculus. The uterus was three and one fourth inches in depth and retroverted. The mucous membrane of the vagina and the integument of the pelvic floor presented no appearance of having been ruptured at any time, but there was not a sign of any muscle or fascia in the center of the space between the vagina and rectum. May 10, 1883.—(The operation was performed in the way de- scribed above. The following is added to the doctor's report by the author.) After rallying from the anaesthetic, great pain at the seat of the upper stitch was complained of, necessitating the free use of opium to allay it. For eight days the urine was drawn by catheter, the patient being unable to void it at any time when lying in the dorsal position. Twenty-four hours after the operation the bowels were readily moved by a single enema, and for several days acted without resort to any provocative. Two of the sutures were removed on the eighth day and the others on the tenth day. Perfect union existed throughout, and three weeks from the day of the operation the pa- tient was up and around the room. INJURIES TO THE PELVIC FLOOR. 157 From this time on the improvement in every particular has been rapid and uninterrupted, with an entire disappearance of the pro- lapse, though the uterus remains considerably retroverted, which position it had occupied for years before the marriage of the patient. At this time, fourteen months after the operation, there has been no return of the former trouble, though she performs all her domestic duties and can exercise without fatigue or distress. At the time of making this report she weighs over twenty pounds heavier than she did one year ago, and to every appearance is in perfect health. Median Laceration down to the Sphincter Ani, complicated with Temporary Relaxation of all the Muscles of the Pelvic Floor, and Pro- lapsus of the Recto-Vaginal Walls.—The patient was twenty-seven years old, well developed, and in good general health. She had been married four years. She had had two children, the first sixteen months old and the second five months. Her second labor was tedious and difficult; the cause unknown. Two weeks after her last confinement she entered actively upon her household duties, and very soon afterward began to suffer from pelvic tenesmus, which was much aggravated by the erect position. Being of an active dispo- sition, she persisted in attending to her duties until her discomfort became so great that she was obliged to seek relief. When first ex- amined, she said that in standing and walking she was tormented with a feeling of dragging downward in the pelvis, and lately had felt " something protruding from the vagina while in the erect po- sition." Her bowels had usually been regular, but lately she noticed that they moved with difficulty, as if there was some loss of expelling power, and when voluntary efforts were made to evacuate the rectum the recto-vaginal walls protruded. All these symptoms were much relieved upon lying down. She weaned her child when it was three months old, because she had not much milk, and her friends made her believe that her suffering was due to nursing. At the fourth month she menstruated, but, not being any better, she sought advice. The laceration was found to be- as already stated. The transversus-perinaei muscles were still attached to the sides of the laceration, and by drawing the parts out- ward the vagina was distended laterally as well as antero-posteriorly. The distance from the vestibule to the anus was increased by the downward and backward displacement of the posterior portion of the pelvic floor. The posterior rectal wall and the anterior vaginal wall were found lying upon the sphincter-ani muscle, and when the patient coughed or strained they protruded a little beyond the hue of the anus. There was also commencing prolapsus of the base 158 DISEASES OF WOMEN. of the bladder and anterior vaginal wall. I>y passing a large sound into the rectum it was found that the recto-vaginal walls, imme- diately above the sphincter-ani muscle, were very thin, indicating that the muscular coat of the vagina had been torn longitudinally, or else that its attachment to the muscles of the pelvic floor had been severed; perhaps both injuries had occurred. The patient was prepared for the operation in the same way as in the case just related. The denudation was made in the usual man- ner, but was carried upward on each side nearly half an inch above the outline of the scar of the original laceration and about three quarters of an inch broad from without inward. The mucous mem- brane was also removed upon the vaginal wall up to the point where it came in contact with the anterior vaginal wall; that was made the apex or most prominent point of the vivifying. This was much be- yond the limits of the laceration. The object in vivifying the tis- sues so high up on either side was to secure the ends of the bulbo- cavernosus muscle in the wound in order to reunite them, and for a like reason the vivifying was made high up on the vaginal wall in the hope of uniting its muscular coat to the muscles of the pelvic floor. When the parts to be united were vivified it was found that all that remained of the vaginal wall at that point had been removed, leaving nothing but the rectal wall. This was not owing to having removed too much tissue, but because the muscular coat of the vagina had been destroyed by the original injury. There was free haemorrhage, especially from the veins in the deep portion of the wound, but the sutures controlled it. The first suture was passed around wholly within the tissues, but the next ones were passed deep in on one side, then out and across in front of the rectum, and finally through the other side, the object being to bring the sides of the wound to- gether in front of the rectum. The fifth and sixth sutures were passed through each side and through the middle coat of the vagina, and the seventh through the sides only. After tying the sutures and placing marine lint over the wound, an abdominal bandage was applied, and a narrow perineal bandage attached to it and fastened rather firmly. When the patient recov- ered from the ether she had vomiting, which lasted into the night; she also had sharp pain, which, toward the morning of the following day, was accompanied with severe rectal tenesmus. This prevented her from sleeping, and made her quite weary. The pain and tenes- mus were caused, I am sure, by the fact that one or more of the sutures was passed through a portion of the rectal wall. I took pains to avoid the rectum, but must have failed to do so altogether. INJURIES TO THE PELVIC FLOOR. 159 A suppository of morph. sulph. and ext. belladonnae, each a fifth of a grain, was used night and morning to relieve the pain, which did not subside wholly until the morning of the fourth day. She took very little nourishment—nothing solid until the fifth day. On the evening of the fourth day she had a dose of pulv. glycyrrhizae comp., and at noon on the fifth day an enema; this moved the bow- els, and from that time they were kept regular by the same means. After the second day the perineal bandage was removed altogether and the lint-dressing continued. On the fifth day after the bowels moved there was a slight discharge from the vagina containing traces of pus. She was then ordered a vaginal injection of sul- phate of zinc, sixty grains to a quart of warm water, given with the fountain syringe at low pressure, so as not to distend the vagina too much. This was continued once a day until the eighth day, and after that twice a day for another week. She was unable to urinate, and hence the catheter had to be used until the tenth day after the operation. This gave rise to a slight cystitis; it was treated by a teaspoonful of sweet spirits of niter in a small glass of flaxseed-tea every five hours, continued for three days. The sutures were re- moved on the tenth day, and union appeared to be complete. She was not permitted to leave the bed until the eighteenth day. The vaginal douche of zinc solution was continued up to the next men- strual period, and then discontinued. After the flow ceased, the douching was resumed, and continued for two weeks longer. She was examined two months after the operation, and the re- sult was found to be perfectly good. Laceration of the Levator-ani Muscle and Laceration in the First Degree in the Median Line of the Pelvic Floor.—The patient was thirty-four years old, and had three children—the eldest ten and the youngest three years of age. The last child was delivered with for- ceps, and she dates her trouble from that time. She gave the symp- toms of displacement of the pelvic organs in a marked degree. Standing and walking caused great distress. She was constipated, and had great difficulty in evacuating the bowels. She felt that the rectum had lost its expelling power, and, when she made voluntary efforts during defecation, the vaginal walls protruded. The laceration in the median line was not more than half-way down to the sphincter-ani muscle, but the parts were relaxed, and both vaginal walls prolapsed. The uterus was also retroverted and low down. There was complete separation of the transversus-peri- naei muscle, and the bulbo-cavernosus muscle was either lacerated or else overstretched, so that it was functionally imperfect. The 160 DISEASES OF WOMEN. posterior half of the pelvic floor was displaced downward, and the levator-ani muscle did not contract on being stimulated. The touch also showed that the levator had apparently become atrophied, lvest in the recumbent position for two weeks, and support of the pelvic floor and uterus by a tampon in the vagina and a perineal bandage, did not restore the tonicity of the pelvic floor sufficiently to encour- age a continuation of that treatment. It was now evident that the levator ani could not be restored. I then decided to operate with the hope of restoring the bulbo-cavernosus and transversus-perinaei muscles and indirectly uniting them to the sphincter ani, to com- pensate, as far as possible, for the loss of the levator. The operation was the same as that performed for subcutaneous laceration in the median line, excepting that all the tissues were re- moved down to the sphincter ani, and the denudation was carried high up in the posterior vaginal walls and on each side. Care was taken to support the pelvic floor during the healing process, and the nurse protected the parts with counter-pressure when the bowels moved. Good union was obtained, and at the end of a month it was evident that the muscles had been restored, excepting the levator ani. The loss of this muscle was, to a considerable extent, compen- sated for by the restoration of the other muscles, but there was still sagging of the posterior part of the pelvic floor. The patient was not permitted to walk or stand much for a month, and the retro- verted uterus was kept in place with a pessary. She was greatly re- lieved, but, at the end of a year, she was still unable to take her full share of active exercise without supporting the parts with a perineal bandage. With the aid of this support her usefulness was nearly restored, but she was not cured completely. Atrophy and Permanent Paralysis of the Muscles of the Pelvic Floor.—The patient was forty-three years old when first treated; she had borne two children, the youngest being fifteen years old, and had had a large number of miscarriages. Her first labor was tedious and instrumental, but she made a fair recovery. When first seen there was a general sagging of the pelvic floor, great distention of the vulva, rectocele and cystocele, and prolapsus of the uterus. There had been a very slight median laceration of the skin and mu- cous membrane, and evidently complete subcutaneous laceration of the muscles at the median line. At that lime, fourteen years ago, I did not understand the nature of such cases, hence I followed the authorities and treated her in the usual way. She was placed in bed and the pelvic organs kept in position, and, when the parts had ap parently improved in nutrition sufficiently to give prospects of heal INJURIES TO THE PELVIC FLOOR. 161 ing, the usual operation was performed. The result was apparently all that could be desired when the sutures were removed. So far as the shape and quantity of tissue was concerned, the perineal body was restored, but it proved to be functionally useless. As soon as the patient returned to her usual habits of fife the vaginal walls and uterus began to descend and put the central portion of the floor upon the stretch, which caused pain in the scar tissue, so that she suffered more than before the operation. The perineal body became thinned by distention until it was only a band not more than a quar- ter of an inch thick, stretching across from one side of the distended vulva to the other. Traction upon this band, of scar tissue mostly, caused by the protruding vaginal walls, gave such acute pain upon standing or walking that it was necessary to incise the parts. It is needless to say that she was not improved by the treatment. She passed from under my observation, but I learned that about a year afterward she was again operated upon by another surgeon with no better results. Nearly five years after my treatment she was found among the incurables. Rigidity of the Muscles of the Pelvic Floor from Inflammatory Sclerosis.—The patient was a delicate blonde, twenty-five years old. She had measles at twelve years of age, and at that time had-some inflammation in the region of the pelvic floor which terminated in a discharge of pus from the vagina. Ever since then she has had leucorrhoea. At puberty the menses appeared, and have continued normal. She was married six months before I first saw her. Coitus was found to be impossible, and all efforts to accomplish it caused her great pain. An examination revealed the fact that she had catarrh of the cervix and a vaginitis such as occurs in the strumous diathesis. The muscles of the pelvic floor were rigid and tender to the touch. It was presumed that, when the inflammatory disease of the cervix and vagina was relieved, she might be capable of fulfilling her social functions, but such was not the case. Nitrous-oxide gas was used to produce anaesthesia, and, with a Sims's speculum, the vulva was distended sufficiently to temporarily paralyze the muscles. Some laceration of the mucous membrane at the vulva also occurred, but when this healed the rigidity and tenderness of the pelvic floor were sufficiently relieved to permit the sexual function. About two months afterward the tenderness and rigidity of the muscles returned to a slight extent, but were promptly and permanently relieved by a repetition of the forcible distention with the speculum. Several years have passed since this treatment was employed, but there has been no return of the trouble. 12 CHAPTER VIII. FISTULA IN ANO AND COCCYODYNIA. FISTULA IN" ANO. Fistula in ano in women differs in no wise from the same affec- tion in men, so far as its pathology, symptoms, and physical signs are concerned ; and, as these are fully described in treatises on surgery, I shall treat of them here only incidentally. But the treatment of fistula in women has some important peculiarities connected with it, and I propose, therefore, in this chapter to deal with the subject of treat- ment alone, giving special attention to those points of difference as I have observed them in the two sexes. Having had several very unsatisfactory results in treating fistula in ano according to the usual methods of surgery, I determined some years ago to seek other means better adapted to the relief of that affection of the rectum. The history of my own failures, and those which I have seen after treatment by other surgeons, may be the best introduction to what I have to say on this subject. My first case, treated in hospital, was a dissipated woman, who did not know her age, but appeared to be about sixty. She had a very severe purulent vaginitis, presumed to be a neglected gonorrhoea, and also a fistulous opening extending from the side of the perinseum, about three quarters of an inch from the mesial fine, into the rectum above the sphincter muscle. When the vaginitis was relieved, I treated the fistula by laying it open in the usual way and placing some lint in the wound so as to make it heal by granulation from the bottom; in this I was disappointed. The divided surfaces slowly healed over, but did not unite by intervening granulations or by new tissue. The result was that the divided ends of the sphincter muscle were never united, and the patient lost the retaining power of her rectum. During the healing process applications were made to the parts, in the hope of exciting proliferations to fill in the space, but without avail. The patient, a disgusting creature to begin with, became much worse after the operation. FISTULA IN ANO AND COCCYODYNIA. 163 While I was thinking of some way to restore her sphincter, she was granted leave of absence from the hospital one afternoon, and, promptly getting drunk, was arrested and sent to jail next morning by the police justice, who remembered her of old'. What her sub- sequent history was I do not know, but I do know that I felt relieved when I heard of the disposition made of her by the judge. The next case of fistula occurred in private practice; it was that of a young lady who broke down from over-taxation and dysmenor- rhce:t. She had a pelvic abscess and finally a fistula, which I was called upon to treat after her physician had partially restored her health. The external opening of the fistula was situated in the an- terior and lateral portion of the perinaeum. Owing to my experience with my hospital patient I was unwilling to operate in the same way, but gladly decided to employ the elastic ligature, strongly rec- ommended at that time in the treatment of fistula. Accordingly, I passed the ligature through the canal, and, bringing the end out through the anus, tied it rather tightly. Considerable pain, which caused my patient great suffering, followed, and lighted up many of the old nervous symptoms from which she had just recovered. The ligature cut its way outward rather too rapidly, perhaps, and in six days all the tissues were divided except a very small portion of the skin, which I snipped with scissors. The parts healed over, but the ends of the sphincter muscle did not unite. In fact, the result was about the same as in my hospital case. For a long time the retain- ing power of the rectum was completely lost. Two years after the operation I examined her, and found that the contraction of the scar tissue had brought the ends of the muscle nearer together, butFstill the function of the sphincter was imperfect. The patient was un- able to retain fluid faeces or gas, although when slightly constipated she experienced very little trouble. Two other cases have come under my observation, in which the conditions presented were very much like those described in my own cases. The first one was a lady, thirty-two years of age, married for ten years, and sterile. For three years she had suffered from a painful growth at the meatus urinarius ; this gave rise to so great tenderness as to prevent coitus and to cause distress during micturition. The tumor was removed and the parts healed well after the operation, but still she had symptoms of vaginismus which compelled her to return for further treatment. A careful examination revealed the following condition : The perinseum was shorter than normal, and was drawn upward by the action of the sphincter-vaginae muscle 164 DISEASES OF WOMEN. until it nearly closed the introitus vagina*. The rectum appeared tc be also drawn forward, so that the distance from the posterior wall of the rectum to the meatus urinarius was altogether shorter than is usually found. A scar was formed on the right margin of the anus. The function of the sphincter ani was impaired. Upon inquiry, I learned that seven years before she had been operated on for fistula, and had never since had complete control of the rectum. The other case referred to so closely resembled in history those just given that it need not be related in full. The only point of difference was that this patient sought advice regarding her want of control of the rectum. It will be observed that in all four of these cases the fistula? were situated either upon the anterior or lateral margins of the anus. A question here arises, whether the operation for fistula situated more toward the posterior margin of the rectum would terminate in the same unfavorable way. This I can not an- swer, as I have never seen a case; I can not, however, see any reason why it should not do so. I am not disposed to believe that the re- sults obtained in the operation for fistula in ano are always so unfort- unate as in the cases recorded here. If that had proved to be the case, the attention of surgeons would have been given to the subject long ago. That the power of the sphincter-ani muscle is lost in a large number of cases after the operation is, I believe, a fact. I might go further than this and say that, in all cases in which the fistula is lo- cated completely outside of the muscle, and it is therefore necessary to divide the sphincter in operating, there is great danger that it will not be fully restored. The divided muscle retracts, and the space between its ends is filled in very slowly with new tissue; as a result, there is usually a large amount of scar tissue necessary to connect the two ends. This must impair its functions, if it does not entirely destroy it. In a healthy subject in whom the termination of the fistula does not extend far outward, and the induration of the tissues around the canal is not extensive, the healing process may go on rapidly, thus connecting the ends of the muscle by means of intervening new tissue. Under such circumstances, the function of the muscle may be re- tained ; on the other hand, if the fistula extends from high up in the rectum to a point some distance outside of the muscle, the operation is almost sure to be a failure. Of course, the greater the amount of tissue between the rectum and the fistula, the farther will the ends of the muscle be separated by retraction, and the longer will the parts be in healing. In such cases the function of the sphincter is FISTULA IX ANO AND COCCYODYNIA. 165 very liable to be impaired. When the fistula is located beneath the mucous membrane only, then a perfect result can always be obtained, Mr. John Gray ("Lancet," December 11, 1880) states that operative treatment should be deferred until the walls of the abscess, as well as the consequent fistulous tract, have assumed a condition of health and a disposition to take on a healing process. This is certainly a good rule in surgery, because it secures, as far as possible, the con- dition necessary to prevent fecal incontinence. In order to avoid such unfavorable results, it was evidently necessary to operate with- out dividing the sphincter muscle, or, if that were impracticable, to secure union of the divided ends of the muscle with the least possi- ble quantity of intervening new tissue. In the hope of curing the fistula without dividing the sphincter, the following method was adopted: An incision was made through the skin and lower part of the sinus large enough to admit two fin- gers below and one at the upper end of the wound. The edges of the wound were held apart with retractors, and the opening in the rectum was found and brought into view by passing the finger into the rectum and everting the rectal wall through the wound. The edges of the opening in the rectal wall were then pared with the scissors, and two or more catgut sutures were introduced and tied. The external edges of the wound were kept apart by a pledget of carbolized lint, which was changed every day until the wound healed. The idea was to first convert a complete fistula into a blind external one, and then finish the cure by compelling the external sinus to heal from below outward. To prevent any strain upon the sutures by distention of the rectum, I paralyzed the sphincter by overdistention, and kept the bowels free by saline laxatives. Of two cases treated in this way one was a success and the other only partially so, as the opening into the rectum closed, but a blind external fistula re- mained. Regarding this method of treating fistula, I can only sav that the danger of losing the sphincter muscle is avoided, which is" very im- portant, but there are objections to it. The operation is difficult to perform—at least the closing of the opening in the rectum with sut- ures is not easy—and, then, my impression is that it will fail to cure some cases. While thinking of some other method of treatment more satis- factory than that given above, I noticed a suggestion in the " Chicago Medical Review," by Dr. Dudley, to lay open the fistula, trim off the indurated tissues along its track, and treat as a lacerated perinaeum, with sutures. It occurred to me that this method was deserving of 166 DISEASES OF WOMEN. a trial, and I determined to put it to the test of practice as soon as 1 could get an opportunity. It was, of course, impossible to tell what the results would be, but I thought that it promised as much as the methods which I had used. Such an opportunity presented itself to me, and the result will be seen in the following history: Fistula in Ano successfully treated by the New Method.—The pa- tient was a married lady, who had anteflexion of the uterus, which caused sterility. On two occasions she had dysentery, which left a tender condition of the rectum and haemorrhoids. While under treatment for the flexion of the uterus, she had an abscess on the right side of the anus, which terminated in the formation of a com- plete fistula. The external opening was about an inch from the anus on the right side, and the internal open- ing was immedi- ately above the sphincter-ani mus- cle. There was the usual exudation around the fistu- lous tract, but it was not so exten- sive as in many of these cases. The rectum having been thoroughly washed out with disinfectants, after a free evacuation of the bowels, a bivalve rectal spec- ulum was intro- duced and the fis- tula laid open. The scar tissue was care- fully dissected out, and special care was taken to vivify the mucous membrane around the upper opening of the fistula. The ends of the sphincter muscle Fig. 89.—The operation for fistula; the tract laid open and the sutures in place, a, anus; f, outer end of fistula. FISTULA IN ANO AND COCCYODYNIA. 167 retracted, so that it was necessary to remove a considerable portion of the mucous membrane and cellular tissue in order to expose the ends of the muscle in the edges of the wound. Fine silk sutures were then introduced into the mucous membrane of the rectum, the lower ones being made to include the sphincter-ani muscle. Deep sutures were then introduced from the outside upward in the same manner as in the operation for restoring the perinaeum. Fig. 89 shows the sutures in place. The deep sutures were tied first. and the slight traction upon them drew the tissues downward and shortened the length of the wound very much. This brought the sutures in the mucous membrane very near together. I should have stated that before the fistula was laid open the sphincter-ani muscle was stretched until paralyzed; this prevented any tension upon the sutures for the first few days. The bowels were moved daily, and after each evacuation the rec- tum was washed out with carbolized water. There was a little sup- puration in the track of one deep suture, but union was complete in ten days. The deep sutures were removed on the ninth day, and the sutures in the mucous membrane were removed at the end of two weeks. The recovery was perfect, the function of the sphincter muscle being fully restored. COCCYODYNIA. This affection was first described as a neuralgia of the coccyx by Dr. Nott in the "North American Medical Journal," May, 184-1, but it attracted little attention until 1861, when Sir James Y. Simp- son revived the subject and gave it the name which it now bears. Pathology.—Pain upon moving the coccyx and contracting the muscles attached to it is the chief characteristic of this disorder. The morbid conditions found are variable. Fracture and dislocation of long standing and caries of the coccyx have been discovered in some cases; in others, no appreciable lesions can be detected. It is presumed that, in the absence of structural changes of the bone and muscles, the pain may be due to rheumatism of the tendons of the muscles or neuralgia of the nerves distributed to them. Symptomatology.—There is little or no suffering while the pa- tient is at rest, but upon rising, sitting down, or evacuating the bow- els, pain over the coccyx is experienced. Sitting is painful in some cases, owing to pressure upon the bone. Any sudden movement is attended with suffering. Some patients are unable to rise from a low seat without assistance. 168 DISEASES OF WOMEN. Physical Signs.—Tenderness upon pressing and moving the coc- cvx is the chief diagnostic sign. Painful hemorrhoids, fissure of the anus, and spasm of the adjacent muscles caused by ascarides in the rectum, may be mistaken for this affection, but they can be ex- cluded by physical examination. Prognosis.—Some cases of coccyodynia are slight, and wear away m time without special treatment; but, though the disease may not perceptibly injure the general health of the patient, it is often of such long duration, and occasions so much suffering and inconvenience, that it is necessary to resort to surgical means for relief. Causation.—Women who have borne children are the most fre- quent, though not the only, sufferers from this disorder. Injuries sustained in parturition, or blows upon the coccyx, exposure to cold, and diseases of the ovaries and uterus, are its chief causes. Treatment.—The surgical methods of treatment are those prac- ticed by Prof. Simpson and Dr. Nott. Neither of them is danger- ous, and one or the other is certain to give satisfactory results. By Prof. Simpson's method an ordinary tenotomy-knife is in- serted at the lowest point of the coccyx, and passed flatwise between the skin and cellular tissue till its point reaches the junction of the sacrum and coccyx. Then the knife is turned and withdrawn, mak- ing a subcutaneous incision which entirely severs the muscles over one side of the coccyx. The same operation is repeated on the other side. No haemorrhage is to be feared in subcutaneous operations unless some large vessel should be cut. An easier operation, and one more likely to effect a cure, is performed by exposing the coccyx through an external incision, raising the extremity of the bone, and severing the muscles with a pair of scissors. The subcutaneous operation, always difficult, is nearly impossible where the bone is covered with much adipose tissue. Should the bone itself be diseased, section of the muscles would not effect a cure. In such cases the coccyx must be laid bare, dis- articulated by the knife, and amputated, according to the method of Dr. Nott. The complete removal of the coccyx is the only method which has proved satisfactory in my practice. Nott's method of operating is to expose the coccyx, detach the muscles, and then take it off from the sacrum with the bone-forceps. In this operation there is danger of injuring the sacrum, and causing a subsequent necrosis. I there- fore prefer to disarticulate with the knife or scissors, cutting through the cartilage. FISTULA IN ANO AND COCCYODYNIA. 169 While all my operations have been finally successful, I have several times seen great suffering and slow healing follow. The subjoined cases will illustrate the pain and suffering which may follow the operation. ILLUSTRATIVE CASES. Removal of the Coccyx and Lower Segment of the Sacrum; Recov- ery.—A married lady, twenty-four years of age, was thrown from a carriage and injured by falling upon her back and side, bruising the lower end of the spine, and having what was supposed to be a fract- ure of the neck of the femur. After recovering from the imme- diate effect of the accident, she suffered from severe pain in the coccyx. At first the pain in that region was almost continuous, and greatly aggravated by locomotion. For about six months from the time of her accident she was tolerably comfortable while resting, but suffered greatly when moving around, especially upon rising from a chair or sitting down or turning in bed. She also had severe at- tacks of sick headache and pains in the back of the neck. On physical exploration it was found that the coccyx and lowest segment of the sacrum projected inward at nearly right angles to the axis of the sacrum. In this dislocation the coccyx was firmly fixed. The dislocation and the tenderness gave rise to violent pain on defecation. The operation consisted in removing the coccyx and the lowest segment of the sacrum. A free incision was made and all the mus- cles and attached ligaments were separated, and then the part to be removed was carefully disarticulated without any injury to the bone. The operation was done with all antiseptic precautions, all haemor- rhage was controlled, and the edges of the wound were brought to- gether with sutures, and dressed with absorbent cotton. On recovering from the anaesthetic she complained of the most agonizing pain in the lower half of the back, pelvis, and limbs. This pain continued for the first three days, and was only partially controlled by large hypodermics of Magendie's solution, ten minims, every two to four hours. An effort was made to relieve the pain with opium given by the mouth, but, although seven grains were given in twelve hours, it was necessary to repeat the hypodermics to give her relief. During all this time of suffering the wound appeared to be healing, there was no undue inflammation, and no suppuration. Five days after the operation the pain was more easily controlled by the morphine, and then the sutures were removed, and the pain from this time on- 170 DISEASES OF WOMEN. ward diminished quite rapidly. At this time the wound appeared to be completely healed, but a portion of the cicatrix broke down, and subsequently healed by granulation. From this time on her progress was entirely satisfactory, the pain subsided in the neighbor- hood of the wound and spinal column, and she was entirely relieved from her sick headaches. Removal of Coccyx; Extreme Pain after Operation; Delayed Heal- ing of the Wound; Final Recovery.—This was a married lady who had one child about eight years old. She had suffered from pelvic cellulitis following miscarriage, so that her health was very much impaired. She fell down-stairs and injured her coccyx about two years before she came under my observation. She recovered completely from her pelvic cellulitis. She de- veloped all the symptoms and physical signs of coccyodynia. The operation was performed in the usual way, and every care taken to secure a good result. After ligating the small vessels, which bled rather freely, there was a little serous oozing, so, before closing the wound with sutures, I introduced a few strands of catgut for drain- age, and dressed the wound with borated cotton. From the time of the operation she had a great deal of pain and tenderness in the region of the wound; this pain and tenderness in- creased until it was necessary to give anodynes liberally to relieve them. After about five days the violent pain subsided, but the wound was still exceedingly sensitive; the drainage-threads were re- moved about the second day, and the sutures at the end of one week. The union was complete, except a sinus in the center which ex- tended downward the depth of the original wound. This promptly closed up after a few more weeks, but there was still great tender- ness remaining there. She returned to her home thirty days after the operation, with the wound apparently healed but still tender. She was free from her occipital headaches and from most of her dis- tressing symptoms. Some time after her return home the wound reopened, and, al- though every care was taken of the case by the physician in charge, it was nearly six months before it healed entirely. Through all this time she was free from the suffering which she had before the opera- tion, but the wound was still tender. Since then she has been per- fectly well. CHAPTER IX. INFLAMMATORY AFFECTIONS OF THE UTERU3. ANATOMY OF THE UTERUS. Before taking up the various forms of endometritis, a few words regarding the anatomy and physiology of the uterus will aid in mak- ing clear what follows with reference to the pathology and physical signs of this variety of uterine disease. The uterus is a triangular body with its apex below when in its normal position in the pelvis. It varies in size in different persons, and is somewhat larger in those who have borne children than in virgins. Its entire length is about three inches; the width from the entrance of one Fallopian tube to the other, that is, the base of the ^^^^wmm^—-^mr^ triangle, is about y^__-^^M_^-^- ___ IIS two inches; audit ^^^H i/iimr^ ^^^^K:mF is about one inch ..............~..... | mm MillW^M in thickness. It is 1 }|w ■Iff divided into the »■ ■IBP-..................0 fundus, body, and b............. ij» lip cervix, the cervix W 1■_ being about as long a..................-......""mm Iff ' as the body and Jljjl very nearly as ^]H thick. The cervix , WB is divided into the jp........................."^^ win T^\;*"' d intra vaginal and ^^ the supravaginal FlG- PO—Mold of uterine cavity Fig. 91. — Mold of uter- r ° in the virgin (Guyon). ine cavity in the multi- portions, the form- b ■ para (Guyon). er being that part which projects into the vagina, and the latter that which extends from above the vagina to the body of the uterus. DISEASES OF WOMEN. 77W Wffl>L F.g. 92.—Section of mucous membrane of uterus from near the fundus (Schafer): a, epithelium of inner surface ; b, b, utricular glands; c, connective tissue ; d, muscular tissue. The walls of the uterus are composed of three distinct ele- ments : the outer covering being peritoneal; the middle coat, un- stamped muscular fiber; and the internal, mucous membrane. The peritonaeum covers the uterus only partially, but the mu- cous membrane lines the entire cavity of the body and cervix, and is continuous with the mucous membrane of the vagina, although differing decidedly in structure. Reference will be again made to the relation of the peritonaeum to the uterus. The cavity of the uterus and its mucous membrane, which are of special interest in this connec- tion, are divided into the cervical canal and its membrane and the cavity of the body and its mem- brane. The cavity of the body is triangular and curvilinear, while the canal of the cervix is spindle- shaped. Outlines of the cavity of the canal of the uterus differ in the parous and imparous uterus (Figs. 90 and 91). The constricted portion at the junction of the body and cervix is the os internum, and the termina- tion of the canal below is the os externum. Taking the cavity of the uterus in its entirety as repre- senting a triangle, with an opening at each of the angles, we find at the upper angles the openings of the Fallopian tubes, and at the lower angle the os externum. The mucous membrane of the cavity of the body is smooth and INFLAMMATORY AFFECTIONS OF THE UTERUS. 173 thin, the membrane proper not being more than the one twelfth of an inch in thickness. It is composed of an epithelial and basement layer, and is firmly united to the fibrous tissue of the middle wall and connective tissues. It is covered with a single layer of columnar epithelium, each epithelial cell having on its free surface a bundle of cilia. It contains a number of glands known as the utricular glands. In a section of the mucous membrane these glands can be seen with a microscope to be lined with ciliated, columnar epithe- lium, and to have free openings on the surface of the membrane. They dip oblique- ly downward, and end in the con- nective and mus- cular tissues im- mediately beneath the membrane. Some of the glands are simple- others are bifur- cated at their low, er ends ; some- times two of these glands have one opening on the free surface. I have said that the glands dip down into the muscular fibers of the middle coat; others describe the muscular fi- bers as running up between the glands, which amounts to the same thing. This arrangement of the utricular glands in the mucous membrane and the muscular wall of the uterus, with the intervening connective tissue, can be seen by referring to Fig. 92. The differ- ences in the infantile and senile uterus can be seen bv reference to Figs. 93 and 94. The mucous membrane lining the cervical canal is arranged in Fig. 93.—Transverse section through middle portion of the corpus uteri of an infant 7 months old. 171 DISEASES OF WOMEN. an entirely different manner from that of the cavity of the body. From the internal to the external os there are sulci which divide the Fig. 94.—Transverse section through the middle portion of the corpus uteri of a woman aged 83. membrane into four divisions or columns. The membrane between these sulci is arranged in oblique folds or ridges, the whole making up that rugous appearance to which the name arbor-vitcB has been given. Fig. 95 shows this peculiar arrangement of the membrane. This membrane is covered throughout with ciliated epithelium. The glands of the cervix, known as the glands of Naboth, are of the racemose type; they open on the free surface, dip down, and divide into numerous branches, which extend deep into the connective tis- sues. Their openings are found on the surface of the mucous mem- brane, both in the elevations and depressions. The point at which the mucous membrane of the cervical canal unites with the membrane which covers the vaginal portion of the cervix is the os uteri externum, and the structure and arrangement of the membrane differ on the two sides of this dividing line. That within the canal is as I have described it, and that which covers the cervix outside of the os internum contains none of the glands of Naboth, and has all the general characteristics of the mucous mem- INFLAMMATORY AFFECTIONS OF THE UTERUS. 175 brane of the vagina. It consists of vascular papillae covered with many layers of squamous epithelium. When, as occasionally hap- pens, the Nabothian glands are found upon the vaginal sur- face of the cervix, it is evi- dence that they have either been developed there or else there is eversion of the mu- cous membrane of the cervical canal, and the latter, I believe, is the true explanation of their presence in most cases. The middle or muscular wall of the uterus is composed of non-striped muscular fibers which appear to be rudiment- ary in the unimpregnated uterus. This middle coat is divided into three layers: a thin subperitoneal one which is continued outward in the location of the uterus, a mid- dle layer, and an inner con- centrated and very abundant layer which surrounds the Fal- lopian tubes, os externum, and os internum ; the inner portion of this layer is less dense than the rest of it, and there is more connective tissue intermingled with the fibro - muscular tis- sues. It is into this layer that ^au^Sr the Uterine and Xabothian Fig. 95.—The oblique ramifications of one of the 1 , , median columns in the cervical canal of a glands extend. virgin, called the arbor-vitae (9 diameters). FUNCTIONS OF THE UTERUS. The function of the uterus which is of most interest to the gyne- cologist is that of menstruation, which has been discussed in the third chapter, to which the reader is referred. It will be spoken of again when treating of corporeal endometritis. The function of the cervix in relation to gestation and parturition 176 DISEASES OF WOMEN. need not be discussed here; a few words, however, may be appro- priate in regard to the relation of the cervix to impregnation. There are two principal theories in reference to the function of the cervix uteri in the transmission of the fecundating element to the body of the uterus. The one is that the cervix dilates, and that the secretion of the glands of Xaboth fills the canal and forms a medium through which the spermatozoa make their way upward by their own migrating power. This appears rational from the fact that the secretion of the xsabothian glands is, in its physical proper- ties, similar to the seminal fluid. The other theory is, that the cer- vix expands, extends, contracts and retracts, producing an action of suction, whereby the spermatozoa are carried up into the uterus. Whether either or both of these theories is correct, there is no doubt that the glands of Naboth secrete a fluid that is concerned in the great function of reproduction, and that derangement of this func- tion tends to the development of cervical endometritis, and that they are subject to important pathological changes in that affection. METRITIS. There are several varieties of metritis. Two of these are desig- nated by the character of the inflammation, acute and chronic; two are classed according to the location of the disease, cervical and cor- poreal endometritis; and there are at least three, which are named in part from the causes which give rise to them, puerperal, gonor- rhoeal, and exanthematous. To define these, it may be said that exanthematous metritis occurs in the course of some of the eruptive fevers, and usually subsides after recovery from the constitutional disease which caused it. It is an acute affection, and always tends to recovery, but the uterus may be damaged by the disease. When it occurs in the young, as it often does, the further development and growth of the uterus may be arrested by it. This is, I am sure, the cause of many cases of imperfect development of the uterus. The acute disease may sub- side, to be followed by a chronic metritis. The puerperal metritis is of most interest to the obstetrician, as it occurs in connection with parturition. It has a traumatic or sep- tic origin, and usually involves the entire uterus, so that changes of structure are found in the mucous and muscular coats of the organ. This also (when it terminates in recovery) tends to chronic inflam- mation of the mucous membrane. The process of involution is ar- rested by this inflammation, and when the tissues are changed by INFLAMMATORY AFFECTIONS OF THE UTERUS. 177 inflammatory action the uterus is not only larger than it should be but is changed in structure. This will be referred to again under the head of subinvolution. Endometritis due to gonorrhoeal virus will also claim a separate notice, and with these few observations I shall for the present dis- miss all the varieties except acute and chronic endometritis, which will be discussed in this chapter. Acute Endometritis.—Acute endometritis is exceedingly rare if puerperal, gonorrhoeal, and septic inflammations are excluded. I am aware that acute cervical or corporeal endometritis is described in books, and Thomas claims that the affection occurs frequently. My own observations lead me to the conclusion that the acute metritis does not progress beyond the stage of acute congestion, and fre- quently passes off without causing the slightest permanent change of structure. Occasionally the acute stage subsides, and a chronic or subacute endometritis follows. When one follows the other in this way they stand to each other in the relation of cause and effect. The disease may affect the cervix or the body or both at the same time. Acute cervical endometritis is more properly an acute congestion, which does not cause any very marked disturbance either of the pelvic organs or the general system. The symptoms are not pro- nounced. Pelvic tenesmus of a slight nature, a sense of aching in the pelvic region, with or without backache, is the evidence ob- tained at first, and then leucorrhoea soon follows. This discharge is usually catarrhal and non-purulent. In some cases there is also a vaginitis and a vaginal leucorrhoea Avhich contains some pus-cells, but when there is a free purulent discharge there is room for a suspicion that the cause may be specific. This form of cervical endometritis frequently ends in recovery, but may become chronic. All else that needs to be said on this sub- ject will be given in the consideration of corporeal endometritis. Acute Corporeal Endometritis.—While I have stated that acute corporeal endometritis may occur alone, I have always found it ac- companied by more or less cervical endometritis. The pathology of acute non-specific endometritis I consider to be a hyperaemia, with such derangement of function as may come from it. This congestion may lead to swelling of the mucous mem- brane, destruction of its epithelium to some extent, and the forma- tion of pus, but these changes are not so marked as they are in me- tritis due to specific causes There is derangement of the menstrual function ; the flow may be retarded, anticipated, profuse, or scanty. A free menstruation is usually very beneficial. Symptoms often 13 178 DISEASES OF WOMEN. subside as soon as a free flow is established, and if this flow con- tinues the usual time or longer the patient promptly recovers, free menstruation has always appeared to me to be a natural means of relief in this affection. The symptoms and physical signs of general acute endometritis are similar to those found in the chronic form of the affection, and to save repetition these points will be taken up under the head of chronic endometritis. Prognosis.—This is favorable. The great majority of cases re- cover, and the worst that may happen is that the disease may linger and assume the chronic form. Causation.—The causes which give rise to ordinary inflammation of mucous membranes generally will produce acute endometritis, especially if operative at or near the menstrual period. Extreme sexual excitation or over-indulgence, exposure to cold, over-fatigue, and injuries from careless examinations with the touch or instru- ments, are fair examples. Treatment.—Complete rest is the first and most important ele- ment in the management. To quiet the nervous system, full doses of bromide of sodium should be given. This may also relieve pain. Should the suffering still persist, opium should be used, but not if it can be avoided with justice to the sufferer. Hot applications should be made over the hypogastrium. Liu- seed-meal poultices, covered with oil-silk, should be preferred, but if the patient complains of the weight flannels wrung out of hot water may be used in the same manner. The hot-water douche should be used twice or three times a day if it gives relief. The bowels should be kept free with saline laxatives; should these cause flatulence and pain, a laxative pill of colocynth or rhubarb and belladonna will answer better. This simple treatment is generally sufficient. More heroic meas- ures are often resorted to, but usually with the result of prolonging the disease. Chronic Endometritis.—One would naturally suppose that in en- dometritis the inflammatory process, wdien once begun at any part of the mucous membrane, would extend to the whole endometrium, but such is not the case. Clinical observations show that cervical endometritis frequently occurs without corporeal. They occur to- gether also, but cervical endometritis occurs most frequently. This law in the pathology of uterine disease, which appears peculiar, is explained possibly by the fact that the mucous membrane in its ana- tomical structure, and more especially in its function, differs very INFLAMMATORY AFFECTIONS OF THE UTERUS. 179 widely in the body and cervix uteri. Certain it is that the pathology and symptomatology, as well as the physical signs, show that corporeal and cervical endometritis are two very distinct affections, demand- ing different consideration and treatment. At the same time I must admit that they have many features in common, and that they also occur together occasionally, hence I shall give some general remarks which will apply to* both. There has been much discussion regarding the pathology of en- dometritis, both cervical and corporeal. Much of this difference of opinion I think arises from the use of the terms. Some claim that the only lesion in this affection is congestion, others claim that there is true inflammation; the difference apparently arising from the fact that one defines inflammation as one thing, while another believes it to be something else. If endometritis, as we usually see it in practice, is compared with the process of acute inflamma- tion in other mucous membranes when it runs its entire course, then it will be found that endometritis is exceptional. It is known that in ordinary inflammation of the mucous membranes there is first congestion, then hypersecretion, then suppuration or purulent secretion, occasionally ulceration, and rarely, if ever, except in spe- cific inflammation, an exudation of plastic lymph; then recovery follows. The damage done to the membranes depends upon whether the process ends in suppuration, ulceration, or exudation. If this is taken as the typical result of inflammation of mucous membranes, then it is a fact that inflammation of the mucous membrane of the uterus is extremely rare ; but the fact is, that the process of inflam- mation in mucous membranes begins in some cases and progresses only to congestion and hypersecretion, and if these are long continued certain changes in the mucous glands, epithelium, and cellular tissue take place, but suppuration or ulceration does not occur as a rule in endometritis. The inflammatory process does not begin, run through all its stages, and then end, but it begins and progresses to a given stage, and is continuous instead of ending at a definite time. Cervical Endometritis. — Pathology. — In cervical endometritis, which is now usually called uterine catarrh, there is very decided congestion and hypersecretion of the glands of the cervix. This secretion differs very little in its physical properties from that which is normal, except that it is excessive in quantity. If this congestion is long continued, the exfoliation of epithelium progresses faster than its replacement by the development of new cells, so that the membrane is covered with young epithelium which gives it a reddish color. L80 DISEASES OF WOMEN. This disturbance of the balance between the process of exfoliation and reproduction not only involves the mucous membrane of the canal, but extends outward from the os externum about half the thickness of the walls of the cervix. This gives rise to the con- ditions which were described by the older writers as ulceration of the cervix uteri. As the process advances the mucous membrane becomes thick- ened by proliferation of the areolar tissue and by distention of the blood-vessels, so that it becomes too large for the surface which it covers; this throws it into the fine rugosities or wrinkles which give the surface a granular or papillous appearance. These pro- jecting points were supposed by the older pathologists to be an enlargement of the papillae of the mucous membrane, but it is now known that they are new formations due to areolar hyper- plasia. It is supposed, also, that the glands undergo some patho- logical change other tlian mere congestion, but probably the only change is a congestion and modification of the epithelium which lines them. It is claimed by some that new glands are developed upon the outer surface of the cervix around the os externum; I am inclined to think, however, that the glands which are seen outside of the os externum in cervical endometritis appear there because of the thick- ening of the mucous membrane which causes a procidentia or pro- lapsus of this membrane. It is difficult to believe that the inflammatory process could lead to the development of new anatomical structures of a normal char- acter, but there is strong evidence to show that this occurs in the mucous membrane of the cervix uteri. Sometimes the irregularity of surface due to hyperplasia is very marked, especially in cases where there is laceration of the cervix. This condition has been called " granular degeneration "—a good enough name, if it is re- membered that it is produced by a throwing up of the membrane into folds or projections by an enlargement and thickening due to hyperplasia, and that it is not a degeneration in fact. In some cases, especially those that have been treated with caus- tics, the mouths of the Nabothian glands become closed and the glands become distended by their secretion, and form cyst-like bodies deep in the membrane. These are usually seen at the surface as whitish, pearly-looking points, which contrast with the deep-red color of the mucous membrane around them. To the touch they feel like shot, imbedded in the membrane; these have lono- been known as the "ovulse Nabothi"--more recently this condition has been called INFLAMMATORY AFFECTIONS OF THE UTERUS. 181 " cystic degeneration of the cervix " (Fig. 96). Sometimes one or more of them become very large, and by pressure cause absorption of the middle wall of the uterus around them. The hyperaemia sometimes extends to the middle coat of the cer- Fig. 9G.—Section through the mucous membrane of the vaginal portion of the cervix showing cystic degeneration. vix, and then for a time the tissues are softened and ©edematous. With this condition there is usually free leucorrhoea and menor- rhagia, especially when the body of the uterus is affected. Occasion- ally, though rarely, the menstrual function is suspended or dimin- ished. In some cases of long standing, especially when there is laceration of the cervix, the areolar hyperplasia extends to all the tissues of the cervix, giving rise to that induration known as scle- rosis. 182 DISEASES OF WOMEN. These are the principal pathological conditions observed in the ordinary forms of cervical endometritis. Occasionally the discharge some specific cause, and hence need not be considered in this con- nection. The ordinary form of cervical endometritis, described above, occurs in parous and im parous alike. There is another form of cer- vical endometritis which occurs only in the imparous, and has some peculiar characteristics which should be noticed here. In these cases the changes in the vessels already noted may or may not be present; usually they are not. The discharge from the cervical canal is not usually profuse, but it is peculiar in character. In place of the clear, translucent secretion we find a very thick and exceedingly tenacious material of the consistency of thick glue, and of a darkish color not unlike pneumonic sputum, though more solid and dense, and not usu- ally so bright-red in color. Associated with this peculiar discharge INFLAMMATORY AFFECTIONS OF THE UTERUS. 183 there are usually marked tenderness and dysmenorrhcea, which are not accounted for by any other condition of the uterus than the state of the cervical mucous membrane. I am inclined to think that this form of cervical disease is due to some malformation or arrest of de- velopment of the glands of the mucous membrane. I have been led to believe this because it oceurs in those in whom the uterus is im- perfectly developed generally, and also the same peculiar secretion is observed in some women after the menopause, when the uterus and its mucous membrane have undergone final involution. In other cases of this class the mucous membrane of the cervix becomes prolapsed, causing dilatation and inversion of the lips of the external os, so that the cervix appears as if it had sustained superficial, bilateral laceration. In such cases the appearance is such as to lead to the belief that the patient has borne children, or had a miscarriage ; but I have found it associated with unruptured hymen, showing that it could not have come from injuries during parturition. Dr. Emmet describes cases of laceration that he has seen follow- ing criminal abortion in those who have not borne children. In the cases to which I refer the anatomical appearances are the same as he describes, but I am satisfied that in those that have come under my observation the laceration was apparent, not real. As soon as the membrane is reduced to its normal dimensions by exsection of a portion of it, and relief of the inflammation by treatment is accom- plished, the external os contracts, and the cervix resumes its original virgin form, showing that no injury to the muscular coats of the uterus has ever occurred. Symptomatology. — Cervical endometritis does not necessarily give rise to marked constitutional disturbance; when it does so the symptoms usually appear in the form of general debility, especially of the nervous system. The patient may become easily fatigued and somewhat changed in disposition, and less inclined to mental activity. Sometimes there is considerable mental disturbance, but much of all this is usually due to the fact that the patient is annoyed by the presence of a more or less profuse leucorrhoea, which gives her discomfort, and leads her to suppose that she is suffering from a serious affection. The constitutional effects of this local affection depend very much upon the sensitiveness of the patient. The menstrual function is not necessarily affected. In cases of long standing there may be irregular menstruation, and the flow may be inclined to diminish, but this is not the rule. The character of the leucorrhceal discharge is diagnostic. It is dense, thick, opaque, and tenacious, while the vaginal leucorrhoea is 181 DISEASES OF WOMEN. serous, non-tenacious, and usually purulent. If the disease is long continued backache comes on, the pain being located in the sacrai region, which distinguishes it from the lumbar pain characteristic of general debility and some of the acute diseases. There is often, also, some pelvic tenesmus. All these symptoms are usually very much aggravated by muscular exercise; the symptoms alone, how- ever, are not sufficient to enable one to make a diagnosis. All that can be learned from them is simply that there is some uterine affec- tion which, if it does not yield promptly to constitutional treatment, demands further investigation in order to settle definitely its char- acter. Physical Signs.—These, as obtained by the touch, are usually rather unsatisfactory. Upon making pressure upon the cervix there is sometimes tenderness, but not always ; in some cases a roughened condition of the mucous membrane around the os externum can be detected by the touch. Not infrequently there is a little relaxation of the vagina, and the uterus rests lower in the pelvis. Speculum examination affords the best means of ascertaining the lesions. We can usually see enough of the mucous membrane within the os externum to determine the presence of the inflammation. This is rendered more positive wThen the redness and erosion of the membrane extend outward upon the vaginal surface of the cervix, and also when there is eversion of the membrane. There is usually a free leucorrhceal discharge from the cervical canal. Sometimes this hypersecretion is the only evidence of the disease present. Passing the sound into the cervical canal shows that it is more sensitive than in health, and the membrane bleeds more easily on touch than it should. It will be seen that the physical signs, as well as the symptoms, are not by any means marked in cervical endometritis, yet they are sufficient for diagnostic purposes. Whenever the con- stitutional disturbance and the local symptoms are severe, it may at least be suspected that the membrane of the cavity of the body of the uterus is also involved. This will be more fully discussed under the head of corporeal endometritis. In the form of cervical endometritis referred to, in which the secretion of the glands is opaque, dark in color, and exceedingly te- nacious, the discharge is not at all times very profuse, but enough can be obtained by using a small curette to show its character. This in itself will be sufficient to determine the diagnosis. Causation.—The predisposing causes of endometritis are imper- fections in the general organization, and in the development and growth of the sexual organs. Scrofulous and tubercular diatheses INFLAMMATORY AFFECTIONS OF THE UTERUS. 185 incline to chronic inflammation of the mucous membranes generally, and the membrane of the uterus is no exception. When the uterus is under size or malformed in a slight degree, so that menstruation is imperfectly performed, an inflammation of its mucous membrane is very likely to come on sooner or later. Sed- entary habits and unsuitable clothing, over-fatigue in standing or walking, or anything which interrupts the return circulation from the pelvis, predispose to this affection. So, also, deranged nutrition, from insufficient nutriment or over-taxation, mental or physical, which leads to impoverishment of the blood. Frequent child-bearing and prolonged lactation also predispose to the same trouble. All these causes act to produce derangement of innervation and circulation, and so favor the development of inflammation. The exciting cause which plays the most important part in endo- metritis is imperfect involution after confinement or menstruation. The great majority of cases take their origin from this imperfection of the menstrual or parturient involution. Other exciting causes which may be mentioned are injuries to the uterus from displacements, the use of ill-fitting pessaries, injuries during confinement, causing puerperal inflammations; abortion, es- pecially if produced, intemperate coition, and efforts to prevent con- ception, and finally gonorrhoeal virus. This specific cause of endo- metritis no doubt produces a form of inflammation which differs from the non-specific forms, and hence we will refer to it at another time. So far as I know the same causes produce both cervical and corporeal endometritis, so that in the present state of our knowledge I am not prepared to state any difference in the causes of the two affections, if any such exists. I am inclined to think, however, that as cervical endometritis is beyond doubt much more common than corporeal, it may be inferred that the one tends to the development of the other. Prognosis.—Of the uncomplicated cases of cervical endometritis the great majority yield to the proper treatment. There is in some a tendency to a recurrence of the disease, even after recovery has apparently been perfect. In those cases of imperfect development there is not the same certainty of giving complete relief. Treatment.—The constitutional treatment of inflammatory affec- tions of the uterus should be based upon the principles of the gen- eral management of local inflammations. To correct any defect in the general health, to improve menstruation, and to calm any excite- ment of the nervous system, comprehends the whole subject. The sexual organs being dependent upon the nutritive and nervous sys- 186 DISEASES OF WOMEN. terns for support, general therapeutic agents can only affect the one by action through the other. There are a few medicines which act especially upon the sexual organs, through the circulatory or nervous systems, such as ergot, hydrastis canadensis, and the bromides, but their effects are not al- ways efficient in controlling inflammation. Constitutional remedies, as already stated, act upon the uterus only so far as they improve general nutrition and innervation. In view of these facts, little need be said on this part of the subject; every means which can improve the general health should be em- ployed in connection with the local treatment. To save repetition, the reader is referred to the section on menstrual derangements, third chapter, for details of constitutional derangements which usu- ally accompany diseases of the uterus. Local Treatment.—Local treatment of the diseases of the uterus —the one organ of the sexual system which is most amenable to local treatment—will be given in the history of cases. Some general re- marks, however, on the principal facts in uterine therapeutics may be submitted in this connection. That which is said now will apply in great part to all forms of metritis. Local treatment should be employed with the view of accom- plishing two objects: first, to remove the disease, and, second, to restore the organ to its normal condition. It wdll at once be inferred that if the first object is attained, the second will follow as a natural consequence ; but it may or may not, according to the character of the treatment employed. I am satis- fied that in times past, and even at present, much of the treatment of uterine disease, while it arrests the inflammatory trouble, proves so destructive to the normal structure of the organ as to render the last condition of the patient worse than the first. In the management of uterine diseases one may be guided by some of the accepted rules laid down by surgeons for the treatment of inflammation generally, viz.: Place the diseased organ at rest; quiet irritation by sedatives, and relieve the congestion by depletion, astringents, alteratives, and sedatives. To accomplish these objects, it is necessary to employ all the improved means brought forward by modern investigation, changing and adapting them so as to meet the peculiarities of each case. First, then, rest should be secured by having the patient abstain from long-continued standing or walking, and from over-excitement of the sexual function. If the uterus is displaced, it should be replaced, and sustained in its normal position by the support of a well-fitting pessary, if need be. INFLAMMATORY AFFECTIONS OF THE UTERUS. 187 To relieve pain and quiet the irritation a vaginal or rectal sup- pository made of extract of belladonna, one eighth to one half grain, with cocoa-butter, and used at bed-time, will often give great relief. Suppositories of iodoform and of conium are also of service when used in the same way. I desire to call attention specially to the next agent, namely, deple- tion, because I regard it is as a remedy of some value. In making this statement I am aware that I encounter much professional prejudice. Bloodletting has ceased to be the fashion of the day. The lancet is condemned as a "little instrument of mighty mischief.■' Few of the younger members of the profession have ever seen a patient bled. Local depletion held its own some time after general venesection was to a great extent abandoned, but even this has gradually given way to the popular prejudice of the day; nevertheless, the fact in surgical therapeutics remains as true as ever, that the removal of blood directly from the vessels of an inflamed or congested organ gives some temporary relief. Frequent repetition of bloodletting should be avoided, but when a case is first seen in which there is marked congestion, the abstrac- tion of a little blood by a few punctures around the os externum, or the superficial scarification of the mucous membrane in this region will pave the way for other applications. To practice depletion exclusively and persistently, as some of the older gynecologists did, is certainly injurious; but, as a means to be employed in suitable cases, it is worthy of consideration. Hot water, used as a vaginal douche, is an antiphlogistic which was first popularized in this country by T. A. Emmet. It depletes the parts by stimulating the circulation, and is at the same time something of a local sedative. It is an exceedingly popular remedy at the present time, and is used rather indiscriminately in all diseases of the pelvic organs, and with heroic persistency. If properly used it gives relief in congestion of the vagina and uterus, and in cellulitis when the inflammation is limited to the cellular tissue about the cer- vix uteri. It is also of service in the passive congestion which often accompanies imperfect involution, but in pelvic peritonitis, salpin- gitis, and ovaritis it is often harmful. It is also very liable to do harm when used, as it often is, after plastic operations about the cervix uteri and perinaeum. Another means of depletion was introduced by J. Marion-Sims. lie employed a small vaginal tampon of cotton saturated with glyc- erin, which caused free exosmosis from the mucous membrane, there- by relieving capillary engorgement and oedema. 188 DISEASES OF WOMEN. Position has much influence in modifying the circulation in the pelvis, and hence patients should avoid the too common habit of sit- ting all day in a chair because they suffer when they walk. Short periods of walking or riding, followed by rest in the recumbent po- sition, should be directed. In the treatment of endometritis with the applications of cura- tive agents, two very important questions arise: First, what agents shall be used, and how, shall they be applied. Bearing in mind that the uterus should not be injured in its structure, the therapeutist is bound to reject all the more powerful and destructive agents, such as nitric or chromic acid, caustic potash, and the actual cautery. All these have been used, and are now, though less extensively, I trust, than formerly, in the treatment of simple chronic endometritis, or hyperaemia of the mucous membrane of the cavity of the uterus. Leaving out of account the value of these potent agents in the treatment of malignant diseases of the uterus, I desire to be distinctly understood as opposed to their use in the treatment of the benign uterine diseases. I readily admit that inflammation of a mucous membrane can and may have been " cured," as the expression is, by such means. The oculist could "cure" a chronic conjunctivitis by destroying the membrane with strong caustic, but I fear the eye would be hardly presentable afterward, and it would surely fail to perform its func- tion. There are those who treat the same affections of the mucous membrane of the uterus with these destructive agents, and the results which follow can be easily imagined. It may be argued, I am aware, that strong caustics are being used less and less by the profession in the treatment of uterine disease, and I am glad to believe that such is the case. Nitric and chromic acids, and other caustics, are being laid aside, but only, I fear, to give place in some cases to new but none the less destructive agents. I allude to the galvano-cautery and the thermo-cautery. These have become the " fashionable " caustics or cauteries of the day, and I trust I most thoroughly appreciate their value in the treatment of malignant disease, when the destruction of tissue is called for; but, in the treatment of inflammation, they can not fail to work great and uncalled-for destruction, like the agents used in the past. The treatment of the cervical canal is fortunately simpler, being more easy to reach, and much more tolerant of irritation. The only difficulty in the way of making applications is the presence of a tena- cious secretion which fills the canal. This should be removed with a small curette before the application is made. INFLAMMATORY AFFECTIONS OF THE UTERUS. 189 The method of applying these agents is by using the pipette (Fio*. 100). Kegarding the agents to be used, a long list might be given, but it will suffice to say that -----=^=^^3zm:m£Ma^fipmSmi the safest and most /^r^ efficient are mild Fig. 100.—Skene's instillation tube. solutions, one or two grains to the ounce, of sulphate of zinc, chlo- ride of zinc, nitrate of silver, tannic acid, and bichloride of mer- cury ; my own preference for general use is tincture of iodine two parts, and carbolic acid one part. The frequency with which these local applications should be made depends upon the nature of the lesions. In ordinary cervical and corporeal endometritis, once every five or six days will answer. This gives time for the tissues to fully profit by the application before it is repeated. I am aware that the practice with some is to make local applica- tions every day or every other clay, but I know that this constant manipulation is irritating, and does more harm than good. ILLUSTRATIVE CASES. A Typical Case of Uncomplicated Cervical Endometritis.—A lady, thirty-two years of age, was married at the age of twenty-one, had borne six children, and had nursed all of them. Her health had al- ways been very good, and her menstruation regular and natural, showing that her general health and organization were excellent. She nursed her last child for eighteen months, her menses returning when her child was ten months old. From that time she had a slight leucorrhceal discharge which gave her no trouble, and was not re garded. Before weaning her child she became quite debilitated, com- plaining of occasional dizziness, shortness of breath in active exer- cise, considerable backache, constipation, and occasionally impaired appetite. Her leucorrhoea about this time increased in amount and alarmed her, because she attributed her general ill-feelings to this discharge. This was her condition when she first applied for advice. On digital examination the uterus was found to be normal in size and position, the external os was larger than normal, and there ap- peared to be slight roughening of the membrane immediately around the os. A speculum examination revealed an areola of a deep-red color around the os externum, and a profuse leucorrhceal discharge from the cervical canal. The cervix appeared to be a little larger than normal, but this increase in size was wholly due to enlargement of the cervical mucous membrane, which was decidedly congested, 190 DISEASES OF WOMEN. and possibly somewhat thickened. The internal os appeared to be normal; the mucous membrane of the cervix bled when touched rather gently with the uterine sound. From the fact that her men- strual flow was quite regular and normal, and that the internal os was not unduly dilated, nor the body of the uterus enlarged or ten- der, the diagnosis of endometritis limited to the cervix was made with positiveness. Her general debility was no doubt due to fre- quent child-bearing and lactation, and not wholly to her uterine dis- ease, as she had supposed; in fact, I believe that the cause of the endometritis was largely, perhaps entirely, due to her exhausted and debilitated condition. She was directed to wean her child as promptly as possible, and to rest from all her taxing household duties; to spend some time every day in the open air, riding mostly, and to take an abundance of good nourishing food. The following prescriptions were given to her: A teaspoonful of comp. liquorice-powder at bed-time, to be repeated every night, the quantity to be increased or diminished in order to keep the bowels regular. Two grains of the pyrophosphate of iron were given after meals, well diluted, and a glass of claret. Locally, she was directed to use a vaginal douche of borax and warm water twice a day. This was continued for about two weeks, when it was found that she did not apparently derive very much benefit from it, and she was directed to use it only once a day, which seemed to answer quite as well, and relieved her from the trouble of using it twice a day, which she complained of as a considerable annoyance. Locally, the treatment consisted of a careful removal of all secretions from the cervical canal with a dull curette. In doing this consider- able haemorrhage was produced at first, and it was necessary to wait until this had subsided before making any local application, but as this only occurred a few times it was soon possible to remove the secretions without difficulty, and a preparation of equal parts of tincture of iodine and carbolic acid was applied thoroughly to the entire canal with the glass pipette (Fig. 100). A few drops of this mixture was drawn up into the tube by compressing and releasing the bulb. The pipette was carried up to the internal os, and while it was being slowly withdrawn pressure was made upon the rubber bulb, which gently expelled this mixture and thoroughly applied it to the entire mucous membrane. This local treatment was repeated every five days during the next two succeeding inter-menstrual pe- riods, and the general tonic and sustaining treatment continued, varying the chalybeate tonics from time to time. From this time onward local applications were made after each menstrual period. INFLAMMATORY AFFECTIONS OF THE UTERUS. 191 and again in about two weeks, making two local treatments between each menstrual period. Her general condition greatly improved; the cervix diminished in size by a marked contraction of the cali- ber of the canal; the leucorrhceal discharge almost entirely disap- peared, and at the end of five months from the time that the treat- ment was first begun she was dismissed quite well. She was di- rected, however, to return after the menstrual period for two or tliree months, to ascertain if there was any disposition to a recurrence of the cervical endometritis. It was found that she remained well, and hence recovery was considered to be complete. Cervical Endometritis, with Hyperplasia of the Mucous Membrane, —This patient was twenty-eight years of age, rather small and deli- cate-looking, but had enjoyed good health up to her last confinement. She had been married eight years and had three children, the last one being ten months old at the time when I saw her first; she had nursed all her children, the first two for about a year, but the last one she weaned when it wTas eight months old, because she did not feel well, and had not sufficient milk for it. When her baby was about four months old she began to suffer from leucorrhoea, back- ache, and pelvic tenesmus—the latter symptoms being very much aggravated by active exercise. She had also lost considerable flesh, was easily fatigued, and somewhat nervous and depressed; her gen- eral nutrition appeared to be fair, and her appetite was good; her bowels were regular, and, although her pulse was not strong, she had a good, clear, healthy complexion. Digital examination revealed slight relaxation of the vagina, especially of the upper portion; the uterus was rather low in the pelvis, and, while the body was normal in size, the cervix was considerably enlarged. The cervical canal was dilated, and the lips of the external os everted. Around the os, and extending outward to about half the thickness of the cervical walls, the mucous membrane was quite granular and rough to the touch. Through the speculum a very free leucorrhteal discharge from the cervix was observed, and the first impression was that there was superficial bilateral laceration of the cervix, but on more careful investigation it was found that the mus- cular wall of the uterus was very little, if at all, injured, and that the enlargement of the os externum and the eversion of its lips were due to the enlargement of the mucous membrane. The corrugations of the thickened mucous membrane were so marked as to give a papillomatous appearance, and the congestion was such that the parts bled freely on being touched with a sponge* The patient was put upon a systematic course of rest and exercise, 192 DISEASES OF WOMEN. simple but nourishing food, and the citrate of iron and quinine as a tonic. Locally, she was ordered a vaginal douche of two quarts of water, two drachms of borax, and a half drachm of tannic acid to be used twice daily. A number of the more prominent points of the mucous membrane, which projected from the os externum, were removed with the scissors. A borated tampon was introduced and removed on the following day, and two days afterward the iodine and carbolic acid mixture was applied to the whole length of the cer- vical canal with the pipette. One week afterward that portion of the cervical mucous membrane which could be seen was smooth, less re- dundant and less vascular; the canal was still dilated, and the rugosi- ties of the mucous membrane were abnormally prominent. The more prominent portions of the mucous membrane of the canal were touched with a fifty-per-cent solution of chloride of zinc applied with a camel's-hair brush. Considerable pain followed this applica- tion, and continued until late in the evening. From this onward the vaginal douche was employed once a day, borax and water only being used, the tannic acid being omitted. The carbolic acid and iodine were applied to the canal of the cervix with the pipette, the secretion being carefully removed with the curette before the appli- cation. This local treatment was employed once a week during the inter-menstrual periods for about five months, after that one appli- cation after each menstrual period for tliree months longer. At this time her general health had been considerably restored, the canal of the cervix had returned to its normal size, the leucorrhceal discharge had entirely disappeared, and the mucous membrane around the os externum was perfectly normal. She had no further trouble from backache or pelvic tenesmus, and she was dismissed perfectly well. locally and generally. Cervical Endometritis, Stenosis of the External Os, and Cystic De- generation of the Mucous Membrane.—This patient was an English lady, thirty-nine years of age. She had two children, the youngest one being five years old. She had an excellent constitution, and her health had always been quite perfect. After her second confinement her convalescence was interrupted for a short time by some local trouble, the nature of which I could not exactly determine. She recovered from this, but afterward suffered from uterine leucorrhoea, This gave her very little trouble, and as she hoped that it might dis- appear she did not seek medical advice until two years afterward, when she called upon a physician, who told her that " she had ulcer- ation of the womb." He treated her for about six months by apply- ing nitrate of silver, making the applications with a swab through a INFLAMMATORY AFFECTIONS OF THE UTERUS. 193 cylindrical speculum. This I learned from the patient herself, who stated that the doctor told her he was using nitrate of silver. The treatment diminished the leucorrhceal discharge, but she beo-an to have backache and pelvic tenesmus, with an occasional sharp pain in the region of the uterus. She also had slight dys- pareunia. She wTas told by her physician that the ulceration was cured, and that her symptoms would'all probably pass away, but after wait- ing for six months and finding that they did not she came under ray observation. Her general health was still fairly good, but the local symptoms caused her considerable nervous disturbance, and the leucorrhoea had returned, but not so profusely as before. The touch revealed an enlargement of the cervix uteri, and around the os there was a number of quite hard points, some of them projecting a little above the general surface, giving an impression that there was a number of shot imbedded in the cervix. The os externum could not be very clearly made out by the touch. The entire cervix ap- peared to be a little denser than normal, and on speculum exami- nation the mucous membrane seemed to be red in spots, while the cysts had a whitish or pearly appearance, some of them showing a deep-yellow color. The os externum was somewhat puckered from scar tissue, one well-marked scar running from the posterior lip of the os outward and backward. This was lighter in color than the general mucous membrane. The os admitted a small uterine probe. The canal of the cervix, above the contracted os externum, was found to be considerably dilated, and contained quite a large accumulation of a thick, tenacious, leucorrhceal secretion. The cervix was tender to the touch, but not extremely so; the body of the uterus appeared to be normal in every way. The conditions here found illustrate a very common class of cases in which there has been ordinary cervical catarrh, which has been treated by the application of a caustic to the vaginal surface of the cervix and the lips of the os externum. The frequent and long-continued use of nitrate of silver almost always produces stricture, scar tissue, occlusion of the Nabothian glands, and the formation of cysts. The treatment in this case was to first take out a triangular piece of the scar tissue from each side of the os externum, which enlarged it sufficiently. The cysts were then all carefully torn open, aud the contents evacuated by pressure; the secretion in the cervical canal was removed with the curette, and an application of the tincture of iodine was made to the canal and the vaginal portion of the cervix. A hot-water douche was directed to be used twice a day. The patient was examined 14 194 DISEASES OF WOMEN. three days after, when the os externum was observed to be contract- ing somewhat as the healing process was going on. A small tampon of cotton was introduced into the os externum, and maintained there for twenty-four hours by means of the vaginal tampon. It was then reintroduced without the vaginal tampon, and again removed at the end of the next twenty-four hours. This tampon, while it pre- vented the contraction of the os, interfered at the same time with the process of healing, so it was given up. At the end of a week after the first treatment there was found still a number of cysts, some of them within the cervical canal. These were all opened and the leucorrhoeal secretion removed from the canal with the curette, and the mixture of iodine and carbolic acid applied; and tincture of iodine alone applied to the vaginal portion of the cervix. These applications were repeated once a week, and the warm- water douche continued for four months. During this time all the local symptoms disappeared except the leucorrhoeal discharge, and this diminished in quantity and became less opaque in character, but it did not wholly disappear. The size of the external os remained ample, while the canal con- tracted very decidedly, so that it was almost of its normal caliber. The scar tissue became less dense, and all tenderness disappeared. After the first four months' treatment the patient was seen for an- other three months, just after the menstrual period, when the iodine and carbolic acid were applied to the cervical canal, and the iodine to the vaginal portion of the cervix. Seven months from the time that she first came under my observation she was found to be preg- nant, and hence was dismissed as recovered. I subsequently learned that she passed safely through her confinement, but 1 have had no opportunity of examining her since, although I believe that she re- mains quite well, and hence it can be inferred that the cure was permanent. Cervical Endometritis treated by Caustic, which produced Con- traction of the lower two thirds of the Cervical Canal.—This lady was twenty-eight years of age, of remarkably strong organization, and had always enjoyed good health until the birth of her third child. At that time she had some difficulty in her labor, and sus- tained a slight laceration of the perinseum; after this she had pelvic tenesmus and leucorrhoea. When she first came under my observa- tion she had slight prolapsus of the uterus, with retroversion in the first degree; there was cervical endometritis, indicated by the deep- red color of the mucous membrane and free leucorrhoea, but there was no other pathological change in the mucous membrane. An INFLAMMATORY AFFECTIONS OF THE UTERUS. 195 application of tannin and glycerin was made to the cervical canal, the uterus was replaced, and she was told that it would be necessary to restore the perinseum in order to give complete relief. The thought of an operation somewhat disturbed her mind, and a friend advised her to place herself under the care of her physician, a homoe- opathist. This she did, and at the second visit he told her that he had introduced a pencil of nitrate of silver into the womb, and had applied some cotton to keep it there, and desired her to return to his office the next day so that he might remove the cotton. On the way home she suffered severe pain, and was obliged to go to bed as soon as she reached the house. She suffered considerably during the night, and the following day sent for the physician, who removed the cotton, and told her that she would be all right. She continued, however, to have a good deal of pain and pelvic tenesmus, especially when she tried to stand or walk. For the next two or three days she had a discharge which differed from the former leucorrhoea; it was less tenacious, yellow in color, and at times quite offensive in odor. She returned to the physician for further treatment as soon as she was able. The discharge became very much less, and finally disappeared entirely. She was encouraged to hope that she would get well without any further treatment. In this, however, she was misled. Her backache and pelvic tenesmus increased in severity, especially when standing or walking, and she began to have painful menstruation. About a year from the time she had the caustic ap- plied she returned to me. I found the displacement about the same; there was no leucorrhoeal discharge whatever, and no external evidence of the former endometritis. The os externum was con- tracted, and its lips curved inward; the tissues around the os were extremely hard, and to the touch and inspection appeared to be mostly scar tissue. The cervical canal was contracted in its lower two thirds, so that a small uterine sound could be passed with difficulty; there was none of the elasticity of the normal canal left, but a hard, almost cartilaginous condition existed. The passing of the sound caused considerable pain, and some haemorrhage. The patient was then sent to my private hospital, and an effort was made to dilate the cervix by the use of graduated sounds. This gave pain, and was not effectual. Then the whole length of the contracted portion of the cervical canal was incised on the two sides, the incisions being made with my hysterotome (Fig. 46) through the scar tissue, and the canal was then dilated sufficiently to admit a No. 23 sound; a tent made of marine lint and dipped in carbolic acid and glycerin, 196 DISEASES OF WOMEN. one part of the former to three of the latter, was passed up into the canal and retained there by a vaginal tampon ; this was left in po- sition for twenty-four hours, when it was removed. A short, hard- rubber stem-pessary, which reached beyond the line of contraction, but not up to the internal os, was introduced and worn for nearly three weeks. During that time it was repeatedly removed and tinct- ure of iodine applied to the cervical canal, and a vaginal douche of borax and warm water was used. The treatment was continued throughout with all antiseptic precautions. After the operation on the cervix the uterus was kept in place, first by means of a tampon, and subsequently by means of the pessary, which answered the purpose while the patient remained in a recumbent position. The perinseum was then restored, and the patient dismissed after two months of treatment in the institution. She subsequently returned to me once a month, when I passed the uterine sound and applied the tincture of iodine, in order to prevent any recurrence of the con- traction. Six months from the time that she was operated upon she became pregnant, and, although some trouble was anticipated in the dilatation of the cervix during her labor, there was none. Prof. Charles Jewett attended her in her confinement, and all went well, and she has remained free from uterine trouble ever since. Cervical Endometritis in an Imparous Woman.—This was a cul- tivated lady, with an excellent constitution, who began to menstruate at fourteen, while she was a school-girl, and continued to do so nor- mally until she had been teaching several years in a high school. She taught many hours daily, and being strong and very ener- getic she preferred to stand, as a rule, while drilling her class. This overtaxation brought on dysmenorrhcea, backache, and leucorrhoea. These symptoms were not marked at first, but as she kept on at her work they gradually increased. When she was twenty-eight years of age she came under my care. She had then been married about one year, and although her symptoms had not increased—in fact, she had enjoyed better health after being relieved from her arduous duties as a teacher—still she had backache and leucorrhoea, especially on taking active exercise; and she was sterile. I found the men- strual function perfectly normal, except that she had backache and some pelvic tenesmus during the flow, but these were relieved to some extent if she kept quiet. Her chief symptom at that time was a rather free leucorrhoea. A digital examination found the pelvic organs well developed. There was no tenderness nor any evidence of disease that could be obtained by the touch, except that the os externum appeared to be larger than is usually found in the virgin INFLAMMATORY AFFECTIONS OF THE UTERUS. 197 cervix. On speculum examination quite a free leucorrhoeal dis- charge was observed, and there was a ring of deep-red color in the mucous membrane around the os externum. The cervix was rather large in proportion to the body of the uterus, and was of a deeper color than normal, and the upper portion of the vagina also was congested. The canal of the cervix, including the internal os, was normal in size, so that the uterine sound could be passed to the fundus without difficulty or causing much pain. As her health was quite good, no constitutional treatment was necessary. During the succeeding two months six applications of iodine and carbolic acid were made to the cervical canal. The next month three applications were made of iodine alone, and the next month after that glycerin and tannic acid were applied. At the end of that time the leucorrhoeal discharge had entirely subsided, the patient suffered much less from backache, and had no pain or discomfort at her menstrual periods. She was then dismissed, and nothing more was heard of her until four years afterward, when she returned to inform me that she was two months pregnant. I have not seen her since, but have heard through her family that she was delivered of a healthy child after a somewhat tedious labor. Cervical Endometritis in an Imperfectly Developed Uterus.—This lady appeared to be rather frail, but had always enjoyed good health. She began to menstruate first at thirteen, and for the first year was rather irregular, and always had some pain the first day. The flow lasted only from two to three days, and the dysmenorrhcea increased somewhat from month to month; and she began to have backache before and after menstruation, with occasional leucorrhoea. When she was twenty-four years old she was married, but from that time onward her dysmenorrhoea increased ; she had almost continuous backache, and a good deal of tenesmus, with occasional attacks of frequent urination. One year after her marriage she came under my observa- tion, and I found the uterus rather below the normal size ; there was slight anteflexion of the cervix, but the body of the uterus was in its normal position. The uterus was tender to the touch, and there was also some hyperesthesia of the vagina. A speculum examination revealed a general congestion of the cervix and vagina, the cervix being smaller than it ought to be; the os externum was small, and while there was a slight vaginal leucorrhoea there was no discharge from the cervix. The canal of the cervix was quite large in propor- tion to the size of the external os, and the os internum was so smaD that an ordinary-sized uterine sound was passed with difficulty, and caused pain. The canal of the cervix contained a plug of very thick, dark- 193 DISEASES OF WOMEN. colored, and very tenacious secretion. This was removed with the curette, but with great difficulty, and quite a free hemorrhage oc- curred during its removal. After removing this secretion very care- fully, and waiting until all haemorrhage had subsided, a mixture of carbolic acid, glycerin, and water was carefully applied to the entire canal for the purpose of neutralizing any septic material which might exist there. A small V-shaped piece was removed from each side of the cervix at the os externum, and four very superficial incis- ions were made at the os internum. The uterine dilator was then introduced, and the os internum and externum dilated until a No. 9 sound could be easily introduced. The patient was kept quiet in bed for several days, and as there was no constitutional or local disturbance at the end of that time she was allowed to get up and go about again. From this time onward for about three months the uterine sound was passed once a week to prevent contraction of the cervical canal. At the same time the secretion was carefully removed from the ca- nal, and carbolic acid and tincture of iodine—one part of the former to two of the latter—were thoroughly applied. A vaginal injection was ordered of one quart of warm water and forty grains of sulphate of zinc, to be used once a day. The effect of this treatment was to relieve the dysmenorrhoea, backache, and general feeling of discom- fort in the pelvis. The leucorrhoeal discharge became more free, somewhat lighter in color, and less tenacious. The application of iodine and carbolic acid was continued for two months longer, when all treatment was sus- pended for three months. At the end of that time she returned, and stated that her leucorrhoea remained the same, although other- wise she felt tolerably well. In passing the sound the canal of the cervix was found to be ample, but the character of the secretion had returned to what it was when she first came under my observation. I made applications of the tincture of iodine to the cervical canal for about two months, without apparently improving the condition; I then tried a 10-per-cent solution of chloride of zinc, applying it once a week, but without improving the case. I then decided to remove a longitudinal strip from each side of the mucous membrane of the cervical canal; this was accomplished by seizing the cervix with a tenaculum, and then passing a small-sized Sims's curette Fig. 101.—Sims's curette. (Fig. 101) up to the internal os, and under strong pressure draw- ing it down and cutting out a deep strip of the mucous membrane. INFLAMMATORY AFFECTIONS OF THE UTERUS. 199 This was repeated on the opposite side. The idea of removing the two sections rather than removing the entire membrane, as recom- mended by Sims, Thomas, and others, was to leave a portion of the membrane, which would expand as healing took place, and in that way compensate for the loss of tissue, and thereby prevent the oc- currence of stricture of the canal by contraction. During the heal- ing process the uterine sound was cautiously passed about every third day. This at first caused some haemorrhage and pain, but soon it could be done without trouble of either kind resulting from it. The applications of iodine were again begun and continued for about two months, six applications in all being made. The final effect of this was to control the leucorrhoea, and the little discharge that remained became more transparent and less tenacious—more like the normal secretion of the Nabothian glands. She was then dis- missed apparently well, and she remained so, but continued to be sterile. I have treated a large number of cases of this class in the same way, except that I have not lost time in trying different applications, but have removed the sections of the mucous membrane at the out- set. Two of my patients have subsequently borne children ; several of them have had some contraction of the canal, which had to be relieved by dilatation. In quite a number of them the leucorrhoea has returned, and while I have been able to keep them comfortable by occasional treatment, they have never completely recovered. Cervical Endometritis in a Young Girl, with Marked Thickening of the Mucous Membrane of the Cervix, Dilatation of the External Os, and Eversion of the Mucous Membrane.—This girl was rather small, delicate, of marked nervous temperament, and highly cultivated. Her circumstances were such that she had been able to obtain an excellent education and every advantage and accomplishment that she could desire. She was precocious, and began to menstruate when she was eleven and a half years old. She had always suffered slight pain during her menses, and also had leucorrhoea, which was trivial at first. She had suffered much from backache, headache, and general debility, but was able to attend to her education until she was sixteen years old. Her leucorrhoea at that time became quite profuse, and her backache and pelvic tenesmus so severe that she was obliged to give up muscular exercise almost altogether. During this time she had been treated with tonics, and change of air. At the age of eighteen she was placed under the care of a physician in Xew York, who said that she had some falling of the womb, and treated her by tamponing the vagina with cotton, after the method 200 DISEASES OF WOMEN. of Boseman, who, I believe, calls this method of treatment "'collimn- ing the vagina.'' She derived no benefit from this, although it was continued for several months. In fact, she became much worse. She was then placed under my care, when she was nineteen years of age; her general condition at that time was one of marked neurasthenia. Her extremities were cold and clammy, her pulse was feeble and rapid: her pupils were widely dilated, and, while she was naturally of a pleasant and happy disposition, she became apprehensive of trouble, and spent most of her time in thinking and talking about her symptoms. Some times she was dull and sleepy, at other times wakeful and sleepless; her appetite was capricious—at times good, and at other times poor; her bowels were constipated ; she was quite emotional, and easily affected to tears by either pleasant or unpleasant mental impressions. The uterus was found in its normal position, its body normal in size and shape, and not especially tender; the ovaries were tender; the cervix was quite enlarged, and to the touch gave the usual phys- ical signs of a cervix that has sustained a bilateral laceration super- ficially, or sufficient to give rise to ectropion, as it is now called. The vagina and vulva were quite relaxed, due, I presume, to the long-continued use of the tampon ; at least, I know of no other rea- son for this condition, although she was evidently of an amorous disposition, and no doubt suffered from physiological congestion of the sexual organs. I have no reason to believe that she had ever abused herself or been abused, unless this tamponing treatment under the circumstances may be called abuse. The speculum revealed a large cervix, looking quite like that of a woman who had borne children. There was well-marked eversion which brought into view anteriorly and posteriorly about half an inch of the cervical mucous membrane, which was easily recognized as such by its rugous arrangement, and the presence of the Xa- bothian glands, which, though they could not be seen, were proved to be present at that point by the secretion which was freely poured out on the exposed surface. The most careful examination failed to find any injury of the muscular walls of the cervix showing that the case was one of ever- sion of the cervical mucous membrane. This patient entered my private institution, and was treated generally by rest, massage, baths, and careful attention on the part of the nurse, with a view to im- proving her mental condition by diverting her mind from herself, and fully occupying her time with the treatment. The bowels were INFLAMMATORY AFFECTIONS OF THE UTERUS. 201 kept regular with a laxative pill; sleep was secured by a dose of bromide in the afternoon, and another at bed-time when necessary; and one ninetieth of a grain of the hydrobromide of hyoscine was given three times a day, with the effect of improving her nervous system. A vaginal douche was given once a day, consisting of sixty grains of sulphate of zinc to a quart of warm water. This had the effect of overcoming the vaginal relaxation after a time. Three weeks after she came under my care her general health had improved noticeably, and she passed through her menstrual period with less pain. I then removed the everted portion of the mucous membrane, being careful not to make the exsection entirely circumscribe the os externum. On the sides, where the eversion was less marked, portions of the membrane were left untouched. This was done to avoid stricture, which I presumed might occur after healing. The exsection was made with the scissors, and though there was consid- erable hsemorrhage, this was controlled by the application of pledgets of cotton dipped in chloride of iron, and kept in place by tampon- ing. When the tampon was removed the douche of zinc solution was resumed, and once a week thereafter iodine and carbolic acid were applied to the cervical canal. As the healing progressed the external os contracted, and the caliber of the canal diminished ; the leucorrhoeal discharge also subsided, and at the end of three months the local trouble had entirely disappeared, and the cervix looked like a virgin cervix, except that the os was somewhat larger and oblong instead of circular. Her general health greatly improved, and she was soon able to take gymnastic exercise and cold baths, and to walk and ride in the open air. She was dismissed quite well, and has remained so. CHAPTER X. CORPOREAL ENDOMETRITIS. The most conflicting views are to be found in the literature of medicine regarding the relative frequency of corporeal and cervical endometritis. Much of this division of opinion comes, no doubt, from imperfect knowledge regarding the diagnosis of corporeal endo- metritis. The facts appear to be as follows: That corporeal endometritis is not so often seen as cervical; that either may occur alone ; that they may occur together; and that corporeal endometritis alone is most rare of all. These facts have been obtained from long-continued observation in a very large field, and I feel confident of accuracy in the facts, because I have given due attention to the means and methods of diagnosis—the only way to arrive at correct conclusions. There is another cause of confusion on this subject growing out of imperfect methods of investigation, and that is, classing under the head of metritis some widely-differing pathological conditions, such, for example, as the changes in the tissues following the acute puer- peral affections of the uterus. It will be seen by what follows that, although the diagnosis of metritis is difficult, careful attention to that part of the subject will secure a degree of accuracy which has not been heretofore generally attained. Pathology.—The pathology of corporeal endometritis is doubt- less the same in character as that of cervical endometritis, but un- fortunately there are not the same opportunities of observing the changes which take place in the mucous membrane as in the cervical form. On this account post-mortem examinations are the chief sources of knowledge of the pathology, and as this disease is never fatal an opportunity of examining the uterus only occurs when pa- tients with endometritis die of some other affection, hence the inex- act knowledge on this subject. CORPOREAL ENDOMETRITIS. 203 There is also a marked liability to error in post-mortem investi- gations of the endometrium. In constitutional diseases, which prove fatal, there are certain changes in the mucous membrane of the ute- rus which resemble those of endometritis, yet they are not exactly the same, and do not represent the anatomical lesions of uncompli- cated endometritis, and should not be taken for such. The facts regarding the pathology of corporeal endometritis which appear quite definitely settled are as follows: In some cases there is a general congestion and thickening of the entire membrane, the lesions of vascularity extending to the glands of the uterus. This gives rise to increased nutritive activity on the part of these glands, and hypersecretion. I am not at all satisfied, however, that the dis- charge from these glands is exactly the same as it is from the cervix. I am inclined to think that it is more serous, less tenacious, and more frequently contains blood than that fiom the cervical glands. The whole mucous membrane may be denuded of its epithelium, or it may be so only in parts; and, again, the congestion appears to be greater in spots, and in these places there is thickening of the mem- brane. These thickened red patches are generally found at the mouths of the glands. Not infrequently there are proliferations of the mucous membranes, polypoid in character—a condition which is sometimes called " endometritis polyposa." This new product is one of the most common results of endometritis of long standing. Sometimes the walls of the uterus are found thickened so that the whole uterus, as well as its cavity, is enlarged. In other cases the walls of the uterus have been found diminished in thickness, and changed in structure by fatty degeneration. These changes in the walls of the uterus may or may not be due to the endo- metritis. Corporeal endometritis belongs to that class of inflammations in which the process does not pass through its various stages, and then end in recovery, with or without permanent changes of structure. In this it differs from acute inflammations, which begin and run through all their stages, and end in recovery. If once well established, the inflammation shows very little tend- ency to recover without treatment; hence it is that the cases are often found that begin in early life, and continue up to the meno- pause. There is very little tendency in the natural history of these affections to become worse or change their character; they often re- main the same, excepting that the constitutional disturbance may increase, and the patient fail in general health. Symptomatology.—Owing to the fact that the diagnosis of cor- 204 DISEASES OF WOMEN. poreal endometritis is difficult, it is very necessary to give close atten- tion to the evidence presented. The symptoms of this affection are well marked, and, although not diagnostic, they are of great value when taken in connection with the physical signs. They naturally arrange themselves into two classes—constitutional and local. The constitutional symptoms are manifested by the nervous sys- tem and digestive organs. There is frequently capricious appetite, flatulence, and constipation. The derangement of the stomach is irregular, often varying in a day, showing that it is a reflex nervous disturbance, not unlike that which occurs in gestation. The mam- mary glands are often sympathetically affected, becoming enlarged and tender, and the areola takes on a darker color. These symp- toms, taken in the aggregate, resemble very closely those found in spurious pregnancy, excepting that the mental obliquity is absent. It will be seen that the symptoms, including the derangement of the digestive organs, are all such as might be expected from reflex nerv- ous derangement, and such, no doubt, is their explanation. I am aware that the symptoms here given have all been said to occur in cervical endometritis, but, while there may be some slight constitutional disturbance from this affection, it is never so well de- fined as in corporeal endometritis. Symptoms referable to the general nervous system, which occur in this affection, are not diagnostic, yet they are valuable when taken in connection with the rest of the history. Headache, sleeplessness, mental depression, and pains in the spi- nal cord, are often present, but I know of no special nerve symptoms peculiar to corporeal endometritis. Among the local symptoms the most important, by far, is derangement of the menstrual function. This I consider the symptom by which the differential diagnosis be- tween cervical and corporeal endometritis can be made, and therefore it should be borne in mind at all times. One would naturally expect that in inflammation of the corporeal endometrium the function of the membrane would certainly be de- ranged, and such is the fact. The catamenial discharge may be pro- fuse, scanty, irregular, and attended with pain, or the function may be suppressed altogether; the rule is, however, that profuse, pro- longed, and painful menstruation is present. When either of these menstrual derangements occurs, and there is no constitutional or other local cause to account for it, we may reasonably infer that the mu- cous membrane of the uterus is at fault. It may appear strange that opposite conditions, like menorrhagia CORPOREAL ENDOMETRITIS, 205 and amenorrhea, should occur in the same affection ; but this is ac- counted for by the condition of the mucous membrane in the differ- ent stages of the disease. The same peculiarities of behavior are noticed in inflammation of other mucous membranes; for example, in bronchitis the membrane at first may be unduly dry, and at an- other stage of the disease there may be a profuse secretion. In ad- dition to these changes, in the menstrual function there usually is marked backache, not different in character, but being more severe than in cervical affections. There is also more pain in the uterus, pelvic tenesmus, vesical and rectal irritation. Leucorrhoea is a marked symptom also. The character of the discharge, as already noticed, is more serous, less tenacious, and more frequently contains a few blood- and pus-corpuscles. When cervical and corporeal endo- metritis occur together, the discharge shows the characteristics of both affections. Physical Signs.—The physical signs of endometritis are the same in character as those indicative of inflammation elsewhere. There is tenderness detected by the bimanual touch, which usually shows that the body of the organ is sensitive. After thoroughly cleansing the vagina with a douche, a small tampon of cotton should be placed against the cervix and allowed to remain for two or three hours. If pus is found on the cotton, it is a valuable sign of cor- poreal endometritis. By the use of the sound, four indications of the disease can be obtained. First, the abnormal tenderness; second, the enlargement of the uterine cavity, as detected by actual meas- urement ; third, dilatation of the os externum; and, finally, the great vascularity of the membrane, as shown by bleeding on touch. In using the sound for diagnostic purposes in corporeal endome- tritis, much skill and practice are necessary in order to make the ex- amination with advantage to the diagnostician and safety to the patient. Moreover, care should be taken to make a disinfectant ap- plication before using the sound, and to be sure that the sound itself is thoroughly aseptic. Many of the difficulties following the use of the sound, related in the books, I believe to be due to lack of care and attention to these points, thus permitting the carrying of septic material into the uterus. The density of the uterine tissues is a valuable sign in determin- ing the existence of endometritis. As a rule, the body of the uterus is less dense than normal, excepting in cases of long standing, in which there is sometimes induration or hardening of the uterus. Prognosis.—Corporeal endometritis is more difficult to manage 206 DISEASES CF WOMEN. than cervical, and hence this has led many of the writers in the past to state that the affection is incurable in many cases. At the present time I believe that a more favorable view of the matter may be taken. The disease in itself is not dangerous to life, and, when uncompli- cated, will usually yield to appropriate treatment. There is a decided tendency in many cases for it to return, but even then it can be re- lieved by removing the cause. The most obstinate cases, and also those that are neglected, recover at the menopause. The affection is not in itself self-limited, but is limited by the period of functional activity of the uterus. There is a prevailing opinion that endometritis, when it continues up to the menopause, complicates " the change of life," and favors the development of malignant disease. The former opinion is true, the latter doubtful. The results vary with the different kinds of treatment used. I have never seen a case cured by certain methods, wdiich have been commended to the exclusion of all others; for example, hot-water douching, and the application of the tincture of iodine to the vagina. Neither does endometritis yield to treatment so long as there is a displacement of the uterus, or a laceration of the cervix; but, when all the conditions necessary to recovery are secured, then endometritis will yield to local treatment in the vast majority of cases. Causation.—The causes of corporeal endometritis have been re- ferred to in discussing cervical endometritis; hence, to save repe- tition, it will suffice to say that there are certain conditions of the general system which predispose to the affection. The strumous diathesis, imperfect general nutrition from either gross living and sedentary habits, or exhaustion from overtaxation, are the chief pre disposing conditions. The direct or exciting causes are complicated labors, miscarriages, derangement of menstruation, and sepsis. The vast majority of cases of corporeal endometritis, which have come under my observation, were clearly due to the causes given above. In fact, if those caused by gonorrhoea are excluded, nearly all the others can be ascribed to lesions of parturition and derange- ment of menstruation, which arrest the post-partum and post-men- strual involution. Treatment.—The constitutional treatment of inflammatory dis- eases of the uterus was briefly referred to while discussing the treat- ment of cervical endometritis, so that it is only necessary to repeat the general statement, that every means should be employed to re- store the general health. The treatment must, as a matter of course. CORPOREAL ENDOMETRITIS. 207 be adapted to the nature and degree of the impaired state of the general organization in the given case. The local treatment, such as the hot-water douche, already de- scribed, applies in part to cervical endometritis, and therefore need not be repeated here. It will suffice to give directions regarding topical applications to the corporeal mucous membrane. I will first consider the indications for intra-uterine medication, the remedies to be used, and the means of employing them. This question is still with many an unsettled one, both as regards the curability of corporeal endometritis, and the value and safety of intra-uterine medication. The literature on the subject of intra- uterine treatment is not very definite, hence I shall confine myself to a few points, which I regard as fairly well established, and likely to be of service in the treatment of this disease. The important questions which come up for consideration on this subject are, first, is it safe and advantageous to make intra-uterine applications ? Second, if so, what curative agents shall be employed; and, third, how shall they be applied \ Turning to the text-books or the current literature on the sub- ject in search of an answer to the first question, I find the greatest diversity of opinions. The pioneer gynecologists of Europe, such as M. Gendrin, M. Jobert de Lamballe, Bennet, and Simpson, rarely, if ever, made ap- plications beyond the os internum, believing that endometritis could be cured by treating the cervix and the cervical canal. On the other hand, we find that Aran, Scanzoni, and Gantillon, and Dr. Henry Miller (who, by the way, was the first to employ intra-uterine medi- cation in this country), Kammerer, Xott, Peaslee, and many others, relied to a very great extent on intra-uterine applications for the relief of corporeal endometritis. Many more names might be mentioned to show the want of har- mony among physicians on this point, but no useful knowledge would be gained thereby. All that can be learned from a review of the literature is that intra-uterine medication is more extensively employed now than formerly. Believing that time tends to drift the profession to the side of correct therapeutics, it may be inferred that local applications to a part or to the whole of the lining mem- brane of the uterine cavity are sometimes necessary, if not indispen- sable, in treating endometritis. In seeking an answer to the second question, one encounters a variety of medicinal agents, ranging from the actual cautery to the blandest anodynes. 208 DISEASES OF WOMEN. Bearing in mind, however, the second object to be gained, name- ly, to restore the organ to health, and leave it uninjured, it is evident that all destructive agents should be avoided. This has already been stated in discussing the treatment of cer- vical endometritis, and all that was then said applies with greater force in regard to corporeal endometritis, because that portion of the mucous membrane is more delicate in structure. In my own practice I employ either bichloride of mercury, one grain to an ounce of water; tincture of iodine; tincture of iodine, two parts, and carbolic acid, one part; or suppositories of iodoform and cocoa-butter. There is so much risk in treating the mucous membrane of the cavity of the body of the uterus that there are certain precautions which should be kept in mind. These may be formulated as fol- lows : That intra-uterine applications, excepting to the cervical canal, should not be used until other means have been thoroughly tried and have failed. The uterus should be in or near its normal posi- tion. The cervix uteri should be sufficiently dilated to allow any excess of the fluid to escape from the cavity of the body. After having carefully freed the cervical canal from the secretion, the easiest and most effectual way of making applications is to use the glass pipette, already described. The solution to be employed is drawn up into the glass tube by the rubber bulb; the instrument is then passed up to the os inter- num or to the fundus uteri, if desired, and, as it is withdrawn, press- ure is to be made upon the bulb which forces out the solution and brings it in contact with the entire lining of the canal. The method generally in use of dipping a probe wrapped with cotton into the solution, and passing that up into the canal, is very unsatisfactory. The cotton on the probe injures the mucous mem- brane, and the solution is deposited about the os externum—very little, if any, getting into the canal. The injections by means of a syringe and a reflux catheter, com- mended by many, I have tried, but I have abandoned the method because it is dangerous and unnecessary. It is well to use some bland fluid, such as warm water and salt, to test the toleration of the uterus before using the more potential agents. A small quantity of the agent used is all that is necessary. Six to ten drops is sufficient to cover the surface to be treated, and more than that is useless. When from long-continued congestion the mucous membrane of the cavity of the uterus has become hypertrophied, giving rise to CORPOREAL ENDOMETRITIS. 209 that condition now known as endometritis polyposa, the use of the curette gives the most prompt relief. The blunt instrument should always be used, because it is perfectly effective and free from dan- ger. Dilatation of the cervix with tents, as a preliminary to the use of the curette, should be avoided. No such dilatation is needed, as a rule. When the mucous membrane is hypertrophied, the canal of the cervix is usually sufficiently dilated to admit a curette large enough to do the work. Method of Curetting.—The pathological conditions which demand the use of the curette have already been referred to. The instru- ment which I use has also been described, and the advantages which I consider that it possesses have been clearly pointed out. There is still something to be said regarding the method of using it. Dilata- tion of the cervical canal sufficient to admit the curette is necessary. In many cases the dilatation which accompanies the disease is suffi- cient. When more is necessary, it should be made rapidly, under the local anaesthesia of cocaine, with Goodell's dilator. In case it is necessary to give a general ansesthetic, the cocaine is not called for. This method of immediate dilatation is greatly in ad- vance of the old way of dilating by sponge or sea-tangle tents, which always caused great pain, and sometimes inflammation and septic infection. The patient is placed in Sims's position and the cervix caught and held with a tenaculum. The curette is then curved so that it will pass into the uterus and to one side, and, while the to-and-fro motion is being made, the instrument is also moved slowly toward the op- posite side. I find that, with my curette, fungosities or decidua can be pushed off or detached with the upward as well as with the downward or scraping motion. When the anterior wall has been thoroughly treated, the instrument is withdrawn into the cervix, bent a little in the opposite direction, and turned around so that it will face the posterior wall, which is then treated in the same man- ner as was the anterior. From a large experience I have come to look upon this operation as one of the safest in gynsecology, and very satisfactory in its results. Of course, the usual surgical cleanliness should be observed, and, if there is decomposing matter in the uterus, the cavity should be washed out with an antiseptic solution. ILLUSTRATIVE CASES. The first case to which I shall refer was a patient thirty-two years of age, who had been married ten years, and had given birth to two children. She made a good recovery from her last confine- 15 210 DISEASES OF WOMEN. ment, and nursed her child for about six months. Her health then began to fail, and the child was weaned. Two months after this the menses returned, and at the time were quite scanty and only lasted for a day or two. After this she suf- fered from backache, pelvic tenesmus, and irritable bladder, with free leucorrhoea, at first like an ordinary cervical secretion in char- acter. Her general condition also became largely disordered. The appetite was capricious ; the bowels constipated, and distended from flatulence. She also had occasional attacks of nausea, and at times headache; she became quite nervous, and her sleep was broken. Her menstruation became irregular, generally coming on at the end of two or three weeks and continuing longer than normal, and was too free. A\Then first examined I found the uterus abnormally large, the increase in size being mostly of the body and fundus. Bimanual pressure being made upon the body of the uterus gave rise to a dull pain. A speculum examination revealed considerable redness around the os externum. The discharge, as seen coming from the canal, was dark in color, as if stained and streaked with blood; around this tenacious material there was a little sero-purulent discharge noticeable. The sound entered two and a half inches, and could be moved about considerably in the cavity of the body, showing that the cavity was enlarged. Gently touching the fundus and sides of the uterus with the sound gave rise to pain, and the patient com- plained of a little nausea and faintness. From the general history and the physical signs the diagnosis of inflammation, involving the entire mucous membrane of the uterus, was made. The subsequent history fully corroborated the diagnosis in every respect. At this time the patient's tongue was coated, her appetite poor, and she was constipated. A dose of blue mass with a grain of ipecac was given at night, followed by a Seidlitz powder in the morning; and after this a bitter tonic of Colombo and wine of ipecac before meals. A teaspoonful of Parish's compound syrup of phosphates, well diluted, was given after meals. The constitutional treatment consisted simply of iron tonics, a lax- ative pill, plenty of nourishing food, and a very little exercise. Once a week I removed the secretion from the cervix, then applied carbolic acid and iodine, and ordered a hot-water douche night and morning. The local application caused pain for several hours, and did not ap- pear to do any good. At the end of the week I passed a medium-sized curette into the uterus, and gently curetted the entire mucous mem- brane of the body; this brought away considerable serum and blood, some of which, from its dark color, had evidently been retained for CORPOREAL ENDOMETRITIS. 211 a considerable time. There was also muco-purulent material which came away at the same time, but this may have come from the cer- vix. On carefully examining all that was removed from the uterus, several little masses of fungous material, about the size of the head of a large pin, were found, and several shreds that looked like por- tions of the epithelial layer of a thickened and softened membrane. The curetting seemed to be a failure, so far as obtaining any large-sized fungosities which I had been led to suspect existed from the frequent and profuse menstruation. Considerable pain was caused by the use of the curette, and it lasted for several hours, but finally passed away. The patient also complained of being faint and having nausea, and, as she appeared pale after the operation, I have no doubt that her suffering was very great, though she was a brave lady, and did not complain without cause. There was considerable oozing of bloody serum from the uterus for two days after the cu- retting. About five days afterward an examination revealed a copi- ous discharge of cervical secretion, which was rather dark in color and slightly yellow, as if it contained pus. Yery small clots of blood were also found entangled in it. The cervix was then freed from the secretion, and iodine and carbolic acid again applied. The next menstrual flow came on at the proper time and was quite free, but it did not last quite as long as usual. Two days after the flow had subsided I again used the curette, with the result of bringing away some blood and muco-serous material, but no shreds of mem- brane nor fungosities. The patient suffered much less this time from the treatment. From this onward, once a week, a pencil made of cocoa-butter, and as much iodoform as the butter would take up (about four grains in all), was passed up into the cavity of the uterus as near to the fundus as possible; carbolic acid and iodine were ap- plied to the cervical canal. This treatment seeming effectual, and the patient improving, it. was repeated once a week for about two months; during this time the uterus diminished in size, the discharge also became less, and changed to the character of that usually found in cervical endometritis. The menstruation then became regular as to time and less profuse, and did not last longer than the usual time. The intra-uterine applications were then suspended, except the appli- cation of iodine and carbolic acid, which was continued once a week to the cervical canal for about two months longer. She had then improved so much in her general condition, and the uterus appear- ing to be normal, except that she still had slight cervical leucorrhrea, I unwisely told her that she was quite well, and she did not return for any after-treatment for six months. Her leucorrhoea at this time 212 DISEASES OF WOMEN. became again rather troublesome, and she came back for further care. I then found that her general condition was entirely satis- factory ; her menstrual flow was regular and normal; the internal os had contracted to its natural size; the uterus measured three inches only in its longest diameter, and all that remained of the former trouble was a hypersemic state of the cervical mucous membrane, with leucorrhoea; this was treated for about six weeks with one part of carbolic acid to three of iodine, and then she was dismissed per- fectly well. I have been informed that she has given birth to a child since she was under my care. Chronic Corporeal Endometritis.—The patient was twenty-nine years old, and had one child when twenty-three, and a miscarriage when twenty-five years of age. Up to the time of her miscarriage her health had been very good, but from this time she began to suffer. The menses, formerly normal, began to be too free, and were attended with pain. In fact, from the time of the miscarriage she had menorrhagia and dysmenorrhcea, and both became more marked as time went on. The pain in the uterus at the time of the menses was not acute, but was continuous and aching. It began a day or two before the flow and continued until the flow ceased, and some- times for several days after. There was some irregularity about the recurrence and quantity of the menses, and she observed that when the flow was very free the pain was not so severe. At some of the menstrual periods the How would begin and go on for a day and then stop for hours, and then come on again quite freely. When these interruptions took place there usually were clots passed, which evidently came from the uterus, because they were expelled after pains which differed from the usual pain in being more acute and intermittent. The menorrhagia and dysmenorrhcea became gradually worse, the pain being greater when the flow was less. She became much exhausted at each period, either from pain, loss of blood, or both. Throughout the whole course of the affection she had a discharge from the uterus which was sero-purulent. At times, especially before the menstrual period, there was a cer- vical leucorrhoea, but the discharge from the body of the uterus was most marked and continuous. It was more yellowish in color, less tenacious than cervical leucorrhoea usually is, and oftentimes it was tinged with blood and quite offensive in odor. There was much backache, pain in the pelvis, and wandering CORPOREAL ENDOMETRITIS. 213 pains in the abdomen. The appetite was capricious; at times fairly good, and at other times very poor. She often had nausea, which lasted for a short time. The bowels were constipated, and she was greatly tormented with flatulence. Her ultimate nutrition was poor; she had lost flesh, and on her face there were many large blotches. The nervous system was very considerably disturbed. Originally of a cheerful disposition, she became irritable and emotional. Sleep was often broken at night, and she had unpleasant dreams. During the day, especially after eating, she became drowsy, but seldom could sleep, if she tried to do so. In other words, she was anaemic and neurasthenic. She suffered at times from a spasmodic cough, due evidently to deranged innervation. There was no organic disease of the lungs or bronchi. The general treatment was tonic and sedative. Mild lax- atives were also given. Locally, the hot-water douche was used, and equal parts of iodine and carbolic acid were applied to the cervix. This did not give any relief to the local symptoms, and her general condition improved very little. The menstrual flow was as free and painful as before. The curette was used, and some fungous material removed; after this she felt better, and the menstrual flow was more natural. Sub- sequently she neglected her treatment, and in a few months all the old symptoms returned. The curette was used again, and a larger quantity of fungous material removed ; after this, one part carbolic acid and two of tinct- ure of iodine were applied to the whole cavity of the uterus, once a week—three such applications being made during the inter-menstrual periods. The applications caused pain, which compelled her to rest in bed during the day on which they were made. The constitutional treat- ment was kept up, and the local applications were continued for a period of three months. After this an application was made after each menstruation for three months. In all, her treatment extended over a period of several months. She was then quite well in general health, and her menstruation was regular and normal. It is now eight years since she recovered her health, and she is quite well. CHAPTER XL SUBINVOLUTION. Subinvolution of the Uterus after Parturition. — The great in- crease in the size of the uterus during gestation, and its rapid reduc- tion after delivery, are among the most remarkable phenomena in the animal economy. The uterus during nine months increases from about two ounces to two pounds in weight during the evolution of gestation, and it is reduced by involution in the short space of two or three weeks. This process of involution (by which the uterus is reduced to its original size) is a transformation and absorption of the tissues. The structural" elements of the uterus, which are no longer needed, un- dergo fatty degeneration and absorption, and are in that way dis- posed of. The time required for this involution to take place, and the causes which may interrupt it, have been clearly pointed out by Dr. Alexander Sinclair, of Boston, in vol. iv of the " Transactions of the American Gynecological Society," 1879. Dr. Sinclair gives the re- sults of careful measurements of the uterus in one hundred and eight cases. These measurements were made from twelve to thirty-six days after delivery, the average being sixteen days. In the great majority of these cases the uterus had been reduced to its normal size at the end of three weeks. In one the uterus measured two and one half inches on the twelfth day. This shows the wonderful ra- pidity with which this involution goes on. In all the cases in which the involution was retarded, there were present certain morbid states, such as laceration of the perinseum or cervix uteri, metritis, or septicsemia. These observations of Dr. Sinclair's are of the highest value in showing the time required for the process of involution, and also the conditions which interrupt, retard, or arrest it. Pathology.—In uncomplicated cases there are no inflammatory SUBINVOLUTION. 215 products, nor are there any new tissue formations. The structures of the uterus are the same as in the normal state, but developed by gestation. In Dr. Snow Beck's case the microscopical appearances were like those found in the middle period of utero-gestation. In other cases evidences of fatty degeneration have been observed in the muscular tissues. AVhen the involution has been arrested by puerperal metritis, the products of the inflammation are found. According to Dr. JNIoeg- gerath, these products are inflammatory exudations and hyperplasia of the cells of the areolar tissue. Stjnijitomatology.—I have never observed any symptoms which were specially characteristic of imperfect involution. The history of the delivery and subsequent progress usually presents some fact which would suggest possible subinvolution. There are usually present leucorrhoea and backache, and pelvic tenesmus upon standing or walking, but all these symptoms occur in other affections. Physical Signs.—Digital examination shows that the uterus is enlarged and softer than normal. Very often it is low down in the pelvis. The vagina also is found to be enlarged and relaxed. The rule is that if involution is arrested in the uterus it is also arrested in the vagina- and in the uterine ligaments. There are many ex- ceptions to this rule, however; as, for example, a laceration of the cervix uteri and perinseum will arrest involution of the cervix and vagina, while the body of the uterus may return through involution to its normal size. This can be made out easily by the touch in most cases. The sound, used through the speculum, shows the exact size of the uterus, and when that abnormal size occurs after confinement, and is not otherwise accounted for, it is a reliable sign of subinvolution. The cervix and vagina are usually of a deep, bluish-red color, and there is dilatation of the cervical canal, and usually some eversion of the lips of the os externum. Prognosis.—Recovery may be expected under proper care if treatment is begun early and can be fully carried out, and there are no complications which can not be removed. In case that the tissues are damaged by metritis the case may go on to sclerosis, and become incurable. AVhen the subinvolution is due to injuries of the cervix, the restoration of the injured parts is usually followed by a comple- tion of the involution. Causation.—Injuries, such as laceration of the cervix and peri- nseum, and septic infection causing either cellulitis, lymphangitis, or 216 DISEASES OF WOMEN. metritis, are the chief causes. Getting up too early after confine- ment, and engaging in hard work in the erect position, are also liable to arrest this process. All the cases that I have seen were traced to some of the above-named causes. Treatment.—The management of subinvolution usually falls to the obstetrician in case he is on the watch for it. When not com- plicated with any well-defined puerperal affection it is apt to pass for a time unnoticed, because it does not give rise to suffering until the patient is about her duties again. When the patient begins to go about after her confinement, and there is pelvic tenesmus, backache, and leucorrhoea, imperfect invo- lution should be suspected; and, if the physical signs confirm the diagnosis, the patient should be put back to bed, and kept there for a time. If the recumbent posture is not sufficient to restore the uterus to its normal position, artificial support should be used, either by pessary or tampon. The hot-water douche should be employed, and if there is imperfect involution of the vagina and pelvic floor, tannin or sulphate of zinc may be occasionally added to the douche. In the past, antiphlogistic measures were employed as the chief treatment. Leeches were applied to the cervix, and puncturing and scarifying were employed to abstract blood from the uterus. This depletion is doubtless beneficial when there is well-marked engorge- ment, and the general state of the patient is good—not ansemic, as is generally the case with these patients. Local bloodletting should not be employed unless there is extreme congestion, neither should it be repeated more than once or twice. A certain degree of hypersemia is necessary to the process of involu- tion, and ansemia will arrest the process. Depletion is only admissi- ble in morbid hyperaemia. That it is useful in such cases is beyond doubt. The value of depletion is seen in those who resume the func- tion of menstruation soon after delivery. A profuse menstruation is generally followed by improvement. I have generally relied upon less depressing measures. While taking care of the general health, I have advised rest, the hot douche, and tincture of iodine applied to the cervix, cervical canal, and upper portion of the vagina. When these have failed, I have used elec- tricity in the same way as in the treatment of uterine fibroids, but not with so strong a current. This agent is one of the most valuable that we have. Massage of the uterus will also be found useful. In cases of long standing there is usually some injury of the cer- vix uteri or the pelvic floor; when such is the case, the lacerations must be repaired before involution will be completed. SUBINVOLUTION. 217 It is almost needless to add that all complicating conditions, such as endometritis, should have due attention. Superinvolution of the Uterus after Parturition.—This affection was first described by Sir .Tames Y. Simpson, and illustrated with cases which occurred in his practice. I presume it must be a very rare condition. I have not seen a case about the diagnosis of which I felt sure. Premature atrophy of the uterus I have seen, due to destructive disease of the ovaries, re- moval of the ovaries, and certain peculiar states in which the meno- pause occurred prematurely, but a case not so accounted for has not occurred in my practice. I saw a patient once in consultation, six months after her confinement, who suffered from pain in the abdo- men, which was due apparently to adhesions from an old peritonitis. The uterus was very small for one who had borne children, in fact it was below the size of a virgin uterus. The menses had been scanty. I made a diagnosis of superinvolution, and gave the attending phy- sician a brief clinical lecture on the subject. He examined the uterus afterward, and confirmed my statement regarding the size of it. While I felt sure that the pain present, and for which I was con- sulted, was in no way connected with the small uterus, I took occasion to say that the patient would remain sterile; and I also predicted an early menopause. To my surprise she gave birth to a healthy child, of full size, about one year after I had made the diagnosis. Perhaps superinvolution, to a certain extent, may not necessarily cause sterility, and my diagnosis may in this case have been correct, but I do not believe so. Owing to my lack of personal knowledge on this subject, I will here give in full the case reported by Sir James Y. Simpson, in his work on "Diseases of Women" : " The subject of this rare pathological affection began to men- • struate at the age of thirteen, and the catamenia recurred regularly every four weeks till she became pregnant when eighteen years old. Utero-gestation went on without any unusual phenomena to the full term; and her parturition was natural but tedious, a male child being born after a labor of seventeen hours. Nothing unusual occurred during her puerperal convalescence and lactation. But subsequent to delivery she never menstruated. She was, however, subject to frequent attacks of diarrhoea, which she herself believed to be gener- ally most severe at recurring monthly intervals; and the dejections were then sometimes tinged with blood. '' Two years after accouchement she became a patient in the fe- male ward of the Royal Infirmary, complaining of the state of amenor- 218 DISEASES OF WOMEN". rhoea, with attendant broken health. She suffered from pain in the back and hypogastrium, with a sensation of weight and pressure in the pelvic region ; dysuria ; a furred tongue; and a weak compressi- ble pulse, generally beating from 80 to 1>») in the minute. She was thin, feeble, and anaemic in appearance. The mammse were shrunk and flat. For some time before admission she had suffered much from occasional headaches and giddiness; frequent nausea and vom- iting ; palpitation and occasional rigors. " On making a vaginal examination, I found the uterus small and mobile. The cervix uteri was much atrophied, and the vaginal por- tion of it scarcely made any projection into the canal of the vagina. The os uteri was so much contracted as to admit a surgeon's probe with difficulty. It was dilated by a slender bougie being left in for two or three days; and, when the uterine sound was subsequently used, the uterine cavity was found to be only one and a half inch in length, or about an inch less than normal. " A variety of means was employed with the view of benefiting the general health of the patient, and of exciting action in the uterine system, but with little or no effect. " Diarrhoea repeatedly occurred during the three or four week? she remained under my care, requiring the free use of opiates for its restraint; and as the uterine symptoms did not at the time seem to admit of special attention and treatment, the patient was transferred to one of the general wards of the hospital, where she was placed under the care of my colleague, Dr. Bennett. " During the following month the diarrhoea recurred from time to time very severely. At last anasarca in the lower extremities and albuminuria supervened ; ascites followed; and shortly afterward her face and arms became cedematous. About a month after these symp- toms appeared delirium at last came on, the faeces passed involun- tarily, and ultimately she died in a state of prolonged coma. " On post-mortem inspection some crude tubercles were found in both lungs, especially in the left. The liver was enlarged, and showed some fatty transformation. The kidneys presented also some stearoid degeneration, and in the right there was in addition a small tubercu- lar abscess. The large intestines were very much thickened in their parietes, and contracted in their caliber, while their mucous mem- brane was ulcerated in various parts. Along the lower end of the ileum several large ulcerations were seen running circumferentially around the interior of the bowel. One or two ulcerations were also found in the stomach. The uterus was very small, and atrophied in its length and breadth, its size being diminished about a third below SUBINVOLUTION. 219 the natural standard in all its measurements, and its parietes were correspondingly thin and reduced. The whole length of the uterine cavity from the os to the fundus was not more than one inch and a half, while the normal uterus usually measures in this direction two inches and a half. When a section was made of the posterior wall of the organ, the thickness of its parietes at their deepest or most developed point was not above three lines, instead of the normal measurement of five or six lines. The tissue of the uterus appeared dense and fibrous, and the section of it presented the orifices of nu- merous small vessels. The ovaries seemed also much atrophied, and smaller than natural. Their tissue was dense and fibrous, and pre- sented no appearance of Graafian vesicles. There was no inflamma- tory deposit on the peritoneal surface of the uterus or its appendages; but some thick pus, or tubercular matter, existed in the distended cavity of the right Fallopian tube." CHAPTER XII. SCLEROSIS OF THE UTERUS. Fifteen years ago I employed this term to designate an affection of the uterus, which up to that time had been known by a variety of names—such as chronic interstitial metritis, hypertrophy, chronic inflammatory hypertrophy, and areolar hyperplasia. Subsequently Gallard used the same term in the same way. This affection of the uterus is a change of structure produced by a pre-existing inflammation or derangement of nutrition, and may be more properly considered as the product of morbid action, rather than active disease. The term which I have selected, therefore, more clearly indicates the true nature of the affection than the names of the affections or processes which produce it, and by which it has heretofore been designated. Pathology.-.—This comprises certain changes of structure, mostly of the middle coat of the uterus, which, as already stated, have been caused by preceding morbid processes. This change of structure consists in an excess of connective tissue, the result of an areolar hyperplasia. This element in the structure of the uterine walls rapidly increases, encroaching upon the mus- cular element, and more especially upon the blood-vessels in the connective tissue. The result is marked increase in the density of the tissues, and ansemia from pressure upon the vessels. There is frequently an increase in the size of the whole organ, but in some cases the uterus is not enlarged. In fact, the uterus may notably diminish in size, when the hyperplasia is sufficient to cause atrophy of the other tissues of the uterus. The histological composition of the tissues differs in different cases, and in different stages of the development of the affection. In those cases which have their genesis in puerperal metritis there is generally at first, in addition to hyperplasia of connective tissue, a fatty degeneration of the muscular tissue, which has not SCLEROSIS OF THE UTERUS. 221 been disposed of by the process of involution. There are, also, in some cases, some of the products of the inflammation in the form of exudation into the tissues. All these give the uterus its increase in size, which to some extent is permanent, although the organ may diminish very much in time. The hyperplasia of the connective tissue causes atrophy of the other tissues, and to that extent the uterus is reduced in size. When the sclerosis follows non-puerperal metritis the uterus, which dur- ing the stage of inflammatory engorgement was larger than normal, may become reduced to, or even below, its normal size. This is more likely to occur when the hyperplasia is extensive, and involves all the tissues of the uterus and their blood-vessels. Sclerosis may be general or local. When due to puerperal or chronic metritis, or to deranged nutrition from long-continued con- gestion, the whole organ shares in the morbid process. When it is due to some injury and inflammation, or deranged nutrition of the cervix, the body may remain normal. Circumscribed patches of sclerosis in the body or cervix have not been found. Finally, this is a permanent affection. When once the changes of structure have taken place they remain, to a certain extent at least. There is no tendency to complete restoration of the normal tissue. There may be a slight diminution of the size of the uterus. I am inclined to think that even at the menopause, the period at which almost all uterine affections subside, this lingers, and possibly remains always. I have had an opportunity of observing several cases some time after the change of life, and the uterus in all of them was larger than it should be. Dr. Noeggerath claimed that sclerosis, or chronic me- tritis, as he called it, predisposed to cancer of the uterus. This may be so. There is in this affection a change of structure, and, accord- ing to the rule in pathology, a consequent lowering of the vitality of the part, and a predisposition to further degeneration. Symptomatology.—The clinical history of this affection differs in many points from that of other forms of uterine disease, but there are no symptoms that are diagnostic. There is more marked constitutional disturbance in the pro- nounced cases than is found in the average inflammatory affections. This may be due largely to the exhausting effect of the disease which preceded the sclerosis—this being quite sufficient to keep up the general ill-health. There is derangement of menstruation, usually amenorrhoea. In well-marked cases neuralgic pains in the uterus are frequently pres- 222 DISEASES OF WOMEN. ent, which are much worse at the menstrual period. The pain at this time often begins before the flow and continues throughout the whole period, and sometimes a day or so after. In some cases the pain is acute and irregular, in others of a dull, aching character, and in a few both varieties of pain coexist. The form of suffering may be likened to a very great aggravation of all the disagreeable feelings of an ordinary menstruation. The clinical history (so far as symptoms are concerned) in the inter-menstrual period closely resembles that of corporeal endome- tritis. Physical Signs.—These are briefly as follows: Anaemia of the uterus, indicated by the pale appearance of the cervix, as seen through the speculum, and suggested by amenorrhoea; enlargement and in- duration of the uterine walls, as detected by touch and sound; in- creased length of the cavity of the uterus without increase of the lateral and antero-posterior diameters; slight retraction of the lips of the os externum, and the small size of the cervical canal compared with the size of the walls of the cervix. The hardness of the uterus is a most valuable sign, but one that is not easily detected. To the touch, the uterus does not' in all cases appear to be more dense than the virgin uterus, but where it is en- larged it is softer in consistency, except in sclerosis; hence, when there is an increase in size and induration, not due to fibroma, the evidence is in favor of sclerosis. In the great majority of cases the uterus is more tender than in any other affection, except acute metritis, and endometritis with flex- ion. The touch excites this sensitiveness, and the passage of the sound causes marked pain. Prognosis.—Sclerosis being a permanent change of structure, recovery with or without treatment is the exception. By relieving any complication which may be present, such as displacement, the patient may be made sufficiently comfortable to reach the menopause, and then recovery may take place. Sclerosis of the cervix may be relieved to a great extent, some- times completely, by trachelorrhaphy, if the cervix has been lacer- ated. In case the cervix has not been injured its size can be reduced, and the tissues may become softened and the nutrition improved by taking out a V-shaped piece on each side, and bringing the parts to- gether, as in the operation for laceration. Causation.—The causes of this affection, given in the literature of medicine, are che same as those of almost all other inflammatory SCLEROSIS OF THE UTERUS. 223 diseases of the uterus. In the cases which have come under my own observation, they were either acute metritis following child-bearing, or miscarriage or long-continued general endometritis, and injuries to the cervix during labor. This leads me to believe that these are the only causes of this affection. In fact, as sclerosis is the result of a deranged nutrition of an inflammatory nature, it follows that the cause must be a pre- ceding metritis, partial or general. Treatment.—Sclerosis is, of course, a preventable disease in the majority of cases. If the inflammatory affections which lead to it are carefully managed the structural changes will be avoided, except- ing in severe puerperal metritis. When once the changes in the tissues which constitute true scle- rosis have occurred, it is still a question whether any known treat- ment can entirely relieve it. As already stated in the prognosis, benefit may be obtained by removing complications, such as lacera- tion of the cervix. In the hope of causing absorption of the areolar tissue, mercury, iodine, copper, and belladonna have all been em- ployed ; and, it is needless to say, that the hot-water douche has also been frequently tried. Dr. Tsoeggerath, of New York, recommends amputation of the cervix, permitting the stump to heal by granulation instead of cover- ing it over with vaginal mucous membrane. This he deems advisa- ble, not only in the hope of relieving the sclerosis and to counteract the effect of the operation, but also to prevent the development of malignant disease. So far as my own personal observation goes, I am obliged to say that I have not seen much benefit from any such treatment, and have come to look upon the disease as an incurable one. There is one remedy which promises to be useful, and that is electricity; but I have not had experience enough in its use to enable me to speak definitely regarding it. I may say, however, that it promises more than anything else that I am familiar with, but more extensive observation is necessary to determine its true value. history of cases. Sclerosis of the Cervix Uteri.—This case is one of the very few that I have seen of sclerosis of the cervix, not accompanied with laceration. It is possible that the cervix had been lacerated during one of the patient's confinements, and that the wound had healed, but I could not find any trace of such injury. The patient was thirty-one years old, and had borne four chil- 224 DISEASES OF WOMEN. dren ; the last one three years before the time when this history was taken. She did not recover from this confinement as well as she had in previous ones, but I could not get any history of serious puerperal disease at that time. After the confinement her health was poor, and she gave the history of some uterine disease. Her menstruation was normal, but attended with more pelvic pain than formerly. She had suffered from leucorrhoea, but this had gradually diminished. At my first ex- amination I found the body of the uterus normal, but the cervix was much enlarged and hard to the touch; the os was circular and small in proportion to the size of the cervix—it was an inch and three quarters in diameter. To the touch the cervix appeared to be as large as the body of the uterus. There was no other lesion found except that there was prolapsus in a slight degree. She was treated with the hot douche and applications of tincture of iodine, but without effect. I then removed, with the hawkbill scissors, a large V-shaped piece from the lateral walls of the cervix, and closed the wound with sutures, making an operation like that for bilateral lacer- ation. Healing was prompt and complete, and the size of the cer- vix—at least, the vaginal portion of it—was much reduced. She was better for the operation, and at the end of one year I found that the whole cervix was nearly of its normal size, and that the tissues were soft and more vascular. The operation had the effect of changing the nutrition of the parts, and causing absorption of the new tissue. In sclerosed tissue due to laceration of the cervix, 1 have fre- quently seen such favorable changes after operations. illustrative cases. Sclerosis Uteri, following Puerperal Metritis.—This patient was thirty-five years old, had been pregnant five times, and given birth to four living children. While pregnant at the seventh month with her fourth child she received an injury which caused her to give birth to a dead foetus a few days afterward. During her fifth pregnancy she received a shock from seeing a friend in a convulsion ; labor came on immediately, and she was de- livered of a seven months' child. Soon after her confinement she complained of pain and tenderness in the region of the uterus, fol- lowed by fever. These symptoms extended over a period of three weeks, and there can be little doubt, from the history given, that she had acute puerperal metritis, which left her health permanently impaired. Since that time her menses have been irregular, scanty, SCLEROSIS OF THE UTERUS. 225 and attended with pain. At times she has a menstrual molimen, but no catamenial flow. During the last year she has menstruated twice, the last time three months ago. This is the previous history of the case. She now suffers from extreme debility and anaemia, which is shown by her general appearance; she also complains of ill-defined aching pains throughout the pelvis, and in the sacral region ; occa- sionally she has very slight leucorrhoea. Her digestive organs are also very much deranged, and her nervous system, from the joint action of disease and drugs, is a miserable wreck. By physical exploration I find that the uterus is enlarged, being three quarters of an inch longer than normal. The body and cervix are tender to the touch, and the sound carried into the cavity gives extreme pain. The cervix is indurated and smooth, and the os is smaller and more circular than is usually found in those who have borne children. Exploring the cavity with the sound, I find that while the longer diameter is considerably increased the antero-posterior and lateral diameters are shortened. The uterine walls appear to lie in close contiguity, so that it is impossible to turn the sound far in any direc- tion. These signs obtained by the probe are of vast importance, for they indicate clearly that the enlargement of the uterus is due to an actual increase in the walls of the organ, and not a mere expansion of its cavity. In other words, the growth is concentric, not eccentric. The cervix, as seen through the speculum, is notably pale; the os is small, with its lips curved inward. This retraction, or drawing inward of the os, is confirmatory of the opinion that the walls of the cervix are enlarged more than the mucous membrane of the cavity. When the mucous membrane of the cervix is swollen, and the walls remain normal, the lips are enlarged or pouting. Briefly, then, the physical signs indicate that there exists a con- dition of unusual hardness and enlargement of the uterine walls, while the relative size of the cavity is lessened. The uterus is also ansemic, as can be seen from a glance at the cervix. It should be noted that this patient has amenorrhoea—a condition that is much more common in the young than in those who have borne children, and is seldom found in connection with enlargement of the uterus. This form of sclerosis presents many points of resemblance to that of general endometritis, but they are essentially different. Contrasting sclerosis with endometritis gives results as follows: The one begins with acute inflammation of the uterus, the other 10 226 DISEASES OF WOMEN. does not; in the one there is amenorrhoea, in the other menorrhagia; in the one the uterine walls are enlarged and the cavity diminished, while the reverse of this obtains in the other; the uterus in the one is indurated and ansemic, in the other it is relaxed and highly con- gested. These are plain outline distinctions, easily recognized, and characteristic of almost opposite pathological conditions. Treatment and Prognosis of the Case.—After each menstruation an effort was made, either with leeches or puncture, to supplement the flow by depletion. This was not successful. It was difficult to extract blood from the ansemic tissues, and what was accomplished did not even relieve the patient. Blistering the cervix was tried with some apparent benefit; cantharidal collodion was applied, and a tampon used to protect the vagina until vesication should take place. This was repeated several times at intervals of two weeks, and the patient had less pain in the uterus and gained a little, but whether from the blistering or tonics and general supporting treat- ment, could not be stated with certainty. Iodine was next tried; it was applied to the canal and vaginal surface of the cervix thoroughly twice a week, but she did not seem to improve much. About this time some one in England reported good results in obstinate uterine affections from vaginal suppositories containing mercury. I tried these until slight salivation was produced. Some harm, but no benefit was the result. Finally, 1 may state that some relief was obtained, but not much. She profited from constitutional treatment, but not much if any from local medication. Considera- ble relief was obtained by wearing a Peaslee's ring-pessary, which gave a little support to the uterus, but it caused irritation, and had to be removed. When she was greatly fatigued, and suffered more pain than usual, a cotton tampon gave relief also. I lost sight of the patient for a number of years, but recently she returned to the city and called to see me about some trouble of her digestion. She told me then that she never fully recovered until the menopause, which occurred at forty-six. Since that time she had been fairly well. The uterus, though larger than it should have been at her age, was smaller than when under observation, fourteen years before. Sclerosis Uteri, resulting from Endometritis and General Congestion. —The patient was twenty-four years old when first seen. She was highly refined, and of a well-marked nervous temperament. She began to menstruate at the age of fourteen, and had continued so to do regularly, but had always had slight pain at the menstrual periods, SCLEROSIS OF THE UTERUS. 227 and was unusually nervous and irritable at such times. She was married at twenty-two, and soon after began to have backache, leu- corrhoea, and more pain than formerly during menstruation, and the flow was more free. These symptoms gradually increased, and her general health failed considerably. Pain in the uterus and general pelvic tenesmus were added to her other symptoms, and after suffering for two years in this way she came under my care. I then found the uterus larger than it should have been, and its tissues softer than normal, especially those of the cervix. The canal of the cervix was larger than normal, and the whole uterus was tender to the touch. Passing the sound caused severe pain. There was considerable erosion of the cervix, the os externum was di- lated, and the mucous membrane was highly congested. There was a free muco-purulent discharge which irritated the vagina and vulva. The usual local treatment for endometritis was employed, and the ordinary means were used to improve her general health. Appli- cations of nitrate of silver (which I used at that time, according to the advice of my former teachers) caused great pain, and were given up for milder means, such as tincture of iodine, and tannin and glyc- erin. She improved very slowly, and about ten months after she came under my care she went to Europe with her husband, who was called there on business. She remained in England for about five years, and occasionally was treated by a distinguished physician there. Excepting various kinds of vaginal injections she had no local treatment while in England. Her general health improved very much, and she bore her local troubles without complaint. Upon her return to this country, I found that her menstrual flow had diminished until she had less than before her marriage. There was very little leucorrhoea, and less pelvic tenesmus. There was quite as severe dysmenorrhcea, and she had intermittent pain in the uterus of a neuralgic character. The uterus, taken as a whole, was a little smaller, and indurated to the touch; the canal of the cervix and the cavity of the body were decidedly diminished in caliber, and still tender to the touch of the uterine sound. The os externum was contracted, and its lips in place of being everted as formerly were now slightly curved inward. In place of the soft vascular condition of the cervix, present when she was first examined, it was now round, well defined, and rather ansemic in appearance. It was only by referring to my notes of the case, taken at the 22S DISEASES OF WOMEN. first examination, that I could fully reahze the change which had taken place. I treated her for a short time in the hope of relieving her dys- menorrhcea and uterine pains, but without much benefit; and, as she was able to get along by resting at her menstrual period, she was dis- missed with the advice to await the menopause, when in all proba- bility she would be relieved^ CHAPTER XIII. membranous dysmenorrhcea. I should prefer to call this affection membranous menorrhoea, believing that the term would be more appropriate, but as the original name has been longer in use, and is familiar to the profession, I shall not attempt to change it. This is an affection which, although rather rare, commands very urgently the attention of the gynecologist, because of the dreadful suffering which it gives rise to, and the obstinacy with which it has heretofore resisted treatment. There is a marked uniformity about this disease. In its pathology and clinical history it varies but little in different cases. A number of affections resemble it to a limited extent, but it stands out well defined, and is easily detected by the experienced diagnostician. Pathology.—An exfoliation in mass of the mucous membrane of the cavity of the body of the uterus at the menstrual period is the chief lesion in this affection. Microscopically, the mass presents all the histological elements of the true mucous membrane of the uterus, including the utricular glands, unchanged by any new or abnormal elements. When it is expelled entire, it represents a complete cast of the cavity of the utenis, and is triangular, with an irregular open- ing at each of the angles, the one representing the internal os uteri, and the others corresponding to the ostia of the Fallopian tubes. This membrane is rather ragged on the outer surface, but smooth on the inner, and looks exactly as the lining membrane of the uterus does when in position. The size is usually about an inch long and less than that in width, and is generally somewhat larger than the normal proportions of the cavity of the uterus; but this is not always the case. In this respect it is like the decidua of pregnancy; in fact, in general appearance it closely resembles the decidua vera, but there is a decided difference in its microscopic elements, sufficient at least to distinguish. This similarity of the two membranes has led 230 DISEASES OF WOMEN. to their being called the decidua gravida and the decidua menstru- alis, the former being the mucous membrane as seen in abortion at a very early stage of gestation, the other the membrane as thrown off at menstruation in this morbid form. Comparing the changes which the mucous membrane undergoes in membranous dysmenorrhcea with its changes in normal menstru- ation, the difference is as follows: In normal menstruation, if we accept the views of Dr. AVilliams, of London, the whole mucous membrane undergoes fatty degeneration, disintegration, and elimina- tion ; whereas in membranous dysmenorrhcea the mucous membrane becomes separated from the walls of the uterus without being changed or disintegrated; exfoliation and expulsion simply occur. The way in which the separation of the mucous membrane takes place is not positively known. It is presumed, however, that fatty degeneration in the deeper structures of the membrane takes place, and thereby it becomes detached from the uterus. It is possible, also, that the capillary haemorrhage, instead of occurring on the free surface of the membrane, takes place in the deeper structures, and in that way dissects off the membrane. This, however, is hypo- thetical, and needs confirmation. Sometimes the membrane is ex- pelled in shreds, which suggests that the exfoliation either occurs in spots or sections, or else that the membrane is completely sep- arated from the uterus, but becomes broken up either during ex- pulsion or in handling it afterward. It is much more probable that it is completely exfoliated and broken up subsequently than that it is separated in circumscribed patches. All these facts lead to the conclusion that the affection is a perversion of nutrition and func- tion rather than an organic disease, inflammatory or otherwise, which gives rise to this peculiar condition of the mucous membrane at menstruation. It is clearly evident that there is nothing pathologi- cal in the condition of the mucous membrane itself, but that the whole morbid process consists in the separation of the membrane in mass, in place of disintegration, which is the normal character of the mucous membrane in menstruation. There are other views regarding the pathology of this affection: one, that it is the result of gestation, which is arrested at a very early stage, and that the membrane thrown off is really a decidua vera. That this theory is fallacious will be seen when the physical signs of this affection are discussed. The idea that it is an inflammatory affection is not well sustained. No such product or result of inflammation is found elsewhere in the mucous membranes of the body, nor is it necessary that inflammation MEMBRANOUS DYSMENORRHCEA. 231 of any part of the uterus should be present in order to produce membranous dysmenorrhcea. Associated with this membranous dysmenorrhcea we occasionally find inflammatory conditions, but not of the mucous membrane of the cavity of the body. There may be, and often is, a general hy- peraemia of the uterus and vagina, but usually it is not greater than that which is seen in normal menstruation. There is occasionally, in cases of long standing, cervical endome- tritis, but this does not extend to the body of the uterus. In fact, I believe that a well defined endometritis can not occur at the same time as membranous dysmenorrhcea. This affection, then, is cer- tainly sui generis, and is not the result of inflammation in any form or in any stage of the inflammatory process ; neither is it a utero-ges- tation ending in abortion at a very early stage of pregnancy, as some have maintained; neither does the membrane partake of the nature of any of the morbid neoplasms which occur in mucous membranes elsewhere in the body. The mucous membrane in this affection is developed in the nat- ural manner after each menstruation, and the gross appearances and histological composition of this structure show that it is normal, and differs in no way from the mucous membrane of the uterus up to the time when the menstrual flow is about to begin. Perhaps there is, in some cases, an increase in the quantity of the membrane, but only to a very limited extent, if at all. In short, the only pathol- ogy connected with this affection is in the manner in which the membrane is thrown off. Symptomatology.—This affection occurs in single and married women—about as often in one class as the other, perhaps. It also occurs in those who have borne children, but in most of the cases that I have seen in married women the patients have been sterile. The recurrence of the menstruation is generally regular; sometimes it is delayed, and sometimes there is a sense of pelvic discomfort before the menstrual flow, but not always. The chief symptom is the pain which comes on usually during the first day, sometimes later, and increases in severity, and is somewhat intermittent in character until the membrane is expelled, when it rather abruptly subsides. The flow sometimes is scanty previous to the expulsion of the membrane, and after that it is generally quite free ; at times abnor- mally so, and occasionally small clots are passed. Sometimes there is a leucorrhoeal discharge succeeding the men- strual flow, the discharge being occasionally tinged with blood. In ■>:\o DISEASES OF WOMEN. other cases the menstrual flow subsides after the expulsion of the membrane, and no leucorrhoea of any account occurs afterward. There is really nothing in the clinical history of this affection by which it can be positively distinguished from dysmenorrhea due to Fig. 102.—The two sides of a half-membrane from a multipara; from the cavity of the body. The slight puckering present is due to alcohol. other causes. Hence the diagnosis must always depend upon the physical signs. Physical Signs.—In order to make a diagnosis, it is absolutely necessary that the membrane expelled should be preserved and examined. The gross appearances of the speci- men are usually all that is necessary to satisfy the diagnostician regard- ing the nature of the affection, but in cases where there is a doubt the microscope must be called in to aid in the diagnosis. The morbid materials expelled from the uterus which simulate the membrane produced in this affection are the decidua expelled in abortion in the earliest stages of pregnancy; the masses of fibrin which have formed in the uterus in menorrhagia; very dense masses of secre- tion from the cervix; and the membranous-looking shreds expelled from the cervix and vagina after astringent or caustic applications. Fig. 103.—Half a membrane from a virgin; from the body of the uterus only. MEMBRANOUS DYSMENORRHCEA. 233 Fig. 104 a. — Frag- ments of mem- brane in the con- dition in which they are often expelled. The decidua in early abortion is most difficult to distinguish from the menstrual membrane. In the early abortion the mem- brane expelled is usually larger and more ovoid or round, and not so mark- edly triangular as the decidua of menstruation, and is also thicker, and usually is accompanied with villi of the cho- rion. If there is still a doubt, the microscope reveals the fact that the menstrual membrane pos- sesses only small cells, while those of the de- cidua-vera membrane are so great as to be easily distinguished. There is a de- cided microscopic difference in the epi- thelium, the tubes, and the inter-glandular tissue. This difference between the two membranes is not only in the decidua of early abortion, but also in the decidua of extra-uterine pregnancy. In being thus able to distinguish be- tween the decidua of pregnancy and the membrane of menstrua- tion, the only great difficulty in the diagnosis is overcome. Inspection will enable one to dis- tinguish shreds of fibrin, masses of unusually dense secretion of the cer- vix, and shreds from the cervix and the vagina after astringent ap- plications from the menstrual mem- brane. The diagnosis can be made with great certainty. Causation.—Discarding the cur- rent views regarding membranous dysmenorrhcea—that is, that it is due to inflammation, or else the re- sult of gestation—one is left with out any very rational view to offer Fig. 104.—A cast from a virgin, where the cervix is also involved. Figs. 104 b and 104 c.—A cast which might be mistaken for a product of conception: m, shaggy interior; s, film of membrane covering it; c, filaments from cervix. 231 DISEASES OF WOMEN. regarding its causation. While it is not, perhaps, the part of wisdom to discredit the accepted views on any cpiestion in medicine until one has something more reliable to offer, still, if the causes assigned can be readily shown to be incorrect, it is infinitely better and safer to be entirely in ignorance of the causes of things than to attribute them to the wrong causes. Fortunately, however, while I find my- self at variance with most of the recent authorities regarding thy cause of this affection, I am in perfect harmony with the views of Dr. Oldham, who was the first to discover " dysmenorrhcea mem- bran acea." Dr. Oldham distinctly pointed out the characteristics of this affec- tion, and stated that the membrane is formed under abnormal ovarian stimulus; and I am fully satisfied that he was not only the discoverer of the disease, but also conceived the true idea regarding the cause of it—viz., some undue ovarian influence or sexual excitation. In other words, it would appear to be some derangement of innervation and nutrition. Taking this view of the causation, I expect to find myself in har- mony with the neurologists at least. This class of specialists mani- fests a willingness to trace many diseases originally to some derange- ment of the nervous system, when they find anything like good reasons for so doing. Hence, I expect their support in choosing, as 1 do, to believe that the starting-point in the pathology of this affec- tion must be some derangement of innervation produced by disease or functional disturbance of the ovaries. Confirmation of this view regarding the cause of membranous dysmenorrhoea may be found in studying the agencies which give rise to other morbid states of the uterus, like the fibroid growth, for example, which in its anatomical elements does not differ especially from the tissues of the uterus from which it springs; and, if we could find the cause of this devi- ation from healthy nutrition, it might be applicable to the disease under discussion. But, unfortunately, the causes of fibroid tumors given in our literature are unsatisfactory, and by no means well sus- tained. From the fact that uterine fibroids are more common in sterile women than in others, it would appear that sterility predisposes to their development, and perhaps no better explanation of the cause of these growths has ever been given than that of my somewhat hu- morous friend, who said that "the uterus, being prepared for normal work and not finding it to do, took up the development of fibroids as a sort of occupation for its formative powers." May it not, then, be that a well-defined predisposition to reproduction, uncalled for by MEMBRANOUS DYSMENORRHCEA. 235 gestation, excites this morbid action on the part of the uterus which leads to this abnormal exfoliation of its mucous membrane ? This view might at least be entertained, because in other cases, when we are unable to detect the cause of a disease in something that is tan- gible, we usually attribute it to deranged innervation and conse- quent malnutrition. This view of the causation is, to some extent, sustained by the effect of medicines upon the lesions. This affec- tion has always been recognized as one that is often difficult to cure, many times incurable, in the hands of the most competent phy- sicians and surgeons. This possibly may have been due to misap- prehension of the nature and cause of the disease, and hence falla- cious therapeutics, rather than to the incurable character of the disease. In favor of this line of thought I may state that the patients whom I have treated in years past, on the theory that the cause was inflammatory, have derived little benefit, while those who were treated for deranged innervation, malnutrition, and undue ovarian excitation, have made very much better progress. I am inclined to attribute most of the trouble to ovarian influence, the condition of the ovaries being that of an undue nerve excitation and possible congestion. I have been led to this belief by two facts: that the majority of the patients that I have seen have been subjects of a highly nervous organization, and in most of them there has been tenderness of the ovaries, and pain at times, without there being any evidence of ovaritis. The rheumatic diathesis is said to favor this affection, and it is possible that this may be so, although I am unable to recall any of my patients as being rheumatic; neither have I been able to trace it to the tubercular or strumous diathesis, nor to syphilis. It is certain, however, that, if either of these conditions existed, it would have its influence in helping to keep up the uterine trouble, and every effort should therefore be made to relieve it by treatment. Treatment.—The treatment of this affection is necessarily both palliative and curative. While the patient is suffering during the expulsion of the membrane, it is very necessary to relieve the pain as far as possible. This, of course, can be most promptly done by the use of opium, which should be avoided if possible, however, be- cause of its after-effects. Sodium salicylate and antipyrine, five grains each, may be given when the stomach is empty. Chloral hydrate answers fairly well in some cases. I am not sure that it has any advantages over chloroform, camphor, and belladonna, or conium and cannabis Indica; in fact, in the major- 230 DISEASES OF WOMEN. ity of cases one has an opportunity to try several agents, and, of course, the patient will decide which gives most relief. Indications for general treatment are to quiet all nervous disturbance and to improve the general nutrition of the mucous membrane. It su happens that when the first part is attended to the latter will follow in due order. To quiet the nervous irritation and disturbance there is nothing that equals the bromide of sodium. This should be given in twenty- or thirty-grain doses three times a day for ten days or two weeks before the menstrual period. And, if the pain is not severe enough to require the addition of some of the remedies already named to re- lieve it, the bromide may be continued throughout the menstrual period and several days after. From this it would appear that the bromide is to be used continuously; but one or two weeks in each month it can be omitted. When the bromide has been employed for some time, and it seems desirable to give it up, conium may be administered in moderate doses combined with camphor, if the pa- tient is weak. If there is any evidence of the rheumatic diathesis, the bromide of lithium should be given. Next to quieting the nerv- ous system, any debility that may exist should be overcome by nerve tonics. Undue nervous excitation so often goes hand in hand with nervous depression that in many cases it is necessary to combine the tonic and sedative treatment. All the remedies which may be used need not be here mentioned. In regard to the modification of nu- trition, it need only be said that any accompanying derangements of the digestive organs that may be found should receive careful atten- tion ; but this hardly need be mentioned in this connection. My rule of treatment has been, after subduing all nervous dis- turbances, to put the patient upon the iodide of sodium in case she is in fair strength and inclined to flesh. If there is anaemia, I prefer the iodide of iron. If these do not accomplish the object, I employ mercury, giving it in small doses, never continuing it long enough to produce salivation, carefully watching to avoid this. In cases of anaemia, where I have feared the debilitating effect of this alterative, I have given the bichloride of mercury with iron. After keeping them upon this treatment until I could see some evidence of its effects, I have then put them upon iodine and arsenic. In regard to local treatment, I have been entirely guided by the views of the pathology as expressed above, and have therefore em- ployed alteratives and sedatives almost exclusively. Of these I have found iodoform most effectual. I have also used iodine and mer- cury with advantage. In cases where I have found any complications MEMBRANOUS DYSMENORRHCEA. 237 I have carefully attended to them, restoring displacements and cor- recting flexions, and so on. When the canal of the cervix has been at all constricted I have enlarged it by incision and dilatation. When the congestion which occurs at the menstrual period has not subsided in a few days, I have employed the warm-water douche. After this, I have applied to the cavity of the uterus small bougies of cocoa-butter with as much iodoform as they would take up. Three or four grains of iodoform mixed with vaseline that has been lique- fied by heat, and introduced through the pipette, is perhaps the best method of applying it. This has been introduced once a week or once every five days. When there has been much tenderness, and the use of the pencils has caused pain, I formerly used aconite and opium and iodine; this I have introduced into the cavity of the uterus. I am now trying cocaine to subdue the tenderness as a pre- paratory means to the use of the iodoform. But so far this new remedy has not been a perfect success. In cases where this has failed and the uterus was not especially sensitive to intra-uterine medication, I have instilled into the uterine cavity a few drops of a 5-per-cent solution of carbolic acid, making one application a few days after the menstrual flow and not repeat- ing it until the next period. In the interval I have used the iodo- form. I have also used the fluid extract of conium and hydrastis Canadensis ; but this I have found gives more pain than any of the other applications that I have used; and so of late I have used an infusion of the hydrastis alone, which appears to answer as well and gives less pain. HISTORY OF CASES. Case I. Membranous Dysmenorrhcea in a Married Lady who was never Pregnant.—This patient was forty-one years of age, of good constitution, and had been married eight years. She began to men- struate at thirteen, and continued to do so regularly and normally until she was twenty-one; then she began to have occasional pain, about the menstrual period, in the region of the ovaries. About a year after this she began to have severe uterine pains during the menses, and states that she occasionally passed masses that looked like membrane from the uterus; they were small, however, and did not appear at each period. After her marriage the pain at the menstrual periods became worse, and almost every month she passed a membranous cast of the uterus. The usual history of each menstruation is that the flow be- gins not very free, and, after continuing for about five hours, the pain becomes very intense and lasts from three to eight hours, when 238 DISEASES OF WOMEN. she expels the membrane and the pain subsides, the flow continuing for a day or a day and a half after the membrane has been expelled. The flow, taken altogether, is not profuse, and only lasts from two to two and a half days, while formerly—that is, before her dys- menorrhcea began—it used to continue from four to five days. When first seen, her general health was good, but she was rather hysterical and nervous, and was somewhat depressed and disappointed because she had not had children. She described the suffering at her menstrual periods as some- thing unbearable, although it did not last more than a few hours at a time. She was first examined midway between the menstrual periods. The uterus was then found to be normal in size and in good position. The internal os was rather sensitive and appeared to be slightly contracted; there was also a distended Nabothian gland in the middle third of the cervical canal, but the uterus pre- sented a normal appearance in every other respect. There was no congestion ; in fact, at this time the mucous membrane appeared rather anaemic. The diagnosis was left an open question until the next menstrual period, when I obtained the membrane expelled and had it examined by my friend Professor Frank Ferguson. His report stated that the specimen was uterine mucous membrane unchanged in its histological composition. This settled the question of diagnosis. Careful inquiry elicited the fact that she had never been preg- nant, so far as I could rely upon her testimony, which I believe to be accurate because of her great desire to have children. I also learned that on several occasions she had lived apart from her hus- band, who was of necessity absent on business for several months at a time, and that she suffered just the same, and at each month there was an expulsion of membrane, showing conclusively that there was no possibility of mistaking this affection for pregnancy and abortion. The treatment consisted, first, in placing her upon the following mixture: Half a grain of the bichloride of mercury, one drachm of the solution of the chloride of arsenic, three drachms of the tincture of iron in a three-ounce mixture of sirup and wTater. A teaspoonful of this was given, well diluted, after each meal. At the same time the internal os was incised superficially in three places, dividing equally the circumference of the canal, and the distended Nabothian follicle was punctured and evacuated. A week after this a sound was introduced of full size, and there was less tenderness; the tincture of iodine was then applied from just within the internal os outward. At the next menstrual period MEMBRANOUS DYSMENORRHCEA. 239 she had less pain, but it lasted just as long, and she passed a mem- brane unchanged, except that it did not appear so thick as formerly. From this onward the local treatment consisted in passing a full- sized sound just beyond the internal os directly after the menstrual period, and again in two weeks, and in nearly every six days about two grains of iodoform mixed with vaseline were passed into the cav- ity of the uterus, well up toward the fundus. This local treatment was continued without interruption for three months, and the first prescription, after it had been taken for two weeks, was followed by the iodide of iron, a grain and a half three times a day. After the second month, and at the third menstrual period from the time that treatment began, she had no pain and passed no mem- brane. At the next period she passed several shreds, but nothing like a complete cast of the uterus. The constitutional treatment, that is, alternating between the first prescription of mercury and arsenic and the iodide of iron, giving first one for two weeks, and then the other, was continued for two months longer. The application of the iodoform was continued for one month longer, once every week, and once after her menstru- ation, at the end of the fourth month of the treatment. Since that time she has had no further trouble; her menses are regular, lasting about three days, and entirely without pain or any discharge of membrane. That was her record at least one year after she gave up treatment, since which time I have not heard from her. Case II. Membranous Dysmenorrhcea occurring after Treatment for Anteflexion and One Miscarriage.—A lady of very high culture and over-refinement, of a well-marked nervous temperament, but otherwise of good constitution, came under my observation when twenty-eight years of age; she had then been married a year and a half. She menstruated first at fourteen years, and continued to do so regularly, but with pain from the very beginning. The pain usually began a day or so before the flow and gradually diminished after. Her suffering at each period gradually increased until her marriage, when it became more severe. This, and the fact that she remained sterile, induced her to seek advice. I found her suffering from anteflexion of the body of the uterus and cervical endometritis; there was also tenderness of the left ovary on pressure. She was treated for the flexion, and completely recovered. The dysmenor- rhea was entirely relieved, and she became pregnant. During her pregnancy she suffered very much from morning sickness, and at the end of the third month began to show some signs of septi- 210 DISEASES OF WOMEN. caemia; she then miscarried, and the ovum was found to be macer- ated, and probably had been dead in -utt.ro for two weeks. She recovered from this and was quite well for about a year, when her dysmenorrhcea returned; she then returned to be treated for what she supposed to be a recurrence of her former trouble, but I found no evidence of the former flexion. But, on inquiry, I found that she passed at each period a membranous cast of the uterus. The patient thought little of this, because in former years, while suffering from the dysmenorrhcea caused by flexion, she occasionally passed small clots which looked somewhat membranous in character, but no doubt were simply blood-clots. She was placed upon treatment similar to that employed in the first case reported, except that there was no necessity for enlarging the internal os as in the former case, the only difference in the local treatment being that I used iodine in place of iodoform during the last two months of the treatment; and once, immediately after the menstrual period, I applied a mild solution of carbolic acid to the uterine cavity. She did not again pass any membrane after the third month of treatment, and her pain from menstruation entirely disappeared. She was dismissed at the end of four months, and two months afterward reported that she was pregnant. Three months after that time she was examined and found to be so, and was progressing well. Since that time I have not seen her, but have heard that she gave birth to a healthy child. Case III. Membranous Dysmenorrhcea treated by Dr. Fordyce Barker, of New York; Complete Recovery.—I give the history of the following case for two reasons: First, to show that iodoform was employed in the local treatment, and that the patient's recovery was complete; and also to take the opportunity of stating that I believe that Dr. Barker was the first to employ this agent. The history is not altogether complete, because I obtained it from the patient herself, who was unable to tell all that was done for her; but I know positively that she suffered from dysmenorrhcea, and that she entirely recovered under the care of Dr. Barker, and has remained well for a number of years. This was an educated lady of a well-marked nervous temperament; she began to menstruate at thirteen, and continued to do so normally until she was twenty-six years of age. At that time she was said to have had an acute attack of ovaritis, and after recovering from that she had dysmenorrhcea. The character of the pain at her menstrual periods then appeared MEMBRANOUS DYSMENORRHCEA. 241 to be ovarian. After suffering in this manner for about four or five years she noticed the expulsion of membranous casts of the uterus at the menstrual periods. During this time and for a year afterward she was regularly treated by her family physician, but without relief. She then consulted Dr. Barker for her general ill-health, but did not call his attention to her derangement of the menstrual function. She improved in her general condition under his care, but found no relief from the membranous menstruation. She consulted him again and called his attention to the uterine trouble, and he immediately placed her under treatment. The constitutional remedies employed I do not know, but the local treatment consisted in dilatation of the cervical canal and the application of iodoform to the uterine cavity. She continued to pass membrane for several months; then the trouble ceased, and has not returned. She now menstruates regularly and naturally, and has done so for over two years. Several other cases might be added, some showing failure of treatment, and others where the patients were really made worse by being treated for inflammation of the uterus which was supposed to be the cause of the affection, but undoubtedly was not. Other cases might be given, also, in which recovery took place, and after several months or years the trouble returned, but they would add nothing to the views already expressed regarding the pathology and treat- ment of this affection. 17 CHAPTER XIV. LACERATIONS OF THE CKKV1X UTERI DIE TO PARTURITION. Regarding this subject Dr. Thomas Addis Emmet says: "Its importance can not be exaggerated, since one half of the ailments among those who have borne children are to be attributed to lacera- tions of the cervix." This estimate of the frequency and consequences of laceration of the cervix uteri is quite sufficient to introduce the subject and secure for it special attention. Sir James Y. Simpson pointed out the fact that lacerations of the cervix uteri frequently occurred, and Dr. Gardiner also described such lesions and their results ; but to Dr. Emmet is due the credit of describing fully the pathology of lacerations of the cervix and their causative relations to many other uterine diseases. He also devised efficient surgical means for their relief. This is certainly the most brilliant of all Dr. Emmet's achievements. The disturbing influences of this injury upon the sexual organs and the general health are usually marked, but depend to some extent upon the magnitude and location of the laceration. The first effect noticed is to retard recovery after confinement. The lacera- tion exposes raw surfaces to the lochial discharges which, when these are decomposing and offensive, may give rise to septicaemia. Even where this does not occur the injury interrupts, more or less, the process of involution and produces all the troubles which usu- ally follow therefrom. There is more or less inflammatory action set up in the parts, and the efforts at healing the laceration develop much scar tissue and not unfrequently enlargement and hardening of the parts from areolar hyperplasia. The scar tissue thus formed and the sclerosed tissues beneath and around the scars are often tender and painful. All this proves to be a source of local irritation, and sometimes causes much general disturbance through reflex action. The inflam- LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 243 matory action which immediately follows the injury does not entirely subside when cicatrization is complete. The inflammation in the cervical mucous membrane lingers there, and hence old lacerations are generally accompanied with marked catarrh of the cervical mem- brane. This is kept up and often aggravated by the eversion or rolling outward of the divided walls of the cervix, which exposes the cervical mucous membrane to friction and the acid secretions of the vagina. Therefore, the cervical endometritis accompanying lacerations has no natural tendency to disappear. It is also rebel- lious to treatment, and finally, if it is subdued, it soon returns unless the original injury is repaired. In lacerations of long standing, and especially those that have been treated by caustics, the mucous folli- cles become closed and distended, assuming the form of small cysts. The presence of these distended cysts increases the size of the cer- vix and gives an irregular outline to the surfaces under which they are situated. By pressure they cause absorption of the tissues of the cervix, so that when they are punctured or ruptured and their con- tents are evacuated the cervix becomes diminished below the original size. The several forms of laceration of the cervix uteri most fre- quently seen in practice are : 1. Lateral lacerations of one or both its walls. 2. Antero-posterior laceration ; usually found in the posterior wall, but occasionally involving both. 3. Multiple lacerations, usually three in number, but occasionally more. 4. Incomplete lacerations, in which the solution of continuity extends from within outward through the mucous membrane and muscular walls of the cervix, but not through the mucous membrane of the vagina. This form of injury is generally bilateral, but occa- sionally the lacerations are multiple, involving the two walls laterally and the posterior and anterior walls also. Sometimes two of these forms of injury are found together, as, for example, a complete bilateral laceration and an incomplete lacer- ation of the anterior wall of the cervix. The first, and by far the most common of these injuries, lateral laceration, presents several varieties. The bilateral laceration, in its typical form, divides the cervix into two equal parts, and extends up to the vaginal junction. As seen at times, the laceration is superficial, extending not more than half way up to the vaginal junction; again, the laceration may extend on one side up above the vaginal junction, while on the other 211 DISEASES OF WOMEN. t * ^1 ^^fl Kk,;. 'f;:TP^^'.' '^^ Hr it is much less extensive. In other cases the bilateral laceration divides the cervix into two unequal parts, the anterior portion usu- ally being the larger (Fig. 10")). The morbid states of the cervix uteri which accompany this form of injury and are caused by it vary greatly. In the simplest forms the cervix, in the aggre- gate, is not much en- larged ; the divided halves rest nearly to- gether, and protect the mucous mem- brane of the cervi- cal canal. Under these circumstances a slight hyperaemia of the cervical mu- cous membrane and a slight leucorrhoea are all the lesions present in many cases. Even these are not always found. In other cases the halves of the cervix are widely separated. The mucous membrane of the canal is everted, and is generally de- nuded of its epithelium, markedly congested, often thickened and irregular, and covered with a profuse leucorrhceal discharge. In still other cases there is, in addition to the above eversion, a marked hy- perplasia of all the tis- sues, especially on the inner surfaces. The new tissue fills in the space between the halves of the cervix, so that the opposite sides of the laceration can not be brought togeth- er (Fig 106). This superabund- Fig. 105.—Bilateral laceration; unequal division of the cervix. Fig. 106.—Bilateral laceration, with thickening of the everted lips. LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 215 Fig. 1<>7.—Extensive multiple lacerations. ant tissue is produced by arrest of involution and areolar hyperplasia. The tissue is denser than normal, and, in fact, presents a true sclerosis. Lacerations of the an- tero - posterior walls, while they are said by Emmet to occur frequently, are comparatively less often seen, because they generally heal promptly and com- pletely of their own accord. Where they are found, they are generally complicated with all the lesions de- scribed in connection with lateral injuries. Multiple lacerations vary greatly in number and ex- tent. A trilateral laceration is most frequently met with. The cervix is usually di- vided into three unequal parts, as seen in Fig. 107. This may be called a complete multiple laceration, because all the tissues of the cervix are divided. There is another form of this injury in which there are a number of lacer- ations which extend from within outward, but do not involve the vaginal mucous membrane (Fig. 108). The lateral incomplete lac- eration may be unilateral or bilateral. Generally, both walls are divided from within outward to the outer mucous coat. This injury is over- looked quite often by gynecol- ogists. At least, I infer this from the fact that Dr. Em- met is the only -writer of all those whose works I have Consulted who mentions it. Fig. 108.—Multiple incomplete lacerations. 21b DISEASES OF WOMEN. It is usually described as a patulous or dilated condition of the cervix, and to the touch and inspection it appears to be so, but a careful examination shows that the cervix is divided into two parts that are held together by the outer coat, or mucous membrane, Fig. 1(>!> shows the lesion. This lesion can be most con- veniently demonstrated by pass- ing the uterine sound into the cervical canal, and then carrying it outward in the line of the laceration, when it will become* apparent that the outer coat of the cervical wall is all that re- mains intact. There is usually no eversion of the mucous mem- Fig. 109.—Incomplete bilateral laceration. , , . , , ,, brane, but almost always there is a marked catarrh of this membrane, which is peculiarly resistant to treatment. In a number of these cases I have found enlargement of the anterior half of the cervix which gave a crescentic appearance to the os externum, Fig. 111. Caused ion. — Laceration of the cervix is usually caused by parturition, either natural or in- strumental. In a great majori- ty of first labors the cervix is injured to some extent, but in many the laceration either unites or, being very superficial, gives no trouble and passes unnoticed, Certain conditions of the tissues of the cervix predispose to lac- eration. Irregular development of the cervix either before or during pregnancy, in which one wall is thicker than the other; induration from previous dis- ease, which lessens the elasticity of the tissues; and a softened oedematous condition of the cervix, produced by pressure in tedious labors—all these favor laceration. In abnormal labors requiring manual and instrumental aid be- fore the cervix is dilated there is additional liability to injury, and Fig. 110.—The incomplete bilateral lacera- tion shown in Fig. 109, as seen by sec- tion of the cervix. LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 217 this frequently occurs; but it is also a fact that lacerations often take place in perfectly easy and natural labors. Indeed, it appears that in easy and rapid labor lacer- ations are very likely to oc- cur, such frequently showing that precipitate delivery is a cause of this accident. Dr. Emmet states in his book that he has seen laceration of the cervix in cases of criminal abortion. I have never seen laceration of the cervix after abortion from any cause at or before the third month of gestation. There is a condition of en- largement of the cervix with eversion of the mucous mem- brane of the cervical canal which presents all the phys- ical signs Of a superficial Fig. 111.—Crescentic laceration. bilateral laceration, and this I have seen after abortion in the first pregnancy, but I have also seen the same condition in the virgin uterus. This affection is described under the head of cervical endometritis, and, therefore, need not be discussed here. From what has been said, it will appear certain that this injury can not at all times be prevented by any skill and care on the part of the obstetrician. This should always be borne in mind and freely stated where the injury is attributed to carelessness on the part of the attendant during labor, a mistaken criticism not uncommonly heard among the laity. The effect of this injury upon the uterus and the general health of the patient, together with the symptoms and physical signs, will be brought out in full in the histories ofi llustrative cases which follow. The treatment of this injury includes the primary and secondary management. It has been suggested that when the injury takes place the laceration should be immediately closed with sutures, but this is impracticable. First, because it is impossible to fully estimate the extent of a laceration in the relaxed condition of the cervix im- mediately after delivery; and, secondly, the difficulty of accurate- ly adjusting sutures under the circumstances would subject the pa- 218 DISEASES OF WOMEN. tient to exposure, which is unwarranted. Besides this, the intro- duction of sutures and the disturbance of the tissues necessary to their introduction would tend to interfere with spontaneous union, a favorable termination not infrequently attained. The primary treatment then must be limited to the usual means employed by the competent obstetrician to secure normal involution of the pelvic organs. The secondary treatment should embrace three objects: First, to overcome the consequences of the injury ; sec- ond, to improve the nutrition of the parts injured, and thus pre- pare them for the third step, the repair of the laceration by surgical means. "When an improvement in the condition of the tissues of the uterus is attained, the general health of the patient is usually bene- fited by securing the best conditions for success in the operation for restoring the laceration. In order to do this it is necessary to overcome as far as can be the endometritis which usually accompa- nies the injury. The means used for this purpose sometimes suc- ceed in relieving the subinvolution which usually is present in those cases. Where there is much enlargement of the cervix from areolar hyperplasia, which makes it impossible to bring the divided edges together, and all ordinary treatment fails to reduce this enlargement, it is sometimes necessary as a preparatory measure to remove a por- tion of the tissue on the inner sides of the divided halves of the cer- vix and allow the parts to heal before performing the final opera- tion. This I have usually accomplished by taking out a section on each inner side of the halves and bringing them together with a couple of sutures. These are left in place for a week or two, and in the mean time the hot-water douche should be used, and such local applications as may be necessary to relieve catarrh or hyperaemia. The sutures are then removed, and after a few weeks the operation for the restoration of the cervix is performed. When there are a number of cysts in the cervix (a condition known as cystic degenera- tion) they should all be opened and evacuated. Sometimes the everted mucous membrane becomes very much thickened, and pre- sents a granular or papillomatous-looking surface. When such is the case, it is best to trim off the more prominent points on the surface, and subsequently make such application as will reduce the thicken- ing and vascularity of the membrane. It has been suggested by some that whenever there is a laceration it should be at once restored. Such authorities are of the opinion that if the operation is successful the other pathological lesions which were caused originally by it will disappear eventually. This is not LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 219 by any means to be relied upon, and I much prefer to remove, as far as possible, all local complications before operating. The objects to be obtained by the operation are to remove the scar tissue formed by the healing of the ununited edges of the lacer- ation, and thereby relieve the pain and reflex disturbances which it may have given rise to, and also to close in the mucous mem- brane and protect it from further irritation. There is still an- other important benefit gained by the operation—viz., when the uterus is larger than normal, owing to subinvolution, a marked reduction in its size will follow after this operation. I believe that the completion of involution generally follows successful res- toration of the cervix, excepting in those who have had puerperal metritis. In recent superficial lacerations I have operated without anaes- thetizing the patient. The pain of the operation is trivial compared with the distress from the after-effects of an anaesthetic. As a rule, however, it is necessary to administer an anaesthetic, especially in deep lacerations of long standing, where there is much scar tissue and consequent tenderness. The operation for the restoration of the cervix uteri must vary a little in detail according to the nature of each form of injury, but the operation, as performed on the bilateral, uncomplicated form of laceration, illustrates in the most perfect way the mech- anism and details of the operation. I will, therefore, describe the operation in this form of laceration, and give cases the histo- ries of which will illustrate the necessary modifications in the other forms. The operation is performed as follows: The patient is placed upon the left side, and a Sims's speculum introduced and held by a trained nurse or assistant. A tenaculum forceps, curved upon the flat side, is fixed in the anterior half of the cervix, at the point which makes the lip of the os externum. The posterior half of the cervix is seized in the same way with a similar forceps, and the operator, taking a forceps in each hand, brings the two flaps together, in order to see exactly where the parts are to be united. The forceps which holds the anterior flap is then given to an assistant, while the one attached to the posterior flap is held in the left hand of the operator, and the surfaces are denuded by the hawk-bill scissors, Fig. 112. The points of the scissors are made to seize the angle formed by the junction of the two flaps as far up as appears necessary to denude them. The flaps are brought together by the aid of the forceps on 17* 250 DISEASES OF WOMEN. each side, so as to bring the tissues more within the grasp of the scissors. The blades of the scissors are then closed, and a strip is removed from above downward on each flap. The other side is treated in Fig. 112.—Hawk-bill scissors. the same way, and the most important part of the denudation is com- pleted. It frequently happens that a portion of the tissue to be so removed escapes from the scissors at the lower portion of the flaps on one or both sides; but when this happens, the denudation is easily completed with the ordinary curved scissors. If the curved scissors only are used, much difficulty is experienced in vivifying the upper angles of the laceration, but with the hawk-bill scissors this portion of the operation can be accomplished accurately and with facility. The hawk-bill scissors, while saving time and trouble, give smoother surfaces for coaptation than can be otherwise ob- tained. A faithful trial of both methods by myself, and observa- tions of the old method as practiced by the most expert surgeons convince me of this fact. It has been said that all the cicatricial tissue can not be removed with the hawk-bill scissors. In regard to that, I can say that I have always succeeded in removing all that was necessary to secure good union and satisfactory ultimate results. Fig. 113, colored plate, shows the two denuded surfaces on each side of the laceration and the strip of the mucous membrane between. The needles used are triangular and pointed. Three lengths are convenient to have, but the medium one can be made to answer for all. The shape and length of these are shown in Fig. 111. The needle-forceps described in connection with the operation for restoration of the pelvic floor is used for this operation. The sutures are introduced in the following mannei : The nee- dle is placed in that groove of the needle - forceps which will give i) 1 f 3i r ■ 2 3 4 5 6 1 I 1 GEO. TIEMANN &GU. 1 ! f Fig. 114.—Triangular needles. PLATE III. Operation for Laceration of the Cervix Uteri. Figure 118. Page 250. Denudation complete. Figure 116. Page 253. The sutures in position. Figure 117. Page 253- The sutures tied. PLATE III. FIG.113 PAGE 250. FIG.116 PAGE 253. FIG. 117 PAGE 253. LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 251 the desired angle, and is held immovable there, while the operator orasps the handle and closes the catch. The needle is then passed into the tissue, and left there while the forceps is unclasped and reversed. Its other end is then used to grasp the point of the needle and draw it through. The first two sutures are introduced at the lower end of the flaps, at points corresponding to the sides of the os internum. In some cases, when the parts do not come together easily, it is well to introduce first a suture on each side at the upper end of the wound, and then the two lower ones. While introducing the first two sutures the parts are held by the tenaculum forceps, which were used during denudation. As each suture is introduced, the ends are united by passing one around the other in a loop-knot. This keeps the sutures from being tangled. The tenaculum forceps is then removed, and, while an assistant steadies the cervix by holding the ends of the first sutures, the others are introduced, a tenaculum being used to make counter-pressure while the needle is passed. The sutures are tied as follows: One or two turns of the ends are made to form the first half of the knot, the assistant takes hold of one end, the other is passed through the loop of a counter-pressure instrument, and then seized by the left hand of the operator. Trac- tion is then made on both ends of the suture, and, at the same time, the loop of the instrument is pushed down along the thread to make the knot slip to its destination. Repeating this manoeuvre completes the knot. The instrument used is about the size and shape of an ordinary Sims's tenaculum, but, in place of having a hook-point, it terminates in a ring (Fig. 115). f^V— -~rr*=---^B^jbtU--^.,. ■-C.TIEMAMN fcCOv'-- -s~---_—nj Fig. 115.—Ring-tenaculum or counter-pressure instrument. By this method the sutures can be tied about as easily and rap- idly in the cavity of the vagina as upon a free surface. The ends of the sutures are then cut off, and a small tampon of well-dressed flax, saturated with pine tar (marine lint), is carefully packed in, first around the cervix, and then below it. This tampon makes a good antiseptic dressing. It promptly absorbs serous oozing, and pre- vents any motion of the uterus which might strain the sutures. At the end of forty-eight hours it should be removed, and, if the parts are then in a healthy condition, no further local treatment is required. if there is any suppuration, a fresh tampon should be introduced, and allowed to remain for forty-eight hours longer. From my experience in a large number of cases, I am satisfied 252 DISEASES OF WOMEN. that the use of the tampon is a reliable after treatment in this opera- tion, and is preferable to the daily injection of carbolized water, which so many employ. The patient should rest in bed, with the privilege of turning upon either side. The bowels and bladder should be evacuated upon the bed-pan. The sutures should be removed upon the eighth or ninth day. If union is imperfect, the lower ones may be left in for two weeks. The simplicity of the after treatment is its chief merit. Keep- ing the patient perfectly still in bed is a great punishment to one in good general health, and tends to prevent union; hence, giving the patient the privilege of tossing about on the bed is a great com- fort. I am inclined to think that I could give the patient liberty to get out of bed to evacuate the bowels and urinate, if the tampon was employed continuously. As bearing on this point I may refer to the case that I operated upon in my office, and sent home in the street-cars. She made a perfect recovery. Another case shows what can be done with impunity. A patient of Dr. George W. Baker's, a very strong, active lady, was operated upon for a bilateral lacera- tion in the usual way. She refused to stay in bed, but rested on the sofa, and visited the water-closet when necessary. Her menses came on prematurely and profusely. A large coagulum formed in the vagina and was passed while straining in the water-closet. Not the slightest hope of success was entertained, but on removing the sutures the results were found satisfactory in every way. These cases convinced me that the absolute quietude usually insisted upon is not necessary, and hence since then I have given more liberty of action. Much discomfort is avoided in this way, and the patient gets up better and stronger. illustrative cases. Typical Case of Bilateral Uncomplicated Laceration of the Cervix Uteri—The patient was twenty-four years of age, and had her first child fourteen months before she was first examined. Her general health was fairly good, but she had backache and profuse leucor- rhoea. Walking or standing gave her pelvic tenesmus, and she was more easily fatigued than in former years. She began to menstruate ten months after her confinement, and gave up nursing her child when it was a year old. The menses were normal, but more free than formerly, and lasted a day longer. She was sterile. Physical examination showed that the uterus was a little larger than it usually is in a person of her size. The cervical mucous membrane was LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 253 hvpergemic, and denuded of epithelium in certain places. There was a profuse leucorrhoea. The cervical canal was cleared of the leucorrhoeal discharge, and an application of equal parts of tincture of iodine and carbolic acid was made. This was repeated at the end of a week and after the succeeding menstruation. The cervix was restored in the way al- ready described without using an anaesthetic. Figs. 116 and 117, colored plate, show the cervix with the sutures in position. A marine-lint tampon was used and kept in position for forty-eight hours. No after treatment was needed. The sutures were removed on the tenth day, and the union was complete. The patient was kept in bed two weeks in all, and during that time was given a good, generous diet, and her bowels were moved daily. She had no pain during her rest in bed, and, although weak when she first tried to walk, she soon regained her strength. After the re- moval of the sutures a vaginal douche of borax and water was used up to the time of the next menstrual period. Three months after the operation she was free from all her former symptoms. The cervix then appeared like that of an imparous uterus. Bilateral Laceration complicated with Enlargement of the Cervix from Hyperplasia.—This patient had her only child when she was twenty-six years old. Her labor was tedious, but otherwise normal. From the time of her confinement until I first saw her, four years afterward, she had not been well. She suffered from backache, pel- vic tenesmus, and profuse leucorrhoea. Her general health, wdiich was formerly very good, became impaired. The appearance of the cervix when first seen is shown by Fig. 106. It was impossible to bring together the edges of the os exter- num, owing to the enlargement of the halves of the cervix. Consti- tutional treatment was employed, and the hot-water douche and tincture of iodine used locally, but at the end of two months there was only a slight improvement in the condition of the cervix. A pre- liminary operation was then performed as follows: A crescentic- shaped piece of tissue was removed from the inner side of each half of the cervix sufficiently deep to permit the halves to be brought together with very little traction. Fig. 118 shows the por- tions removed, the dark lines indicate the lines of incision. Two sutures one on each side of the os externum, were introduced to hold the parts together while healing was going on. Figs. 119 and 120 show the parts brought together with the sutures, and Figs. 121 and 122 show a different method of doing the same operation. Before tying the sutures a piece of muslin saturated with wax was 254 DISEASES OF WOMEN. placed between the halves of the cervix, and left there for four days to keep the coaptated parts from meeting. The sutures were Fig. 118. Fig. 119. Fig. 120. Fig. 121. Figs. 121 and 122 Fig. 122. -Another method of closing gap- the Fig. 118. Removal of crescentic shaped piece (seen in section) when the everted lips are thickened. Figs. 119 and 120. Method of bringing the sides of the sections together. removed at the end of two weeks, when it was found that the parts where the exsections were made had nearly healed over. Tliree weeks afterward the cervix was restored in the usual way, and good union was obtained, and the patient subsequently recovered. In cases like this 1 have sometimes removed the re- dundant tissue of the cer- vix at the time of perform- ing the final operation for the restoration of the cervix. When this is done, it is necessary to keep a plug in the cervical canal during the healing process in order to prevent the vivified portions from uniting. I much prefer to do the preliminary operation, believing that I can get better results by so doing. Laceration of the Posterior Wall of the Cervix Uteri, complicated with Enlargement of the Cervix and Cystic Degeneration of the Mucous Membrane.—The patient was first seen when thirty-four years of age, and had been married thirteen years. The injury of the cervix oc- curred twelve years before, when she had her only child. She got up from her confinement with leucorrhoea, backache, and pelvic tenesmus, and continued to suffer from these for about one year, when, becoming tired of being told that her pelvic symptoms would disappear when she gained her strength, she consulted another phy- sician. Local treatment was then employed with benefit, but it proved to be temporary. The leucorrhoea and other symptoms re- turned in an aggravated form. She continued in this way, getting a little temporary relief from treatment and again going uncared for. LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 255 up to the time that she came under my care. For three months she was treated for cystic degeneration, catarrh, and hypertrophy of the cervix. The latter appeared to be due to imperfect involution and hyperplasia combined. The laceration extended up to the vagi- nal junction, and there were erosion and eversion, but not to any great extent. In restoring the cervix, its sides were seized with the tenaculum forceps, and the upper angle of the laceration vivified with the hawk-bill scissors. The denudation was carried down- ward to the os externum with the curved scissors. The introduc- tion of the sutures and, the after-treatment were conducted as usual. The union was satisfactory in every way. There was no return of the former symptoms, and she was classed among the suc- cessful cases, although she remained sterile without any apparent cause for it. Multiple Laceration of the Cervix.—A large, muscular lady had her first child when she was twenty-six years old. Her labor was tedious, the membranes rupturing before the cervix was fully dilated. Man- ual dilatation was resorted to, and the forceps used to deliver before the head had fully descended into the pelvis. This much of the history was obtained from the physician who attended her in confine- ment. Four years subsequently I first examined her and found a multiple laceration of the cervix. The irregular nodulated state of the cervix and its density to the touch suggested the thought that there might be malignant disease present. This suspicion was still further aroused by a speculum examination, which revealed a profuse leucorrhoea and a rough, vascular, papillomatous state of the mucous membrane. The fact that the parts improved promptly on treat- ment settled the diagnosis. The cervix was divided into three un- equal parts (Fig. 108). For two months she was treated for the in- flammation of the cervix, and at the end of that time the laceration of the posterior wall was operated upon in the usual way. It was not necessary to anaBsthetize the patient, as the operation required only a short time and was not very painful. She was kept in bed for a week, and good union was obtained. This left the patient with a simple bilateral laceration, which was successfully operated upon five weeks afterward. Multiple Laceration incomplete, complicated with Endometritis Poly- posa.—The patient was .thirty-seven years old, married seventeen years, and had borne three children, the youngest of whom was two years of age. It was impossible to ascertain when the cervix was injured. The history showed that her health began to fail after the birth of her second child, and that she broke down completely aftej 256 DISEASES OF WOMEN. her third one was born. When she came under my observation she had menorrhagia, a poor appetite, and constipation. She was ema- ciated, very amende, irritable, sleepless, and suffered much from headaches—in short, was perfectly useless, and a great sufferer. She had free leucorrhoea, backache, and ovarian pain, which was at times quite annoying. The physical signs indicated that there was a polypoid state of the endometrium. There were four lacerations of the cervix. Two lateral, the largest, and one in the anterior wall and another in the posterior wall. These latter might be called fissures. They did not extend through the whole of the middle coat of the cervix. The lateral lacerations were complete, involving the entire wall of the cervix for about a quarter of an inch below and were incom- plete above. The fungosities of the endometrium were removed with the curette. This relieved the menorrhagia and improved the general health of the patient to some extent. The restoration of the cervix was effected by operating upon the lateral lacerations in the prescribed way, i. e., first making complete lacerations of them, and then vivifying the parts and closing them with sutures. The antero-posterior lacerations or fissures were treated by vivifying their sides as well as could be done before closing the lateral ones. When the sutures were tightened in the lateral lacerations it was found that the traction appeared to hold the antero-posterior lacerations together. The result proved that such was the case. There was good union, and the patient gained in strength rapidly and was quite well at the end of three months. Typical Case of Bilateral Incomplete Laceration of the Cervix Uteri.—The patient, a lady of excellent physique, married at thirty- one years of age, and had her first child three years later. Her labor was tedious in the first stage, but her recovery was without any marked interruption. When her child was twenty months old she became pregnant again, and miscarried at the third month. Six months after her miscarriage she was first examined. She then suffered from menorrhagia, pelvic tenesmus, and profuse leucor- rlnea, which caused some general depression—but not to any great extent. The uterus was retroverted, and the cervical canal admitted the index-finger nearly to the internal os. The uterus was a little larger than normal, and its mucous membrane congested and irregu- lar to the touch of the sound. The uterus was restored to its position and retained there with a pessary. The canal of the cervix was touched with tincture of iodine. This gave her relief from tenesmus, but did not control LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 257 the menorrhagia nor the leucorrhoea. Subsequently the cavity of the uterus was curetted, and carbolic acid and iodine were applied to the canal of the cervix. From this time on the menses were nor- mal, but the leucorrhoea returned again and again. Treatment would arrest it for a time, but it returned, and she proved to be ster- ile. Restoration of the cervix was proposed in the hope that the operation would give her permanent relief. The operation was performed as follows: Taking hold of the anterior and posterior walls of the cervix with the tenaculum for- ceps, a straight scissors was passed into the cervix half its entire length, and the mucous membrane of the vagina (the portion of the cervical wall which escaped laceration) was divided. The other side was treated in the same way. The halves of the cervix were drawn apart, so that the extent of the internal laceration could be clearly seen, and then the angle on each* side was vivified with the hawk- bill scissors. After this there still remained a little redundant vagi- nal mucous membrane at the lower portion of the cervix, and be- tween the vaginal and cervical mucous membrane the site of the laceration, the muscular walls remained modified. The redundant vaginal membrane was removed and the middle walls of the cervix were vivified with the curved scissors. This modification of the method of vivifying the parts to be united became necessary because of the lacerations being incomplete. In some cases of incomplete laceration when the cervix is large, it is best to divide the vaginal mucous membrane first. By using the hawk-bill scissors a Y-shaped piece can be taken out on each side which completes the vivifying with a single clip of the scissors on each side. The sutures were introduced and the operation completed in the usual way. The case progressed favorably, union was complete, and there has been no return of the leucorrhoea nor any of her for- mer symptoms. Incomplete Laceration with Hypertrophy of the Anterior Half of the Cervix.—The patient had suffered from a profuse leucorrhoea since the birth of her child five years before. She had been treated oc- casionally, and derived only temporary relief, the symptoms return- ing again when treatment was suspended. The enlargement of the anterior half of the cervix was confined mostly to the mucous mem- brane. This gave a crescentic appearance to the os externum (Fig. 112). The treatment consisted of exsection of the hypertrophied portion of the mucous membrane in the anterior wall, and when the parts had healed the laceration was operated on in the same 18 258 DISEASES OF WOMEN. manner as in the case of incomplete laceration preceding this one. The exsection was made by seizing the part to be removed with a tissue forceps, and with a slightly-curved scissors, clipping off the whole of the mucous membrane on that side up as high as the hy- pertrophy extended. There was some bleeding, but that was very easily controlled by packing the cervical canal with cotton, and using a vaginal tampon to keep it there. The Results of the Surgical Treatment of Lacerations of the Cervix Uteri.—There are some points that remain to be settled by reliable observations regarding the results of the surgical treatment of these injurieSo More statistics by reliable observers are needed to deter- mine definitely all the benefits which may be reasonably expected from this form of treatment. It may be fairly claimed that successful restoration of the cervix will relieve the inflammatory troubles of the cervix, including the suffering from scar tissue in the great majority of cases. Sterility due to the injury of the cervix and the consequent le- sions is cured in many cases. Labor is not, as a rule, retarded by the condition of the cervix after the operation. .Nor does laceration necessarily occur again. I have been able to compare the dilatability of the cervix after trachelorraphy with that of lacerated cervix with scar tissue, and I have found that the results are greatly in favor of those patients in whom the cervix has been restored. CHAPTER XV. CICATRICES OF THE CERVIX UTERI AND VAGINA. Cicatrices, the results or products of diseased action and inju- ries, are of pathological importance according to their size and loca- tion. They derange the conditions of health and comfort by the tender and painful character of scar tissue, and by its inelasticity, which interferes with the free motion of the pelvic organs. The slow, persistent contraction of this abnormal tissue, by which the adjacent normal parts are united, causes p?in by making pressure on the terminal nerve-fibers. Tenderness, also a characteristic of scar tissue, is developed in the same way, or perhaps from the excessive irritability or imperfect protection of the nerves found in cicatrices. This tenderness is most marked in scars at or near the introitus vagina1, and varies according to the age of the new tissue. When an uninterrupted cicatrix surrounds the cervical canal, the os ex- ternum, or the vagina at any point, stenosis is produced, and all the derangements consequent thereon, according to the partial or com- plete development of the stricture. Causation.—The causes which lead to the formation of cicatrices are familiar to all, and require only to be named in order to recall them for present consideration : Injuries during parturition suffi- cient to cause sloughing or loss of tissue ; lacerations which heal over without uniting the divided parts, or which are united by interven- ing new tissue; amputation of the vaginal portion of the cervix ; exsection of a portion of the vagina, especially where healing takes place by granulation ; destruction of the mucous membrane and sub- jacent structures by the free use of caustics, and extensive ulceration either simple or specific. These are the chief affections which give rise to the conditions now under consideration. Symptomatology.—The symptoms developed by cicatrices are pain, which is often intermittent or remittent, and is usually in- creased bv exercise. When the scar involves the circumference of 260 DISEASES OF WOMEN. the cervix, and the caliber of the canal is reduced below the normal size, dysmenorrhoea occurs in some cases. When the vagina is ex- tensively involved, the functions of the bladder and rectum are occa- sionally deranged so as to give rise to frequent and difficult urination and painful defecation. This is due, doubtless, to the tenderness of the scar tissue, and diminished mobility of the parts. For the same reason, coition is painful, and in some marked cases impossible. It will be observed that the same derangement of the sexual function occurs in vaginitis, vaginismus, and in that rare neurotic affection in which there is extreme hyperesthesia without any apparent change of structure or circulation to account for it. In short, any or all of the symptoms caused by cicatrices may arise from other pathological conditions, such as are found, for example, in conva- lescence from pelvic peritonitis or cellulitis. On that account the diagnosis must be based chiefly on the physical signs. These I may briefly mention. They are the presence of abnormal tissue, which is usually tender, always indurated, less elastic than healthy parts, and sometimes lighter in color, and having a smooth surface. Cica- trices of the vagina are easily detected ; those of the cervix are liable to be confounded with sclerosis and incipient malignant disease. The points of distinction are the increase of tissue and abnormal vascularity found in the latter. Knowing the evils which cicatrices give rise to, the first duty of the practitioner is to guard against thei^ formation. This can be accomplished to a great extent, I am sure, by observing certain lines of practice. Lacerations of the pelvic floor, occurring during nat- ural or artificial delivery, should be immediately brought together by sutures, when it is possible to do so, in place of leaving them to heal as best they may, which is the usual practice. In many such cases the patient is anaesthetized when the injury is sustained, and, if the obstetrician has the requisite instruments at hand—as he ought to have—the operation of closing such wounds with sutures is prac- ticable ; if such wounds can be made to heal without the interven- tion of much new tissue, the cicatrices are very unimportant com- pared with the large scars which are sometimes formed where healing takes place by granulation. In making these statements, I am aware that the ground taken may be questioned. In opposition to this practice, it may be said that such wounds often heal promptly without the aid of sutures, and even when sutures are employed there is no certainty that good union will take place. On the other hand, it can be fairly claimed that, if the edges of a lacerated wound are held together, the chances CICATRICES OF THE CERVIX UTERI AND VAGINA. 261 of their uniting are better than if left alone. Even should healing take place by granulation, the sutures, preventing the wide separation of the parts, will tend to lessen the size of the cicatrix. When there is so much to be gained by good union, and so much suffering en- tailed by bad, the use of sutures in such cases is surely good surgery. The formation of troublesome cicatrices following the use of caustics may be prevented by carefully circumscribing the space to which they are applied, and by avoiding their use to an extent suf- ficient to cause destruction of the deeper structures of the mucous membrane. When it is necessary to apply a caustic—say nitric acid —to the os externum or cervical canal, a portion of the membrane should be left untouched if possible, so that the eschar, if one is formed, will not completely circumscribe the canal. By attention to these points, cicatrices may be prevented, or, if they follow, they will be less troublesome in character. In amputating the cervix, that method of operating should be chosen which will secure the most serviceable stump. The flap or circular amputation, in which the mucous membrane is brought over the stump and held in place by sutures according to the methods of Sims or Schroeder, gives the most satisfactory results, especially so where the parts heal promptly. When suppuration occurs, and the parts heal by granulation, the stump is less perfect; but even then it is better, as a rule, than when the stump is left unclosed. Treatment.—In the treatment of cicatrices the chief indications are to relieve the pain and tenderness of the parts, prevent contrac- tions, and, where deformities exist, to correct them. These require- ments can be most promptly and perfectly fulfilled by removing the whole of the cicatrix, and bringing together the normal tissues, and obtaining as near immediate union as possible. But this radical treatment is only called for in rare cases, and is not always practica- ble, owing to the size, depth, and unfavorable location of the cica- trix. Exsection should not be undertaken in any case unless the scar is movable on the subjacent tissue. It is necessary to wait until this mobility is established, which usually occurs sooner or later. When the scar can not be removed altogether, contraction should be guarded against by preventing it from shortening. In oblong cicatrices, contraction in width rarely gives trouble, while shorten- ing causes deformity. This can often be prevented by dividing the scar at one or more points, and then putting the parts on the stretch by the tampon or pessary. The divided edges thus held apart are united by intervening new tissue, and the scar is lengthened, while the process of narrowing still continues. Sometimes the contractility 262 DISEASES OF WOMEN. of the normal tissues is sufficient to draw the divided c(\ge> of the scar apart, so that incising the scar is all that is necessary. When a cicatrix surrounds the os externum, it should be divided on two sides, the lateral being preferable in most cases; a tent of sea-tangle should then be introduced and worn during the process of healing. The tent should be short, so as not to enter the internal os, and it can be held in position by a pessary by stitching it to the walls of the cervix. The frequent use of the sound or dilator will answer the same purpose. In the management of cicatrices of the vagina, very satisfactory results are obtained by the treatment proposed. After dividing the cicatrix, the parts are put upon the stretch by the glass dilator em- ployed by Sims and others in the treatment of atresia vaginae. 1 have also used for the same purpose elm-bark, made into a roll of the proper length and thickness, and beaten until it is soft. It is then dipped in carbolized water, and introduced like a pessary. Thia has the advantage of being agreeable to the tissues, and by expand- ing very slowly it causes distention, which is easily borne. By en- larging the size used from day to day, the vagina can be distended slowly and without pain. I am satisfied that this method of treatment has another advantage, which is, that by slow, continuous dilatation the normal portions of the vagina can be developed so as to compen- sate for the contraction of the cicatrix to a very considerable extent. When there is no considerable deformity, and pain and tender- ness are the only symptoms, the most marked relief will often follow an incision of the cicatrix at a number of points. I have also been led to believe that softening of the scar and relief from pain were obtained by the frequent application of equal parts of tincture of opium, aconite, and iodine. A word might be said about complications, such as vaginitis, cervical endometritis, etc. They are to be treated in the usual way, of course. I need only add that, so far as my observations have ex- tended, it has been found that by relieving trouble caused by cica- trices, recovery from accompanying affections is facilitated. This is as might be expected. ILLUSTRATIVE CASES. Scar Tissue producing Stenosis of the Vagina. Primary Cause: Acute Inflammation during the Course of the Fever.—A lady, thirty years of age, large, well formed, and in general good health, men- struated first at fifteen years of age, and has continued to do so regularly and normally ever since. She has been married twelve CICATRICES OF THE CERVIX UTERI AND VAGINA. 263 years, and during that time coition has been impossible. Before marriage she had no symptoms of uterine disease, but soon after she developed uterine and vaginal leucorrhoea, which have continued in- termittently ever since. She has also suffered occasionally from backache and irregular pains in the pelvis. Examination by the touch revealed contraction of the whole vagina, so that the index- linger could with difficulty be introduced, and at the upper portion there was a stricture through which the finger could not be passed. In a pocket beyond the stricture the cervix uteri was subsequently found. The stricture was due to scar tissue, which formed a circular band about a quarter of an inch wide. From this ring, extending downward, there was another cicatrix which terminated at the re- mains of the hymen. There was subacute vaginitis and the papillae of the mucous membrane were enlarged and exceedingly tender. The examination caused intolerable pain. At another time an anaes- thetic was given and the stricture divided. The uterus was then found to be normal in size and shape, but there was a little erosion about the os externum and congestion of the cervical mucous mem- brane and hypersecretion. Nothing in the history of the case, nor in the local lesions, gave any clew to the cause of the trouble, but on re-examination it was found that when the patient was a child she had what was called typho-malarial fever followed by pelvic inflammation and the forma- tion of abscesses. From this much of the history obtained from the patient's mother, I presumed that the cicatrices of the vagina were the prod- ucts of the disease of her childhood. The treatment employed in this case was such as has been de- scribed, and marked improvement has followed. At the end of four months after beginning the treatment the vagina admitted Cusco's speculum; the tenderness was reduced, but not wholly relieved. The patient went to the country for the summer, to return in October for futher treatment. Scar in the Vaginal Wall resulting from an Injury sustained during Labor.—I was called to see a lady two months after her con- tinement with her first child. I learned that she had had a tedious labor and was delivered by forceps. She made a good recovery, ex- cept that when she undertook to stand or walk she suffered from sharp pains in the vagina and a feeling of dragging and weight, especially on the left side. On examination I found a recent cicatrix on the left side extend- ing from the lower portion of the labium majus up the vagina for 264 DISEASES OF WOMEN. about three inches. The scar, which was about half an inch in width, was quite tender to the touch, and in the center of it, here and there, a few granulations remained and bled on being roughly touched. The patient, although very healthy and strong, had not been able to go up or down stairs or leave the house for two months after her confinement, the time when I saw her. No other uterine or pelvic disease could be found. This case shows the trouble which wounds of the vagina, sus- tained during confinement, will cause, and it is reasonable to suppose that if the parts had been united by sutures at the time of injury a more prompt recovery would have followed. Scar Tissue between the Posterior Wall of the Cervix Uteri and Vagina, caused by Former Treatment.—This lady was fifty years old, and had passed the menopause several years. Her health had been very good during most of her life. She had some uterine inflamma- tion and leucorrhoea after the birth of her last child, and was treated with caustic applications which relieved the leucorrhoea. After this she began to have pelvic pain of a neuralgic character, which in- creased gradually. This pain was greatly aggravated by exercise. The effect of the local suffering and inability to take active exercise upon her nervous system was very marked. A vaginal examination by the touch detected a thin band of scar tissue extending from the posterior wall of the cervix to the vaginal wall. The scar was quite tender, and when touched with the probe or finger gave rise to the neuralgic pain from which she generally suf- fered. The patient was placed on the side, and a Sims's speculum introduced. The cervix was caught with a tenaculum and drawn forward. This put the scar tissue on the stretch and made it promi- nent. The whole scar tissue was removed with one sweep of the curved scissors, and the edges of the mucous membrane of the vagina were united with a few catgut sutures. The parts healed without delay, and all the local pain and general disturbances promptly subsided. The relief was so prompt, complete, and per- manent, that there can be no doubt about the scar tissue being the whole cause of the patient's suffering. This case is a fair sample of a class, now fortunately diminish- ing in number, in whom scars are produced by the use of caus- tics. The general practitioner using a Ferguson speculum and a swab in treating diseases of the cervix uteri, usually does very little to cure the disease, but much to destroy the tissue of the cervix and vagina. The swab charged with a strong caustic solution and pushed up into the canal is compressed so that the caustic runs down CICATRICES OF THE CERVIX UTERI AND VAGINA. 265 on the posterior wall of the cervix and vagina. While the diseased tissues get very little of the application, the normal tissues at that point are destroyed. This is often repeated, and results in forming scar tissue such as that presented in this case. Such results of treat- ment were often seen years ago, and at the present day they are far too common. A Band of Scar Tissue just within the Introitus Vaginae, and ex- tending across from Side to Side of the Vagina, caused by Forceps De- livery.—The patient was undersized, but a strong, healthy lady. She was confined with her first child five months before I saw her. Her physician told me that the child was large in proportion to the mother, and that he was obliged to deliver with forceps while the head was high in the pelvis. In the delivery, much damage was done to the cervix and vagina, but the pelvic floor was not torn. She recovered slowly from her labor, and continued to have a dis- charge and pain, mostly of a neuralgic character. I found a semicircular band of scar tissue running from the ramus of the pubes, high up and around the vagina to the opposite side. The scar was unyielding, so that the finger could be intro- duced with some difficulty into the vagina. It extended deep down below the mucous membrane of the vagina, and at the upper ends was fixed to the pubic bones. It appeared to me that in the original injury the whole of the vaginal wall, together with the bulbo-caver- nosus muscles and the anterior fibers of the levator-ani muscle had been torn away from its attachments to the floor of the pelvis. I have never before nor since seen an injury exactly like this, and hence I do not know positively how it was produced, but pre- sume it occurred as I have stated. About half an inch from the median line of the posterior wall of the vagina the scar tissue was divided on each side. Traction backward was then made with a narrow-bladed Sims's speculum which distended the vulva and at the same time brought the ends of the incisions, which were made parallel to the axis of the vagina, together. The sides of the incis- ions were held together with sutures. The immediate effect of this operation was to relieve, in a marked degree, the pains from which the patient had suffered. It also restored the dilatability of the vulva, so that the patient could resume her sexual duties when the incisions had healed. She still has pain and tenderness, and I pre- sume that there will be contraction again which will require further treatment. The case being a recent one, its future history has yet to be de- veloped. CHAPTER XVI. INVERSION OF THE UTEKU9. Inversion may be defined as a turning inside out of the uterus, in which its walls descend into its cavity. The external surface be- comes the internal, and the fundus uteri, which should be highest in the pelvis, becomes lowest. There are several de- grees of inversion, varying from a mere depression of a portion of the uterus, to a complete inversion. In practice two degrees can be made out, and these can be easily comprehended by a reference to Figs. 123 and 124. In the first form there is a depression of one side or partial inversion ; the second form is a com- plete inversion. When the vagina is also inverted, the condition is known as inversion and prolapsus. This complication occurs as a rule in the puer- L'ig. 123.—Partial Peral state oniy- In all cases of inversion, at least inversion (Thom- at the time when this accident occurs, enlargement as) . and relaxation of the tissues of the uterus are found. This is particularly so in the puerperal state, when inversion oc- curs most frequently. Symptomatology.—The severity of the symptoms depends upon the extent of the inversion and the sudden- ness with which it occurs. Partial inversion, brought about gradually, may not cause suffi- cient disturbance to attract attention. The symptoms of shock are present when the in- version occurs suddenly, as it does in the puer- peral state. The shock and pain are more marked, as a rule, when the inversion is accom- panied with prolapsus. In a few recorded cases, T fi u i i j x j. i t-■ .i • Fl°- 124.—Complete in the shock alone proved fatal. If there is great version (Thomas). INVERSION OF THE UTERUS. 267 haemorrhage as well as shock, the patient is more likely to suc- cumb. Haemorrhage occurs when the inversion is incomplete as well as when complete, especially at the time when the accident takes place. The presence of the uterus in the vagina causes disturbance of the bladder and rectum, by pressure. These are the symptoms which occur in acute inversion, and if the patient passes safely through this stage then the symptoms of chronic inversion appear. In complete inversion after the uterus has fully contracted, the hemorrhage is not profuse, except at the menstrual periods, when there may be menorrhagia. This is generally a sero-sanguinolent discharge for the first week or even later, then the irritation may cause congestion, ulceration, and general inflammation of the vagina and mucous membrane of the uterus, and a consequent leucorrhoea and purulent discharge. If the uterus remain outside of the vagina it usually becomes dry from exposure to the air, but it also becomes abraded in places and finally ulceration occurs. Whether the uterus remain in the vagina or becomes completely prolapsed, the inflammation, ulcera- tion, haemorrhage, and the purulent discharge which arise there- from may break down the general health of the patient and the case terminate fatally. Throughout all this there is pelvic pain and tenesmus. Physical Signs.—The diagnosis (which is not by any means easy in all cases) depends largely upon the physical signs. These differ somewhat in recent cases and in those of long standing. When the inversion occurs after labor, the bimanual touch will reveal two very important facts. The uterus is not found in its position behind the pubes, but occupies the pelvic cavity, and can be outlined in the vagina. By moving the uterus between the two hands, the fundus and body will be found below in the true pelvis, while in place of the fundus being found above, a depres- sion in the uterus can be felt at the superior strait. If the vagi- nal touch alone is relied upon, the condition will be taken for the coming placenta. The placenta being attached to the uterus, as it usually is at this time, obscures the uterus, but upon trying to re- move it from the vagina by hooking down one of its edges with the finger, the solid uterus will be found above the placenta, the two being united, but easily separated. Wrhile this exploration and re- moval of the placenta—if it is present—are going on, the left hand is placed upon the abdomen, and the absence of the uterus above is 2<;s DISEASES OF WOMEN. observed, as already stated. Passing the flnger above the mass in the vagina, in search of the walls of the cervix and the os uteri, a furrow is felt which shows that the walls of the vagina and utenis are continuous, and that there is no opening into the cavity of the uterus. These signs will suffice for any one wdio is familiar with the normal condition of the parts in labor, to make a diagnosis. In fact, there are only two things which could easily be mistaken for inversion, a fibrous tumor and the presenting membranes in a case of twins. The latter could be made out by palpating the abdomen and finding the large uterus with the child, and the other, though less easily, could be detected by the presence of the uterus behind the pubes and the presence of the uterine canal which could be fol- lowed by the touch beyond the tumor. These physical signs should be sufficient to suggest the diagnosis, which can be confirmed by restoring the inversion. This is easily accomplished by any one familiar with obstetric manipulations. When there is complete prolapsus, as well as inver- sion, the diagnosis can be made by inspection. The form of the tumor, the appearance of its mucous membrane, the presence of the placenta, or, in case that it has been detached, the irregular appearance of the placental site compared with the rest of the membrane, and the contractions of the uterus, which can be noticed while handling the parts, are quite sufficient to settle the diagnosis. In old cases, in which the uterus has become reduced to its origi- nal size by involution, the diagnosis is not so easy as in recent cases, and yet, by the aid of the sound and the bimanual touch, the diag- nosis can be made with certainty in the great majority of cases. By the touch the round tumor is found projecting into the va- gina, and the lips of the os externum can be distinguished surround- ing the tumor. The fornices can sometimes be made out also. In most of the cases that I have seen the cervix was thinned out so that its walls felt as if continuous with the vagina, and the fornices were also obliterated. In either condition the evidence is in favor of inversion, but when the cervix can be found the evidence is more valuable, especially if the finger can be passed up into the cervix between its walls and the body of the uterus. There the mucous membrane of the cervix can be felt reflected upon the tumor to the same extent all around. These signs can be made out by the vaginal touch. The biman- ual touch is still more satisfactory. By that method the uterus can be raised up in the pelvis by the finger or fingers of one hand in the INVERSION OF THE UTERUS. 269 vagina, while with the other hand a body with a depression in its center can be felt through the wall of the abdomen. In spare pa- tients with relaxed abdominal muscles the bimanual touch will usu- ally suffice to make the diagnosis quite positive. y In doubtful cases the uterus may be drawn down with a tenacu- lum or pressed down by a hand upon the abdomen, while a rectal examination with the index-finger of the other hand is made. In this way the fingers of the two hands may be made to meet above the uterus, and at the same time the finger in the rectum may detect the cup-shaped end of the uterus above. In case the bimanual touch is not practicable, owing to the patient being very stout, or the abdominal muscles unyielding, the same signs can be obtained by passing a sound into the bladder and turning it backward until it meets the finger in the rectum above the uterus. To facilitate either or both of these methods of examination by the touch, the uterus may be drawn downward by a noose made of tape or rubber passed around the cervix, as recommended by Barnes. Chronic inversion is likely to be mistaken for fibrous polypus of the uterus. A number of mis- takes of this kind are on record, but most of them occurred before the time when the uterine sound and the bimanual touch were employed for diag- nostic purposes. The differentiation can usually be made by the methods of examination already de- scribed. In polypus, the uterine sound can be passed be- yond the tumor into the uterus above, whereas, in inversion, the progress of the sound is arrested at the neck of the uterus. The bimanual touch, rec- tal touch, and vesico-rectal examination, reveal the uterus above the tumor. The inverted uterus is tender, the polypus is not. This sign is of much value. By seizing the tumor and turning it around it will move in the cervix if it is a polypus. The rio. 126 -Polypus two surfaces will glide backward and forward upon simulating com- " , plete inversion each other, but in inversion no such motion can be (Thomas). produced. Incomplete inversion is not easily diag- nosticated under the most favorable circumstances. To distinguish partial inversion from an intra-uterine fibroid of small size is next to Fig. 125.—Polypus simulating partial inversion (Thom- as). 270 DISEASES OF WOMEN. impossible. Fortunately, such a diagnosis is not imperative, because active treatment is not often called for in these incomplete and doubtful cases. Prognosis.—Inversion is always a grave condition. If it does not prove fatal at first from shock and hemorrhage, it becomes a continuous trouble, which either gradually undermines the general health, and thereby shortens life, or else keeps the subject in a state of impaired usefulness and ill health. There is no certain tendency to natural recovery, and although quite a number of cases hive been recorded in which spontaneous replacement of the uterus was said to have taken place, such an occurrence must be very rare. From the fact that most of these cases are recorded by the older authors, it is possible that in some of them the diagnosis was incorrect. One thing is certain, no such fortunate termination should be expected or relied upon. Without treatment the condition will probably continue. The prognosis is rendered more grave by the fact that the treatment is not without danger. There are several methods of treating inversion, but neither of them is wholly safe. This statement applies to chronic inversion. When the inversion occurs during labor, immediate replacement is easy and not attended with any great risk. The dangers in restor- ing an old inversion are from inflammation and septicaemia, pro- duced by the injuries to the uterus, vagina, and adjoining parts during the violent efforts necessary to accomplish the object. These dangers are greatly increased by unskillful operating, still unfortunate results have occurred in the practice of the most skillful surgeons. Causation.—The conditions which predispose to inversion are enlargement of the uterus and relaxation of its tissues. These are best illustrated in the puerperal state. Inversion can not take place in a normal non-puerperal uterus. The condition of the uterus im- mediately after the delivery of the child is most favorable to the accident, and it is at this time and under these circumstances that inversion most frequently occurs. Predisposing causes, other than pregnancy or parturition, are known, but they are operative in bringing about a condition of en- largement of the uterus and relaxation of its tissues. These are distention of the uterus from tumors or fluids. The relaxation of tissues which is found in imperfect involution and prolapsus is also given as a predisposing cause, but I have not seen the record of any case which could be clearly traced to this cause. To briefly restate this matter, the tendencies to inversion depend upon enlargement, distention, and relaxation. The exciting causes INVERSION OF THE UTERUS. 271 are traction or pressure upon the fundus uteri when it is in a con- dition favorable to inversion. The direct causes are traction upon the umbilical cord or pressure upon the fundus uteri at the moment when the child is expelled, or sudden delivery of the child, either by traction or the natural muscular efforts. Muscular efforts, when there is relaxation of the uterus, are mentioned as a cause, and cases are recorded in which inversion is said to have occurred in that way, but that cause must be seldom operative. Prolapsus uteri is also credited with having some causative relation to inversion, but I have no knowledge on this subject. Next to parturition come intra- uterine tumors in the causation of inversion. All the cases which have come directly under my own observation, or that have come to my knowledge indirectly through competent contemporary authori- ties, have been clearly traceable to parturition or fibrous polypi. The conditions are alike in pregnancy and intra-uterine tumors, so far as the uterus is concerned in the predisposition to inversion. There is enlargement of the uterus with relaxation followed by muscular contraction. During the growth of the tumor the uterus increases in size, and finally endeavors to expel the growth, and when the muscular contractions are going on the fundus uteri is dragged downward by the pedicle of the tumor. In this way all the predisposing and mechanical conditions are present which are most competent to cause inversion. Treatment.—There are several methods of managing inversion. Of course the indications are to restore the uterus to its proper rela- tions. This is often difficult in chronic inversion, and sometimes impossible, hence other means must be employed to give all relief possible. In case replacement can not be accomplished, the most promi- nent symptoms should be relieved by treatment; hemorrhage should be controlled by astringents and inflammation should be reduced by appropriate care. Inversion can be successfully treated if seen im- mediately after it occurs. The method of operating is to grasp the uterus in the right hand, and carry it upward until the cervix can be felt with the left hand through the abdominal wall; counter- pressure is then made while the fundus uteri is being forced upward with the right hand in the vagina. The abdominal walls being thor- oughly relaxed, as they are immediately after confinement, the bi- manual manipulations are comparatively easy. The os uteri can be felt with the left hand, and by pressing the abdominal wall down into it with the fingers it is dilated, and when the fundus is restored far enough to engage in the os, the lips of the cervix can be pushed 272 DISEASES OF WOMEN. over the fundus, in the same way that they are pushed over the head of the child in delivery. Cases of Recent Inversion.—I have seen four cases of inversion soon after they occurred, one in my own practice and three in con- sultation. Two of these were inversion with complete prolapsus, and the other two were uncomplicated. My own case was that of a strong young woman in her second confinement. The pelvic outlet was rather narrow, and the perinseum rigid, so that the pains which ex- pelled the head were most powerful, especially the last one. The moment that the head passed the perinseum the whole child was expelled with extraordinary force. While the nurse rested her hand upon the abdomen I tied the cord, and then I found the placenta presenting at the vulva. I passed my finger up to bring the edge down and then deliver it, but I found a hard body above to which it was attached. I then passed my left hand over the abdomen, and found that the uterus was not there. Inversion was suspected, and I at once separated and removed the placenta, which was very easily done in this case, and then with bimanual manipulation restored the uterus with the greatest facility. The removal of the placenta and the reduction of the uterus occupied but a moment. The patient did not apparently suffer, but I think that there was slight shock and consequent ansesthesia, so that the reduction was painless and finished before she reacted. I found I could grasp the fundus easily, and by making firm press- ure upon one corner with my thumb and upon the other with the middle finger, and thus raising the whole uterus up until I could feel the os with the fingers of the left hand, the pressure and counter- pressure effected the reduction with ease and rapidity. I found that the reduction of one horn first, as recommended by Dr. Noeggerath, answered well, first because the horn was more easily brought under pressure, and also because it appeared to yield most readily. In grasping the uterus the thumb naturally rests upon one horn, and by making firm pressure at that part, which is more convenient than to press upon the center of the fundus, it appears to be the natural way of effecting reduction by the unaided hand. The hand was made to follow up the reduction, so that when it was completed the hand was fully within the uterus, and it was left there, and pressure upon the uterus with the left hand upon the abdomen was made until the uterus contracted and the hand was expelled. This was the part of the procedure which required the most time, owing to the uterus being slow to contract. INVERSION OF THE UTERUS. 275 The tliree other cases were seen in the practice of others. One that I saw with Dr. A. R. Matheson, was a complete prolapsus as well as inversion. I saw the patient in about half an hour after the inversion occurred. There was considerable shock, and the doctor was obliged to hold the uterus with the placenta attached in the firm grasp of both hands to prevent haemorrhage. The prolapsus was reduced first and then the inversion, in the same way and in about the same time as the case just described. I saw another case of in- version and prolapsus with Dr. Bliss. It was of three days' stand- ing. The doctor did not attend in confinement, but was called to see the patient because of the inversion. When I saw her she was exceedingly weak. The pulse 140, and feeble. She was ansemic, and the abdomen greatly distended and tender to the touch. The uterus was resting between the limbs, and parts of the mucous mem- brane here and there were in a sloughing condition, and other por- tions were dry and glazed looking. Vaseline was applied over the whole surface, and the uterus first pushed up into the vagina and then grasped with the hand, and the inversion reduced. The opera- tion in this case was more difficult and prolonged. Owing to the tympanitic state of the abdomen it was difficult to make proper pressure upon the lips of the cervix, and that was a cause of delay. The extreme depression of the patient (while it raised a doubt as to her being able to stand the operation of reduction) gave that com- plete relaxation and general anaesthesia which was favorable. Ko anaesthetic was given. In about ten minutes the reduction was effected. The patient recovered. One other case I saw with Dr. Bodkin. The inversion occurred at two o'clock, and three hours later it was reduced. There was some excitement of the pulse, and the patient had pelvic pain. There was very little haemorrhage, but there had been considerable at the confinement. Chloroform was administered, and the reduc- tion was accomplished by the same method. More time was required than in either of the other cases, because there was more contraction uf the uterus, but by means of upward pressure and counter-pressure upon the lips of the cervix the reduction was accomplished in a short time. Chronic inversion is far more difficult to manage than recent in- version. In fact, when the inversion has existed long enough to permit the uterus to regain its original size, or nearly so, by involu- tion, and has contracted firmly, its reduction is always difficult, and sometimes impossible. This has led surgeons to devise several methods of reducing this inversion under these circumstances. 39 274 DISEASES OF WOMEN. Dr. Thomas has classified these methods as follows: Method> of effecting gradual reduction and methods of effecting rapid reduc- tion. The method of reduction by taxis is the oldest and most re- liable, and should be tried first in all cases, because, if it fails, the gradual reduction may be tried subsequently, providing that the taxis is not so violent and prolonged as to cause fatal inflammation. There are several ways of applying taxis, but only two ways of attaining the desired end. The principle of the one is to reduce first that portion which was last inverted, and the other is to reduce the fundus first and dilate the cervix at the same time, so that the portion first inverted is first reduced. To some extent both objects may be attained at the same time by so manipulating that both changes of position may go on together. The method of operating is as follows: The patient should be placed upon the operating table in the dorsal position, and the surgeon's hand carefully in- troduced into the vagina. It is necessary to dilate the vagina, in the great majority of cases, in order to admit the hand. Some- times the dilatation is difficult to accomplish with the hand without rupturing the vagiua. When this is the case, dilatation as a pre- liminary measure should be accomplished by stretching with the speculum and the inflatable rubber bag. The right hand is introduced into the vagina and the uterus grasped with the thumb and fingers. The uterus is compressed and at the same time carried upward, and held against the left hand, which makes the counter-pressure. The manipulations with the right hand should be so directed.that one or both horns should be reduced first. The cervix should be dilated, and reduction begun at that point at the same time that reduction of the horn is effected. Fortunately, the efforts to accomplish the one favor the other. This method of Noeggerath's, which has already been discussed, is that which I prefer, but there are certain modifications which are of value in certain cases, and should be employed when failure of the one method makes the trial of the modified methods necessary. For example, Dr. Thomas has employed a cone of wood in place of the left hand for dilating the cervix. In thin patients this can be inserted into the ring of the cervix, which can be felt through the abdominal walls, and gradually forced into the cervix until sufficient dilatation is obtained. Barren placed the fingers around the body of the uterus and the thumb upon the fundus, and forced the cervix against the sacrum to secure counter-pressure. Courty's method consists in using the index and middle fingers of the left hand in the rectum, to dilate the cervix and make coun- INVERSION OF THE UTERUS. 275 ter-pressure. This method of using the left hand combined with the method of Dr. Koeggerath is highly commended by Dr. T. G. Thomas. Dr. Emmet describes his method as follows : " In 1865 I succeeded in effecting a reduction by passing my hand into the va- gina, and, with the fingers and thumb encircling the portion of the body close to the seat of inversion, the fundus was allowed to rest in the palm of the hand. This portion of the body was firmly grasped, pushed upward, and the fingers wTere then immediately separated to their utmost; at the same time the other hand was em- ployed over the abdomen in the attempt to roll out the part form- ing the ring, by sliding the abdominal parietes over its edge. This manoeuvre was repeated and continued. At length, as the trans- verse diameter of the uterine cervix and os was increased by lateral dilatation with the outspread fingers, the long diameter of the body became shortened, and the degree of inversion proportionately less- ened. After the body had advanced well within the cervix, steady upward pressure upon the fundus was applied by the tips of all the lingers brought together." This method, which appears to me like Vandel's, is natural in theory, but in trying it I have found that I could not separate the fingers to any extent, owing to the fact that the extensor muscles are feeble in their action, and not capable of doing more than resisting the pressure of the vagina. Dr. Emmet also commends the closure of the cervix with silver sutures in cases where the reduction can not be completed. He gives a diagram representing the cervix as being about three times as long as the body, and drawn over the fundus and held there by sutures. I have never practiced this treatment for the reason that in all the cases in which I have been able to get the body and fun- dus reduced wholly within the cervix, the complete reduction has been easily and speedily accomplished. Again, I can not see how sutures of any kind would resist the pressure of a partially inverted uterus, with a strong tendency, which there always is, to become further inverted. Repositors have been used to aid in the taxis by De Paul, Avel- ing, White, and others. The most useful of these, and one that fulfills the requirements is that invented by Dr. John Byrne, of Brooklyn. It consists of a cup and stem with a movable plug or button in its center. The button forms the bottom of the cup when it is placed over the uterus, and while the cup is in place the plug 's pushed forward by the screw in the handle against the fundus, and in that way makes the required upward pressure. 276 DISEASES OF WOMEN. Fig. 127.—Byrne's method of reduction. Fig, 127 shows Dr. Byrne's repositor as used, and its cup or bell-shaped instrument with the plug and screw adjustment for making counter - pressure and dilatation of the cervix. A piston in the lower cup pushes the fundus up. There are a number of ad- justable cups which can be adapted to the require- ments of different cases. Cases are sometimes met which can not be restored by taxis. Resort must then be had to such means as gradual reduction by con- tinuous pressure. This is effected by a cup and stem (Fig. 128) which are held in place by a perineal band of rubber or elastic fastened to a bandage applied around the pelvis. When using this instrument care must be taken to keep the uterus in the line of press- ure. When the va- gina is relaxed the uterus may fall backward or for- ward out of the line of pressure ; this can be avoided by using a tampon around the uterus, which may be worn for two days if no great distress is caused by it. It should be examined from time to time, and if there IS much Fig. 128.—Cup pessary to exercise gradual pressure (Thomas) INVERSION OF THE UTERUS, 277 irritation the instrument should be removed and vaginal injections used until relief is obtained, and the use of the instrument may be again resumed. The rubber bag filled with water answers a very good purpose. To apply this, the patient should be placed in Sims's position, and through the speculum, the upper portion of the space between the uterus and vagina should be filled with prepared wool; then the bag should be introduced between the fundus uteri and the pelvic floor, and distended with water. A firm perineal band is then used to support the pelvic floor. Dr. Thomas recommends a strip of adhe- sive plaster for the perineal band, one end being fastened to the 6acrum and the other to the abdomen, with two openings, one for the tube of the bag, and the other opposite the urethra to permit urination. I prefer the ordinary muslin or elastic band, because it is more easily removed and readjusted. The degree of pressure and the time which it should be continued must depend upon the re- sults. If there is much pain or irritation the treatment must be sus- pended. The combination of elastic pressure and taxis has been employed with advantage. After the pressure has been used for a time taxis should be tried, and in case this fails the elastic pressure should be again attempted. Care must be exercised in the use of taxis—it should not be too violent or long-continued; this must be de- cided by the operator in each case. Dr. Charles Martin, of France, succeeded by using a stream of nold water projected against the fundus uteri, through the speculum. This he employed twice a day. The stream was thrown with con- siderable force; he also filled the speculum with cold water, and kept the uterus in it three or four minutes. Dr. T. G-. Thomas, from whose work I take the above statement, approves of this method. Dr. Thomas has devised another method, which I understand he employs or advises where other methods fail. The following is taken from his work on diseases of women: " Thomas's^ method consists in abdominal section over the cervical ring, dilatation with a steel instrument, made like a glove-stretcher, and reposition of the inverted uterus by any one of the methods mentioned, by the hand in the vagina. Fig. 129 will render this clear. " This procedure, let it be remembered, is not offered as a method of treating inversion of the uterus, but as a substitute for amputa- tion. Few cases will, I think, resist elastic pressure and judicious taxis; but that some will do so can not be questioned. It is to 278 DISEASES OF WOMEN. save these few cases from amputation that I suggest abdominal section. "One of the cases operated on in this way has proved fatal. Let it not be forgotten that a certain number of these cases treated by elastic pressure and by taxis likewise do so, for, as in my second case, these operations are often performed upon exsanguinated women whose blood is impoverished. One instance of death after reduction by elastic pressure is recorded by Dr. Tait in the eleventh volume of the ' London Obstetrical Transactions,' while one of the earliest cases on record reduced by taxis—that of Dr. White, of Buffalo, likewise ended fatally." One other method is worthy of mention, name- ly, that of Dr. Brown, of Baltimore. He makes a free incision in the fun- dus uteri, and through the opening thus made he stretches the cervix and then reduces by taxis. In ease of failure of all ef- forts, hysterectomy may be performed. This, I consider advisable, if the patient is near to or past the menopause, but it should not be un- dertaken until all other methods have failed. There are several methods of amputating the inverted uterus. Dr. McClintock applied a string ligature around the highest portion which strangulated the uterus, and in two or three days when de- composition of the tissues began, he amputated. Hegar accom- plished the same object by passing strong sutures through the cer- vix, and after drawing them tight enough to close the vessels and close the peritoneal cavity, the body was amputated. It will suffice to simply mention amputation without giving elab- orate details. It was frequently practiced in the past, but is sel- dom heard of now. Other methods succeed, and with the method of Thomas in reserve—in case pressure and taxis fail—amputation will seldom, if ever be called for. Cases might be quoted to illus- trate the treatment of chronic inversion, but they would add noth- ing of value to the methods of operating given above. Fig. 129.—Replacement of uterus by dilatation through abdomen. (Thomas.) CHAPTER XVII. DISLOCATIONS OF THE UTERUS. The uterus is peculiarly subject to physiological changes of position. The bladder in front causes the uterus to move forward and backward according to its dilatations and contractions. In a similar but much less extensive way, distention of the rectum acts to push the uterus forward. The abdominal pressure from above is constantly changing, and is, therefore, constantly affecting the posi- tion of the uterus less or more. The movements of the uterus under the influence of the ever varying degrees of abdominal press- ure are easily observed by watching the anterior vaginal wall and uterus through a Sims's speculum in the living subject. There is an up and down motion, very limited but constant, caused by ordi- nary respiration, and under extra exertion, such as coughing, the displacement becomes very marked. Below there is the pelvic floor, which has least of all to do with changing the position of the uterus, and yet much to do in counter- acting the inclinations to displacement produced by other influ ences. These changes of position, when limited in degree, are physio- logical, the organ promptly returning to its original position as soon as the displacing influence is removed. It is only when the uterus remains displaced permanently or is carried far beyond the physio- logical limits that the dislocation is to be regarded as pathological. When this occurs, the malposition gives rise to suffering from de- ranged menstruation, circulation, and innervation, and in some cases to sterility. Usually, the functions of the bladder and rectum are disturbed and the general system suffers from reflex influences. It is only when such symptoms as these are present that displacements of the uterus claim the attention of the gynecologist. In order to fully comprehend displacements of the uterus it is very necessary that the normal position of the uterus should be 280 DISEASES OF WOMEN. clearly understood, and this can only be attained by a knowledge of the anatomy of the pelvic organs. Anatomy.—In discussing this subject attention will be chiefly directed to the position of the uterus in the pelvis, its relations to neighboring organs, and the position and character of the structures which keep it in position. One would naturally turn to the cadaver in the hope that by careful dissection the exact position of the uterus could be deter- mined, but after life is extinct the uterine supports lose their firm- ness, and changes of position usu- ally take place. Moreover, it fre- quently happens that the pelvic or- gans are less or more displaced toward the end of life, so that a normal state of the parts is not often found in the cadaver. Dis- section also tends to displacement, no matter how carefully it may be performed. To obviate this, sec- tions of the frozen subject have been made, and much valuable in- formation obtained from them. Still, the greater part of useful in- formation on this subject must be obtained from careful and oft-repeated examinations of the living subject. With information obtained from all these sources there are still differences of opinion among authors on certain points. Under the circumstances, in place of giving a number of conflict- ing opinions, it will be better to give the views which I have adopted as the result of my own observations on the living subject, and after a careful investigation of the views of others. In the first place, it may be said that the uterus is wholly within the true pelvis. The line on the diagram running between the symphysis pubis and the promontory of the sacrum divides the true pelvis from the abdomen, and all the pelvic organs, the uterus included, are below this plane, the superior strait, as the obstetricians call it (Fig. 64). The long diameter of the uterus in the pelvis corresponds very nearly to the axis of this plane, as represented by the line (Fig. 130), and it is equidistant from the sides of the pelvis. The position of the uterus varies from time to time, as already Fig. 130.—Section of pelvis, showing its inclination and the axis of the inlet. DISLOCATIONS OF THE UTERUS. 281 stated, but in all its changes it returns to the axis of the inlet of the pelvis, slightly behind the center of the true conjugate. This is not mathematically correct, but is sufficiently so to form a basis from which further studies, both anatomical and clinical, may be con- ducted. In order to obtain some idea of the position of the uterus and the influences which the other pelvic organs have in changing this posi- tion, reference should be made to Fig. 64, which shows a section of the normal pelvis. Fig. 131 shows the changes in the position of Fig. 131.—The normal range of the uterine axis, varying according to the distention of the bladder; a, with bladder empty ; d, with bladder full (Van der Warker). the uterus during the several degrees of distention of the bladder. These physiological changes should be noted and the causes which give rise to them, in order that they may be recognized clinically. Xext in the order of inquiry are the anatomical structures by which the uterus is held in position. This requires a consideration of the 282 DISEASES OF WOMEN. structural associations of the uterus and all the other pelvic organs and tissues. The position of the several pelvic organs may be given in a general way as follows: The uterus in the center, Fallo- pian tubes and ovaries on either side, the bladder in front, rectum behind, and the vagina below. Covering all of these, except the vagina, is the peritonaeum, which is the chief bond of union be- tween the upper portions of the pelvic organs, and out of which are formed the ligaments which have much to do in keeping the uterus in place. The peritonaeum, while it covers the pelvic organs, is attached to the bony walls of the pelvis through the medium of the periosteum and areolar tissue, so that one end of each liga- ment may be said to have an attachment to the inner side of the pelvic bones. The round ligaments are anatomically an exception to this rule. They contain muscular tissue in considerable quan- tity, and are really outgrowths from the uterus in the form of round cords, which start from the uterus near the proximate ends of the Fallopian tubes, and sweeping round the outside of the pelvis. pass out through the inguinal rings into the labia majora. These ligaments, as well as all the others, can be seen by looking down upon the pelvic organs in situ. The uterus is seen in the middle of the pelvis, and extending across on either side of it are the two broad ligaments made up of the two folds of peritonaeum, which unite after covering the uterus. Running backward from the uterus to the sacrum are those peritoneal folds known as the utero-sacral liga- ments. Between the uterus and the bladder, on the sides of the latter, the folds of peritonaeum form the utero- vesical ligaments. These ligaments Fig. 132.—Diagram of the uterine liga- are so called, not because they are ments as seen on looking into the brim. , ,. -,. , composed of ligamentous tissue, but rather because they perform a function similar to that of ligaments. With the exception of the round ligaments which are composed of muscular tissue covered with peritonaeum, the others are made up of double folds of peritonaeum containing between these folds are- olar tissue and some fibers of the pelvic fascia. An idea of the position of these ligaments and their relations to the uterus may be obtained from Fig. 132. I have noticed that, in the dissecting-room, gentlemen are not able at all times to find the utero-sacral and utero-vesical ligaments; the broad and round ligaments they easily note. The others can be DISLOCATIONS OF THE UTERUS. 283 brought into view in the following manner : If the uterus be drawn well forward by a tenaculum, two tense bands will be seen, the utero- sacral ligaments, extending from the side of the uterus back to the sacrum, and as they are thus raised up a pouch of peritonaeum ap- pears between them. This is the sac of Douglas. By reversing this manipulation, and drawing the uterus backward, the utero- vesical ligaments will be seen running forward on either side of the bladder. The utero-vesical ligaments, in addition to their attachments to the uterus and bony walls of the pelvis, are also connected indirect- ly to the anterior vaginal wall by intervening areolar tissue. The utero-sacral are connected in the same indirect way with the upper portion of the posterior vaginal wall, and also to the rectum, on the left side at least. At the junction of the supra-vaginal portion of the cervix and body of the uterus all the ligaments, except the round ones, are attached. Here also the anterior and posterior vaginal wall and a portion of the bladder join these other structures. The union of these structures at this point is not direct, but is through the intervention of areolar tissue which is found in con- siderable quantity in this region. From this it will be seen that these ligaments are continuous from side to side, and also from be- fore backward. The chief function of these ligaments, aided by the anterior vaginal wall, is to keep the uterus and bladder in position. This is clearly evident from the mechanical principle apparent in the anatomical arrangement of the parts in question, and from the fact that the uterus remains in place for a considerable time when the pelvic floor is defective, and the abdominal pressure more marked than normal. In short, many cases have been seen clinically in which all the other means that could possibly contribute to supporting the uterus were removed by disease and injuries, and yet the uterus was main- tained in position under ordinary circumstances. The most rational idea of the means and ways by which the uterus is maintained in the pelvis I obtained from the following statement by Dr. Frank P. Foster. Speaking of the supports of the uterus, he says: " Ordi- narily, they consist wholly of the anterior wall of the vagina in front, and the utero-sacral ligaments behind, which together con- stitute what may be called a beam traversing the pelvis antero- posteriorly on which the uterus rests, being interposed between them, firmly attached to the one anteriorly and to the other poste- 284 DISEASES OF WOMEN. riorly, making them, so far as mechanical effect is concerned, one structure." This is a clear and comprehensive statement of the prin- ciples upon which the utero-sacral ligaments and the anterior vagi- nal wall act in supporting the uterus. I would go one step further than Dr. Foster, however, and claim a like function for the other uterine ligaments. The broad ligaments, firmly attached to the bony walls of the pelvis, and holding the uterus in their folds, make a continuous structure extend- ing across the pelvis in its transverse diameter. These structures, taken to- gether, act like " beams" or (to be more mechanically accurate) cables of a suspension-bridge, which support to a large ex- tent the uterus in its center. The utero - vesical ligaments also supplement the anterior vaginal wall as a supporting medium. According to this view of the subject, the chief supports of the uterus are the vesico-uterine, and broad liga- FlG, 133.—Section of pelvis with the slings of the uterus; behind, the utero-sacral liga- ments ; in front, the anterior vaginal wall (after a section by Hart). anterior vaginal wall, utero-sacral, ments. Fig. 133 shows a section of the pelvis with these ligaments and the anterior vaginal wall with the uterus resting upon them. Fig. 134 shows a transverse section of the pelvis just in (&jS&a< front of the uterus and broad nvx ligaments, and represents these structures and the manner in which they support the uterus. A similar function may be claimed for the round liga- ments, at least so far as their effect in preventing the back- ward displacement of the uter- us. Some have claimed that the round ligaments have but little supporting power to sustain the uterus in place, while oth- ers give it much credit in this direction. Those who believe in Fig. 134.—Diagram of the uterus slung between the broad ligaments. DISLOCATIONS OF THE UTERUS. 285 Alexander's operation of shortening the round ligaments for the relief <>f retroversion of the uterus certainly claim great supporting power for these ligaments, and with good reason, I think. Finally, I may add, that I believe that the ligaments, the vagina, and the other pelvic organs all aid in keeping the uterus in position, and are sufficient to do so under ordinary circumstances. Still, when extraordinary strain is brought to bear upon the pelvic organs, the pelvic floor supplements these supporting structures. Moreover, the relation of the trunk to the pelvis has much to do, if not in keeping the pelvic organs in place, certainly in freeing them from pressure from above. The pelvis is so placed that, in the erect posture, its cavity is be- hind rather than beneath the abdomen, and the abdominal muscles partially divide the greater cavity from the lesser. This is shown in the accompanying diagram, where the arrow indicates the direction of the force transmitted to the pelvis through pressure from above (Fig. 135). There is very little direct ab- dominal pressure upon the pelvic organs in the erect posture. The axis of the pelvis is backward and downward, while that of the ab- domen is perpendicular, so that the pressure is indirect from above. Some claim that a suction power is exerted upon the pelvic contents by the diaphragm. It is said to act like a piston in the cylinder of a pump. There is reason to be- FlG- 135.—The normal inclination of the !• ,-. . , . . . pelvis and the transmission of force lieve there is something m this, from above. from the fact that, on examination through a Sims's speculum, the uterus is seen to rise and fall with respiration. This motion is to a large extent arrested when the pa- tient is in the erect posture. If it is a fact, as it appears to be, that the abdominal organs are fixed by suspension in their normal position, and that in their descent during this limited motion the pressure upon the pelvic organs is indirect, then this relationship contributes to maintain the position of the pelvic organs as surely as if there were some traction or sue- 286 DISEASES OF WOMEN. tion action of the diaphragm tending to draw these organs up- ward. In regard to the pelvic floor and its relations to the displacements of the uterus, that subject has been fully discussed under the head of injuries of the pelvic floor. It is only necessary to repeat my belief already expressed to the effect that, while the pelvic floor docs not directly support the uterus, it indirectly aids in doing so, and if it is lost from injury prolapsus of the pelvic organs follows as a rule. DISPLACEMENTS OF THE UTERUS. There are a great many forms of displacement of the uterus, if every change of position of that organ be taken into account, but of those that occur as primary affections there are only two that are often seen, and one that is very rare. These are downward, back- ward, and forward—that is, prolapsus, retroversion, and antever- sion. Prolapsus and retroversion are really the only forms of displace- ment which practically claim attention in this connection. These the gynecologist is called upon to treat daily as primary affections. Occasionally, a case of anteversion may be seen which apparently is not caused by some other affection more important than the conse- quent displacement, but this is exceedingly rare. Again the uterus may be anteverted to a considerable extent without causing the slightest trouble. This form of displacement (quite a rare one) is generally produced as a consequence of some other disease, either of the uterus itself or the organs and tissues around it, or else when it does occur it gives no trouble ; and, as a rule, very little can be done to relieve it by the ordinary methods of treating uncomplicated dis- placements. Taking all this into account, it is evident that the downward and backward displacements alone demand special atten- tion, either in practice or in the discussion of the subject. The other forms of displacement of the uterus, described in text- books, are the right and left lateral anteversions and retroversions. These displacements are al ways due either to some lesion of develop- ment or to some previous affection, the products of which either push or pull the uterus out of place. There is also a retrocession of the uterus and an antecession, which are not described in books. Perhaps better names for these would be transposition backward or forward. In these dislocations the uterus is found either behind or in front of the axis of the pelvic cavity, or superior strait. These, like the lateral dislocations, are secondary to some abnormal state DISLOCATIONS OF THE UTERUS. 2S7 which caused them, and hence they are to be looked upon as signs and consequences of the primary disease. By adopting this classification it simplifies the subject very much, and leaves one free to give attention to the downward and backward dislocations and their pathology, diagnosis, causation, and treatment. Again, the two forms of displacement in question are the onlv conditions of malposition that can be directly treated with favorable results. In the other forms, such as lateral versions, treat- ment must be employed to remove the morbid states which push or pull the uterus out of place, and therefore, the discussion of such displacements should be confined to the diseases which cause them. PROLAPSUS OF THE UTERUS. This is a downward displacement of the uterus commonly called falling. It is of necessity always associated with displacement of the other pelvic organs and tissues, to a greater or less extent, according to the degree of descent of the utenis. There are several de- grees of prolapsus uteri which have been various- ly described. While au- thors designate the most important stages of de- scent by degrees, it should be understood that practi- cally there is no line of demarkation between the degrees. According to this arrangement, when the uterus sinks so that the cervix rests entirely on the pelvic floor, it is named prolapsus of the first degree ; when the uterine axis has be- come vertical or coincides with the axis of the outlet, the cervix ap- pearing at the vulva, the second degree is present; while in the third degree the organ is partly or wholly outside the introitus. Fig. 13i! shows the three degrees, and may convey a clearer idea than further description. Fig. 136.—The three degrees of prolapsus. The upper outline is a little above the normal position. 2S8 DISEASES OF WOMEN. By some authorities all the degrees of prolapsus in which the uterus still remains within the vulva are termed incomplete, while those in which it protrudes partially or completely beyond the vulva are called completeo This latter arrangement of the subject is perhaps as easily com- prehended and as useful in practice as any other. The complete degree is often spoken of as procidentia. Pathology.—Prolapsus of the uterus takes place slowly, as a rule. Sudden prolapsus may possibly occur, but it must be a rare thing, ex- cept in the first degree. In the few cases that I have had an oppor- tunity of watching from beginning to completion, the displacement has been gradual At first the uterus descended to the first degree of prolapsus, and then to the second, and finally to the third or com- plete stage. The time occupied in making the complete descent varies from months to years. The changes which take place in the supports of the uterus and the other pelvic organs during the pro- gressive development of the prolapsus are usually the same in all cases with few exceptions, but the order in which they appear differs according to the cause of the descent. This again depends upon the point in the structures at which the lesions begin to develop. There are three methods of development of prolapsus. In the first, the uterus begins to descend because it is too heavy and makes too great demands upon its immediate supports, or else these supports become defective from pathological changes. This is a descent of the uterus from loss of direct support. The second order of descent is by loss of the pelvic floor, which permits the vagina, bladder, and part of the rectum to descend, and then the uterus follows. The third in order is made up of the two others, the first and the second, all the conditions mentioned in those being operative at the same time. The changes in the supports are elongation from imperfect in- volution after parturition, or stretching produced by enlargement of the uterus, or pressure on it from above by long standing, stooping. or lifting. In the former condition the supports are too long; in the latter they are attenuated as well as elongated. In both states the upper portion of the vagina is distended and the bladder slightly prolapsed or drawn backward. There is also, in some cases, loss of the areolar tissue, and the pelvic fascia has lost its strength of liber. This traction upon the rectum, bladder, and the blood-vessels is pre- sumed to interrupt the return circulation. Whether that is a fact as regards the causation or not, there is usually a passive hyperaemia of the parts in these displacements. These changes of the positior DISLOCATIONS OF THE UTERUS. 289 and relations of these parts are gradually developed. In case the prolapsus proceeds to the third degree, the pelvic floor gives way under the influence of the continued pressure. The perineal mus- cles become overdistended and the vulva enlarged, until the uterus is permitted to protrude without resistance. In the second order of the development of prolapsus—that is, where the loss of the pelvic floor is the starting-point of the mal- position, the first lesions appear in the vagina. The walls of the vagina at the introitus begin to protrude and their descent is gener- ally attended with increase of tissue. Usually both walls prolapse together, but in many cases one or the other takes precedence. As the prolapsus progresses the bladder and anterior wall of the rectum descend, producing rectocele and cystocele. In due time the uterus follows with all the changes in its supports already described above. There are cases in which the prolapsus begins at the lower part of the vagina, while there is no apparent injury of the pelvic floor. This has been accounted for by imperfect involution of the vagina after,child-bearing. The large, heavy, and lax walls of the vagina make undue pressure upon the pelvic floor and it gives way before them. A similar state of things occurs, so far as appearances are concerned, where there has been subcutaneous laceration of the mus- cles of the pelvic floor which impairs its function. Prolapsus of long standing changes the structure of all the tissues. Atrophy of the muscular tissue of the vagina and pelvic floor occurs, and the ligaments of the uterus lose their character- istics so that they can not be restored to their original state by any means. There is a prolapsus which occurs as the result of degeneration of the supports of the uterus. It occurs in feeble old women in whom general nutrition is greatly impaired. The perinseum and vagina lose their elasticity, the adipose and areolar tissue disappear, and the vaginal walls, bladder, and atrophied uterus descend. Such patients are also subject to prolapsus of the rectum and sometimes prolapsus of the mucous membrane of the urethra. I have called this senile prolapsus to distinguish it from the ordinary descent of the uterus which usually occurs in middle life. I believe it to be due to the general atrophy of the pelvic viscera because of the time of life when it occurs, and the fact that I have seen it in those who have not borne children. The first case that I carefully studied was in an old maiden of seventy years of age. Symptomatology.—The natural history of prolapsus uteri as manifested by symptoms and physical signs, differs to some extent 20 290 DISEASES OF WOMEN. in different cases, though the pathological conditions appear to be the same in all. The suffering caused varies according to the general health and nervous sensitiveness of the subjects affected. What is more strange still, is the fact that incomplete prolapsus often causes more suffering than the more advanced stages. It is not an uncom- mon thing to see a patient with complete prolapsus of the uterus who complains less than another in whom the uterus is still within the pelvis. The symptoms indicative of prolapsus uteri maybe classed under two heads : First, the derangement of the functions of the other pelvic organs, and, second, the disordered nutrition of the tissues of the pelvic viscera generally. The dragging of the uterus upon the bladder and rectum, and the abnormal pressure cause irritation, which gives rise to rectal and vesical tenesmus. The constant desire to evacuate the rectum and bladder, is often very distressing. These symptoms are greatly aggravated by walking, lifting, coughing, and especially by standing, and they are all relieved in a very marked degree, often completely so, by lying down. This difference in the feelings of the patient, when in the erect or recumbent posi- tion, is a diagnostic point of very great value. The recumbent po- sition generally gives relief in the majority of the diseases of the pelvic organs, but not so markedly as in displacements of the uterus. The malnutrition produced by irritation and deranged circula- tion leads in time to inflammatory affections of the uterus and other pelvic organs. This is not an acute inflammation which can be seen, but a hyperaemia accompanied by tissue changes such as areolar hy- perplasia and catarrhal states of the mucous membrane. It is prob- able that the endometritis so common in prolapsus uteri may, in many cases, precede the displacement, but the displacement certainly tends to keep it up. The symptoms of these affections need not be given here. The symptoms manifested by the general system in this affec- tion are not marked nor special. Beyond the backache and deranged digestion which often accompany prolapsus, and the depression which comes from a consciousness of having some chronic ailment which impairs locomotion and general usefulness, there is not much that need be mentioned. Physical Signs.—In prolapsus in the first degree, the uterus presses the posterior vaginal wall downward, and encroaches upon the rectum to some extent, at the same time it inclines backward. In some cases the cervix rests so heavily upon the floor of the pelvis that it becomes flattened. This is easily detected by digital exam- DISLOCATIONS OF THE UTERUS. 291 ination, which reveals the descent of the uterus. The space from the pubes to the anterior wall of the body and fundus uteri is en- larged and remains so when the bladder is empty. The upper por- tion of the vagina is often relaxed and wider than normal. cervix Fig. 137.—Prolapsus uteri with cystocele. In the second degree of prolapsus, the os points toward the os- tium vaginae, and is at or near the vaginal outlet. The fundus uteri lies back toward the sacrum but not usually so far as in marked re- troversion. In complete prolapsus the uterus protrudes from the vagina, and can be easily recognized by inspection. In this third degree of prolapsus, the bladder and anterior wall of the rectum are usually drawn with the uterus, and in extreme cases, the urethra also. The extent to which these organs accompany the uterus in its descent varies considerably. This may be determined by passing a sound into the bladder and ascertaining its direction, and the same means will show the extent of the prolapsus of the rectal walls. 292 DISEASES OF WOMEN. Diagnosis.—The affections which simulate prolapsus uteri are hypertrophic elongation of the cervix, fibrous polypus, and inver- sion. A polypus and an inverted uterus may be excluded by the absence of the os and cervical canal, and by the fact that they are covered with the mucous membrane of the uterus, while the pro- lapsed uterus is covered with the mucous membrane of the vagina. The elongation of the neck of the uterus can be detected by passing the sound, and at the same time pushing the uterus up into the pelvis, until the fundus can be detected by palpation of the ab- domen ; that is, by making the bimanual examination. The fact that this hypertrophy of the cervix occurs, as a rule, in those who have not borne children, will also aid in the diagnosis. There are cases of prolapsus in which the uterus is greatly relaxed, and be- comes elongated, so that the sound, when passed to the fundus, shows a great increase in its long diameter. By replacing the uterus it becomes shortened very considerably; the shortening, I presume, is due to contraction or condensation of the tissues. This has been described by Emmet as a process of telescoping, but I think the term is ill chosen. One can not conceive of portions of the uterus being pushed into each other like sections of a tele- scope. In the physical examination of prolapsus, care should be taken to discover any compli- cations which may exist, such as neoplasms of the uterus, which greatly increase its size, abdominal tumors which crowd the uterus downward, and atro- phy of the muscles of the pel- vic floor and vagina. Causation.—The fine ad- justment of the uterus and the means which keep that organ in its place, and yet permit con- siderable motion, are such that any increase of weight of the one, or loss of strength of the other will cause displacement. The formation of the pelvis, and its position in relation to the vertebral column; the character of the V-.„>V.--"" Fig. 138.—The shallow pelvis with lessened inclination of brim. The direct action of the pressure from above is shown by the arrows. DISLOCATIONS OF THE UTERUS. 293 fiber of the uterine supports, the quantity and consistence of the areolar and adipose tissue; one's habits in regard to clothing, posi- tion in standing and sitting, if main- tained unduly long, character of oc- cupation, strength or weakness of general organization ; and the acci- dents and injuries incident to child- bearing, all have certain influences in causing dislocations of the uterus. A shallow and wide pelvis (Fig. 138) which is more than sufficient for the accommodation of its con- tents, while it is favorable to easy parturitions, predisposes to descent of the uterus. Again, if the pelvis is tilted forward, so that it is brought more immediately under the axis of the abdomen (Fig. 138) the pelvic organs are constantly under greater pressure than normal, and prolapsus ^ , 1 , . ti i riG. 139.—Increased inclination ox m- and retroversion are likely to OCCUr. let. Pelvic organs escape pressure. These facts regarding the form and position of the pelvis are factors of great importance in the problem of uterine displacement, and deserve more attention than has been given to them. The habit of walking erect has the effect of maintaining this favorable relation of the abdomen and pelvis, while stooping disturbs this harmony of relative positions. In this,both in regard to forma- tion and habit of standing and walking, there is the greatest diversity among women. The tissues of the uterine supports, when defective in quantity or quality, are incapable of performing their functions. These effects may be the result of imperfect development such as occurs in those of sedentary habits in youth, or they may come from debilitating diseases. In the one case they have never been well de- veloped, and in the other they have become atrophied. Standing and walking to an extent that is fatiguing, bring undue strain upon the pelvic organs, and if persisted in, will in time produce prolapsus. Active exercise, with liberal periods of rest, will tend to strengthen the uterine supports, but fatigue will overcome their power of re- sistance. Stooping forward while in the sitting position has a two- fold injurious influence—it interrupts the return-circulation in the pelvis and impairs the nutrition of the organs and brings increased 294 DISEASES OF WOMEN. downward pressure to bear on them. The position of the girl at the sewing-machine and that of the lady of leisure, bent over in her easy-chair while reading a novel, are alike hurtful, but worst of all, the school-girl, bending over her desk all day, while her body is, or should be developing, suffers the most injury. Among the errors in the use of clothing, the abuse of corsets does the most harm. I would not be understood as condemning corsets. Long use has ren- dered that kind of support necessary to highly civilized women, but tight-lacing forces the abdominal viscera out of place and in time displaces the pelvic organs. Heavy lifting, if persisted in, is a cause of displacement. This is noticed among the poor who do heavy work. The women of In- dia, who were at one time supposed to bear children with ease and impunity, and to suffer less from uterine affections than our Ameri- can women, are very subject to complete prolapsus uteri, caused no doubt from their want of care after confinement and in carrying heavy burdens. General weakness, induced by exhausting diseases and extreme old age, affects the pelvic organs very decidedly. This, no doubt, is the cause of prolapsus uteri in women with consump- tion and in the very aged. The most important, certainly the most frequent, causes of uter- ine displacement are the injuries and improper management incident to child-bearing. The condition of the uterine supports after partu- rition is that they are all greatly enlarged through the growth of gestation, and, while they are competent to maintain the large uterus which rests in the abdominal cavity, they must undergo involution in conjunction with the diminution of the uterus. If this involu- tion fails in the uterine ligaments and vagina while it goes on in the uterus the supports fail, because they are too long and relaxed. Im- perfect involution, not only of the uterus but of all the other tissues and organs of the pelvis, is seen to give rise to displacement. This imperfect involution may be due to post-partum inflammation or to the patient resuming the active duties of life before involution is completed. In regard to the injuries of the pelvic floor and their effect on the position of the uterus the reader is referred to the chapter on that subject. Finally, enlargement of the uterus, whether from imperfect in- volution, inflammation, or the presence of neoplasms, will cause prolapsus. This will occur although all the supports may be nor- mal ; the balance between the supports and the organs to be sup- ported being disturbed by the increased weight of the uterus, de- scent will occur. DISLOCATIONS OF THE UTERUS. 295 It should also be borne in mind that the abnormally large uterus will prolapse in spite of the normal supports, while, on the other hand, defective supports which permit a normal uterus to descend will give rise to enlargement of the uterus by congestion, swelling, and, finally, hyperplasia, and by this increase of weight will incline it to remain displaced. TREATMENT OF PROLAPSUS UTERI. There are four important objects to be attained in the treatment of prolapsus uteri: to restore the displaced organ, to keep it in place, to restore the supports of the uterus, and to remove complications and accompanying affections if any such exist. The restoration of the uterus to its proper place is performed as follows: The patient is placed in Sims's position, and, if the pro- lapsus is complete, the uterus is grasped in the fingers, and, while compression is made, it is pushed upward in the axis of the pelvic cavity. By these means the displacement is reduced from the third degree to the second; then the perinseum should be retracted with Sims's speculum, and with two sponges in holders the uterus should be raised to its normal elevation. Difficulty in accomplishing this is sometimes caused by the fundus uteri turning backward while the upward pressure is being made, so that, in place of overcoming the displacement, the prolapsus is changed to a retroversion. This can be guarded against by making the pressure mostly on the posterior side of the cervix. Passing the sound and making it guide the uterus in the right direction while upward pressure is being made is another way of managing difficult cases. While these manipulations are being made the patient should relax the abdominal muscles by avoiding all straining. Many patients fail to obey orders in this respect; they continue to hold the breath, and strain as if preparing to resist the pain of some injury about to be inflicted upon them. I have overcome this annoyance by causing the patient to take long regular respirations while being treated. In rare cases, in which much difficulty is met in replacing the fallen uterus, the patient should be placed in the knee-chest position, and then the chances are that the uterus will slip back to its position without much help. If any aid is needed it can be given by the sponges in holders, or what is quite as good, if not better, in manipulating with the patient in this position, is to use one or two fingers in place of the sponges. With a very limited experience and a knowledge of the methods described any one can manage this portion of the treatment. To 296 DISEASES OF WOMEN. keep the uterus in place is the question which is not easily settled. The object of all the mechanical means which may be employed is, first, to keep the organ in position and thereby give relief. At the same time through the agency of the artificial support, and other means, to restore the natural supports. If the prolapse is not beyond the second degree, and is due to relaxation only of the uterine supports, and not associated with any injury that destroys the integrity of the pelvic floor, the uterus may be retained by means of a pessary or tampon until the supports recover their original strength. In connection with these mechani- cal means, rest in the recumbent position is one of the most im- portant factors in bringing about the desired result. The material used for the tampon should be absorbent cotton, wool, or lint. To simply keep the uterus in place the cotton is no doubt the best. It is soft and most agreeable to the tissues. When there is any vaginitis or endometritis causing a free discharge, ma- rine lint does better. It takes up the discharge, disinfects it, and prevents decomposition. This it does better than the cotton. In some cases the lint is irritating to the tissues and can not be long continued.' Sometimes I have alternated the use of the cotton and lint with much satisfaction. Since the introduction of antiseptic material for dressings, the tampon has been far more useful in surgery. In the past when sponges, not well prepared, were used, they could be retained in place but a few hours without causing decomposition. Now the marine lint or borated cotton can be worn twenty-four or forty-eight hours without being offensive. For those who have vaginitis or any inflammation of the uterus I direct that the tampon be applied in the morning after having used the douche of hot water, plain or medicated. At night the tampon is removed and the douche again used and afterward the tampon re- placed, if the uterus will not stay in place without it, but omitting it for the night if the recumbent position will overcome the tend- ency to displacement. When there is no inflammatory complication the tampon may be left in place two days and a night. At the end of the second day it should be removed at bed-time and replaced next morning, the douche being used after removal and before intro- ducing it again, Astringents of various kinds have been employed with the tam- pon, the cotton being saturated with the solution to be used, or the agent may be employed in powder. The latter is much the prefer- able way when the milder astringents are selected. As a rule I pre- DISLOCATIONS OF THE UTERUS, 297 fer the borated cotton or marine lint alone, using such astringents as mav be required in the douche. In manv cases there is some loss of the pelvic floor from pre- vious injurv. This structure should be restored as soon as the tis- sues are in a condition to warrant surgical treatment. As a rule, in those cases of prolapsus which have existed for some time, the nu- trition of the tissues is impaired and needs treatment preparatory to operating. For a more complete discussion of this subject the reader is referred to the chapter on injuries of the pelvic floor. Keeping the uterus in its position by the tampon and other means of support has the effect of not merely relieving the prolapsus, but also of giving the uterine ligaments every chance to regain their normal condition. Artificial support is palliative and curative as well. The mechanical supports used in the treatment of prolapsus include a variety of devices. The pessaries used are of two kinds— those that are placed in the vagina and are held in position by the pelvic floor, and those that are held in place by being attached to a strap round the waist. The former are applicable in the first and second degrees of prolapsus while the pelvic floor remains normal or nearly so. The latter are used in complete prolapsus, and in those cases where there is so much loss of the pelvic floor that it will not keep the pessary in position. When the perinseum is sufficient to support the vagina and the prolapsus is limited to the first or second degree, the instrument known as Peaslee's pessary answers very well. It is a simple ring made of whalebone and covered with soft rubber (see figure). When in position it rests upon the pelvic floor. It should admit the cervix without making pressure upon it, and should fit the upper portion of the vagina without distending it to any ap- preciable extent. It acts by carrying the upper portion of the vagina and the cervix backward into the normal position, and at the same time raises the uterus to a very slight, but sufficient extent. If well adapted it takes off the pressure from the lower part of the vagina and permits it to contract and regain its tonicity. Fig. 137 represents prolapsus in the second degree. Fig. 140 shows the pes- sary in position after the uterus has been replaced. When there is relaxation of the pelvic floor due to the prolapsus it is necessary to keep the patient at rest much of the time during the first week or two that the pessary is worn. If this is not prac- ticable a perineal band should be worn to support the pelvic floor while the patient is exercising. In the progress of the treatment the vagina should contract when the uterus is supported by the pessary. This, in time, requires that a smaller instrument should be 2 u* 208 DISEASES OF WOMEN. used. The rule is that the smallest instrument should be enipbved that will keep the uterus in place. If too large a pessary is used it Fig, 14U.—Uterus replaced, with pessary in position. will keep the uterus in place, but will overdistend the vagina and weaken the supports of the uterus in place of restoring them. One great advantage which the ring pessary has is in being easily introduced or withdrawn, and that it does not become displaced except to settle downward, and this can be easily corrected by the patient assuming the knee-chest position from time to time. When the uterus inclines to retrovert after having been elevated, a common occurrence, a retroversion pessary will act better than the ring, but the use of that instrument will be more fully discussed under the head of retroversion. Prolapsus occurring after the menopause when the uterus has undergone final involution, may be relieved in some cases by the old glass-globe pessary. It certainly is the best instrument that I have DISLOCATIONS OF THE UTERUS. 999 found for old patients having prolapsus of the vaginal walls, bladder, and the remains of the atrophied uterus, if the pelvic floor remains sufficient to support the pessary. It simply keeps the uterus and bladder up in the pelvis by distending the vaginal walls. The ute- rus may be anteverted or retroverted, but is so small that it makes no difference what position it occupies so long as it is kept high enough up. The globe is easily used. In fact no mistake can be made with it except to use one that is too large. This must be avoided, be- cause one that is too large will cause vaginitis and ulceration. It is a fact also that the pessary which answers when first used will be too large when the parts regain some of their original tonicity. For a time the patient should be kept under observation and the in- strument changed to suit. This globe pessary is the most trouble- some instrument to remove. I have usually succeeded by using a small Sims's speculum and a Sims's vaginal depressor, and seizing the instrument between the two and making traction. When this fails, a pair of miniature obstetric forceps should be made out of strong copper-wire, by doubling it to form loops and twisting the ends to make the handles. AVith this the globe is very easily grasped and removed. The intra-vaginal pessaries, such as the ring and globe already mentioned, and all others that rest wholly within the vagina are liable to slip down and give the patient great dis- comfort, and sometimes they come away entirely. This is especially the case when first introduced. To obviate this, a perineal band should be worn until the perinseum, upon which the pessary de- pends for support, regains its tonicity. I>y this arrangement the same results are obtained as by the use of the cup and stem pessary, to be noticed hereafter—in fact, better results so far as the comfort of the patient and the final effects are concerned; therefore, I have always endeavored to relieve prolapsus when possible by the intra- vaginal pessary. Several uterine supporters have been devised to meet the require- ments of cases in which the pelvic floor is relaxed from long disten- tion, so that it has not power to sustain a pessary in position, and the patient's circumstances will not permit long rest in the recum- bent position and the use of the tampon. They are all constructed on similar principles of mechanism and action—namely, cup and ring to receive the cervix uteri, and a stem attached which projects from the vagina and is fastened to a perineal band, which in turn is attached to a waistband. The advantages claimed for this kind of uterine supporter are that if properly ad- 300 DISEASES OF WOMEN. justed it will certainly keep the uterus in place, and the patient can remove and readjust it when desirable. These are valuable features no doubt, and may be fairly claimed for the instrument as a rule, but not without many exceptions. There are cases where this form of instrument, while it will keep the uterus at its proper elevation, will not keep it in its proper axis without very great care in its ad- justment. Under such circumstances the patient can not remove and replace the pessary with any satisfactory results. While pushing up the uterus, during the introduction of the pessary, a retroversion takes place, and wearing the instrument only aggravates that form of displacement. The further objections which may be placed over against the advantages of this kind of pessary are that it can not be worn for any great length of time without doing harm and caus- ing great discomfort, and where in a given case the patient can not adjust it properly herself it will do more harm than good, and should not be employed on any account under these conditions. Again, in the most favorable cases, it is a constant source of irritation, less or more. The vulva is irritated by its presence and usually becomes inflamed in time; the pressure of the cup against the cervix and upper end of the vagina causes inflammation and ulceration, if the patient takes much active exercise. The reason for this is that the pessary is firmly fixed by its support outside of the body and the movements of the pelvic organs against this fixed instrument cause great friction. The intra-vaginal pessary moves with the pelvic organs, but the stem pessary does not accom- modate itself to the requirements, and hence its power to do harm. From the little that has been said, it will appear that the use of the vaginal stem pes- sary for the relief of prolapsus is most unsat- isfactory. All that can be said of such means of support is, that in some cases they may be used for a time in the hope of helping to restore the natural uterine supports. Dr. Paul F. Munde has truly said, "The ideal pessary for complete prolapsus uteri is yet undiscovered.'' The instrument which I have cm. 141.—Diem pessary. <• -, , ■, „ ,-, • Modification of Cutter's, found to answer best of the stem pessaries is a modification of Cutter's (Fig. 141). These pessaries should be fitted with care, and just here another difficulty is encountered in the fact that they are all made of one size and shape, so that it is difficult to change them to suit special DISLOCATIONS OF THE UTERUS. 301 cases. This I have tried to overcome by making the stem flexible, or rather so that it can be molded, and capable of being shortened, so that it can be made to suit each case. Fortunately, stem pessaries are rarely needed, and, I may say, that everv year I find less need for them. By a careful and judicious use of the ring and the tampon, aided bv the T-bandage to support the pelvic floor, one can accomplish nearly all that can be done by these artificial supports. The important facts in connection with pessaries already men- tioned, may be recapitulated here, and they should be borne in mind. They are as follows: First, these means of relief for prolapsus most- ly are temporary and palliative, and can only keep the uterus in place until the tissues are prepared for the operation of perineor- raphy when the pelvic floor has been injured ; second, they keep the uterus in place till the normal supports are restored ; and, third, they reduce a complete prolapsus to an incomplete, when an intra- vaginal pessary will answer the purpose. While these artificial means of support are being employed, ef- forts should be made to strengthen the parts and to remove all com- plications which tend to keep up the prolapsus, astringent injections should be continued, standing and walking should be limited to an amount which is sufficient for exercise, and lifting heavy weights and wearing tight and heavy clothing should be avoided. The bow- els should be kept free, so that straining at stool may be unneces- sary. This last point should be carefully attended to. Constipation is a potent cause in producing and keeping up prolapsus. The gen- eral health should be cared for, and if there is any debility it should be met by the proper tonic treatment. In some of the most favorable cases complete relief will be ob- tained by the means described, so that all mechanical supports can be given up. Care should be taken not to remove the pessary too soon. I have found in cases of prolapsus that it is best to reduce the size of the pessary by changing from time to time to a smaller one. Martin, of Berlin, has reported one hundred and ninety-two cases in which he has operated for the cure of prolapsus. In all but six he was obliged to perform an operation upon the cervix; in three instances it was necessary to extirpate the entire uterus. In one hundred and seventy-one cases silk sutures were used, in seventeen the continuous catgut, the latter being highly commended, al- though it is noted that it is not safe to depend entirely upon these, as secondary haemorrhage may occur if they are not re-enforced with 302 DISEASES OF WOMEN. silk. Relapses occurred only eleven times, and those, too, in old subjects. The operations performed were anterior and posterior kolporrhaphy, with perineorrhaphy. In comparing my own results with the above, 1 find that I have succeeded as well by the combined use of mechanical supports and surgical operations. That in the treatment of prolapsus, where op- erating upon the cervix uteri and pelvic floor has failed, kolpor- rhaphy has also been useless. I have, therefore, abandoned that op- eration. TREATMENT OF PROLAPSUS BY GALVANO-CAUTERY. Dr. John Byrne, of Brooklyn, has treated successfully nine cases of prolapsus of the uterus by galvano-cautery. In three, the cervix uteri was completely amputated with the galvano-cautery. The other six were treated by partial amputation of the cervix. The de- scription of the operation is given by Dr. Byrne as follows: " A diverging double tenaculum was passed into the cervical canal and fixed in the tissues so as to secure complete control of this part. The entire mass was next returned within the pelvic cavity, and the uterus elevated sufficiently to show the line of vaginal in- sertion in its entire circumference. While in this position, a small platinum knife, brought to a red heat, was slowly carried around the base of the cervix, close up to the vaginal fold, and to a depth suffi- cient to accommodate a platinum loop, and to insure it against slip- ping. The latter was next adjusted, and the amount of battery im- mersion being duly estimated to guard against overheating of the wire, the loop was slowly and with intermissions contracted, until about one quarter of an inch in depth had been reached. The wire was now removed, and a firmly-rolled tampon, one and a half inch in diameter and four inches long, smeared with glycero-tannin, having four per cent of carbolic acid, was passed into the vagina, and a T-bandage applied.'' Two of the six cases required linear cauterization of the vagi nal walls as well as partial amputation. The following is Dr. Byrne's description of the operation : " The parts having been returned as in the former case, the line of vaginal insertion was noted, and merely marked in spots by the cautery knife. The entire mass was then brought down and out, and with the same instrument a deep, circular fissure about three eighths of an inch in depth was made around the entire circumfer- ence of the cervix, the knife being carried upward and inward in DISLOCATIONS OF THE UTERUS. 303 the direction of the os internum, and precisely as I am accustomed to do in suitable cases of carcinoma. This being done, three diverg- ing fissures were made, one central, one toward either side on the anterior, and one only on the rectal surface, starting from and con- necting with the circular incision for a distance of about three inches ; care being taken that the entire depth of the hypertrophied vaginal membrane should be incised." I am unable to speak from experience regarding this method of treating prolapsus of the uterus. The histories of the cases given by Dr. Byrne in the " Transactions of the American Gynecological Society " for ISSU, are very satisfactory. CHAPTER XVIII. RETROVERSION OF THE UTERUS. Retroversion of the uterus is a change in the axis of that organ in which the fundus points toward the sacrum and the cervix turns toward the symphysis pubis or vaginal outlet. This displacement varies in extent in different cases ; three degrees are usually de- scribed. In the first degree the fundus points towTard the promon- tory of the sacrum ; in the second the uterus lies almost transversely in the pelvis; and in the third the fundus is low down in the pel- vis, while the cervix is thrown upward at a higher elevation than the fundus. Retroversion is usually progressive, except in the first months of pregnancy and in the puerperal state. In these conditions retrover- sion may occur abruptly, and so it may under other circumstances, but usually it comes on gradually, passing from the first degree to the second, and on to the third. It is exceedingly rare to find retroversion in the first degree ex- isting for any length of time, the displacement usually passing on to the second and third degrees. The anatomical changes which take place in backward displace- ments are to some extent the same as those found in prolapsus. The same changes in the supports of the uterus are found, and though differing in detail are the same in kind. This arises from the fact that nearly every case of prolapsus is associated with more or less retroversion, and in nearly all cases of retroversion there is also a slight prolapsus. These changes have been discussed under the head of prolapsus, hence it is only necessary for me to point out here the anatomical features which are particularly concerned in retroversion. In retroversion there is shortening of the posterior vaginal wall by contraction. The exceptions to this are when there is rectocele. and in recent cases in which the vaginal wall is apparently short- RETROVERSION OF THE UTERDS. 305 ened, but in reality is thrown into folds. The anterior vaginal wall is generally distorted rather than displaced. Its upper end is Fig. 142.—The three degrees of retroversion, crowded upward and sometimes forward by the cervix uteri, and its lower part is sometimes pressed downward and forward, giving it the appearance of a urethrocele. The relations of the cervix and vagina are changed more or less in the majority of cases. In some the projection of the cervix into the vagina is apparently very much increased posteriorly. To the touch the vagina appears to be attached to the whole length of the cervix. This is apparent, not real, and is usually found so when the vagina has still maintained its tonicity. In other cases, with marked shortening of the vaginal wall, the invagination of the cer- vix is lessened. Nearly always the invagination of the cervix ante- riorly is less than normal. The position of the uterus as regards elevation varies greatly in different cases. This may be normal in the pelvis, simply changed in its axis, or it may be prolapsed so that the cervix is close to the vulva, the anterior vaginal wall being much shortened. Again, the posterior wall of the uterus may rest upon 21 306 DISEASES OF WOMEN. the pelvic floor and altogether be placed far back in the pelvis, so that the fundus presses upon the rectum, while the bladder may not. Fig 143.—Retroversion of the second degree. as a rule, be much affected, either in its position or function, yet it frequently is. The weight of the uterus being removed from be- hind there is nothing except the vesical ligaments to prevent the bladder from extending backward when distended. It then rests upon the retroverted uterus instead of rising up toward the abdomi- nal cavitv, and the ovaries and Fallopian tubes are to some extent car- ried backward and downward with the uterus. The extent of this displacement varies greatly. In some cases there is complete pro- lapsus of one ovary, or of both of these organs, so that they lie in the sac of Douglas and the uterus rests upon them. In other cases the ovaries rest upon the retroverted uterus. One case of this kind RETROVERSION OF THE UTERUS. 307 I well remember to have operated upon. The ovaries were diseased and gave so much trouble that I decided to remove them. One was in its normal position, the other, the right one, was adherent to the side of the uterus. This prolapsus of the ovaries is one of the worst complications of retroversion. There is a strongly-prevailing opinion that the circulation in the pelvic organs is much deranged by retroversion, and that changes of structure of these organs follow in consequence. How far this is a fact it is difficult to determine. It is true that in nearly all cases of retroversion are found some congestive inflammatory trouble and structural changes, either from degeneration or hyperplasia, but whether these changes preceded the version and perhaps aided in producing it, or whether they resulted from the change of position, can not at all times be ascertained. There is good reason for be- lieving that all malpositions cause deranged nutrition which in time lead to organic changes, and still such pathological conditions are found when there is no displacement, showing that these relations of cause and effect are interchangeable in displacements and some other diseases of the uterus. COMPLICATIONS. There are cases of retroversion so complicated that they are per- manent and incurable. These should be clearly understood ; hence I refer to them briefly in this connection. There are two classes of such cases : Those which have had pel- vic peritonitis while the uterus was retroverted, the adhesions made by the products of the inflammation permanently fixing the uterus in its malposition. I presume that a similar result is sometimes produced by pelvic peritonitis, the products of Avhich (behind the uterus) will by contracting drag the uterus into the position of re- troversion. This complicated form of retroversion has been con- sidered incurable, but recently encouraging efforts have been made to relieve it by surgical treatment. This subject will be referred to and discussed at the end of this chapter. The other class is one in which a similar condition occurs as the result of malfor- mation or congenital malposition. In cases of this kind the uterus is retroverted, the posterior vaginal wall short and rigid, the utero- sacral ligaments are short and rather unyielding, and although the uterus is slightly movable it can not be restored to its proper place. In such case the pelvis is wide and shallow, and there is often a lack of cellular tissue around the pelvic organs. When I first had my attention directed to this class of cases I presumed that they 308 DISEASES OF WOMEN". must have had pelvic peritonitis, but in many of them there was no evidence obtained from the past history to warrant any such conclusion. Further investigation satisfied me that the lesions were the result of perverted development and growth. Some of these cases do not suffer much, but they are sterile as a rule. Symptomatology.—The clinical history of retroversion, so far as the symptoms are concerned, is not sufficiently definite to be diag- nostic. Many of the symptoms are common to prolapsus and cer- tain other affections of the uterus. Another curious fact is that the suffering caused by retroversion varies greatly in different pa- tients. The rule is that retroversion causes much discomfort, but I have seen one patient who had retroversion for many years and yet was one of the most active women I have ever known, and was per- fectly free from all evidence of any affection of the pelvic organs. The symptoms which belong more especially to retroversion are rectal tenesmus and the feeling of obstruction to a free action of the bowels. Backache, general pelvic tenesmus, aching of the limbs, irritation of the bladder and rectum, neuralgic pains in the pelvis, and the fact that these symptoms are aggravated by walking and standing and are relieved in the recumbent position, are all evidences of re- troversion, but also occur in prolapsus. Menstruation is frequently deranged and menorrhagia, dysmen- orrhcea of a mild form, and irregular recurrence of the menses, have all been traced to this form of displacement; but all these are more frequently caused by other affections. In several cases that I have seen, the menstrual discharge was offensive and very distressing to the patient. This symptom I have noticed more frequently in retro- version and retroflexion than in any other affection of the uterus. Physical Signs.—The physical signs are obtained by the touch and uterine sound. The vaginal touch reveals the os uteri pointing toward the introitus vulvae, or in extreme cases, toward the sym- physis pubis. The anterior vaginal wall is often found projecting downward in front of the cervix. The upper portion of the pos- terior vaginal wall is found to be pressed downward and forward, so that the junction of the posterior cervical wall of the uterus and the vagina are much nearer to the vulva and more easily touched with the finger. In some cases this prolapsus of the posterior vaginal wall is very marked, and appears to aggravate the version by push- ing the cervix against the bladder. If the bladder is empty and the muscles of the abdomen are re- laxed, the bimanual examination will show that the uterus is not in RETROVERSION OF THE UTERUS. 309 its normal position, but must be retroverted, as indicated by the signs obtained by the vaginal touch. These signs of retroversion, while quite reliable, might, in rare or complicated cases, be misleading, so that it is well to confirm or correct by the use of the sound the evi- dence obtained by the touch. Placing the patient on the left side and using Sims's speculum, the sound can be passed with ease, and its direction will show the dislocation of the uterus. In doubtful or complicated cases, when all the evidence is needed that can be obtained, the rectal touch maybe employed. The finger in the rectum can be swept all around the fundus and body of the uterus while it lies low down in the sac of Douglas in the retro- verted state. The rectal touch can be made more effective still by making the abdominal or vaginal touch at the same time. By these means of examination a diagnosis can be made with the greatest cer- tainty, and proof of the accuracy of the diagnosis may be obtained by replacing the uterus. Regarding the conditions which may be mistaken for retroversion and the differentiation little need be said. The question which most frequently arises is whether there is retro- version or retroflexion. This can always be settled by the evidence obtained from the physical signs already obtained, and the fact that in flexion the uterus is bent upon itself, a fact that is noticed by the touch and confirmed by the use of the sound. Causation.—The causes which produce prolapsus uteri are ap- parently the same as those which give rise to retroversion. The reader may refer back to the causation of prolapsus for the facts re- garding this matter. This will save repetition. It is clearly evident, however, that while there may be much in common in the causation of the two forms of uterine displacement, prolapsus and retrover- sion, there must be some difference in the causes which produce such different effects. This appears to have been quite an obscure sub- ject, for I find that the text-books are very indifferent in regard to it. My own observations lead me to believe that the causes of re- troversion are the loss of support from morbid states of the uterine ligaments occuring while the pelvic floor remains normal or not wholly useless as a means of support, and that prolapsus is due to defects in the uterine supports and loss of the pelvic floor also. This may be stated in another way, which will show what this view is based upon. In the great majority of cases of retroversion which I have seen, the pelvic floor has not been wholly wanting, in fact, in some of the cases it has been quite normal; while in prolapsus it is usually defective. It will be easily understood that when the sup- ports of the uterus are defective, especially the anterior ligaments, and 310 DISEASES OF WOMEN. the vagina and pelvic floor are in their normal condition and keep the cervix uteri in place, the tendency would be for the uterus to fall backward into the retroverted position. Changes in the condition of the cervix uteri and in its relations to the vagina, have some influence in the causation of retroversion. In those who have had cellulitis, after confinement, in the tissue around the cervix above the vagina the invagination of the cervix is lessened, indeed, sometimes obliterated. The vagina to the touch is like a cul-de-sac, the entire uterus being above the vagina. This condition favors retrover- sion. Fig. 144 shows retrover- sion with imperfect invagina- tion of the cervix uteri in a patient who has had cellulitis. Laceration of the cervix bilaterally produces a similar condition of imperfect invagi- nation, which is often associated with retroversion. The ante- rior half of the cervix becomes lost in the anterior vaginal wall and the posterior part of the cervix is apparently less prominent in the vagina, if not really so. This is more frequently seen where the lateral lacerations extend above the vaginal junction, Fig. 145 shows this condition. In such cases the state of the cervix has much to do with keeping up the retroversion, as well as causing it. This I have demonstrated Fig. 144.—Retroversion with imperfect invag- ination of cervix due to inflammatory products about it. Fig. 145.—Apparent imperfect invagi- nation due to bilateral laceration of cervix : c, c, lips of the cervix. Fig. 146.—The same uterus with its lips drawn back into piace by tenacula. RETROVERSION OF THE UTERUS, 311 by trving to keep the uterus in place before restoring the cervix, and finding it very difficult, while it was quite easy to do so after the cervix was restored. The immediate effect of operating was to bring the cervix prominently into the vagina and sustain it there. Fig. 146 shows the change effected in the case represented in Fig. 145, after the restoration of the cervix and before restoring the retroversion. Further evidence is also obtained to show that these mal-relations of the vagina and cervix, just mentioned, favor retroversion of the uterus in the fact that in those cases in which the cervix has been amputated, the uterus is generally retroverted. These points I consider to be of much importance and of special interest because they are not, so far as I know, discussed in medical works with reference to the causation of retroversion of the uterus. Treatment.—The indications are to replace the uterus and keep it there, and, by so doing, the supports of the uterus may regain their normal condition, and complete relief follow. The methods of replacing the retroverted uterus are to place the patient on the left side, and through Sims's speculum to raise the body of the uterus up with two sponges in holders, used as in Fig. 147. By upward press- ure the uterus can be raised as far as need be, or as far as possible, and then one of the spong- es should be with- drawn or placed in front of the cervix, %^-^ and backward press- ure made there. This helps to com- plete the replace- ment, and at the same time holds the uterus in place, while the sponge is removed from its position behind the uterus. To succeed in this operation, it is ne- Fig. 147.—The three steps in replacing the retroverted uterus by means of sponge-holders. cessary to have the 312 DISEASES OF WOMEN. bladder empty, and that the patient should not resist the efforts of the surgeon to replace the uterus. When there is any difficulty met in the practice of the method described, the patient should be placed in the knee-chest position (see Fig. 150), and the Sims's speculum used. This alone is sufficient in some cases to effect re- placement. AVhen it does not do so, the upward pressure of the sponges behind, or drawing the cervix back with a tenaculum, will accomplish the object, or both sponge and tenaculum may be used. It is sometimes difficult to replace the uterus in cases of long standing, owing to the contraction of the posterior vaginal wall. The changes in the parts which have taken place to accommodate the malposition, can not always be immediately overcome. In such cases all that can be accomplished is to raise the uterus as far toward its normal place as possible, and then hold it there by means of a temporary support. By the use of the cotton tampon or a pessary, all that is gained by the first and succeeding efforts to replace the uterus is kept, and if the pessary is used properly it will make con- tinuous upward pressure upon the fundus uteri, and thereby con- stantly gain more and more. In cases of long standing the displace- ment becomes completed by slow degrees, as the tissue changes in the support of the uterus and vagina have taken place as the result of long-continued influences, and they can not be abruptly rectified. It takes time to undo that which it has required months and years to do; hence, the process of restoration must be accomplished b\r degrees and by repeated efforts. The details of this method of treatment will be given in the clinical histories of cases to be related hereafter. The next object to be attained is to keep the uterus in position. This raises the question of the mechanical supports of the uterus. I think that Dr. Frank P. Foster, of New York, has given the most rational discussion of the subject that I have seen, and 1 will quote his views later on. THE TREATMENT OF RETROVERSION BY THE USE OF PESSARIES. There are a great many kinds of pessaries employed in treating retroversion of the uterus. A few of them can be made to do much good when skillfully employed. The great majority of them are useless, and all of them are capable of doing much harm if used without a clear idea of how they should be used. During a discus- sion of displacements of the uterus at a meeting of the A-merican Gynecological Society held in Boston, in 1877, Dr. E. R. Peaslee RETROVERSION OF THE UTERUS. 313 expressed himself in favor of the use of pessaries, claiming, at the same time, to have obtained very gratifying results from their use in his own practice. In the same discussion, Dr. W. L. Atlee said : k* I have had no experience with pessaries, at least with their intro- duction, but I have had a very long experience with their removal. I do not think that there is a day when I am at home and in my otHce, that I do not have the privilege of taking out a pessary. I have removed pessaries of all forms and sizes, and pessaries intro- duced by the most distinguished men of the profession.'1 Peaslee and Atlee were certainly two members of the profession of this country, equally distinguished in ability, profound judgment, and thorough honesty, and why they should hold such opposing views upon a subject so practical may not be capable of explanation by any one. It has appeared to me, however, that the one came to his conclusions from a careful investigation of the utility of pessaries when properly used, while the other based his opinions upon the fact that as generally employed, pessaries do very great harm. Viewing the subjects from these two stand-points, both conclusions are perfectly rational, and ample proof may easily be obtained of the good and evil which come from the use of these instruments. At the present day, I presume that if the harm done should be placed opposite the good accomplished by all the pessaries in use, the results would be about equally balanced. It follows, then, that as matters stand at this moment, it is a question whether the human race would be better or worse if all the pessaries were put out of ex- istence. The all-important fact remains, however, that pessaries are of great value, and capable of giving relief to those who suffer from some of the forms of uterine displacements, if properly used. The same may be said of nearly all valuable agents employed for the re- lief of suffering. That any agent, capable of giving relief when skillfully employed, is likely to be as potent for evil when misused, is a well-known fact; hence, the object should be to attain to a more perfect and general knowledge of how to make and use pessaries in order to promote the good results, and lessen the evil. There are many difficulties which naturally arise in the investi- gation of the use of pessaries. Not only do authorities differ very widely in their views regarding their use, but one's own experience is oftentimes misleading. For example, a pessary may be used to correct a displacement, and marked relief is obtained. The patient testifies to the fact that her symptoms are relieved and her useful- ness extended while wearing a pessary, and yet that instrument may 314 DISEASES OF WOMEN. be doing harm by still further damaging the supports of the uterus. These may appear like contradictory statements, and yet such are the facts observed many times in practice. The same thing is seen in the abuse of corsets. The lady who has contracted her waist by tight lacing suffers great discomfort when she goes without corsets, and is relieved by wearing them, and yet no one doubts the fact that great injury is caused by this article of wearing-apparel. The mechanical action of pessaries must necessarily be clearly understood in order that they may be employed with favorable re- sults ; misunderstanding on this point is no doubt the cause of much unsatisfactory practice. Judging from the many errors made in the use of pessaries, as seen in practice and from the various opinions expressed by writers, I am fully satisfied that this part of the subject is not as clearly understood as it should be by the profession gener- ally. My own views are so fully in accord with those of Dr. Foster, that I shall quote his article : " It can not be said that opinions are wholly agreed as to the way in which vaginal pessaries most commonly effect changes in the situation, form, and attitude of the uterus. Those who have given any considerable amount of thought to the matter will probably ad- mit (1) that a pessary may operate by virtue of mere lateral disten- tion of the vagina, being itself too bulky to escape readily from the pelvic outlet, and thus preventing the parts resting upon it from so escaping; (2) that the pressure exerted by a pessary may be trans- mitted directly to the body of the uterus, lifting it up when ante- verted or retroverted, as the case may be ; and (3) that such pressure may operate by dragging the lower portion of the organ in a certain direction, thus causing its upper portion to move in the opposite direction. " While there can scarcely be a doubt that each one of these methods of action may explain the work done by pessaries under certain circumstances, it may be not only interesting as a mere matter of curiosity, but profitable as tending to greater precision in practice, to inquire into the relative frequency with which the one or the other actually operates, which of them is therefore of the greater practical importance, and which of them should be specially emphasized in teaching. The question as to whether certain pes- saries act as levers, or whether they are merely forced bodily in a certain direction, and so fulfill their purpose, is quite foreign to this inquiry, and, therefore, I shall not enter upon its considerations. " In regard to the method of action first mentioned—that of lateral RETROVERSION OF THE UTERUS. 315 or transverse distention of the vagina—it may simply be said to apply only to special forms of pessaries, which, although in common use before Hodge's time, have now almost fallen into disuse—deservedly, I may be allowed to add. " The second method, that of pressure transmitted directly to the body of the uterus, is undoubtedly the one that is most prominent in men's minds, most taken into account in practice, and most ap- pealed to in teaching. And yet, it seems to me, its scope is really quite limited, and its practical importance almost nil. If an ex- treme mal posture of the uterus is corrected by the act of inserting a pessary adapted to the case, as may often enough be done, the in- strument may act at first, I admit, by direct transmission of its press- ure to the body of the organ lifting the latter from a state of ex- treme anteversion or retroversion, as the case may be. But such action is only momentary; long before it could restore the uterus to its normal attitude another agency is called into play, so that when the full action of the pessary is attained, its pressure is no longer transmitted to the body of the organ. In any case, then, this direct action on the body of the uterus is of but momentary duration, and accomplishes but a partial result; and, if the malposture is not originally very decided, or if it is corrected before the instrument is inserted into the vagina, it does not come into play at all. " These statements embody no novelty, but they are so at variance with the views that seem to be held by the most influential teachers of gynecology, that it seems best to put forward some reasons for them. To illustrate, then, suppose a case of retroversion. In order that a pessary may fully restore the uterus to its normal attitude, and hold it in such attitude (acting all the time by direct pressure on the body of the organ), its pressure must be exerted not only upward, but forward, and that, too, at a point situated high in the pelvis. Now, from my own experience, from observation of the practice of others, and from the drawings employed by authors to illustrate the action of pessaries, I believe that pessaries long enough to fulfill these conditions are seldom if ever used. Granting, however, that I may be mistaken in this respect, it will scarcely be disputed that either such a pessary, besides being very long, must have a very pronounced curve in order to enable its middle portion to lie wholly below the face of the cervix while its upper end exerts the pressure m question (in which case its introduction, supposing the perinseum to be intact, would be well-nigh impossible) ; or else its limbs must diverge to such an extent as to accommodate the cervix between them, making the instrument very broad, in which case it would not 316 DISEASES OF WOMEN. pass between the two utero-sacral ligaments without stretching them apart to such a degree as practically to shorten them, thus causing them to pull the lower portion of the uterus backward, and conse- quently throw its upper portion forward. The result of this latter state of things would be that the retroversion would be corrected before the upper end of the instrument had been forced high enough to restore the body of the uterus to its normal position by direct pressure upon it, or by pressure directly transmitted to it. Further than this, I believe that in the great majority of instances the men- upward and backward pressure upon the posterior vault of the vagina would suffice to drag the cervix backward in the same way before the instrument had penetrated at all into the space included between the utero-sacral ligaments. This, however, would depend upon the degree of tonicity with which the vagina was endowed. " With regard to anteversion the case is even stronger, while at the same time it is simpler, for the anterior wall of the vagina is naturally tense, and its tension is usually heightened by the mere fact of the uterus being in a state of anteversion. In this tense condition of the anterior vaginal wall we have a marked contrast with the posterior wall; the latter is much longer than a straight line drawn between its two extremities, and its lower end is con- nected with parts that are comparatively mobile ; the former is firmly attached to the pubic arch. By reason of this tension of the an- terior wall of the vagina, its virtual shortening occurs almost at once whenever any noteworthy pressure is made upon it: hence, any of the various forms of anteversion pessaries that are supposed to act by lifting the body of the uterus directly up, really accomplish its ascent by stretching the anterior wall of the vagina, and thus drag- ging the cervix forward. In proof of this statement, witness the insignificant size of the anterior projections of these instruments— projections utterly incapable of reaching to the height that they would have to reach in order to make direct pressure upon the body of the uterus, even with the bladder intervening, when the organ had approached anywhere near its normal position. The great sen- sitiveness of the anterior vaginal wall to pressure, the well-known liability of ulceration to occur upon it under the pressure of a pes- sary, both point to its greater tension as compared with the posterior wall. " Passing now to the third of the various methods of action that I have attributed to pessaries—that of traction upon the lower portion of the uterus—but little need be said about it, for the considerations brought forward to show the limited scope of the direct-pressure RETROVERSION OF THE UTERUS. 317 theory, all conspire to advance the traction theory to the most im- portant position. Such I believe it ought to occupy, unless the statements I have put forth are shown to be erroneous. I will simply add that always in anteversion, and usually in retroversion, it is through the medium of the vaginal wall, in my opinion, that pes- saries make traction upon the cervix. "'I will briefly mention some of the practical applications of the doctrine I have sought to uphold. In cases of retroversion it is usually sufficient if pessaries are to be used at all, to employ an in- strument simply with the idea of making backward pressure upon the posterior wall of the vagina, directing the pressure somewhat upward, unless there are special reasons for not doing so, but not resorting to pessaries with such an exaggerated pelvic curve as to render their introduction difficult. If the instrument is curved rather sharply at a point very near its upper end, the pressure will be distributed more evenly over the posterior vault of the vagina, and, therefore, will be borne better. u The usual forms of retroversion pessaries (the Hodge instrument and its various modifications, including those with external support) seem to me to act in this way, and to be as unobjectionable as any we are likely to hit upon. More or less stretching of the posterior vault of the vagina is apt to re- sult, but it is of little consequence even should it prove permanent, for it in no wise interferes with the FlG 148._Albert Smith pessary. natural functions of the parts. Broad pessaries, penetrating between the utero-sacral ligaments, should never be used, for these ligaments form a part of the mech- anism by which the normal situation and attitude of the uterus are maintained, and anything that stretches and relaxes them interferes with the permanent cure of retroversion." ADAPTATION OF PESSAKIES. The adaptation of pessaries for the relief of retroversion, is facili- tated by keeping in mind the object to be accomplished, and the way in which the instrument acts in fulfilling these requirements. All that remains, then, is to shape the pessary to the case in hand, and to place it in position after the uterus has been restored to its place. This is an easy or difficult task, according to the artistic and me- chanical skill of the surgeon. Badly-adjusted pessaries are not so 318 DISEASES OF WOMEN. common as badly-fitting shoes and clothes, because they are not so generally used. No one who is destitute of some knowledge and skill in mechanics, will ever succeed in the treatment of displace- ments of the uterus by means of mechanical supports. The gravest errors are committed every day by using pessaries without under- standing the principle of their action or the methods of adapting them. This lack of knowledge and of the required ability lead to the too frequent use of certain kinds of pessaries known by the names of their inventors. The prevailing idea being that a certain form of pessary recommended by some one in authority will answer for all cases, a slight variation in size being all that is necessary. This is certainly a great mistake. The only pessary which can be of service is one that is correctly adjusted to the patient who is to wear it; not a ready-made one with a distinguished name and repu- tation. An abundant experience, so far as seeing and treating many cases goes, and some practical knowledge of the mechanical art, en- ables me to say, that no two cases of displacement are alike, and, therefore, each one must be fitted with a pessary of the special form and size required. This really simplifies practice greatly, because it enables one to reject the vast number and variety of ready-made pessaries in the market, and to choose the simplest forms and adapt them according to certain principles and the requirements of cases. In the books there is no end to the number of instruments com- mended, and the directions to introduce and remove them are ample and sufficient, but there is a conspicuous absence of any definite and useful directions regarding the manner in which such instruments are to be fitted. In the simpler cases when the uterus can be restored to its posi- tion completely, and when thus restored the vaginal walls assume their normal shape, the pessary is easily adapted. The length of the vagina should be obtained from the posterior fornix to a point cor- responding to the upper end of the urethra, and the width of the vagina at that part indicated by a line bisecting the center of the cervix uteri should be taken. These measurements give the size of the pessary required in length and width, and are usually taken through a Sims's speculum, with the patient on the left side. The longitudinal measurement is easily obtained by a sponge and holder (Fig. 149), which are carried up by the side of the cervix to the upper termination of the vagina, and there marking, with the finger resting on the stem of the sponge-holder, the point opposite the junction of the bladder and the urethra. The transverse meas- urement may be taken by sight, or, if the eye is not trained suffi- RETROVERSION OF THE UTERUS. 319 ciently for this, by a pair of long dressing-forceps having a mark on the handles the same distance from the lock as the point of the blades. The for- ceps are passed up and the blades ex- panded until they reach the lateral walls of the vagina, and, while held in this position, the measurement is ob- tained from the ex- tent of separation of the handles. The size being obtained, the shape next de- mands attention. The outlines of the Albert Smith pes- sary (Fig. 148) are adapted to the lat- eral vaginal walls in a general way, and any change to suit special cases is easily made. The curves for the antero-posterior walls are slight modifications of the ogee curve of the mechanic, which is two seg- ments of a circle joined and reversed. This shape may be taken as a basis from which changes of form must be made in every instrument used. The guide for the form of these curves I have ob- tained in this way : I first ascertain by touch and in- spection the length of the invagination of the cer- vix posteriorly, and then make the posterior up- Fig. 149. -The method of measuring the length of the pes- sary ; p, retracted perineal body. anterior vaginal wall Fig. 150.—Diagram of pessary in situ on looking at it in Sims's position, through Sims's speculum. ward curve of the pessary a little short of the extent of this in- 320 DISEASES OF WOMEN. Fig. 151. -Slight invagination of cervix posteriorly with suitable pessary. vagination. The ante- rior downward curve is made about equal to the posterior, subject to slight variations to meet special cases. Figs, lol and i:>2 show two cases dif- fering in the extent of invagination, with pessaries adapted to them. These rules for the adaptation of pessaries are only useful as a basis to start from ; each case requires one deviation or more from these rules. This ne- cessitates a material for a pessarv wdiich is easih' molded, and this is happily now afforded in the instrument made of whale- bone and fine copper-wire, and then covered with soft rubber. This kind of a pessary can be modeled with the greatest facility to any form. To restate briefly the most important points in the manage- ment of mechanical supports in the treat- ment of retroversion, I would say that my method is as follows : Sims's position and his speculum are used in replacing the uterus, and when it is restored the measurements are taken, a pessary se- lected of the proper size and modeled to suit as nearly as possi- , , -n. • v. • G' ^5~-—Decided invagination of cervix posteriorly Die. It is then intro- fitted with a suitable pessary. RETROVERSION OF THE UTERUS. 321 duced and careful observations made to see if it fulfills the require- ments. If it does not it is removed, altered, and reapplied, care being taken never to have the instrument large enough to make general pressure on the vaginal walls, nor of such shape that it will make undue pressure at any one point. Where possible, I prefer to introduce and remove pessaries through Sims's speculum. The method of doing this is very sim- ple. In the introduction the perinaeum is retracted, and the pessary turned up on the edge is passed beyond the vulva and then turned half round, which brings it into position. It is usually the case that, in the treatment of retroversion, the pessary requires to be changed in shape quite frequently during the first two or three weeks that it is in use, but with the material de- scribed this is easily done. When the uterus is well in place, and the vagina no longer appears to be undergoing any changes from involution and contraction, then a hard-rubber pessary is made, using the soft one, which has been made to answer the purpose, as a model. The hard rubber, of course, can be worn a much longer time than the soft, and is much more agreeable to the tissues. In regard to the modifications to be made in pessaries, to suit cases as they present themselves, all that is necessary will be said when giving the histories of cases. It is important, however, to keep in mind what has been said in regard to the cases in which the uterus can not be fully restored to its normal position, owing to changes in the posterior vaginal wall and the uterine ligaments. In such cases the restoration to the normal position must be gradual, and hence the use of the pessary is to keep the uterus in the posi- tion in which it is placed by the efforts at restoration, and by the support of the instrument to favor a tendency toward the normal position on the part of the uterus. In the management of such cases the posterior part of the pessary should not be much curved upward, if at all, be- cause the object is to have the pessary carry the posterior vaginal wall backward behind and below the uterus to support the body and fundus, while the cervix resting be- tween the bars of the pessary is unsupported and free to sink downward and backward Fig. 153.—What the pessary as the body of the uterus rises. Here the does not d°" principle of the lever acts to change the axis of the uterus. This is shown in Figs. 154 and 155. The lever action of the pessary is made more effective by the 22 322 DISEASES OF WOMEN. post. vagr- wall ant. vatf wall p*ss»ry Fig. 154.—IIow the pessary acts—shown by the arrows in the diagram. pressure of the bladder and the anterior vaginal wall upon the ante- rior part of the instrument, which inclines to raise the posterior part upward, and so bring the pessa- ry into a more oblique position as the uterus rises. See Fig 154. The pessary being wedge- shaped— that is, narrower in front than behind—is held up- ward by the contraction of the lower portion of the vagina, and the wedge-action helps the lever-action of the pessary to raise the uterus and throw it forward. In regard to the surgical operations employed in the management of retroversion, I may say that, where the cervix uteri is lacerated, it should be restored, and also that the pelvic floor, if injured, must be operated upon in order to cure retroversion. In fact, very little progress can be made in the treatment of retroversion, unless the pelvic floor and uterus are normal or nearly so. This is all the surgical treatment that I now employ, besides mechanical support, in the management of these displacements. In recent times, Alexander, of Liverpool, has devised a plan for the correction of uterine dis- placements, which consists in shortening the round ligaments. In his presentation of the subject, to the British Gynecological Society, he said that the operation has now been per- formed in nearly all prominent cities in the world, and by most operators with more uniform success than generally befell any new operation. He never found any difficulty in finding and drawing out the ligaments. An incision was to be made upward and outward from the pu- bic spine, in the direction of the inguinal canal, for one and a haK to two or three inches, according to the fat- ness of the subject. A considerable thickness of subcutaneous fat Mas then met with, which must be cut through by subsequent incis- ions, until the pearly, glistening tendon of the external oblique muscle was reached. Midway through the fatty tissue an aponeu- rosis sometimes appeared, so firm and smooth, that it might cause the operator to think he was deep enough, but he would find no hga- Fig. 155.—Second step; the uterus falls into the pessary. RETROVERSION OF THE UTERUS. 323 ments at this spot. The first stage of the operation consisted simply in cutting down upon the tendon of the external oblique muscle, until it appeared clean and shining at the bottom of the wound. Fio. 156.—The knee-chest position—air enters the vulva, and distends the vagina, and the fundus falls in the direction of the arrow. The external ring was then found. The finger passed to the bottom of the wound detected the spine and the ring outside. Having iso- lated the external wound, and tied any little vessels, the next step was to find the end of the ligament. By everting all the structures upward, the round ligament could be seen, generally at the lowest part, and with the white easily distinguished genital branch of the genito-crural nerve along its anterior surface and close to it. The ligament at this stage was more or less rounded in shape. It was an easily recognized flesh-colored structure. When the ligament was identified, the small nerve on its surface was to be cut through without dividing any of the ligament. Then gentle traction was to be made, either by the fingers or by broad, blunt-pointed forceps. Bands holding it to neighboring structures were cut through with scissors. As soon as it began to peel out, it was left, ano) the oppo- site side begun. The final stage of the operation consisted in placing the uterus in position by the sound, and pulling out the ligaments until they were felt to control that position. A curved threaded needle, with fine catgut, was used to stitch each ligament to both pillars of the ring and the external abdominal ring was closed with- out strangulating the ligament as it lay between them. The ends of the ligaments were now cut off, and the remainder stitched into the wound by means of the sutures that closed the incision. A fine drainage-tube was inserted, and the wound washed out with carbolic or other lotion before these sutures were tied. 324 DISEASES OF WOMEN. The after treatment consisted in rest. The tubes were removed on the second day, when the wound was dressed. The mortality of the operation might be set down as nothing. Three deaths had oc- curred, but they were due to preventable causes. As mortality did not seriously enter into any consideration of the results of this opera- tion, the real question at issue was whether it fulfilled the intentions of the operator and satisfied the expectations of the patient. The operation was designed to correct certain uterine displacements, and these alone. Whether the discomfort of the patient would be there- by relieved, entirely depended on whether or not the symptoms were due to the displacement. To secure success, the operation must be properly performed, and the after treatment must be rational, so that no strain might be placed on the ligaments until sound union had taken place. Most excellent results from this operation have been reported by many surgeons. I have not practiced it, for the reason that the cases which are curable by Alexander's operation are curable by the means which I have described, and the cases that are incurable by such means are also incurable by Alexander's operation. Further experience, however, may prove that the shortening of the round ligaments will cure retroversion more promptly and per- manently than any other method of treatment, but up to the present time that question is not fully settled. Retroversion with fixation of the uterus from adhesions has been considered incurable in times past. The use of electricity, massage, and absorbents, such as iodine and ichthyol, frees the uterus from adhesions so that it can be replaced. Kecently some valuable con- tributions have been made on this subject. Such cases have been treated by laparotomy, breaking up the adhesions and restoring the uterus to its place. Prof. W. M. Polk has given the results of his labors in this field, in a most valuable paper, published in the " American Journal of Obstetrics," for June, 18ST, from which I make the following quo- tations : "Laparotomy for adherent retroflexed or retroverted uterus. A. W., aged thirty-eight. This patient has suffered from pelvic pain for several years. The originating cause was obscure, but it seemed to have been due to pelvic inflammation, induced by treat- ment for posterior displacement of the uterus. Examination showed that the uterus was retroverted and bound down. Sensitive masses were discovered on both sides of the uterus in the broad ligament regions. Upon opening the abdomen, the remains of pelvic pen- RETROVERSION OF THE UTERUS. 325 tonitis were evident. The uterus was fixed in the cul-de-sac. Chronic salpingitis and periovaritis were present on both sides, the tubes and ovaries being attached to the posterior face of the broad ligaments, but not to the pelvic floor. u The adhesions binding down the uterus were separated and the tube and ovary upon the left side removed, after which the mass upon that side could no longer be felt. The appendages upon the right side were not disturbed, owing to the accidental wounding of a vessel close to the uterus. There was prolonged and very trouble- some bleeding. By the time this was controlled I did not think it wise to further prolong the operation, the patient's condition forbid- ding it. This case afforded me an opportunity to study the behavior of an inflamed tube after the adhesions binding it down and crip- pling it had been torn up. I carefully freed the right tube and ovary from the adhesions binding them to the posterior face of the broad ligament, and satisfied myself that they, as well as the append- ages on the left, represented the mass felt in this region through the vagina. I used a drainage-tube, as there had been a good deal of manipulation in the pelvis. This served the additional purpose of keeping the uterus forward " The patient remained in the hospital nearly two months, and when I examined her just before her departure I found both sides of the uterus free from the masses, and from sensitiveness as well. "■ Mrs. A., aged twenty-six. Seven years ago had a severe at- tack of pelvic inflammation ; she was very ill for tliree months, and then made a gradual recovery. The prominent local condition dur- ing the attack was a mass in the left iliac region. This slowly dis- appeared, but ever since the illness she has been conscious of uneasi- ness in that region. From the date of the inflammatory attack to the present, she has suffered severe dysmenorrhcea, this pain lasting, as a rule, for three days, and of sufficient intensity to compel her to keep in a recumbent posture during its continuance. Aside from this menstrual pain, the soreness in the left iliac region, and an occa- sional attack of rhematism, she has been in good health. a Two months ago she was married, since which she has been a constant sufferer from pelvic pain, with much increase in the dys- menorrhea. Upon examination, I found the uterus retroflexed and tirmly bound in Douglas's cul-de-sac; the body enlarged and very sensitive. Upon the left side, in the broad ligament region, there was a fixed sensitive mass, about as large as a walnut; upon the right, in the corresponding region, a similar but smaller mass was likewise detected. 326 DISEASES OF WOMEN. "Diagnosis.—Retroflexed, adherent uterus, with adherent tubes and ovaries; the whole the result of a prior salpingitis and peritoni. tis. I advised laparotomy, and in March it was done. The ad> hesions binding the uterus, tubes, and ovaries were easily broken up and those organs liberated. The tube walls were somewhat thickened, but there was no distention of the cavities. The right ovary was small, the left somewhat enlarged; this one was much more firmly and extensively adherent than the right. A drainage-tube was placed in position, as usual, behind the uterus, and the wound was closed. The patient made a good recovery, and has had one men- struation free of pain. " The uterus, to-day, is in normal position, with the exception that it is somewhat lower in the pelvis than I would prefer. It is now movable, and it, together with the appendages, is as free from pain on pressure as could be possible so soon after operation." Massage.—Massage, as performed by Brandt, is of great value in the treatment of backward displacements of the uterus complicated with adhesions. The favorite method of some surgeons of the present day is to perforin laparotomy and then divide the adhesions; but there is a great liability for these to reform and render the operation useless. When relief is obtained by massage, it is permanent, as a rule. In such cases Brandt begins by performing massage on the gan- glia and lymphatic vessels in the neighborhood of the promontory of the sacrum, in order to empty them of the lymph which they contain, and thus make a demand upon the lymphatics for material for absorption. Then he carries his hand above the periphery of the adhesions, in order to empty the efferent vessels, which are thus prepared to receive the lymph coming from the center. The direct massage of the adhesions which bind the uterus backward is per- formed in the same, manner as the bimanual examination. Under these circumstances Brandt advises massage of the adhesions from before backward with the left hand, while the right index-finger in the rectum sustains them. In many cases this can be done just as well, in my opinion, per vaginam. This method of Brandt achieves excellent results in a short time, even in cases of old exudates whose disappearance causes the com- pression of nerves and the consequent pain to cease. The mechan- ical action of massage combats pain and modifies temperature, and is therefore both analgesic and antiphlogistic. Bimanual massage, according to Brandt's method, is best adapted to broad adhesions and the excessive inflammatory exudations of RETROVERSION OF THE UTERUS. 327 pelvic peritonitis and cellulitis. Where these are reduced, and in cases that from the first present cord-like peritoneal adhesions, stretching should be practiced. I do not mean the forcible and rapid breaking up of these adhesions, but a repeated, methodical traction upon the adhesion bands, by grasping the uterus bimanu- ally, and, while trying to replace it and holding the adhesions on the stretch, moving the uterus up and down. As soon as the uterus can be brought into or toward its normal position, efforts should be made to retain it, first by tampon, and finally by a pessary adapted as described at page 312. Hysterorrhaphy.—Hysterorrhaphy is the name given by Howard A. Kelly to the operation of fixing the fundus uteri to the abdominal wall; it is also known as ventro-fixation of the uterus. It has been found to be efficient in cases of backward displacement of the uterus with adhesions which do not yield to other methods of treatment. This procedure is not in accord with the highest principles of surgery; to produce one pathological condition in order to relieve another is always objectionable, and should be avoided if possible. Relief follows this operation in some cases, but in these it will usually be found that, after some months, the uterus has broken away from its attachment to the abdominal wall and has regained its normal mobility. In some cases the displacement will recur, while in others the patient will remain well. When the latter results are obtained, it is perhaps because the fixation remained long enough to permit the supports of the uterus to regain their normal state and keep the uterus in place after the fixation to the abdomen had ceased. The operation is performed as follows: An incision is made just above the pubes sufficient to admit two fingers. The adhesions are broken up by the fingers, and the fundus uteri is gently drawn up to the incision ; a Peaslee needle threaded with silk, catgut, or silk-worm gut, according to the choice of the operator, is passed through the abdominal wall, then through one horn of the uterus, and back through the abdominal wall again. This is repeated on the other side, and the sutures are tied. Some surgeons prefer not to include the fundus uteri, but to pass the sutures beneath the round or ovarian ligaments. In order to obtain firm union of the opposing surfaces, the uterine and parietal peritonasum is partially vivified by scraping. I consider this unnecessary. The abdomen is afterward closed in the usual manner. If free Invmorrhage follows the separation of the adhesions, it should be controlled by pressure with hot sponges. 328 DISEASES OF WOMEN. RETROFLEXION OF THE UTERUS. In the chapter on anteflexion of the uterus the pathology of flexions generally was discussed, and the classification adopted was that flexion was a deformity and not a simple dislocation. In fact, a very broad distinction was made between displacements and flex- ions. It was observed at the same time, that retroflexion of the uterus was frequently, in fact in the great majority of cases, produced as a result of a retroversion. The uterus first becomes displaced back- ward, and, in consequence of the deranged fofces acting upon the uterus, it becomes bent upon itself—that is, flexed as well as dis- placed. Owing to this close association of retroversion and retro- flexion, and the fact that the treatment of both has much in com- mon, I have placed them together. In practice I have made out two degrees of retroflexion, and the flexion is confined to the body, the cervix maintaining its normal points forward more than it should, but less so than in retroversion. This gives rise to a little shortening of the anterior vaginal wall, or else an undue invagination of the anterior wall of the cervix. Symptomatology.—The symptoms present in retroflexion are very much the same as those of retroversion, hence it is only necessary here to note some few that are more marked in flexion than in RETROVERSION OF THE UTERUS. 320 version. In retroflexion the menstrual function is more frequently disturbed. Dysmenorrhoea is often present, and although the pains are less acute than in anteflexion, they are far more marked than in retroversion. In many of those having retroflexion the men- strual discharge is often quite offensive; this also occurs in other conditions, but, taken in connection with other signs and symptoms, it is valuable as a means of diagnosis in this affection. Physical Signs.—The points of difference between retroflexion and retroversion are, as observed by the touch, that the cervix in flexion does not point toward the vulva or pubes, but is nearly in its normal position. There is less relaxation of structure of the upper portion of the vagina. Behind the cervix the rounded fundus can be felt by the examining finger to be pointing downward and back- ward, instead of directly backward as in retroversion. Between the cervix in the vagina and the fundus uteri the angle of flexion can be felt. All this can be made out by the vaginal touch, and, in favorable cases, the bimanual examination will help to verify the signs obtained. When the abdom- inal muscles are very lax and the vagina long and elastic the uterus can be carried upward with the fin- ger which is in the vagina, and brought within reach of the hand on the abdomen —i. e., the uterus can be grasped and exam- ined bi manually. In that case the defor- mity of the uterus can be clearly made out; but it is rare that this is practicable. It is usually impossible to reach the anterior wall of the uterus by the hand placed upon the abdominal muscles. In the great majority of cases I have been obliged to depend upon the vaginal touch and the uterine sound to make a positive diagnosis. The two conditions which I have found simulating the physical Fig. 158. Prolapsed and adherent ovary simulating retro- flexion. 330 DISEASES OF WOMEN. signs are a large and prolapsed ovary and a subperitoneal fibroma on the posterior wall of the uterus. These are shown in Figs. 157 and 158. In either of these affections the touch gives the signs of retro- flexion, and it is only by using the sound and proving that the uterus is in its proper position and form that they can be distin- guished from flexion. While the sound is not absolutely necessary to differentiate between retroflexion and such conditions as those named, I find that it gives confidence in the diagnosis in retroflexion to pass it and see that the canal runs backward and is not distorted by the flexion. Sometimes it is very difficult to pass the sound around the point of flexion, and in order to do so it may be necessary to raise up the fundus and also the cervix, in order to straighten the canal. When the uterus is very tender, much care should be exercised in using the sound. The application of cocaine is useful in relieving the hyperaesthesia. Causation.—Retroflexion occurs in single women, and also in those who have borne children. In the former, I have found it much more frequently. For practical purposes, this affection might be divided as regards causation into two forms, congenital and ac- quired. From the history of those cases in which this flexion is found in early life, I believe that it is brought about by some lesion of development. It may not be, strictly speaking, a con- genital malformation. It is more likely that the infantile uterus becomes retroverted before puberty, and then when secondary development takes place, the increase in weight of the body and fundus causes displacement of the upper part of the uterus, and the cervix being held in place by the resistant vagina, the flexion is produced. This is the only explanation of the production of these cases at puberty. When it is acquired after bearing chil- dren, I believe that retroversion occurs first, and if the cervix meets resistance from the anterior vaginal wall and bladder in front, the flexion is produced. If the uterus is made to bend a little at the point of flexion, the pressure at that point will cause atrophy at that point, and thereby the flexion will gradually in- crease. It is possible that in some of the acquired cases there is some lesion or excess of involution at the junction of the body and cer- vix, and the walls of the uterus being thus weakened at that point, permit the uterus to fall over backward. Prognosis.—In acquired cases, and uncomplicated, appropriate RETROVERSION OF THE UTERUS. 331 treatment will usually give relief if persisted in long enough. In the so-called congenital forms, there will be found cases, which do not yield to treatment. Relief from the most distressing symptoms may be obtained, but as soon as the mechanical support is removed the flexion will return. The resistance of some cases to treatment I have found due to a rigid state of the posterior wall of the va- gina, which prevents the use of a pessary which would extend far enough back to throw the fundus forward. In such cases the use of a pessary often aggravates the trouble. Treatment.—The principles of treatment in retroflexion are the same as in retroversion, aud hence need not be discussed here, fur- ther than to note some of the additional means necessary in flexion. To restore the uterus to its normal form and position it is often necessary to use the Elliott adjuster, and to repeat its use a number of times; then a pessary should be employed as in retroversion. In adjusting the pessary, care should be taken not to curve the poste- rior bar too much, but to shape it so that it will carry the posterior vaginal wall back behind the body and fundus so as to support both. This can be made clear, perhaps, by showing the effect of a pessary which is not of proper shape, and which increases the flexion by making pressure upward in place of backward (Fig. 153). Alexander's operation is suggested to the mind by those cases which do not yield readily to treat- ment, and I presume it would be use- ful. However, the only cases which resist the usual treatment are those in which the posterior vaginal wall is unyielding, and the uterus can not be straightened by Elliott's adjuster. In such cases there is reason to sup- pose that the uterus is fixed in its malposition by some old cellulitis or peritonitis ; and if so, Alexander's operation would not succeed. It is rather rare that the treat- ment prescribed fails. In obstinate cases in which the frequent straightening of the uterus does not stimulate the growth of tissue at the point of flexion, the stem pessary should be tried. The canal of the cervix should be dilated sufficiently to admit a fair-sized glass or hard-rubber stem. The stem is then introduced to overcome the flexion and keep the uterus straight, and the pessary 332 DISEASES OF WOMEN. is used to keep the stem in place. The same kind of stem and pessary as are used in the treatment of anteflexion are employed, with this difference, that the pessary is adapted to keep the utenis in position as well as to hold the stem in place. To recapitulate, the stem corrects the flexion, and the pessary corrects the retroversion, as well as keeping the stem in place. Atrophy of the Uterine Walls at the Junction of the Body and Cer- vix. — This is a condition which causes anteflexion and retroflexion, which may alternate by turning the body of the uterus backward or for- ward. I have found it in those who have borne children, and also in those who have not. Pathology.—There is a defect in the middle layer of the anterior and posterior walls of the uterus at the internal os which permits the uterus to bend forward or backward with equal facility. Fig. 100 shows the appearance of such a uterus. Such cases are rare, and have a clinical history very much the same as ante- flexion. I can give the best descrip- tion of the affection by relating the history of a well-marked case. ILLUSTRATIVE CASE. A dressmaker, single, and in fair general health, twenty-seven years old, came under my care in the hospital, giving the following history: She began to menstruate at fifteen, and from that time until she entered the hospital, had suffered from dysmenorrhcea. The pain at her periods became progressively worse, until she was entirely unfitted for her duties. She sought relief in medicine, but only large doses of opium sufficed. Becoming wholly useless, she entered one of the hospitals of this city, and remained under treatment there for four months. During that time she had violent hysterical convulsions at her men- strual periods, and deriving no benefit from treatment was dismissed as incurable. Upon examination, I found marked anteflexion of the body of the uterus; and, owing to slight stricture of the internal os and the extreme tenderness of the utenis, the sound could not be passed until she was anaesthetized. I then found that the os Fig. 160.—Uterus with defective walls ; the supra-vaginal portion of the cer- vix is elongated (after Winckel). RETROVERSION OF THE UTERUS. 333 internum was constricted. I incised it and dilated until I could pass a No. t) English sound. At the same time I used Elliott's ad- juster to straighten the uterus, and carried the fundus backward. This was accomplished with unusual facility, the uterus making no resistance to bending in any direction. The instrument was with- drawn, and the patient placed in bed to rest; there was no pain or inflammation following this treatment. Three days afterward I made a digital examination, and found the uterus retroflexed. By using again the Elliott adjuster I was able to change the retroflex- ion back to the original anteflexion, which remained so for several days. It being necessary to pass the sound every third day to pre- vent the recurrence of the stricture at the internal os, I took advan- tage of the opportunity, by changing the flexion a number of times, and found that whatever position I placed the body of the uterus in, it would remain there. The dilatation of the os externum gave the patient great relief from the dysmenorrhoea. The usual treatment for congestion and hypersesthesia was continued, and the canal kept dilated by the use of the sounds. A stem pessary was tried, but she could not tolerate it except by keeping in bed. She improved so much in two months that she left the hospital, and only returned occasionally as an out- patient. For two years I kept her under observation and, although she was not entirely free from pain, she was able to make her living. In this case I feel sure that the trouble originated in an imper- fect growth at the time of secondary development. In one other case of which I have full notes, the flexion came after the patient's second confinement, and, perhaps, was due to a derangement of involution. CHAPTER XIX. ABCSE OF PESSARIES. Injuries to the Pelvic Organs Caused by the Improper Use of Pessaries.—The dangers of stem pessaries have already been referred to in the chapter on flexions, so far as their liability to cause acute inflammations of the uterus, pelvic cellular tissue, and peritonaeum. There are still other injuries which they may give rise to. When the stem is small and badly adjusted with reference to the character of the flexion, the point of the instrument may become imbedded in the wall of the utenis, or the lower part of the stem may divide the posterior wall of the cervix. Both of these injuries I have seen in practice. In one case, an anteflexion of the cervix, a small stem of steel with a hard-rubber disk at its end was introduced by a general practi- tioner, and left in place for three months. The patient soon began to suffer from a purulent discharge, which gradually in- creased, and there was much pain, greatly aggravated by walking. When I saw her the relations of the stem and uterus were as shown in Fig. 161. After the removal of the stem, the cervix presented exactly the same appearance as that seen after Sims's operation for flexion, except that there was more thickening of the edges of the wound and more inflammation than I have ever before seen after discision of the cervix by the surgeon. The inflammation subsided under ordinary treatment, and she was at least none the worse for having worn the stem. Another patient came under my observation while wearing a stem pessary, which had been introduced six weeks before by her medical Fig. 161.—Stem of pessary ul- cerating through cervix. ABUSE OF PESSARIES. 335 attendant. She had suffered pain and tenderness from the time that the stem was introduced, and for a week before she came under my care the suffering was so great that she was obliged to stay in bed and take opium freely; she had also a purulent discharge, and at times bleeding. The stem was about the thickness of a No. 9 catheter. It was made of hard rubber, and was held in place by a cup pessary in the vagina. While the stem was still in place (the vaginal pessary having been removed) the body of the uterus was found to be markedly anteflexed, and its anterior wall near the fundus was unusually prominent, as if it contained a small fibroid tumor. The flexed shape of the uterus led me to suppose that the stem must be curved, but on removal it proved to be straight. I then passed with some difficulty, owing to the tenderness of the uterus, a much-curved sound into the cavity of the uterus, and then after straightening the sound, it was passed into the groove made in the posterior wall by the stem. One might suppose that the cavity of the uterus was simply dilated so that the sound could be curved forward and then straightened and passed along the posterior wall, but I am confident that such was not the case. The posterior wall of the body was flexed forward and rested upon the anterior wall on either side, and the sul- cus made by the stem was in the center. Fig. 162 shows the conditions as they ap- peared to me during my examination. There was considerable bleeding after the removal of the stem, and the uterus be- a -, ,, ., Fig. 102.—Stem cutting came more flexed apparently as soon as the through body of uterus. support was withdrawn. There was relief from the acute symptoms and inflammation caused by the instru- ment, but the dysmenorrhcea was worse than before. Atrophy of the muscular tissue of the vaginal wTalls from over- distention by pessaries that are too large is quite frequently seen. Practitioners who are not skilled in the use of pessaries, yet never- theless use them, produce this injury of the structures of the vagina. The same unfortunate results are effected by those who believe in the theory that in order to keep the uterus in place, in retroversion, for example, it is necessary to use a pessary large enough and suf- ficiently curved to force the posterior wall of the vagina far up in the pelvis above its normal elevation. 336 DISEASES OF WOMEN. The following case will illustrate this: The patient had children, and was said to have had a displacement; probably retroversion. She was treated with a variety of pessaries, so she told me, but did not get well; when she came to me, she had much backache, pelvic pain, and vaginal leucorrhoea; she was then wearing a pessary nearly large enough to fill the pelvis, and much curved both in front and behind. The uterus was in about its proper place in the pelvis, but the vagina was greatly overdistended and its walls were thin, especially the posterior wall behind the cervix. On removing the pessary, a difficult task owing to its size, the vaginal wall, and the rectal wall also, I think, fell downward and formed a rectocele high up. Fig. 163 will give an idea of the state of the parts as they appeared to the touch, after the pessary was removed. The part of the thin wall of the vagina bulged down- ward, and felt to the touch exactly like the ordinary rectocele, except that the protruding mass was at the upper part of the vagina in- stead of the lower; when seen through the speculum introduced about an inch and a half, this was confirmed by the eye. The first impression obtained by the touch was that of a portion of intestine distended with gas lying behind and below the cervix uteri. The patient felt a little more distress, strange to say, after the pessary was removed ; when she tried to walk without it, she suffered from pain and tenesmus very severely. This I have found to be the case in all instances of overdistention of the vagina; patients suffer with the support, and for a few days suffer more without it. This is much the same experience as ladies have who can not go without corsets, and the tighter they lace them and the more damage they do, the more they miss them when they discontinue their use. This patient was kept rather quiet for a time, and astringent in- jections were used, which, after a long time, restored the vagina more Fio. 168.—High rectocele due to improper pes- sary. ABUSE OF PESSARIES. 337 nearly to its normal caliber. There remained for over a year, when I last saw her, and perhaps ever since, a sagging of the upper part of the posterior vaginal wall. Another case, somewhat of the same character, came to me from the West. She was forty, and single ; her health and strength had been good until she was thirty-six years of age, when she began to have a variety of nervous symptoms clearly due to general debility. She was treated by several reputable physicians, but not recovering as fast as she desired, she consulted still another, who told her that she had falling of the womb, which caused all her troubles. There was not a symptom that pointed to any disease or displacement of the sexual organs, but a Cutter pessary was introduced and the patient wore it about two years. Her general health improved very little, and the pessary soon caused her trouble; still she persisted in wearing it because the doctor said she must do so ; her condition be- came so wretched that she came East, in the hope of gaining relief. When she came to me she had some vaginitis and vulvitis caused by the pessary, but the uterus was perfectly normal in every way. The Cutter pessary had pushed up the posterior vaginal wall far beyond the cervix, which lay on one side of the instrument, not between the bars as it should have done. The condition of the posterior vaginal wall at the upper part was about the same as in the case just related. The lower part of the vagina was normal, excepting the inflammation caused by the pes- sary. The vulva was also inflamed, and she suffered greatly from this, especially in taking exercise. This patient also felt the want of the pessary when it was removed, but only for a short time. She was examined seven months after the removal of the instrument and was found to be perfectly well. Injury of the Posterior Vaginal Wall by the use of Pessaries in Cases of Incurable Retroversion.—This case illustrates a class which, though not large, deserves notice. In retroversion with fixation of the uterus, either from a congenital state or because of adhesions or shortening of the post-uterine ligaments, there is sometimes a slight mobility of the uterus which admits of its being partly restored. This leads the practitioner to hope that, by the use of the pessary, the displacement can be corrected. The result is that the posterior portion of the pessary makes too great pressure upon the vaginal wall and produces inflammation and abrasion. This usually causes a five vaginal discharge and pain enough to make the patient seek relief before much permanent injury is done. In all such cases pes- saries should not be used at all, but if one is employed in the hope 338 DISEASES OF WOMEN. of doing good, it should be abandoned as soon as it causes any irri- tation. In these incurable cases, a slight relief may sometimes be given by using a Peaslee's ring, or a Smith's pessary very little if at all curved posteriorly. Either of these instruments will hold the utenis a trifle higher in the pelvis, and this will, in some cases, give a sense of support and relief to the patient. Overdistention and Atrophy of the Anterior Vaginal Wall from the use of Anteversion Pessaries.—This condition is rarely seen ex- cept among the patients of those who look upon anteversion as a morbid state of importance whenever it occurs. In order to raise the body of the uterus up when it is anteverted, it is necessary to elevate the anterior vaginal wall far beyond its normal position. In order to do this, the instrument must make well-marked pressure upon the parts, and, if this is continued, the muscular wall becomes atrophied and overdistended, and this can be carried on to a very great degree, the whole length of the vagi- nal wall becoming double that which it originally was. When the pessary is removed in such a condition, there is at once observed a well-defined and large prolapsus of the vaginal wall, and if the instrument is left out, cystocele will soon follow. This is the rule, but the final results depend to some extent upon the length of time that the pessary has been worn. The stretching of the vaginal walls caused by pessaries can be overcome by removing the instrument, and prescribing rest and astringent injections. But if the overdistention has been kept up long enough to cause atrophy of the muscular tissue, the injury is permanent and can be very little improved by treatment. There is also danger to the bladder and urethra from the ante- version pessary. The following case will show how this comes about: Frequent Urination associated with Slight Anteversion of the Blad- der.—The lady was about thirty, and had a child seven years old. She gradually developed a pelvic tenesmus and some irritability of the bladder. She consulted her physician, who diagnosticated ante- version of the uterus, and stated that the disturbed function of the bladder was due to the malposition of the uterus. Thomas's ante- version pessary was introduced by the physician in charge; this gave the patient a sense of support which was agreeable, but more disturbance of the bladder was caused. The physician urged the patient to wear the pessary, telling her that she would get used to it, and the unfavorable effects would pass off ; but this proved not to be the fact. The patient then came under my care, having worn ABUSE OF PESSARIES. 339 the pessarv for two weeks; I at once removed it, with the result of giving some relief, but there was still more impatience of the blad- der than before the instrument was used at all. The true state of affairs proved to be that the patient had a slight catarrh at the neck of the bladder, not due to the malposition of the uterus at all, and the pessary only increased the original affection. In proof of this, the symptoms all disappeared when the disease of the bladder was removed, and without changing the position of the uterus in the least. Cup Pessary with an Extra-Vaginal Support, causing Vulvitis and Ulceration of the Vagina.—All the pessaries having a stem attached to a band around the body have given trouble when worn for any length of time. The evil caused by the one used in this case, is typical of most of them. The patient lived in the country, and, while suffering from pel- vic tenesmus, called in a physician who adjusted a Babcock's uterine supporter for " falling of the womb." She was directed to remove it at night and introduce it in the morning. For a short time she felt some relief, but soon began to suffer from a profuse vaginal dis- charge and great tenderness about the vulva. The suf- fering increased until she was unable to walk, and the introduction of the support- er gave great pain. AVhen I examined her I found the relations of the uterus and supporter as rep- resented in Fig. 161. The uterus was retroverted and the cup and stem were situ- ated in front of the cervix and held the anterior vaginal wall high above its normal position. There was some ulceration of the vaginal wall and general vaginitis and vulvitis. The apparatus was removed, vaginal injections of borax and water employed, and in a short time the inflammation was relieved. The uterus was then restored to its normal position, and retained there with a pessary such as I use in such cases, and she did very Fig. 164.—Displacement caused by a badly adjusted pessary. 340 DISEASES OF WOMEN. well. But for several months there was a tendency to prolapsus of the anterior vaginal wall, owing to the overstretching of it by her former supporter. The Upper Rim of a Cup Pessary partially imbedded in the Vagina, around the Cervix Uteri.—This patient had a prolapsus uteri, and the physician who had her in care used a cup and stem of soft mb- ber; the cup was quite a large one and its edges were rather sharp. I think it was called the Barrington supporter. She was much re- lieved by this instrument, being able to do her duty as a laundress, but she began to have a vaginal discharge and occasional bleeding, with pain and tenderness. I saw her with the doctor and found a ring of raw tissue in the vagina, around the cervix uteri, correspond- ing to the size and shape of the cup. The uterus was large, measuring nearly five inches. Evidently the pressure upon the instrument was more than the tissues of the vagina could stand. The patient rested for a time and used vagi- nal injections; the parts healed promptly, but the scar tissue re- mained tender, and gave way under the pressure of the instrument, whenever she wore it for any length of time. I think that this patient could have been cured by rest in the recumbent position until the enlargement of the uterus and relax- ation of the vagina had been overcome, and then the pelvic floor restored. But she could not give the time to this, being poor, and obliged to work to live. She was directed to wear a perineal pad fastened to a waist-belt, and she got along fairly well in that way. A Pessary imbedded in the Posterior Vaginal Wall.—In the cur- rent literature there have been many extraordinary cases recorded of pessaries having passed through the vaginal walls into the rectum and bladder. Some of these cases have been very remarkable, and have been recorded as matters of curiosity. Little has been said about the causes of such accidents or how to manage them. The following case illustrates the most common forms of this ac- cident : The patient was a widow who had borne several children, and had been well until the menopause, when she became insane. At the outset of her mental derangement, her physician suspected that she had some uterine disease, and, on investigating the case, found the uterus larger than it ought to be and retroverted. He restored the organ to its normal position and introduced a pessarv which held it there; the instrument was well adapted and answered the purpose well. After this his attention was wholly directed to her mental condition, and she recovered her mind in about one year. The pessary was forgotten by her physician, who introduced it ABUSE OF PESSARIES. 341 while she was in the asylum. Wrhen she came home, or soon after, she began to have a discharge from the vagina and occasional bleed- ing. I then was called to examine her, and found all that portion of the pessary which rested behind the cervix uteri, imbedded in the vaoinal wall. The tissues to the extent of nearly a quarter of an inch had united in front of the pessary bar. Traction was made upon the pessary until the tissues inclosing it were made tense, and they were then divided down to the mstru- ment; there was much bleeding, but the parts healed well, leaving a large scar in the posterior vaginal wall. This case is one the like of which is not infrequently seen ; they differ from most of those already mentioned, in the important fact that they occur in cases in which the instrument is well adjusted and answers its purpose for a time, causing no trouble until the vagina begins to contract during the final involution at the menopause. The vagina contracts so much that the pessary, which, at the time of its introduction was small enough and had plenty of room, becomes altogether too large and must imbed itself in the vaginal walls. I have seen a sufficient number of these cases to satisfy my- self that they occur in the practice of the most competent gyne- cologists, sometimes, perhaps, from neglect in giving specific direc- tions to the patient to report from time to time, so that the behavior of the pessary may be watched, but more often from the fact that the patient having been relieved of all her symptoms, either forgets the pessary, or else feels secure and safe, so long as there is no suf- fering which she can not, in her own opinion, attribute to the meno- pause, the time when there is the greatest danger of the accident in question. Pessary entirely imbedded in the Vaginal Walls, except about three quarters of an inch.—This patient came to me when she was forty-six years old; she was still menstruating, but irregularly, and on one or more occasions had menorrhagia. She was suffering from a prolapsus of the uterus which caused her much trouble when she was on her feet. I restored the uterus, and used an instrument to keep it in place. This gave her relief at once, and she was able to take up her duties as in times past. She came to see me several times and I made some applications to the uterus which caused a slight endometritis. I directed her to continue her visits from time to time, in order that I might see how the pessary was acting ; this she did not do, for feeling perfectly well, she concluded that there was no need of further treatment, and she acted accordingly. Ten years passed, and though she began to have a purulent discharge 34-2 DISEASES OF WOMEN. and occasional bleeding from the vagina, still she neglected her self. After a time she called a physician, who made a superficial examination, and told her that he suspected that she might have can- cer; he advised her to place herself again under my care; this .die did, and I found the vagina almost completely closed. On the right side anteriorly, I found a small portion of the pessary exposed, but the rest was imbedded in the vaginal walls and covered over by considerable tissue. The granular and highly-vascular character of the tissues sug- gested that the doctors suspicion of cancer might be correct. The pessary could be felt through the wall of the rectum which appeared to be quite thin at that point. Passing a sound into the bladder, a part of the pessary appeared to be encroaching upon it. With difficulty the finger could be passed between the free portion of the pessary and the vaginal wall until it reached the cervix uteri, which was normal. The pessary had to be removed, yet the task appeared to be a difficult one. There was so much haemorrhage caused by the examination that I dared not divide the tissues which enclosed the pessary, neither did I feel that I could with safety rapidly and forcibly tear the instrument out of its place, fearing that I might do damage to the rectum and blad- der. I finally adopted the following method with success: Using a Sims's speculum, I seized the part that was exposed in the anterior part of the vagina with a very strong forceps, and with a small finger-saw cut out the section within reach. I then laid hold of an end and by traction caused the pessary to revolve until another por- tion came into the place of the one removed; this was sawed off, and piece after piece was taken out in this way until the whole was removed. The sinus was washed out for the purpose of cleaning it and stopping haemorrhage, but there was so much bleeding that I had to use a tampon to control it. The patient did quite well, and beyond a marked thickening of the vaginal walls, has now no trace of the injury. Since my experience with this case, I have seen quite a number of cases of imbedded pessaries, and have removed them in the way described. Two eases I have in mind now in which the pessaries were imbedded in the posterior vaginal wall, were treated by sawing out the anterior half or third of the pessary, and then by turning the remaining portion around it was destroyed and removed without breaking down or dividing the tissues surrounding it. CHAPTER XX. HYPERTROPHY OF THE CERVIX UTEEI. Tins is a peculiar and rather rare affection. It differs from the enlargement of the entire uterus, which occurs in pregnancy and in some of the inflammatory affections. The hypertrophy is confined to the vaginal portion of the cervix, and is distinct from the enlarge- ment of the supra-vaginal portion, which occurs in connection with metritis, subinvolution, and pregnancy. Pathology.—The only change in structure of the cervix is in quantity. The length of the cervix is increased, which is the main point in the pathology. Sometimes it is thickened, but.not in pro- portion to the elongation. It is characterized by great increase in length without increase in the diameter of the cervix, and no changes occur in the composition of the tissues. This is a true hypertrophy, which occurs from causes wholly different from the ordinary conditions which produce hypertrophy. The extent of hypertrophy differs in different cases; this is due, to some extent, to the stage of progress when the first examination is made. In some cases the cervix projects from the vulva one or more inches, while in others the cervix rests just behind the hymen or in the vulva (Fig. 165). The cervix is generally conical and the os externum is generally small, as it should be in the virgin cervix. It occurs in the unmarried most frequently, but occasionally in those who are married but sterile. Symptomatology.—The symptoms are exactly the same as those due to prolapsus. In the first stage there is pelvic tenesmus, and a sense of overdistention of the vagina. The presence of this large cervix causes irritation of the vagina and consequent leucorrhoea. Owing to the great increase in the length of the uterus, it becomes doubled up in the pelvis, and this often affects the menstrual func- tion, giving rise to dysmenorrhcea. In the last stage of the affec- 344 DISEASES OF WOMEN. tion, in which the cervix protrudes from the vulva, there is much discomfort; and the feeling of distention causes great irritability of Fig. 165.—Hypertrophy of the cervix. (■£.) the general nervous system. Excoriations and ulcerations of the mucous membrane are produced. Physical Signs.—The bimanual touch reveals the fact that while the fundus uteri is at its normal elevation, the cervix is either down at the vulva or protruding beyond it. At the same time the firmness of the vaginal walls, occupying their normal position, shows the great length of the extra-vaginal part of the cervix. This sign is diagnostic when the cervix is still within the vulva, but when the cervix has escaped through the vulva there is prolapsus of the vagina which obscures the signs to some extent. Emmet claims that elon- gation from prolapsus of the uterus has been mistaken for hyper- trophic elongation. This does not seem possible for one who knows anything about the rudiments of gynecology. By restoring the pro- lapsed uterus, any little elongation which may have come from stretching will disappear, while no change of position will make any difference of length in hypertrophy. The use of the sound also HYPERTROPHY OF THE CERVIX UTERI. 345 helps greatly in determining the extent of the hypertrophic elon- gitiuii. Causation.—The fact that this affection is limited to the virgin cervix makes it appear as if the hypertrophy might be due to neg- lected functions, but the fact is that its cause is not known. Prognosis.—The hypertrophy yields to surgical treatment very promptly. All the cases that I have treated, five altogeth- er, have been com- pletely relieved by amputation of the cervix. Treatment.—The removal of the super- abundant intra-vagi- nal portion of the cervix by amputa- tion, is the only meth- od of treatment which gives satisfaction. Several methods of operating have been employed, such as the circular method, made with the knife or scissors, the ecrascur, and the galvano-cautery wire. Originally, in all of these methods the stump was left to heal by granula- tion. J. Marion Sims greatly improved the operation by covering the stump with mu- cous membrane. Simon and Marckwald made a double- flap operation, and I have adopted a modification of this method. The details of the operation, as I perform it, are Fig. 168. — Dia- f 11 ,. . gram of the as I0110WS . pieces removed. A rubber cord is passed around the cervix and drawn tight enough to control the haemorrhage; the ends of this cord are then seized with a fixation-forceps, which keeps them from slipping, and also holds the cervix in the desired position. The cervix is divided from the canal outward on either side as 0;}# Fig. 166.—The first step; splittin Fio. 167.—The double of the amputation. 346 DISEASES OF WOMEN. high up as the amputation is to be made (Fig. 166) flaps are then made with the scalpel in such a way short flaps The double that the two are on the in- side (Figs. 167 and l'is,, The portions removed are wedge-shaped. Two middle sutures are then introduced from the cervical mucous mem- brane, or short flaps, to the outer mucous mem- brane, and the lateral sut- ures are used in the same way as in restoring a bilat- eral laceration. Fig. 169 shows the sutures as intro- duced, and Fig. 170 shows them when tied. Before tying the sut- ures the rubber cord should be loosened, and if there are any vessels that bleed freely they should be controlled. Slight ooz- ing is controlled complete- ly by tying the sutures. There are two things which have been brought out by experi- ence, and these should be kept in mind. The first is, that the cer- vix after amputation retracts or shrinks, so that it should not be amputated too high up, but left a quarter or three eighths of an inch longer than it should apparently be. It will be found short enough two or three months after the op- eration. The next point is, that the middle and outer layers retract after the operation far more than the mucous membrane of the cervix ; especially is this the case when there is a cervical endometritis present. In several of my cases, I found several months after the operation that the mucous membrane protruded from the os externum, and had to be clipped Fig. 169.—The sutures in place. Fig. 170.—The sutures tied. HYPERTROPHY OF THE CERVIX UTERI. 347 off. This is a simple thing to do, but by observing the directions this item of after-treatment will not be required. The after-treatment is the same as that employed in the op- eration for restoring a lacerated cervix uteri, and need not be de- scribed here. In a certain number of cases I have noticed that the outer walls of the cervix retract more than the mucous membrane after this operation. Immediately after the parts have healed, the cervix is quite perfect, but in a few months the mucous membrane protrudes beyond the muscular wall. This is more likely to occur, I think, in case there is a cervical endometritis accompanying the hyper- trophic elongation. When this condition of protrusion or prolapsus of the cervical mucous membrane is found subsequent to amputa- tion, the easiest and quickest way is to draw the superabundant tis- sue and clip it off. Just here I may mention that hypertrophic elongation of the anterior half of the cervix occasionally occurs in bilateral laceration. When this elongation is very great, I have found it best to amputate the redundant part as a preliminary to the operation for the lacera- tion. This is done in the same way as taking off a finger by the flap operation. CHAPTER XXI. FIBROMA OF THE UTERUS. Thkse new growths of the uterus belong to the middle period of life occurring during functional activity of the uterus, and are the most benign, both in composition and behavior, of all the neoplasms of the uterus. They partake far more of the nature of a hyper- plasia than a degeneration. Fibromata originate in the middle coat of the uterus and in histological composition are the same as the tissues which produce them. Efforts have been made to find some difference between the structure of these growths and that of the wall of the uterus, and several names have been employed which would convey some idea of their structure. Fibroid, fibrous myoma, fibro-myoma, and hysteroma are the names that have been used to designate these tumors. I prefer the term fibroma, believing that it is as comprehensive and indicative of the character of the growth as any. By comparing a section of the uterine wall with a section of fibroma, it will at once appear that they are very much alike. Both are composed of muscular fibro-cells, fibro-plastic elements, and cellu- lar tissue. There is also a similitude in their function or, more prop- erly speaking, both the tissues of the middle coat of the uterus and those composing a fibroma are similar in their behavior in this re- spect ; they are both given to great increase by growth and decrease by atrophy. While it is a fact that the same histological elements are found in the wall of the uterus and in fibromata, the construction and ar- rangement of these tissues differ sufficiently to cause a difference in the physical characters of the two. Compared with the wall of the uterus the fibroma is more pearly white in color, less vascular, usual- ly more dense to the touch, and cuts more like cartilage. Fibromata grow usually in the body and fundus of the uterus. but in rare cases they have been found in the cervix. All of these growths must of necessity begin in the muscular tissue of the wall of FIBROMA OF THE UTERUS. 349 Fir 171. Figs. 171, 172. Fir,. 172. Interstitial fibro- mata (Winckel). the uterus, but the direction in which they grow varies in different cases, and this has led to a very clear and useful classification of fibromata. When the tumor remains im- bedded in the middle coat of the wall of the uterus it is called interstitial (Figs. 171 and 172), when it grows toward the outside, subperitoneal, and when it grows toward the cavity of the uterus, submu- cous. Figs. 171 to 173 will show the three forms classed according to location. The subperitoneal variety might well be divided into two classes, those that are situated outside of the broad ligament and those that are within its folds. Though very little has been said in books about the fibromata which grow within the folds of the broad ligament, the history of such differs so much from the ordinary subperitoneal variety that a special notice is quite necessary. Fibromata situated in this position, instead of becoming pedunculated, extend out- ward between the folds of the broad ligament and drop down deep into the pelvis. It is not until they become quite large that they7 extend up out of the pelvis. Being surrounded by the folds of the broad ligament they are more firm- ly fixed in the pelvis than other subperitoneal tumors, and consequently cause more displace- ment of the pelvic organs. The uterus and the bladder are usually pushed far over to the oppo- site side of the pelvis, and the pressure upon the ovaries and pelvic nerves made by such a tumor causes much pain. Fibromata in this position cause the most suffering of any of this class of tumors, and they are more likely to cause cellulitis than when located elsewdiere. In some cases the tu- mor drops down very low in the pelvis behind all the pelvic organs. One case of an unusually large fibroma which came under my care had a large mass behind the rectum which extended down to the peritoiueum. It appeared to be a part of the tumor, but I presumed that it must be something else. Dr. Thomas Keith saw the case, and pointed out that the tumor had split up the broad ligament in its growth, and extending downward beneath the peritonaeum neces- sarily got behind the rectum. The location of the tumor has a marked influence upon its his- Fig. 17H.—Subperitoneal and submucous fibro- mata (Winckel). 350 DISEASES OF WOMEN. tory and treatment; the classification should be clearly understood and kept in mind on this account. Those that grow toward the in- side of the uterus may remain broad- ly attached to the uterine wall or the v may become pe- dunculated. Fig. 174 shows this lat- ter condition. They may be single, conglomer- ate, or multiple, The single tumor consists of one mass, the multiple of several masses situated apart and at different places in the uterus, and the conglomerate consists of a num- ber of masses growing close to- gether and sur- rounded by one capsule. These growths occur, as a rule, in the body and fun dus of the uterus rarely in the cervix. They vary greatly in shape. When very small they are usually round, but as they grow they sometimes be- come irregular, especially is this true of the conglomerate variety. In all cases the tumor is in a sense distinct from the wall of the uterus. The tumor is in the uterine wall, but not a part of it. There is in almost all cases a clear line of demarkation between the tumor and the tissues of the wall of the uterus. The tissues which surround the tumor and separate it from the neighboring tissues are chiefly cellular, and are called the capsule. This, after all, is only a separation in the arrangement of the tissues of the uterine wall and tumor which shows the difference between the two. Were it not Fig. 174.—Pedunculated submucous fibroid (Simpson). 9�99995 FIBROMA OF THE UTERUS. 351 for this the morbid growth would be very much like circumscribed hypertrophy of the uterus. As it is, the development, growth, and decay of fibroids are influenced by the uterus, from which they take their origin and nutrition, and are governed by the same laws. Fibroids occur only during the active functional life of the uterus. They increase in size during pregnancy, and generally diminish in size after confinement, and after the menopause they often disappear with the final atrophy of the uterus. Even in the absence of pregnancy the growth of a fibroma resembles the normal growth of a pregnant uterus, in the respect that there is simply an increase of tissue without change of structure. The rule is that fibroids are never seen before puberty, and they usually disappear after the menopause, but not always immediately after the cessation of the menstrual function. Usually, the menopause is postponed in cases of fibroma, the patient continuing to menstruate until fifty years and over. Neither does the decrease in the the tumor begin as soon as the menses stop in all cases. On the contrary, the organic forces which maintained the menstrual function being no longer called for are devoted to the growth of the fibroma, and this growth may go on for some time after the menopause, but the rule is that in time the process of atrophy begins and the tumor diminishes, and finally disappears, or nearly so. During the growth of these tumors they frequently change their position and relations to the uterus. The submucous tumor extends more and more into the cavity of the uterus. This change in posi- tion diminishes the area of connection between the tumor and uterus. It becomes pedunculated, and in this condition is sometimes de- scribed as a fibrous polypus of the uterus. This process of expulsion of the tumor from the uterus may go on until separation is com- plete, the tumor being expelled as is an ovum in miscarriage. Fig. 171 shows this. The same changes occur in the reverse direction in subperitoneal fibromata. They frequently become pedunculated, and it has happened that they have become detached from the uterus altogether. When this has occurred (which has not been often) there are usually found adhesions of the tumor to the ab- dominal viscera, and a vascular communication between the tumor and the parts to which it has become attached has been established. Sometimes such adhesions occur in tumors which are not peduncu- lated, but it is a notable fact that fibromata are the least liable to form adhesions of all the neoplasms. There are certain facts in the clinical history of fibromata regard- ing their growth and decay, which should be noticed. It has al- 352 DISEASES OF WOMEN. ready been stated that we should expect that these fibromata, bein<* like the uterus in structure and depending upon it for nutrition, would have many features in common with the uterus, and such is the case. The growth and decay of fibroids are subject to the same laws and influences as the uterus. The density of fibromata differs in different cases, and it also changes in the same case. They sometimes, especially if large, be- come soft and oedematous. Sometimes collections of serum, blood, or pus are found in the tumor. These give a feeling of softness and ill-defined fluctuation. When this condition is found the tumor is usually7 called a fibro-cyTst, but there is a difference in pathology be- tween a fibro-cyst and a fibroma with cyst-like cavities containing blood, pus, and serum. I have seen two cases of fibroma which gave the physical signs of fibro-cyTsts. They were both large submucous fibroids, and both were situated in the body of the uterus leaving the fundus free. The tumor closed the lower part of the cervix uteri, and the men- strual fluid and secretions of the mucous membrane accumulated in the fundus and upper part of the cavity of the body, and formed what appeared to be in every way a fibro-cyst. After the menopause these fibromata usually diminish or remain stationary and give no trouble, except by mechanical action upon neighboring organs. The rule is that they either disappear or at least give no further trouble. At one time it was believed that fibromata were capable of being converted into cancer. That is a mistake, I believe. Malignant disease may appear in connection with fibromata, but I have not yet found any reliable evidence that the one is converted into the other. Perhaps fatty transformation is the usual change which takes place; occasionally, calcareous or osseous degeneration occurs. Tumors which have undergone calcareous degeneration I have seen several times, but I have not seen anything like true osseous forma- tions. Perhaps it would express the facts better in most cases to call this material bone-like rather than to convey the idea that it is true bone. These changes or degenerations in fibromata usually are conservative. First the tumor stops growing, and then undergoes atrophy, or is transformed into osseous-like or calcareous material, but in either case the rule is that the patient is relieved. I believe that in some rare cases the tissues soften and suppurate, and septi- caemia is produced. One such case occurred in my practice and proved fatal. FIBROMA OF THE UTERUS. 353 CHANGES IN THE UTERUS FROM THE EFFECTS OF FI- BROMATA. The pathological changes which take place in the uterus dur- ing the presence of a fibroma are of much interest. It becomes enlarged in all cases, but most of all in the submucous and inter- stitial varieties, less so in the subperitoneal, and least in the pedunculated subperitoneal. Certain changes in the mucous mem- brane of the uterus usually occur. There are, in many cases, poly- poid growths developed, and endometritis is almost always present. In regard to the changes in the mucous membrane, which occur in connection with fibroma, Dr. Wyder, of Berlin, makes the follow- ing statement: " Fibro-myomas are said to be likely to give rise to malignant diseases of the mucous membrane. Martin has formerly maintained that these conditions furnish an indication for total extirpation. The reader, having examined a number of cases, does not share this view. " With subperitoneal myomas, the mucous membrane was found much thickened; the most important alteration was a very perfect glandular endometritis. In one case, adenomatous polypi were pres- ent ; in another, on one side glandular, on the opposite side inter- stitial endometritis. " For interstitial myomas, three groups must be formed : "■ 1. Where the tumors are separated from the uterine cavity by a wall one half to one centimetre thick. " 2. Where the tumor is beneath the mucous membrane but does not project. " 3. Where the tumor projects largely into the uterine cavity. " Of seven cases in the first group, in one no alterations were found; in two, glandular endometritis (mucosa four to ten milli- metres thick); in three, interstitial endometritis. In most cases the vessels were very numerous, and their walls very thick. u In the second group, the deeper layers of the mucous mem- brane were completely transformed into connective-tissue trabeculse ; at the surface was a greatly dilated capillary network with thick- walled vessels. " In the third group, interstitial endometritis was found. " The thicker the wall separating the tumor from the uterine cavity the more is the glandular structure developed (glandular en- dometritis) ; the closer the tumor approaches the mucous membrane the more pronounced becomes the connective-tissue character of the proliferation in the mucosa (interstitial endometritis). We then 24 351 DISEASES OF WOMEN. find the mucosa on one side atrophied into connective tissue, and on the other in a state of glandular proliferation. As regards the source of the haemorrhages, it should be remarked that no vascular changes are to be expected in subperitoneal tumors. It was found that, where glandular endometritis was alone present, no haMiior- rhages had gone before. In the case of interstitial tumors associated with glandular endometritis exclusively, there was likewise no pre- ceding haemorrhage. It was present only with interstitial en- dometritis. Therefore, haemorrhage will not take place where the interglandular tissue is quite intact; but it will occur where both structures proliferate equally (endometritis fungosa), or where one or the other form develops predominantly, or where glandular en- dometritis exists on one side and interstitial endometritis on the other. Compression of the numerous vessels causes venous con- gestion ; haemorrhage will set in, especially when glands and tissue have proliferated equally. The glands exert no influence on the under surface ; their character is usually benign. The border-line between mucosa and muscle is intact. Endometritis glandularis is of a benign nature." These pathological changes in the mucous membrane and the increase in its extent by the great enlargement of the uterus, cause a marked increase in the vascularity. To this state is due the menor- rhagia and haemorrhage which are so generally present in cases of fibromata. Deformity of the uterus is produced in many cases, but in some even large tumors the uterus presents the form of that of pregnancy. It is simply enlarged but not changed in form. There is often displacement of the utenis, especially in the interstitial and subperitoneal varieties. The tumor either drags the uterus toward the side upon which it is located, if it is small, or pushes the uterus in the other direction, if the growth is large. The cervix uteri may be disturbed in many ways. It is some- times greatly elongated and far out of its normal position. Many times it is spread out on the tumor so that it appears to be a part of it. The canal of the cervix is often tortuous and its caliber lessened. The effects of fibroma of the uterus upon surrounding organs are due to pressure which may cause derangement of function. These effects depend upon the size and location of the tumor, with refer- ence to the degree of the derangement. When the tumor is still small enough to remain in the pelvic cavity and make pressure to a limited extent only, the symptoms produced resemble those caused by uterine displacements and small ovarian cysts. The rectum may be pressed upon and its function perverted. The bladder may suf FIBROMA OF THE UTERUS. 355 fer from pressure which may prevent it from distending, or it may be rendered irritable and tender from pressure. In some cases the pressure may become so great that the function of the bladder and rectum may suffer, and even the ureters themselves may be affected in the same way. I have seen several cases, three, in all, I think, where the ureters were obstructed from the pressure of fibromata, and the kidneys were affected in consequence. The pressure may become so great that the function of the rectum or bladder becomes arrested, and inflammation of the cellular tissue or peritonaeum may occur and prove fatal. I have repeatedly seen slight attacks of pel- vic inflammation caused by pressure of fibromata ; one case proved fatal from pelvic inflammation and rectal obstruction. I saw the patient first when she began to have inflammation, and I found the tumor impacted in the pelvis and it could not be dislodged by any means. The inflammation progressed, and the obstruction of the rectum became complete by the addition to the tumor of the prod- ucts of the inflammation. In most cases the tumor can be raised up out of the pelvis when it becomes large enough to give much trouble by pressure. The pressure may be directed upon the pelvic nerves so as to cause very great pain. When fibromata escape from the pelvic to the abdominal cavity, they do not cause so much trouble unless they become very large. They may cause peritonitis and intestinal obstruction, but that is rare. They were supposed to cause ascites, because fluid in the peritoneal cavity was found in a certain proportion of cases. Keith believes that this fluid is a trans- udation from the tumor rather than from the peritonaeum, as in or- dinary ascites. The quantity of the fluid is seldom sufficient to cause much trouble. Symptomatology.—The symptoms of uterine fibromata are natu- rally of three kinds: First, those manifested by the general system, which are also called constitutional or remote; second, those which originate in the uterus itself; and, third, those that are produced by the pressure of the tumor upon neighboring organs. The severity of the remote symptoms depends upon the size and location of the tu- mor. There are a great many patients who do not suffer in general health from fibromata of the uterus until the growth has advanced to a considerable size. Sooner or later, according to the extent of disturbance which the growth causes, the general health becomes impaired. The patient becomes anaemic and is generally debilitated, because of either the loss of blood or deranged nutrition, or both. These symptoms are not by any means diagnostic, but may come from a variety of affections. In the most marked cases, when the 356 DISEASES OF WOMEN. patient is extremely anaemic, the skin becomes slightly bronzed, and gives to the patient the appearance of having malignant disease. The symptoms which are manifested by the uterus are pain and haemorrhage. The pain is not always pronounced, in some cases it is not at all persistent. It is irregular, spasmodic in character, and is most marked when the tumor is submucous, and least so in the interstitial variety. The haemorrhage is the most prominent symp- tom of all. It usually comes on periodically, and is, therefore, in some cases a menorrhagia. Menstruation is too free, and lasts too long, and recurs too often. Bleeding may come at any time, there being no regularity whatever in some cases. This symptom is so constantly present, that Dr. J. Mathews Duncan called fibroma the bleeding disease of the uterus. This name is well deserved, for certainly no other affection gives rise to so much haemorrhage of the uterus as does this. The size of the tumor does not influence the severity of the bleeding. In some small tumors the bleeding is greater than in others of mon- strous size. It is the location of the tumor which determines the haemorrhagic symptoms. It is greatest in the submucous, less in the interstitial, and least in the subperitoneal as a general rule. The submucous pedunculated variety is the worst of all for causing bleeding. A very small tumor of this kind may cause the most persistent and exhausting haemorrhage. The symaptoms caused by the effect of the tumor upon neighboring organs arc generally most marked when the tumor occupies the pelvic cavity. Then the press- ure upon the bladder and rectum causes irritation and functional ob- struction of these organs; less or more pelvic tenesmus of a general character is sometimes very severe. The effect upon the bladder is to render urination very frequent and sometimes difficult or impossi- ble. I have seen three cases in which there was retention of urine. The tumor was pear-shaped in all of them, and large enough to ex- tend above the brim of the pelvis. The urethra and bladder were carried upward, so that the urethra was caught between the tumor and pelvis, and compressed. Urination in these cases was, for a time difficult, and then retention came. All voluntary efforts to evacuate the bladder only made matters worse, by forcing the tumor downward and wedging it into the superior strait. Relief was given first by the catheter, and then by pushing the tumor upward, the pa- tient being placed in the knee-chest position. Pressure upon the pel- vic nerves and ovaries often causes much pain. Pain in the back and limbs, which is often present, no doubt comes from the same cause. Pressure upon the ureters may cause obstruction and hydro- FIBROMA OF THE UTERUS. 357 nephrosis, and all the unfortunate results to the kidney which must follow. In such cases there is at first pain in the region of the ureters, and subsequently the symptoms of renal disease appear. Fibromata large enough to occupy the cavity of the abdomen give very little trouble, as a rule. So far as affecting the neighboring organs, very large tumors interfere with free respiration, and the action of the stomach and bowels to some extent. The ascites which sometimes accompanies fibromata of the uterus was supposed to be due to irritation of the peritonaeum. It is more likely that it is a transudation from the tumor itself, as already stated. This is sug- gested by the fact that hydro-peritonaeum is usually found in connec- tion with oedematous tumors. Physical Signs.—The positive signs of fibroma are the increase in size, change in form, and consistence of the uterus, and the dis- placement or distention of the canal, as related to the body of the uterus. The touch discovers the fact that the uterus is enlarged, apparently, and by the bimanual touch it usually can be proved to be really so. The shape of the uterus is changed in nearly all cases. It is irregular in outline, one side being much larger than the other. In the subperitoneal variety, this deformity is quite marked. The tumor projects from the surface of the uterus so boldly that it can be instantly detected. In some of the cases of submucous fibroma, and occasionally in the interstitial, the uterus is uniform in shape, and appears like a uterus enlarged by gestation, and even when there is some irregularity of form it is not unlike that which is often found in pregnancy, but the uterus is very hard in the one case, while in the other it is very soft. The hard character of the tumor and uterus is a very reliable sign of fibroma. In all conditions which cause enlargement, the uterus is softened except in fibroma and in very rare cases of cancer. Whenever the uterus is enlarged and in- durated, fibroma may be strongly suspected. Deflection of the canal of the uterus from the center is a very important sign of fibroma. The relations of the canal of the uterus to the axis of the pelvis, as shown by the sound, are changed in all forms of displacement, but the canal is still in the center of the uterus. In fibroma the canal is excentric and very often tortuous. The use of the sound, by which this displacement of the uterine canal can be detected, gives this most valuable evidence of the ex- istence of a fibroma. Figs. 175 and 176 will show this point very plainly. The one shows a uterus large, owing to subinvolution, the other about the same size from enlargement due to a fibroid. In not a few cases the canal is so deflected, displaced, or com- 358 DISEASES OF WOMEN. Fig. 175. Fig. 176. Figs. 175, 176.—Enlargement due to subinvo- lution compared with that from growth of a fibroma (after Winckel). pressed, that the sound can not be passed. A flexible bougie may be used, under these circumstances, and although it will not posi- tively show the position of tlie canal it gives valuable indica- tions of it. When the sound can not be used at all, this valu- able sign is not obtainable, but the fact that the canal in a large uterus will not admit the sound is evidence of fibroma. There is no other condition of enlarge- ment of the uterus in which the sound can not be passed, as a rule. Small fibromata, which oc- cupy the pelvic cavity, present some physical signs which resemble displacements of the uterus, ovarian tumors, tubal pregnancy, the products of former inflamma- tions and diseases of the Fallopian tubes. The differentiation between flexions and versions of the uterus and fibromata is based upon the following facts: In flexion and version the uterus is not much enlarged, and, as a rule, can be re- stored to the proper position when all signs suggestive of fibroma disappear, and then, too, the sound shows that the cavity of the uterus is not displaced nor enlarged. Ovarian tumors are distin- guished from fibromata by being less dense and not usually fixed to the uterus; one can be moved without the other. Early pregnancy is usually distinguished from a fibroma by the history and symp- toms, but the physical signs differ. The uterus is soft in pregnancy, while it is unduly hard in fibroma. The enlargement and softening extend to the cervix in pregnancy, but not in fibroma. Should a doubt exist, the differential diagnosis can easily be made in a short time by watching the progress of the case. The signs of pregnancy will soon become sufficiently pronounced to settle the question. The most difficult cases to deal with are those in which preg- nancy takes place while there is a fibroma present; I have seen sev- eral cases of this kind. Two of these were pregnant when first seen, and in both the diagnosis of fibroma was made and in only one did I suspect pregnancy at my first examination. In the others I was aware of there being a fibroma present, but I did not detect the pregnancy until several months had elapsed. Fibromata situated within the folds of the broad ligament are not FIBROMA OF THE UTERUS. 359 easily distinguished from the products of a pelvic cellulitis, extra- uterine pregnancy, and diseases of the Fallopian tubes. The history of the case, taken in connection with the physical signs, will usually suffice to enable one to make the diagnosis. Large fibromata which occupy the abdominal cavity have to be differentiated from fibro-cysts of the uterus and ovarian tumors. In regard to the distinctive signs by which the diagnosis between ovarian tumors and fibromata is made the reader is referred to the section relating to the diagnosis of ovarian tumors. The solid hard fibroma is easily distinguished from a fibro-cyst of the uterus by its density, as recognized by the touch, but a soft fibroid may be so elastic as to give the signs of an imperfect fluctua- tion, and simulate a cyst with a thick wall. In such cases of doubt the chances are in favor of the tumor being a soft fibroma, but if it is very necessary to make a diagnosis it may be done by aspiration. The accumulation of fluid in the upper part of the cavity of the uterus, occurring as a complication of a uterine fibroma, gives the physical signs of a fibro-cyst so perfectly that one must certainly be led to make a false diagnosis. I have seen two such cases, one was a very large intra-uterine fibroma which closed the canal of the uterus below by pressure in the latter stages of its growth. The secretions of the mucous membrane accumulated at the fundus and gave distinct fluctuation. One of the most distinguished gyne- cologists of this age saw the patient with me and thought as I did that it was a fibro-cyst, but it was not. The histories of these cases, especially one which is given further on, will show more fully the peculiar character of the pathology and the difficulties of diagnosis. Causation.—Very little, if anything, is known about the true pathogenesis of uterine fibroma; certain facts in regard to age, race, and social relations have been ascertained which favor the occur- rence of these neoplasms. The age when women are most liable to these growths is between thirty and thirty-five years. There are many exceptions to this, however, but it is rare to have these growths come before puberty or after the menopause. It may be more cor- rect to say that they never occur before puberty and rarely after the menopause. In regard to race, the negro is more liable to fibromata than the white, although no good reason has been discovered why this is the case. The influence of the social relations is stated by Thomas Addis Emmet as follows : u The development of these growths is retarded by child-bearing, and even by marriage, for the sterile woman is less liable than the 360 DISEASES OF WOMEN. old maid, but in turn she is more so than the woman who has borne children." These facts are deductions from large tabulated observa- tions of cases by Dr. Emmet, and are therefore reliable. He also gives his views regarding these social states as related to the causa- tion of these neoplasms, in the following: " Between the ages of thirty and forty years the unmarried woman is fully twice as subject to fibrous tumors as the sterile or the fruitful. I have already referred to this subject, when treating of the causes of disease, and pointed out that this is one of the tributes which an unmarried woman pays for her celibacy. It seems as if it were the purpose of Nature that the uterus should undergo the changes dependent upon pregnancy and lactation about once in three years throughout the child-bearing period, and that if the uterus is not physiologically occupied in child-bearing there is greater liability to the development of fibrous tumors as the woman advances in life. This will also be the case with the married woman who has taken means to prevent conception, as well as with her who has been sterile from some cause beyond her control, but to a less degree in the latter case. I think I have had occasion to note that the sterile woman who has earnestly wished for children does not have her liability to fibrous tumor increased by the fact of her sterility, an instance, probably, of the remarkable effect of mind upon the body. Finally, the woman who may have been fruitful in early life, but remained sterile long afterward, from some accidental cause, may have a tumor developed, but is less liable thereto from having once borne a child." Prognosis.—Fibromata of the uterus, while the most frequently seen of all the neoplasms of the sexual organs, are the most harmless so far as their tendency to destroy life. They occasionally prove fatal, but many cases progress until the menopause, when the growths disappear altogether or become reduced during the final involution of the uterus, so that they are harmless. The dangers are, first, haemorrhage, which recurs so often in many cases that it endangers life. Yery few patients bleed to death directly, but some become so reduced by the long-continued loss of blood, which impairs nutrition, that death comes as the result of some secondary affection which would not have occurred except for the exhausted state of the patient. Peritonitis and cellulitis are liable to be set up by fibromata, and of the fatal cases peritonitis is a not infrequent cause. Softening of the tumor and decomposition may cause a fatal septicaemia. Blood-poisoning sometimes occurs during the expulsion of extra-uterine fibroma. The tumor being in part FIBROMA OF THE UTERUS. 361 cut off from the circulation undergoes necrosis before its expulsion is completed, and causes septicaemia, and death takes place when relief and recovery appear to be within the immediate reach of the sufferer. Pressure upon the pelvic organs may cause death by arrest- ing the functions of these organs. This is most likely to take place when the tumor grows in the broad ligament and is therefore fixed in the pelvis. I have also seen death occur from pressure upon the ureters causing obstruction to the flow of urine, renal disease, and finally uraemia. Although there are dangers from all of the com- plications named above, a very small percentage proves fatal even when left without treatment; and by judicious management a large number can be relieved entirely or helped sufficiently to be able to pass through life in comparative comfort. Within the past few years such means as ovariotomy, hysterectomy, and electrolysis have been employed in the treatment of uterine fibroma, with re- sults which raise the hope that the great majority of these neo- plasms will be controlled, and the death-rate from this cause re- duced to a minimum. Treatment.—The size and location of uterine fibromata, and the conditions and complications produced by them differ very greatly, and hence the treatment must vary with each case. The ways and means may be said to vary from the simplest medication to the most daring surgery, and each method, if judiciously adapted to the re- quirements of cases as they come, gives satisfactory results. Medicinal agents have been employed in great variety, but ergot alone has been found of real value. The action of ergot upon fibromata may accomplish beneficial effeets in two ways. By excit- ing uterine contractions it may produce expulsion of the tumor if its relations to the uterine wall are such that it can be expelled. On this account ergot does its best work in the submucous variety of uterine fibromata. In the same way the ergot, by causing con- traction of the uterine walls, may lessen the area of attachment of a subperitoneal fibroma, and arrest or retard its growth by lessening its blood-supply. This view of the beneficial effects of ergot upon the progress of subperitoneal fibromata, is based upon the fact that when such tumors are pedunculated, they do not, as a rule, grow so fast as when they are attached to the uterus by a broad base. In this respect, the action of ergot is simply to aid in the natural method of disposing of these growths, viz., by expulsion, which in the submucous or intra-uterine variety is often complete, the growth being wholly expelled from the uterus. Ergot also acts in another way to arrest the growth of such tu- 362 DISEASES OF WOMEN. mors. By keeping the uterus in a condition of permanent contrac tion, and by contracting the blood-vessels, the size of the tumor is diminished, and atrophy takes place. In order to obtain the good effects of ergot in this way, it must be given in liberal doses, suffi- cient at least to produce all the contractions of the uterus that the patient can endure the pains of, and it must be continued for a long time. It sometimes happens that the patient can not take ergot for any length of time without having indigestion and loss of appetite; occasionally, also, the uterus fails to contract in response to full doses of this drug. In either case it is useless, and should not be con- tinued. In some cases the use of ergot, while it does not diminish the size of the tumor nor aid in its expulsion, appears to retard its growth, and it also controls the bleeding which is a great gain. When the patient can be guarded against the great loss of blood, she may be enabled to live in comparative comfort and usefulness until the menopause. The menorrhagia can sometimes be helped by treating the endo- metrium. The endometritis is often attended with fungous growths which greatly increase the tendency to haemorrhage. The removal of such fungosities with the curette will often give relief, and the subse- quent application of tincture of iodine to the uterine mucous mem- brane at regular intervals, is of service. In order to use the cu- rette and apply the iodine, it is necessary that the cervical canal should be sufficiently large to permit an entrance to the uterine cavity. In some cases the cervical canal is so narrow and the cavity of the uterus so deflected that such treatment is impossible. When expulsion, with or without the use of ergot, has advanced far enough to pedunculate an intra-uterine tumor and dilate the cer- vix uteri, the tumor can be separated from the uterine wall and re- moved by dividing the pedicle. When the dilatation of the cervix is complete, and the tumor is expelled from the uterus and is lodged in the vagina (the pedicle still remaining attached to the uterus) the separation and removal of the tumor are quite easy. There are several methods of dividing the pedicle. I prefer to use the wire ecraseur. The galvano-cautery ecraseur has been used but it is difficult to apply, and it is impossible to avoid burning the uterus and vagina, and has no advantages over the wire or chain. The ecraseur which I use is modified to suit the wire. The por- tion to which the wire is attached is so arranged, that each end of the wire is held fast by a pinching screw, so that the loop of wire FIBROMA OF THE UTERUS. 363 can be lengthened or shortened in a moment (Fig. ITT). I employ the steel wire used for piano or zither strings, the thickness of the wire being adapted to the size of the pedicle. The wire has one very great advantage over the chain in being easily applied. It is elastic, and yet stiff enough to be easily made to slip over the tumor to be snared. Objections to the wire or chain ecraseur have been raised. There is danger, it has been claimed, of the uterine wall being drawn into the grasp of the chain and a part of it removed, and an opening made directly into the perito- neal cavity. The fact is, that as the wire is tightened around the pedicle, the tissues are forced out of its grasp equally on both sides. There is no drawing of the tissues into the grasp of the wire. If there is inversion of the uterus at the point of the attachment of the pedicle, the wall of the uterus might be included in the ecraseur-wire and removed. This happened once in my own practice, and I believe the same thing has been done by other operators. Fig. ITS shows the condition referred to as it occurred in my own patient. The inversion of the part of the uterus was not detected before the operation was com- pleted, but an examination of the tumor showed that the inverted portion of the uter- ine wall was completely removed. No harm came from it. The patient did well, but the greatest anxiety was felt for some time. Sometimes it happens that the tumor, while it protrudes into the vagina to a slight extent, is grasped by the cervix so firmly, that the wire of the ecraseur can not be applied. The same difficulty has been encountered when the tumor—the size of a fetal head—is lodged in the vagina. Under such circumstances, the tumor should be re- duced by rapidly taking sections of it away with a strong scissors, and then the ecraseur can be used, or if the haemorrhage is not great the base of the tumor can be enucleated. The removal of the base of a tumor is easily accomplished by seizing the mass in the center with a tenaculum forceps and separat- Fig. 177.—Ecraseur. 361 DISEASES OF WOMEN. ing it first from the mucous membrane which forms the capsule, and finally from the muscular wall. Much care and gentle handling of the enucleating instrument should be employed, because the muscular wall of the uterus at the point of at- tachment of the tumor may be ab- sorbed, and the base of the tumor rest upon the peritonaeum. This state of affairs I have found in two cases which I treated by enucleation, the histories of which will be given. Intra-uterine fibromata have been treated by dilatation, or division of the cervix uteri and enucleation be- fore they became pedunculated. At one time this treatment was quite in vogue in this country. The operation is difficult and dangerous. The dangers are from shock, haem- orrhage, and septicaemia, and so far as I can learn the results have been in many cases unsatisfactory. Some years ago I abandoned this method for other methods of treatment which I believe to be less dangerous and more effective in such conditions. Removal of the ovaries for the relief of small fibromata which cause exhausting haemorrhage has given very satisfactory results. This plan of treatment was suggested by the fact that these neo- plasms disappear, as a rule, after the menopause. Reasoning from this it was presumed that by removing the ovaries, and thereby in- ducing the cessation of the menstrual function prematurely, the same effect upon the fibromata would be obtained. Practically, it was found to be so, and hence in properly selected cases the re- moval of the ovaries is the best treatment. In some cases, although the removal of the ovaries appears to be the best means of giving re- lief, it is found impractical. When the ovaries can not be reached with sufficient ease to make their removal possible, or when they are so closely adherent to the uterus, as they sometimes are, that they would require to be dissected from their attachments it is unsafe to try to remove them. Under such circumstances it is better to per form hysterectomy. Fig. 1 IS.—Wall of uterus caught in ecraseur-wire and removed. FIBROMA OF THE UTERUS. 365 It is well in view of these facts, to be prepared to remove the uterus, when ovariotomy is undertaken for the relief of uterine fibromata, for should the one operation prove to be impossible the other could be resorted to. Beyond the fact that the ovaries are sometimes more difficult to get at in these cases, there is nothing in the operation which differs from ovariotomy generally, hence noth- ing need be said about it in this connection. It should be understood that the exact value of this method of treatment is still under consideration, and more time and cases are needed to settle the question definitely. All who have practiced this method of treatment often enough to obtain valuable experience report favorably of it. Wildow states, that in seventy-six cases the menopause occurred immediately in sixty-one. In four cases, the effect upon the haemorrhage was temporary. In sixty-three cases the fibromata diminished. In three cases there was a primary diminution and a subsequent increment of the tumor. More recently Wildow has given the statistics of one hundred and forty-nine cases, of which fifteen died. I presume that the death-rate has been less than this with some operators. Should it prove to be so great as ten per cent it would become a questionable procedure, notwithstanding that the results in the successful cases should prove to be satisfactory. Hysterectomy for the relief of uterine fibromata has now been performed a sufficient number of times to enable one to discuss its relative merits with some degree of certainty. In the first place it is adapted to large, rapidly-growing tumors, which do not yield to less heroic treatment, but render the patient useless and threaten her life. Dr. Thomas Keith, who, up to this time, is by far the most suc- cessful operator, in speaking of this subject, says : '" I often ask myself the question: Does a mortality of eight per cent justify an operation for a disease that, as a rule, has only a limited active life, that torments simply, and that only for a time, though of itself it rarely kills ? The mortality of an ordinary uter- ine fibroid, if left alone, is nothing approaching a death-rate of eight per cent. I doubt even if the mortality of the extreme cases exceed this. And, after all, the great difficulty is, not in doing even the worst of these operations, but in knowing what are the cases in which it is right to advise those who trust themselves to us, to run the risk of a dangerous operation, with all its attendant miseries. Could we get the mortality down to five per cent in the bad cases, and these only are the fit subjects, then one might advise interfer- 366 DISEASES OF WOMEN. ence with a more easy mind. I do not think that we can so advise, if the mortality can not be kept under ten per cent." It appears at the present time that by the judicious use of other means of treatment the number of cases which will require hyster- ectomy in the future will be diminished, but still there may always be some that will demand it. Dr. Keith says that all his operations were done on account of repeated hemorrhages and ruined health. He also states that the time chosen for the operation was a day or two before menstruation was expected, because the patients had then regained more or less force from the loss of the previous period. Electrolysis.—This method takes the highest rank among the means of treating fibroma of the uterus. In order to fully compre- hend this subject, some knowledge of the elements of electro-physics should be obtained. The following treatment of this matter was prepared for me by my friend Prof. Charles Jewett: Some knowledge of electro-physics is essential to the intelligent use of electric- ity as a therapeutic agent. The limits of this chapter, however, will not permit more than a brief mention of such ele- mentary facts as are necessary to a proper understanding of the terminology and technique of electrical treatment in gyn- ecology and a few words of advice with reference to the selection of apparatus. For a more extended knowledge of the subject the reader must be referred to the many standard works on electrical science. The physical forces are no longer re- garded as having a distinct and inde- pendent existence and manifesting them- selves by their effects upon matter, but rather as affections or conditions of mat- ter itself. In short, the different physi- cal forces are different modes of motion Fig. 179.—Electrical action in a in the molecules of bodies. The phenom- singie cell. ena 0f electricity, then, are due to a mode of molecular motion. It is an important practical fact that the molecular forces are mutually convertible. Any one may be trans- formed into any other force. Familiar examples of the conversion of force are the transformation of heat into light when a bit of wire FIBROMA OF THE UTERUS. 36T is brought to incandescence in a gas-flame, the generation of heat by friction or impact, the production of light by electricity, and so on. In practice, electricity is derived from a variety of sources. The electricity of a frictional machine is the product of the mass motion of the glass plate, or rather of the muscular force expended in turn- ing the plate. Magneto-electricity is obtained from magnetism. The electrical energy of a galvanic battery is the result of the chem- ical action of its elements. In accordance with the law of the cor- relation of forces, the amount of electrical energy, by whatever method developed, is the mathematical equivalent of the force ex- pended in producing it. Galvanism, faradism, and static electricity are the kinds of elec- tricity commonly used for therapeutic purposes. Galvanism, for use in medicine, is generally obtained from chemical sources. A simple example of a galvanic cell may be constructed hy immersing, at a short distance apart, a plate of gas carbon and one of zinc in dilute hydrochloric acid in a common glass tumbler (Fig. 1T9). A moment- ary chemical action takes place in the cell. The chlorine of the acid enters into combination with the zinc, forming the chloride of zinc, which goes into solution in the fluid of the cell. Bubbles of free hydrogen collect upon the surface of the carbon plate. It can now be shown, by methods familiar to electricians, that the free ends of both plates are charged with electricity. If the free ends of the plates be conjoined by means of a copper wire the plates imme- diately deliver their charges through the wire. But since the chemi- cal action now becomes continuous the charge is continuously re- newed, and thus a constant flow of electrical disturbance is main- tained. If the wire be disconnected, the chemical action ceases in the cell, and the flow of electricity is arrested. Both are renewed on again connecting the plates. The active metal, zinc, is called the positive element of the cell, the carbon the negative element. The conjunctive wire, the plates, and the intervening column of fluid constitute the electrical circuit. The continuous propagation of the molecular disturbance in the circuit gives rise to the term current. For convenience, the cnrrent through the wire is said to flow from the carbon to the zinc plate, though in fact we have two currents, one of positive electricity flowing from carbon to zinc, and one of negative electricity from zinc to carbon. The free end of the carbon, from which electricity flows through the wire, is termed the positive pole, the corresponding end of the zinc is the negative l>oJe of the cell. If the conjunctive wire be cut, the free ends of the wire now become the poles of the circuit, one the positive, the other 368 DISEASES OF WOMEN. the negative pole. For ordinary therapeutic uses metallic plates variously covered with moist sponge, chamois, or otherwise, are at- tached to the free ends of the wire, and are commonly termed electrodes (from ekeicrpov and ohos, the electrical pathway). The positive electrode, sometimes called the anode (ava and oSo?, the way up), the negative electrode, the cathode {Kara and 080$, the way down). A combination of several galvanic cells in a common cir- cuit is a galvanic battery. Bodies which, like the conjunctive wire, are capable of transmit- ting electricity, are called conductors. Others which lack this prop- erty are termed non-conductors. These terms, however, are merely relative. Different substances differ widely in their conducting power, and, strictly speaking, no body is so good a conductor as to oppose no resistance to the passage of the current, none so poor a conductor that its resistance may not be overcome in some measure by power- ful currents. The metals are examples of good conductors, silver and copper being the best. Glass, vulcanite, ivory or bone, and dry wood are good non-conductors. Such substances, when used for the purpose of preventing leakage of the current, as in the handles of electrical instruments, are termed insulators. The capacity of a galvanic cell for generating electricity is de- nominated its electro-motive force. It depends upon the energy of the chemical action in the cell, and therefore varies with the ma- terials which enter into its construction. In a battery of similar cells arranged in series (the zinc of one cell being connected with the carbon of its neighbor), the electro-motive force will be increased in proportion to the number of cells. The term current is not only applied to the flow of electricity in the circuit but is also used in a quantitative sense. It is employed in the sense of current strength, and represents the quantity of elec- tricity flowing through the circuit. The term resistance is used to denote the degree of obstruction opposed by the circuit to the pas- sage of electricity through it. As may be inferred from what has already been said with reference to the conducting power of bodies, resistance varies with the materials of which the circuit is composed. In case of wire, or other conductor of given material, the resistance varies directly as its length, and inversely as its sectional area. Xot only the conjunctive wire, but the exciting fluid as well, and the plates of the cell offer a greater or less amount of resistance. The total resistance within the cell is designated the internal, in distinction from that without, which is called the external resistance of the circuit. The electro-motive force of a battery corresponds approximately FIBROMA OF THE UTERUS. 369 to the horse-power of a steam-engine, the current to the motion of the machinery. The value of the current in a given circuit will depend not only on the electro-motive force of the battery, but also upon the resistance in the circuit. It will vary directly as the electro-motive force, and inversely as the resistance. In other words, the current will be equal to the electro-motive force divided by the resistance. This is the law of currents, and is known as Ohm's law, so named from its discoverer. Letting C stand for current, E for electro-motive force, and R for resistance, the law may be conveniently expressed by the p» following formula, C = ^ . Putting R' for the internal resistance, E and R" for the external, we have C= ^—-=^. By application of sim- ple algebraic rules, any three of these quantities being known, the other may be found. A knowledge of this law and its uses is of the utmost importance in all practical applications of electricity. By its aid many of the perplexing problems encountered by the beginner in electrical practice may be readily solved. For quantitative determinations we must have units of quantity. The adopted unit of electro motive force is the volt, that of resist- ance the ohm, and that of current the ampere. A volt is the amount of electro-motive force necessary to yield one ampere of current through one ohm of resistance. An ohm represents approximately the resistance offered by 230 feet of pure copper wire of No. 16 American wire gauge. A volt is very nearly the electro-motive force of a single Daniell's cell. To illustrate the application of Ohm's law in practice, suppose the electro-motive force of a given galvanic cell to be 1*5 volts. Let the internal resistance be one ohm, and that of the connecting wire E 1*5 ".") ohm. We have V = ^—-=— = — = 1. One ampere is then XX —j— XV J-' O the strength of current that flows in such a circuit. If, now, we have a battery of fifty such cells, connected in series, the total elec- tro-motive force of the battery will be T5 volts, and the total internal resistance will be 50 ohms. Suppose that a portion of the human body and the necessary instruments for regulating, measuring, and applying the current be introduced into the external portion of the circuit. If the tissues of the body in the circuit offer a resistance of 1,000 ohms and the instruments and conducting wire a total of 4r>0 ohms, the entire external resistance will be 1,450 ohms. From Ohm's formula we have----------= '050. The current in this 25 50+1,150 370 DISEASES OF WOMEN. case will therefore be fifty thousandths of an ampere, or, as it is ex- pressed, 50 miiliamperes, the milliampere being one thousandth of an ampere. From C = j^jp we get R'+ R" = ? and R" = ? - R'. The required data being given, we may by means of this formula find the total external resistance or any component part of it. Sup- pose a portion of the body be connected in circuit with the same battery, instruments and conducting wires as in the case last cited. Suppose the current is now found to be 50 miiliamperes. The resistance, exclusive of that offered by the tissues interposed, being known, we may readily compute the resistance of the portion of the body through which the current is passed. We have from the last formula, R" = ~ - R', R" = ^ - 50 = 1,450. Deducting the known resistance of the wire and instruments, we have 1,450 —150 = 1,000. The resistance offered, then, by the portion of the body placed between the electrodes is 1,000 ohms. E E From the formula C = -p/ pg we also have R' = — — Pw" XV -f- XV (j and E = C (R' + R"). The application of these formulas in practice is obvious from the illustrations already given. When enormous resistances like those of the human body are con- cerned, such elements in the computation as the internal resistance of the battery, if it be low, and that of the conducting wires may be disre- garded. The results will be sufficiently exact for practical purposes. The resistance offered by the human body is by no means a con- stant quantity. It varies by hundreds of ohms not only with the amount of tissues interposed in the circuit, but also with the varying character of the tissues in different parts of the body, the area of the electrodes and their firmness of contact, with the degree of moisture of the part to which they are applied, and other causes. It is well known that the conducting power of the electrodes and the com- pleteness of the electrical contact may be increased by moistening the electrodes with a saline or acid solution, instead of plain water, a fact often useful in practice. The accumulation of hydrogen bubbles which takes place upon the surface of the carbon plate when the battery is in action weakens the current in proportion to the extent of surface so covered. This phenomenon is known as polarization. Various means are provided in the construction of different batteries for overcoming this diffi- culty, or, as the expression is, for depolarizing. For example, de- FIBROMA OF THE UTERUS. 371 polarization is accomplished in certain cautery batteries by occasion- ally agitating the fluid and thus removing the hydrogen from the plate. In ordinary batteries the effects of polarization are partially or wholly obviated by various chemical provisions. By electrolysis (eXe/crpov and A.u, and the temperature 102-2°; flatulence was troublesome. She felt weak, and had whisky and water to drink. There were only four ounces of bloody serum from the tube. On the third morning, the pulse was 120, and the temperature 101°. On the fourth day, the pulse was 111 to 125 ; the temperature ranged from 101° to 103'5°. On the fifth day, after a restless night, the temperature had risen to 106°; it fell to 101°, and again in the afternoon it rose to 105*5.° There was oedema of the labia, and much cellular infiltration in the pelvis. She looked very ill during these days, not caring for food, though taking stimulants freely ; on the sixth day the pulse dropped to 92, and the temperature also fell to 101'6°. The tube was re- moved, there being only a tablespoonful of reddish serum in the pelvis. On the ninth day the wound was found healed throughout. The stump was dry and sweet. The pulse and temperature almost normal. In the third week there was again a rise of pulse, and of tem- perature from 101° to 103.° This continued for ten days, and caused some anxiety. On the eighteenth day, the wires were loose and were removed. The loop was two inches and three quarters in diameter. Seven weeks after the operation she left the hospital. She is now a strong woman, in perfect health, and can do anything. Soft Bleeding Fibroid; Intra-Peritoneal Treatment of Pedicle; Recovery. (Keith).—In 1870, Dr. Kidd, of Alyth, sent me an un- married woman—a domestic servant—with a fibrous tumor, low in the pelvis and extending to the umbilicus. She was no longer able for 392 DISEASES OF WOMEN. her situation, partly from pain and partly from excess at the menstrual periods. She was twenty-nine years of age, and of fairly healthv appearance. I advised her to delay interference, unless such be- came absolutely necessary. After three years she came again, very anxious for relief. She was much changed; the tumor now filled the abdomen ; she was extremely anaemic, and quite unfit to make her living in any way. The tumor varied much in size: very large and tense before menstruation, much smaller and softer after this was over. The loss of blood was sometimes very great. Operation was on July 16, 1879. Carbolic spray was used. An incision not exceeding ten inches was made; by taking time, the tumor molded and could be pushed through the opening. Both broad ligaments extended up to the fundus of the tumor on a level with the ribs. The portion containing the ovarian vessels was first transfixed and ligatured, locking-forceps being put on close to the tumor, before the ligament was divided. The same process was repeated on the other side. The tumor was then separated down- ward all around from its cellular attachments, and a soft-iron wire, secured quite low down—in this case, almost round the top of the vagina—by Koeberle's instrument. There was thus left a large cavity, from which the pelvic portion of the tumor had been shelled out. Koeberle's instrument—five and a half inches in length—was left dipping into the pelvis, as it could not be secured outside. There was little bleeding from the separated surfaces, and the wound was kept as open as possible around the instrument, to allow of the escape of serum. The operation lasted one hour and a quarter. There was a good deal of pain, and several opiates were required during the afternoon, There was very free perspiration for some days. The highest pulse reached was 124, about thirty hours after the operation ; the highest temperature was 100-5°. Recovery was uninterrupted. The serre- nceud came awray with the slough in ten days; she returned home thirty-two days after the operation, the wound being quite cicatrized for some days. The tumor was a soft, oedematous fibroid, and weighed nineteen pounds. This patient has enjoyed perfect health since the operation. Fibrous Tumor of Uterus, containing an Inflamed, Suppurating Cavity; Operation; Recovery. (Keith).—An unmarried woman, aged forty-four, was admitted into the Royal Infirmary in February, 1874, under Dr. Matthews Duncan. She was a pale, thin, un- healthy looking woman. She had granular, everted eyelids, and was half-blind from inflammation of the cornea. Up till the pre- FIBROMA OF THE UTERES. 393 vious June her health was fairly good. She was then obliged to give up her situation as cook in London, where she had lived for more than twenty years. Menstruation was regular and normal. Five weeks before ad- mission a tumor was detected. It was hard, elastic, quite fixed, and reached to the umbilicus. The cervix was drawn to the left side of the pelvis; it was almost beyond reach of the finger, and felt as if lost in the tumor. This was supposed to be ovarian. I never had any doubt that the case was one of uterine fibroid, and declined to operate on it. After two months' residence in the hospital she was dismissed, and went to her friends in the north. In the course of the summer she began to write letters to say that she suffered severely, and that the tumor had increased. She was importunate, and wished something tried. At last, wearied by her importunity, she was allowed to come back. The tumor had certainly got much larger; its appearance was changed. It was very tender now, and had become prominent on the right side, push- ing the loin outward. There was some free fluid. The feeling of elasticity was less marked, while that of a deep, obscure fluctuation was pretty distinct. The relations in the pelvis were the same, the tumor filling the whole upper pelvis. It was everywhere fixed and immovable. On September 5th, a needle was put in at the umbilicus, and sixty ounces of a dark-brown fluid were removed. This was pronounced to be ovarian. There was little apparent diminution of the tumor. Much irritation followed the puncture, and in ten days the tension was greater than ever. The aspirator was again used; the same quantity of fluid, which was again said to be ovarian was removed. This time much relief followed. She was again sent away, for I had not changed my mind, and still thought the tumor was uterine. She was encouraged to hope that, as menstruation seemed about to cease, the tumor would quiet down. In a few weeks she was back again, urgent for operation at any risk; her life was miserable from pain, her health had given way, and she had to work that she might live. The case was now quite a clear one for interference, and I willingly agreed to try and remove the tumor, the patient clearly understanding that this might not be accomplished. On December 12th an incision, twelve or fifteen inches was made at once. The tumor was of a dusky-brown color, covered by enor- mous veins. It was firmly attached to the right iliac fossa, right 394 DISEASES OF WOMEN. lumbar region, and to the wall from a little below the umbilicus. This extent of adhesion quite accounted for the fixed state which the tumor had always presented. Upward of four pints of a dirty, black, purulent-looking fluid were removed, the incision was en- larged, and with one strong pull of the arm, pushed in from behind, the adhesions were broken up and the tumor dragged out. So rap idly was blood lost from huge, torn veins in the capsule, that she became faint. The left ovary only could be included in the wire ligature. From the previous elevation of the cervix, the stump was secured in the lower angle of the wound with less tension than in the first case. This part of the operation occupied only a few min- utes, but it was upward of two hours ere the wound was closed. Much trouble arose from stopping bleeding in the torn adhesions, more especially those high up on the insides of the ribs, near the posterior margin of the liver. A glass drainage-tube was left in, passing to the bottom of the pelvis. The patient was pulseless when placed in bed. This was an anxious operation on account of the unusual loss of blood. It is unnecessary to give details of the slow convalescence. The tube was removed on the fourth day, and the whole amount of red serum that came away did not exceed three ounces. This could easily have been absorbed. The pulse had fallen to below 100 by the fifth day, and there was scarcely any disturbance of the tem- perature. There was, however, much flatulence during the second and third weeks, also much trouble with the bowels, and at one time there was a fear of obstructed intestine. It was thought—though there was no evidence of this—that there might have been some adhesion at the angles of the bowel, caused by the presence of the drainage-tube. As in the former case, the slough extended far be- yond the wire, and a large cavity was left on its separation. Six weeks later she went home. I saw her quite recently. She was in perfect health, and had been so ever since her operation, now nearly ten years ago. The application of electrolysis to the treatment of fibroids has been so thoroughly elaborated by Prof. George J. Engelmann, M. D., of St. Louis, that I have with his permission given here a few cases from his work on that subject: Uterine Fibro-myoma with Menorrhagia, Retro-uterine Hematocele, and Left Cellulitis.—The haemorrhagic state of this case, the existing inflammation, which was active, subacute, contra-indicated electrol- ysis or negative electro-puncture. To check the haemorrhage, posi- tive electro-cauterization was resorted to, the platinum sound con- FIBROMA OF THE UTERUS. 395 nected with the anode in the uterus, the large dispersing cathode upon the abdomen. At the first sitting a current of 60 miiliamperes was used for eight minutes, no stronger current being admissible on account of the existing inflammation. The effect was good, haem- orrhage and pain lessened. Two days later the treatment was re- peated, 100 miiliamperes used for six minutes; bleeding, which had been almost constant, was stopped. After three further treatments upon alternate days, the menses appeared: previously profuse, now normal in quantity. This symptom being overcome, the inflamma- tory conditions were attacked by vagino-abdominal galvanism; the negative pole, a large metallic ball covered with absorbent cotton, moistened in warm water applied per vagina, the large plate in con- nection with the positive pole upon the abdominal surface of the exudation. From 40 to 60 miiliamperes were so used, serving to relieve the pain. Haemorrhage and excessive suffering being overcome, the patient was ordered to bed at her home, and di- rected to continue the use of poultices and hot-water injections until more active measures could be taken for the destruction of the tumor. Uterine Fibro-myoma (bilobar) extending to one finger's breadth above the navel. First tentative treatment, May 2d : negative electro-puncture; small stylet introduced to the depth of 3 centimetres; 80 miiliamperes for five minutes. Second puncture, May 5th: large platinum stylet introduced to the depth of 4 centimetres ; an intensity of 100 miiliamperes for five minutes; no pain was experienced from the internal electrode, and the abdominal burning diminished greatly toward the end of the sitting. Third sitting, after an easy menstrual period, May 12th : 80 mii- liamperes, six minutes; highest portion of the tumor 3£ centimetres below the navel. Fourth sitting, May 24th: 60 miiliamperes, eight minutes; large stylet introduced to the depth of 7 centimetres; highest portion 5 centimetres below navel. May 31st, notwithstanding that a current of only 60 miiliamperes had been applied on account of insufficiency of the battery, local pain followed, the tumor enlarged in circumference, extending above the navel, became tense, swollen, apparently fluctuating; no rise of pulse or temperature. Treatment deferred. June 2d, fifth treatment: 50 miiliamperes, six minutes; tumor harder, less elastic, much diminished. 396 DISEASES OF WOMEN. June 7th, sixth treatment: large stylet, s centimetres, 60 miili- amperes, seven minutes. June 15th, seventh treatment: 60 miiliamperes, ten minutes; tumor very hard, extending half-way to umbilicus; pelvis, which had at first been almost full, more free; vagina, which had been a fan-like expansion, now assuming more normal proportions. Ice-bag immediately after treatment, since it had answered well when applied during the apparently inflammatory enlargement. The patient re- turned to her home after the ninth treatment greatly improved in health, functions re-established, the tumor reduced very much in size. Each of the nine sittings had lasted from five to ten minutes. Uterine Fibro-myoma.—General debility, scanty menstruation. Patient aged thirty-two. A fibro-myoma, similar to the last, filling the pelvic cavity, its left half extending to the height of the navel, the right an inch and a half lower, the uterine cavity possessing a depth of 13 centimetres. This tumor, which had been first noticed in November, 1885, had been rapidly growing, notwithstanding active local and constitutional treatment, mainly with ergot, at the hands of one of our ablest gynecologists, first came under my ob- servation March 9,1886, recommended to me by her previous attend- ant, my esteemed friend Prof. Boisliniere. April 28th, first tentative treatment; the puncture made with a small stylet; a current of 45 miiliamperes was used for five minutes. Treatment was continued once a week, the puncture hereafter being made with a large platinum stylet through the cervical tissue, and the prominent vaginal projections of both right and left masses, which were punctured to a depth of from 7 to 8 centimetres. For the six treatments following the first, a current of from 100 to 110 miiliamperes was used; then a still higher intensity, from 160 to 200, was applied. The burning, occasionally intense, often decreased to a minimum toward the end of the sitting (by reason of the anaes- thetic effect of the positive pole), the punk- and chamois-covered plate being used, leaving the abdomen, after its removal, sometimes slightly reddened, but always cool. This patient, feeble, subject to fevers, at first did not improve constitutionally. The tumor, after the third puncture, was 3 centimetres below the navel on the left side, 4 on the right—the pelvis more free, a most decided shrinkage, due, I presume, in part to the powerful contraction caused by the high intensity used. In this case free bleeding followed several of the applications, from one to six hours after treatment, after the fourth puncture; coming at one time when still on the table, checked with considerable difficulty by iron cotton tampons. By June 2Sth FIBROMA OF THE UTERUS. 397 the tumor seemed again to increase ; her general condition not hav- ines of aromatic spirits of ammonia, camphor, and chloric ether, with small doses of cannabis Indica This combination is best suited to tho>e who get relief from gin or whisky, but it is to be preferred, as al- coholic stimulants ultimately do harm, though they may give tem- porary relief. Direct or local treatment should be adapted to the social state of the patient, and the presence or absence of complica- tions, such as endometritis. In the unmarried, local treatment is often injurious. In fact, in such cases it is better to avoid any ex- amination of the pelvic organs, if the history is sufficiently clear to enable one to make a diagnosis with reasonable certainty. Hot sitz- baths, counter-irritation, and hot vaginal douches, the latter to be employed by a competent nurse, comprise about all that I employ in the way of direct treatment The vaginal douche should not be continued unless it is decidedly sedative in its effects. Baths used according to the rules of modern hydrotherapy are of great service. In weak, nervous patients I begin with the wet-pack, used for half an hour at a time. Those wrho require a sedative are put into water at a temperature of 95° F. for ten or twenty minutes and then dried by brisk rubbing. When the sedative effects of the bath are no longer needed, the tonic bath should be used. This consists of the cold sponge, shower, or plunge bath. The water should be warm at first, and gradually reduced in temperature at each bath. In married women (and those who are so in all but the name) local treatment is more valuable. The treatment of any disease or displacement of the uterus that coexists should be managed in the usual way, and such local applications should be used as may aid in relieving the tender and hyperaemic ovaries. I employ a small tam- pon or pledget of cotton or wool saturated with equal parts of tinct- ure of belladonna and glycerin, applied behind the cervix uteri and permitted to remain forty-eight hours, and after its removal a hot douche. These are continued during the first days of treatment. The effect is to support or steady the ovaries, while the sedative ef- fect of the belladonna and the depleting effect of the glycerin are obtained. This I have followed with applications of tincture of iodine, after the manner of Dr. Emmet. Recently I have used, with good effect, the sulphichthyolate of ammonium, five parts in nine- ty-five of glycerin, applied in the same way as the belladonna and glycerin. The general and local treatment thus briefly outlined gives re- DISEASES OF THE OVARIES. 467* lief from the more pronounced symptoms. The pain becomes less, and the tenderness also. The general health improves, and the pel- vic congestion subsides. This is apparent in the color of the mucous membrane, the improvement of the menstrual functions, and the diminished leucorrhoea. Then the local treatment may be employed at longer intervals, or suspended altogether. The constitutional treatment should now be modified. Tonics and laxatives may still be required, but alteratives are also indicated. Iodine and mercury are the chief agents. They act upon the ovaries, as they do upon all glandular organs, and modify or arrest the morbid histological changes which take place slowly. Small doses of bichloride of mercury, with chloride of iron, wdien iron is indicated, followed by syrup of the iodide of iron in doses as large as can be borne. These can only be used when the bromides are relinquished. When giv- ing these alteratives the patient often misses the bromides used to produce sleep. Sulphonal at such times is of great value. In fact, it is the most potent sedative that is at the same time free from ultimate or after effects that are unfavorable that we have in gynae- cological practice. When a sedative is required while iodine or mercury is being used, I find that ten grains of salicylate of sodium and five grains of antipyrin, tliree times a day an hour before meals, give much relief, especially in those who suffer from nervous dys- pepsia and flatulence. Important elements in the treatment are patience and careful watching. Improvement comes, and the patient or the physician gives up treatment, and there is danger of relapsfe. The poor in hospitals often suffer for want of time for prolonged treatment, and this frequently tempts the surgeon to seek more prompt relief by removal of the ovaries. This does not apply with the same force to those who have time and means to secure the needed care. The description of the operation for the removal of ovaries de- stroyed by inflammation, as well as that for the removal of diseased tubes, will be found at page 552. Displacement of the Ovaries.—The ovaries have been found dis- located in a variety of ways. Cases are recorded in which the ova- ries descended through the inguinal canal after the manner of the testicles. The most interesting of these is one reported by Percival Pott, who removed both ovaries that were found in the usual posi- tion of an inguinal hernia ; and still another is mentioned by Tait, in which the ovary found its May outside of the inguinal ring and there developed a cystic tumor, which was removed by a Spanish surgeon. The ovaries have been found dislocated laterally and high up in the 468 DISEASES OF WOMEN". pelvis. They are, in such cases, usually fixed in the malposition by adhesions. Prolapsus of the Ovaries.—Downward dislocation of the ovaries is quite a common affection compared with all the other displace- ments. It is the only affection of this class which has an interest to the gynecologist derived from the frequency of its occurrence and the great suffering to which it gives rise. On that account it de- serves more than a passing notice, such as I have given to the other forms of displacement of the ovaries. Prolapsus of the ovaries I have described as occurring in two degrees—complete and incomplete. This classification is based upon the fact that displacements of the ovaries must in practice have the natural division. In the incomplete form the ovary has simply de- scended from its normal position until it has reached the side of the sac of Douglas or the utero-sacral ligament, where it lodges. In the complete form the ovary rests in the most dependent portion of the sac of Douglas. Fig. 1S9 shows the position of the ovary in com- Fig. 1S9.—Ovary displaced and bound down in the cul de sac by adhesions, ro, right ovary; lo, left ovary. plete and incomplete prolapsus, and the relation of the prolapsed organ in relation to the uterus and sac of Douglas. The figure also shows what is sometimes found in practice—namely, complete prolapsus of one ovary and incomplete prolapsus of the other occur- ring in the same subject. While prolapsus of both ovaries in dif- fering degrees, or both in the same degree, may occur, I more fre- quently find one displaced, while the other is in its normal position. DISEASES OF THE OVARIES. 469 The left is the one most frequently displaced, or else it causes the most suffering, and on that account attracts more attention than the ri^ht, and is oftener discovered. Prolapsus necessitates a stretching of the supports of the ovary, or it may be an elongation from an increase of tissue, the result of hyperplasia or new development. Prolapsus does occur without complications or coexisting affections, which cause the displacement. Such cases are not very common, and they are probably the result of arrest of development. In many cases, perhaps the majority, there is some accompanying affection which has some part in the causation of the prolapsus. The ovary itself is often enlarged from inflammation or some degenerative changes. In other cases the sup- ports of the ovary are elongated from imperfect involution after con- finement. Retroversion of the uterus is also frequently associated with prolapsus of the ovary. A not uncommon and a very unfor- tunate complication is the formation of adhesions from peritoneal inflammation. Symptomatology.—The degree of suffering arising from disloca- tion of the ovaries is extremely varying in different cases. This is due largely to the fact that, if the ovaries are quite normal and sim- ply displaced, but little inconvenience is experienced by the patient. It is rare to find this state of things, because the ovaries are often diseased, or else displacement soon leads to congestion, tenderness, and pain. As a rule, then, in displacement of the ovaries there is pelvic tenesmus and pain on walking or standing, relief from which is obtained by the recumbent position. In this the history differs from inflammation of the ovaries. There is usually backache and pain along the thighs, and pain and tenderness during and after sexual intercourse. There is pain after defecation, especially when the left ovary is displaced, which is most frequently the case. This pain is peculiar and, I believe, diagnostic. It comes on during or imme- diately after the action of the bowels, and continues for an hour or two. It is a dull, aching pain located in the region of the ovary, and radiates to the abdomen. It produces in many cases faintness and nausea, compelling the patient to lie down until it subsides. It is easily distinguished from the acute, smarting pain due to haemor- rhoids or fissure of the anus, on account of its location and character. There is in some cases derangement of menstruation, usually menor- rhagia. The pain in the ovary is generally aggravated at the men- strual period. The constitutional symptoms are generally produced from the confinement of the patient, made necessary by the suffer- ing caused by taking active exercise. There is often headache 470 DISEASES OF WOMEN'. mental depression, indigestion, and anaemia, ending in general de- bility. It should be understood that the symptoms alone will not suffice to make a diagnosis, because in many cases they arise more directly from the condition of the ovary rather than from its mal- position. PJtysical Signs.—The method of making a vaginal examination by the touch, to detect a prolapsus of the ovaries is as follows: The finger should be carried as far upward on either side of the cervix uteri as the vaginal wall will permit, and then brought downward toward the sacrum, so that if the ovary is displaced it will be caught between the examining finger and the sacrum. In that way it can be outlined by palpation, and its sensitiveness determined. Its mobility or fixation can also be determined in this way. I have frequently found while teaching my class of post-graduates that these few hints would enable them to find the displaced ovaries when they had tried in vain to make out their location. AVhen an ovary is completely prolapsed, it is found directly behind the cervix uteri in the most dependent portion of the sac of Douglas. So ex- actly central is the position of the ovary that in most of my cases I could not tell whether it was the right or left ovary, and could only settle that question by finding the other one in its normal position. If the prolapsus is incomplete the ovary is found on one side of the cervix uteri, usually at a point a little above the junction of the body and cervix. In complete prolapsus the ovary feels not unlike the fundus uteri, and gives the impression of retroflexion of the uterus. The distinction can be made by the peculiar sensitiveness of the ovary to pressure, and by the fact that the finger can usually be insinuated between the uterus and the ovary. Should there still be a doubt, the question can be solved by passing the sound which will exclude flexion of the uterus. There is another condition which proves to be somewhat puz- zling, that is complete prolapsus of the ovary with the retroverted uterus lying directly upon and above it. In one such case which came under my care, I was able to make out the true state of affairs by passing the sound, and while it was in place raising the uterus far enough to lift it off the ovary, so that by the touch I could dis- tinguish the one from the other. Prognosis.—The prospect of permanently overcoming the dis- placement depends upon the length of time that the malposition has existed; upon the condition of the ovary, whether normal or diseased, and whether there are other complications, such as adhesions, retro- version, or retroflexion of the uterus. In recent uncomplicated cases DISEASES OF THE OVARIES. 471 a permanent restoration may be effected if the patient can be kept under treatment for a sufficient length of time. In complicated cases all ordinary local treatment fails. It is then that the question of advisability of removing the ovaries comes up for consideration. Should the patient be near the menopause, she may be carried along past that change, and the recovery may come. In younger subjects the ovaries should be removed if all else fails to give relief. Causation.—The following are the causes of displacement of the ovaries, named, as far as my knowledge guides me, in the order of their frequency. Subinvolution; enlargement of the ovaries from hyperaemia, ovaritis, or other affections; displacements of the uterus; congenital malposition from derangements of development and growth. In regard to subinvolution, it may be well to call to mind the fact that in the puerperal state, the ovaries—especially the left one—are very large, nearly twice as large as at other times, and if care is not taken to secure complete involution after confinement the heavyr ovaries will naturally descend, and by making traction upon the peritonaeum and ligaments will overstretch them. I believe also that subinvolu- tion of the broad ligaments will permit the ovaries to descend into the pelvis when they are not much enlarged. At any rate, I have found the ovaries prolapsed when they were not large, but when the broad ligaments were long and relaxed, a condition which followed continement. In regard to the other causes of prolapsus of the ova- ries they are sufficiently clear to warrant my saying nothing more about them. Treatment.—The first thing to do is to ascertain if the displaced ovary is movable and can be raised up to its normal position. If that can not be accomplished, owing to adhesions, then there is little to be hoped for from treatment. When the ovary is movable it can be placed in position by putting the patient in the knee-chest posi- tion, using a Sims's speculum, and then making upward pressure through the vaginal wall with a sponge held in a sponge-holder. In short, the same method is employed as in restoring a retroverted uterus. To keep the ovary in place the cotton tampon is the best. It should be removed every forty-eight hours, and two or three times daily the patient should take the knee-chest position if she is able to he up from bed during the day. The use of the tampon in this way takes much time, and I have taught several of my nurses to use it with very satisfactory results. Prof. (4oodell recommended that the patient should separate the labia while in the knee-chest position, in order to distend the vagina 472 DISEASES OF WOMEN7. with air, and Dr. C. F. Campbell uses for the same purpose a glass tube open at both ends, which is introduced into the vagina before the patient takes the knee-chest position. I have tried both of these methods, but have given them up for two reasons: In the first place, because distention of the vagina is unnecessary. In the knee- chest position the pelvic organs will rise high enough and as>mne their normal position as well with the vagina closed as open; of this, any one can satisfy one's self by making an examination before and after this position has been assumed. In the second place, I find that the less local treatment patients give themselves the better it is for them. The first medical book of any kind that I ever read was entitled " Every Man his own Physician," by one Dr. Buchan. It was a very useless production, but had the good effect of preju- dicing me against making every woman her own gynecologist. I much prefer the tampon and the knee-chest position. If there is retroversion or flexion of the uterus present at the same time, that organ should be replaced each time that the tampon is changed. When considerable has been gained by the above treatment, and the ovaries and uterus are replaced sufficiently to get a pessary under them, one should be introduced. The form of instrument and the method of using it are the same as in retroversion of the uterus and need not be detailed here. I have tried the special forms of pessa- ries recommended by Tait, Munde, and others, but have not been able to do as well with them as with the instrument which I employ in retroversion of the uterus. In a few cases I have succeeded in forc- ing the uterus, ovaries, and vaginal wall upward and backward, thus giving some relief for a time, but the traction upon the vaginal wall causes stretching, and when the pessary is removed the displacement returns to a degree as great if not greater than before. While this local treatment is employed every effort should be made to improve the patient's general health. Rest should be in- sisted upon, in the recumbent position at first, and as the case progresses favorably, short stages of exercise may be permitted. Throughout the whole treatment all sexual relations should be pro- scribed. When all other treatment fails, and the patient still remains a use- less invalid, the ovaries should be removed, or attached to the upper margin of the broad ligament or abdominal wall. CHAPTER XXVI. NEOPLASMS OF THE OVARIES. I have made a classification of the morbid growths of the ova- ries which I believe will best serve the practical requirements of the gynecologist, although it may not be quite in keeping with the arrangement of the subject usually found in the text-books. In fact, it would be hardly possible to make any classification which would agree with all of the many authorities on the subject. Nor would it be possible to present an argument in favor of the classification which I have adopted without either taking more time and space than I can afford, or else omitting to mention the statements of many whose views are well worthy of consideration. I am obliged to sim- ply state in brief that which to my mind appears necessary to the 6tudent and practitioner. The first class is made up wholly # of cystic tumors, with a single exception, to which I shall refer later, and of these there are two varieties—follicular cysts and adenoid cystomata. Both of these va- rieties occur in a simple and in a compound form. Thus we may have (a) simple unilocular cystoma, and (b) simple follicular cysts, or of the compound form we may have (c), multiple follicular cysts, {(l) multiple cystoma, (e) multilocular cystoma, (f) papillary cys- toma, and (g) dermoid cystoma ; and also (A) fibrous, and (i) cysto- tibromi. The second class, which many speak of as malignant growths, contains four varieties: (a) carcinoma, (b) cysto-carcinoma, (c) sar- coma, and (d) cysto-sarcoma. Classification. —These morbid growths I have arranged in two classes : 1. Those that are most frequently seen in practice, and that are to some extent amenable to surgical treatment. 2. Those that are rarely met with, and that resist all kinds of sur- gical treatment, and tend by their very nature to a fatal termination. 474 DISEASES OF WOMEN. Tumors of the first class are spoken of by some authorities as benign, while the term malignant is applied to those which I have placed in my second class. OVARIAN CYSTS. Pathology.—The kind of ovarian neoplasm most frequently seen is the cystic tumor, or ovarian cyst, as it is generally called. The development and growth of ovarian cysts and cystomata vary in different cases in many respects, and still there is a certain sameness in the majority. The growth of these has been divided into three stages, the division being based upon certain features of the natural history of these neoplasms rather than upon any changes in their pathology. In the first stage the tumor is small, and confined to the pelvic cavity. This stage begins with the formation of the morbid growth and ends when it is large enough to rise out of the pelvis into the abdominal cavity. The duration of this stage can not be estimated, because there is no way by which the morbid growth can be detected until it has attained considerable size. In many cases an ovarian tumor gives rise to no marked disturbance, and therefore remains unnoticed until it has reached the second stage. This stage begins when the tumor rises up into the abdomen, and ends when the patient's general health begins to deteriorate. These constitutional effects of the morbid growth mark the begin- ning of the third stage. The first stage often passes by without the presence of any abnormality being suspected. It is only when press- ure upon the pelvic organs or when some inflammatory action in the ovary or pelvic peritonaeum occurs, that there is any likelihood of the affection being discovered. There is reason to believe, from the cases which have been watched, that the growth is steadily pro- gressive as it is in other neoplasms. The natural history of non- malignant tumors is that they go on gradually increasing until they attain a size sufficient to destroy life. This requires from two to three years on the average, but there is a great variation in time in different cases. There are periods of cessation of growth followed by rapid increase in size. These alternations of increase and pas- siveness may occur repeatedly, or the progress may be continuous. In the third stage the general health of the patient begins to suffer. There is usually loss of flesh, and the face shows evidence of ill-health. A certain facial expression has been described as the facies ovarii, but this is difficult to describe or recognize. It may be said to be an emaciated, careworn appearance, without the bronze hue of the cachectic state. This malnutrition is due at first to ex- NEOPLASMS OF THE OVARIES. 475 haustion from the growth of the tumor, and finally to pressure upon the neighboring organs. The functions of the abdominal and thoracic organs become deranged from pressure, and cause exhaus- tion and death by slow degrees. Death sometimes comes suddenly from asphyxia due to pressure upon the thoracic organs. Sometimes peritonitis is the immediate cause of death. In the majority of cases that are permitted to run their course, the patient is slowly crowded out of existence by the enormous size of the tumor. Fortunately, there are few cases in this age that are permitted to be lost in this way. Toward the end of the third stage oedema of the limbs generally appears. This is more likely to occur if the patient is unable to lie down in bed. The simple cyst is the most easily comprehended, and will there- fore be first described. It is composed of the cyst proper and the pedicle. The cyst is made up of the cyst-wall and the contained fluid. The pedicle is usually composed of the ovarian ligament, Fallo- pian tube, and part of the broad ligament. The cyst and the pedi- cle have one covering in common—namely, the peritonaeum. Simple Cysts.—The simple cyst is usually globular in form, and its walls are generally of uniform thickness. The size varies in dif- ferent cases from a microscopic object to one weighing one hundred pounds or more, according to the age of the growth. By the term simple or unilocular cyst it is not intended to imply that the tumor is absolutely composed of a single cyst, since it is believed by the best authorities that ovarian cysts are always multiple, but the term is applied to that variety of cyst which in its gross anatomy appears to be single, and which can be managed by the surgeon as a single cyst. The one sac or cyst is large and appears to be single, but on close inspection minute cysts are generally found in varying num- bers in the major cyst, or in that portion of it which joins the pedicle. Compound Cysts.—These are distinguished from the simple vari- ety by being multiple—that is, the whole tumor or mass is formed by the aggregation of several simple cysts, each being large enough to be easily recognized. The usual form of this multiple variety of cyst is that in which one of the divisions or cysts is much larger than all the others taken together. The greater contains the lesser ones, which are usually formed in a cluster attached to one side of the major cyst, near the pedicle. It will be observed that the difference between the single and multiple cyst is that in the latter there are a number of well-defined 476 DISEASES OF WOMEN. Fig. 190.—Left ovary distended into one large cyst, into the interior of which smaller cysts project (Farre). cysts, one large one and a number of others varying in size from that of a man's head to a small hazel-nut, while the former is com- posed of one cyst with a few almost imperceptible cysts. Multilocular Cysts.—These are so called because the sacs or cysts, which in the aggregate make up the whole tumor, are larger in size and more nearly equal. The general appearance of the mass is of one large cyst-wall contain- ing a number of cysts which vary in size. Sometimes one or more of the cysts is much larger than the others. In other cases there are several cysts varying in size from that of a human head to that of an orange, with a large number of smaller cysts. From the general appearance and arrangement it would ap- pear that the cysts included within the major cyst-wall had been developed from the inner cyst-wall, and others still had been developed from the second crop by a process of endogenous proliferation. This may or may Fig. 191.—Compound and proliferating cyst (Farre). NEOPLASMS OF THE OVARIES. 477 nnt be the fact, but it is more likely that the ovary from which the morbid growth is developed contains a number of germs included in the structure of the ovary which forms the cyst-wall, and that thev all grew from similar germs and are aggregations rather than proliferations. The gross appearance of such tumors is the chief point of interest to the surgeon, viz., that one cyst-wall contains within it a number of cysts; usually, there are one or two large cysts a larger number of medium size, and a very great number of small ones, varying in size and united to each other. The cavities of these cysts rarely communicate with each other. Occasionally a cyst is found the cavity of which is divided by septa, but associated with 6uch there is always a number of independent cysts. I have, on one occasion, seen two cystomata growing from an ovary, one on each side, the whole resembling somewhat a dumb- bell in shape. Complex Cystoma.—These tumors are called complex or mixed because they differ from those already described by the addition to the cyst structures of other pathological elements, or else there is a marked development of some special portion of the cyst elements— the cyst-wall, for example. These peculiar portions of the growth may consist of a hyper- trophic increase in the tissues of an ovarian follicle, or of hypertrophy of the stroma of the ovary, infiltrated with serum or other morbid fluids. Proliferation of the fibrous tissue may give rise to. one or more fibrous masses connected with the cyst. The cyst-wall may be greatly thickened generally, or in certain portions, from hypertrophy <»f either its inner or middle layer. The inner surface or lining membrane of a cyst may develop new structures or proliferations. 47S DISEASES OF WOMEN. Again, the contents of a cyst may be of a character entirely differ- ent from the ordinary fluid found in simple or compound cystic tumors. In this way the following complex tumors are formed : Papillary Cysts.—In this form of cyst the connective tissue of the cyst-wall undergoes hyperplasia in certain places, and the growth Fig. 193.—Papillary cystoma of ovary showing proliferation (Winckel). of the tissue pushes the lining membrane of the cyst before it, and in that wray a great number of papillae are found projecting into the major cyst and covering, it may be, the whole internal surface of the sac. The papillae are sometimes very vascular, and are covered with columnar epithelium. Dermoid Cysts.—The characteristics of these tumors differ very markedly from those already described. The genesis of this cyst is Fig. 194.—Dermoid cyst of ovary, filled with hair and tallow-like masses (Winckel). peculiar, and this may account for the fact that its contents are made up of specimens of most of the tissues of the body; hair, bone, teeth, and adipose tissue are usually in the greatest abundance. NEOPLASMS OF THE OVARIES. 479 CyBto-Fibroma.—In this form of tumor the fibrous portions closely resemble, in structure, fibrous tumors of the uterus. They do not differ in their outward appearance from the ordinary simple cyst, but the touch shows one part of the mass to be solid and the other fluid. These morbid growths are quite rare. I have met with but two in my own practice. FIBROMA OF THE OVARIES. This rare form of ovarian tumor I have classed with the cys- toinata, not because it presents any features in common with the class, but because it calls for surgical interference and does not in any way belong to the second class, having no inherent tendency to Fio. 195.—Fibroma affecting both ovaries (Winckel). prove fatal except by indirect effects. It is rare, and hence not of sufficient importance to demand a separate class for itself alone. In describing this form of neoplasm I may say that it is like the cysto- fibroma, minus the cyst or cysts. The composition of the growth is similar to that of the fibroid tumors of the uterus. That the fibroma of the ovary is very closely related to the cysto-fibroma, is further shown from the fact that so-called fibromata have been found with small cysts. In the one the cyst element predominates, while in the other the solid or fibrous element is the principal or only one found. 32 480 DISEASES OF WOMEN. Cyst-Wall—The walls of the cysts of ovarian tumors are, as a rule, nearly all the same. For convenience of description and for the purposes of the surgeon the wall is divided into three layers. The external is a serous membrane corresponding to the peritoneum, which it is in fact. The middle coat is areolar tissue, and contains the main blood-vessels of the cyst, The internal layer is like the external, so far as its fibrous elements are concerned, but it is really a mucous membrane. It is less uniform than the other layers in appearance, and usually contains small cysts in process of develop- ment, or follicles which have undergone degeneration. Papillae are often found developed on this layer, as already stated. AVhile this in a general way describes the cyst-walls, they are subject to certain modifications, as follows: The middle layer, which is well defined at the base of the tumor, contains the large vessels, and is easily sepa- rated from the peritoneal layer. It becomes thinner the farther it departs from the pedicle, and when it reaches about the middle of the tumor there are only two layers easily distinguished, while at the summit there is only one that can be made out by ordinary dis- section. AVhile the middle layer diminishes gradually as it gets farther and farther away from the base and finally disappears, the internal and external bayers come together and are united, and increase in thickness so that the cyst-wall becomes a fibrous homogeneous mem- brane. Some authors have made more minute subdivisions of the layers of the cyst-wall, but that I look upon as a super-refinement in dissection which has no value in this connection. The outer and inner coats are often modified in appearance and character. The external layer is changed in places by circumscribed peritonitis, or by great vascularity, and the internal coat is often changed by inflammatory action, degeneration, or hyperplasia. The appearance of the outer coat has a special interest for the surgeon. To be able to recognize the cyst-wall when one comes to it in operating is very important. Many times, in simple uncompli- cated cases, the cyst-wall is smooth, of a whitish color, slightly tinged with a pinkish, pearly tint which resembles the peritonaeum, every- where covering the abdominal viscera, and yet easily distingmMied. When there has been peritonitis, the cyst-wall becomes covered with lymph or adhesions, and so changed in appearance that it is difficult to recognize it when it is reached, owing to the products of inflam- mation. The vascularity of the outer coat of the cyst varies greatly. Sometimes the whole surface presents a fine network of vessels all over the parts that are seen; in other cases the vascularity is exag- NEOPLASMS OF THE OVARIES. 1S1 gyrated in patches. This great vascularity, when it occurs with- out preceding evidence of inflammation, makes a marked contrast between the cyst and the abdominal viscera, which enables one to promptly distinguish the one from the other. In a few tumors, all of them occurring in oldish patients, I have found large portions of the cyst-wall of a pale, grayish-white color, without any recognizable vascularity. This made the cyst very peculiar in appearance and ea-ily recognized. This rare and peculiar color is caused by com- mencing necrosis. Contents of Ovarian Cysts.—The contents of the simplest variety of cyst are a serous fluid of a lemon or amber color, but subject to marked variation in different cases. The character of the fluid is modified by the size of the cyst, the length of time it has existed, and whether the cyst has been tapped ; under these modifying influ- ences the fluid may be colorless, or chocolate-colored from the pres- ence of blood in varying quantity, or it may be of a greenish-yellow color, from the presence of pus produced by inflammation of the cyst. Shreds and flakes of whitish lymph are sometimes found with the pus when there has been inflammation. Occasionally the fluid is viscid. It generally contains albumen or paralbumen, and sometimes crystals of cholesterine are found in it. The contents of the multi- locular cysts resemble those just described, presenting the same dif- ferences in different patients. Usually the fluid is more viscid or gelatinous, sometimes quite thick, so that it escapes with, difficulty. In one case I found the cyst contents exactly like jelly, but different in character in this, that jelly is friable, but this material was ex- ceedingly tenacious, so that it could not be pressed out of the sac, and was even pulled out with the hand with great difficulty. The fluid in the several cysts of a multilocular tumor is not always the same. It often differs in color and consistency in the different divisions of the tumor. In addition to the albumen, blood, choles- terine, pus, and lymph, which may be present in the fluid of ovarian cysts, there are other chemical and anatomical elements found which are of interest, The contents of ovarian cysts have been most thoroughly investi- gated as to their chemical composition by Eichwald. As has already been stated, they may be as fluid as serum, or, as is more often the case, viscid sometimes to such a degree as to be gelatinous in con- sistency. The specific gravity may be as low as 1007, or as high as h)'2o. There are two distinct classes of elements which occur in the contents of these cysts: the one mucous in its nature, which 482 DISEASES OF WOMEN. predominates in the younger cysts; the other albuminous, which is characteristic of the large and older colloid cysts. The colloid sub- stance is regarded as a modified mucine formed from the substance of the colloid bodies and the parenchyma of the cells of the ovaries. Colloid degeneration is therefore but another name for mucous metamorphosis. The first or mucine class consists of four ele- ments : the substance of the colloid corpuscles, mucines, colloid substance, and mueo-peptone. These are distinguished by their solubility in water, and by various reactions which need not be mentioned here. The second or albuminous class is characterized by the presence in the contents of the cysts of free albumen and the albuminate of soda. In colloid tumors the free albumen becomes albuminoid pep- tone, while the albuminate undergoes no change. The conversion of free albumen takes place slowdy; it first becomes paralbumen, then metalbumen. These are not fixed bodies, but pass on to the condition of peptone. Thus, the albuminous elements wdiich are found in this albuminous class are albuminous paralbumen, metalbu- men, and albuminoid peptone. In a chemical analysis of the con- tents of a cyst, Eichwald found the following to be its composition: AVater.................................. <)31.96 Organic substances....................... 50.77 Potass, sulph............................. .os " chlor..............................-iiJ Sod. nit ................................ (5.2!) " phosph............................. .16 '• carb................................38 Salts insoluble in water.................... .71 Loss.................................... .03 looo.OO MICROSCOPIC CONTENTS OF OVARIAN CYSTS. Under the microscope the contents of different cysts present very different appearances. The cell elements abound in those which are colloid in their nature, while those which are serous are very defi- cient in this respect. Eichwald, in one of the colloid cysts, found so large an amount of corpuscular elements that he was unable to examine it satisfactorily with the microscope until he had diluted it with water. When thus treated he found fatty elements, round and serrated cells, large colloid cells, round cells resembling those de- scribed by Lebert as pyoid bodies, and by Henle as exudation corpus- NEOPLASMS OF THE OVARIES. 183 cles; globular aggregations of various sizes, scales of epithelium, crystals of cholesterine, and brown pigment were also found. As a rale, the morphological elements found in the fluid of ovarian cysts are granular cells, free granules, small oil-globules, epithelial cells, blood-corpuscles, Gluge's corpuscles, and pus cells. From time to time various cells have been described as characteristic of the ovarian cyst. Among others, Drysdale has described such a cell, which he speaks of as " the ovarian granular cell," and which he regards as pathognomonic of ovarian disease. His claim to the discovery of this cell is thus put: " I claim, then, that a granular cell has been discovered by me in ovarian fluid, which differs in its behavior with acetic acid and ether from any other known granular cell found in the abdominal cavity, and which, by means of these reagents, can be readily recognized as the cell that has been described; and, further, that by the use of the microscope, assisted by these tests, we may distinguish the fluid from ovarian cysts from all other abdominal dropsical fluids." This "ovarian granular cell" of Drysdale is generally round, but sometimes oval, is very delicate and transparent, and contains a number of fine granules, but no nucleus. The size of the cell varies from -gyaV^ inch to ^inr inch. AVhen aceti.e acid is brought in contact with this cell it becomes more transparent, and its granules appear more distinct. On the other hand, when thus treated with acetic acid it becomes larger, and from one to four nuclei appear. It is distinguished from Gluge's inflammation corpuscle by the fact that, when ether is added, the ovarian cell is unaffected—at most, has its granules made paler; while Gluge's corpuscle loses its granular appearance, and sometimes entirely disappears through a solution of its contents by the ether. In reference to this subject it may be said that the views of Drysdale deserve the most careful consideration, but I am not as yet satisfied in my own mind that this corpuscle is pathognomonic of ovarian disease, nor indeed that the diagnosis can he positively made by either chemical or microscopical analysis. Complications.—There are certain pathological changes which occasionally occur during the progress of an ovarian tumor which may be considered as complications of the original affection. The presence of an ovarian tumor tends to excite circumscribed inflam- mation of the peritonaeum, which gives rise to adhesions o,f the cyst or tumor to the pelvic or abdominal viscera. This is the most fre- quent complication, and one which is of exceeding interest to the surgeon. The location, extent, and firmness of the adhesions differ . greatly according to the duration, size, and character of the cyst or 484 DISEASES OF WOMEN. tumor. It is also possible that the state of the patient's constitution and general health may have some influence in determining the development of inflammatory adhesions. In regard to the effect wdffch the nature of the tumor has upon the occurrence of adhesions my observations lead me to believe that malignant growths and those that are mixed—that is, in part benign and in part malignant —are most frequently found to have adhesions. It is also a ques- tion whether the adhesions found by some of these neoplasms result in all cases from peritoneal inflammation. In some cases that I have seen it appeared to me that the ovarian tumor became attached to the viscera in contact with it by an extension of the ovarian dis- ease. It may be that in such cases the malignant disease may have begun in other organs and tissues as well as in the ovary, and that the diseased parts became united without intervening products of inflammation ; occasionally adhesions occur where the tumor is small, and then they are found in the pelvis or in relation with the lower intestines. When they take place after the tumor is large enough to distend the abdominal walls they are found higher up. Then the tumor may be adherent to the abdominal wall, omentum, stomach, loin, diaphragm, or to the lumbar region. Such extensive adhesions are rather rare, still they occur sufficiently often to be of the great- est interest to the surgeon. These adhesions sometimes displace the pelvic organs and derange their functions. When a small tumor becomes adherent to the uterus or bladder it will carry these organs up out of place when it grows larger and rises up into the abdominal cavity. Obstruction of the intestines may be caused by the traction of adhesions and also by the pressure of a very large tumor. Occasion- ally a small tumor in the pelvis may make pressure upon the rectum sufficient to obstruct the action of the bowels, but that is rather rare, unless the tumor is so firmly fixed by adhesion that it can not be dis- lodged. Rotation of the tumor upon its axis occasionally takes place. This produces twisting of the pedicle and partial or complete stran- gulation of the blood-vessels and tissues of the pedicles. The result is that the blood can not return from the tumor, and hence the ves- sels become overdistended and sometimes rupture follows. The bleeding into the cyst suddenly distends it and causes shock. Some- times the cyst ruptures under the pressure of the haemorrhage with- in it and death may take place. Cases have been known of haemor- rhage into the cyst which have proved fatal from shock and loss of blood without the cyst bursting. Should the patient withstand the shock and haemorrhage, peritonitis and cystitis are likely to occur. NEOPLASMS OF THE OVARIES. 485 Death takes place as a rule, if the twisting of the pedicle is suffi- cient to completely arrest the circulation. This proves fatal unless the tumor is removed. If the twisting is not sufficiently marked to arrest the nutrition of the tumor suddenly and completely atrophy mav take place instead of gangrene or necrosis. Spontaneous cure has taken place in this way, the tumor shriveling up and disappear- in^. Some very curious things have happened from twisting of the pedicle. Atrophy has taken place so perfectly that the pedicle has b?en severed, the tumor becoming entirely free from all attach- ments. More strange things still have happened. The tumor has be- come adherent to some part of the abdominal viscera and subse- quently the pedicle has become separated from the tumor by a pro- cess of slow atrophy. "While the separation of the pedicle is slowly disappearing the vascularity increases at the point of adhesion, and the tumor derives its nourishment from its new attachment. This has been described as transplantation, a term wThich clearly indicates the process which takes place. Dragging of the Pedicle gives results similar to twisting. This dragging is produced usually when pregnancy7 occurs during the ex- istence of an ovarian tumor. The uterus growing faster than the pedicle pushes the tumor upward and makes strong and continuous traction upon the pedicle and obstructs the vessels. Again, if the ovary is adherent in the pelvis, and the pregnant uterus ascends, traction will be made sufficient to damage the nutrition of the ovary and any cyst that may exist there. There is another way in which traction of the pedicle may occur. A cyst or tumor may be carried high up in the abdomen with the pregnant uterus, and become adherent at its higher part, and when the uterus descends after delivery the pedicle may become stretched. It is presumed that cystic tumors may become atrophied and a spontaneous recovery oc- cur. This belief is based upon the fact that in old women the ova- ries have been found to contain shrunken cysts imbedded in very hard, thickened stroma and it is believed that this condition is the result of atrophy by cystic tumors. There is no absolute proof that absorption of the fluid and shriveling of the cyst-wall occurs except by obstruction of the blood-vessels in the pedicle as already de- scribed. Bupture and Perforation of Ovarian Cysts.—Rupture may occur as the result of overdistention of the cyst-wall from rapid accumula- tion of fluid in the cyst, or from injuries such as direct blows or concussions from falling or sudden exertion. The bursting of a 486 DISEASES OF WOMEN. cyst may cause death, or the opening may be (dosed by inflammar tory exudation and the cyst refill. It has also been claimed that the cyst may disappear, and the patient recover. AVhen this spontane- ous recovery occurs after the bursting of a cyst, there is always room for doubt about its being an ovarian cyst. For the present it must remain an open question whether ovarian cysts ever disap- pear in this way. It is, however, well known that cysts of the ovary frequently burst and empty their contents into the abdominal cavity. The results of this differ greatly; sometimes there is not much trouble if the fluid is clear and non-irritating; in other cases death is caused in a short time by shock, or peritonitis may follow and cause death or terminate in closing the opening in the cyst and forming extensive adhesions of the cyst- and abdominal-walls and viscera. In those cases which recover from the shock of rupture and the subsequent peritonitis and the cysts refill there are always extensive adhesions found. Perforation differs from rupture in being a slow process and in the fact that the opening is frequently into the adjoining viscera of the abdomen or pelvis. There are two ways in which perforations occur; the one by thinning of the cyst-wall from pressure, either from within the cyst or from without at a given point, and the other and most frequent by suppuration or ulceration. Perforation occur- ring in either way may open into the peritonaeum, but in case the opening is the result of suppuration it may be into some of the neighboring organs. In some cases the perforation is very small and the opening is closed by exudations which also form adhesions to the neighboring organs. This fact has led to the belief that many of the adhesions found are the result of these small perfora- tions which admit of a limited escape of the cyst fluid. Should the perforation be large a free escape of the fluid may take place, and the result would be the same as in case of rupture. When the per- foration is into the intestine, the contents of the sac may be wholly emptied, but this form of perforation is rare. Another rare form of perforation has been seen in which a communication between an ovarian cyst was formed by ulceration extending from the intestine and opening into the cyst. Ovarian Cystitis.—Inflammation of the interior of the cyst occurs occasionally and is a serious complication. In multiple and multi- locular cysts the inflammation is usually limited to one or more of the cysts, the others in the tumor remaining in their original condi- tion. The inflammation is of a low form in most cases and ends in suppuration; in others there is a mixture of pus with shreds and NEOPLASMS OF THE OVARIES. 487 flakes of lymph. The original fluid in the cyst is supplanted to a larire extent by these products of inflammation. This was well illustrated in a case of a monocyst which came un- der my care years ago. I tapped the cyst, and withdrew a half a pint of clear fluid, inflammation followed, and the cyst slowly filled up but did not increase beyond its original size. It became adher- ent to the abdominal wall and finally opened externally, and it was then found to be filled with pus. In another case a hypodermic syringe full of clear fluid was drawn off from the major cyst of an ovarian tumor, and then inflam- mation followed, and the patient was subsequently brought to me for operation. I found pus and lymph in the cyst, but the most of the original clear fluid had disappeared. Abdominal dropsy is still another complication which may occur. There is in many cases a little free fluid in the peritoneal cavity which is not of special interest, but in other cases the quantity of fluid is such that it mayT in bulk exceed that of the ovarian tumor. This is more likely to occur in malignant growths and in papillary ovarian cysts. This will be referred to again while discussing diag- nosis and treatment. There are many local and constitutional conditions which may be found accompanying ovarian tumors, but those complications which can be rationally considered as resulting from the affection of the ovary have been mentioned. CHAPTER XXVII. CYSTIC TUMORS OF THE OVARIES—SYMPTOMATOLOGY ANI) PHYSICAL SIGNS. The most peculiar feature in the clinical history of this variety of ovarian tumor is the fact that subjective symptoms are often ab sent. Cases are sometimes seen in which the patient is unconscious of anything being wrong until the tumor becomes noticeable by the increased size of the abdomen. It is equally strange that the tumor is often unobserved by the patient until it has attained a con- siderable size. But, while cases occur without noticeable symptoms. the majority of patients suffer from some pain and discomfort, and at the same time there is more or less derangement of the function of the ovaries, and occasionally some disturbance of neighboring organs. The symptoms differ in the different stages of the growth of the tumor. I will, therefore, take up the three stages in order. In the first stage, while the tumor still occupies the pelvic cavity, the patient may have a feeling of fullness in the pelvis, and pos- sibly some pelvic tenesmus on standing or walking; pain is also present in the affected side. The severity of the pain differs great- ly in different cases. In some it is only sufficient to attract the attention of the patient at times, but is not acute enough to pre- vent her from performing her ordinary duties. In others it is quite severe, and accompanied with well-defined tenderness, dis- abling the patient to some extent. These symptoms may or may not be continuous. The pain may be at times very slight for days or weeks, then increase, and again subside, and yet at no time be sufficiently7 marked to cause the sufferer to seek advice, and its ex- istence is only brought out by interrogation at a more advanced stage of the affection. When the pain is acute and sufficient to dis- able the patient, there is usually some local inflammation to account for it. When such is the case, there is ordinarily some constitutional disturbance indicative of the local affection. In quite a number of CYSTIC TUMORS OF THE OVARIES. 489 cases there is pain for a few days at or just before the menstrual period, or it may be midway between the periods. The pain is in the affected ovary, and is often of that character which is called ovarian. It has been supposed that this kind of in- termittent pain is due to ovulation, occurring in the morbid ovary. When the pain occurs in the intra-menstrual period, it is presumed to be caused by some trouble during the maturation of the ovule; and, when it comes on about tbe menstrual period, it is due to the process of rupture of the Graafian vesicle. Menstruation is fre- quently deranged, but not always. AVhile one ovary is affected, the other may be normal, and, so far as the ovaries influence men- struation, there is no change, and the uterine function goes on in the usual way. This is sometimes the case when both ovaries are affected. It would appear that, while a part of the ovaries is mor- bid, there still remains enough that is normal to perform the func- tion and maintain the ovarian influence upon menstruation. It frequently happens, however, that menstruation is deranged dur- ing the existence of ovarian tumors. As already stated, there may be pain at the menstrual period, which is easily mistaken for dys- menorrhcea. Irregularity or suppression of the menses is, I believe, the most common derangement. Profuse and too frequent men- struation occasionally occurs, but either of these derangements may be due to some constitutional condition or some uterine affection, which may accompany the ovarian tumor. When the ovarian tumor attains considerable size, and is yet not large enough to rise out of the pelvis, it may cause displacement of the uterus or bladder, and give rise to symptoms peculiar to this displacement. It is not often that these cause sufficient suffering to lead the patient to seek relief at the hands of the gynecologist. When the left ovary is the sub- ject of the morbid growth, there is, in some cases, slight obstruction of the rectum, which causes disturbance in the action of the bowels. The important fact still remains that, in the first stage of cystic tumors of the ovaries that are uncomplicated, the symptoms are often so mild that the patient may not come under the care of the medical attendant, and, if she does, the symptoms do not afford any reliable guide to the nature of the affection. In short, there is nothing diagnostic in the symptomatology of this stage of ovarian tumors. In the second stage, an enlargement of the abdomen is noticed sooner or later by the patient. If the pedicle is short, the enlarge- ment may be on one side; usually it is central, or nearly so, when first noticed. Here, again, there are no other very well-marked 490 DISEASES OF WOMEN. symptoms. As the tumor increases, the weight and pressure cause discomfort. This is likely to be felt earlier in those who have not borne children than in those who have. In such patients the ab- dominal muscles do not yield so readily to accommodate the tumor. Slight pains recurring at intervals and tenderness are common syni{>- toms, and are usually due to tension of the cystic walls from increase of the contents. AVhen such pains occur, the tension of the cyst i> marked, and the pain subsides when the cyst becomes flaccid. If inflammation of the cyst or portions of the peritonaeum occurs, there are, in addition to pain and tenderness, some constitutional symp- toms, such as fever, rigors, and, if the inflammation is extensive. deranged digestion, loss of flesh, and hectic may follow. Thesj symptoms are relied upon as indicating inflammation, which will produce adhesions, especially if the peritonaeum is involved; but it should be borne in mind that quite extensive adhesions may take place without their having been at any time well-defined symptoms of circumscribed peritonitis. Ordinarily, these are all the symptoms manifested in the second stage. In the third stage, when the tumor begins to make strong press- ure upon the different viscera, another class of symptoms appears. These were hinted at while discussing the growth of ovarian tumors. Deranged digestion and impaired micturition, difficult breathing, distressing weight, and a dragging on the abdominal muscles, to- gether with pain and tenderness, may all supervene. Some of the symptoms which characterize the first stage, and disappear in the second, often recur in the third. Pressure on the bladder may cause frequent urination, and the bowels may become obstinately consti- pated. Paroxysms of pain in the limbs and abdomen may be very severe, caused by obstructed circulation. From the same cause ef- fusion of fluid into the abdominal cavity and oedema of the legs may occur. The patient becomes emaciated, weak, and sometimes hectic, but not, as a rule, cachectic in the benign forms of ovarian tumors. Physical Signs.—The physical examination of ovarian tumors is made by the means generally' employed, and fully described in the first chapter of this work. They are inspection, vaginal touch, palpation, percussion, auscultation, measurement, exploration by as- piration, microscopical and chemical examination of fluid obtained by aspiration, and, finally, laparotomy. The evidence obtained by phys- ical exploration differs in each stage of the growth of ovarian tumors. In the first stage, the bimanual examination of the pelvic contents is all that is necessary, this giving all the information which cau be CYSTIC TUMORS OF THE OVARIES. 491 obtained, except in obscure cases, where aspiration may be advisable. Sometimes it may be necessary to pass the sound into the uterus to confirm or correct the impressions obtained by the touch. Occa- sionally, also, when the parts are tender and resisting, it is necessary to give an amvsthetic in order to make a satisfactory examination. The method of searching for small ovarian cysts in the pelvis is the same as that recommended in prolapsus of the ovary, and described in a previous chapter. AVhere the tumor has attained any consider- able size, the bimanual touch gives the most satisfactory evidence. The tumor, caught between the fingers of the two hands, can be outlined, and its consistence ascertained with a tolerable degree of accuracy. In the early stage the cyst is usually found on one side of the pelvis, or else in the sac of Douglas, exactly behind the uterus, or a little inclined to one side. It is usually soft and slightly yielding to the touch, sometimes globular and smooth of surface, or else globular in the main, with some irregular projections. These irregu- larities are due to the presence of small cysts and the portions of the ovary that remain normal. The physical signs obtained by this examination determine the fact that there is a neoplasm, and that it is possibly cystic ; but there is no direct, positive evidence regarding the structure of the tumor, nor that it is ovarian. In other words, the physical signs are not diagnostic—i. e., direct and positive. It is necessary, on this account, to employ the method of diagnosis by exclusion. Differential Diagnosis in the First Stage.—There are many affections which may present symptoms and signs remotely resem- bling cystic tumors of the ovary. Those which most nearly approach them in character are, dilatation of the Fallopian tube from hydro- salpinx or pyosalpinx, parovarian cyrsts when small, extra-uterine pregnancy, pregnancy in a bicornute uterus, subperitoneal fibroids of the uterus, fibroid tumor of the ovary, and tumors of the second class, which include the cystic and solid malignant growths, and in a less degree pelvic hematocele, pelvic peritonitis, and cellulitis. Fecal accumulations in the upper part of the rectum, and back- ward dislocations of the uterus, have also been mentioned as simulat- ing ovarian tumors, but these can be so easily differentiated that they need only to be named. Dilatation of the Fallopian tube may be distinguished from a cystic ovary by its oblong shape, and some- times, when the tube is low down in the sac of Douglas, the normal ovary can be felt above the tube by the bimanual touch. In case the dilatation of the tube is due to pyosalpinx, the history will tell 492 DISEASES OF WOMEN. of a previous inflammation, and the constitutional symptoms are usu- ally more marked. Should it be necessary to make an immediate diagnosis, the tumor may be aspirated, and the characteristic epithe- lium of the tube, if found by the microscope, will decide the question. It is safer and surer to wait and watch the progress of the case. In time the ovarian tumors will grow and rise out of the pelvis, while in case of a dilated tube there will not be any great increase in size, but there will be more local and constitutional disturbance. This difference in the progress of the two affections is the most reliable means of differentiation. Parovarian cysts can not be distinguished from ovarian wdien they are small, unless the ovary can be separated from the cyst, and ascertained to be normal. Fortunately, it is not of great importance to distinguish the one form of cyst from the other in the first stage of their growth. Extra-uterine pregnancy presents physical signs which can not always be distinguished from those of ovarian tumors, and in both there is a gradual increase in size, so that neither the physical signs nor the progress of the case are reliable aids in diagnosis. The general signs and symptoms are usually sufficient to decide. In cases of doubt, the electrical treat- ment which arrests the progress of the gestation should be tried. Pregnancy in the uterus bicornis may be detected by finding the other horn of the uterus, and perhaps the ovaries may be found nor- mal. These conditions are rare, and wdll not frequently coine up as questions of diagnosis in ovarian affections. Small, subperitoneal fibroids of the uterus differ from ovarian cysts in being firm to the touch, and generally accompanied with enlargement of the uterus and menorrhagia. They are, wdien small, usually united closely to the uterus. An ovarian cyst is likely to be mistaken for a fibroid of the uterus when it is very tense and adherent to the uterus by inflammatory adhesions. Here, again, time will determine, because the ovarian will grow faster than the uterine tumor, and will show its characteristics more clearly the larger it grows. A fibroid tumor of the ovary can not be distin- guished from a tense ovarian cyst or a fibro-cyst of the ovary in all cases by physical signs, but the history will help materially in mak- ing a diagnosis, and, when the fibroid becomes large enough to rise out of the pelvis, its solid character will be easily made out. Neither can a fibro cyst of the ovary be distinguished from a multiple cystic tumor in which the cyst-walls are very thick. But the diagnosis of the exact composition of such tumors is not of any practical importance in relation to treatment. From what has been said it will be seen that the question to be CYSTIC TUMORS OF THE OVARIES. 493 decided is, AVhether the tumor found in the pelvis is ovarian or not; and, when that is settled, the next question which arises is, AVhat is the nature of the tumor? If it can be determined that the tumor belongs to the first class of ovarian neoplasms, that will suftice for such cases. It is otherwise in tumors of the second class, because in malignant affections it is important to make a diagnosis early. If the tumor is of the first class, no harm can come from waiting, while, if it is of the second, surgical interference may be necessary while the tumor is yet small. The physical signs of malignant ovarian tumors will be spoken of in another chapter, but I may briefly state here that the density and irregularity of outline, so commonly found in malignant disease elsewhere, are wanting in the cystic tumors of the ovary. The constitutional disturbances are usually developed early in malignant diseases, while it is otherwise in the benign forms. Pelvic hematocele, pelvic peritonitis and cellulitis may, after the acute stage of these affections has subsided, present certain physical signs, which may lead one to suspect an ovarian cystic tumor. But the history of such affections will put the diagnostician on his guard, so that time may be given to see whether the tumor which has been discovered grows, as it will do if it is a cystic ovary, except in rare cases of an ovarian cyst arrested in its growth by inflammation or other causes. D'fferent'ad Diagnosis in the Second and Third Stages.—By the time that such a tumor has escaped from the pelvic to the abdom- inal cavity, and attracts attention by its presence there, it will have attained a size equal to that of the gravid uterus at the fifth month of gestation. In patients of spare habit it might be noticed sooner, hut (piite as often it escapes notice until a much later period. The physical signs wdiich are of most value to the diagnostician in the second stage are enlargement of the abdomen, especially of the lower portion; some irregularity in the form of the abdomen, one side being larger than the other, and the lower being larger proportion- ately than the upper; the tumor is well defined and movable in the cavity of the abdomen, most freely from side to side. It is elastic and fluctuating, the fluctuation extending through the whole tumor if a mono-cyst, while, if a multiple cystic tumor, the fluctuation may he limited to sections of the tumor. The tumor does not change its form to any extent when the position of the patient is changed, neither does the form of the abdomen change. It is attached to the pelyic organs, and if drawn upward will drag the broad ligament with it. The gross and microscopic appearances and chemical com- 494 DISEASES OF WOMEN. position of the fluid obtained by aspiration are also to be regarded. The contents of the cyst are characteristic, to some extent, of the affection, as is also the appearance of the cyst as seen after opening the abdomen. The physical signs are very few, and none of them alone is diagnostic. In fact, each of them may be found in other conditions than cystic ovarian tumors; hence arises the diflicultv of making a diagnosis. The signs and the means of detecting them may now be discussed. By inspection the increased size of the abdomen is detected. In the second stage this is most marked at the lower portion. The increase in size may be uniform, the twTo sides being alike, or one side may be larger than the other, and in some cases there is an irregularity of outline of the tumor, which gives a nodular appear- ance upon inspection, and which is also apparent to the touch. A tumor, large enough to be noticeable in the abdomen, is usually in the center, and, when it is eccentric, it is because of adhesions, as a rule. The irregular outline or nodular appearance is indicative of a multiple or multilocular tumor. By palpation the tumor can usually be distinctly outlined. This is always the case, unless the tumor is very flaccid, and there is much fat in the abdominal walls, or the bowels are distended, but it is rare that these two conditions are found together. By grasping the tumor in both hands, it can be moved from side to side in the abdominal cavity. It can be felt sliding about under the abdominal walls. When there are extensive adhesions, this valuable sign, mobility, is wanting. By inspection the mobility may be detected by causing the patient to take deep inspirations and expirations, which will cause the tumor to move up and down beneath the abdominal walls. This movement will be absent if there are adhesions. The vaginal touch may detect a portion of the tumor in the pel- vis, or may show that the round globular mass rests on the pelvic brim. The uterus can be made out, in a large number of cases, as normal, and not directly connected with the tumor, although it may be displaced. Beyond this, the touch per vaginam only gives valua- ble negative evidence. Palpation also shows that the tumor is clearly outlined and easily distinguished from the neighboring organs in some cases. When the cyst is tense, the tumor can be easily out- lined, but when flaccid, as often occurs, it is not by any means easy to map out its boundaries. Percussion assists in outlining the tumor when it is not clearly defined to the touch. The flatness on percussion over the tumor CYSTIC TUMORS OF THE OVARIES. 495 contrasted with the tympanitic resonance of the intestines, will indi- cate its size and position. The consistence can be determined by palpation, whether solid and very hard, solid and soft, or fluid and fluctuating. Fluctuation, as a sign of encysted fluid, may be obtained in several ways. If the tumor is a monocyst and is large enough to touch the walls of the abdomen on both sides, diametrical fluctuation can be obtained by placing the fingers upon one side, and percussing diametrically op- pusite. The fluctuating wave will be easily found if the contents of the cvst are markedly fluid. If the tumor is divided into several sacs, fluctuation can only be obtained by palpating sections of it. Resting the fingers of one hand at one point on the abdomen, and percussing at another point a little distance from that at which the lingers rest, a surface wave will be produced. In case the fluid is semi-solid, and does not give the clear wave on percussion, fluctua- tion may be produced by placing the fingers of both hands upon the tumor some distance apart; then, by making pressure with the fin- Fms. 196, 197.—Area of dullness in ovarian tumor and in ascites (Barnes). gers of one hand, the contents of the cyst will be pressed under the fingers of the other. This is fluctuation by displacement, not by the wave produced by pressure. The fact that fluctuation is limited and does not extend through- out the -whole abdominal cavity is most valuable evidence that the fluid is encysted. Further evidence of this is also obtained by an- other sign, that is, the tumor does not change its form when the position of the patient is changed. By turning the patient first on 33 496 DISEASES OF WOMEN. one side and then on the other, it will be observed that wdiile the tumor may gravitate to the lower side it does not change its form. In the second stage it can be ascertained that the tumor is at- tached to the broad ligament. This sign is obtained by passing the finger of one hand into the vagina and then pushing up the tumor with the other. By this means the tumor will be observed to drag upon the broad ligament. In regard to the signs obtained by an examination of the con- tents of the cyst, it may be said, that it is not often that this need be resorted to in the second stage, but when it is, the reader should turn to the description of the contents of ovarian cysts for all de- sired information on this point. The physical signs of ovarian and other abdominal tumors obtained by laparotomy are, of course, peculiar to each. The de- scriptions of these appearances may help one to recognize such tumors when seen and felt, but much experience in observation is necessary to tell what a tumor is when one sees it in the abdominal cavity. The ambitious and rash may open the abdomen to make a diagnosis, and be unable to recognize that which they find. AVhile I clearly appreciate the value of laparotomy as a means of diagnosis in obscure cases, I am as fully aware that it should only be under- taken by one possessing comprehensive knowledge gained by exten- sive experience. There are certain other affections and conditions wmich resemble to some extent ovarian tumors in the second stage. The chief of these are pregnancy, normal and pathological, neoplasms of the uterus, such as fibroids and fibro-cysts; distended bladder; fecal impaction; encysted fluid in the peritoneal cavity, e. g., in tubercu- lar peritonitis ; cysts of the kidney, liver, or spleen ; enlargement and displacement of the spleen, kidney, or liver; cancerous disease of any of the abdominal organs, omentum or abdominal glands; and parovarian cysts. Pregnancy, in its normal state, differs greatly from ovarian tu- mors in all respects but the fact that both gravid uterus and the tumor occupy the abdominal cavity, still a number of cases have been reported in which an error in diagnosis was made, and ovari- otomy undertaken when the case was one of pregnancy. In sev- eral of these cases the trocar has been thrust into the uterus, the operator believing that he was tapping an ovarian cyst. At the present time such a mistake can only be made through want of knowledge or want of attention. One might, in trying to make a diagnosis, mistake the pregnant uterus for an ovarian cyst, but upon CYSTIC TUMORS OF THE OVARIES. 497 opening the abdomen one having knowledge enough to warrant him in undertaking ovariotomy ought to be able to tell the one from the other by sight. AVhen there is any doubt, it is far better to wait until the end of the time of gestation. This can always be done. There is no good reason for removing an ovarian cyst until it is as large or larger thau the uterus at full term of gestation in doubtful cases. While I believe in removing ovarian tumors in the second stage of their development when the diagnosis is clear, in case there is room for doubt, wdiether the case is one of ovarian cyst or of preg- nancy, time will decide, and there is no valid argument against wait- ing. The fact is that those who are the least capable of making a diagnosis are the most inclined to operate early, and this I presume accounts for the mistakes recorded. I need not give the differential diagnosis between ovarian tumors and normal pregnancy ; the symptoms and signs of the former have been given, and those of the latter can be found in any text-book on obstetrics, if not already familiar to the reader, and they are so very different that byT contrast the diagnosis can be made. Extra-Uterine Pregnancy.—This usually comes up for diagnosis in connection with the first stage in the growth of ovarian tumors, as has already been stated. It is only the abdominal variety which in any way resembles ovarian tumors in the second stage. The signs of a living child in the abdomen are so perfectly diagnostic that they can hardly be mistaken. In case the child is dead, more difficulty might be experienced in making a diagnosis. The history of the case and ballottement, or the ability to move the dead child in the sac, will usually suffice to settle the question. Rupture of an Ovarian Cyst.—This, and the extensive adhesions which follow, most closely resemble ventral pregnancy after the death of the child, both in history and in physical signs, and I can understand that it might be impossible to discover the exact nature of the trouble without the aid of laparotomy. Fortunately, under these circumstances it would be perfectly right to employ this method of making the diagnosis, because it is part of the appro- priate treatment in either case. In the cases of abdominal pregnancy that I have seen the diag- nosis was very easy; so much so that no one with any experience could have made the mistake of suspecting ovarian tumor. Uterine Fibroids and Fibro-Cysts, when large, present some of the evidences of ovarian tumors. The position of the tumor in the 498 DISEASES OF WOMEN. abdomen, and its shape and mobility, are the same as those of some ovarian tumors, and these are the only resemblances. In fibroids, the uterus is enlarged as shown by the touch and sound. The tumor is solid and is intimately connected with the uterus, in fact forms a part of it. In the majority of cases the cav- ity of the uterus can be probed, and will be found enlarged in case the tumor is uterine, while it will not be if the tumor is ovarian. Distended Bladder has been mistaken for a cyst of the ovary, but only at a first examination or by one not used to such cases. AVhen the bladder is overdistended there is incontinence, usually the urine coming away constantly, or in spurts when the patient moves. This leads the medical attendant to suppose that the blad- der must be empty and that the tumor is an ovarian cyst, but the catheter readily settles the question, and it should always be used in cases with such histories. Fecal Impaction has always been mentioned as one of the condi- tions which might be mistaken for an ovarian tumor, but I have not considered such a thing possible. The irregular form and solid character of the fecal mass differs in every respect from ovarian tumors of all the benign variety. Encysted Dropsy of the Peritonaeum.—This is an extremely rare affection and occurs in the progress of tubercular disease as a rule, and follows an attack of peritonitis. The physical signs differ, in that the fluctuation is not so general as in ovarian cyst, and the fixa- tion is complete. The surface of the abdomen is not so prominent as in case of a cyst, but often has irregular depressions, as well as elevations, and the veins are not prominent. The general health is greatly reduced early in the progress of the disease ; nutrition is markedly impaired, and there is often sep- ticaemia in case that there is pus encysted. The vaginal examination is often quite sufficient to settle the diagnosis, by showing that the pelvic organs are normal and can be outlined and separated from the mass in the abdomen. When this can be accomplished, ovarian disease is at once excluded. Enlargement and Cysts of the Liver, Spleen, and Kidneys.—In all of these the diagnosis, so far as the exclusion of ovarian disease, can be easily made if the cases are seen early, or a correct history can be obtained. It is found that in them all the enlargement begins above and on one side, and, as a rule, is fixed there from the begin- ning, and the pelvic organs can be separated from the tumor above, and proved to have no connection with the morbid growth, and to be normal. These two diagnostic facts will suffice in most cases to CYSTIC TUMORS OF THE OVARIES. 499 settle the question, but additional evidence can be obtained from the general history of the growth and its effects upon the general health, also the composition of the fluid in cysts, which should be obtained by aspiration in doubtful cases. In regard to the differential diagnosis in cancer of the pelvic and abdominal organs, this will be discussed in connection with these affections, and hence is omitted here. Parovarian Cysts, or serous cysts of the broad ligament, as they are called, are not \ery easily recognized at all times. Fortunately it would be no veryr great mistake to remove one of these cysts suppos- ing that it was an ovarian cyst. They are very rare as compared with ovarian cysts, they grow slowly, and occur mostly in young per- sons. The general health does not suffer, as a rule. The physical signs differ in no way from those of the ovarian monocyst, except that the fluctuation is more distinct and the fluid differs, being clear like water and without albumen. Tapping, or rather exploratory aspira- tion, is the means to be employed to settle the diagnosis, and should be practiced when there is a doubt. Affectons which resemble Ovarian Neoplasms in the Third Stage. —There are only a few affections which resemble ovarian cysts in the third stage. These are ascites, uterine fibro-cysts, and very large uterine fibromata. The first mentioned, ascites, is the most likely to be mistaken for ovarian cyst. The chief points of difference in history are, that as- cites is, as a rule, preceded by some acute disease or general ill- health, suggestive of some chronic disease of the liver, heart, or kid- neys. There is anasarca also in most cases of ascites, and the pa- tient is generally ansemic early in the progress of the disease. The enlargement of the abdomen comes on rather suddenly, and is not confined to its lower part; that is, it is not circumscribed. The ex- pression of the face, while showing anaemia in ascites, is not anxious, as it usually is in ovarian cyst. The history of ovarian cyst in growth and general constitutional symptoms is almost the reverse of ascites. The physical signs of ascites differ from ovarian cyst, chiefly in that the fluid in ascites changes its position with every change in the position of the patient. When the patient is placed upon the back, the abdomen is symmetrical and flat; in the erect position, the lower portion bulges from the gravitation of the fluid, and the same change in the position of the fluid occurs when the patient is turned toward either side. AVith these changes in the position of the fluid, there is a change in the resonance on percussion. The flatness is 500 DISEASES OF WOMEN. found at the most dependent part, while the resonance is found at the upper. In large cysts there is dullness or flatness on percussion at all points except the flanks, where there is always resonance, except when the colon is distended with gas and fixed deep in the side, so that the fluid of ascites can not gravitate below it; and in ovarian cyst there may be dullness on percussion in the side due to fecal im- paction of the colon. There is another exception to the rule that in ascites there is always resonance at the highest point of the abdomen whatever the position of the patient may be, and that is when the disturbance of the abdomen is extreme, and the mesentery is not long enough to permit the intestines to rise to the top of the fluid while the pa- tient is upon the back. There is also a difference in the fluids, which gives some help in the diagnosis in case aspiration is practicable, as it may be in doubtful cases. Uterine Fibro Cysts or Fibromata seldom attain sufficient size to resemble ovarian cysts, but occasionally they do so. The fibro-cysts of the uterus more closely simulate the ovarian cystic tumors than the fibromata. The difference in the history and the fact that the uterus is involved in the tumor in fibro-cyst and free in the other form, are the chief points of difference. This subject was discussed in treating of the diagnosis in the second stage of ovarian tumors, and need not be repeated in full in this connection. Intraligamentous Ovarian Cystomata.—I deem this variety of ovarian tumor of sufficient importance to merit a separate consid- eration. The difference between intraligamentous and the ordinary forms of ovarian cystomata is simply in the position they occupy in rela- tion to the ligaments. The location may be called an unnatural one. because it differs from that which ovarian cystomata usually occupy. The intraligamentous ovarian cystomata are comparatively quite rare. This suggests that the causes operative in determining their location are exceptional. Two theories have been advanced to ex- plain the topographical anatomy of intraligamentous cystomata. The one assumes that, owing to some error of development, the ovary. during embryonic life, finds its way into the folds of the broad ligament and there remains. In that case, if a cystoma of the abnor- mally located ovary occurs it is certain to split up the ligament and convert it into a capsule for itself. The second theory "is, that during the growth of the cystoma it burrows, so to speak, into the folds of the ligament, and once having CYSTIC TUMORS OF THE OVARIES. 501 insinuated itself there pushes the folds apart, and these folds grow with the cystoma and form a ligamentous capsule for it. In order that this may come about, the ovary must be closely attached to the ligament, in place of being held by a special fold of peritonaeum, which leaves it to some extent free from the ligament proper. Or the ovary,may be bound down to the ligament by an inflammatory adhesion. AVhere a cyst develops deep in the ovary and meets re- sistance on the free peritoneal surface, it pushes its way in between the folds of the ligament. There is good evidence in favor of this theory in the fact that these cystomata come from the paroophoron, which is the portion of the ovary that is nearest to the uterine ligament. Furthermore, I have in one of my own cases found the o\ary from which the cystomata came imbedded in the posterior fold of the ligament. It would be more correct, perhaps, to say that the ovary was stretched out upon the posterior fold of the ligament. It was so changed in form that I should have overlooked it had it not been that there were several small cysts in it surrounded by what appeared to be ovarian stroma. In another case I found, while enucleating the cyst, that it was \ery firmly adherent at a point in the posterior fold of the liga- ment where the ovary should be found. The vessels were larger at that point than anywhere else, which led me to think that the ovary was there; but the tissues were so changed by inflammatory products that I could not positively detect any ovarian tissue. This, I think, is sufficient to settle this point in the pathology and causation of some of these cystomata, and presumably the larger portion, if not all, of them. Still, it may be admitted that malposition of the ovary, be- cause of a lesion of development, may obtain in some cases. Pathology.—These cystomata may be single or multiple. I think, however, they are more often single. All of my own cases, eight in number, have been monocysts. Another interesting feature is that they are generally papillary or proliferous cysts. This, ac- cording to some authorities, notably Bland Sutton, of London, is due to the fact that they are developed from the deeper structures of the '•vary, the paroophoron, as already noted. The position of these cystomata and their relations to the pelvic organs have a very important bearing upon the question of treat- ment, as will be seen further on. In my own practice, I have found them occupying widely differ- ing positions in relation to the ligaments and pelvic organs. In *ome, the tumor was situated in one ligament, displacing the uterus to the opposite side of the pelvis, and, in a lesser degree, the bladder 502 DISEASES OF WOMEN. also. In others, the tumor occupied a position in both ligaments and between the uterus and bladder. AVhen thus located the tumor, uterus, bladder, and ligaments have been found high up out of the pelvis, so that the most dependent portion of the tumor could not be easily reached through the vagina. Again, I have found the tumor behind both the uterus and bladder, and yet between the folds of both ligaments. In all these the pelvic organs were carried up into the abdominal cavity, while the tumor descended deeply into the pelvis. It appears that there is a rule which deter- mines the location of those tumors which occupy both ligaments, in regard to their relations to the pelvic and abdominal cavities. This rule may be formulated as follows: AVhen the tumor is between the uterus and bladder, all three structures rise up into the abdomen; whereas, if both of these organs are in front of the tumor, it dips well down into the pelvis. The reason is, that in the one case the vagina arrests the process of burrowing downward, while in the other there is no resistance to the descent of the cystoma. In all cases the broad ligaments become greatly enlarged and thickened, usually covering the whole cyst, although they are thinned out at the upper portion. AVhen the cyst does not descend into the pelvis and has attained considerable size, the upper portion of the cyst may present a wall of medium thickness; in fact, the liga- ments diminish in thickness and vascularity until there is little left but the peritonaeum; and the upper part of the cyst then appears more like an ordinary intraperitoneal ovarian cystoma. These facts are of the utmost importance in regard to treatment. and hence the reason for this brief account of the various positions in which these intraligamentous cystomata may occur. Symptomatology.—These tumors cause more pain and functional derangement of the pelvic organs than the ordinary ovarian cysto- mata, but in other respects the history is the same. Physical Signs.—The diagnosis of such cases is of interest chiefly because of the difficulties encountered in operating and the urgent necessity of clearly comprehending the exact conditions present, in order to manage them to the best advantage. I have found it im- possible to make a complete and comprehensive diagnosis in all cases. It is generally possible to make out that there was a cystoma in the broad ligament, but with no definite certainty as to 'its posi- tion and topographical anatomy. Judging from the literature of the subject, it appears that others have suffered from a like uncer- tainty in some cases. AArhen a cystic tumor exists in the abdomen and is firmly fixed below, with no history of inflammation during the CYSTIC TUMORS OF THE OVARIES. 503 earlier stages of the growth of the tumor, and the uterus is drawn up out of the pelvis and lies behind or in front of the cystoma, I Mispect that it is intraligamentous. If the uterus is displaced later- ally in a marked degree by the cystoma that is present, or if the cyst descends deep down into the pelvis while the uterus is high up and in front of the cyst, the facts point to the same conclusion. When a portion of the tumor found in the pelvis is cystic, this is a great aid ; but, as a rule, these tumors, as already stated, are prolifer- ous, and there is so much solid material in the most dependent part that fluctuation is not found, and the tumor appears to be solid to the touch and may be mistaken for a fibroma or fibroevst of the uterus. One case was seen by two well-known ovariotomists, and both sus- pected fibroma of the uterus as well as ovarian cystoma. My first impressions were the same, but upon opening the abdomen I found the uterus normal, but displaced upward by an intraligamentous ovarian cystoma. Cases may be divided into two classes—those in which a com- plete diagnosis can be made, and those in which the diagnosis is incomplete. In the one, the nature and composition of the tumor, its relations to the abdominal and pelvic organs, and the extent and location of its attachments, can be clearly determined; in the other, which is incomplete, there may be sufficient evidence to warrant either operative treatment or a full assurance that the case is not amenable to surgical treatment. The first or complete diagnosis can be made from the usual physical signs and the history. The incom- plete diagnosis may be made complete by surgical means, such as aspirating or by laparatomy. It is of the utmost importance to dif- ferentiate between these two classes of cases. AVhen only a partial diagnosis can be made, leaving doubts as to a possible malignant ele- ment existing in the case, the question of the propriety of ovariotomy may be determined by an examination of the intraperitoneal fluid, which is often present. If this proves negative, the operation is advisable; while, if the cells characteristic of malignant disease are found, the case should be left alone. Keeping still to the question of diagnosis, I may say that in cases of intraligamentous cystomata one can usually make sure that an operation is called for and is jus- tifiable, but the diagnosis must often remain incomplete until the abdomen is opened. At the same time it is not an easy task to com- plete the diagnosis after laparotomy. A few words on this subject may be admissible, in view of the importance of the matter. AVe hear much of making an exploratory operation for diagnostic pur- poses, but I am satisfied that skill and experience are very necessary 5(»4 DISEASES OF WOMEN. to do this. To recognize just what is present, and to determine what to do in these cases when the tumor is exposed, is no easy task; and still, upon a rapid inspection and palpation, and prompt decision regarding the exact conditions and how to manage them, depends the success of the surgeon in complicated cases. I may not have seen or carefully thought of all the conditions which simulate, and hence may be mistaken for, intraligamentous cystomata, but such observations as I have made cover the most important part of the ground. AVhen the tumor is exposed by laparotomy its intraligamentous character can be determined by incising the peritonaeum, which will retract and expose the cyst-wall. In all other tumors the perito- naeum is so closely adherent that no retraction occurs. The appear- ance resembles most closely a uterine fibroma, and owing to the thickness of its walls it feels to the touch like a fibroma, especially if the cyst has very tense walls, as usually is the case; but by rest- ing one finger on the tumor and percussing the abdominal wall at a distant point, fluctuation can be unmistakably made out. This excludes fibroma at once, but still leaves the possibility of the tumor being a uterine fibrocyst, and, although this is not important as bear- ing upon the main question of removal of the tumor, it affects the method of procedure and should be correctly decided at once. This can be done by tapping, which shows the character of the fluid, which is all-sufficient, with few exceptions. If pus is found, it may be impossible to say whether the cyst is uterine or ovarian. The tapping, however, gives more room for the introduction of the hand, which enables the operator to make out the attachments and the relation of the tumor to the pelvic organs, and thereby complete the differentiation. The pregnant uterus also looks, in color and vascularity, like this form of tumor, and may lead to doubt. At least I think that when this mistake has been made, an intraligamentous tumor must have been suspected, because it is the only ovarian cystoma that appears at all like the uterus. This can be made clear by observing con- tractions of the uterus, which can be easily excited, and by passing the hand into the abdomen the ovaries can be found, and the condi- tion of the cervix uteri and normal ligaments will show that there is pregnancy. Treatment.—These tumors require special treatment, owing to the fact that they are not pedunculated like the ordinary cystomata, but are encapsulated, and differ in their relations to the pelvic organs. CYSTIC TUMORS OF THE OVARIES. 5»)5 The several methods adopted in operating are as follows: Enu- cleation ranks first, because it is adapted to more cases, perhaps, than anv other. This well-known method, devised and introduced by Dr. Miner, of Buffalo, has been practiced by many ovariotomists. It was employed in the treatment of ordinary pedunculated cystoma when fir.-t brought out, and is now seldom practiced except in par- ovarian cysts. In fact, I do not think that Dr. Miner ever employed his method in the treatment of the class of cases now under con- sideration ; but if he did, he omitted a description of some of the details which are necessary. Enucleation is adapted to all cases in which the cystoma descends into the pelvis, completely separating mie or both ligaments. In all such cases it should be tried, and it will succeed well unless there has been inflammatory action which lias firmly united the cyst-wall and folds of the ligaments, or the pyst-wall is thin and friable. In such conditions the enucleation may prove to be impossible, and other means of treatment, to be hereafter noted, must be adopt- ed. In the first place, it is important to tap the cyst high up, in order to avoid wounding the thickest portion of the broad ligament. To do this it is sometimes necessary to extend the incision in the wall of the abdomen higher than usual. The cyst being emptied and drawn well out of the wound, the separation of the ligament and cyst-wall should be begun at that point high up where the liga- ment is so thinned out as to be hardly noticeable. AVhen the dis- section is begun all around, the capsule can be lifted up and the dissection continued with the knife-handle, and finally the deeper portions can be separated with the finger. The traction should be made upon the cyst-wall, as the capsule or ligaments is easily lacer- ated. During enucleation, if any large vessel, artery, or vein is in- jured, it should be ligated or controlled with forceps at once. The management of the ligaments, after the cystoma is removed, is first directed to the control of haemorrhage. In some cases a general oozing is all that there is. Occasionally a wounded vessel here and there needs ligating. AVhen the cyst extends deep* down into the pelvis, there is often very troublesome bleeding from veins. These should be ligated, if possible; but if that can not be done, pressure with a hot sponge should be tried, and, if that fail, styptics may be used. The ligamentous capsule now presents a pouch, the inner surface of which is raw, and from which there will be some bleed- ing and much serous oozing. This should be treated as follows: The upper portion of the opposing sides should be folded in so as to bring the peritoneal surfaces together, and these should be fixed 506 DISEASES OF WOMEN. by a continuous catgut suture. The suturing should begin nri both sides, and be from the sides toward the center, and close the parts, except at a point beneath the abdominal wound, where an open space should be left for the drainage-tube. If the ligaments thus approximated by sutures can be brought up to the lower angle of the abdominal wound, they should be fixed to the abdomi- nal wall by silk sutures passed through the ligaments on each side of the opening for the drainage-tube, and then through the wall df the abdomen. AVhen the ligaments can not be brought up to the wall of the abdomen, a drainage-tube without side-openings, should be carried down to the bottom of the cavity. AVhile this mode of treatment is perfectly satisfactory in suitable cases, there are difficulties attending the operation in exceptional cases, and hence certain dangers The cyst-wall may be easily torn, and there is liability of leaving portions of it. AVhen this happens. it is necessary to destroy the secreting surface. This may possibly be done by applying pure carbolic acid. The most difficult part of the operation is, in some cases, to stop the bleeding. This has been referred to; but I may say further, that the oozing at the time of operating, and the liability to suppuration which may occur after- ward, render the convalescence rather tedious in many cases. The next procedure is to remove the cystoma, and its capsule also, by ligating the ligament below the tumor. This method is adapted to those cases in which the cyst is situated in one broad liga- ment and does not dip down very far into the pelvis. Such cases are described in books as having a very broad pedicle, but the most that can be correctly said of them is that they are partially pedun- culated. In this condition the ligament can be ligated with the repeated continuous ligature. This is applied in the following man- ner : One end of the ligature is passed through the ligament and a portion of it tied, then the other end of it is passed through the portion which is already ligated, carried forward, and brought back through the ligament in such a way as to secure another portion, and the two ends again tied, and so on until the whole is secured. The cyst and its capsule are then cut off. This leaves no cavity, arrests all possible haemorrhage, and in this respect is all that can he desired. But there are difficulties and dangers that may arise, even in cases where the method is applicable. There is danger of wounding the ureter or including it in the ligature. A knowledge of the loca- tion of the ureter and its anatomical relations is not always sufficient to guard against this accident, because the ureter may be displaced. By drawing the cyst and ligament out of the abdominal wound, it CYSTIC TUMORS OF THE OVARIES. 507 may be possible to see that the ureter is not in the way; but this can not always be done, and then one has to depend upon the touch to localize the ureter and avoid it. This is possible, owing to the fact that the ureter feels like a cord crossing the ligament; but in case the tissues are thickened by inflammatory products it is difficult indeed to find the ureter. There is still another way of managing these cases, and that is by a combination of the two methods already described. It is well adapted to cases that can be enucleated easily, and has the advantage of surely avoiding the ureter. The cyst is first enucleated, and the capsule, or so-called pedicle, is tied and cut off. The advantages arc, that it is easier to handle the capsule after the cyst is removed, and there is no danger of including any portion of the cyst in the ligature—an accident that may occur in operating by the second method alone. There is one fortunate feature in this method of treatment, viz., in case enucleation can not be effected, ligation alone can be resorted to. It is well, then, to try enucleation, even if it has to be abandoned. There still remain for consideration tumors that can not be re- moved by any of the methods known at the present time, and there are such. A cystoma that descends into the pelvis and has become firmly adherent to the ligaments by inflammatory products, can not be enucleated, neither can the capsule be ligated. At least enucle- ation can not be done with any degree of safety. That complete removal of such tumors has been tried, is no doubt true, but the result has been to open into the rectum, and cause uncontrollable bleeding or peritonitis, either of which must prove fatal. These complications are always present in suppurating intraligamentous cystomata, and hence when pus is found on tapping, it may be in- ferred that enucleation is impossible. I have found, however, that a non-suppurative cellulitis has so firmly united the cyst-wall to the ligamentous capsule that they could not be separated. The treat- ment of such cases is by drainage. I am well aware that the more skillful the operator, the more surely will he overcome difficulties, and the more frequently will he have complete operations; but when the conditions which have been named are present, I am confident that it is wiser and better to empty the cystoma and unite the cyst- wall to the abdominal wall, and then drain by means of the ordinary tube. The cyst fluid is usually septic (this is always so in suppu- rating cvsts\ and it is very difficult indeed to save the peritonaeum and abdominal wounds from contamination. After emptying the cyst and opening it, it should be thoroughly cleaned out with sponges 50S DISEASES OF WOMEN'. or absorbent cotton, and papillary tissue, if present, may be scraped off. This should be done with the cyst drawn well out of the wound. If the cystoma is large, an effort should be made to separate the cvst- wall from the capsule as far down as possible. If that can be dune, the detached portion of the sac is then cut off, leaving it of suffi- cient length so that the central portion will come up to the abdominal wall without dragging. Bleeding vessels in the cyst-wall are ligated or twisted. The detached portions of the capsule are folded into the cyst and united with a continuous suture, beginning on each side and continuing toward the center, but leaving space enough between their meeting to admit the drainage-tube. In this, great care has to be taken to keep the hands and instruments, which have touched the inside of the cyst, from coming in contact with the peritonaeum or abdominal wound. Again, in fastening the partially closed cyst to the abdominal wall, it is necessary to pass the needle from the abdominal wall into the cyst, and not use that needle again unless it is thoroughly cleansed. If, on the contrary, the sutures are passed from the inside of the cyst outward, septic material will surely l>e carried into the tissues of the abdominal wall, and trouble will fol- low. One suture on each side of the opening in the cyst for the drainage-tube will suffice to unite the wall of the cyst and the ab- dominal wall at these points; and one suture above, and one below, carried through the sides of the abdominal wall, and into the cyst- wall, but not through, will complete the coaptation. If this much is accomplished without contaminating the normal tissues, there is very little danger of septic peritonitis occurring, or septic inflamma- tion of the abdominal walls. The drainage is so perfect that, though suppuration in the remaining portion of the cyst may go on, there is not much danger from it if it does not extend outside the sac. The drainage must be long continued, and the convalescence is very slow, comparatively. In case the secreting surface of the cyst has been thoroughly destroyed by suppuration, the recovery is usually not long delayed. Contraction and closure of the cavity come in a month or thereabout. If, on the other hand, the secreting surface is left, the discharge may go on for months; but the patient, mean- time, may completely regain her health and be able to attend to her duties comfortably. AVhen a small pocket and sinus remain, it facilitates recovery to inject iodine or carbolic acid. I may be preju- diced in favor of this mode of treating such cases from the fact that I have had two intraligamentous cystomata and four adherent ordi- nary ovarian cystomata which were treated by drainage, and all recovered. CHAPTER XXArIII. OVARIOTOMY. The operation of removing ovarian tumors has been generally known as ovariotomy. Every one understands the meaning of the term, established by usage, as indicating the removal of the ovaries when the subjects of morbid growths. Since Dr. Battey introduced the procedure of removing the normal ovaries the term oophorectomy has been used more frequently, and there appears to be a disposition among some to use the term ovariotomy when speaking of the re- moval of ovarian tumors, and oophorectomy when referring to the removal of the ovaries when not enlarged. This use of two terms which mean exactly the same thing is confusing in any case, but much more so when an attempt is made to make the terms indicate different operations. I shall use the term ovariotomy in all cases when treating of the removal of the ovaries, no matter what their condition may be. Ovariotomy has in the past been the term used for the operation which includes the removal of the Fallopian tubes with the ovaries. In nearly all the ovarian tumors the Fallopian tube is so united to the neoplasm that removal of the one necessitates the removal of the other. The operation first practiced by Tait and Hegar of removing the tubes when diseased along with the ovaries, is now quite generally spoken of as removal of the uterine appendages. This is a very un- satisfactory way of expressing the fact. It is absurd to speak of the ovaries and tubes as appendages of the uterus. One might as well speak of hysterectomy as the removal of the ovarian appendage. In the evolution of development the uterus is added to the ovaries and tubes in the higher animals, and ovaries, tubes, and uterus have independent structures and functions; hence, neither one is an ap- pendage to the other. To designate the operation of removing the ovaries and Fallopian tubes, I shall use the term tubo ovariotomy. 510 DISEASES OF WOMEN. GENERAL CONSIDERATIONS OF OVARIOTOMY. Before taking up the details of the operation, I shall call atten- tion to certain general facts which belong to all surgical procedures. and have a special bearing on ovariotomy. AVhile most that will be said pertains to the removal of ovarian tumors, it will be equally applicable to the removal of the small-sized diseased ovaries or nor- mal ovaries and tubes, the more modern operation. I have long entertained the opinion that ovariotomy is the most difficult operation in the whole field of surgery. This is, however, a matter of opinion, and may be an error on my part, but it is posi- tively certain that a thorough knowledge of surgery and all attain- able dexterity and skill in operating can be employed with advan- tage in removing ovarian tumors. This operation differs from all others that I know of, in the number and variety of complications which it affords. It is seldom that two cases exactly alike occur in the practice of any surgeon, hence it is not until a very large num- ber of cases have been seen that the operator is prepared to meet all the conditions which may come before him. To the operator of limited practice, the operation in this respect often presents the characteristics of a new investigation. To this extent, then, the operation is unlike anything else in surgery. Most all other operations are, to a great extent, definite; the anatomy being the same and the modus operandi fixed according to well-defined rules. The surgeon has it in his power to learn such operations by practice upon the cadaver, until he may be almost master of his work (if he has in him the surgical diathesis) before touching the living subject. No such opportunity is offered to acquire the art of doing ovariot- omy. The division of the abdominal walls, the first and simplest step in the operation, may be studied and practiced upon the cada- ver, but here ends the value of dissection as a special aid to the ova- riotomist. Books and lectures, then, are the most available sources of in- formation, but this reading and listening to others talking, although a means of acquiring a knowledge of science, is a poor way of learn- ing how to perform an operation. It is true that one may familiarize himself with all the steps of an operation and the complications which may be found in each case, and he may be able to recall them at will, and think of them clearly before and after an operation, but to recognize the indications and promptly meet them while operating, can only be learned by prac- tical observation. OVARIOTOMY. oil The first essential, then, is to know how to operate—a self-evident proposition this, which need not be made here were it not for the fact that many try to perform ovariotomy who are not qualified to do so. It is a notorious fact that this most important of operations has been performed by many who had no claim to being called sur- geons. Obstetricians who, having turned their attention to some of the plastic operations of gynecology and succeeded, have next taken to ovariotomy. A few, bolder still, have made their debut in sur- gery as ovariotomists, without any previous surgical experience. Why men should be found who will undertake this operation while they would shrink from iridectomy or lithotomy, is a difficult ques- tion to answer. Perhaps the difficulties in the way of learning to do this operation may account for it. It is clearly evident that one should be well grounded in the science and art of surgery before taking up ovariotomy. The consummate surgeon can readily transfer his art to this department of abdominal surgery with far more hope of success than one who seeks to acquire skill by practicing ovariotomy as his maiden effort. The best and surest way of all to qualify for this operation is to secure facility in general surgery, and then to take lessons of some successful operator ; to witness, and if possible to assist in, a sufficient number of operations so as to see the different kinds of cases and the various complications. By such means the surgeon can secure one great element of success, a knowdedge of manipulations. Next to knowing how to operate is how to obtain competent assistants. An operator of large experience may be able to do the operation with assistants who know little, if anything, of the operation, his famil- iarity with the work being such that he can give much of his atten- tion to those who are helping him, and so command success. It is quite different with one of more limited experience. His whole time and attention are taken up with that which he is doing himself, and if his assistants are unacquainted with their duties, they gener- ally hinder rather than help. It is a sad sight to see a beginner, with untrained assistants, trying to do ovariotomy. The ease with which such assistants make simple things complicated and lose time in hurrying is quite extraordinary^. I know this from having played the role of operator and also assistant when I did not know either of the parts. Skill in diagnosis is a means of success of prime importance, and for many reasons should have been disposed of first; but I put the operation first in my argument simply because I believe that more failures come from poor operating than from errors in diagnosis. u 512 DISEASES OF WOMEN, The text-books give all the rules and means of diagnosis so fully that no one needs more theoretical instruction—but here again much practice is needed. Diseases of the ovaries present such variety of physical signs that a very large experience is required to see all the different kinds of cases. Ovarian tumors differ so in their form, composition, and complications in the way of adhesions, that their real nature is difficult to make out. Again, there are many abdom- inal tumors and products of disease which simulate in their physical signs ovarian tumors so closely, that experts of long practice are at times unable to make a correct diagnosis. Still, great accuracy can be attained in diagnosis by long and careful observation. In many affections we can successfully adapt our treatment to the deranged conditions manifested, although the exact nature of the pathology may be unknown ; but in ovarian tumors we must have rather definite ideas of their character before we can begin their surgical treatment. Ovariotomy, as an operation, differs so much with the different operators, both as regards the methods of procedure and results ob- tained, that I propose to notice some of the conditions upon which the success apparently depends. Dexterity on the part of the operator and all available means which save time and secure accuracy are obvious necessities, and need not be urged in this connection. In an operation of such magnitude the question of anaesthetics requires a passing notice. Sulphuric ether has still the best reputation. Its administration should be prompt and carefully kept up. The less ether that the patient takes the less the danger and the better the condition of the patient afterward. Fifteen or twenty minutes wasted in anaesthetiz- ing give just so much unnecessary blood-poisoning, and this to some extent retards recovery. Giving nitrous-oxide gas first, and following it up with ether, is the most rapid way of anaesthetizing. I have seen this method employed by others with great satisfaction. I use ether altogether, and administer it with the apparatus already described. I believe that the great majority of ovariotomists use this anaesthetic, and I am perfectly satisfied with it when it is given in the wray that I have mentioned There are a number of points of importance which might be discussed in this connection in regard to the different methods which surgeons employ in performing certain steps of the opera- tion. AVhen describing the operation I shall give the methods which in my judgment are the best, but a general discussion of some of these matters appears to be necessary in order to show reasons for my preferences. OVARIOTOMY. 513 In the management of the pedicle, for example, we find that even the renowned operators do not all agree. Through the influ- ence of the most successful of all operators, I am firmly convinced that the cautery gives the best results, and I am also satisfied that it is because the method of using it is not fully understood that it is not more generally employed. The object is to desiccate at least half an inch of the end of the stump and to avoid charring it. This can only be accomplished by strongly compressing the pedicle, using a heavy clamp, with blades half an inch thick, and then heating it Fig. 198.—Cautery clamp. with a very heavy cautery until the portion in the grasp of the in- strument is thoroughly desiccated. The stump thus treated looks like a piece of translucent horn. The divided ends of the vessels are completely closed, which guards against haemorrhage. I pre- sume that the end of the stump does not slough, but becomes hydrated, and finally organized. The advantages of the cautery may be briefly summarized as follows: It is a reliable way of controlling haemorrhage; it leaves the stump in a condition requiring the least reparatory care; and, finally, it avoids all sources of irritation such as that to which the ligature gives rise. I have recently employed a cautery clamp which, I think, has some merits worthy of notice. It compresses the pedicle on four sides. The long blades keep the tissues from spreading, while the short sliding blade presses the tissues against the other cross-bar. The advantage of this is that the pressure upon the pedicle is equal at all points, and it thereby gives a smaller stump. The trouble with the old straight clamp is, that it spreads out the pedicle too much, and while it firmly holds the central or thickest part, the outer edges are liable to slip out of its grasp. 514 DISEASES OF WOMEN. The next, and perhaps the most important, essential of success is cleanliness, or, to put it technically, the antiseptic method of operat- ing. Surgeons were beginning to feel a certain sense of security in performing ovariotomy when they carried out all the details of the Listerian method; but more recently they have found that carbolic acid in place of saving patients, sometimes sacrifices them. AVhen the danger of carbolic-acid spray in ovariotomy was first announced many surgeons thought that Thomas Keith had given up antiseptic surgery; but that great surgeon is still as earnest and enthusiastic in his war against dirt as he ever was. Although he has given up the use of the spray, because he found that the good that it did was counterbalanced by its injurious effects, he still retains all the other known elements of antiseptic surgery. These elements I under- stand to be, first, to keep wounds free from extrinsic germs, which are in themselves injurious to living tissues, or which favor morbid action in the tissues ; and, on the other hand, to provide for the es- cape of morbid material which may be developed in wounds. To prevent the entrance of septic germs perfect cleanliness of every- thing which pertains to the operation is necessary. The carbolic- acid spray can at most only disinfect the air in the operating-room, and consequently it is only one fraction of the antiseptic method of operating. Clean operators and assistants, clean instruments, sponges and everything which may directly or indirectly come in contact with the patient before, during, and after the operation, are all of the highest importance. Still more, it is absolutely necessary to keep all things clean during the operation. A clean, fair start may be made ; but during the operation the operator's hands and the instru- ments may become contaminated by contact with the contents of the cyst, and the patient be exposed to septicaemia. This has often occurred when the spray has been thoroughly and faithfully used. Indeed, if too much dependence is placed upon the spray, there is great danger of contamination from want of care in other respects. Some of the fluid contents of the cyst may enter the abdominal cav- ity, or the hands of the operator or his assistants may become soiled from the same source, and mischief may be wrought in that way. In short, it is exceedingly difficult to guard against all sources of un- cleanliness in this complicated operation. I think, then, that if all the other essential elements of antiseptic surgery are carefully ob- served, the spray may be left out and still the highest success can be attained. But spray or no spray, too much can not be said in favor of antisepsis in relation to ovariotomy. There is still another fact which stands out prominently, and OVARIOTOMY. 515 upon which success depends, and that is the management of the dead material which may be unavoidably left in the abdominal cavity, or that may accumulate there after the operation. Blood or bloody serum or the contents of the cyst that may be left or may accumu- late in the peritoneal cavity is dangerous, and should be removed by drainage. It is true that within the last year or twro there has been some difference of opinion regarding the value of drainage. Some of the great men in London have laid it aside as a rule, while Keith still employs it and insists that he saves many of his patients by it. I believe that I can see that those who employ drainage have the best of it. I incline to this view because Keith, who practices drain- age when necessary, has had the highest number of successes ; and because the reasoning against drainage by those who have given it up does not appear to fully harmonize with the facts in the case. it is claimed that if ovariotomy is performed with all the attendant means of antiseptic surgery, including the spray, any fluid which may be left or that may accumulate in the peritoneal cavity is harm- less. Spencer AVells states that fluids do not accumulate after the use of antiseptics, or if they do collect they do not putrefy, but are absorbed without injury. Now it is difficult to understand how antiseptics used in the operation could prevent the accumulation of serum in cases where there were many and extensive adhesions, and, on the other hand, it is equally incomprehensible that carbolic acid in sufficient quantity should remain in the abdominal cavity to disinfect the fluids which transude from broken surfaces. AVithout daring to decide the matter or to express any positive opinions, I may state that the truth appears to me to be this : Antiseptic operating will lessen the danger to a very great degree, but there will always be cases which call for drainage. The value of drainage depends largely upon the mode of using it. The method which I have usually seen practiced in this country is to pass a tube through the lower angle of the wound down into the sac of Douglas, and then to close its outer end with a cork. This cork is removed several times a day, and the fluid pumped out. This gives a kind of intermittent drainage which is very imperfect. The method which I obtained from Dr. Keith is much better. In place of closing the end of the tube he passes it through the center of a piece of rubber cloth, and then places a carbolized sponge upon the end of the tube. The rubber cloth is folded over the sponge, and tied securely with a string. The tube and the sponge are thus 516 DISEASES OF WOMEN1. excluded from the air, and any fluid which accumulates wells up through the tube, and is taken up by the sponge. The sponge is changed several times a day, and any residual fluid which may re- main is pumped out at each dressing. In this way continuous drain- age is kept up, and still a perfectly antiseptic dressing is maintained. This may appear to be a simple matter, but it constitutes the differ- ence between perfect and imperfect drainage. In a case operated upon last summer, I obtained twelve ounces of fluid in thirty-six hours by this method of drainage, and the temperature of the pa- tient never rose above normal, excepting one day when it reached one hundred, and remained there for a few hours. This case alone would be sufficient to demonstrate both the safety and value of drainage. In addition to the requisite skill in diagnosticating ovarian tu- mors, it is highly essential to success to make a correct estimate of the patient's general condition before operating. Preparatory Treatment for Laparotomy.—One meets not infre- quently with urgent cases which must be taken as they are and operated upon at once. The majority of cases, however, can be kept under observation long enough to obtain a clear idea of their characteristics. AVhen the diagnosis of the local condition is made, the general state of the patient should be carefully examined into. The advantage accruing from acting on this principle was recently impressed upon my mind in a case of a large fibro-cystoma of the uterus wThich required removal AVhile under preparatory treat- ment the patient's temperature rose to 103-|o F., and there wras much pain in the abdomen. Septic peritonitis was suspected, but the temperature came down and again went up, showing that the trouble was a zymotic one, and it yielded promptly to the use of quinine. Had I operated without knowing that the patient was disposed to this form of fever, I doubt if she would have recovered as promptly as she did. The Xervous System.—The state or condition of the nervous system should be investigated, and, if found defective, should be cor- rected as far as possible. Many patients leave home to be under the care of the special surgeon, and this, together with the dread of the treatment, often deranges the nervous system. All this can be over- come, usually, while other preparatory treatment is instituted. Time should be given for the patient to become accustomed to her sur- roundings and to gain confidence in the nurse and surgeon. Dur- ing this time the true state of her nervous system can be ascertained. If she is sleepless and depressed, relief should be given by nerve OVARIOTOMY. 517 sedatives and tonics. Quite often the damaged state of the nervous system is due to impaired nutrition, and will be relieved by improv- ing the digestion. Occasionally the nervous trouble is primary, and requires direct attention. Opium in small doses is most reliable in producing sleep and relieving depression, but it deranges digestion and nutrition in some cases, and on that account other remedies should be employed. Sulphonal does remarkably well as a sleep- producer, and is much preferable to bromide, chloral, or any com- bination of these remedies. It produces the desired result in the great majority of cases that are not kept from sleep by severe pain. This remedy is worthy of note as rather new, and is certainly one that will cause sleep with no other perceptible effect, good or bad. To restless, anxious patients, who find the days very long even when they sleep at night, and on whom opium does not act well, I have given large doses of lupulin and small doses of cannabis Indica. If these do not answer, opium should be tried. One of the greatest advantages of this preparatory treatment is that the effect of opium on the case in hand can be observed, so that, if it becomes necessary to use it in the after-treatment, the surgeon knows how far to depend upon it and what effects may be expected. Tin- Xutritice System.—This requires attention in all patients. In the majority, nutrition is impaired because of derangement of the digestive organs. In others the general nutrition is good, while the digestive organs alone are at fault. The time during which the trouble calling for surgical treat- ment has existed makes the difference in the general condition of the patients. There are two classes of patients usually met in practice who re- quire attention in regard to digestion and general nutrition: First, those who have not been long under the influence of the affection, and need very little treatment, except, perhaps, to relieve consti- pation and subacute indigestion Such cases are often left with- out any preparatory treatment save a cathartic the day before the operation. This may be safe enough, but in the majority of cases the tongue is coated, the bowels sluggish, the appetite variable, and the kidneys act imperfectly. These conditions can all be relieved by a few small doses of the mild chloride of mercury, followed by a saline laxative. If this does not clear the tongue, improve the state of the stoniacli, and increase the action of the kidneys, the treatment should be repeated in a few days. Second, the more advanced cases, in which there is general mal-nutrition as well as impaired digestion. 1 hese require more care and for a longer time. It sounds well to 51S DISEASES OF WOMEN". say of such patients that the cause being the neoplasm, if this is re- moved the mal-nutrition will be cured; but the chance of the patient being able to stand the operation may be improved by overeominir the constitutional derangements as far as that is possible. Gas- tric sedatives, such as bismuth or cerium, may relieve the irritation and improve the appetite, and tonic laxatives, such as mix vomica, belladonna, and rhubarb, will relieve constipation far better than salines. Management of the Bowels.—The objects in view in the man- agement of the bowels are threefold : First, to clear out the canal; second, to establish as far as possible normal secretion ; and, third, to remove the causes of flatulence, whatever they may be. A cathartic should be given two days before the operation. In the choice of a laxative or cathartic, one should be sought which will meet all these indications. In cases showing deranged secretion, in- dicated by the state of the tongue and appetite, an alterative dose of mercury should precede the cathartic, as already suggested. The mercury, being a reliable disinfectant, will also meet another indica- tion, the relief of flatulence. The selection of a cathartic to be given just before the operation is important. Castor oil is the best in case there is constipation or a suspicion of faecal impaction. The only difficulty is that many patients strongly object to it. AVhen it can he taken, it should be given two nights before the operation. This gives time for the oil to act, and also gives the bowels a chance to be- come quiet. The rectum should be washed out the night before the operation or early in the morning. In feeble patients who require a cathartic and yet are not strong enough to stand its operation. I give half an ounce of castor oil and two drachms of oil of turpen- tine. This is a most valuable preparation, if the stomach will retain it. In fact, this is the only cathartic that will act thoroughly in weak, debilitated patients without causing depression. The dose of turpentine is large, but if less is given it will affect the kidneys and fail as a cathartic to some extent. This may be called a tonic or stimulant and cathartic. A similar effect may be obtained by giving six grains of rhubarb, one grain of compound extract of colocynth, one grain of camphor, and a tenth of a grain of extract of bella- donna, in pills. There is a little depression following the action of this, but it is not so certain in its action as oil and turpentine. To those who can not take either oil or pills without having their stomachs upset, I give one or two teaspoonfuls of calcined magnesia and half a teaspoonful of charcoal, followed in a few minutes with a glass of warm lemonade. This empties the bowels and relieves flatu- OVARIOTOMY. 519 lence very thoroughly. This is given in the morning of the day before the operation, the object being to have the bowels quiet and empty at the time of operating. The condition of the heart and kidneys should be carefully no- ticed, especially that of the kidneys. The urine should be thorough- ly examined before giving an anaesthetic. I am satisfied that disease of the kidneys is the most important of the contra-indications to the use of anesthetics. If any renal disease is found, it should be care- fully treated and watched, and, if it proves to be acute or subacute, sufficient relief can in time be obtained to warrant the operation; but chloroform might be chosen in place of ether as the anaesthetic, and extra efforts should be made to shorten the time of operating. I have for a long time made it a rule to examine the urine always before giving an anaesthetic, and believe that it should be the invari- able practice to do so. I refer to that matter here because I have found many who do not think it necessary. In regard to the state of the heart, I find that it is often de- ranged in its function from pressure or indigestion, and it nearly always improves under treatment. AVhen there is time, I order muscular exercise as well as remedies to improve nutrition, and find that much improvement in the heart action follows. Organic heart disease, other than extreme hypertrophy, moderate dilatation, or aortic stenosis or insufficiency, does not deter me from giving an anaesthetic and operating. Many cases having disease of the mitral valve take ether very well. The day and evening before the operating day call for certain attentions. The bath so generally given the night preceding the operation is not always advisable. If the patient is used to daily or frequent bathing it may be safe to give it, but otherwise it is dan- gerous. The patient may get cold or become exhausted. The bath- ing should be done, in such cases, several days before, and then with great care. AVhen there is marked debility, with weak heart, digi- talis and nux vomica should be given the preceding day; especially is this necessary -when the operation promises to be a bad one. I formerly gave quinine, believing that it was a good tonic and helped to prevent shock, but I am satisfied that digitalis and nux vomica are better. The number of doses should depend upon the effect. As soon as the heart action is noticeably improved the drugs should be withheld. The food should be of the most nourishing kind, and at the same time easily digested, or else it should be artificially digested. Sterilized or peptonized milk, clear soups, tender beef, mutton, eggs, 518* DISEASES OF WOMEN". and raw oysters, either or all of these, according to the preference of the patient, may be used. The time to operate is, as a general rule, midway between the menstrual periods. An exception should be made in cases of menor- rhagia and dysnienorrhoea, in which there is an improvement in the strength toward the period of menstruation. Advantage should be taken of that temporary improvement by operating immediately be- fore the menses. The morning is by far the best time to operate. The patient is then at her best, and the stomach is empty—a condition very neces- sary to the taking of an anaesthetic. This would not be referred to here were it not for the fact that a great many surgeons in this coun- try operate late in the day. There are many disadvantages in doing so. The patient suffers from anxious anticipation, and becomes fa- tigued if food is not given ; and if it is given, it is not, as a rule, either digested or absorbed, and the stomach acts badly during and after the anaesthesia under such circumstances. I am led to dwell a moment on the general therapeutics of ab- dominal section, for the reason that my attention and that of my as- sistants has been so fully7 engrossed with the details of antisepsis and the technique of the operation, that many important items in the general therapeutics have been at times overlooked. It is likely that a similar experience may fall to the lot of others. There are certain points in the management of the patient dur- ing the operation which may be briefly mentioned. The patient should be kept warm, but the room should be cool, not over TO0 F. A very warm room has been advised, and there are many surgeons who still prefer it, believing that there is dan- ger of chilling the patient by exposing the abdominal organs to cool air. This can be obviated in other ways, by keeping the patient's head and feet warm by hot water if need be, and protecting the trunk with rubber cloth. Chilling the peritonaeum is avoided by the use of warm sponges. One large sponge should be placed in the wound as soon as the tumor is removed. This prevents the es- cape of the intestines, and protects the peritonaeum from the air. The sponges are maintained at the proper temperature by being kept in a pail which is placed in a larger one filled with hot water. The sponges are thus kept dry, while the water in the chamber around the inner pail keeps up the warmth. In case the operation is a long one, the water surrounding the sponge-pail can be renewed. Warm ether is also of value in avoiding shock and chilling the patient. This is obtained by using my ether-inhaler, in which the OVARIOTOMY. 519* ether is vaporized i n a reservoir and conveyed to the patient through a rubber tube. This warms the ether sufficiently to make it agree- able and safe. I have on former occasions spoken of the advantages of this ether-inhaler, by which the anaesthetic can be given pure, or diluted with pure air to any degree, and without the reinspiration of the expired air. I may7 add here that experience only tends to confirm my confidence in that method of using an anaesthetic such as sulphuric ether. List of Instruments and Appliances usually required in the Operation.—Scalpel with fixed handle; dissecting-forceps; artery- Fig. 199.—Keith's short compression-forceps. forceps; six Keith's compression-forceps (Figs. 199 and 200); one vulcellum forceps; one fenestrated forceps; small, straight, blunt- pointed scissors; large, straight scissors; trocar and rubber tube. These are placed together in an enameled pan filled half-full with a one-to-forty carbolic-acid solution. Twelve to twenty sponges, the exact number to be carefully noted, prepared and placed in a double tin pail with hot water in the outer compartment; six towels soaked in a one-to-twenty carbolic solution, and put in the sponge pail; No. 1, 3, and 11 prepared silk for liga- tures. These should be cut the proper length for ligating thick adhe- sions and the pedicle, and wrapped in gauze and put into the car- bolic solution. No. 4 silk for the abdominal sutures should be prepared in the same way ; No. 2 catgut ligatures; Keith's needles, two for each ab- 520 DISEASES OF WOMEN. dominal suture (Fig. 201); Peaslee's needles; Keith's fine forceps for carrying the ligatures (Fig. 202) through the pedicle; sutures to Fig. 201.—Keith's needle. be used with Peaslee's needle if required; a sheet of rubber cloth, three by four feet, with an oval hole in the center, the border of Fig. 202.—Keith's ligature forceps. which is coated with sticking-plaster an inch wide all around ; long straps of saddle-girth to fasten the patient's limbs to the table; a yard of gauze or cheese-cloth soaked in a solution of one part of carbolic acid to eight of glycerin for a dressing; sheet of absorbent cotton large enough to cover the abdomen ; flannel bandage ; safety-pins. Instruments and Appliances that may be needed.—Cautery clamps; cautery irons; Keith's clamp (Fig. 203); curved scissors; Fig. 203.—Keith's modification of Spencer Wells's clamp. concave mirror; counter-pressure instrument for tying ligatures in abdominal cavity ; several drainage-tubes of different sizes ; piece of sheet-rubber, ten by ten inches, to cover the end of the drainage- tubes ; twelve or more extra sponges; twelve to twenty extra com- pression-forceps ; aspirator; elastic ligature. These should be clean and placed within reach of the operator, but not mixed with the other instruments named. The instruments to be used should be placed on a stand beside the operator, and also a basin with carbolic solution, or such disin- fectant as the surgeon chooses to use for keeping the hands clean. OVARIOTOMY. 521 The sponges, ligatures, towels, and dressings may be placed beside the first assistant Assistants.—Three assistants are certainly needed, and one more may be required. One gives the ether, one stands on the left side of the patient, facing the operator, the third on the left of the op- erator, and the fourth one attends to the washing of the sponges. The chief assistant on the opposite side of the table sponges the wound during the incision of the abdominal walls, holds the vessels or adhesions when the operator is ligating them, supports the cyst when brought out, helps to apply the sutures to the wound, and ful- fills all orders of the operator. The second assistant supports the abdomen and cyst or tumor while the abdominal walls are being opened, and, when the cyst is being removed, he helps to expel it by pressure, and at the same time prevents the escape of the ab- dominal viscera. The assistants carry the patient from the bed to the table. A blanket is wrapped around her limbs, and a rubber bag of hot water 4'SECOND? flOPERATORfil |?ASSISTANT4 V----- ' •-■ SI Fig. 204.—Position of operator, assistants and accessories in the operation. Both arms should lie close to the patient's side. placed at her feet. The strap is passed over the thighs and around the table. The abdomen is made bare by opening the dressing-gown and raising the undergarment. The rubber cloth is spread over the 522 DISEASES OF WOMEN. patient, and the edges of the opening in the center stuck fast to the skin around the lower and central portions of the abdomen. One of the carbolized towels is laid over the thighs of the patient, upon which are placed the instruments which are first to be used. This diagram will show at a glance the position of all concerned. The several steps of the operation are as follows: 1. Making the incision in the abdominal wall. 2. Exploring for adhesions. 3. Tapping the cyst or cysts. 4. Treating adhesions and removing tumor. 5. Treating the pedicle. 6. Examination and treatment of the other ovary. 7. Cleansing the abdominal cavity. 8. Closing the incision. 9. Dressing the abdominal wound and placing the patient in bed. The details of the several steps in the operation in uncomplicated cases are as follows: The incision is made in the linea alba—traces of which can usu- ally be seen—down to the muscular layer. The length of the incis- ion should be about three inches, extending from one inch above the pubes upwards. The assistant should follow the knife with the sponge, and any bleeding vessels should be caught up in plain for- ceps. The tissues at the bottom of the wound should be picked up with a dissecting-forceps, and an opening made in the median line with the knife, the edge of which should be directed away from the tumor. AVhen making this opening care should be taken to find the median line between the muscles. This is often done at the first trial, but, if the muscle is exposed, its sheath should be followed in either direction until the median line is found, and then another opening made there. The knife is then put aside, and one blade of the blunt-pointed scissors is introduced into the opening, and the incision completed by cutting in both directions. This usually ex- tends through the muscular layer; the fascia and the peritonaeum still remain. These should be opened in the same manner. A sound, finger, or the whole hand may be introduced to de- termine the presence and character of adhesions, if such exist. The trocar and cannula are then plunged into the cyst at the highest end of the incision, the trocar drawn back and handed to the assistant, who takes care that fluid does not enter the abdominal cavity. The cyst- wall should be seized with a lock-forceps between the cannula and left side of the incision. This is also handed to the assistant, who holds it and the trocar in his left hand, and makes the necessary OVARIOTOMY. 523 traction to withdraw the cyst, which he grasps with his right hand when it comes out, and holds it without making traction upon the pedicle. The operator pushes a sponge into the wound behind the tumor. The pedicle is then examined to ascertain its size and character, and whether it be twisted. The cautery clamp (if that method of treat- ing the pedicle is to be practiced) is then applied, and the pedicle di- vided within half an inch of the clamp. The operator then sponges the abdominal cavity, taking special care not to leave any fluid be- tween the bladder and the uterus. The assistant meantime takes care of the clamp. The operator examines the other ovary, and decides whether it requires to be also removed or not. One or more sponges are left in the abdomen while the pedicle is being treated with the cautery. Two carbolized towels are placed under the clamp, and the remains of the pedicle are removed with the cautery^. The clamp is then loosened a very little by unscrewing, and the cautery applied until the clamp is heated throughout to a degree that will admit of the finger being firmly placed upon it. Before finishing the cauterizing, the clamp should be screwed up tight. AVhile the cauterizing is being done, the assistant should remove all fluid and debris with a sponge and forceps, and, if the towels beneath the clamp become heated, they should be changed. The clamp should be cooled with a moist sponge without touching the cauterized edge. The pedicle is then seized with two forceps below the clamp, which is gradually and with great care loosened. The stump of the pedi- cle should be watched for a few seconds to see if the blood inclines to pass up any of the vessels in the part that has been cauterized. If there is no sign of such taking place, then the stump is dropped back and covered with intestines, and the omentum over all. Should the operator decide to ligate in place of using the cautery, the pedi- cle is secured by two compression-forceps, and a double ligature is passed through the center of the pedicle with a Keith's ligature- forceps, and ligated in two halves. Care should be taken to cross the ligatures, so that when the two are tied they will draw the tis- sues together in one mass. AVhen the pedicle is small and long, it can be tied before cutting away the cyst, and without using a clamp at all. The sponges should be recounted at this stage of the operation, to make sure that none is left in the abdominal cavity— an accident which has occasionally happened. A flat sponge is placed over the omentum and beneath the edges of the wound, and left there while the sutures are being introduced. All bleeding vessels in the abdominal wall should be ligated. Two 521 DISEASES OF WOMEN. Keith's needles are used for each suture, one at each end. The needles are introduced from the inside of the abdominal wall, and include the peritonaeum. This method of introducing the sutures is the quickest and the best when the incision is long or medium in length, but when the incision is short I prefer to use Peaslee's needle of smaller size than that which is usually found in the shops. The needle is passed from without inward, and the suture is carried through the double of the thread in the needle, and, as the needle is withdrawn, the suture is brought into place. Having introduced all the sutures, the ends on each side are gathered together and held while the flat sponge is removed. The air should be pressed out of the abdominal cavity, and the sutures tied. Slip-knots are prefera- ble. The sutures should be close together, about four to the inch. Here and there a superficial suture may be needed to make the co- aptation as complete as it should be. The dressing of gauze, soaked in the one-to-eight solution of glycerin and carbolic acid, is applied, and over that absorbent cotton and a flannel bandage. The patient is put into a warm bed, and hot water-bags or bottles put around her, and one sixth or one quarter of a grain of morphine given hypo- dermically. Complications.—The several steps in the operation are liable to be complicated by a variety of conditions. The chief of these may be mentioned in the order in which they come. AVhen there is much fat beneath the skin it is difficult to make a straight incision. In that condition the wall may be grasped in the left hand, raised up and transfixed with the bistoury and divided from within outward. This leads down at once to the muscular layer, and then the incision is finished in the usual way. Great vascularity of the abdominal wall, while easily managed, takes time. One or two bleeding vessels may be caught in plain forceps and con- trolled, but when there are many it is better to tie them because a number of compression-forceps are in the way during the operation. Firm adhesions of the tumor to the abdominal wall in the line of incision are often a troublesome complication, which leads the opera- tor either to open into the sac before knowing it, or else to sepa- rate the peritonaeum from the abdominal walls. AVhen the tumor can once be reached at any one point, it is very easy to separate the adhesions, but it is often difficult to get that one point. Enlarging the incision is a help, and it should be carried in the direction up or down according to the possibility of reaching a point where the cyst is free. Sometimes the exudation which forms the adhesion can be recognized when it is reached; it is then easy to follow it up until OVARIOTOMY. 525 the detachment is complete. AVhen the cyst is exposed all the par- ietal adhesions should be loosened. This should be done by the hand. AVhen the tumor has been of slow growth and is tense and the walls opparently thick and strong, a very great amount of force can be used in separating adhesions. If the tumor is flaccid it is well to steady it with a pair of for- ceps while separating the adhesions and before introducing the trocar. Parietal adhesions are treated before tapping the cyst, at least as far as they can be easily reached by the hand. EMPTYING THE TUMOR IN COMPLICATED CASES. In multiple cyst and multilocular cases in which the contents of the sac can be removed by tapping, the trocar and cannula are thrust into the nearest cyst and it is emptied in the usual way ; the trocar is then pushed into another sac, which in turn is emptied, and so on, until all are emptied. To do this safely the tumor should be steadied with the left hand, while the trocar is used with the right, and this helps to make sure that the trocar goes into the sac and not into the viscera or abdominal walls. AVhen the contents of the tumor are semi-solid and will not flow through the cannula, the trocar and cannula should be removed, and the opening in the sac enlarged in the axis of the body ; i. e., the opening should correspond to the opening in the abdominal wall. A pair of forceps should be fastened near each end of the opening on the left side, and perhaps a small one at the lower end on the right side. These forceps are held by the assistant, and as the tumor becomes smaller he draws the sac out and down until the opening in the sac is below the level of the opening in the abdomen. The operator introduces his hand through this large opening into the cyst that is emptied, and breaks down the other cyst-walls and sweeps them out; while the finger of the right hand is boring through the cyst-walls the tumor is steadied with the left hand on the abdominal wall. In this way the contents of large tu- mors may be broken down and removed. AVhile this is being done the edges of the rubber cloth should be raised so as to direct the fluid into the tub or basin at the side. AVhen the tumor is very vascular and great bleeding is likely to occur in emptying the contents, the pedicle should be found if pos- sible and compressed with catch-forceps. Adhesion of the omentum and the abdominal and pelvic viscera 35 526 DISEASES OF WOMEN. is treated after the tumor is emptied of its fluid contents. The omental adhesions are most easily tied while attached to the tumor, and that should be the rule, but if it is necessary to get the omen- tum out of the way before the operator has time to tie it properly, compression-forceps may be put on, and the whole wrapped up in a carbolized towel, and left on the abdomen at the upper angle of the wound until the cyst is removed, when attention can be given it. It should then be tied in sections of about the width of two fin- gers. Dr. Keith treats adhesions to the bowels and mesentery by mak- ing traction upon the cyst and pressing against the adhesions with a sponge. In this way the adherent tissues can be pushed apart with less injury than in any other way. Pulling upon adhesions should always be avoided, if possible. Sometimes when there are many ad- hesions high up strong traction must be made, there being no other way of separating the firm adhesions, but it is a dangerous practice and only to be resorted to when it can not be avoided. Long bands of adhesions should be tied before being detached, and the following points should be observed ; to have no tension upon these parts ; to ligate as far from the free end as possible, and make sure that all bleeding is stopped before letting go the parts. The bleeding which comes from the broad adherent surfaces which have been separated, should be controlled by placing sponges in the abdomen and making pressure, and as soon as possible bleeding points should be looked for and the vessels ligated. AVhen the sponges are removed the position of the bleeding vessels can be seen. AVhen there are many adhesions high up in the abdomen, it is an advantage to find the pedicle, clamp it with two spring catch-forceps, and divide it, and then remove the tumor from the pelvis first. AVhen the adhesions are all treated and the tumor removed, the sponges which have been introduced should be removed, and the bleeding vessels caught up and tied. During this search for bleeding vessels in the pelvis the assistant holds the side of the abdominal wound with his left hand, and with a concave mirror in his right throws light into the pelvis. In using the mirror the assistant directs it so that he himself can see, knowing that if he can see the operator will see also. The artificial light is to be used as little as possible, because if once begun it is difficult afterward to do without it. Drainage should be employed when from the number of adhe- sions there is seen to be a free transudation of serum ; when all the bleeding has not been or can not be stopped, and when either of the above conditions are present even in a very limited degree and the OVARIOTOMY. 52Y patient is feeble. The tube should be left in until the discharge becomes clear. AVhen adhesions to the intestines or pelvic organs are so firm and extensive that they can not be separated with safety, Dr. T. F. Miner, of Buffalo, enucleates the tumor or cyst from its peritoneal covering. This can be done, but it is often exceedingly difficult, and there is left a large surface from which a free transudation takes place, and requires long-continued drainage. This method is not practiced much now, except in cases of intraligamentous cyst. AVhen adhesions are very extensive and firm there usually has been inflammation of the cyst, and then its layers can not be sepa- rated ; this renders enucleation impossible. Treatment by Drainage answers in such cases if the cyst is small or of medium size. If the cyst is adherent to the abdominal wall it is laid open without being separated and its cavity thoroughly cleaned out, and a drainage-tube introduced, and kept in place. The sac is washed out frequently, and when it has contracted down it may be induced to close by the use of tincture of iodine and car- bolic acid. AVhen not adherent to the abdominal wall, but so gen- erally adherent to the viscera that exploration is deemed impossible, the free portion of the sac should be trimmed off and its edges care- fully united to the ineision in the abdominal wall, and then the drainage practiced. I am aware that an experienced and dexterous operator can man- age very bad adhesions, but there are cases where it is safer to use drainage. Five cases have been treated in this way in my own prac- tice, and four of them recovered. In the fifth, a bad case of rupt- ured cyst in which there had been very general peritonitis, the cyst was adherent everywhere. I could not find a single free spot, and the patient was very feeble. The sac was filled with inflamma- tory products, which were carefully cleared out, and large drainage- tubes used. She improved for a time and took food better than she had done before, but died at the end of a week, apparently from uraemia; the kidneys were found to be diseased. In case of very intimate adhesions to the liver, spleen, uterus, bladder, or intestines, Dr. AV. L. Atlee did not detach them at all, but separated the peritoneal from the middle coat of the cyst at the point of attachment, and left it there. This also is not often neces- sary, but it may be the easiest and safest thing to do, and if drain- age is employed good results may be expected. In this I have had no experience. Arrest of Haemorrhage.—All adhesions in the form of bands ex- 528 DISEASES OF WOMEN. tending from the cyst to other parts should be tied before dividing them. This applies especially to adhesions of the omentum. Large bands should be tied with prepared silk ligatures. The finer bands may be tied with catgut. In my own practice I use silk alto- gether. Intimate adhesions which have to be separated by trac- tion leave bleeding surfaces, and if any large vessels are found they should be tied if possible. General oozing can usually be stopped by pressure with a sponge. Haemorrhage deep down in the pelvis from vessels large enough to be ligated can be reached by throwing in the light from the mirror and using a long artery-forceps. The ligature can be easily tied by using the counter-pressure instrument employed in tying the sutures in the operation for restoration of the cervix uteri. To check oozing from surfaces like the uterus, liver, or spleen, pressure with sponges is to be performed as stated already. An application of persulphate of iron is made by some operators, and the thermo-cautery has also been commended. Both are objection- able, and should be avoided if possible. After-Treatment.—The bed in which the patient is placed should be warmed to about the normal surface temperature. The patient's head should be covered with a soft woolen shawl or soft blanket. The hands should be kept under the bed-covers and not disturbed. The pulse should be watched at the temporal artery. A hot-water bag may be placed near the feet, but not in contact with them. I have repeatedly seen the feet burned by placing a hot-water bag close to the skin. This will not occur when the bag is wrapped in flannel. The air in the room should be kept at about 70° F., and ventilation secured without having the patient in a draught. For a number of hours ether is thrown off with the expired air, and it is difficult to keep the air in the room agreeable. It is fortunate if the patient sleeps after the operation, and no effort should be made to awaken her, as is frequently done, to find out how she feels. During the first twenty-four hours or more, the greater the amount of rest that can be obtained the better. Absolutely noth- ing should be given in the way of food or medicine unless there is some urgent demand for either. Nausea and vomiting, which occa- sionally occur, should be counteracted with sips of hot water if the patient is anxious to have something to drink—not otherwise. Keith usually gives a hypodermic dose of morphine immediately after the operation, to control the restlessness which supervene^ when the patients come out of the anaesthetic. This is not always necessary. I wait and see if there is much restlessness or pain, and OVARIOTOMY. 529 if there is, the hypodermic is given. Nervous restlessness alone can often be controlled by the efforts of a judicious, experienced nurse. If the patient can be controlled until night, it is better to withhold the morphine until then. This expectant treatment should be continued until the stomach has become reliable and gas has passed from the bowels. In many cases nothing else is required during the first forty-eight hours. I am sure that great harm is done by giving nourishment and medi- cines when there is no demand for either. I certainly have seen more harm come from doing too much at first than from doing too little. There are exceptions to this rule of doing nothing. In case the vomiting continues, and is not relieved by hot water, I use the following: Magnesiae carb., 3 ij ; magnesiae sulph., 3 iij ; aquas menth. pip., ^ iij- Of this, a teaspoonful may be given every one, two, or tliree hours in a dessertspoonful of Avater. This prescription is used in the Samaritan Hospital in London. A mustard plaster to the pit of the stomach is also useful. AVhen these remedies fail, and the patient complains of burning in the stomach, dessertspoonful doses of iced water may be used. AVhen the patient is depressed, ten drops of whisky in a teaspoonful of water every few minutes will be of service. In desperate cases I have given a large quantity, as much as the patient could drink, of lukewarm water and a little table salt. This is thrown off promptly, and sometimes gives relief. It should not be repeated. If relief is obtained and the nausea returns, the stomach should be washed out in the usual way. AVhen the vomiting is attended with abdominal pain, morphine hypodermically will give relief in many cases. Peritonitis and Septicaemia after Laparotomy.—From recent re- ports in the literature of medicine it appears that a new departure has been taken in the after-treatment of cases of ovariotomy and similar operations. In place of giving opium and keeping the bowels at rest for several days, the bowels are moved early, and opium is withheld. Cases which show signs of septicaemia or peri- tonitis are given saline cathartics. It is claimed that free action of the bowels effects a kind of drainage which arrests the tendency to inflammation of the peritonaeum, and also favors the elimination of septic material. One should gladly accept whatever theories or facts may be advanced in favor of this plan of treatment, or any other which might prove better than the old ways of managing such cases. But I have failed to see that this new treatment has many advantages. So far as I can learn, the results, on the whole, do not compare 528* DISEASES OF WOMEN. well with those of other surgeons who give opium and let the bowels and the stomach rest, until the first dangers are past. Furthermore, I have found in my own practice that as soon as the indications for cathartics appear, it is impossible to have the patient retain them, in the great majority of cases. Perhaps the advocates of this treatment may be able to anticipate the coming storm, and, by giving salines, ward it off; but I have not been able to do so. AVhile there are a number of reasons why opium should be used, I have not yet heard of any good reason why it should not be, in certain cases. That there are patients who do not need opium, and others with whom it does not agree, must be admitted; but the majority require it to relieve pain, produce sleep, and, above all, rest and quiet, which are so very necessary to recovery after major operations. These effects of opium, it may be claimed, simply contribute to the comfort of the patient, but do not secure safety or aid in recovery. Grant- ing that such may be the case, the humane surgeon will find in this good reason for the use of opium; but I am confident that opium has a therapeutic value in addition to that of relieving suffering. The danger from shock which arises from major operations is, I am sure, controlled by opium better than by any other drug. So also is the depression from anaemia resulting from haemorrhage. All careful observers have noticed that the rapid and feeble pulse becomes fuller, slower, and steadier under the influence of opium. The anxious, pinched face also changes to a better expression. This has led me to look upon opium as the most reliable of all heart ton- ics in the depression which follows these operations. AVhen the organic nervous system is tottering under the oppression of severe injuries to the abdominal and pelvic viscera, opium is the greatest sustaining agent. Alcohol, no doubt, will bridge over a moment of extreme and immediate danger, but its effects must almost always be supplemented with opium in order to obtain a continuous sus- taining effect. Perhaps more important still is the question, Does opium have the power of preventing peritonitis and septicaemia, or of controlling their fatal tendencies % To judge fairly of the therapeutic effects of opium in surgery, it is necessary to keep in mind the fact that after an operation there are injured tissues left that must be repaired. These tissues may or may not be affected with septic material, but in either case the safety of the patient depends upon these wounded tissues being speedily closed in by reparative material, which re- OVARIOTOMY. 529* stores continuity of tissue and at the same time protects the normal surrounding tissue from inflammation and the patient from general septicaemia. Now this process, by which the general system is pro- tected from the dangerous effects of local injuries, requires time; and it is the most important time, because upon completion of this protection depends the safety of the patient to a great extent. Wounds may do badly, but, if an exudation has been thrown around them which protects from septicaemia, recovery may be expected Of course, the modern surgeon protects his cases from sepsis by his cleanly operating; but in spite of his best efforts there may be trouble occasionally, and then the great point is to gain time for this natural protective process, which comes, or should come, first in the order of restoration. The principal condition necessary to secure the protective factor in the general process of repair is re- pose or quietude of the nervous and circulatory systems, and opium is the most potential agent in effecting this condition. The process of repair is arrested when the nervous system is in turmoil and the circulation is running wild, and opium should be used to give the necessary rest. It is a fatal mistake to wait until there is evidence of inflammation or septicaemia. It should be given to control the nervous excitation which generally precedes these complications. The time to give it, then, is an important question. Some of the most successful surgeons give it immediately after the operation, and that is best when the case is bad and there is shock. In easy cases I prefer to wait until the ether effects pass off to some extent; and if there is distress or pain present, then is the time to give opium, and the effect should be kept up until there is no danger of complications, so far as the condition of the patient indicates. The way of giving it is of some importance, no doubt. I prefer to give it at first hypodermically, and keep up the effect in that way, or by rectal instillations of opium and warm water. The question which follows is, AVhen shall the opium be with- drawn, and cathartics resorted to ? Opium should be gradually given up as the constitutional and local evidences of disease sub- side, and then cathartics or laxatives should be given. To state this in another way: opium should only be given when there are indications for its use, and it should be given up as soon as the indi- cations disappear. The bowels should rest until the time for peri- tonitis is past, or, if there has been inflammation or sepsis, when the acute symptoms and signs of these have subsided. CHAPTEE XXIX. ILLUSTRATIVE CASES OF OVAKIAN NEOPLASMS. In giving the histories of ovarian neoplasms it has been deemed best to omit simple and typical cases, because they would add noth- ing to the description already given. The following complicated ones, on the other hand, will tend to convey clearer ideas of the peculiar cases which are frequently met in practice, and the approved methods of management adopted at the present time. Monocyst of the Right Ovary; Firm Adhesions to the Abdominal Wall; Necrosis of the Posterior Wall of the Cyst; Ovariotomy; Re- covery.—The patient was fifty four years old, and the mother of four children. After the birth of her last child, the attending physician told her that she had a small tumor on the right side of the uterus. There was considerable intermittent pain in the region of the neo- plasm from the time that it was fiist discovered up to the time that she came under the care of my associate, Dr. Palmer, four years afterward. The growth of the tumor was slow, scarcely noticeable for the first three years, but very noticeable during the last year. AVhen she first came under the care of Dr. Palmer the tumor ex- tended above the umbilicus, and fluctuation was well marked. There was evidence of circumscribed peritonitis, and, although the tumor was movable, adhesions were being formed. The peritonitis was quite pronounced at this time, and the constitutional symptoms were well defined. She was treated for this, and in about two weeks the acute symptoms subsided, but she still remained weak. The doctor sent her home in the hope that she would gain strength, and the tumor being still small there was no urgent necessity for its re- moval. In a month she returned to the hospital not improved. She was losing flesh, the parts were still tender, the appetite poor, the pulse weak, and the temperature kept above 100° F. Another effort was made to get her into better general condition, but withont success. She lost strength gradually, and it was de- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 531 cided that the only chance for her was by removing the tumor. At this time the adhesions were firm and involved all parts of the ab- dominal wall which were in contact with the tumor. Just before the operation the pulse was 120 and the temperature 101°. AVhen the abdominal incision was made, the adhesions were very firm and vascular, except in a small space just above the sym- phisis pubis. The cyst was emptied by tapping, and the lower por- tion, which was not adherent, was drawn out, and the pedicle grasped with strong fixation forceps, and divided. The adhesions were now easily reached and separated. The pedicle was then ligated, and the bleeding stopped by pressure with sponges. By managing the pedi- cle in this way, the tendency to bleeding from the site of adhesions was lessened very decidedly. AVhen all bleeding had stopped the wound was closed and dressed in the usual way7. An examination of the cyst showed a portion of its posterior wall (about the size of one's hand) perfectly bloodless, of a dirty gray color and friable, indicating that it was necrosed. No doubt the death of this portion of the sac had taken place many days be- fore the operation, and I presume was the cause of the constitutional disturbance. From the facts in this case and from those observed in other cases of necrosis of the cyst-wall, I believe that the dead tissue causes a form of septicaemia, certainly in this case there was nothing else found to cause the high temperature and pulse, and the subsequent history confirms this view. The operation was performed between eleven and twelve o'clock. She soon recovered from the ether, and showed no depression. At seven in the evening her condition was better than before the oper- ation. The pulse was 112, temperature 99*5° F. and respiration 20. During the night she had slight pain in the abdomen and was given a hypodermic injection of morphine. She slept well, and had no vomiting. On the second day there was some slight distention of the abdomen from gas ; this was relieved by six grains of sul- phate of quinia in solution, given by the rectum. From this time onward her progress was very satisfactory. The temperature never rose above 99° F. Five days after the opera- tion the bowels were moved by enema. On the twelfth day she left her bed, and four days later was able to walk about the ward. About four weeks after the operation the left leg became swollen, and remained eo for about a week. The cause of this was not certain. She was discharged from the hospital at the end of the fifth 532 DISEASES OF WOMEN". week feeling perfectly well and having gained flesh and strength surprisingly. Intraligamentous Ovarian Cystoma; Multiple Cyst of the other Ovary; Ovariotomy and Hysterectomy; Recovery.—This patient was under the care of my friend Dr. F. H. Stuart, and most of the facts in the history of the case—before and after the operation—are given here as I obtained them from him. The lady was fifty-six years of age, and had passed the meno- pause about six years. At the age of thirty-nine years she had a pelvic abscess which opened into the bladder, and she was then sick for a long time. About three years before the time when this history was taken she noticed a tumor in the right iliac region. She was first seen by Dr. Stuart, April 30, 1886. He found the uterus high up behind the symphysis, attached to an elastic tumor, which was immovable, and by external examination appeared to be larger than a fetal head and extending up into the right iliac fossa. There were two other tumors of smaller size, one above and one to the left of the larger one. These appeared to be adher- ent to the first one, and were also rather immovable. 1 saw the patient the next day with the doctor, and confirmed the diagnosis of ovarian cysts. On account of the adhesions, and as the patient was not suffering any great inconvenience, we thought it best to await further developments. She passed a very comfortable summer, but increased steadily in size, with a corresponding increasing discomfort in locomotion. About the 1st of December, 1886, she began to have frequent and painful urination, and some fever. After a few days of quiet and some quinine (as there was a decided intermittence in the irritability of the bladder), she became again quite comfortable. Immediately before the operation the physical signs were as fol- lows : The general outlines of the enlarged abdomen were irregular, three cysts could be mapped out, and fluctuation was distinct in each. The most dependent cyst was about the size of the uterus at the seventh month of utero-gestation, and occupied the center and lower region of the abdomen. It was not movable to any extent, and appeared to be separated from the other cysts except at the up- per and right side, where it seemed to be adherent but not firmly so. The two other cysts occupied the upper and left lower regions of the abdomen, raising the diaphragm and causing the lower ribs to project slightly. These two cysts could be moved together in the abdomen, but were closely united forming one tumor. The fluctua- ILLUSTRATIA7E CASES OF OVARIAN NEOPLASMS. 533 tion was very clear in each of them, but was not distinctly felt through the mass formed by the two. All around the circumference of the abdomen there was dull- ness on percussion, and distinct fluctuation, though broken at points where the divisions between the cysts were. These signs simply in- dicated the presence of a multiple cystic tumor. The umbilicus was high up, showing that the lower portion of the abdominal mus- cles was distended most, and in a space about five inches in diame- ter in the umbilical region there was tympanitic resonance and gurgling on pressure, showing the presence of intestines at that point. Taken altogether the abdomen appeared to be occupied by a large cystic tumor with a mass of intestines in a cup-shaped space in its center. By vaginal touch the uterus was found displaced upward and forward, and the cervix could be reached without difficulty, owing to its being crowded toward the pubes. Behind the uterus and ex- tending down into the upper and posterior portion of the pelvis a segment of cyst was found. The uterus was displaced by moving the cyst in front, and pushed forward by raising the cyst behind it. The examination indicated very certainly that there was a cystic ova- rian tumor of the multiple variety, but there was evidently more than that. The fact that the uterus was involved raised the ques- tion of uterine fibro-cyst, as well as ovarian tumor, but there was some doubt about the nature of the whole mass. It was possible that the uterus was simply adherent to the cystic tumor, and that the adhesions had been formed while the tumor was still in the pel- vis, and the uterus had been carried upward as the tumor grew. It also was presumed that there might be two cystic tumors, and that the uterus was attached to one of these. AVhile the exact pathological conditions were not decided upon, two facts were quite evident; first, that there was at least an ovarian tumor, and that the patient must obtain relief, if at all, by ovariot- omy. Operation.— After making the abdominal incision, the first cyst was exposed, and adhesions of the omentum were found on the right side. The omentum was vascular and its adhesions covered the upper part of the tumor. After emptying the cyst by tapping, the omental adhesions were ligated and separated, and it was then found that this cyst had no connection with the cysts above, but was situated between the folds of the broad ligaments, and extended from one side of the pelvis to the other, between the uterus and the bladder. The uterus, being behind the cyst-wall and firmly attached to it, had 534 DISEASES OF WOMEN. been stretched laterally so that its long diameter was transverse. The empty cyst was held outside of the abdominal wound at this stage of the operation by forceps, and the incision extended upward so that I could reach the other tumor, which I found to be a multi- ple cyst of the left ovary. The four largest cysts were tapped separately, first the one on the right side, and next the one above and to the left, then the one that dipped down behind the cyst of the broad ligament and uterus, and lastly a middle one between the upper and lower cysts. There was a deep fissure between the two cysts on the left side through which the intestines found their way up to the abdominal wall, which accounted for the tympanitic resonance obtained during the examination. This tumor had an ordinary pedicle starting from the left posterior surface of the broad ligament, which was ligated with silk, and the tumor removed. Having disposed of this tumor, I returned to the cyst of the broad ligaments, and upon laying it open and inspecting its cavity, I found at the bottom of it a papillomatous mass which had the ap- pearance of an epithelioma. I then undertook to enucleate this cyst, the lower portion of which was fixed in the broad ligaments, between the bladder and uterus, as already stated, but the adhesions were so firm and the vascularity so great, that this was impossible. I then tried to enu- cleate the inner wall of the cyst, but this was also impracticable. The thought occurred to me that I might stitch the cyst-walls to the sides of the incision in the abdominal walls, but as the cyst dipped down into the broad ligaments on both sides, two pockets would have been left, which would have been difficult to drain. The papillomatous mass in the central part of the sac would have been left also, and that, I presumed, would have interfered with the clos- ure of the sac, and the final recovery of the patient. It seemed as if the whole thing should be removed, but I could not take in all the tissue involved in any ordinary clamp. I then tied and divided the broad ligament on both sides from the outside toward the center, so as to form a pedicle which could be grasped in the clamp. The bladder was dissected from the cyst- wall far enough to let the clamp get down below the uterus and the most dependent portion of the sac. Keith's modification of Baker Brown's clamp was then applied, and the cyst and uterus removed. A drainage-tube was introduced above the clamp, and the abdom- inal wound closed from above downward. The operation was completed at noon, and five minims of Ma- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 535 gendie's solution of morphine were given hypodermically at once. She slept quietly for about two hours and then had some nausea, and vomited a mouthful of mucus. The remainder of the day was passed comfortably, the catheter was used, and sips of hot water were given. At midnight the temperature was 99f ° and pulse 86. The second day was without much to note except that the temperature went up to 101f° but, toward midnight, it came down to 100° and the pulse was 86. There was some distention of the bowels which was relieved by quinine, given by the rectum. From this onward the patient did very well, the pulse was good and temperature ranged from 99° to 100°. She required morphine to keep her comfortable, but noth- ing more. After the operation the kidneys acted very well, the catheter be- ing used for two days, and after that the patient urinated without trouble and passed the usual quantity of water. On the tenth day, while urinating, the dressing of the wound became saturated with urine, showing that the upper part of the bladder had opened; the dressings were removed, but the opening was covered by the clamp and could not be seen. Several times afterward when she urinated she passed a very small quantity of water by the urethra, the larger portion passing by the side of the clamp. Between the times when she urinated there was no leaking from the opening in the bladder. She was not permitted to urinate after this; the catheter being used at regular intervals. For two days very little urine escaped from the opening, and then a little began to come, which made the wound unclean. It being quite evident that the stump, below the clamp, had un- dergone necrosis to a considerable extent, an elastic ligature was passed around the stump, below the clamp, in the hope that it would cut its way through the softened and dead tissues, and set the clamp at liberty; it did so to a limited extent only, and, as it was very difficult to keep the wound clean, the clamp, on the fifteenth day after the operation, was carefully liberated by dividing the dead tissues of the stump with the knife and scissors. No haemorrhage was caused. When the clamp was removed, it was found that the necrosis of the tissue extended farthest on the right side, and it was at this point where the bladder was open. At first it was thought that the blad- der had been included in the clamp; but that did not seem possible, because of the extreme care taken to avoid it when applying the clamp, and also from the entire absence of all functional disturb- ance of the bladder during the ten dayTs immediately succeeding the operation. 536 DISEASES OF WOMEN. After removing the clamp, and seeing how far the death of the tissues of the stump had extended on the right side, it appeared that the opening of the bladder was due to this destruction of the tissues. The opening occurred on the right (as has been already stated), at the site of the old cellulitis, which she had years ago, and where the abscess discharged into the bladder, in all probability, and this may account for the death of the tissue below the clamp. During the operation it was noticed that the right broad liga- ment was thickened greatly, and changed in appearance, owing no doubt to the products of the old inflammation, and the damaged state of the tissue probably favored the necrosis; this may have been also favored by the pressure of the abdominal wall. The pedicle was broad, so that it stretched the wound, and the pressure of the strongly retracted edges of the wound may have helped to strangu- late the right side of the stump, the vitality of which was of a low order. The dressing of the stump and abdominal wound now became a rather difficult task, owing to the escape of urine. Iodoform and absorbent cotton did best of all. Although the catheter was used, there still was some leaking above. The urethra became tender to the passing of the catheter, and then the doctor tried keeping it in the bladder continuously. This did well for a time, but had to be given up because of the pain caused. By the free use of cocaine the catheter could be used, so that the leaking in the wound was not great. During all this time her general condition was fairly good, but the wound healed slowly, and she needed morphine to keep her comfortable. About this time several of the ligatures used in tying the broad ligament on the right side came away through the wound. About five weeks after the operation, and while she was apparently well, except that the fistulous opening of the bladder remained and her strength had not returned fully, she was taken quite ill; the tem- perature ran up to 103°, and the bowels became constipated; the appetite was entirely lost, and she looked badly in the face, and lost flesh rapidly. There was a hard, irregular mass felt in the right side of the abdomen at this time, which was presumed to be a local inflamma- tion due to the ligatures used in ligating the omentum. The doctor and I were not without some fears that it might be the beginning of some malignant disease, but it proved not to be so. Quinine given by inunction and the rectum controlled the fever after a time, and then the stomach and bowels began to act again. ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 537 From this time her progress was favorable, and she is now (one year after the operation) perfectly well. A Papillomatous Monocyst of the Ovary. Ovariotomy. Fatal Termination from Haemorrhage.—The patient was thirty-five years old. She had had two children. For about one year before the ovarian tumor was detected she suffered from menorrhagia. AVhen I first saw her she was quite anaemic from long-continued and pro- fuse menstruation, caused by polypoid fungosities of the uterine mucosa. She was promptly relieved by curetting. At that time the ovarian cyst was about the size of a pregnant uterus at four and a half months. The cyst increased in size rather slowly. She had two attacks of circumscribed peritonitis, one at the upper part of the cyst, which gave rise to adhesions to the abdominal wall above and to the left of the umbilicus. About eight months from the time that I first saw her, and after the slight attacks of peritonitis, she was attacked with severe pain in the region of the cyst, but there was no evidence of inflammation. At this time the cyst became very tense, and there was general tenderness and heavy pressure. These symptoms subsided for a time, but there were several attacks of this kind, each one being marked by a sudden increase in the tension of the cyst. The patient continued to be rather anaemic, there were wandering, ill-defined pains in the abdomen, and the general condition showed that she suf- fered more than is usual in cases of uncomplicated ovarian cystoma. This led to the determination to operate, though the size of the cyst did not demand immediate interference. When the wall of the abdomen was opened, and the cyst exposed, it was darker in color than it should be; adhesions were found at the upper and left side, and also low down and near the median line. Tapping was tried, but the contents of the cyst would not flow. The sac was then opened, and its contents were found to be blood and old blood-clots with very little ordinary ovarian fluid. It was neces- sary to pass the hand into the cyst to evacuate its contents; this caused fresh and profuse bleeding. The patient showed the loss of blood very rapidly; great haste was made to separate the adhesions, which were very vascular and required ligating. The depression became more and more marked, and it looked as if the patient would die on the table. The cyst was hurriedly re- moved, and the abdominal wall was closed. There was some oozing from the adhesions, and, as there was little time for sponging the peritoneal cavity and stopping the bleeding, which was only a very little oozing, a drainage-tube was used. The patient ralhed a little, 538 DISEASES OF WOMEN. and there were hopes that she might be saved. There was consid- erable discharge of bloody serum from the tube, which, in place of becoming less, as I expected it would, increased. AVhenever the pulse improved, and the patient gained a little strength, the bleed- ing increased. It was never free enough to warrant my opening the abdomen to stop it, but kept on just enough to keep the patient down. At the end of the third day there was very little bleeding, and there was a promise of success, but then she began to show signs of heart-clot, and she died on the fourth day. The inside of the cyrst was lined with a layer of papillomatous material, which presented a cauliflower appearance not unlike that of epithelioma of the cervix uteri. The points of greatest interest in the history of this case are the frequent haemorrhages which took place in the cyst during its growth and the unsatisfactory character of the operation which permitted the loss of so much blood. There is no doubt in my mind but that the attacks of distress and extreme and sudden distention of the sac were due to the haemorrhages in the cyst. This view of the matter was confirmed by the large number of blood-clots which were found during the operation. The evidence of these extra cystic haemor- rhages was so marked and peculiar that I am sure a diagnosis could be made with certainty in similar cases. This would be a great gain, because it would enable one to operate before the frequent losses of blood had weakened the patient, and while the cyst was small, and could be more easily removed—two advantages which would tend to the safety of the patient. There were several unfortunate incidents in the operation which could have been in part prevented had I had more experience in such cases. In the first place, when the patient was anaesthetized, the cyst was handled with considerable force for the purpose of de- termining the presence and extent of the adhesions. This, I am sure, started the bleeding, which might have been avoided. AVhen the cyst was opened, and the active haemorrhage detected, I should have found the pedicle, and temporarily controlled it with com- pression-forceps. This would have saved much of the haemorrhage, and then I could have taken time to treat the adhesions properly. These facts, I believe, explain fully the failure in the case, and they throw much valuable light on the diagnosis and treatment of this peculiar variety of ovarian neoplasm. Ovarian Cyst between, the Folds of the Broad Ligament. Incom- plete Removal of the Cyst; the Remaining Portion treated with Drain- age ; Recovery.—This lady was thirty-five years old, and had been ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 539 married nineteen years. Her general health had been fairly good, but she did not menstruate until she was nineteen years of age. The menstrual flow had always been scanty and of short duration, and she never had been pregnant. These facts indicated that probably the sexual organs were im- perfectly developed. About one year before she came under my care she noticed a small tumor in the right side of the abdomen, low down. It steadily increased in size, and then she lost flesh and strength, and suffered from pain in the abdomen and back, and her appetite failed. AVhen first seen by me she had a bronzed appear- ance, was feverish, and the pulse was fast and rather weak. She had the general appearance of one in the last stage of ovarian dropsy, and also cachectic. The tumor was about the size of the uterus at the seventh month of pregnancy. It was very hard, and fluctuation was very indistinct. Though not apparently adherent to the abdomi- nal wall the tumor was not at all movable. It was firmly fixed in the pelvis, and there was much tenderness. By the vaginal touch the hard tumor was found deep down in the pelvis, firmly fixed, and not the slightest fluctuation or elasticity could be detected. The uterus was pushed to the left and upward, so that it partly occupied the left iliac fossa. The irregularity of the surface of the tumor, as felt through the vagina, indicated that it was surrounded byT the products of inflammation. The physical signs, as observed by the vaginal touch, were such as would indicate a uterine fibroid developed in the right broad liga- ment, but the character of the tumor, as felt in the abdomen, showed that it was a cyst. The question of fibro-cyst was then raised, but the history of the case was not in favor of this. AVhile there was little doubt regarding the true nature of the tumor I fav- ored the diagnosis of ovarian cyst complicated by inflammation of the cyst-walls. The patient was placed under treatment in the hope of improving her digestion and general health, but beyond relieving her consti- pation and flatulence there was no real gain. Her pulse remained about 98, and her temperature fluctuated between 99° and 101°. During the few days that she was under observation the cyst became a little less tense so that fluctuation could be more surely made out. The chief points of interest in the operation were as follows. The tumor, easily and fully exposed by an incision three inches long through the abdominal walls, was adherent to the omentum over its entire anterior surface. The cyst was emptied by aspiration of its con- tents which contained pus and lymph. The omentum was hgated 36 540 DISEASES OF WOMEN. in sections with silk, and detached from the cyst-wall. It was then found that the folds of the broad ligament covered the cyst com- pletely, and were so intimately blended with the walls of the cyst that they could not be separated to any extent. Careful and persist- ent efforts were made to enucleate the cyst, but in vain. The open- ing in the cyst was temporarily closed with forceps, and the left ovary looked for. It was found far over on the left side and con- tained several small cysts. It was removed in the usual way. The major portion of the cyst-walls and broad ligament was then re- moved, and the larger vessels ligated to control hemorrhage. An- other effort was made to enucleate the remainder of the cyst-walls, but they extended so deep down into the pelvis and the tissues were so exceedingly vascular and matted together by inflammatory prod- ucts that it could not be done. The remains of the ligament and cyst-walls were carefully stitched to the abdominal wound, the sac carefully sponged clean, and a large drainage tube introduced. The after-treatment and progress of the case were as follows: She had for the first two days considerable nausea and pain. For this she was given hypodermic injections of morphine. The sac was washed out thoroughly every four or eight hours according to her temperature. There was not much nourishment taken during the first six days. The pulse and temperature varied greatly. The pulse kept above one hundred most of the time, and the temperature fluctuated between 100° and 102° and occasionally 103°, but this high temperature never lasted long at a time. During the first ten dayTs the morphine was required, and stimu- lants had to be used. In spite of the frequent washing out of the sac and free drainage there was some blood-poisoning. Quinine was freely given (whenever the temperature went up) by the rec- tum and by inunction, From the twelfth day onward there was not much of interest. The patient's nutrition was poor, the pulse and temperature kept a little above normal, and occasionally the temper- ature rose to 101°, rarely to 102°. The sac cavity gradually dimin- ished, and the discharge became less. At the end of the third week the temperature was normal and remained so afterward. She took food well, and began to gain strength and flesh. The cavity was very small, and the drainage-tube used was a piece of a No. 10 elas- tic catheter. The wound had completely healed, except where the tube was in place, at the end of the fourth week. Five weeks after the operation, and when the patient was up and apparently about well, there came a swelling quite hard at the side of the sinus, and the temperature went up to 102°. It was sus- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 541 pected that an abscess was forming there, and in the hope of reach- ing it, if suppuration occurred, the opening was enlarged, and a tube of greater caliber introduced, but the swelling entirely subsided and the tube was removed. The patient was discharged in good condition two months after the operation. A Medium-sized Ovarian Cyst which could not be removed owing to the Character of the Adhesions; treated by Drainage; Recovery.— The patient, a German lady, thirty-four years of age, was admitted to the hospital, and gave the following history : She had had several children and had noticed a " lump " in the abdomen about one year before my first examination. This gradually but slowly increased, and at times there was pain but not severe, until about four months after she discovered the tumor. At that time she was seized with violent pain in the abdomen, especially on the right side. According to the history she evidently had at that time a severe inflammation. This slowly subsided under the care of her family physician, but she did not regain her health, and continued to lose flesh, her bowels were constipated, and there was much pain and tenderness in the region of the tumor. The size of the tumor increased, and it was much more prominent on the right side. At my first examination, I found the tumor firmly fixed on the right side, the adhesions to the abdominal walls and viscera being evident at all points, especially high up in the lumbar region on the right side. The fluctuation though not clear, was sufficiently so to indicate that the tumor was a monocyst. Her general condition was very poor, she was greatly emaciated, her skin was bronzed, and she had the general appearance of one suffering from malignant disease. Her pulse was feeble, and her temperature varied between 98° and 100°. She had pain and tender- ness in the abdomen, especially on moving. Efforts were made to improve the general health, but without effect. The points of special interest in the surgical treatment were the following : The abdominal wall at the point of incision was very vascular, and the adhesions were also thick and vascular, and were with difficulty separated from the cyst-wall. On tapping the sac it was found that the contents contained lymph and some pus, show- ing that there had been inflammation of the interior wall of the cyst. On the left side the abdominal wall was separated sufficiently to en- able me to pass my fingers into the peritoneal cavity, and there I found the intestines adherent to the cyst-wall. I tried first to sepa- rate the adhesions but that could only be done by dissection, and the 512 DISEASES OF WOMEN. bleeding was such that I had to abandon that procedure. I then tried to dissect the peritonaeum off from the cyst-wall and leave it attached to the intestines, but this was impossible. In a dissection about an inch long and half an inch in width I had to use three ligatures to stop the bleeding. I also found that every portion of the sac was fastened in by strong and vascular adhesions which I knew I could not separate without losing my feeble patient. The fact is I could not remove any considerable portion of the sac, only a very small portion in front. I thoroughly cleaned out the sac, and stitched the edges to the abdominal wall. This was easily7 done because the cyst was adherent all round to the abdominal wall, except on the left side. A large drainage-tube was introduced and the sac washed out with carbolized water twice or three times a day. The patient did well. She began to gain soon after the opera- tion, and continued to increase in strength slowly, but without in- terruption ; at the end of two weeks after the operation the sac had contracted very much, and there was considerable suppuration. The long tube was removed, and a shorter one was used to maintain the opening in the abdominal wall. The thorough washing out was kept up, and about five times in all I distended the sac with equal parts of carbolic acid and tincture of iodine. This destroys the secreting surface of the sac, suppuration followed, and the sac contracted grad- ually. At the end of two months there was little more left than a solid mass with a narrow and not very deep sinus in it. The patient was sent home, and directed to wash out the sinus daily. She was not seen again until five years after, when she returned to the hospital to see my associate Dr. Palmer. She had greatly improved in appearance, and stated that she had been quite well, and had attended to her household duties since she left the hospital after the operation. The opening in the sac remained for four months after she went home, but finally closed altogether, and gave no trouble afterward. She had a ventral hernia, which appeared at the point of the wound two years after the operation. I am satisfied that in certain cases in which the adhesions are extensive and very vascular that it is safer to leave the operation uncompleted, and employ drainage. I have had five successful cases treated in this way, and one very bad case that proved fatal, but probably would have recovered had the patient not had organic disease of the kidneys, of which she died. Mature judgment, based upon experience alone, can enable one to de- termine when to employ drainage in place of removal of the tumor. The only way to determine this is to examine the extent of the ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 543 adhesions, and whether or not they can be separated without injury to the abdominal viscera. Should the cyst prove unmanageable by the operator, the part of it which can not be removed should be left and treated by drainage, and washed out with antiseptics. I am well aware that an expert and experienced operator can manage very formidable adhesions, but, when an operator of limited ability en- counters adhesions that he can not handle safely, he will be more sure of success if he relies upon draining the cyst or that part of it which can not easily be removed. Recovery is sometimes tedious, but generally sure, according to my observations. The following cases of suppurating ovarian cysts, reported by Dr. Keith, together with his comments on them, are of such great value that I quote them in full: SUPPURATING OVARIAN CYSTS. The following narratives help to show that operation ought to be the rule of practice in cases of acute suppurating cysts, or when typhoid symptoms come on after tapping : Ten years ago, when cases of ovariotomy were few, and there was little to guide one in unusual circumstances, a young woman in the last stage of ovarian disease came to me a long journey from the north. The fatigue of traveling was too much for the strength that was left, and she arrived completely worn out. It did not seem possible that, in such a condition, life could be prolonged many days, for the pulse was almost imperceptible, there was vomiting and diar- rhoea, (edematous limbs, and albuminous urine, while a profuse fetid discharge was going on from an opening near the umbilicus. The intensity of this putridity was such that one became aware of it before entering the house, and the antiseptics of those days were powerless to arrest it. Day7 after day I went expecting and hoping to find her dead, yet, though shriveled up like a mummy, with an aspect scarcely human, respiration went on for nearly a month, the brain retaining its clearness, acutely alive to what was going on around. To remove a putrid cyst in such a condition of feebleness did not at that time even occur to me; yet, since then, I have oper- ated more than once under circumstances not less unfavorable, and, looking back upon this case now, I think that operation might have turned out well; certainly death after it would have been the more merciful way. Soon again (December, 1804) there came another case of very large tumor. The patient had been jolted for some hours in a coach, 544 DISEASES OF WOMEN. and, in the hope of relieving the pain thus set up, tapping was per- formed after her arrival. The pain was not reheved, abdominal distention from flatus became excessive, and typhoid symptoms rap- idly set it. Fearing a repetition of the slow-death process—which those who saw will not easily forget—ovariotomy was this time per- formed during the semi-delirium of septic fever. This was proba- bly the first time that surgery broke in upon an acutely inflamed peritonaeum. The intense lividity, amounting almost to blackness, of the abdominal contents, and the spongy tenderness of inflamed intestine, were then strange to me, though thought little of now. Recent lymph was present everywhere, adherent bowel and mesen- tery hedged in a thick-walled cyst, the base of which was in a com- plete state of slough. Inflammation had gone on to gangrene, and there was intense putridity, just as in the previous case. After an operation which went on for two hours, the patient was placed in bed, cold, vomiting, and nearly pulseless. It seemed as if we had simply killed her, yet she got rapidly into heat, the restless delirium at once disappeared, there were warm perspirations, much sleep, and a recovery without a drawback. This case, which was at the time fully reported in the " Lancet,"' 1865, page 480, has been to me as a landmark. Since then I have ten times met with cases of acute suppurating cyst, besides two chronic cases. In all of these, save one, the chance of ovariotomy was given, however hopeless looking the case might be. In the exceptional case ovariotomy would also have been performed had it been possible to remove the patient from her poor home and un- favorable surroundings. She was seen with Dr. Menzies on the third day after her fourth confinement. He had been called to her for the first time only the day before. A large ovarian cyst had existed with at least two of her pregnancies. The distention was so enormous that urgent dyspnoea had to be relieved at once by tap- ping. Upward of six gallons of fluid, containing much blood and pus, were got away, and ovariotomy was agreed on as soon as she could bear removal. This could not be accomplished, and, after three weeks, tapping was again had recourse to. This time the pus was intensely putrid, and, as the cannula got choked with pieces of fetid lymph, an incision, sufficient to admit two fingers, was made into the cyst, and its putrid contents thoroughly cleared out. For- tunately, the cyst was single; a perfect recovery took place, and this patient has had two children since. Xone but the strongest of women could have borne the exhausting suppuration that went on for nearly four months. Pulse and temperature remained high, and ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 545 of at least six weeks of her illness she has now almost no remem- brance. Recovery in such circumstances must be rare; yet it may be well to note that during the whole time she was supported en- tirely on milk and buttermilk, and had no stimulants whatever; neither was there any washing out of the cyst. Of the ten more or less acute cases operated on, eight recovered, while the two chronic cases got well easily. During 1872-73 sev- eral came about the same time, and the following series of seven occurred in the course of my second hundred operations for ovarian tumor, none of which have yet been published. To an onlooker, few operations look so hopeless as those for the removal of acute suppurating cysts. The general condition is always unfavorable, and, as a rule, ovariotomy is in these circumstances tedious and se- vere. To be believed in, such cases need almost to be seen. Suppurating Ovarian Cyst; Ovariotomy; Recovery.—Mrs. M., aged thirty-five, was sent to me in the end of June, 1871, by Dr. Soutar, of Golspie. An ovarian tumor was detected toward the end of 1869. In January, 1870, she had severe abdominal pain. After a fortnight's rest, this passed off, but only to return with increased severity. Loss of flesh and rapid growth of the tumor followed, and it was nearly a whole year ere she was again able to be out of bed. During this time her sufferings, as told by a friend, must have been great. Often for weeks together she could not be moved from one position, while the changing of her dress, or the arranging even of the bedclothes, brought on such pain that her cries were heard in the street. It was eighteen months after her first illness that she was able to make the journey to town. I saw her after she had rested two days. The pulse was then 156; the temperature 103°. She was a tall, fair-complexioned, blanched-looking woman, ex- tremely emaciated; the lips and fauces were very anaemic; the girth at the umbilicus was forty-six inches; the lower part of the tumor felt solid, but fluctuation was distinct above the umbilicus; the ab- dominal wall was hard, thickened, and oedematous; the skin even in some places feeling as if adherent. It was evident that there were adhesions of a very unusual nature. Two days after this examination, with the assistance of Dr. Drum- mond, of Nice, I removed three gallons of thick pus by tapping some inches above the umbilicus. A large, prominent, hard tumor re- mained below this. Much relief followed, and for a few days the pulse and temperature somewhat fell. In three weeks the cyst had refilled; the pulse was again rapid and feeble, varying from 120 to 546 DISEASES OF WOMEN. 160; the morning temperature was 101° to 102° ; that of the even- ing, 103° to 104°, sometimes higher. The skin was dry and shriv- eled, and she was, if possible, thinner than before. Ovariotomy was performed on the 13th of July, 1871. Sul- phuric ether was given. The incision extended from the umbilicus downward eight inches. The wall was much thickened, the peri- tonaeum of almost cartilaginous hardness, and the whole parts so un- usually vascular, that no time had to be lost in completing the oper- ation. The upper cyst was emptied of its purulent contents, the lower semi-solid portion thoroughly broken down, and the cyst- walls, weighing eighteen pounds, dragged out. There was not any part of the tumor non-adherent. The connections were of the ut- most firmness, especially those in the pelvis. Posteriorly7, there was more adherent intestine and mesentery than I have met with except twice. The peritonaeum was thickened by old lymph. Large flakes, like pieces of cartilage, were peeled off the wall after removal of the tumor. Some of these were as large as the hand, and it was difficult to tell what really was the peritonaeum. All bleeding points were tied with Lister's ligatures, a broad, thick pedicle secured by a clamp, and the wound closed with silk sutures. The operation lasted upward of an hour; much blood had been lost, and she was placed in bed with great fears for her immediate safety. She lay for some hours with an almost imperceptible pulse. She was restless, and great bursts of clammj7 perspiration broke out every now and then, such as one sees in those suffering from the shock of injury. Fortunately, there was no vomiting. By evening she was comfortably warm; flatulence was troublesome ; there was much thirst. Pulse, 125.; respirations, 32 ; temperature, 102.° She slept during the night, but got low and faint toward morn- ing, and there was some vomiting. Brandy and soup enemata were given every two or three hours. She improved toward evening. Flatus first passed forty-four hours after operation. The pulse was rapid and feeble, and she scarcely opened her lips for many days. In the third week there was pain and swelling in the right iliac fossa, and fluid formed. Four weeks after operation this swelling was punctured, and about a teacupf ul of yellow serum was removed by a syringe; the rest was absorbed. She was able to return home in five weeks, and is now a strong, healthy woman. CHAPTER XXX. DISEASES OF THE FALLOPIAN TUBES. Before considering the various morbid conditions of the Fallo- pian tubes, I shall briefly review their anatomy. The tubes—one on either side—are contained in the broad liga- ments, and run transversely from each lateral corner of the uterus out to the ovaries, to which they are joined by a short, ligamentous cord. Each tube, or salpinx, is four to five inches long; the right tube is usually slightly longer than the left. The diameter in- creases from the uterus toward the ovary; and the canal similarly increases. They are formed of an external peritoneal covering, of an internal mucous surface, and of an intermediate proper muscular tissue, arranged in two layers, of which (1) the longitudinal seems to be a prolongation from the uterus ; while (2) the circular, pecul- iar to the tubes alone, ends as a kind of sphincter upon the abdomi- nal orifice. The mucous membrane is lined by cylindrical epithelium, the motion of whose cilia is toward the uterus. Numerous fusiform cells are found in an incompletely-developed connective tissue. The arteries arise from the utero-ovarian trunk, entering the substance of the tube at its lower border. The veins empty into corresponding vessels. The nerves come from the hypogastric and ovarian plexuses. A study of the development, in the embryo, of the female or- gans of generation, shows the closest structural relationships existing between the tubes and uterus. Some observers claim that part of the menstrual blood comes from the tubes. Anomalies of form and situation are frequent; the tubes may be absent; there may be only one tube ; alternate stenosis and dila- tation may exist; and there may be marked difference in length be- tween the two tubes. Two abdominal orifices for a tube may exist, and fimbriae from each may project into the peritoneal cavity,, 548 DISEASES OF WOMEN. Again, the tube may be dislocated, twisted, bent into knuckles, or may have suffered hernia along with portions of the intestine. The tubes may open into the womb abnormally low down, which may possibly account for placenta praevia in some cases. The tube may be completely separated from the ovary. A rare condition is hernia of the mucosa, where the muscular tissue is ab- sent or so weak that it allows the mucous membrane to protrude, forming a pocket into which the fecundated ovum may drop. Neoplasms may be found in the tubes; among them tubercle, carcinomata, sarcomata, cysts, fibromata, myomata, lipomata, and papillomata. Morgagni's hydatid is a vesicle often hanging to a fimbria. Cysts, tubercles, and fibromata are the most frequent of these neoplasms, but even these are so rare that they need only to be mentioned here. So many morbid tubal conditions are either direct or indirect sequelae of salpingitis or " catarrh of the tubes " that this condition first demands attention. Salpingitis.—Inflammation of the tubes may be acute or chronic. Pathology.—In acute catarrh the mucous membrane of the tube is thickened, congested, and covered with neutral or acid mucus, muco-pus, or an opaque fluid which contains lymph-corpuscles and epithelial cells which are changed in form or which have undergone granular degeneration. The longitudinal folds of the mucosa are effaced; the fimbriae are obliterated or obscured by inflammatory products, and the ends of the tubes are usually closed. If not, the contents of the tube enter either the uterus or the abdominal cavity in which latter case pelvic peritonitis results. In very severe cases (and sometimes in diph- theria) false membranes may be formed in the mucosa. Peri-salpingitis usually occurs in severe cases. The tube is in- creased in size, tortuous, and dilated irregularly, and when the puru- lent secretion accumulates the tube which is closed at each end be- comes greatly distended. This is known as pyosalpinx. In this condition the epithelia are flattened and the mucous and muscular coats are gradually thinned, so that rupture into the peritoneal cav- ity is not infrequent, in which case general peritonitis or pelvic peritonitis results. In rare cases the rectum has been perforated and the contents of the tube discharged through that viscus. Chronic catarrh is accompanied by the adhesions of the tube to the neighboring organs in some cases, the result of localized perito- nitis. The lower part of the tube is adherent oftener than other adjacent parts. The ovary is also congested or inflamed in the ma- DISEASES OF THE FALLOPIAN TUBES. 549 jority of cases. The mucosa is much thickened, and secretes a fluid which is either thin and watery or thick and cheesy, not purulent as in acute salpingitis. Occasionally, chronic dropsy of the tube is the result of the secre- tion of serous fluid, and the tube may become distended and form a small cystic tumor; or, it may be converted into several distinct cysts without any intercommunication, since the tube between them has been totally obliterated by the inflammatory process. This is known as hydrosalpinx. In this condition all the coats of the tube sometimes become extremely thin. Dropsy of the tube may suddenly terminate when an opening of the duct into the uterus occurs ; this, however, is very rare. Cases are recorded where a hydrosalpinx has communicated with an enlarged and diseased ovary. Symptoms.—This affection so often follows gonorrhoea or endome- tritis that the symptoms of salpingitis are merged with those of the primary7 disease or are completely masked by them, until pelvic peritonitis occurs. This is the most dreaded outcome of salpingitis, and too frequently the first symptom which leads one to suspect its occurrence. Usually, however, when salpingitis occurs there is an increase in the symptoms so marked as to attract attention. The pain though less pronounced than that of peritonitis, is sufficient to compel the patient to rest in the recumbent position. There is usu- ally some constitutional disturbance or slight symptomatic fever. In acute cases this fever is well defined, and attended with deranged digestion and nutrition. In short, it may be stated that the local and constitutional symptoms are the same as in other pelvic in- flammations, less acute than in pelvic peritonitis or pelvic hem- atocele, but as well marked as in pelvic cellulitis of a mild type. AVhen pyosalpinx occurs there are symptoms of mild blood poi- soning. Menstrual disturbances usually occur in salpingitis but not al- ways. It frequently happens that the severity of the symptoms is lessened, indicating that the inflammation has subsided, but it again lights up, and becomes for a time as marked as at first. Periodical watery fluxes with diminution in the size of a swell- ing in the region of the tubes, and accompanied by colicky pains, are indicative of tubal dropsy where the tube is incompletely closed near the uterine end. Physical Signs.—In the first days of the inflammation before the tubes are distended the chief sign is tenderness in the region of the tubes. When a tumor can be made out it is felt to be elongated, 550 DISEASES OF WOMEN. fluctuating, movable, not separable from the uterus, and lying on one side in the retro-uterine space. By aspirating, a fluid which contains columnar ciliated epithelium is found. Of twenty one cases in which the fluid was examined by my colleague Dr. F. Ferguson, this epithelium was found in nineteen. This is a most valuable diagnostic sign, but as aspirating is not without danger it should not as a rule be resorted to. Except when the tube is enlarged a positive diagnosis of salpin- gitis can not be made. The condition with which salpingitis is apt to be confounded is a small ovarian cyst. It is impossible, often, to positively decide this question immediately. By waiting and watching the case the ovarian cyst will be found to gradually become larger without any increase in the constitutional symptoms; while in tubal disease the increase in size is limited. Prognosis.—I believe that salpingitis may subside, but as a rule the tube is obliterated entirely or in part. When hydrosalpinx oc- curs there is not much chance of recovery. In pyosalpinx recov- ery can only be insured by removal of the tube. Causation.—Gonorrhoea of the uterine mucosa, and simple and puerperal acute endometritis are its chief causes; but it may occur during the course of any acute infectious disease, from the presence of neoplasms or from intense hyperaemia of the generative tract, as in prostitutes. It is possible that syphilis may cause it just as it causes otitis or ozaena. Sometimes it is secondary to diseases of the ovaries. Microbes may find entrance into the tubes, and on this (not yet proved) statement, Sanger, of Leipsic, classifies salpingitis as S. gon- orrhoica, S. tuberculosa, and S. actinomycotica. He also has a salpin- gitis septica including S. pyaemica, ichorosa, purulenta, and diphthe- ritica, which are due to specific microbes identical with those produc- ing traumatic infection. Treatment.—Acute and subacute salpingitis, in the early stages, should be managed in the same way as other inflammations of the pelvic organs and tissues. Rest and anodynes for the relief of pain ; counter-irritation and attention to the bowels are the chief indica- tions. When the acute symptoms subside, iodine, ichthyol, and mercury have been used locally, and massage and electricity also, with some possible good results. AVhen once hydrosalpinx or pyosalpinx is developed it is doubt- ful if any treatment except laparo-salpingotomy is effective. Cer- tainly this is the case in pyosalpinx. DISEASES OF THE FALLOPIAN TUBES. 551 Laparo-salpingotomy, as first practiced by Tait and Hegar is the recognized treatment in these otherwise incurable diseases of the tubes, and the results are very satisfactory. It is not always possi- ble to ascertain whether hydrosalpinx or pyosalpinx exists; hence it is wise to perform laparotomy and remove the diseased tube if the subject of pyosalpinx; should a hydrosalpinx be found it may be deemed best to try stripping the tubes or catheterizing and cleaning them out and restoring them to their normal situation, and trusting to curing the trouble thereby. This has been tried by Polk, but the results are not sufficiently well known to determine the merits of this procedure. In the former case the woman is sterile, in the latter not necessarily so. TUBERCULOSIS OF THE TUBES. Pathology.—In this condition the tubes are rigid, thick, and bound down by7 pseudo-membranes. The thickening results from infiltration. Acute catarrhal salpingitis usually co-exists. Both ends of the tube are usually closed but between them the cavity is much dilated, containing mucus, muco-pus, pus, or cheesy debris. The vessels of the tubes are enlarged and thickened and the nodules upon them, as well as the nodules on the mucosa and in the muscularis contain the tubercle bacillus. Symptomatology.—The tubercular diathesis which is usually present is the only indication of the nature of this affection. It may be possible to recognize the dilated tube by palpating the abdomen, and by manual examination when its immobility, size, tortuosity, and nodular feel, taken in connection with the constitutional conditions causes us to suspect tuberculosis of the tube. Possibly7 the dilated tube may be felt by a vaginal examination. German gynecologists advise that the secretions from the uterus should be examined for the bacilli which if found are evidence of tuberculosis. Treatment.—Were it possible to diagnosticate isolated tubercu- losis of the tubes, extirpation would afford a means of (possible) radi- cal cure. HEMATOSALPINX. Blood in the tubes induces hypertrophy of the walls except at one point, which, growing thinner and thinner, forms a sac varying in size from a pin's head to an orange. Any portion of the tube 552 DISEASES OF WOMEN. may be the seat of such a tumor. Fatty degeneration or ulceration of the walls of the tube may induce rupture and peritonitis. At times the uterine end of the tubes permits of partial or complete evacua- tion of the tumor. Symptomatology.—The symptoms are the same as those of hydro- salpinx except that they are more acute at first, and at the time of the menses are all markedly increased in intensity7. Etiology.—Intense hyperaemia of the genitals, retroversion, typhoid fever, measles, and purpura haemorrhagica have been known to cause haematosalpinx. When blood can not make its way out of the uterus it may flow back into the tubes. There is no doubt, how- ever, that the mucous membrane of the tubes alone is capable of being the source of the haemorrhage. Treatment.—Laparo-salpingotomy is the proper treatment, and if the diagnosis is made the tube should be removed before peritonitis occurs. The prospects of a favorable result are then very good. LAPARO-SALPINGOTOMY AND OVARIOTOMY. The operation for the removal of the tubes and ovaries differs in many respects from that of ovariotomy for cystomata, and requires a word of description: The incision in the abdominal wall should be short, just sufficient to admit two fingers. Extra care is necessary to avoid wounding the omentum or bowels. If the intestines are adherent to the ab- dominal wall, the incision should be enlarged in order to find a part where there are no adhesions, before opening the peritonaeum. This is easier than to separate the intestines. This complication is, fortunately, seldom met. I have often found the omentum adherent to the intestines, and occasionally to the abdominal wall near the median line, but it is generally free on one or both sides, so that the tubes and ovaries can be reached by passing the fingers beyond the adhesions and pushing the omentum to one side. When no free part can be found, the omentum should be picked up and divided in the incision, and the bleeding vessels tied. Two fingers should be passed into the wound and the fundus uteri found. This is a guide to the tubes. Adhesions, which are usually present, should be separated gently; and when both tube and ovary can be found, they should be hooked up with the fingers and brought out through the wTound, or into it. By traction in this way a pedicle is found and included between the fingers, when it can be transfixed and tied. The Staffordshire knot is the best to use. Much skill, which can only be obtained by practice, is required DISEASES OF THE FALLOPIAN TUBES. 553 to separate the adhesions and bring out the tubes and ovaries. If the adhesions are old and can not be broken up easily, it is safer to enlarge the wound and tie and divide them. If the tubes are largely distended and their walls thin, the adhe- sions should be separated only where that can be easily done and the tubes emptied, or partially so, with the aspirator, and then seized with the forceps and brought out and the adhesions separated. The pedicle is then ligated, and tube and ovary removed. Where there are many adhesions there will be some bleeding, which usually can be stopped by pressure, but it is safe to drain for a day or so. The after-treatment is the same as after ovariotomy in general. ILLUSTRATIVE CASES. Hydrosalpinx; Repeated Discharge of the Contents of the Tube through the Uterus; Recovery.—My friend Dr. William H. B. Pratt, called me to see a rather delicate and very refined lady, wTho gave a history of some rather obscure pelvic affection, which had ex- isted for more than a year. The doctor found, when he was first called to see her, that she had a retroversion of the uterus, and pre- sumed that this was the whole cause of her suffering. He was able to restore the uterus to its place, but could not keep it in place, be- cause a pessary or cotton tampon caused great suffering. This was the history at the time that I saw her. I also learned that she was unable to ride or walk for any length of time, owing to the severe pelvic and rectal tenesmus, which the erect position brought on. By a digital examination, I found the retroversion of the uterus, and also a cystic tumor, low down on one side of the sac of Douglas. The tumor was oblong and elastic, and there was distinct fluctua- tion. I suspected that it was an ovarian cyst. Treatment gave her some relief, but she did not recover. She had repeated attacks of pain in the pelvis, and suffered so much on taking exercise that she was obliged to live an invalid life. Some time after seeing her the first time, she menstruated more freely than normal, had more pain and discomfort than usual. Soon after the menses she had a sudden and free discharge of fluid of a whitish, turbid character, and was much relieved after it. I exam- ined her soon thereafter, and found that the cystic tumor had en- tirely disappeared. Her symptoms, though modified for a time, returned again, and again the tumor was found in the same place. Another discharge of fluid occurred, followed by relief and the dis- appearance of the tissues. This much of the history, in the way of filling and emptying of 554 DISEASES OF WOMEN. the tube, was repeated a number of times with this difference—that the accumulation of fluid was less. I regret that 1 do not have notes of the length of time that the trouble lasted, but it will suffice to say that the patient recovered completely, and has had no return of her hydrosalpinx of seven years ago. Double Pyosalpinx; Recovery without Operative Interference.— The notes of this case were given to me by Dr. Buckmaster. The history is a rare one, and is of special interest. I have in the past doubted if ever pyosalpinx ended in recovery without removal of the tubes, but this case shows that such may occur. The patient was married, and twenty-five years old. She had an abortion pro- duced, and peritonitis and salpingitis followed this maltreatment. Dr. Buckmaster saw her two weeks after the time of the abortion. She was then suffering from severe pelvic inflammation. The tem- perature was at that time 104° F. There was marked pain, tender- ness, and abdominal distention. The products of the inflammation quite filled the pelvis, and there was fixation of the uterus. She was treated in the usual way by the doctor, and, at the end of two months from the time that she first came under his care, " the in- flammatory products had largely disappeared, and the utenis was slightly movable, but on each side there were two masses about the size of small lemons. Several days afterward there was a sudden discharge of ill-smelling pus. On examination at this time it was found that the mass on the left side had disappeared. Soon after this there was another free discharge of pus, and the mass on the right also disappeared. For three months subsequently there was a slight but constant discharge of pus from the cervix uteri, but finally it ceased. One year from the attack the patient was in fair health, but suffered from pelvic pain at times, which appeared to be due to adhesions of the peritonitis. The histories of many cases of pyosalpinx might be given in which no benefit could be obtained by general treatment, but were promptly relieved by salpingotomy. In fact, the only reliable treat- ment for the relief of this affection of the tubes is to remove them. The operation is the same as for the removal of the ovaries, and need not be described here. Those who desire full details of this subject are referred to the works of Lawson Tait, whose brilliant achievements in this department of surgery were the first and greatest. No case of haematosalpinx has come under my observation, hence the reader is again referred to Lawson Tait for cases illustrating this subject. CHAPTER XXXI. PELVIC CELLULITIS. The anatomical distribution of the pelvic cellular tissue is the same as that in all other parts of the body, and its function in this region is also the same as elsewhere. It fills in all the interspaces between organs and tissues, being most abundant where there is the greatest mobility, and it is the principal accommodating and protect- ing medium through which the blood-vessels and nerves are con- veyed to all parts of the body. In the pelvis it fills all the unoccupied spaces lying between the Fig. 205.—Diagrammatic transverse section of the pelvis (Luschka). 37 556 DISEASES OF WOMEN. pelvic organs, except between the peritonaeum and the middle por- tion of the fundus uteri. At that point it exists (if at all) in so small a quantity that it can not be demonstrated. Inflammation of the cellular tissue here located has received many names—pelvic cellulitis, peri-uterine cellulitis, parametritis, peri-uterine phlegmon, pelvic abscess, and inflammation of the broad ligaments. I prefer the term pelvic cellulitis, which was given to it by Sir James Y. Simpson because it indicates the nature and location of the disease. Inflammation of the cellular tissue may occur wherever that form of tissue is found, hence the term pelvic cellulitis does not definitely locate the site of the disease, and yet the name is as spe- cifically descriptive as any of the other terms used. Moreover, pel- vic cellulitis, limited to the areolar tissue around the cervix uteri, and between the folds of the broad ligaments, comes under the ob- servation of the gynecologist more frequently than in any other location in the pelvis; hence it should be understood that the term pelvic cellulitis is here applied to inflammation of the cellular tissue, located in the broad ligaments and about the supravaginal portion of the cervix uteri. Pathology.—This differs in no respect from inflammation of cellular tissue elsewhere, except so far as it may be modified by the peculiarities of the location. There is, first, a stage of active con- gestion, followed by an effusion of blood serum, and later, an exuda- tion of the higher organized constituents of the blood, and, finally, suppuration. In some cases the inflammatory process stops short of suppura- tion, and the products of the inflammation are removed by absorp- tion, and the recovery is soon completed. This is called ending in resolution. There are a few cases in which the products of the mor- bid process are packed so densely into the tissues that the circula- tion is arrested and the cellular tissue destroyed, and a dead mass or slough is formed. These cases, fortunately rare, are very severe, and sometimes fatal. They7 are also complicated with inflammation of other organs in the pelvis, as a rule. In fact, fatal cases are generally complicated, the uncomplicated cases rarely proving fatal. When suppuration takes p ace, the pus usually makes its escape by some one of the following avenues, mentioned in the order of frequency as nearly as can be: Yagina, rectum, bladder, abdominal walls, saphenous opening, pelvic floor near the anus, pelvic foramina, obturator or sacro-ischiatic foramen, and through the pelvic roof into the peritoneal cavity. PELVIC CELLULITIS. 557 I have seen three cases in which the pus from an abscess in the broad ligament burrowed outward to the iliac fossa, and then ex- tended upward to the diaphragm, and in one it opened through the lung into the ?arge bronchial tube. Brief histories of these cases will be given at die end of this chapter. AVhen the pus escapes into the vagina or rectum at the most de- pendent part of the abscess sac, the evacuation is usually complete, and the after-drainage favorable; the walls of the abscess come to- gether, and the cavity is soon closed. The walls of the sac become thin by absorption, the fixation and swelling of the parts subside, and the recovery is complete. In examining a case in after years that I had treated for cellulitis, I found that all traces of the disease had disappeared, so far as could be ascertained by physical exploration, and the functions of the pel- vic organs were all performed normally, thus showing that the recov- ery was complete. This is the history of the pathology of the sim- plest cases of pelvic cellulitis. When the pus escapes into any other pelvic viscera at a point above the most dependent part of the abscess sac, the evacuation is necessarily incomplete, and the drainage imperfect. Chronic sup- puration and discharge will occur under such circumstances, and the duration of the case is very indefinite. This is often the result when the point of escape is through the abdominal walls or the pel- vic foramina; but the same thing occurs sometimes when the open- ing is into the vagina or rectum or bladder, especially the rectum. Judging from several cases that I have seen, in which the open- ing was into the rectum, I am inclined to believe that the direction Fig. 206.—Pelvic abscess opening Fig. 207.—Pelvic abscess opening obliquely downward. obliquely upward. of the opening has something to do with keeping up the suppuration. When the opening is low down, and enters the rectum obliquely downward, and the drainage is complete, the opening will close 558 DISEASES OF WOMEN. promptly (Fig. 206); but, if the opening into the rectum is direct or obliquely upward, the contents of the bowels will escape into the abscess sac, and keep up suppuration for an indefinite length of time (Fig. 207). These conditions in the pathology of cellulitis afford a reasonable explanation, perhaps the true one, of the difference in progress be- tween cases that, up to the time of evacuation of pus, appeared to be alike. There is yet another condition in the morbid products of the disease which retards recovery. In place of the suppurative pro- cess, involving the whole mass of inflammatory products, a number of small abscesses are found producing a honey-comb state of the parts, a number of small abscesses opening into each other by small sinuses, and all opening into some of the pelvic viscera, by one or more openings. This pathological condition delays the progress of the case greatly. All these exceptional peculiarities in the pathology which complicate the progress of the disease also tend to make the after-effects—i. e., the damage to the pelvic organs—greater. The wralls of the abscess are thicker, and the scar left in the tissue contracts more, and hence, displacements are often found. Pelvic pains of a neuralgic character of ten follow, and the functions of the pelvic organs, uterus, rectum, and bladder are to some extent occasionally deranged. There is still another form of behavior noticed in some cases. Suppuration takes place at one point, usually a small one, and instead of the pus escaping in the usual manner, it finds its way into the circulation causing septicaemia, which is intermittent in character. The temperature and pulse run up high for a time and then sub- side, the fever being sometimes preceded by a chill or rigor. These paroxysms are repeated over and over again, the general nutrition of the patient being greatly impaired. The chief cause of pelvic cellulitis is septicaemia, and is usually traumatic in its origin. Injuries to the uterus and vagina during parturition or abortion develop septic material which is conveyed to the cellular tissue by absorption through the lymphatics principally. It is possible that lymphangitis is primarily developed, and sub- sequently, cellulitis. Be this as it may, the fact is that two thirds of all the cases occur after abortion or parturition. Whenever cellulitis follows parturition, it may be presumed that it is caused by the absorp- tion of septic material from the parturient canal. It is possible, how-' ever, that contusions of the cellular tissue occurring during parturi- tion may give rise to decomposition of the injured tissue and septic cellulitis, which, in that case, is autogenetic, and not due to absorption. PELVIC CELLULITIS. 559 The other and far less common causes of cellulitis are surgical operations, the use of caustics, ill-fitting pessaries, dilatation of cervix uteri with sponge tents and direct blows, but with all of these the cause is septic, the morbid material being developed by the injury. Cellulitis occasionally occurs secondarily to some pre-existing in- flammation, such as endometritis, pelvic peritonitis, salpingitis, and ovaritis. These last-named affections, when they precede the cellu- litis, stand in a causative relation to it. It quite frequently hap- pens, however, that the above-named diseases are developed in the course of a cellulitis, and are caused by it, and hence become com- plications of the cellulitis. The duration of cellulitis varies very much according to the ex- tent of the inflammation, but more especially is the progress modi- fied by the termination of the inflammatory process. In case that resolution takes place, recovery may occur in a few weeks, but on the other hand, if suppuration occurs and the discharge of pus is incomplete, owing to the unfavorable point of escape, then chronic suppuration may go on for months or years. When suppuration takes place and the discharge of pus is at the dependent part of the abscess, the average duration of the disease is about six weeks. Much has been said about chronic cellulitis, but I have never been able to recognize any such condition. Chronic suppuration in a badly-drained abscess may go on for any length of time—this we often see ; also, frequent or repeated attacks of cellu- litis may occur, but a chronic or continuous inflammation such as we see in inflammation of mucous membranes, is something which I have never met with in practice. This is quite in accord with what we know of cellulitis ekewhere, where the process begins, pro- gresses, and ends and recovery follows, or, it may be, that the inflam- mation progresses to the stage of suppuration, and for some reason suppuration is kept up, but this is simply a chronic condition of one stage of the process. I think that the so-called chronic cellulitis, recognized and treated as such by some authorities, is nothing more than the products of the inflammation which remain after the inflammation itself has subsided. The consequences of pelvic cellulitis depend largely upon the extent of the tissue involved and the quantity of inflammatory exu- date. Sometimes, the tissues become infiltrated with the products of the inflammation which do not all break down in the suppurative process; when this occurs, it requires a long time to effect the absorp- tion of these products, and during that time, the patient is likely to 560 DISEASES OF WOMEN'. suffer from derangement of the functions of the pelvic organs and also from pelvic pain. So, also, when the products of the inflamma- tion have all been disposed of, if much damage has been done to the tissues, which is usually the case, contractions follow which are apt to displace the pelvic organs to some extent, and to give rise to trouble; and yet, in the majority of uncomplicated cases of cellu- litis, complete and perfect recovery generally takes place. This, I have frequently been able to verify by subsequent examination of cases that I have formerly treated. More than that, it not infre- quently happens that patients, after a well-defined cellulitis, recover and bear children, showing conclusively that the recovery was com- plete and perfect. In the clinical history of pelvic cellulitis, as manifested by the symptoms and physical signs presented, there is a great variation in different cases ; just as the extent of the local lesions differ in degree and extent, so the symptoms vary in their severity. There is usu- ally a decided symptomatic fever as indicated by the frequency of pulse and elevation of temperature. This may, or may not be pre- ceded by a chill or rigor which is promptly followed by fever. The temperature as a rule is not high, from 101^° F. to 103° F. being about the range. There is also marked derangement of the digestive organs; sometimes, there is some nausea and vomiting, almost always tympanitic distention of the bowels, and usually con- stipation. It is rare that there is any delirium or very marked de- pression of the nervous system. The patient usually complains of pain, the intensity of which varies considerably; it is usually most marked in the rare cases which arise from causes other than parturi- tion at the full term. When the cellulitis follows delivery, there is abundant room for the products of the inflammation in the cellular tissues of the largely developed broad ligaments, and so the pain which is usually caused by pressure of these products, is not so great. In other cases due to injuries, intercellular haemorrhages, and the like, the tissues resist the distention and the exudation, and hence the pain is much greater, and there is usually decided disturbance of the function of the pel- vic organs. If the attack comes on when the menstrual period is near there may be a menorrhagia, There is also quite often vesical and rectal tenesmus. There is tenderness on deep pressure in the iliac regions, and the pain is usually aggravated by any movement on the part of the patient. This usually compels the sufferer to rest quietly on the back. Occasionally, some relief is obtained by drawing up the PELVIC CELLULITIS. 561 limbs while resting on the back, but this position is not by any means as frequently assumed and persistently maintained as in peritonitis. These symptoms, both general and local, usually continue without much modification, except that relief which may be obtained through the influence of medication, until the exudation is com- pleted ; then there is usually a lowering of the temperature and pulse, and relief from pain. The temperature, however, usually re- mains above 100° F. AVhen suppuration begins, there is a renewal of the symptomatic fever; sometimes a chill precedes this recurrence of fever. On the other hand, if resolution takes place, the fever does not return to any very great extent. During the suppurative process until the time when the pus is discharged, the temperature remains usually above 100° F., sometimes, suddenly running up to 103° F., indicat- ing that there may be a little acute septicaemia. AVhen the abscess opens and is completely emptied, there is usually a prompt and al- most complete relief from the symptomatic fever. In case that the pus remains imprisoned or is only partially evac- uated, and the suppuration and discharge continue to go on, there is usually marked constitutional disturbance, manifested by high tem- perature which varies abruptly in degree; at times running down almost to normal and again going up to 104° F., or to 104^° F. Physical Signs.—These necessarily differ according to the stage of progress of the inflammation. During the stage of engorgement, a digital examination usually detects only swelling of the parts and tenderness on pressure, and if the examiner's sense of touch is very acute, increased heat may be detected ; any7 effort to move the pelvic organs will usually cause pain. AArhen the exudation takes place, the touch detects marked induration of the parts involved, and when it is complete, a MTell-defined tumor in both broad liga- ments will be found, or it may be that this mass is found on either side of the cervix. If the tenderness when pressure is made upon the abdominal walls is not great, and there is not much tympanitic distention, the tumor can sometimes be accurately outlined by the bimanual examination. Usually, however, not much can be accom- plished in this way because of the distention of the abdominal walls and the tenderness on pressure there. The size of the tumor of course depends upon the extent of the exudation; in some cases it is not larger than a small orange, in oth- ers, both broad ligaments may be split up, and so filled with the exudate as to extend above the true pelvis and come in contact with the abdominal walls, so that the mass can be easily identified by ab- 562 DISEASES OF WOMEN. dominal palpation. This I have seen in but one case, though I have frequently seen the tumor on one side large enough to be distin guished in this wayr. The extension of the tumor upward out of the true pelvis, is much more frequently seen in cellulitis following labor, and it is a physical sign characteristic of cellulitis as compared with pelvic peri- tonitis. When the tumor occurs on one side, there is usually displace- ment of the uterus, that organ being pushed in the opposite direc- tion. When both broad ligaments are involved, the uterus may be carried upward and forward. In cases occurring in the non-puer- peral state, the uterus is often crowded somewhat downward ; in all cases there is most marked induration of the parts presented to the digital touch, and also fixation of the uterus. When resolution ter- minates the case, a gradual diminution of the tumor will be observed from time to time. When suppuration and evacuation take place, there is a more prompt reduction in the size of the mass. The physical signs sometimes change when suppuration occurs, but it is exceedingly difficult to detect the presence of pus in this location, although it is often important to do so. It is usually im- possible, also, to detect fluctuation, because the abscess can not be touched at two points far apart. One must rely then upon the soft- ening of the mass as felt by the index-finger, as the sign of suppu- ration. This is liable to be simulated by oedema of the abscess-wall, but this can readily be distinguished by observing that the parts pit on pressure. It often happens, however, that one can not decide re- garding the presence of pus, and if it is of great importance to so determine, the aspirating-needle should be employed. Treatment.—During the first stage of cellulitis, treatment should be employed with the view of controlling the inflammatory process, and, if not able to abort the trouble, to limit or circumscribe it as far as possible. To accomplish this, perfect rest should be enjoined, and all pain relieved or made tolerable by the use of opium. The opium should be given by the mouth in doses sufficient to give re- lief, and be repeated often enough to maintain that relief. In case the stomach is so irritable as to refuse the opium, then it should be administered hypodermically. There is at the present day some belief that quinine given in large doses often controls or modifies local and inflammatory action ; this appears to be so in some specific inflammations like pneumonia, and it possibly may have some such controlling influence in cellulit- / PELVIC CELLULITIS. 563 is; if the stomach will admit of it, no harm can come from giving ten or fifteen grains of quinine in a day at the outset of pelvic cel- lulitis, and possibly much good may result. Opium, however, is the chief agent when there is much pain or restlessness in the first stage; the opium not only relieves the pain but also keeps the bow- els at rest, which is quite desirable; the bowels, however, should not be kept too long confined; in fact, I make it a rule when a case is seen early, and the rectum is distended, to empty it by means of a mild enema, then the bowels should be kept quiet until the tem- perature and pulse come down and the pain subsides, when the bow- els may be again moved by enema; this secures one evacuation be- tween the stage of exudation and suppuration. Local applications sometimes give the patient a certain amount of comfort, and, when such is the case, there should be employed warm poultices, or, better, flannels wrung out of hot water, and cov- ered with oil-silk. The exudation may be limited to some extent, it is claimed by some authors, by the use of counter-irritants; this, I think, is doubt- ful ; therefore, if they are used at all, the milder agents, like mus- tard paste, may be employed. During all this time the patient should be nourished as well as possible. If a vigorous subject, less care in the way of diet is necessary; but, if feeble, an abundance of nourishing food should be offered. Prof. Yirgil O. Hardon, M. D., of Atlanta, Georgia, has practiced aspiration with good results in the stage of serous infiltration. A case illustrating this mode of treatment will be given hereafter. When suppuration occurs, the majority of patients will bear at that time sustaining means, nourishing food, full doses of quinine, and, in some cases, stimulants. To sustain the patient is the chief object at this stage. If the case promises to end in resolution, that should be favored by counter-irritants, and the internal use of the preparations of iodine combined with tonics. When the abscess opens, and discharge fol- lows, sustaining measures are all that is necessary. If suppuration takes place, and the pus is not discharged, but is retained, and causes septicaemia, it should be removed by aspiration, and this operation repeated if need be. If the accumulation occurs again and again after aspiration, the sac should be more freely opened and drained through the vagina. When the drainage is incomplete, because of the opening being too high up, an opening should be made at the most dependent part, and the drainage-tube inserted. In case that the imprisoned pus can 564 DISEASES OF WOMEN. not be reached through the vagina, and the patient's life is in danger from chronic suppuration or septicaemia, the practice of Lawson Tait may be adopted—that is, opening the abdominal walls, and draining the abscess with a drainage-tube in the abdominal wound. The operation of opening the abdominal walls, and indirectly draining a pelvic abscess, involves all the difficulties and dangers of laparotomy. It is a very different thing when the abscess sac is adherent to the abdominal wall. Making an opening at the adher- ent point, and draining the sac, is little more than opening an or- dinary abscess. These are the principal points in the treatment of cellulitis; other details of the clinical history and treatment will be brought out in the history of cases. ILLUSTRATIVE CASES. A Case of Cellulitis uncomplicated, ending in Suppuration.—AA7hen this patient was twenty-six years old she gave birth to her second child. The labor, for some reason unknown to me, was tedious, and her physician delivered her with forceps. She progressed fairly well until the fourth day, when she had a chill, followed by fever, her temperature running up to 100° and 102-J-0. She also had pain in the pelvis and distention of the abdomen, but the lochia and milk secretion continued, although in diminished quantity. Her general condition remained about the same, except that she obtained relief from opium given by her physician until four days afterward. At that time I saw her, and found, on examination, a large mass on the left side, filling the upper portion of the pelvis, pushing the uterus to the right, and extending above the superior strait, so that I could distinctly make it out through the abdominal walls. This mass was so closely united to the uterus that it appeared to be a part of that organ, but was as large as the uterus itself. There was ten- derness to the touch, marked induration, and yet the mass and the uterus were very slightly movable. Pain at this time was not great, and the patient only complained of a little local distress and discom- fort, and said that she felt weak. At the same time, her pulse and temperature were both above 100. There was also laceration of the cervix uteri, and the discharge was muco-purulent. At this time she had very little nourishment for her child, and yet there was a little. She was directed to have perfect rest, nourishing food, opium sufficient to keep her free from pain and to secure comfortable nights, with tonic doses of quinine. PELVIC CELLULITIS. 5G5 The disinfecting vaginal douche which had been used was con- tinued ; tonic doses of quinine, with fluid extract of ergot, were or- dered three times a day, and turpentine stupes were directed to be applied to the abdomen. One week later I saw her again in consul- tation, and learned from her attendant that but little change had taken place in her condition ; the temperature was lower, her appe- tite had improved, there was almost no pain, and she felt stronger. On examination, there was little if any change in the tumor, the physical signs being about the same; the local discharge still con- tinued, but was less purulent and offensive ; the surface temperature varied from time to time; occasionally the skin was hot; at other times there was free perspiration. It was impossible at this time to detect the presence of pus in the mass in the pelvis. Five days afterward I saw her again, when I learned that she had had a chill, followed by a rise of temperature and pulse; she had also suffered from rather profuse sweating. At this time her general appearance was less satisfactory; she had a somewhat dusky hue of face, the pulse also was not as strong, and the milk had stopped entirely. Just before the chill her bowels had been moved by enema, and both patient and physician were disposed to attribute the increase in her trouble to the effect of the enema, but it undoubtedly was due to suppuration having begun. On examination, the mass was felt to be softer at the most de- pendent part, and yet no distinct flexion could be made out. Qui- nine was given in somewhat larger doses, the vaginal douche was continued, and a little wine was added to the bill of fare. A few days after this her pulse and temperature improved con- siderably. She had then very little pain, but a sense of heat, full- ness, and dull aching in the pelvis. Four days after this there was a copious discharge of pus from the vagina, followed by marked improvement in the pulse, temperature, and general condition. The day following a marked diminution in the size of the tumor was noticed; there continued to be a discharge of pus in diminishing quantity for nearly a week, but during that time she improved in general condition very decidedly. The mass gradually diminished, and the uterus also progressed in involution, and her strength re- turned, so that she became anxious to get up. She was kept quiet, however, for some time, until involution was complete, and all that remained of the inflammation was a small, hard, but not tender mass on the left side of the uterus and in the broad ligament, evidently the collapsed or the contracted walls of the abscess. From this time onward the improvement was steady and unin- 566 DISEASES OF WOMEN. terrupted, and she was soon able to resume her duties, with the exception of nursing her child. At the end of two months from the time of the attack, she was quite well, and no traces of her trouble remained except a decided thickening of the broad liga- ment. A Case of Cellulitis, ending in Resolution; the Cause Dilatation of the Uterine Canal by Sponge Tent preparatory to curetting.—A lady twenty-eight years of age, who had been married seven years, had suffered for some time with menorrhagia, caused by fungosities of the endometrium, and, although the cervical canal was quite empty, it was deemed necessary to dilate the canal with a sponge tent before removing the fungous growths. The sponge tent was introduced late in the evening, and remained during the following forenoon; the curette was used immediately afterward, and the abnormal growths completely removed. Twenty-four hours after this she began to have pain in the region of the left broad ligament, at the same time developing symptomatic fever, the temperature running up to 101^° F., and the pulse being accelerated. She also had a little nausea when the pain was most severe, with loss of appetite and some tympanitic disturbance of the bowels. On digital exam- ination, made three days subsequently7, a somewhat ill-defined mass was found in the right broad ligament, which increased during the following forty-eight hours until it attained the size of a hen's egg. There was a little displacement of the uterus to the right, but very little. This mass was quite tender to the touch, and could not be moved; neither could the uterus be moved without causing acute pain. Opium was given to relieve the pain, and the bowels were allowed to remain constipated for about four days. A vaginal douche of borax and warm water was used twice daily, removing a muco- sanguinolent discharge. The pain gradually subsided, and at the end of four or five days the bowels were moved; the fever also di- minished, the appetite slowly returned, and about this time the mass began to slowly diminish in size. At the end of two weeks the pa- tient was permitted to leave her bed and sit in her chair, but was not allowed to take any active exercise until after the next menstrual period. During that time she was confined to her bed, fearing that the inflammatory process might again be lighted up. After the period, which lasted about five days, she was permitted to resume her duties gradually, but was directed to rest quietly at the next menstrual period, which she did. Afterward, on examination, it was found that the mass in the broad ligament had wholly disap- peared, there was no tenderness and no evidence of congestion or PELVIC CELLULITIS. 507 any other trouble, and her subsequent history shows recovery to have been complete. I am quite sure that the diagnosis in this case was correct, and 1 am also satisfied that the cellulitis was cause'd by the treatment. The case occurred at a time in my practice when I knew less about the management of fungosities of the uterus, hence, I used a sponge tent before using the curette, an entirely unnecessary procedure. I know now that there was dilatation enough, but I followed the rules laid down in the books, and so employed the tent to the disadvantage of the patient. I am satisfied also that this case was due to sepsis, for at that time less was known about antiseptic sur- gery, and I have no reason to suppose that the sponge tent and the instruments used were surgically clean. This, I believe, from the fact that, although I have often used the curette since then and oc- casionally sponge tents, I have never caused cellulitis. Uncompli- cated cellulitis rarely proves fatal; it is only when peritonitis super- venes that there is much danger in the early stages of the disease. The cases that end fatally do so usually in one of tliree ways: First, by acute septicaemia, which may take place immediately after sup- puration occurs; second, by chronic septicaemia and exudation from prolonged suppuration in badly-drained cases; third, and very rarely, when the abscess opens into the peritoneal cavity, and at once sets up a septic and usually fatal peritonitis. Pelvic Cellulitis following a Haemorrhage into the Cellular Tissue.— A young, recently married lady, while very much fatigued from un- usual physical exertion, was suddenly seized with acute pain in the pelvic region. When called to see her, I found her lying in bed suffering from severe pain and some rectal tenesmus ; the pulse was somewhat accelerated, but the temperature was normal; the skin moist and cool. There was no constitutional disturbance beyond nervous excitation due to pain. On examination, I found a tender point low down and to the right of the uterus, there was also a swelling which extended to the right and downward a little way, apparently between the rectum and vagina. The pain was relieved by opium, and on the following day the swelling was found to have increased and become denser, and yet, there was no symptomatic fever. Two days later the physical signs remained the same, and there was also a marked discoloration or ecchymosis of the vagina, especially in the upper and posterior part of its walls. This discoloration, taken in connection with the history of the case, satisfied me that the case was one of haemorrhage into the cellular tissues of the pelvis. 568 DISEASES OF WOMEN. The pain gradually became less but there was still a feeling of fullness and pressure in the pelvis and an annoying rectal tenesmus. which made the patient feel as if great relief would be obtained if the bowels were moved. A mild laxative was given, followed by an enema, which secured a free evacuation of the bowels, but in place of relieving, this rather aggravated her sufferings. On the sixth day after the attack, the patient felt a little chilly, and soon after- ward developed fever; there was also a slight recurrence of the acute pain in the pelvis. At this time the temperature was 102^° F., and the pulse about 110. On the day following this, an examination was made, and the mass in the pelvis appeared to be softer than it was before; but this I think was due to oedema of the vaginal walls. The fever con- tinued for several days and then gradually subsided, and the tem- perature remained about 100°, The pain and general pelvic tenesmus continued, though not in a marked degree ; her condition remained about the same during the following week, then the pain became more severe, the temperature rose a degree or more, and she was more restless and uncomfortable. Two days after this a discharge of pus from the vagina occurred, quite profuse at first, and continued in a modified way for a couple of days. The discharge contained black specks which were found to be shreds of clotted blood. Forty-eight hours after the discharge first appeared, a careful examination by the touch was made in the hope of discovering the opening of the abscess, but without success ; a very careful speculum examination was then made, and by the aid of the probe the opening was found to the right and a little below the cervix uteri. The opening appeared to be just above the mass, which extended down, apparently, between the vagina and the rec- tum. A uterine dilator of small size was passed through the open- ing into the abscess sac and slow dilatation made. AVhen the opening was sufficiently enlarged to admit a curette, a large piece of blood- clot was removed ; several strands of thick, prepared silk were intro- duced into the opening to keep up the drainage, and during the next few days considerable pus was discharged, together with shreds of old blood-clots. As the opening showed no disposition to close, the drainage was abandoned, and from this time onward the discharge diminished and the swelling and thickening of the tissues also slowly disappeared. Finally, the discharge stopped altogether, and thickening and indura- tion of the tissues gradually disappeared, and complete recovery took place. PELVIC CELLULITIS. 569 Pelvic Cellulitis caused by Amputation of the Cervix Uteri.—This patient came into the hospital about eighteen years ago with a very much enlarged and eroded cervix uteri; in fact, the cervix seemed to be divided into two large, round masses, the surfaces of which were very irregular and so vascular that they bled profusely on touch. This was before Dr. Emmet had told us about laceration of the cervix uteri and its consequences, and I supposed that the case was one of incipient malignant disease. This diagnosis was con- curred in by several of my colleagues, and amputation of the cer- vix was deemed the best mode of treatment, and the operation was performed after the method commended by J. Marion Sims. In removing the posterior half of the cervix, I am satisfied that I went beyond the walls of the uterus into the cellular tissue ; sut- ures were introduced to bring the flaps together and to hold them there, and the operation appeared to be quite a success. At the end of the second day the patient developed all the constitutional symptoms of local inflammation and soon afterward the physical signs of pelvic cellulitis were manifested. The subsequent history of the case was that of ordinary pelvic cellulitis which ended in suppuration and discharge, which occurred at a point corresponding to the right angle of the junction of the flaps made in the amputation. The discharge soon ceased and all constitutional and local disturbance subsided, and the patient recov- ered from the acute attack. She subsequently did rather badly, there was considerable con- traction of the scar left by the amputation, and there was evidently some contraction of the parts involved in the cellulitis so that she suffered a good deal in after years with pelvic pain and dysmenor- rhea, and it became necessary to dilate the remaining portion of the cervical canal in order to give relief. This case is mentioned simply to illustrate cellulitis as it occurs after operations about the cervix uteri, and it no doubt was septic in its origin. The case was treated before the days of antiseptic surgery, and I have no doubt that I exposed my patient to all the septic influences possible in such an operation. Indeed, the management of the whole case was rather bad as it appears to me now, and I am inclined to believe that it was not at all malignant to begin with, and that amputation of the cervix was therefore uncalled for. Such a case now would be considered as a laceration of the cervix with areolar hyperplasia, and would be treated in the usual way. A Case of Pelvic Cellulitis; the Abscess opening into the Rectum and Long-continued Suppuration occurring in consequence.—This patient 570 DISEASES OF WOMEN. was also seen in hospital; she gave a history of having had pelvic cellulitis seven months before admission. About five weeks from the time that she was taken ill she had discharges of pus from the rectum which were followed by marked relief. After this she con- tinued to have repeated discharges of pus in the same way ; for a few days at a time she would be comparatively comfortable, though never well; then she would have a little fever, with considerable pain, and then a discharge of pus, which would give relief for a few days. These remittent attacks of pain and fever followed by a discharge of pus, continued at varying intervals up to the time that I saw her. On digital examination, I found fixation of the uterus, with evidence of induration in both broad ligaments and around the cervix, above the vagina. She was anaemic, emaciated, and had a somewhat cachectic ap- pearance. She was placed under ether, and a most careful examina- tion of the rectum made. The opening from the rectum into the cellular tissue was found about three inches up the rectal wall, by bending the probe into the shape of a hook. I was able to pass it from above downward and forward, showing that the opening ran from the rectum obliquely downward into the abscess about an inch. A counter-opening was made in the most dependent part of the sac through the vaginal wall; the opening was made with the thermo- cautery. This I believe to be the best method of making counter- openings in these old cases, as haemorrhage can be avoided and the lymphatics closed by the cautery, which to some extent guards against septicaemia. The opening in the vagina was maintained by small drainage- tubes which completely drained the abscess. The patient improved generally and locally, and after a time the drainage-tube was given up ; a little discharge continued from the opening for several days, when it closed. The case did well, and was soon dismissed from the hospital, although there still remained considerable induration and thickening of the tissues of the broad ligaments. Presuming that her recovery would be effected in time, she was dismissed from the hospital; but returned in about three months with a rectal abscess, which, when it was opened, proved to be a rectal fistula. Evidently, the opening in the vagina had closed while that in the rectum re- mained, thus forming an internal rectal fistula. This was treated in the usual way and the patient finally recovered. Pelvic Cellulitis; Abscess discharges through the Saphenous Open- ing.—In this lady's fourth confinement calcareous degeneration of the placenta was found. It was retained for a long time in spite of PELVIC CELLULITIS. 571 all the ordinary efforts used to deliver it; it was found necessary to detach it from the uterus, a very difficult task. She did very badly from the beginning, soon developing a metritis and cellulitis; she remained in a very precarious condition for about two months ; the products of the inflammation formed a large mass on the left side which extended up to, and finally became adherent to, the abdominal walls. Full details need not be given, suffice it to say, that at the end of twelve weeks an abscess opened through the inguinal canal. Much relief followed the opening and the copious discharge of pus, but it continued to discharge for weeks, and although she had improved after the opening of the abscess, she began to run down from this chronic suppuration, and her life was again despaired of. A probe was passed from the anterior opening and downward into the pelvis until its point could be felt on the left side of the cervix; there was still, however, a very thick wall between the vagina and the end of the probe. After faithfully trying the effect of careful washing out and drainage, without success, a counter-opening was made through the vagina by means of the thermo-cautery, and a drainage-tube carried through the opening in the abdominal walls down into the vagina. This tube was injected three times a day, and as the patient improved quite fairly the tube was drawn down toward the vagina, leaving the outer opening free. No discharge occurring at the abdominal opening and the wound showing a disposition to close, the tube was gradually withdrawn, and finally removed entirely. The discharge continued for some time after the removal of the tube, but finally ceased, and the patient recovered and has remained well ever since, a period of eighteen years. Pelvic Cellulitis in which the Discharge was delayed, but finally re- lieved by Aspiration.—The history of this case has nothing peculiar in it except that it progressed as cellulitis usually does, until the time when the abscess was expected to discharge. It failed to do so, and the patient's general nutrition beginning to suffer, it was deemed advisable to use the aspirator; this was done and the abscess, which was in the right broad ligament, was emptied of about eight ounces of pus. This gave great relief, but in time the abscess filled again, and again it was aspirated, but this time before removing the needle, the sac was carefully washed out with carbolic acid and water. Great care was taken not to inject quite as much as the quantity of pus removed, for fear that by overdistending the abscess, some thin point in the sac might rupture and cause mischief. There was considerable reaction after this aspiration, the pulse S8 572 DISEASES OF WOMEN. and temperature running up, but soon subsiding again. Nothing of importance occurred in the history of the case, and she recovered in due time. A Case of Cellulitis terminating in Multiple Abscesses, cured by enlarging the Opening and breaking down the Walls of the Small Ab- scesses.—This case had a history during its early stages, quite in ac- cordance with the ordinary progress of the disease, but after suppu- ration and discharge the patient was not relieved, and the suppura- tion continued. The opening was found to be a very small one, situated behind and to the left of the cervix uteri. After trying every possible means to improve her general condition without effect, the opening was enlarged by dilatation, the patient being an- aesthetized ; after dilatation, the finger was passed up into the mass, and the walls of several small abscesses broken down. This was rather easily accomplished because the uterus and the mass of in- flammatory products were low down in the pelvis and within reach, and while the finger was passed through the opening, the other hand was placed upon the abdomen to act as a guide and to guard against breaking through into the peritoneal cavity. After this, the discharge was very free, and a number of shreds of broken tissue were evacuated. Drainage was kept up and the parts washed out daily until the mass had greatly7 diminished and the discharge had almost subsided. The drainage-tube was then removed and the patient slowly recovered. A Tedious Case of Cellulitis causing Septicaemia from a Very Small Point of Suppuration; treated by Laparotomy and Drainage; Recovery.—This case was seen in consultation with my friend Prof. Jewett, who gave me the following notes : The patient was thirty years old, and was confined March 3, 1885, with her seventh child. She had ante-partum haemorrhage and inertia of the uterus, which rendered it necessary to deliver with forceps at the superior strait. The nurse was incompetent, drunk, or stupid, or all three, and allowed the patient and her bed to remain filthy for two days. At the end of the third day, the patient developed cellulitis in the left broad ligament; there was also a circumscribed peritonitis limited to the location of the cellulitis. At the beginning of the disease, the temperature ran up to 103° and the pulse to 140; this elevation was attained on the 7th of March, and from that time until the 15th, the temperature ranged between 100° and 102°, and the pulse between 90 and 110. There was a marked difference between the morning and evening temperature. From the 15th until the 20th, the con- stitutional disturbance subsided, the local inflammation also dimin- PELVIC CELLULITIS. 573 ished, and there was every reason to suppose that the cellulitis would end in resolution. From the 20th to the 2Sth she was appa- rently convalescent, and was able to walk about, but on the 29th she had a relapse, the temperature running up in the afternoon to 104°. The following morning it was down to 97°, and from this onward to the 18th of April her temperature was most extraordinary in its variations. On the 4th and 5th it was 105° in the afternoon and 100° in the morning; from the 6th to the 11 th it ranged between 100° in the morning and 103° and 104° in the afternoon. All this also in spite of quinine and other recognized antipyretics. From this date to the 18th, the temperature became more irregular, occa- sionally dropping down to 98£°, and suddenly and at irregular times running up to 103° and 104°. It was thought that this variation of temperature was due to septicaemia, and yet no pus accumulation could be detected in the pelvis. Prof. Jewett practiced aspiration with negative results, but subsequently made a number of appointments for further explora- tions ; but the patient was an exceedingly intractable one, and her friends had no control of her, so that he was unable to carry out his wishes in this regard. The physical signs during all this time since the relapse remained about the same. The patient by7 this time was exceedingly anaemic, the skin was of a bronze hue, and the digestion and general nutri- tion very poor, and altogether her condition was critical. On May 2d she submitted to an anaesthetic, and Prof. Jewett performed laparotomy. He made an incision through the abdominal walls directly over the tumor in the broad ligament, and, after mak- ing a small puncture in the tumor, opened up the cavity with the finger; no pus was found, and not more than a teaspoonful of septic fluid was evacuated. The cavity was drained and irrigated with a bichloride solution for about four weeks, when it closed completely. The temperature never rose above 101° after the operation, and, after the first three days, it became normal, and remained so ever afterward. She rapidly gained in her general health, and in five weeks had completely recovered. Pelvic Cellulitis ending fatally from Septicaemia.—About sixteen years ago, while in charge of the lying-in department of the Long Island College Hospital, one of my cases developed a metritis and cellulitis after confinement. The case progressed in the usual way, differing in no respect from many cases of the kind, except that the products of the cellulitis were unusually great. The metritis subsided, and the cellulitis, which was located in the left broad liga 574 DISEASES OF WOMEN. ment, went on to suppuration, and, while I was looking for the ab- scess to discharge, the patient began to show signs of septicaemia. There was, no doubt, a large accumulation of pus in the broad ligament, but, as we were unable by physical signs to determine that, I unwisely abstained from exploring the abscess. All constitutional treatment known to us was carefully employed, but the patient died. On post-mortem examination, a very large abscess was found in the left broad ligament, and nothing more. The peritonaeum covering the abscess was congested, and there was much subserous oedema, but not the slightest evidence of any peritonitis. This case, like many others, illustrates very well two important points: First, that cellulitis occurs without the slightest pelvic peri- tonitis accompanying it, and this fact tells strongly against those who make no distinction between the two affections; and, second, if this case had come under my observation in recent years, when I appreciate the value of aspiration and abdominal section and drain- age, as taught by Lawson Tait (all honor to him for this!), the case might have been saved. Great progress has been made in the management of cellulitis within the last few years in the employment of aspiration, counter- openings, drainage, and abdominal section and drainage, as the above cases have illustrated. Acute Cellulitis treated by Aspiration in the Stage of Serous Infiltra- tion (by Virgil O. Hardin, of Atlanta, Georgia).—" The patient was twenty-four years of age, and had borne a child three months before. The history of the patient showed that her menses had always been of normal character up to her pregnancy, and that she had never suffered from any symptoms which would indicate pelvic disease of any kind. Since her labor she had had tenderness of the abdomen and pain in walking and in micturition. Her general health, how- ever, had been good. On the day before I saw her she was seized with pain in the back, pelvis, hips, abdomen, and thighs. This pain was acute and excessive. Micturition and defecation became very painful, especially the latter. She had a slight chill, followed by high fever, thirst, and complete loss of appetite. When seen by me, she was in bed, tossing and moaning with pain, which was re- ferred principally to the pelvic region. Pulse, 120, temperature, 101°, skin hot and dry, face flushed, tongue coated. Vaginal and rectal examination were rendered impossible by excessive tenderness of the parts. The following morning she was fully anaesthetized, and a complete examination effected. The vagina was hot and dry. The cervix was lacerated on the left side. The womb was low in PELVIC CELLULITIS. 575 the pelvis, and was pushed forward against the bladder. In the posterior fornix, and occupying the whole space between the cervix and the rectum, could be felt a rounded, bulging mass, which had a boggy, cedematous feeling. By a finger in the rectum this mass could be outlined, and felt to extend upward about an inch. No fluctuation could be detected, and, when pressed by the finger, the mass could not be displaced upward. Considering the condition to be that of pelvic cellulitis in the stage of serous infiltration, I decided to attempt to draw off the serum from the cellular tissue, hoping thereby to abort the disease and prevent the formation of solid plastic exudation, with possibly a subsequent abscess. Accordingly, an as- pirator-needle was thrust into the tumor from the vagina at three different points successively, and about an ounce in all of serum tinged with blood was withdrawn. The tumor was then found to be so softened and diminished in size as to be scarcely perceptible to the touch. A quarter-grain of morphine was given hypodermic- ally, and the patient ordered to remain perfectly quiet in bed, and take only liquid diet. When seen twenty-four hours later, she had had a good night's sleep, the pain in the pelvis was almost entirely gone, defecation was no longer painful, appetite had returned, the pulse had fallen to 80, the temperature to 99°, and the patient begged to be allowed to get up. The mass in the posterior fornix could be felt only as a slight thickening. Two days later the patient was ap- parently in her usual health." Pelvic Cellulitis, with Certain Complications, which, so far as I know, have not been noticed or described heretofore.—The patient was thirty-seven years of age, and the mother of six children. She was confined in June, and was fairly well for five days. She got up on the fifth day, and tried to attend to her housework. Four days later, while about the house, she was taken with severe pain in the pelvis, and was obliged to take to her bed again. This much of her history was obtained from the patient. She was seen for the first time by Dr. J. H. Raymond about six weeks after her confinement, and he learned that she had had no regular medical care, and but very poor nursing, her poverty depriv- ing her of necessary attention. From the history and physical signs, the doctor made the diag- nosis of pelvic cellulitis of the left broad ligament. The tempera- ture at that time was nearly normal in the morning, but rose to 101° or 102° at night. There was marked constitutional disturbance, such as generally obtains in long-continued suppuration or septi- caemia. 576 DISEASES OF WOMEN. The doctor urged her to go to the hospital, but she declined until August, about ten weeks after her confinement. During the inter- val from the time that she was first seen until she entered the hos- pital she was confined to her bed with her left thigh flexed upon the body, and the leg upon the thigh. AVhen she was admitted to the hospital she was very anaemic, had night-sweats, and had the general appearance of a tubercular patient. The flexion of the leg and thigh continued, and there was false anchylosis of the joints. The tumor in the pelvis was much smaller than it had been, but there were pain and tenderness in the left iliac region, extending up to the lumbar region. The temperature ranged from 100° to 103°, being very irregular in its rising and falling. There was no point in the pelvis where pus could be detected, and, although there was some swelling in the left side of the abdomen, no signs of pus could be found after repeated examinations. She was able to take food and stimulants fairly well, and every means was employed to reduce the temperature and improve her strength, but without any favorable result. Hopes were entertained that the location of the suppuration would be found, and that relief might be obtained by aspiration or other means of evacuation. In spite of the constitutional treatment, she gradually declined, the anaemia became very marked, and the temperature increased, frequently being 104°, and sometimes a frac- tion higher. She appeared to be doomed to die of septicaemia, and, as a last resort, it was decided to make a laparotomy, in the hopes of finding the source of the septicaemia. Immediately before giving the ether her temperature was 104|°, pulse, 140, and feeble. The anchylosis of the knee- and hip-joints was with difficulty broken up, and then a more careful exploration of the left iliac region was made. There were swelling and hardening of the wall of the abdomen on that side, but not to any great extent. An as- pirating-needle was introduced at a number of points in the hope of finding pus, but without avail. The abdomen was opened, and a most careful exploration of the pelvis was made by the touch. The left broad ligament was considerably thickened and much less elastic than it should have been, showing the effect of the inflammation, which had subsided. Not the slightest sign of any point of sup- puration could be found, but, by the bimanual touch, with the fin- gers of one hand in the abdominal cavity, and those of the other on the outside, I detected obscure fluctuation, indicating that an abscess or sinus extended along that side of the abdomen. The location of the pus having been clearly marked, the wound in the abdomen was PELVIC CELLULITIS. 577 closed, and an incision was made in the side down to the pus. It was found that the pus cavity was very small at its lower and most superficial end. It would not admit the little finger. This ac- counted for the fact that it was not found with the exploring needle. Passing a probe from the opening made upward, I found that the sinus was wider above, and extended up to the diaphragm. The cavity was washed out, and a drainage-tube introduced. Dr. Palmer, who aided in the operation, conducted the after- treatment, and the following facts are taken from his record, as kept by the house-surgeon: The patient reacted well under the effect of morphine and atropia, given hypodermically at the end of the operation, and again in three hours. Whisky with hot water was given four hours after the opera- tion ; she retained it well, and from that time onward the morphine and whisky were given to meet requirements. Five hours after the operation the temperature was 99£°, pulse, 12$, respiration, 2$. Two hours later the pulse went up to 100£°. The night was passed very comfortably, but she required morphine and whisky in large doses, not altogether because of the pain or exhaustion, but largely from the fact that she was used to both. For years she had been a drinker, and, during the long illness previous to the operation, she had taken morphine. At five o'clock on the following morning the tempera- ture was 102°, but in two hours it came down to 99°. From this time onward her progress was favorable, at times the temperature went up one or two degrees, but came down when the pus sac was washed out. She improved in strength but the sup- puration high up in the cavity continued, but in a much less degree. Her lung-trouble progressed slowly, but she seemed doomed to pulmonary phthisis. One month after the operation there was still a little discharge from the wound, but she did not apparently suffer from that to any extent, but her cough was worse, and the lungs not improving. At this time she returned to her home. The final re- sults I have not yet obtained. The following case was similar to the above, but terminated fatally, and a post-mortem examination revealed the exact nature of the lesions. The patient was thirty-seven years old, and had been confined of her fifth child four months previous to the time that I first saw her in consultation with Dr. R. L. Dickinson. From the history that we could gather, she had fever from the day after her confinement, and had been sick ever since. She was emaciated, and her skin dry and dusky; the temperature ranging from 101° to 102°; she had 57$ DISEASES OF WOMEN. but little appetite, and was constipated. She rested <>n the right side with the legs and thighs flexed, and complained of severe pam in the right groin and leg. Owing to the fixed position of the right leg and the great pain which she suffered in moving, a physical examination was not easily made. The uterus was apparently nor- mal and movable, but high up, at or above the brim of the pelvis, on the right there were evidences of inflammatory products. The diagnosis of abscess in the false pelvis was made, causing septicae- mia. She was taken to the hospital, and explorations were made with the aspirator, in the hope of finding the exact location of the pus, but with negative results. Laparotomy was performed by Prof. Charles Jewett. The pelvic organs were normal, except that there were evidences of a former cellulitis in the upper portion of the right broad ligament. The presence of pus was made out in the right iliac and lumbar regions; the abdominal wound was closed, and an opening made above the right groin into the abscess. It was found that the abscess cavity extended upward along the spine for twelve inches. The subsequent treatment consisted in washing out the abscess cavity, and supporting the patient with nourishment and stimulants. She did not rally well, but gradually failed, and died the third day after the operation. The autopsy showed that the abscess cavity extended from the right broad ligament upward behind the kidney and to the right of the spinal column to the diaphragm. The psoas muscle was in- volved in the abscess, but there was no bone-disease, and it was the opinion of all who attended the autopsy that the disease began as a cellulitis of the right broad ligament. A case similar to the above came under my observation twelve years ago. Upon being admitted, the patient gave a history of cel- lulitis following confinement. She was in a very low condition from septicaemia. I found signs of suppuration in the left iliac region, and, on making an incision, I found a large abscess, which extended upward to, if not beyond, the diaphragm. The patient had a cough with purulent expectoration, but no well-defined signs of any disease of the lungs. After washing out the abscess sac wdth carbolic acid and water, the patient declared that she could taste the acid; this led me to suspect that the abscess had opened into one of the larger bronchi; water colored with car- mine was injected, and the matter expectorated afterward was col- ored with the carmine. She died of exhaustion, and at the autopsy it was found that a sinus extended up behind the diaphragm and opened into a bronchial tube. CHAPTER XXXII. PELVIC PERITONITIS. The peritonaeum which covers the pelvic viscera of the female dif- fers in no respect in its anatomical construction from the general peri- tonaeum, and its function is the same. It differs only in the organs which it covers, and in the fact that there is in this region a direct communication and union between the mucous and serous mem- branes at the opening of the Fallopian tubes. Fio. 208.—The pelvic peritonaeum as seen on looking into the brim (Hodge). Diagramatie. 580 DISEASES OF WOMEN. From the fact that the peritonaeum is a continuous membrane, one would naturally suppose that an inflammation beginning at one Fig. 209.—The reflections and pouches of the pelvic peritonaeum looking into the cul-de-sac from behind (Hodge). Diagramatie. point would incline to extend to the whole membrane, so that gen- eral peritonitis would be the rule in the pathology of inflammation of this membrane. It is a fact, however, that the pelvic peritonaeum becomes the seat of inflammation very often and without any general disposition to extend to the abdominal peritonaeum. The two affec- tions then, that is, pelvic peritonitis and general peritonitis, while they are the same in their pathology, differ so in their clinical his- tory and causation, as to render them two separate and distinct affections. There is a form of peritonitis which occurs after parturition, in which the inflammation begins in the uterus and extends to the general peritonaeum and is known as metro-peritonitis, but this also differs entirely from pelvic peritonitis, which occurs far more fre- quently than either general peritonitis or metro-peritonitis. The pathology of pelvic peritonitis is the same as in inflamma- tion of serous membranes generally. There is first, subserous con- gestion, followed by a transudation of blood serum, and then an exudation of plastic material, or the higher organized constituents of PELVIC PERITONITIS. 581 the blood. Ordinarily, this ends the formative stage of the inflam- matory process, and the products of the inflammation are disposed of first, by the absorption of the serous transudation and the organiza- tion of the exudate. This organization simply consists in the devel- opment of blood circulation, either in or beneath the exudate, suffi- cient to maintain it in a vitalized condition and prevent its further degeneration and disintegration. The peculiar characteristic of this exudate is to form adhesions to adjoining tissues and to undergo contraction in its after-life, so that following an attack of pelvic peritonitis, the parts in the grasp of the exudate become adherent, and are often drawn out of their normal position by its contraction. Occasionally, but rarely, the in- flammation of this serous membrane goes on to suppuration. When this form of peritonitis takes place, pus accumulates usually in the sac of Douglas; there it sometimes is walled in by an exudation of lymph which unites the two folds of the peritonaeum which form the sac. Occasionally, too, small abscesses may be formed in the exudate which is thrown, out around the ovaries and Fallopian tubes. There is a wide range in the degree of severity in cases of pelvic peritonitis; in some, a circumscribed spot of inflammation may oc- cur which gives rise to a little discomfort at the time, and, passing off, leaves no suspicion that there ever had been an inflammation there. These cases we know occur from the fact that the traces of inflammation are found post-mortem. From these circumscribed and exceedingly mild attacks, we find all grades of severity, up to the most marked, where the whole pelvic peritonaeum is involved and suppuration occurs, and the case termi- nates fatally. In this respect, pelvic peritonitis strongly resembles pleurisy, the milder cases representing the circumscribed, dry pleu- risy, and the more severe corresponding to that of pleuritic em- pyema. There is also another form of pelvic peritonitis, in which there is an unusual transudation of serum which accumulates in the sac of Douglas, and corresponds to the ordinary pleurisy with effusion. J udging from the number of cases of peritonitis met in practice. and also from observations made post-mortem, this is one of the pelvic diseases which occurs perhaps as frequently as any; cer- tainly, it is much more common than pelvic cellulitis uncomplicated. It no doubt occurs quite frequently or occasionally in the progress of other pelvic affections, like cancer of the uterus, pelvic cellulitis, sal- pingitis, etc., but under these circumstances, it is a secondary affec- tion, and in that form need not be discussed here, 5S2 DISEASES OF WOMEN. In less severe cases the exudation gradually disappears, and the mobility and functional activity of the pelvic organs may be again restored and the patient may be considered as having recovered. But this takes a long time before it is accomplished. \\ hen pelvic peritonitis terminates fatally, it usually does so because the inflam- mation has gone on to suppuration, and may be called a purulent peritonitis, and in that case the patient may die in a few days from Fig. 210.—Retroverted uterus bound back by peritonitic adhesions ; a, b, adhesions. (Winckel.) the time of the attack, either from shock or acute septicaemia, or both, or inflammation may extend to the general peritonaeum, and in that way sacrifice the patient. Causation.—In regard to the causes of pelvic peritonitis, we find that non-parous women are most liable to it, especially those who suffer from imperfect development of the sexual organs and de- rangement of their functions, like dysmenorrhcea, for example. The immediate causes of pelvic peritonitis are of three kinds: First, where it is secondary, and evidently caused by some affection or inflammation of some of the other pelvic viscera, like ovaritis, salpingitis, and endometritis. Second, traumatic influences, such as injuries of any kind, imprudence during menstruation, and all sur- gical operations or treatment. In those who have suffered long from displacements and flexions of the uterus and general irritability and congestion, injuries appear to be sufficient to set up a peritonitis, like the passing of a uterine sound, or the application of caustics to the uterus. Third, specific causes, such as the escape of septic mate- rial from the Fallopian tubes, in cases of endometritis and salpin- gitis, but more especially, the virus of gonorrhoea. In a large num- ber of cases the cause will be found in this specific virus ; this is the reason why pelvic peritonitis is such a common affection among prostitutes. PELVIC PERITONITIS. 583 The duration, termination, and after-consequences of pelvic peri- tonitis, depend largely upon the extent of the inflammation and the cause which gives rise to it. In some cases where the exudation is limited recovery will take place in a few weeks, and but little after ill effects will be noticed, except occasional pain from time to time in the region of the exudate. In other cases where the whole pel- vic peritonaeum is involved, the fimbriated extremities of the Fallo- pian tubes become involved in the exudate, and are virtually de- stroyed. If this includes both sides, the function of the ovaries and tubes is arrested because of the damage to the structure. Degeneration of the ovaries often follows under these circum- stances; sometimes they become inflamed and succulent; at other times they become atrophied, due, no doubt, to the pressure of the contracting exudate and the interruption of the circulation in them; in short, in some of these cases, the adhesions and the quantity of exudation so destroy the anatomical relations that on post-mortem it is almost impossible to recognize the tissues or organs. A mass of tangled adhesions and products of inflammation covering the uterus and broad ligaments, is about all that can be made out. When such patients live, they suffer greatly from pelvic pain and dysmenorrhoea, if the function of menstruation is not arrested, as it sometimes is, by the destruction of the ovaries. Symptomatology.—This varies according to the severity of the attack; in average cases there is a well-defined symptomatic fever, the pulse being characteristic of inflammation of the serous mem- branes, being small and wiry, and running up from 110 to 130; the temperature is variable, often running to 103° F. and 104° F., and in severe cases to 106° F. At first, the skin is usually dry and hot; there is marked de- rangement of the digestive organs, nausea and vomiting often occur- ring ; sometimes in the severer cases vomiting of that greenish ma- terial so common in general peritonitis, occurs. There is usually marked tympanitic distention, and the patient prefers resting quietly on the back with the limbs drawn up, a position which seems to be the easiest; there is usually a considerable disturbance of the nerv- ous system, the patient being anxious, restless, and the facial ex- pression showing anxiety and dread. Sometimes there is delirium, but not usually, and when it does occur, I am inclined to think it shows that the ovaries are affected; at any rate, and in several cases that I have seen, where I have every reason to believe that the ova- ries were also inflamed, there was great mental excitement, and tem- porary insanity in some, 584 DISEASES OF WOMEN. The pain in the pelvis is usually acute, much more so than in cellulitis, and there is great tenderness to the touch ; the pelvic ves- sels are generally affected, and there is marked rectal tenesmus, and, if the peritonaeum in front of the uterus is involved, there is vesical tenesmus also; in fact, this vesical irritation is often an exceedingly annoying symptom. The physical signs obtained by a vaginal examination during the first stage simply reveal tenderness with some apparent thickening of the roof of the pelvis. This may be limited to one portion of the pelvis, but in well-marked cases it extends throughout. When exu- dation has taken place, complete fixation of the uterus is found, and the roof of the pelvis, as felt through the vagina, presents the extreme hardness which is characteristic of peritonitis, and has been called the dealboard hardness by some. If much lymph is thrown out, especially if it is associated with considerable serum, a mass will be found behind the uterus occupying the sac of Douglas. At no time, however, do the products of this form of inflammation extend above the superior strait, unless as an exceedingly rare exception; in case that the disease goes on to the formation of pus, a well-de- fined tumor may be found in the sac of Douglas, and if this pus is discharged, the intense hardness at that point may disappear in part; but if the entire exudation is lymph, it remains hard for a long time. There is almost always a displacement of the uterus as well as a marked fixation, and this fixation is likely to remain also; as contractions occur subsequently the position of the uterus may be- come changed, and not only is the organ thus displaced, but it is fixed in this position. The difference between the physical signs of pelvic peritonitis and other diseases of the pelvic organs, such as cellulitis and pelvic haematocele, will be given in treating of the signs of the latter. Treatment.—The objects to be attained in the treatment of pel- vic peritonitis, are first, to control or limit the inflammation so far as possible, and to relieve the pain which is usually very great; by accomplishing the latter, we do all that is possible to effect the former, the means employed to relieve pain, fortunately, having the greatest control over the inflammation. The great remedy then in the earliest stages of pelvic peritonitis, is opium; Alonzo Clark wTas the first to discover the value of this agent in general peritonitis, and to him we owe most of our knowledge of the management of this affection, and it is equally available (that is, the opium treatment) in pelvic peritonitis. The quantity of opium to be given should be measured by the PELVIC PERITONITIS. 585 effect obtained; the pain should be relieved and kept in abeyance by the regular administration of doses sufficient to accomplish this object; when it is possible, opium or morphine should be given by the mouth, because in this way the patient can be kept more uni- formly under its intluence; it often happens, however, that the stomach is too irritable to retain it at the outset; the morphine should then be given hypodermically until the stomach is quiet. In some cases where there is marked pelvic tenesmus, the opium may be given by the rectum; it should then be given in solution or enema, because if administered in suppositories it is too slightly absorbed. Sometimes in giving the opium in this way it will aggravate in- stead of relieving the pelvic tenesmus, which is often an exceedingly annoying symptom. In many cases the patient has a constant de- sire to urinate, but all efforts to do so only increase greatly the suf- fering ; this induces the patient to resist the desire, so that there is a vesical tenesmus wdth retention ; under these circumstances great relief can sometimes be given by the careful use of the catheter. Warm applications may be made to the abdomen in the form of fomentations; counter-irritation, also, is often useful, which may be obtained by the use of mustard-pastes, turpentine stupes, etc. The bowels should be kept quiet for a few days by the use of opium until the acute stage has passed, when they should be relieved by the mildest possible means. If the patient is seen at the yery onset of the attack, and the rectum is found to be dis- tended, it should be emptied at once by enema; during the early part of the first stage, if the stomach is, as it usually is, very irrita- ble, but little will be accomplished in the way of giving nourish- ment ; the thirst may be alleviated by giving ice or minute quantities of effervescing waters. If there is great prostration, a little champagne and Apollinaris water or carbonic water may be given to relieve the thirst and sustain the patient. As soon as the stomach will admit of it, nourishing food, mostly fluid, should be given; the beef-extracts, digested milk, and gruel will usually an- swer the best purpose. At the end of the acute stage, when the pain is subsiding or relieved, and the temperature and pulse are down, then the opium can be greatly reduced in quantity, or given up entirely if the patient sleeps well; usually, however, small doses will be required at night to secure rest. The next object in the treatment is to favor a further limitation of the plastic exudation, and to promote the absorption of the in- flammatory products; this can be accomplished, if at all, by the use of counter-irritation. Small blisters applied in the iliac regions, and 586 DISEASES OF WOMEN. repeated, often give the patient relief from disturbance, and appar- ently favor the absorption of the inflammatory products. The best method of employing blisters under these circumstances is to apply two. one on each side, to be kept there until the skin is thoroughly vesicated, then puncture the vesicle and let out all the serum and allow the cuticle to fall down upon the cutis, and then apply over this absorbent cotton, and allow it to remain undisturbed until heal- ing is complete, which usually takes place in from two to four days; blisters may again be applied in the same way. During this time the patient should be sustained by nourishment and tonics, quinine being one of the most reliable agents. When all acute symptoms have subsided and there is no evidence of any serum or pus accu- mulated in the pelvis, the further disposition of the inflammatory products may be favored by the U3e of iodine. The tincture of iodine may be applied through the speculum to the roof of the pel- vis, that is around the cervix uteri and upper part of the vagina, and iodide of iron may be given internally. Counter-irritants from time to time should be continued, one part of croton-oil dissolved in two parts of sulphuric ether to which are added three parts of tincture of iodine, makes a good application for keeping up continu- ous irritation; this should be painted over the lower portion of the abdomen, and repeated when the fine eruption which it produces has disappeared. These remedies should be changed after a time to the iodide of potassium or the bichloride of mercury with chloride of iron, the latter being the most valuable as a tonic and alterative. "While there are still some of the products of inflammation remaining in the pel- vis, or at least for a long time after the subsidence of the acute in- flammatory symptoms, the greatest possible care should be taken to guard the patient against undue labor ; standing, walking, or riding may produce a relapse, and hence, the patient should be made to carefully feel her way in sitting up and in taking exercise ; especially should this care be insisted upon at the menstrual periods. No rules can be laid down with reference to this except that any exer- cise which excites pain should be avoided; short stages of exercise, followed by rest in the recumbent position, should be adhered to, a little more liberty being given every day, in case it does not pro- duce pain. All exercise of the sexual functions should be prohibited until pain and tenderness have subsided. In case there is an accumula- tion of serum or pus in the sac of Douglas, this should be removed by aspiration ; if pus is found, the cavity should be washed out PELVIC PERITONITIS. 587 with a weak solution of carbolic acid and water, or of bichloride of mercury, and if this does not relieve the pain, an opening may be made and drainage established, but this is usually unnecessary. ILLUSTRATIVE CASES. A Typical Case of Uncomplicated Pelvic Peritonitis.—A lady twenty-five years of age, who had been married for two years, and was sterile, began to menstruate first at fifteen, and had also had dysmenorrhea slightly for the first years of her adult life, but it was much aggravated after her marriage. She was subject to attacks of pelvic pain, though not severe, after much exercise. At the time of the attack now under consideration, she was menstruating, and went out into company, and, I believe, engaged in dancing, and took cold on her way home. In the night she was seized with vio- lent pain in the pelvic region, with nausea and vomiting. She was seen early in the morning, and her temperature was found to be 102° F., and her pulse 120; it was also observed that she was a feeble-looking person of a tubercular diathesis ; there was much ten- derness to the touch in the lower portion of the abdomen, and also considerable tympanitic distention. On digital examination, there was evidently an increase in temperature, with congestion and marked tenderness in the region of both broad ligaments and behind the uterus. There was no fixation apparent nor hardening of the tissues, but, owing to the increased tenderness, it was difficult to make a very critical examination. The rectum was distended with fecal matter. A hypodermic injection, consisting of ten minims of Magendie's solution of morphia, was given, and warm water was injected into the rectum; the immediate effect of the enema and evacuation was to increase the pain, and in two hours afterward it was necessary to give five more minims of Magendie's solution hy- podermically; this gave considerable relief, but it did not produce sleep. In the middle of the day she was found to be still restless, with an anxious and somewhat pinched expression, and expressed herself as fearful of some dangerous trouble. Another hypodermic injection was given, because she still had nausea, but no vomit- ing ; late in the evening she was still in much pain, having come partially out from under the influence of the opium; she was still nauseated, and her temperature was 103^° F., and her pulse over 120; she complained of some headache, felt hot and feverish, and yet she was in a perspiration. Fifteen more minims of Magendie's solution was given, which secured for her several hours' sleep. Early in the morning she was found wakeful and restless, and the 39 588 DISEASES OF WOMEN. pain had returned; her stomach still being irritable, another ten minims of Magendie's solution of morphia were given ; during the night, while awake, small pieces of ice were given, which were grate- ful to her, but she was still thirsty, and begged for a large drink of cold water; she was given half a wine-glass of cold Vichy every half-hour when she desired it; she retained some of this, and in the forenoon took a little clear coffee, which she relished and retained. She still continued to suffer from nausea, great abdominal tender- ness, and considerable pelvic pain ; she also complained of a very urgent desire to urinate, but any effort to do so gave her so much pain that she resisted the desire ; the nurse was directed to pass the catheter, which she did, and drew off less than half a pint of urine of a remarkably dark color. At night she again had fifteen minims of the solution of morphia, which gave her a few hours' sleep, when she again awoke with pain ; ten minims was then given, which car- ried her through the night fairly comfortable. On the third day after the attack, upon digital examination, the parts of the portion of the pelvis within reach were found to be hard, and the uterus fixed. The hardness and fixation extended entirely across and behind the broad ligament and the uterus; a diagnosis of pelvic peritonitis was then made without hesitation. The nausea at this time was less marked, so that she retained the Yichy-water and coffee and tea, and occasionally a little beef-tea; but these were ad- ministered in small doses, care being taken not to give her the Vichy immediately before or after she took any of the others. Every little change in the temperature was observed at this time. It had required from forty-five to fifty minims of Magendie's solu- tion to keep her comfortable during the twenty-four hours up to the end of the third day ; after that the opium was given by the mouth, twenty minims of Squibb's liquor opii comp. were given every three, four, or six hours, according to the disturbance or pain which she had, and from twenty-five to thirty minims at bed-time. This was sufficient to keep her tolerably comfortable, and to secure a sufficient amount of sleep in the night and an occasional nap during the day. About this time she suffered very much from tympanitic distention ; occasionally she could raise gas from the stomach, but this gave her very little relief. On the fifth day six grains of quinine, dissolved in sulphuric acid, and added to an ounce of sirup of acacia and a little warm water, was given by enema; this was retained, and pro- duced partial relief from tympanitic distention. About a week from the time of the attack the pelvic peritonaeum was evidently covered with a marked exudation, especially that por- PELVIC PERITONITIS. 589 tion forming the sac of Douglas, while the fixation and induration involved the entire roof of the pelvis; it was most marked behind the uterus, extending down to a point on a level of the surface of the cervix uteri. On about the eighth day a marked improvement had taken place in her general condition; the temperature was 101^° F., and the pulse a little above 100 ; her tongue was still thickly coated, but was beginning to clean off on the end and sides; the nausea had mostly subsided, but she had no appetite; she was able, however, to take a fair amount of fluid nourishment—beef-extract, digested gruel, and milk, with a little tea and coffee from time to time; she still had thirst, and took considerable water. We were able at this time to reduce the quantity of liquor opii comp. about five drops every three or four hours, with twenty-five drops at bed-time. At this time we began the use of small blisters, and continued to keep the lower por- tion of the abdomen in a state of irritation for the next ten or twelve days; she was also given a pill three times a day, composed of one grain of quinine, one tenth of a grain of extract of belladonna, one half grain of comp. extract of colocynth, and one fourth grain of ipecac; this, after a couple of days, excited some peristaltic action of the bowels, and, after an enema of soap-suds, the bowels moved. This relieved the tympanitis considerably, and, although she felt greatly distressed immediately after the movement of the bowels, she was apparently better for it. All this time she had a good deal of irritation of the rectum and bladder, and a constant sense of fullness and distress in the pelvis, with pain that varied very much in severity. From this onward she suffered very little, although obliged to keep quiet in bed ; she continued to take a fair amount of nourishment and solid food, such as rare steak and a chop, which with toast and milk, were added to her bill of fare. The quantity of opium was diminished until she only took one dose at bed-time; the pills were continued, and the bowels moved every third day by enema; the temperature had now come down to 100° F., and the pulse to 95, but there was still very little apparent difference in the condition of the pelvis. This line of treatment, including the counter-irritation, was continued until the end of the third week ; at that time she was permitted to sit up a little in bed, and was able to turn from side to side without much discomfort. She continued in this way for three days longer, when the pain began again, and the pulse and temperature ran up; her stomach became again disturbed, although there was no vomiting, and the 590 DISEASES OF WOMEN. opium had to be given in small doses more frequently, in order to relieve her—in short, there was every appearance of a lighting up of the acute trouble, but the temperature did not go beyond 10 L° 1., or the pulse beyond 110, and she was exceedingly irritable, nervous, and despondent at this time; the menstruation then came on, and after a day her pain began to subside a little, and at the end of the third day her condition was about what it was before the relapse took place. This undoubtedly was simply a dysmenorrhoea from a lighting up of the inflammation. After the menstrual flow subsided, she improved in her general condition very decidedly, and, at the end of the fifth week from the beginning of the attack, she was able to sit up a little while in bed, and to be occasionally lifted into her reclining-chair. Her tempera- ture and pulse were nearly normal, but she was quite weak, and still had some disturbance in the region of the pelvis; milder forms of counter-irritants were employed, occasionally using a mild mustard- paste, and sometimes painting with the tincture of iodine; she was then put under general tonic treatment, including quinine and iron. The bowels were kept regular by the pills which were prescribed before. At this time there was still marked fixation and induration in the location of the pelvic peritonaeum, and from this onward the treatment consisted in good, generous nourishment, wine, and tonics; the iodide of iron alternated with bichloride of mercury and chloride of iron was continued off and on for about six months; at the end of that time her health was about as good as it was before she was taken ill, although she suffered more from her dysmenorrhoea than formerly, and was obliged to keep in bed during the menstrual period. About this time an examination was made when the indura- tion had partly disappeared, but not wholly ; there was still fixation of the uterus, and efforts were now made to relieve her dysmenor- rhcea, which was evidently due to an anteflexion of the body of the uterus, by enlarging the canal by gradual dilatation ; the first at- tempt at this, however, gave rise to so much pain and suffering that no further efforts were made in that direction at that time. A vag- inal douche of hot water was ordered, but that did not give her any apparent relief, nor did it appear to influence the disposition of the inflammatory products. Tincture of iodine was applied around the cervix uteri and upper portion of the vagina once a week for a month or two, and this appeared to be beneficial; at least she im- proved while this was being employed, but I presume that the con- stitutional medication had most to do with her progress—in fact, my PELAGIC PERITONITIS. 591 experience with this case and many others has satisfied me that local treatment in old cases of pelvic peritonitis does harm ten times to once that it does good. She was kept upon her general tonic and alterative course of treatment for six months after suspending all local treatment, and then it was found that there was a marked im- provement in the local condition ; as soon as the slight mobility of the uterus was established, the induration and fixation much more rapidly diminished. The patient passed from under my observation, but returned again in two years to be treated for dysmenorrhoea, and I then had an opportunity of examining her carefully, and found considerable mobility of the uterus, and also of the broad ligament; the marked induration had wholly disappeared—in fact, the only trace of her former peritonitis remaining was a small mass in the most dependent part of the sac of Douglas; this did not appear to give her any trouble; there was also less anteflexion of the body of the uterus. I was then able to treat her for her dysmenorrhcea, and succeeded in relieving her to some extent, but not wholly. Four years after I heard of this patient, and she had still maintained fair health, but suffered slightly at her menstrual periods. A Case of Circumscribed Pelvic Peritonitis of the Mildest Charac- ter.—A young lady of somewhat delicate organization, who had suf- fered from irregular and painful menstruation, was seized about the time of one of her periods with violent pain in the left ovarian re- gion ; she was out at the time the pain came on, and I believe was overfatigued; she returned home and went to bed, and I saw her several hours afterward; she then had tenderness on deep pressure in the left iliac region and also had pain there of an acute character. Her temperature was below 100° F., but her pulse was over 100 ; she was somewhat nervous and restless ; I gave her a dose of bromide of sodium with a few minims of liquor opii comp., and ordered it to be repeated during the night if she did not sleep. One more dose was necessary to give her a comfortable night, and in the morning when I saw her there was no constitutional (lis- turbance except a loss of appetite and some flatulence ; her pulse was a little rapid and there was still pain and tenderness, but not marked, in the left side. In the evening of that day her menstrual How began and continued normally though more free than usual; this improved her condition somewhat, and although she continued in bed for about a week on account of the return of pain upon trying to sit up, still she made a good recovery, and was around as usual the week following. For a number of weeks she had occasional at- 592 DISEASES OF WOMEN. tacks of pain and tenderness on that side, especially at her men- strual periods. This attack passed off, and she was in fair health until three years afterward, when from exposure she contracted double pneu- monia, of which she died. The physician who attended her at that time obtained a post-mortem examination, and, knowing that she had been a patient of mine at former times, invited me to be present; nothing of interest being found in the thorax I suggested the pro- priety of examining the pelvic viscera in the hope of determining the pathological conditions which gave rise to her irregular and somewhat painful menstruation. I had at this time entirely forgot- ten the attack above described, and only remembered it when we found the products of the pelvic peritonitis on the left broad liga- ment. The fimbriated extremities of the Fallopian tube were matted together by the old exudate, and the peritonaeum covering the outer portion of the tube and extending downward showed evi- dence of an old inflammation; the ovary, however, did not appear to be affected, except that two or three fimbriae of the tube were ad- herent to it. This case illustrates the circumscribed mild form of pelvic peritonitis which occurs quite frequently no doubt, but is overlooked, except when found at post-mortem. Septic Peritonitis Terminating Fatally.—This case illustrates the other extreme from the one just related. A strong, healthy servant- girl had leave of absence on Saturday, and staying out too late, tried to save time by crossing a field instead of taking the road home; and upon jumping a fence near the house, she was sud- denly seized with the most violent pain in the pelvis ; she reached home with great difficulty, and was helped to bed by her fellow-serv- ants ; nausea, and vomiting came on, and she became pale, faint, and covered with cold, clammy perspiration; the physician of the fam- ily, Dr. Woodruff, was sent for in the night, and by the judi- cious use of morphine hypodermically and stimulants administered by the rectum, he succeeded in bringing her out of her state of par- tial collapse. Her temperature then rapidly ran up to 105° F., and her pulse to 130 ; there was extreme tenderness of the abdomen and distention; the vomiting continued so persistently that it was impossible to administer nourishment or medicine by the mouth. The physician made a diagnosis of peritonitis which he believed to be general, and I saw her with him in the morning and, concurring in his diagnosis, we continued the use of opium, but her pulse had improved and the stimulants were suspended. The temperature and pulse continued very high and her general appearance was more like PELVIC PERITONITIS. 593 that of a case of puerperal peritonitis than any other, but there was still some hope entertained of saving her until Tuesday afternoon when she began to vomit that greenish material so often seen in gen- eral peritonitis. Her pulse became feeble and very rapid; her temperature in the vagina ran up to 106° F., and she appeared like one passing into a state of collapse. She became more and more depressed, and died of shock on Wednesday morning. The case being somewhat un- usual, a grave question was raised as to the causation ; and hence a most careful post-mortem examination was made. On opening the abdomen we found that a few coils of the small intestine had dipped into the upper part of the pelvis, and wrere ad- herent by recent soft exudate to the upper part of the uterus. The sac of Douglas was found nearly full of pus, and the whole pelvic peritonaeum was covered with the products of acute inflammation. On carefully removing the pus and some soft lymph from the sac of Douglas and broad ligaments, a recent opening was found in one of the ovaries which led to a cyst not larger than a hazel-nut; in this cyst were found a few drops of brownish-looking fiuid which was preserved for microscopical examination. The general peritonaeum, except that covering the intestine which rested upon the uterus, was perfectly normal. Nothing else abnormal was found in any of the organs of the body; the heart was rather below the average size, and so were the blood-vessels; beyond this all was normal. It is clearly evident that this girl had small ovarian cysts, the contents of which were highly septic, and when the rupture occurred this fluid set up peritonitis, which being highly septic in character, developed the violent attack which overwhelmed the patient's nerv- ous system. A Case of Pelvic Peritonitis caused by Gonorrhoea, and followed by Pyosalpinx—This lady was twenty-six years of age, and had always enjoyed very good health until she was married. Two years after her marriage she was suddenly taken with acute vaginitis and ure- thritis ; she then came under my care, and I then made a diagnosis of gonorrhoea and subsequently procured unmistakable evidence from her husband that such was the nature of the attack. The vaginitis and urethritis yielded promptly to treatment, and she was dismissed apparently well, but returned to state that she still suffered from uterine leucorrhoea; I then found a well-marked cerv- ical endometritis with some remaining vaginitis of the upper portion of the vagina. AVhile she was under treatment for this she suddenly 594 DISEASES OF WOMEN. developed a pelvic peritonitis, which was not especially severe but in which there was considerable exudation, as indicated by the fixation and induration of the pelvic organs. Under ordinary treatment she progressed fairly well, but the case was unusually tedious. At the end of the year I considered her well, but she still had some pelvic pain occasionally, although the products of the inflammation had been almost entirely disposed of, so that there was mobility of the pelvic viscera and very little hardening of the parts except in the sac of Douglas where there still remained some of the old exudate which presented a somewhat irregular, nodulated condition to the touch. At this time she was agaiu taken ill with the symptoms of another attack of pelvic peritonitis; the pain and tenderness on this occasion, however, were limited to the left side, and a tumor was soon developed which was elastic to the touch; this led me to sus- pect that this was a case of salpingitis instead of peritonitis, and when the acute symptoms subsided somewhat, I endeavored to con- firm my suspicions by aspirating the tumor; I found pus and was able to draw off about an ounce and a half of it; the sac soon filled up again, and she suffered a great deal of pain and constitutional disturbance, evidently due to a slight septicaemia. As the case was one of long duration, she became discouraged with my treatment at this time, and on the advice of friends, went to the hospital. I learned afterward, that while in the hospital she was operated upon, the distended tube being removed after the manner of Lawson Tait. A Case of Pelvic Peritonitis, followed by Permanent Displacement of the Uterus, Dysmenorrhoea, and Cystitis.—This was a married lady, about twenty-nine years of age, who had suffered most of the time from dysmenorrhcea and sterility, caused by anteflexion of the body of the uterus with slight retroversion. During the treatment for this malformation of the uterus she was attacked with pelvic peri- tonitis, the exciting cause being a rather forcible effort to correct the retroversion. The pelvic peritonitis ran its ordinary course, and terminated in recovery; but afterward the uterus was found in a markedly retroverted condition, and bound down to the posterior wall of the sac of Douglas; the bladder was also drawn backward with the uterus, and held in that position. This gave rise to dys- menorrhoea quite as marked as that from which she suffered before her peritonitis. The malposition of the bladder caused by the ad- hesions rendered it impossible to completely empty that organ, and the partial retention of the urine developed a very troublesome cystitis. PELVIC PERITONITIS. 595 All efforts to restore the uterus and bladder to their normal po- sitions were without avail. The dysmenorrhcea was partly relieved by treating the cervical endometritis, wThich she also had, and dilating the internal os a little. The cystitis was controlled by long-continued local treatment, but she still suffered from some pelvic tenesmus, and, in fact, remained something of an invalid during the five or six years that she remained under my observation. Pelvic Peritonitis, which went on to Suppuration, the Pus accumu- lating in the Sac of Douglas; treated by Aspiration; and Recovery.— This patient was a lady who had married and had borne two chil- dren, became a widow, and married a second time, and who had contracted gonorrhoea, which led to a severe attack of peritonitis. There was nothing peculiar in the clinical history of the case, except that it was very severe, but she progressed fairly well up to the time when the acute symptoms should have disappeared. Her tempera- ture and pulse continuing high, and her general nutrition showing evidence of some septic influence, it was presumed that pus had been developed somewhere in the pelvis, and, as there was a large tumor or a well-defined mass in the sac of Douglas, the aspirating-needle was introduced in the hope of finding the location of the suppura- tion. Over two ounces of sero-purulent fluid were drawn off, which improved the patient's condition almost immediately; she had less pain afterward, her pulse and temperature improved, and her gen- eral nutrition also; this improvement, however, was only for a short time, when the former symptoms returned, and aspiration was again practiced with the result of finding a small quantity of pus. The sac was at the same time washed out with a solution of bichloride of mercury, and from this onward she did well, although she did not fully regain her original health; she still had attacks of pelvic pain at times, and active exercise usually brought on pelvic tenes- mus. The last time that she was examined, about a year and a half from the time of the pelvic peritonitis, there was still considerable fixation of the pelvic organs and induration, showing that the prod- ucts of the bygone inflammation had not by any means been all dis- posed of. 30* CHAPTER XXXIII. PELVIC ILEMATOCELK. Pelvic haematocele is, as the term indicates, an accumulation of blood in the pelvis, or, more strictly speaking, in the sac of Douglas, or else in the cellular tissues of the pelvis. Of course, the accumu- lation of blood is merely the result of some other lesion, and conse- Fig. 211.—Subperitoneal pelvic haematocele. U, displaced uterus ; B, empty bladder. PELVIC HEMATOCELE. 597 quently pelvic haematocele is secondary to the lesion which gives rise to it. There are two forms of pelvic haematocele, distinguished accord- ing to the location of the accumulation of blood : Subperitoneal pelvic haematocele, or that in which the haemorrhage occurs in the cellular tissues (Fig. 211), and intra-peritoneal haematocele, in which the blood accumulation is in the pelvic cavity—that is, in the sac of Douglas (Fig. 212). The subperitoneal variety is not always a very serious affection, while the intra-peritoneal variety is one of the most dangerous dis- Fig. 212.—Intraperitoneal pelvic haematocele. eases which comes under the observation of the gynecologist; there- fore, the former will be dismissed with a few remarks later, while the most of what follows will refer to the intra-peritoneal variety wholly. The sources of the haemorrhage giving rise to this affection which have so far been accurately determined are from rupture of blood-vessels of the ovaries or veins of the broad ligaments, and from rupture of an aneurism of some of the pelvic arteries, reflux of blood from the uterus or Fallopian tubes, and general transuda- 598 DISEASES OF WOMEN. tion from the smaller blood-vessels in certain conditions of the blood, such as that of purpura, for example. Rupture of the sac m cases of extra-uterine pregnancy has also been mentioned as a source of haemorrhage, giving rise to pelvic haematocele. But, as extra-uterme pregnancy is a matter wholly by itself, it need not be considered in this connection. It will be seen from this that the conditions which give rise to haemorrhage may all be classed under two heads—first, some condition of the blood-vessels which favors their giving way, and, second, the conditions of the blood, which favor haemorrhage, such as we find in persons of the haemorrhagic diathesis. The extent of the accumulation depends to some extent upon the size of the ruptured vessels. If the haemorrhage is extensive, the loss of blood and shock may cause a fatal termination in a few hours. This shock is due to the impression made upon the peri- tonaeum by the sudden effusion of blood, which acts as a foreign body. If this does not occur, and the haemorrhage ceases, then pel- vic peritonitis, sometimes general peritonitis, supervenes, and the products of the inflammation are thrown around the blood-clot, and in this way it becomes walled in. If, again, the patient survives the acute peritonitis, the serous portion of the blood is slowly disposed of by absorption, and in time the solid clot softens down by degrees, and is also disposed of in the same way; and, again, the patient may recover with the pelvic organs damaged by the inflammatory prod- ucts, which remain and behave very much as in simple pelvic peri- tonitis. Occasionally, however, it happens that, in place of the blood-clot being disposed of in this way, it breaks down, and sup- puration of the products of the peritonitis occurs, and death ensues from septicaemia. This, then, gives three well-defined stages in the progress of pel- vic haematocele : First, the stage of haemorrhage ; second, the stage of pelvic inflammation; and third, the stage in which the clot is disposed of by absorption, or breaks down, and gives rise to sup- puration. The extent of pelvic peritonitis, and the subsequent disposal of the clot, or the extent of suppurative action which may take place, depends to some extent upon the quantity of the blood accumula- tion, and also upon the patient's general condition at the time, and the character of the blood. In case the patient is not in vigorous health at the time of the haemorrhage, and if the haemorrhage is great, the shock is more likely to prove fatal; or, if that does not take place, then the extent and character of this inflammation, and the tendency to decomposi- PELVIC HEMATOCELE. 599 tion and suppuration, are rendered greater in case the blood is in any way abnormal. A limited quantity of normal blood in the sac of Douglas does not necessarily give rise to very great trouble, but we can readily suppose that, if blood is abnormal, as in the case of scorbutus or purpura, then it is more likely to be irritating, and hence the greater will be the inflammation and tendency to suppuration. The accom- panying figures, 211 and 212, illustrate the two varieties of pelvic hematocele, classified according to location. Causation.—The causes of pelvic haematocele are necessarily predisposing and exciting. There are three predisposing causes— certain changes in the blood-vessels of the pelvis, overdistention of the vessels which enfeebles their walls, and degeneration of the walls of the blood-vessels, which renders them more easily ruptured under extra pressure. Any one of these conditions of the blood-vessels may be produced by continued hyperaemia or, more especially, engorge- ment. It is well known that congestion on the venous side of the circulation tends to degeneration of tissues of all kinds, and the walls of the blood-vessels prove no exception. Hence, in cases of long- continued congestion of the pelvic organs from any cause, such as obstruction of the portal circulation, imperfect involution after par- turition, or in persons whose occupation compels their continued standing or sitting, the strength of the walls becomes impaired, and they are liable to rupture. On the other hand, in certain abnormal conditions of the blood, such as that found in purpura or scorbutus, there is a tendency to haemorrhage from the small vessels under extra pressure. It follows, also, that the predisposition to haemor- rhage will be most marked during the period of ovarian activity, and also at the menstrual period. The exciting causes of pelvic haematocele are, in a word, anything which can produce overdistention of the blood-vessels, sudden check- ing of the menstrual flow, maintaining the erect position for any great length of time, violent exercise and overexertion, and the like, injuries or falls, and when the haemorrhage comes from the Fallopian tubes or the uterus, it is caused by some obstruction of the cervical canal or the Fallopian tubes. Symptomatology.—In the majority of patients who have this affection, the haemorrhage is often preceded by symptoms indica- tive of some pelvic affection, but these need not necessarily be suffi- ciently marked to call the attention either of the patient or the phy- sician to them ; so it may be said that the symptoms of pelvic haem- atocele are developed suddenly. The symptoms, of course, differ 600 DISEASES OF WOMEN. as the disease progresses, each stage having its own characteristic manifestations. AVhen the haemorrhage occurs, there is first, severe pain in the pelvis, followed soon after by all the evidences of shock, such as faintness, coldness of the extremities, pallor, and cold, clammy perspiration, a feeling of nausea, and sometimes vomiting. If the temperature is taken at this time, it will be found to be subnormal, and the pulse irregular and rapid, although sometimes it is slow and feeble. In a short time to these symptoms are added well-marked pelvic tenesmus, including vesical and rectal tenesmus, and tympanites. If the haemorrhage stops and the patient recovers from the shock, then inflammatory symptoms are developed. These constitutional and local symptoms are exactly the same as those observed in peritonitis, because they are due to the peritoneal inflammation which usually starts up about forty-eight hours after reaction from the haemorrhage. If the patient passes through the inflammatory stage and the blood accumulation is disposed of by absorption, the symptoms will then be altered to a modified pelvic tenesmus with occasional pain of a mild character and a general malnutrition, indicating some source of a mild form of septicaemia. On the other hand, if suppuration and breaking down of the blood- clot take place, the constitutional disturbances as indicated by high temperature, rapid pulse, and deranged nutrition, will show the sep- ticaemia which usually takes place under those circumstances. Physical Signs.—In the stage of haemorrhage there are simply tenderness and distention of the sac of Douglas, indicated by a mass which fluctuates on pressure ; the tumor is soft, smooth, and uni- form. After coagulation has taken place the mass becomes solid, but is still soft and yielding to the touch; the uterus is displaced, usually upward and forward, so that the cervix will be found just behind or above the symphysis. The rectal touch will also show that the tumor presses upon the bowel; abdominal palpation made after the tympanitic distention has subsided, will often show the mass extend- ing up to the superior strait and sometimes higher, and in one case that I saw, the blood-clot extended upward half-way to the umbilicus. After inflammation takes place this mass becomes surrounded above with the products of the inflammation which increase the density of the tumor and also give it a more perfect fixation. After the inflammation has subsided and the serous portion of the blood has all been absorbed and the solid clot has undergone considerable contraction, the mass that was originally smooth to the touch now PELVIC HEMATOCELE 601 becomes quite irregular. As the case advances still further and the blood-clot breaks down and suppuration occurs, the mass may be- come softer and give the impression of obscure fluctuation to the touch. The great difficulty which the diagnostician encounters is to distinguish between pelvic cellulitis, pelvic peritonitis, and haemato- cele. It is also stated that pelvic haematocele may be confounded with retroversion of the uterus, extra-uterine pregnancy, fibroid tumors, and inflammation of a small ovarian cyst which is lodged in the sac of Douglas, and hydro- or pyo-salpinx. There is very little likelihood of confounding so grave an affection as pelvic haemato- cele, the clinical history of which is so marked, with any of the above-named conditions, except it might be an acute inflammation of an ovarian cyst, located in the sac of Douglas, or a Fallopian tube, very greatly distended with serum, pus, or blood. In either of these conditions—except the latter—if a diagnosis could not be made, and it was important at once to do so, the use of the hypodermic syringe used as aspirator, would settle the question definitely. Treatment.—During the stage of haemorrhage this consists in using means to arrest the haemorrhage, relieve the pain, and sustain the patient against the shock and loss of blood. To control the haem- orrhage the patient should be placed on the back with the head and shoulders slightly elevated, in order that the blood as it accu- mulates in the pelvis may, by its own weight, make pressure upon the rupture in the vessel. Cold applications to the abdomen have been recommended, but usually are not well borne. Pressure made by applying a compress and bandage is more likely to do good ; to relieve the pain and sustain the patient, morphine given hypoder- mically is the most reliable and valuable of all remedies; under the circumstances the opium acts as a stimulant as well as a relief to pain. In case the shock is great and liable to prove fatal, stimulants should be used hypodermically or by the rectum ; but in many cases the rectum will not retain them owing to the irritability caused by the haematocele. It has been proposed by Dr. M. A. Pallen to open the abdomen, remove the blood, and stop the haemorrhage by ligating the rupt- ured vessels. This, theoretically, appears to be good surgery, but unfortunately it can never have any very wide practical application ; the fact is it should never be undertaken in eases where the shock and depression are great, because the patient would most certainly die under the operation, and in the less severe cases of haemorrhage which are not attended by any great shock, it can usually be arrested by milder means. I can conceive of no condition where laparotomy 602 Diseases of women. would be justified, except in cases where the haemorrhage is slow but persistent. If one is satisfied that a haemorrhage is going on in the pelvic cavity, which persists in spite of all ordinary efforts to check it, and the patient does not suffer from shock, then lapa- rotomy might be undertaken ; such cases, however, are extremely rare, and it is difficult to diagnosticate the conditions above men- tioned ; hence, I think that it will be seldom, if ever, that this prac- tice will be followed. However, abdominal surgery has attained such a degree of perfection in the hands of some, at the present day, that it is well to keep this mode of treatment in mind as a possible means to be employed. When the inflammatory stage begins the treatment should be the same as that already advised in cases of pelvic peritonitis, and if the case progresses favorably the treatment should be continued on the same principle. If, however, suppuration takes place, and the pa- tient is placed in danger of septicaemia, the question arises how to relieve that condition. There are two methods, either or both of which may be employed if the location of the pus can be reached through the vagina ; aspiration may be practiced, and if that gives relief it may be repeated if need be; if, however, this fails, the needle may be again introduced until the pus is reached, and being left there as a guide, a larger opening may be made, and drainage established ; or laparotomy and drainage may be practiced. Years ago, Recamier proposed to evacuate the blood-clot as soon as the patient had sufficiently rallied from the shock of haemor- rhage ; by so doing he hoped to lessen or avert entirely the inflam- matory stage and the long tedious and sometimes dangerous process of disposing of the clot. Xelaton took up this practice, but soon found that it was a dangerous proceeding, inflammation and septi- caemia of a dangerous character being very liable to follow. It is possible that to-day, with the great improvements in surgery, this practice might give better results than in years past; one thing I am sure of, and that is if the blood-clot is not disposed of in a quiet and favorable way but sets up a suppuration after the inflammatory stage is past, I should be in favor of evacuating it. This I have tried successfully in one case, a rather desperate one it was too, and with perfect success. I would not, however, advise operating except under the conditions named, because, if the evacuation of the clot is undertaken before it is walled in by inflammatory products, there is very great danger of starting up another haemorrhage which might not be controllable, and again there is more danger of exciting peri- tonitis which might become general, and end fatally. PELVIC HEMATOCELE. 603 ILLUSTRATIVE CASES. A Case of Pelvic Haematocele uncomplicated.—A lady of some- what phlegmatic temperament who was also chlorotic, had suffered all her life from dysmenorrhcea in a marked degree, and also scanty menstruation as a rnle, although at times this was more free. She had been twice married, the last time for eight years, but had never been pregnant. In taking her previous history at the time I first saw her, I found that she had symptoms of some former pelvic dis- ease, probably general congestion as indicated by her dysmenorrhoea, leucorrluea, and pelvic tenesmus which was aggravated on walking. She had lived a somewhat indolent life taking very little phys- ical exercise. When I saw her first I learned that on the last day of her menstrual flow she had been riding and walking more than usual, as she had some visitors whom she was entertaining by tak- ing them about the city. While getting out of her carriage she slipped and fell on the sidewalk; she was taken with pain in the left side of her pelvis, and had to be helped into the house, and immediately went to bed; her pain increased in severity, and she became very faint and nauseated ; I saw her about two hours after this slight accident, and found her suffering from partial shock; her pulse was exceedingly feeble and rather rapid; her temperature was 97£° F., and her skin was cold and clammy; she was sighing frequently, and had an expression of extreme anxiety and distress ; she had vomited frequently and was exceedingly nauseated; she complained in a low whispering voice of a violent pain in the vaginal pelvis. There was considerable tympa- nitic distention of the abdomen with marked tenderness in the epi- gastric region. On digital examination I found considerable tender- ness, but not as much as might have been expected. There were signs of fluid in the sac of Douglas, but this was eas- ily displaced by the touch; a diagnosis of pelvic haemorrhage was made, and hypodermic injections of morphine were given sufficient to relieve her pain ; a little brandy-and-water was also administered at first, but this she almost immediately rejected ; an abdominal band- age and compress were applied without giving any distress for two or three hours, but at that time she complained of its tightness, and it was necessary to remove it; bottles of hot water were applied to the feet and limbs and also to the arms, which were kept under the bed-clothing. All this gave her relief from pain to some extent and the shock did not apparently increase, and yet she showed very little disposition to rally. About three hours afterward some brandy 40 604 DISEASES OF WOMEN. and beef-extract were given by enema, and repeated at intervals of two or three hours for some time; the hypodermic injections of morphine were also repeated as often as every three hours during the first twelve hours. During this time she was given a grain and a half of morphia altogether. She then began slowly to recover from her shock, the haemorrhage evidently having stopped; her pulse became more rapid and a little fuller; she breathed more nat- urally, and her skin became warm; she also had less of that extreme faintness and depression ; still she remained nauseated although she was able to retain very small quantities of brandy and Seltzer-water and beef-extract; the pain however was not any less except when controlled by the morphine. In addition to this she complained of marked pelvic tenesmus, especially of the bladder and rectum. She described this feeling as one of great fullness, weight, and pressure in the pelvis, which she fancied would be relieved by free evacua- tion of the bowels. She remained in this condition with very little change; taking opium freely and very little nourishment for about forty-eight hours; at that time the physical signs showed that the sac of Douglas was filled with blood which was now beginning to coagulate as shown by the less pelvic fluctuation on touch. Her temperature now rather rapidly increased, running up to 103° F., her pulse became more rapid and fuller; the pain also increased, and nausea and vomiting again returned. She was now very tym- panitic and had acute tenderness on touch in the lower part of the abdomen; in short, she had all the symptoms of acute pelvic peri- tonitis with unusual marked constitutional disturbance, owing no doubt to the general depressed condition due to pelvic haemorrhage. On the fourth day there were well-defined evidences that the products of the pelvic inflammation were being developed ; there was much greater hardening of the parts, and the mass in the sac of Douglas was solid or more solid as indicated by the touch. From this onward the physical signs were those of a pelvic peritonitis with an unusual accumulation in the sac of Douglas. The progress of the case from this time was that of a severe pel- vic peritonitis, and the treatment was the same as has already been described, hence nothing further need be said on that subject. At about the end of the third week the physical signs were the same, except that on examination a mass appeared behind the uterus which was somewhat irregular, small depressions and elevations beino- de- tected here and there ; the temperature and pulse had both come down, and yet remained above 100 ; the patient was now able to take a fair amount of nourishment, and her bowels were moved but with PELVIC HEMATOCELE. 605 the greatest possible difficulty; laxatives and repeated enemata were given each time that an evacuation was obtained, and she also suf- fered great distress when the bowels moved. About this time she be- gan to show decided malnutrition; she had lost considerable flesh, was pale and rather slightly bronzed looking, and her skin was dry and ill conditioned, giving the impression that the absorption of the serous portion of the blood was probably causing a mild form of septicaemia. From this time onward her progress was exceedingly slow but entirely satisfactory under tonics, nourishing diet, and mild counter-irritation over the hypogastric region; she gradually re- gained her strength. The pain and discomfort in the pelvic region had become very trifling except when she tried to take exercise. There was no change in the physical signs except that the mass in the sac of Douglas had greatly diminished in size, and the uterus which had been pushed upward and forward close to the pubes, had returned in part toward its normal position. The hardening of the pelvic roof and the fixation of the pelvic organs remained about the same. It is needless to follow the progress of this case from day to day ; suffice it to say that she made a very slow recovery, that at each menstrual period she suffered great disturbance, and that for a long time was unable to walk or ride without suffering pain. Tonics, alteratives, and nourishing diet were given which improved her gen- eral condition. Ten months after the attack there were still signs of an excessive exudation in the pelvis, and also the remains of a blood-clot in the sac of Douglas; still, from this time onward she was able to enjoy life in her own somewhat indolent wray, but could not walk or ride without suffering more than in former years. A year and a half subsequently I had the opportunity of examining the pelvis, and found that there was still considerable fixation of the pelvic organs, and also some hard, irregular, small masses in the sac of Douglas, but she did not appear to suffer very much from these, and her gen- eral health was fairly good. Pelvic Haematocele; Evacuation of a Clot; Recovery.—A French- woman, occupied as polisher in a watch-case factory, where her duties required her to occupy a standing position all day long, was suddenly taken ill while at work; violent pain, followed by faintness, came on while she was at work. She was carried from the factory to her home near by, and one of my assistants was called to see her. He attended to her immediate wants, and saw her again afterward, when he made a digital examination, and found a fluctuating mass in the 606 DISEASES OF WOMEN. sac of Douglas. On the second day he gave me a detailed history of the case, and we came to the conclusion that she must have had a pelvic haemorrhage; the inflammatory action soon set m after she rallied from the shock which occurred, and was very severe at the onset of the disease, and she was again in a most dangerous condi- tion. Being poor, her surroundings were very unsatisfactory, and, by advice of the doctor, she was removed to the hospital; she was admitted about ten days after the time that she was taken ill. At that time the pelvis appeared to contain one solid mass, so that noth- ing could be distinguished except a somewhat shortened vagina and the cervix uteri, which was curled up and firmly fixed behind the pubes. Her bowels were very much distended, and she suffered ex- tremely from pain and tenesmus; her general condition was very wretched, indeed, and, as it was impossible to move the bowels, the question arose, What could be done to relieve the extreme pressure in the pelvis which threatened to destroy the organs and tissues, and prove fatal'( I had the extreme good fortune to secure the counsel of the late Prof. William Warren Greene, and we decided to evacu- ate the blood-clot in the hope of thereby saving the life of the pa- tient ; accordingly, an incision was made through the posterior vag- inal wall into the most dependent part of the tumor, which extended well down into the middle line of the pelvis; a large blood-clot was found, which was broken up and evacuated, and the cavity cau- tiously washed out. No haemorrhage of any amount followed, and she was very much relieved. I succeeded then in moving the bowels, which, while it distressed her at the time, subsequently gave her relief. The improvement lasted but a little while, however, for she soon developed a violent septicaemia, and it now appeared as if she certainly must die; she became delirious, her pulse was extremely rapid and feeble, her temperature w7as 105^° F., and she was bathed in clammy perspiration; her breath also had that peculiar sweetish odor characteristic of septicaemia or pyaemia. There was a free discharge of pus at this time from the wound. Every effort was made to sustain her by stimulants and quinine, given by the mouth and rectum also, and the sac was washed out carefully and frequently with boracic acid and water. For two days it seemed as if she might die at any time. A free and profuse diarrhoea came on, and lasted for several hours, and, at a consultation held by the surgical staff of the hospital, all agreed that she had very little chance of recovery. The treat- ment was thoroughly carried out, and soon the blood-poisoning began to diminish, the sac became smaller, the discharge less free and, PELVIC HEMATOCELE. 607 finally, the wound closed, and she recovered from all but the prod- ucts of the inflammation, and these remained slightly diminished up to the time that she was discharged from the hospital, three months from the time that she was admitted. AVhen she left the hospital her general health was fairly good, but there was still fixation of the pelvic organs, and marked induration extending across the pelvis behind the broad ligament and uterus. I found out afterward that she took care of her household after her return from the hospital, and about six months afterward returned to her occupation in the factory, where she remained at work when last heard of, two years from the time she was first taken sick. A Case of Subperitoneal Haematocele; Recovery.—A lady, whose age does not appear in my notes, was married, and had three chil- dren, and was under my care for endometritis, associated with a good deal of general congestion of the pelvic organs. She was progressing fairly well until one day, when she went to New York shopping; she walked and stood considerably, and on her way home in the afternoon, after crossing the ferry, decided to walk to her house, a distance of about three quarters of a mile ; she did this because she was somewhat proud of her improvement under treatment. When about half through her short journey, she was seized with pain in the left side of the pelvis, which became so severe that she was obliged to sit down on the door-steps of a house near by, and, after resting for a short time, she managed to get home, went to bed, and applied a mustard-paste over the painful side; the next day or two she re- mained in bed, the pain gradually diminishing, though it did not wholly disappear. Four days afterward she rode to my office, and, on digital examination, I found a round, rather flat tumor in the left broad ligament, low down ; it was somewhat solid to the touch, and tender. Being very desirous of knowing what this peculiar and sud- denly developed tumor could be, I introduced a small aspirating- ueedle, and drew off a few drops of blood-serum and a few very minute shreds of blood-clot, but failed to find anything more, al- though I made a strong effort to do so. I then withdrew the needle, and found that it contained a long shred of blood-clot; this satisfied me that she had had a haemorrhage into the cellular tissue of the broad ligament. I watched her with care and anxiety, but there was no inflammatory action established at that point, and the tumor slowdy and completely disappeared. Subperitoneal Pelvic Haematocele discharging into the Pertioneal Cavity, and ending fatally.—The following case is taken from the work of Thomas on "■ Diseases of Women " : " In a case which I saw 608 DISEASES OF WOMEN. with Dr. Emmet, we were unable to make a diagnosis of a tumor which lay obliquely anterior to the uterus. In twenty-four hours the patient fell into a state of collapse, and, as we saw her thus, the nature of the tumor, which we were doubtful about on the previous day, became evident. Upon a post-mortem examination, an ante- uterine haematocele as large as a goose's egg was found under the peritonaeum, through which it had broken, discharged a portion of its contents into the peritonaeum, and caused collapse and death. This is the only ante-uterine, but not the only subperitoneal, haema- tocele with which I have met." For an illustration of subperitoneal pelvic haematocele giving rise to cellulitis and suppuration, the reader is referred to a case given under the head of " Pelvic Cellulitis." DISEASES OF THE UEINTAEY OKGANS. CHAPTER XXXIV. ANATOMY AND DEVELOPMENT OF THE BLADDER AND UEETHEA. This portion of the present work is undertaken with the full assurance tbat the medical profession is in need of a systematic and practical treatise on the diseases which affect the urinary organs of the female sex, and that such a treatise should be included in every work on gynecology which lays claim to being complete. Those engaged in active practice often encounter cases of cystic disease among their female patients, many of which are exceedingly trouble- some if not altogether impossible to manage. There is, moreover, but little in English literature, at least, to aid them when thus per- plexed with the difficulties of diagnosis and treatment. In considering this important subject after the plan which I have adopted, much will be purposely omitted, which, though interesting, is not absolutely necessary to a clear understanding of its essential principles. The conflicting views of various authors regarding un- settled questions will, when possible, be entirely disregarded in order to make room for the more practical points which the physician is expected to carry with him in his daily practice. In short, it will be my purpose to supply, so far as I may be able, the deficiency in tliis branch of medical literature, the existence of which a busy life in private practice and in teaching medical students and post-gradu- ates has demonstrated. To proceed systematically, I will first take up the form and struct- ure of the bladder and urethra, and the relations which they bear to otber organs and tissues in the female, and then pass on to the con- sideration of their development. Anatomy of the Bladder.—Tbe bladder is a musculo-membranous sac, situated in the anterior part of the true pelvis. Its form varies with the age of the individual and the degree to which it is dis- 610 DISEASES OF WOMEN. corpus or body (bladder) tended. In childhood, the vertical diameter is the longest; in mid- dle life, the transverse; in old age, from the sagging of the infe- rior fundus and gradual atrophy of the pelvic organs, the vertical again becomes the longest diameter. When empty, its walls are closely coaptated, and it lies behind the pubes. Pet ween the pubes and the bladder is a space containing loose fat. When moderately filled, it rises slightly above the pubes, and assumes a somewhat ovoid shape, which is much more marked during distention. In the fe- male the bladder has a shorter antero-posterior and a greater lateral diameter than in the male. The bladder in the female is, for accuracy and convenience of description, divided into corpus (body), fun- dus (base), and cervix (neck) (see Fig. 2Pi). The corpus is all that portion of the organ lying above an imaginary plane, passing through the vesical openings of the ureters and the center of the symphysis pubis. That part lying below this plane is the fundus or base, and is variously divided. The portion which lies between the vesical openings of the ureters behind, and the vesical orifice of the urethra in front (Fig. 214), is known as the trigone, or vesical triangle. That portion of the base lying just behind the ureteric openings is known as the has fond. This is usually but a slight depression in early and middle life, but in disease and advanced age it often becomes a deep pouch or sac. This is more often the case in the male than in the female. The cervix or neck of the bladder is that funnel- shaped space at the apex of the trigone, where the bladder and ure- thra merge into each other. The bladder has three coats—two complete and one partial or incomplete. From without inward these are the serous (incomplete), the muscular, and the mucous. The serous investment of the blad- der, like that of all the abdominal and pelvic organs, consists of peritonaeum, of which I will speak more fully when I come to con- sider the ligaments and topographical relations of this organ. The middle or muscular coat has a peculiarly efficient fiber ar- rangement. Its layers have been divided into two—external and internal—but so frequent and so intimate are their interlacements that, though when minutely considered they are two, practically they act and appear as one. The main direction of the outer fibers is Fig. 213.—Diagram of the bladder to show corpus and fundus. ANATOMY OF THE BLADDER. 611 longitudinal; of the inner, circular. There is also a thin stratum of muscular fiber lying just under the mucous membrane, and con- tinuous with the longitudinal fibers of the urethra. The main fibers are of the unstriped or involuntary kind, and take their origin chiefly from the neck of the bladder. According to some authors, the sphincter vesicae is formed by a strong band of muscular fibers, varying from one eighth to half an inch in thickness. By others, and these are perhaps the best au- thorities, it is claimed that there is no true anatomical sphincter of the bladder. The function of the sphincter vesicae is said to be per- formed by the closing together of the longitudinal folds of the tis- sues at the junction of the bladder and urethra, or by the transverse semicircular folds that close over each other. At the base of the bladder two little muscular slips arise from the portion usually designated as the sphincter vesicae, and find in- sertion about the vesical openings of the ureters. These muscular fasciculi are but imperfectly developed in the female, and probably bave little if any specific action. The lining or mucous coat of the bladder is like that of the ure- ters and urethra. It consists of a basement membrane, supporting two or more layers of epithelium, in some parts squamous, in others cylindrical, the whole lying upon an elastic, cellulo-vascular bed' that is fitted into the meshes of the reticulated muscular coat beneath. This mucous membrane is nowhere attached closely to the sub- jacent muscular layer, save at the trigone, the neck, and about the orifices of the ureters. Owing to the general looseness of attach- ment when the bladder is partially or wholly contracted, the mucous membrane is thrown into rough, uneven folds everywhere, save at the points of close attachment already mentioned. In the trigonal space the membrane is thinner, more closely ad- herent, and the surface epithelium is usually of the medium-sized, squamous variety. The nerve-supply to this small space is very rich, and, in consequence, it is the most sensitive part of the blad- der. Although Savage denies the presence of glands or papillae in the mucous membrane of the bladder, Holden and many others main- tain (and correctly, I think) that the membrane is studded with numerous little glands and follicles, whose function is to supply mucus to the internal surface of the organ. They are most numer- ous at and about the vesical neck. The trigone in the female is a smaller space, and has less dis- tinctly marked boundaries than in the male. That little elevation 61-2 DISEASES OF WOMEN. of mucous membrane lying at the very apex of the trigonal space, and known as the uvula, is also but little developed in the fe- male. Running between the vesical orifices of the ureters, Jurie claims to have found what he calls the inter-arete ric ligament, in the ends of which he asserts that the ureteric orifices are imbedded. To its action he attributes the power that the bladder has of preventing regurgitation into the ureters. I will speak more fully on this point presently. Normally, the bladder has three openings, one for each ureter, and the urethral orifice. The openings of the ureters lie on each side of the median line at the base.of the bladder, about one inch and a half behind the vesical opening of the urethra, and about two inches apart. The ureters pierce the bladder-wall obliquely, and their openings are so minute as to be hardly visible to the naked eye. Their points of entrance are marked by a slight puckering in the mucous membrane. The third opening is the ostium urethrae internum, which is a diagonal slit at the juncture of the vesi- cal neck and urethra. According to Ru- tenberg, the color of the vesical mucous membrane in the liv- ing subject before dilatation is a dull, grayish red ; but, as dilatation proceeds, and the irregular folds are straightened out, it becomes grad- ually a brighter red, and, when complete distention is accom- plished, the minute arteries can be seen forming a beautiful interlacing network on the bands of the muscu- lar reticulae. Whenever it has been my good fortune to see this membrane in the living subject, it has appeared to me as being of a Fig. 214.—Base and neck of the bladder (Savage), a, sym- physis pubis. 1, 1, Ureters. 1', Ureteric openings. 2, 3, Uterine artery and veins. 4, Outline of cervix uteri. 5, Vesical neck. 6, Arcus tendineus and vesico- pubic muscles. V, 7, Pubo-coccygeus muscles. ANATOMY OF THE BLADDER. 613 grayish-pink color, not unlike that of the mucous membrane of the cervix uteri when anaemic. The vascular supply of the bladder is very free, being derived from the superior, middle, and inferior vesical arteries, and branches from the uterine artery. They all arise from the anterior trunks of the internal iliac arteries. The anastomoses of the arterial twigs are numerous and free. The veins are also numerous and large, form- ing by interlacement and connection thick, tortuous plexuses about the base, sides, and neck of the bladder, and finally terminate in the internal iliac veins. This plexus about the neck of the bladder com- municates freely with that of the labia minora, uterus, and rectum. These venous plexuses are the chief elements in the so-called " haem- orrhoids of the bladder." In their tortuous course these veins are accompanied by lym- phatics that seem to have their origin in the submucous cellular tissue of the bladder. They enter the glands situated about the internal iliac artery, and from there go to the lumbar glands. The nerves of the bladder are of two kinds—spinal and sympa- thetic. The spinal nerves are branches, usually from the fourth, sometimes from the third, and rarely from the second sacral nerve. They terminate chiefly in and about the neck and base of the blad- der. The sympathetic nerves have their origin from the hypogastric plexus, which lies in front of and on the last lumbar and first sacral vertebrae. It is formed by a mazy interlacement of numerous gan- glionic fibers, and branches from the spinal nerves, especially the second sacral. Ganglia are common, more particularly at the point of junction of the spinal and sympathetic nerves. This plexus sends branches to all parts of the bladder, and to the vagina, uterus, and rectum. This common nerve-supply to the various pelvic organs must be borne distinctly in mind in order that the functional de- rangements and neuroses of the bladder, hereafter to be described, may be thoroughly understood. Anatomy of the Urethra.—The female urethra is a musculo-mem- branous canal, from one to two inches in length, the average being about one inch and three eighths. Its diameter is greater than that of the male, being about one fourth of an inch. It lies in the median line, just under the pubic arch, and is held m position by the median pubo-vesical ligament. In the erect posi- tion it has a direction upward and backward, and at all times, when normal, its axis closely corresponds to that of the pelvic outlet. It terminates anteriorly at the base of the vestibule by an opening 614 DISEASES OF WOMEN known as the meatus urinarius, and posteriorly at the neck of the bladder. It has a cellular, a double muscular, and a mucous coat. Accord- ing to Robin and Cadiat, its mucous membrane is richer in elastic tissue than any other in the body. The epithelial covering of the anterior or lowest portion is of the pavement variety, and closely resembles that of the vagina, except that it is not so large. Figs. 217 and 218 show the difference between the two. Posteriorly and superiorly it is like that of the bladder — columnar and squamous. Scattered throughout are little papillae, con- taining blood - vessels, and near the meatus there are numerous lacunae surrounded by villous tufts. There is also a number of small mucous glands, that in old people often con- tain black particles, like the prostatic concre- tions of the male. Upon each side, near the floor of the fe- male urethra, there are two tubules large enough to admit a No. 1 probe of the French scale. They extend from the meatus urinari- us upward, from three eighths to three quar- ters of an inch. Fig. 215 is a drawing from a section of the urethra, laid open by division of its posterior or vaginal wall. The tubules, having been distended by probes passed into them, are plainly seen. Fig. 216 shows the same thing from the opposite side, the ure- thra having been laid open by section of its ante- rior wall. The space between the tubules is the floor of the urethra. From these it will be ob- served that the tubules run parallel with the long axis of the urethra. They are located beneath the mucous mem- brane in the muscular walls of the urethra. This is represented by Fig. 217, which is a draw- ing taken from a transverse section of the ure- ^ thra, about a quarter of an inch from the meatus. The mouths of these tubules are found upon the free surface of the mucous membrane of the urethra, within the labia of the meatus urinarius. fig. 216.—Urethra laid The location of the openings is subject to slight °Pcn with probes in variation, according to the condition and form teriorwaUdivide^ Fig. 215. — Urethra laid open with probes dis- tending the glands (pos- terior wall divided). ANATOMi OF THE URETHRA. 615 of the meatus. In some subjects, especially the young and very aged, and in those in whom the meatus is small, and does not pro- ject above the plane of the ves- tibule, the orifices are found about an eighth of an inch with- in the outer border of the mea- tus. When the mucous mem- brane of the urethra is thickened and relaxed, so as to become slightly prolapsed, or when the meatus is everted, conditions not uncommon in those who have borne children, the openings are exposed to view upon each side of the entrance to the urethra. What is here described is rep- resented in Fig. 219. The labia of the meatus have been slight- ly everted to bring the orifices into view. The upper ends of the tu- bules terminate in a number of divisions, which branch off into the muscular walls of the ure- thra. By injecting one of the tubules with mercury, and then dividing it, the openings of the branches can be easily seen. This description of the anatomy of these glands is taken from dissections and microscopical examinations made by Drs. B. F. West- brook and J. M. Van Cott, Jr. I have called them glands because they differ in size and structure from the simple follicles found in abundance in the mucous membrane. When I first discovered these glands I presumed that they were mucous follicles that were accidentally of unusual size in the subject examined, but, having investigated more than one hundred of them in as many different subjects, and finding them constantly present, and so uniform in size and location, I became satisfied that they were worthy of a separate place in descriptive anatomy. The dissections made by Dr. Westbrook, and the pathological lesions to which these structures are subject, confirm this belief. So far as I know, the anatomy of these glands has not been de- scribed, nor have the diseases to which they are subject been referred Fig. 217.—Transverse section of urethra with tiland on either side. 616 DISEASES OF WOMEN to by pathologists. At least this much may be said, that the stand- ard text-books on anatomy and gynecology in English, German, and French contain no reference to them. It is easy to understand why these insignificant glands should Fig. 218.—Longitudinal section of urethral glands. have been overlooked by anatomists, or, if noticed at all, classed with other mucous follicles. It is only when their pathology is under- stood that their real importance becomes apparent. I know nothing about their physiology. They serve some pur- pose in the economy, no doubt, but what is their function is a ques- tion to be answered in the future. This will doubtless be attended to at an early date, as the subject is worthy of investigation. The pathology of these glands, so far as has been investigated up to this time, is of great practical interest, and there remains, no doubt, much still to be studied. Clinical observation has already shown that they are subject to inflammation of various degrees of intensity and duration. The meatus urinarius iu the female differs from that of the male in being a puckered and somewhat prominent, rather than a slit-like ANATOMY OF THE URETHRA. 617 and depressed opening. The mucous membrane of the urethra is thrown into longitudinal folds throughout, save when opened and unwrinkled during micturition or by arti- ficial dilatation. When at rest it is a closed canal. Beneath the mucous membrane there is a thick fibro-elastic network into which the mucous glands dip. These are lined with cylindrical epithelium and surrounded by a network of veins. This submucous areolar tissue has direct vascular connec- tion with the muscular layer that sur- rounds it by means of cavernous venous si- nuses, partly in the muscle and partly in the elastic connective tissue. Thus there is an arrangement almost exactly like that of the corpus cavernosum penis in the male. The venous plexus of the urethra is situated chiefly at the sides, in what is FlG- 219.—The meatus everted, , n * , , . showing the mouths of the known as the urethro-pnbic space. glands. (From a prepara- The muscular layer is double, the outer tion preserved in alcohol.) portion being composed of both circular and spiral fibers mixed, and the inner of longitudinal fibers only, and these two layers are so closely bound together by the cavernous venous sinuses as to be in reality but one. Dr. Uffleman claims to have found an additional external layer, the fibers of which are voluntary. He divides this layer into two—an external and an internal—the former longitud- inal, the latter transverse. These make what he calls the outer or voluntary sphincter of the bladder. From the vesical neck to a point about half-way down it wholly invests the urethra, forming only a partial investment from that point to the meatus. Luschka claims to have found a sphincter of the urethra and vagina. He describes it as being smooth and circular, from one sixth to one third of an inch broad, lying directly behind the vesti- bule, and girdling both the vagina and urethra. Its function, he sivs, is to close the urethra by pressing it against the urethro-vagi- nal septum. Being closely adjacent to the cavernous venous tissue of the urethra, it locks its fibers posteriorly with those of the mus- culus transversus profundus. In the female as in the male, the urethra pierces the triangular subpubic ligament, two layers of which extend around it; one back- ward and the other forward. 618 DISEASES OF WOMEN. There is great diversity of opinion as to the nature of the vesi- cal opening of the urethra in the female. According to Winckel and Simon it is a diagonal slit, the mucous membrane of which is longitudinally and superficially corrugated. According to Savage, it is a triangular opening; and according to Ilolden and others, a funnel-shaped opening. It of course varies somewhat with age. size of urethra, vesical contraction, or quiescence, and in the living and ■ dead subject; and hence the diverse opinions of the various ob- servers. Anatomical Relations of the Bladder and Urethra.—Having dis- cussed the anatomy of the bladder and urethra, it remains to exam- ine the topographical relations of these organs. This is very neces- sary to a proper understanding of the influence of other organs in causing diseases and displacements of the bladder and urethra. The bladder of the female lies lower in the pelvis than that of the male, between the pubes anteriorly, the uterus posteriorly, the vagina and uterine cervix inferiorly, and the small intestines superi- orly. The organ when empty lies behind the symphysis pubis, its highest point slightly overtopping it. In this position it occupies but little space. When partially or wholly filled it rises above the pubes to a varying extent. In doing this it alters but slightly the position of the other pelvic viscera, although relatively its position is somewhat changed. Anteriorly the bladder is separated from the posterior face of the pubic symphysis by intervening cellular tissue. Inferiorly it forms a close attachment to the anterior vaginal wall by means of a dense cellular cushion which increases in thickness from before back- ward. The bladder rests upon this vesico-vaginal septum as far up as the point where the body and neck of the uterus join each other. Posteriorly and somewhat superiorly to the bladder lies the uterus, and superiorly and postero-laterally are the ovaries and broad liga- ments. The close attachment of the vesical neck to the arch of the pubes, by the pubic ligament anteriorly and the vagina inferiorly, makes a kind of wedge that gives but little surface for bagging downward if the vagina holds its proper position. Though imperfectly, still to a certain extent, this arrangement resembles the perinseum in the male. Superiorly, the organ is held in position by a number of ligaments; five false and five true. The false ligaments (one supe- rior, two lateral, and two posterior), are formed of peritonaeum. This membrane is reflected from the inner face of the anterior ab- dominal wall to the bladder investing it superiorly laterally and to RELATIONS OF THE BLADDER AND URETHRA. 619 a certain extent, posteriorly. It joins the organ in front, dipping down just above the pubic summit to the superior vesical surface, iind passes as far backward as the point of contact between the vesi- cal base and uterus, which is at the junction of the uterine body and cervix. Although this peritoneal covering of the bladder is firmly adherent, it never leaves its uterine or other attachments, however much the bladder may be distended and rise above the brim of the pelvis. That portion of the bladder lying behind the pubes, that resting on the vagina and uterine neck, and a small posterior and lateral portion have no serous investment. The true ligaments are also five in number—two anterior or vesico-pubic, two lateral, and the superior or urachus cord. Laterally, the round ligaments of the uterus pass over the blad- der-wall, and just below and posteriorly the ureters enter that organ. These ducts, the excretory ducts of the kidneys, are usually de- scribed as passing downward, forward, and inward, after entering the cavity of the pelvis, to the base of the bladder, and after passing for an inch between the muscular coats of that organ opening into it by constricted orifices. In their course they pass along the sides of the cervix uteri and upper part of the vagina, and at their points of entrance into the bladder are from one half to three quarters of an inch in front of the cervix uteri. It is very important that the re- lation of the ureters to the bladder should be borne in mind, espe- cially in the operation of gastro-elytrotomy. Garrigues, who has in- vestigated this point, says: " The ureter does not lie in the broad liga- ments, it does not keep the same direction on reaching the wall of the bladder, and it does not lie close up to the wall of the cervix, as taught by anatomical authorities. After having crossed the iliac vessels the ureters diverge, running downward, backward, and a lit- tle outward on the wall of the pelvis, behind the broad ligaments to a point near the spina ischii. Then they lead downward, forward, and considerably inward so as to converge toward the bladder. They pass beneath the base of the broad ligament, lying in the abundant cellular tissue found in this locality. They cross the cervix at some distance from behind, at an acute angle, so as to come in front of and below it. They lie outside and above the anterior part of the side wall of the vagina on a spot as large as the tip of the finger. On reaching the wall of the bladder they turn rather sharply inward and go downward until they open with a small slit into the inte- rior of the bladder at the outer angle of the trigonum vesicae. But 620 RELATIONS OF THE BLADDER AND URETHRA. on dissecting the bladder from the uterus and vagina their substance is seen to continue as a solid ridge between the two apertures, and forming the base of the trigone (June's inter-ureteric ligament.) The illustration of Gar- rigues makes this descrip- tion very clear (big. 220.) Just in front of the small lateral space lacking serous investment the ob- literated umbilical arteries pass upward and forward to the summit of the blad- der reflecting the perito- naeum, and thus forming a double pouch on either side. The relations of the urethra are as follows: it lies just under the pubic symphysis, and, piercing the deep perineal fascia, extends from the vesical neck, at the ostium ure- thrae internum, to the meatus urinarius or ostium urethrae externum, situate at the base of the triangular space known as the vestibule. Its anterior three fourths are imbedded in the vaginal wall. The meatus urinarius lies about four fifths of an inch below the clitoris, in the vaginal margin of the vestibule. The vesical end of the urethra is about the same distance below the lower surface of the pubic symphysis. Its course is upward and backward forming a very slight curve. Development of the Bladder and Urethra.—With this brief sketch of the structure of the bladder and urethra their development may be next considered. It would be very interesting, from a scientific point of view, to examine the process by which the bladder and urethra are formed in the embryo ; but it would, I think, be rather tedious to take up the subject in all its minutiae. A few of the more important points in the process of development must be un- derstood, however, in order to comprehend the malformations which are occasionally met with. Most, or at least many, of the malfor- mations of the urinary apparatus, like those of other organs are due to arrest of development at various stages of that process. A clear Fig. 220.—The relations of the ureters (Garrigues). c, uterus ; b, bladder; ur, ureter ; u, urethra; v, vagina; f, Fallopian tube; o, ovary ; b, broad ligament; r, round ligament. DEVELOPMENT OF THE BLADDER AND URETHRA. 621 conception of the normal, therefore, will aid in better understanding the abnormal. The urinary organs are developed in separate portions or sec- tions having distinct points of origin, and by the union and fusion of these parts the entire apparatus is completed. The bladder is formed from a portion of the allantois. When the abdominal plates of the embryo close around that portion of the allantois that forms the umbilical cord, they also shut in a portion which forms the urinary bladder. There remains, for a time, a di- rect communication between that portion of the allantois from which the bladder is formed and that which makes the cord, which takes the name of the urachus. The canal or duct in the urachus is usu- ally obliterated before or soon after birth, so that all that remains of it is an impervious cord known as the superior vesical ligament. It will thus be seen that the bladder is developed from the allantois, which may be called one center of development for the urinary ap^ paratus. The centers of development for the ureters are the same as those for the kidneys. Indeed, the ureters are processes that are developed from the kidneys, and extend downward until they unite with the bladder, and finally open into it. While the bladder and ureters are being thus formed, the lower portion of the alimentary canal—that which forms the rectum—be- comes separated from the section of the allantois that forms the bladder. Into this space, between the rectum and bladder, Muller's ducts descend, and, uniting, form the vagina (see Figs. 53-57). Posterior to Miiller's ducts and anterior to the rectum, a mass of tissue is developed which helps to form the recto-vaginal wall above and the perinaeum below. Anteriorly Muller's ducts unite with the lower portion of the bladder, and aid in the formation of the urethra, or, at least, the up- per portion of its posterior wall. The lower or external portions of the genito-urinary organs are formed from an ovoid eminence which appears in the median line of the lower anterior part of the trunk of the embryo. At the lower part of this eminence there appears a fissure, which, incurvating and uniting with the lower portion of Muller's ducts (vagina) forms the terminal portion of the urethra and the introitus vaginae. From this same center of development the labia majora, the labia minora, and the vestibule are formed. CHAPTER XXXV. MALFORMATIONS OF THE BLADDER AND URETHRA. Malformations of the Urethra.—Malformations, as has already been said, are usually the result of arrested development. Various fail- ures in the processes necessary to form the complete urethra result in a number of malformations. The most important of these may be classified as follows: 1. Defectus urethrae totalis. 2. Defectus urethrae externus. 3. Defectus urethrae internus. 4. Atresia urethrae. In the first form (defectus urethrae totalis) there is, as the term implies, entire absence of the urethra. It is said to be due chiefly to an arrest in the development of the vagina at a point where it should form the main portion of the posterior wall of the urethra. It is very probable that there is also an arrest of development of the clitoral process. Coexisting with this malformation other developmental defects are generally but not invariably found, for it has been known to exist with an otherwise perfect genito-urinary apparatus. Petit tells of the case of a child, four years old, who had neither urethra, clitoris, nor nymphae, but had a comparatively wide vagina. Langenbeck men- tions the case of a girl, nineteen years of age, in whom the bladder and vagina formed a common canal. She was incontinent up to the age mentioned, and is reported to have gained control of the bladder afterward. The second deformity (defectus urethrae externus) is due to the absence of the lower and anterior portion of the urethra. It has been called '" hypospadias in the female." One of the most marked cases has been recorded by Von Mosengeil. The subject was a girl eight years old. The opening in the urethra was situated below a large chtoris, having a very full prepuce. It was much higher than MALFORMATIONS OF THE BLADDER AND URETHRA. 623 the normal situation of the meatus urinarius. There was a groove running from the lower border of the vestibule up to the opening of the urethra, and it appeared to be formed from the anterior wall of the urethra. The upper portion of the urethra held its normal rela- tions to the bladder and vagina, but was only half an inch in length. The bladder, in comparison with the other organs, was larger, and had a number of sacculae. It will be observed that in this case the upper portion of the urethra was complete, and that there were present in the lower portion of the canal an anterior and two rudi- mentary lateral walls, the posterior wall alone being absent. There is another form of defectus urethrae externus or hypos- padias, in which the lower part of the canal is entirely wanting. In such cases there is but one opening between the clitoris and peri- mvum, and but one canal, this dividing into vagina and urethra at some distance from the outer opening. An interesting example of this was observed by Willigk, in a woman, who died at the age of forty-six. The uro-genital canal, at its opening, was about the size of a catheter, and ran in a curved direction under the pubes. About an inch and a half from its outer opening it divided into two pass- ages, one anteriorly, 1" long—the urethra, and one posteriorly, 2" to 10" long—the vagina. The third deformity (defectus urethrae internus) is that in which the internal or upper portion of the urethra is wanting, and is a comparatively rare affection. The only cases, so far as I know, are given by Oberteufer and Duparcque. In Oberteufer's case, as I understand it, the lady was forty-two years of age, and all her life had passed water from the umbilicus. Her vagina was normal, and so were the external genital organs. The upper or internal portion of the urethra alone was wanting. Duparcque's case was one in which the urethra was pervious as far as the bladder, but was there closed. This case, however, appears to me more properly to come under the head of atresia urethrae. The fourth class (atresia urethrae) is a comparatively common affection. There are two forms of congenital atresia mentioned by authors. The first is produced by imperfect development of the vaginal process, or of both the clitoral and vaginal segments. Du- parcque's case was of this kind, the urethra being open up to the bladder and there closed. It was a form of defectus urethrae in- ternus with atresia at the upper end of the canal. In this case the bladder and ureters were greatly distended. The other form of atresia is found when the clitoral and vagi- nal processes are both defective. In such cases there is no trace of 624 DISEASES OF WOMEN. a urethra, except an imperfect vaginal wall which extends obliquely downward and closes the bladder. E. Kose relates a case of this kind in which the bladder, kidneys, and abdomen were filled with water. The urethral malformation was not the only one in this case, the vagina and uterus suffered from an arrest of development and were both double or rudimentary. Before leaving this interesting subject I will mention another rare malformation. It is an obstructive anomaly, and consists in a double condition of the urethra. The only case, so far as I know, which has been described with any accuracy, is that of Furst. He observed in a preparation taken from the body of a young virgin the following peculiarities : In looking at the anterior bladder-wall at the first glance only one urethral orifice was to be seen, but one tenth of an inch forward toward the meatus the single urethra was seen to bifurcate; a fine septum, nearly straight, divided it from right to left into an anterior and posterior half ; these continued with an ever enlarging and diverging septum until they opened into the vagina about one tenth of an inch apart. In this way they twisted, so that the anterior or superior one opened toward the right, while the posterior (the one in the region of the bladder) opened into the vagina on the left. The left urethra opened with a caliber of one fifth of an inch into the median line of the vagina. The right opened on the right of the median line, having a caliber of only one tenth of an inch. The length of the whole urethra was one inch. It is of very rare occurrence that the double condition of the allantois persists in this manner, and, considering all the changes that the sinus uro-genitalis has to undergo, it seems strange that blending did not take place. It is also interesting from the fact that the allantoic openings into the cloaca can only take place by a very rapid and early interruption of development. The uterus and vagina, in this case, were perfectly normal. Symptomatology of Malformation of the Urethra.—The symptoms that arise from malformation of the urethra are incontinence in the one class of cases, and retention of urine in the other. When the urethra is deficient in part and the bladder perforate, urine con- stantly escapes; and from the wetting, the excoriation, and the odor, the unfortunate subject is kept in continual misery. In cases where there is an abnormal contraction of the vagina the urine can be retained, partially at least. This is supposed to be effected by the small size of the genito-urinary sinus, and, possibly, a voluntary contraction of the sphincter vaginae muscle which may act as a sort of sphincter and aid in the retention of urine. MALFORMATIONS OF THE BLADDER AND URETHRA. 625 Atresia of the urethra and the consequent retention of the urine cause hydrops of the bladder, ureters, and kidneys, and also ascites, as has already been mentioned. Distention of these organs occurs in utcro, and such malformed children are usually born dead, or die mon after birth. So great is this distention of the bladder and ab- domen in some cases that delivery is difficult or impossible until the fluid is evacuated by puncture. I remember seeing one such case. The head was delivered, but there was great difficulty in de- livering the body. The abdomen was enormously enlarged by the overdistention of the urinary organs. The child was very feeble, and after moaning for a few hours, died. No effort to relieve the bladder was made because a diagnosis was not reached until the lit- tle one was dead. This malformation usually leads to fatal results, and our knowl- edge avails us little save in accounting correctly for the cause of death. The only natural way that the evil effects of this malforma- tion can be obviated is by the occurrence of another developmental anomaly, viz., fistula of the urachus, the urine then escaping from the umbilicus. Atresia is an undoubted factor in the production of urachal fistula. I shall speak more fully of this when I come to consider vesical malformations. When defectus urethrae externus occurs in patients whose uro- genitals are otherwise normal, the function of the bladder and re- productive organs may all be performed easily and uninterruptedly. Coitus has been possible, and conception has been known to occur in such cases. Diagnosis.—In making a diagnosis of these deformities reliance can not be placed on the symptoms alone. A physical examination of the parts is necessary. The general relative appearance of the external organs must be observed, and if the vagina is large enough to admit the speculum it should be used, and if there is any malfor- mation internally it can easily be discovered and its exact location and nature ascertained. There is usually very little trouble with such cases, but where the entrance to the vagina is so narrow that it will not admit a sound or speculum, the diagnostic skill of the physician will be severely taxed. Such cases resemble imperforate hymen, or acquired atresia of the vulva, and one case, at least, has been mistaken for an hermaphrodite. Under such circumstances an attempt should be made to pass the sound into the bladder, and by introducing the finger or another sound into the rectum the pres- ence or absence of a vagina may possibly be made out. If the patient is an adult, and the case one of imperforate hymen, men- 626 DISEASES OF WOMEN. strual fluid will probably be found in the vagina. Should there still remain any doubt, the only resource would be to try dilatation of the introitus vaginae, and see what lies beyond it. Treatment.—The treatment may be either radical or palliative. Where there is an entire absence of the urethra, with the existence of vesical fissure, or in persistence of the sinus uro-genitalis with partially developed urethra, the production of an artificial canal has been suggested. This may be done by dissecting from the vaginal wall a flap from under the symphysis. It should be about one third of an inch in breadth, and after being turned with its epithelial sur- face inward, should be united with the freshened edges of the vesi- cal fissure. It is objected by some authors that even if the opera- tion is successful, the patient will be but little benefited, the new urethra being devoid of muscular tissue, and consequently lacking the power of contraction. The passing of urine into the vagina, however, will be done away with, and the general condition of the patient will be greatly improved by the use of an artificial urinal. This of itself is a great point in favor of the operation. Heppner believes that the method of producing an artificial ure- thra by trocar puncture of the soft tissues and sewing up the vesical fissure is dangerous, because vessels of considerable size are liable to be injured; a further disadvantage being that the canal tends to close. The cases of Carbol and Middleton bearing on this point he puts aside as unreliable. He moreover maintains that reduction of the vesical fissure to the size of the urethra is a disadvantage, since the anterior wall of the fissure will be without any muscular tissue. The experience of those who have treated fistula has been, so far as he knows, that linear clefts, even of greater caliber, hold back the urine better than round openings of smaller size, the former allow- ing more complete coaptation of the edges. In Heppner's case, there being only nocturnal incontinence, he contented himself with applying a bandage in the manner suggested by Sawostitzki. A girdle was put around the lower part of the ab- domen, and to it was fastened a little olive-shaped compress, by means of a steel spring, something after the manner of a truss. When put into the vagina this compress pushed the posterior vesi- cal wTall toward the pubic symphysis, thus closing the opening and relieving the incontinence. The patient soon became used to the instrument, and obtained great relief from it. Atresia of the urethra can only be cured by operation. Carbol operated in 1550 on a servant-girl in Beaucaire, who had suffered from this difficulty from her youth up. The urine flowed from a MALFORMATIONS OF THE BLADDER AND URETHRA. 627 coxcomb-like growth, some four fingers in length, at the umbilicus. The stench that arose from her body was intolerable. Carbol per- forated in the region of the urethra, and successfully removed the growth at the umbilicus by ligation. In the case of a child, seven days old, who had never passed urine, and whose bladder was enormously distended, Middleton pushed a trocar through in the direction of the absent urethra, emptied the bladder, and kept the opening pervious. Oberteufer's patient, who had atresia urethrae and urachal fistula, relieved herself somewhat by wearing a large sponge over the um- bilicus secured in position by a bandage. In such cases as this the apparatus usually employed in urinary fistula should be made use of. MALFORMATIONS OF THE BLADDER. These malformations follow the general rule of being in most in- stances due to some defect in the normal process of development. Those which are of sufficient importance and especially demand atten- tion are: 1. Fissure.—The most frequent and prominent anomaly of devel- opment in the bladder is that of fissure. It consists in partial or complete absence of the anterior vesical wall, and is usually accom- panied bv malformations of other organs. The anus and umbilicus in these cases, as a rule, lie nearer than normal to the pubic symphy- sis. There are various grades of this affection. There may be sim- ple fissure of the lower part of the bladder, with the opening about three quarters of an inch in breadth, as has been seen by Desault, Palletta, Gosselin, Coates, and others. In the cases reported by them the symphysis pubis was but loosely united. There may also be fissure of the clitoris. A higher grade of this malformation is that in which the fissure is near the umbilicus, the lower part of the pelvic cavity and the pubic symphysis being closed, and the lower part of the bladder, urethra, and external genitals normal. This condition is next in order to patency of the urachus—fistula-vesico-umbilicalis. In the latter case, the urachus may remain pervious its entire length, and open into the ring of the umbilicus. The highest grade is that in which the whole anterior wall of the bladder seems to be absent. In these cases the inferior abdominal region is generally much shorter, and the umbilicus nearer the base of the pelvis. The abdominal walls are divided, and the resultant 62S DISEASES OF WOMEN. fissure is filled up by the bladder-wall, the mucous membrane of which is puffed out and red, and gradually merges into the skin of the abdomen. It is often wrinkled, thickened, moist, shiny, and the edges dry and covered with thickened epidermis. On each side of the lower portion of the everted bladder are situ- ated the orifices of the ureters. They usually appear as little ex- crescences, but are sometimes hidden in the folds of the membrane. The pubic bones are imperfectly developed, and the pubic symphy- sis never closed, save by a ligamentous band, the bones lying from half an inch to three inches apart. These separations of the pubic bones, as has been shown by Dubois, Dupuytren, Mery, and Littre, are congenital. As a rule, in such cases, the urethra is absent. The clitoris is either divided with a portion on each side of the upper part of the imperfectly formed labia, or there may remain but a trace of it, or, again, it may be entirely absent. The hymen can be seen beneath the fissure. The vagina may be absent, as in cases observed by Herder and Eschenbach, and the uterus may be divided by a septum. Atresia vaginae and imperfect ovaries have also been found in such cases. This grade is known as eversio or exstropia vesicae. If there is simply a fissure of the bladder the organ may be pro- lapsed through the fissure (inversio vesicae cum prolapsu per fis- suram). This must be distinguished from inversio vesicae cum pro- lapsu per urethram and exstropia per urachum. That this may be clearly understood, it must be remembered that inversion of the bladder occurs in three ways: First, by a protrusion of the organ through an opening or fissure in its own walls (the form now under discussion); second, by an inversion through the urethra; and third, by an inversion through a pervious urachus. The ureters, as a rule, are considerably widened. Isenflamm found them dilated from three quarters of an inch to more than an inch; Petit as much as two inches; Flagani and Bailie found them to be four inches; Desault three inches; and Littre two and one half inches, and containing small calculi. Their course, as a rule, is changed, sinking deeper into the pelvis, and thence rising up into the bladder. There are, however, exceptions to their enlargement. Bonn, in one case, observed as long ago as in 1818, found their leno-th and breadth normal. Winckel also speaks of a case wrhere both kid- neys and ureters were normal. The anomalies known as epi- and ana-spadias belong under the head of vesical fissures. 2. Double Bladder.—Cases of double bladder, says Yoss, are be- MALFORMATIONS OF THE BLADDER AND URETHRA. 629 coming quite rare as pathological knowledge advances, for many of these were probably cases of pathological division of the vaginal wall. Mollinetti mentions, in his '" Anatomico-Pathological Disserta- tions," the case of a woman with five bladders, five kidneys, and six ureters. Blasius describes a case of perfect division of the bladder into two separate halves, which at the vesical neck ended in one common urethra. Each bladder had one ureter. The subject was a male adult. Isaac Cattier has found this anomaly in little children. One case was that of a child fifteen days old. The bladders were separated by the rectum to such a degree that a finger could be laid between them. Sommering found this condition in a child two months old. In one that was born miserably nourished, and lived but twelve hours, Schatz found perfect division of the whole geni- tal apparatus, double bladder, and double congenital vesico-vaginal fistula. In double bladder, the double allantois, instead of forming one passage, forms two, with a ureter opening into each. Testa gives a case of perfect separation by the vaginal wall. Scanzoni found, in making a post-mortem examination on the body of a tuberculous woman, a division of the bladder into two lateral halves. He does not say, however, whether the division was com- plete or whether the septum was pervious. Sometimes horizontal septa are formed that are due probably to a crumpling up of a part of the bladder while growing, or a com- mencing closure of the urachus lower down than usual. Koser, of Marburg, had a case of urachal cyst, which, when enormously distended, reached as far as the umbilicus. By means of a small connection with the bladder it was filled when that organ contracted, and, finally, it and the bladder were emptied by contrac- tion of the abdominal muscles. Vesical cysts and diverticula may be confounded with the anomalies resulting from arrest of devel- opment. The slightest grade of anomaly is that in which, as Chonsky has observed, there is no full septum, but simply a band or seam, appar- ent externally. Etiology.—The original urinary sac of the embryo, it will be remembered, is the allantois, which takes its origin as a ad-de-sac from the rectum, and is, consequently, an offshoot of the intestine. It is formed by the bagging of the cloaca, which bagging is due to the collection there of urine from the primitive kidneys. This allan- tois, especially in the human species, is double, and remains only a short time. After the fourth week of embryonic life, the layers 630 DISEASES OF WOMEN. coalesce, and the division ceases. Yet the original double form may remain for some time beyond the normal period, if there are anv hindrances to union. Koose and Creve maintain that the cause of this malformation is the failure of the pubic bones to unite. Meckel takes exception to this, and says that the bladder in its primitive condition shows itself as a simple, plain surface, which only becomes a cavity by the grow- ing toward each other and union of its edges. Duncan and, at a later date, A. Bonn, and, still later, B. S. Schultze and Thiersch, held that vesical fissure had, as its primary cause, an atresia of the urethra, with great dilatation of the bladder, the distended organ pushing aside, first, the recti muscles, later, the cartilaginous pubic bones, and, finally, bursting. E. Rose, on the contrary, maintains that these cases of bladder-fissure are cases of perpetuated urachus, and are due to developmental failure in the bladder itself, remain- ing open as far as the urethra. He says positively that the edges of recent preparations of the bladder show a fresh, smooth surface, and that there is no trace whatever of any cicatrix or callosity. He mentions one case of tearing and rupture where the evidences were plainly to be seen. Moergelin, who was unable to find proof of rupture as a cause of this anomaly, says that, if there was a quan- tity of urine in the bladder, greatly distending it, there would be a reopening of the urachus or a bursting into the abdominal cavity, rather than a rupture through the abdominal walls. He looks favor- ably on the idea of a bursting of the allantois before the abdominal walls have closed in front of it. Against this, however, is the fact that Hecker extracted a foetus with atresia, having an enormously dilated, unruptured bladder. He found in the abdominal walls a cicatrized slit covered by perito- naeum. This makes manifest the possibility of a rupture of the ab- dominal walls, and also of the bladder, occurring at a comparatively late date. In the case related by Rose no information is given as to whether there was a normal umbilical cord or not, whether there was any urachal fistula, whether the abdominal ring was closed entirely, or whether the fissure was confined to the inferior part of the anterior vesical wall, as described by Gosselin, Bertet, and others. In their cases it was not possible for the fissure to have originated by the re- opening of the urachus. In any event, most of the late authors are agreed that hindrance to the outtiow of urine has most to do with the production of this anomaly, and it may, as Rose has shown, and as has been said before, arise from atresia or absolute absence of the urethra. MALFORMATIONS OF THE BLADDER AND URETHRA. 631 Another possible mode of causation of this malformation is by the falling of some of the larger abdominal organs into the pelvic canty, compressing the urethra, and hindering its formation. E. Rose once found the right kidney in the pelvis, and Winckel has recorded a case described by one of his students, Dr. Kruger, where the left lobe of a considerably enlarged liver and a quantity of small intestines were so tightly wedged into the pelvis as to cause marked bulo-ing of the perinaeum. Such a condition, coming at a time when the urachus and urethral end of the bladder are firmly closed, must tend to form a vesical fissure. Perfect eversion of the bladder may, however, be found at a very early date, even before the two halves of the allantois are joined, as in cases related by Friedlander, E. Rose, and Winckel. Lying be- tween, and in front of the single- or double-everted bladder or blad- ders, there are sometimes found, as in Rose's and Winckel's cases, bands of perforated skin-folds, behind which a sound may be passed. Their presence may be explained in this way : That the underlying rtous connective tissue1 (Rathke's membrana reuniens inferior), which closes the abdominal cavity before the development of the skin and muscular system, is the covering of all urachal fistula?, open bladders, and persistent allantois. Then, where the urine pressure is the greatest, the bladders move upon each other, so that no further development can take place between them ; but the abdominal plates develop themselves around and between them. This intermediate development, owing to the imperfection of the lower connective tissue, becomes a band or rim where the two conically formed bladders push together, so that they can not become a symmetrical whole, but have an intermediate arch. In these cases the cause probably lies in the patency of the urachus and the eversion of the bladder; also the open condition of the abdominal walls, inter- ference with the development of the lower parts of the musculi recti, and, later, the imperfect development of the pelvis. There can, however, be a fissure of the abdominal walls without a fissure of the bladder, the closed organ protruding from the ab- dominal fissure (ectopia vesicae). Lately Ahlfeld has brought forward the hypothesis that eversion *»f the bladder is complicated with and dependent on a pulling down- ward of the ductus omphalo-meseraicus, making an obtuse angle in- feriorly, whereby, the rectum being pushed forward, it pushes the inferior wall of the allantois before it. Communication between the rectum and the allantois ceases, and the allantois, becoming enor- mously distended, bursts. Ruge and Fleischer contend that in this 632 DISEASES OF WOMEN. affection the duct of the umbilical vesicle is implicated, and hold that the tense cord (duct) in question is a continuation of the urachus. Winckel is of the opinion that bursting of the bladder at an early stage from urine-pressure is the weightiest cause in the produc- tion of bladder fissure. Against the idea of Rose, which is that eversio vesicae does not take place from rupture, Winckel says that the presence of scars is not absolutely necessary to prove the point, for the abdominal walls are not yet joined, and therefore can not be ruptured; and, moreover, he has often seen children immediately after birth in whom the umbilical cord was normal, and yet an ever- sion of the bladder existed. He raises the query as to why we can not have rupture of the bladder at an early period, since we know that it occurs later in life, as in women with retroflexion of the gravid uterus. Another fact that he advances in favor of the view that rupture of the bladder is due to urethral obstruction is that it occurs oftener in males than in females, the former having a canal much more favor- able to such obstruction, for, of sixteen cases of vesico-umbilical fist- ula, given by Stadtfeldt, fourteen were males and two females. Dr. Wunder, of Altenberg, in 1831 observed the cases of two boys, aged respectively eight and eleven, with congenital eversion of the blad- der. It is interesting to note that their mothers were sisters. The various causes that give rise to vesical fissure produce also imperfectly developed pelvic bones, dislocation of the head of the femur, and other malformations from pressure. The excessive dilata- tion of the bladder drives the horizontal rami of the pubes asunder, and the changed direction and imperfect growth of the pelvic bones cause a lessened acetabular circumference and consequent slipping out of the head of the femur. Thus does Voss explain the disloca- tion occurring in one of his cases. It will be found on touching the red mucous membrane of an exposed bladder that it is exceedingly sensitive. In such a case the urine may be seen oozing from the ureters and dribbling over the surface. The mucous membrane is often protruded and wrinkled up by the movements of the bowels, and can, in case the bladder- opening is great, be inverted through the fissure (inversio vesicae per fissuram) or through the urachus (inversio vesicae per urachum). If the fissure is small it may remain for years without any inversion. If the prolapsed mucous membrane is replaced and indirect pressure is made on the dilated ureters, the urine will spurt from the ureteric orifices. Sometimes these patients have partial control over their urine: MALFORMATIONS OF THE BLADDER AND URETHRA. 633 as in cases where an umbilical hernia exists with umbilical fissure, the posterior wall of the bladder being forced into the opening plugs it up. Such a case is described by Paget. The hernial sac, which was about the size of a goose-egg, completely plugged the umbilical foramen by pressing firmly against the posterior bladder- wall. If the patient desired to urinate, the contraction of the blad- der caused a gradual disappearance of the hernial tumor; and when it had entirely disappeared he passed urine from the umbilicus and then through the urethra. After the urethral flow began the stream from the umbilicus ceased, and no urine passed at that point unless strong pressure was made upon the abdomen. Another way in which partial retention may be accomplished in imperfect eversion is by the greatly thickened muscular walls acting as a sort of sphincter. Such a case given by Toss is that of a female child, twenty months old. When lying down and quiet, the urine did not flow away so freely. The bladder-wall was nearly one inch in thickness, and the ureters, though three inches broad, were greatly narrowed at their point of entrance into the bladder. In fissures situated low down there may be coincident inguinal hernia, as is illustrated by a case related by Bertet. This complica- tion may act so as to aid in the retention of urine. From the con- stant flow of urine, the inferior end of the fissure and neighboring parts become moist, red, eroded, and sometimes incrusted and ulcer- ated. There are various painful sensations, as itching and burning, and the patient becomes a nuisance to herself and to those about her from the offensive urinous odor that is constantly given off. The edges of the mucous membrane in time become changed, and resemble skin in appearance. At other points, oftentimes, the membrane is much changed, having upon its surface loose, villous growths, that bleed readily when touched, and give the impression of a malignant new-formation. By reason of a separation of the pelvic bones there is an irregu- lar, uncertain gait. The pelvic diametric proportions, as observed by Moergelin, are in these cases much changed, the transverse being much greater than the antero-posterior, the dissimilarity increasing as age advances, the proportion being sometimes trebled. Women with these troubles, however, have borne children. A close inspection of the ureteric openings being possible in these cases, the interesting observation may be made that in action the kidneys seem quite independent, the one of the other, the right discharging urine and the left none, or the reverse, or both may dis- charge together. 634 DISEASES OF WOMEN. Diagnosis.—the diagnosis of urachal fistula is comparatively easy, for the affection is at once recognized by finding the ureteric orifices with the urine flowing from them. As to frequency, the following statistics are of importance : In 12,689 new-born children, Sickles found this malformation to occur twice in twenty-seven cases of developmental anomalies. In thirty-five hundred births occurring in the Dresden Institute, from 1ST2 to 1875, Winckel saw one case. Yelpeau, in the year 1833, mentions seeing and finding on record more than one hundred cases of this kind. Percy says that he has seen it twenty times in his own practice. Winckel saw five cases, three of which were girls, and two boys. Phillips saw twenty-one cases, all girls; but in Wood's twenty cases, only two were girls. Prognosis.—The prognosis is usually unfavorable. The children are weak and puny, and, as a rule, die early. They are, however, seldom destroyed by the fissure itself. Many of them are born liv- ing, and can be kept alive, and some attain a fair age. Lebert saw in Salpetriere Hospital, Paris, an old woman with this affection. Operative procedures and the various apparatus to prevent trick- ling of urine are of little avail. This, however, is only the case in total eversion. Urachal fistulae, simple fistulae, above the pubic symphysis, and even those situated inferiorly, where the pubic bones are united, may be readily cured by the ordinary operation for fistula. Treatment.—Stadtfeldt operated in eight cases of urachal fistula, in seven of which he obtained perfect healing. In deep fistula he recommends freshening of the edges of the skin and mucous mem- brane, and attempting union by the first intention. In cases where the edges extrude themselves very much, he puts on either a clamp or ligature. Winckel favors operative procedure since, in that way, the ab- normal protrusion can be removed. Sometimes, as recommended by Paget, it will be sufficient to freshen the edges, put in insect-pins, ligature, and union may be expected in from two to four weeks. In fissura vesicae, superior or inferior, an attempt might be made to draw the edges together, and even to loosen the skin in front by incision, so as to remove traction from the edges. In that case it will be necessary to freshen the edges and put in sutures. The re- sult, unfortunately, is not uniformly successful. In earlier times, in cases of true eversion of the bladder no one dared to operate, and the only alleviation granted to the patient was such as could be obtained by a properly-adapted urinal. A'u- MALFORMATIONS OF THE BLADDER AND URETHRA. 635 merous appliances have been invented for this purpose, some of them very useful. Gerdy was the first to operate for eversion by closure. Failing to bring an inverted bladder back into place, he tried to form a suf- ficient sac by partial excision of the ureters. The patient, a man, was attacked with peritonitis and nephritis, and died. Jules Roux, in 1853, proposed cutting out the ureters, and unit- ing them with the rectum. Simon tried this once, and succeeded; but the patient died six months after from peritonitis and exhaus- tion. At a later date, he again attempted to treat this malforma- tion by operative procedures. He made one inferior and two lateral flaps, but these became gangrenous. Ten years later, these attempts were more successfully made by John Wood and Holmes, and their results recorded by Podruzski. The first one, however, who obtained a perfect result was Dr. Daniel Ayres, of Brooklyn. He cut a long flap from the under and lower side of the abdominal walls, turned the skin-side in, and united it with both edges of the bladder. A full account of this case will be found at the close of this chapter. Since then I have 6een three cases, but as they were not patients of mine I had no opportunity to interfere surgically in their treatment. Subsequently, Wood operated on a girl one year and a half old, whose bladder-fissure was continuous with the uro-genital sinus, so that the os and cervix uteri were always wet. He raised one flap from the neighborhood of the umbilicus, and another from the soft parts, and turning the skin-side in, covered them with a larger flap from the other side. The mucous membrane, however, pushed through inferiorly, and broke the fresh adhesions. Ashhurst's case was more successful. He cut a piece from under the umbilicus, and joined it with two flaps from the sides (they being somewhat turned) so that their upper edges met each other in the median line. They were joined by sutures, and through each side of the upper flaps two pieces of malleable iron-wire were carried, then drawn through the lateral flaps, and twisted over little rolls of plaster. Traction was thus relieved. The flaps healed by the first intention. The sutures were removed on the eighth day. The rest of the wound healed by granulation. When in the up- right position, incontinence of urine still continued ; but when lying upon her back, the patient was able to retain urine for about two hours, her general condition being thus greatly improved. Ashhurst gives a resume of twenty cases of eversio vesicae, oper- ated on up to his time. Fourteen of these were successful—Ayres, i2 636 DISEASES OF WOMEN. Holmes, Wood, Morey, and Barker, each being credited with one. Three were unsuccessful, by Holmes and Wood; and tliree resulted fatally, by Richard, Pancoast, and Wood. In the last two death resulted from causes other than the operation. In all cases when the skin is turned in, the growth of hair al- ready present or to come will be apt to give rise to incrustations. Thiersch, in his six cases, allowed the flaps to granulate on their raw surface before applying them. When the flap-union is perfect, he advises closing completely the upper part of the bladder. The diagnosis of double bladder may be made by urethral dilata- tion and exploration by the finger and catheter. Destruction of the bladder-septa is not to be thought of. In case of the existence of urachal cyst causing difficult urination, one might try extirpation of the cyst by cutting into the abdominal walls, and after freshening their edges unite them with those of the bladder. ILLUSTRATIVE CASES. Extroversion of the Urinary Bladder. (By Daniel Ayres, M. D., LL. D.)—The patient was admitted to the Long Island College Hos- pital, November 1, 1858, and a history of the case recorded by the house surgeon, Dr. Ostrander. She is twenty-eight years of age, born of healthy parents, both of whom were free from deformity; her height is below the aver- age of females, and she is unmarried. She declares her health to have been always good, appetite and- digestion excellent, bowels regular, and the catamenia in all respects normal. She states that, on the 5th of July preceding, she was delivered of a well-developed child, having carried it to maturity without extraordinary difficulty. Labor commenced with free haemorrhage (footling presentation), and lasted two hours, at the end of which time the child was born, having died in process of delivery. Peri- naeum uninjured. She reports having made a tolerable recovery, though for a long time weak, and her present appearance is some- what anaemic. Shortly after she began walking about symptoms of prolapsus uteri came on, becoming gradually worse, until the organ projected external to the vulva, attended with dorsal, dragging pain, difficulty of locomotion, and gastric disturbance. In quest of relief, she entered the Brooklyn City Hospital on the 1st of September following her confinement, and remained there one month. Here she states that a variety of pessaries were tried none of which could be retained, and finally a surgical operation MALFORMATIONS OF THE BLADDER AND URETHRA. 637 was performed, the nature and character of which is not very appar- ent. A short article, descriptive of this case, appeared in the " Vir- ginia Medical Journal" for January, 1859, written by the house surgeon of that institution. The writer states that an attempt was made to retain the prolapsed uterus " by removing an inch of mu- cous membrane from the bottom and sides of the vulva, and unit- ing them by two figure-of-eight sutures, which were removed on the sixth day, when no adhesion was found to have taken place." The writer continues: " The patient was allowed to get up on the fourteenth day, when the prolapsus was found to exist nearly as much as before," etc. It is obvious that no effort was made to relieve the congenital deformity, and that she was discharged in much the same condition as when she entered. Finally, a species of stem-pessary was contrived which was in- tended to support the uterus, while kept in position by strings passed around the thighs. This, however, proved very inefficient— the uterus slipping by the instrument upon the slightest extra exer- tion. Moreover, the parts had now assumed an irritable condition, partly due to increased friction of the apparatus, and undue attention to cleanliness, added to the causes already noted ; altogether, her de- plorable condition was scarcely susceptible of being made worse. I may here remark that the figures, both before and after the operation, have been photographed from accurate plaster-casts, taken directly from the patient—a very difficult and delicate procedure, for which I am much indebted to the skill and kindness of my colleague Dr. Bauer, and our valuable assistant, Mr. J. F. Esslinger. Fig. 221 is an exact representation of the parts at the time of presentation to the clinical class of the Long Island College Hospi- tal, for the purpose of critical examination. The prolapsus, having been carefully and completely reduced, was found to retain its place so long as the patient maintained the recumbent position. The distance between pubic abutments was estimated at about three inches. The bladder (a) formed an oval, elliptical tumor, mammillated upon the surface, which in the recumbent position measured two inches in its long, and one inch and a quarter in its short diame- ter. This was soft, elastic, or bright vermilion color, and covered with a £hick tenacious mucus; bleeding readily when rudely han- dled, and so exquisitely sensitive, that while under the full influence of chloroform, and insensible to the knife, a sponge passed over the exposed bladder excited reflex motions. 638 DISEASES OF WOMEN. The integument immediately surrounding the bladder was found red and puckered, but very soft, delicate, and free from hair be- tween the bladder and point of sternum. The labia majora (o, o,) thick, fleshy, and luxuri- antly covered with hair, were gathered into folds swelling away toward either thigh ; these were carefully shaved previous to taking the cast and per- forming the operation. The nymphae occu- pied isolated positions on each side of the vul- va, and are designated in all the figures by the let- ters b, b. Between these and the vagina below no trace of clitoris or urethra could be distinguished, but the whole surface was cov- ered with mucous mem- brane, continuous with the vaginal lining. Here, then, we had to contend with two formidable difficulties, either of which was a problem in itself, viz., aggravated prolapsus from an entire ab- sence of an anterior support, added to the original congenital mal- formation. To form an estimate of the value attached to surgical operations in these cases, we can not do better than quote the opinion of Prof. Erichsen, of University College, London. Having collected the experience of the profession on this topic, his eminent position at the center of surgical science, added to his well-known and exten- sively recognized erudition, renders him at once a reliable and com- pendious authority on the subject. " This malformation," says he, " is incurable. Operations have been planned, and performed with a view of closing in the exposed bladder by plastic procedures, but they have never proved success- ful, and have terminated in some instances in the patient's death; they do not, therefore, afford much encouragement for repetition." Fio. 221.—Extroversion of the bladder. exposed, forming a bright vermilion tumor; b,b, labia minora; o, o, above labia majora; c, vagina; d. anus. MALFORMATIONS OF THE BLADDER AND URETHRA. 639 So unsatisfactory have been the results of these operations that the profession has not been favored with their general plan, their details, nor the causes of failure. It must be evi- dent, however, that op- erations based upon the principles of plastic sur- grv alone offer pros- pects of success. The most probable source of failure, and one which challenged our early attention, was the disastrous result to be apprehended from urinary infiltration, which, by its irritating character, would neces- sarily destroy all pros- pect of union, if it did not induce extensive sloughing of the abdom- inal parietes; peritonitis and purulent phlebitis are likewise probable sources of danger, unless carefully guarded against. Indeed, these may all become inevitable consequences of attempting to accomplish too much at one time; and it was there- fore determined to arrange our proceedings with a special view, if possible, to avoid them. The indications which it was proposed to follow were: 1. To form an anterior wall for the exposed bladder. 2. To restore the urinary canal. 3. To establish the anterior fourchette of the vulva. 1. To supply means to prevent the prolapsus, and to collect the renal secretions. The delicate character of the integument above the bladder and its well-known transmutability into the conditions of a mucous mem- brane peculiarly adapted it to supply the anterior cystic wall, and thus fulfill the primary indication. With these objects in view, the operative proceedings were di- vided into two stages. The first consisted in raising a flap from the anterior portion of Fig. 222.—e, Linear cicatrix, formed by the flaps cov- ering the bladder; b, b, nymphae brought together, and inclosed by the vulva. 4145 I III) DISEASES OF WOMEN. the abdomen, including the superficial fascia, turning its cuticular surface down over the exposed bladder as far as its inferior border, and securing the lateral union of the flap in that position, while a free exit below was maintained for the urinary discharge; an im- portant result, still further assisted by the dependent situation of the outlet of the ureters already alluded to. By these means it was proposed to accustom the highly sensitive bladder to a gradual and methodical compression while the flap it- self was insured ample space to undergo such swelling as might be anticipated from its new position and the unusual stimulation of a new secretion. Time was likewise given for the necessary trans- mutation of tissues to make some progress. The steps of this procedure will perhaps be better understood by a more detailed state- ment of the first operation, in connection with the di- agrammatic plates, Figs. 223 and 224. It was performed on the 16th of November last, the patient being thor- oughly under the influ- ence of chloroform, and a sugar - loaf - shaped flap having been previously marked out upon the ab- dominal integument ; its base, E, F, three inches in width, was situated tliree fourths of an inch above the cystic tumor, and ex- tended five inches in length, with its apex to- ward the ensiform carti- lage. The dark line E, H, G, I, F (Fig. 223), indicates its form, position, and the line of incision. This flap being left sufficiently large to meet the elevated form of the bladder and allow for shrinkage, was quickly but carefully separated from its cellular attachments, down to the line E F while two lateral incisions, E, J, and F, K, were continued directly downward and toward the nymphae, to serve as beds for receiving the sides of the new flap. Fig. 223.—a, Bladder, covered by deep flaps; b, b, nymphae; c, vagina ; d, anus. MALFORMATIONS OF THE BLADDER AND URETHRA. 641 The integuments covering the lateral and inferior portions of the abdomen, extending from G to J on one side, and from G to K on the other, were now sufficiently separated from their cellular attach- ments to the muscles beneath to insure their sliding freely, and meet- ing without tension at the mesial line, G, IS" (Fig. 224). When brought into this position they completely covered from view the raw surface of the flap already turned over, and investing the blad- der, with the exception of a triangular space, J, N,K (Fig. 224), formed by the coaptation of the lateral flaps ; this was temporarily covered by reflecting back upon it- self the corresponding tri- angular free end of the deep flap, J, C, K (Fig. 2l;1), and attaching it along the line, J, N, K. Numerous points of in- terrupted suture were used to retain the parts in situ, assisted by long strips of adhesive plaster, compresses, and a reten- tive bandage around the body. It will be observed that the lower portion of the cystic tumor was thus temporarily left free and partially ex- posed, while no portion of cut or denuded surface remained uncov- ered. The patient received a large dose of opium, and was strictly maintained in the recumbent position upon a bed, properly pro- tected; such additional measures being adopted as would secure cleanliness. As the parts subjected to operation began to swell, she com- plained of irritation and pressure upon the bladder, which, however, were promptly met with morphine alone, and subsided in the course of a few days. Now was exhibited the great importance of leaving the tumor partially uncovered, while all the cut surfaces were in close contact, and thus freed from the action of irritating secretions; important facts duly dwelt upon and recently enforced with great Fig. 224. Bladder; nymphae ; c, vagina : 642 DISEASES OF WOMEN. stress by the distinguished Prof. Syme, of Edinburgh, whose con- tributions to the surgical treatment of the urinary organs have alone placed both hemispheres under permanent obligation to him. On the fourth day after the operation all sutures were removed, the wounds having healed by first intention or primary adhesion, with the exception of a spot the size of a ten-cent piece, situated just above the point of the triangle, and where the deep flap had been reflected over the bladder. At this point the lateral abdominal flaps were necessarily raised up from the tissues beneath, and could not be brought into contact even by the use of compresses. This, however, granulated kindly, and was nearly cicatrized on the 7th of December, when the second and last operation was performed, as follows: The patient being under the influence of chloroform the lower triangular flap, J, N, K (Fig. 224), was dissected from its recent and temporary attachments, both lateral and deep, and turned down over the vulva as indicated by the dotted line, J, C, K. Two incisions, J, L, and K, M, were now carried from the ex- ternal angles of this triangle, perpendicularly toward and terminat- ing just behind the nymphae, B, B. The lateral flaps bounded by the lines 1ST, J, L, and N, K, M, and including the labia majora, were then freely dissected from over the abutments of the pubic bones until they could be readily slid to meet each other at the central line, N, C, which, being a continua- tion of the line G, N, reduced the whole to a single linear wound, occupying the " linea alba." (See Fig. 222.) During the operation several arterial branches bled freely, and were arrested by torsion and the free application of ice, after which the flaps were confined at the mesial line by points of inter- rupted suture, the most inferior one, viz., at L, and M, being made to include the apex C, of the triangular flap. Fearing to depend on sutures alone to secure the approximated flaps, and the use of adhesive plaster being excluded by the irregu- larity and position of the parts, the whole surface between the points of suture was hermetically incased by strips of patent lint, soaked in collodion and accurately applied. In addition to this, pieces of muslin were by the same method firmly attached to the labia majora, at some distance from the mesial line, and to these sutures silk was fastened in such manner as to form a lacing across and over the wound. By means of this dressing all tension was removed from the sutures, urine was totally excluded, while rapid and perfect ad- hesion soon followed. MALFORMATIONS OF THE BLADDER AND URETHRA. 643 Thus a urinary canal was formed which would admit the little finger to be passed up one inch and a haK. The anterior four- chette of the vulva was firmly established, and the mons veneris as- sumed its prominent and natural appearance. The last cast of the parts representing her present condition (Fig. 222) was taken on the 4th of January, 1859, previous to which time, the parts being all firmly united, she was permitted freely to walk about, and left the hospital to spend the holidays with her friends. No artificial support whatever was applied, in order to as- certain how far the operation would succeed in preventing the pro- lapsus. After a severe test, the anterior fold of the vagina alone de- scended, and that for a short distance, forming a pale, oedematous tumor, occupying the vulva, about the size of an English walnut. The anterior fourchette of the vulva remaining firm and resisting, a light, oval pessary, made of vulcanized rubber, and perforated, was introduced into the vagina and readily retained in situ. After thor- ough trial, this was found to support the parts completely, and with- out the slightest uneasiness, even under active exertion and straining. This was a better result than had been anticipated, inasmuch as it was intended to rely mainly upon a disk-shaped pessary, sup- ported by a foot attached to a simple apparatus which we had con- structed to act as a reservoir for the urine. January 20, 1859. The patient was again examined at the hos- pital, in the presence of a number of medical gentlemen, she having walked a distauce of two miles without experiencing any incon- venience. The parts were all found sound and firm, and her gen- eral health and spirits much improved. Patent Urachus with Calculus. (H. D. Vosburgh, M. D., " New York Medical Record," September 22, 1877.)—Several months ago I was called to see J. H. B., fifty, a mechanic, of spare habit, and always in good health. He complained of soreness and constant pain at the umbilicus, and on examination I found the natural de- pression filled up by a rounded tumor, apparently the natural tissue enlarged by swelling. There was also circumscribed hardness of the tissues around the umbiUcus. The parts were red and very tender to the touch, having every appearance of an ordinary erysipelas. At the time of my visit he told me that a score or more of years before, after a similar experience, his attending physician at that time removed a " stone " from the umbilicus. I applied a poultice, and awaited developments. The above condition continued from day to day, with the exception that the tumor projected more and 644 DISEASES OF WOMEN. more from the umbilicus, and the circumscribed hardness decreased. Any movement of the body or handling of the tumor produced se- vere cutting pain in the part, The tumor was exquisitely tender. No constitutional symptoms accompanied the trouble. On the tenth day from my first visit I made an incision into the tumor for the purpose of exploration, about half an inch in depth, when I came upon a hard substance which, after considerable diffi- culty, I removed, and found to be a concretion, smooth and ovoid in shape, about the size of a medium hickory-nut, and of the color and appearance of a phosphatic calculus, with a strong urinous smell. After the removal the wound readily healed. The ordinary retraction of the tissues within the navel fossa took place, and the man has suffered no inconvenience since. What was the concretion ? In the " Medical Record," No. 354, Dr. Rose's article describing a patent urachus called this case to mind, and I have transcribed the above from my notes of the time. I can not conceive this concretion to have been anything else than a calculus formed from urinary deposit in a patent urachus. No treatise within my reach mentions anything of the kind, and the novelty of the case is my reason for reporting it. In this man there was doubtless a similar calculus formation something more than twenty years before. Very Rare Form of Monstrosity of the Female Genito-TJrinary Or- gans (" Gazette des Hopitaux.")—In the words of M. Tillaux, at the Hospital Lariboisiere, there is at present a small, deformed woman, twenty-six years of age, who presents an exstrophy of the bladder, with complete absence of the vagina. The external organs of gen- eration are represented only by the orifice of the uterus, which is situated in the median line almost on a level with the skin, and by rudimentary labia minora and majora which are not united in front. The clitoris, urethra, and anterior wall of the bladder are absent. The ureters open into the rudimentary bladder near the median line. Palpation shows that the pubic bones are separated in front by a space that is about as wide as five fingers, and the pelvis seems to be enlarged to that extent. The umbilical cicatrix is located at the middle of the superior border of the exstrophic bladder. The cervix uteri forms a slight prominence into which the skin is attached. It is conical in form. The cavity of the uterus is of nearly the normal depth, but rectal examination shows that in shape the organ retains the peculiarities of childhood. The patient began to menstruate at the age of fifteen years, and since then has been perfectly regular. Operative Treatment of Ectopia Vesicae. (By Prof. Trendelen- MALFORMATIONS OF THE BLADDER AND URETHRA. 645 burg, Bonn; " Centralbl. f. Chirurg.," 1885, No. 49.)—Former meth- ods are criticised. Thiersch's flap-closure, e. g., does not secure use of the bladder musculature. Trendelenburg's first attempts to secure direct union of a vesical and urethral fisssure by joining its lateral edges were begun five years ago. His plan is by dividing the sacro- iliac synchrondrosis on each side to mobilize the iliac flanges, and then by lateral pressure to approximate them in front. Finally, the fissure thus narrowed is, after reposition of the bladder to be directly closed by freshening and suturing its edges. Inferiorily the union is to be continued at least to the beginning of the pars bulbosa ure- thrae. Division of the sacro-iliac symphysis is in children simple, and, when carefully done, not dangerous. The child is laid on its belly, and a finger introduced into the rectum to determine the po- sition of the incisura ischiadica major and superior gluteal artery. A long cut is then made over said symphysis; this is gradually deep- ened until strong lateral pressure makes the pelvic flange yield. On account of the large pelvic vessels it is not permissible to cut through the deepest portion of the symphysis. Toward puberty and later in life this operation would have to be done with the chisel, and would be more serious. The construction of a continuously active com- pressing apparatus that could be tolerated for weeks proved diffi- cult. Tourniquet arrangements were not borne. A girdle crossing in front, with extension weights of ten to fifteen pounds attached, has of late proved satisfactory. Where previously the spinae sup. ant. were seventeen centimetres apart, they approached to within eleven and a half centimetres. The two pubic symphysis stumps, formerly two inches apart, were now almost in contact. It is well to delay the operation for the fissure some six or eight weeks. This second operation begins with freshening the fissure borders ; he then frees the edges of the bladder somewhat, and unites with Lem- bert's sutures. The urethra has usually been included in the oper« ation. A catheter is left for a few days. In all cases as yet the union to the extent of urethra and bladder-neck has subsequently separated. In a two and a half year old boy the remainder of the bladder held and the prolapse was remedied. He thinks that by further perfecting his operation it may prove successful. Operation for Congenital Extroversion of the Bladder of an Infant Five Days old.—(By H. C. Wyman, M. D., Detroit, Michigan, " New York Medical Record," December 12, 1885).—From the umbilicus down to the triangular ligament there was a failure of development causing an extroversion of the posterior wall of the bladder, show- ing the orifices of the ureters and an absence of the dorsum of the 646 DISEASES OF WOMEN. penis. Dribbling of urine from the ureters was constant. Under chloroform incisions were made on either side through the integu- ment and superficial fascia just forward of the anterior superior spine of the ilium two inches upward, to secure relaxation; the edges of the fissure were then pared and fastened together with harelip pins with intermediate sutures, and the wound dressed with oxide of zinc and absorbent cotton, a drainage-tube for the urine be- ing left in the wound. The penis was not touched, being reserved for a secondary operation. The recovery was rapid and perfect. The child died from convulsions two months later, before the opera- tion upon the penis could be performed. CHAPTER XXXVI. FUNCTION OF THE BLADDER. The function of the bladder is to act as a reservoir for the urine, and at proper intervals to expel it through the urethra. The filling of the organ with urine is a comparatively slow and gradual process, the fluid entering it from the ureters drop by drop, or in a very small stream. As it enlarges it does so in the direction of least re- sistance, viz., laterally and superiorly. The lateral being its long- est diameter, it enlarges first in that direction, until after a time a limit is set by the bony pelvic boundaries, when it rises from the pelvis somewhat, thus escaping from the pressure below. This movement of the bladder is facilitated by its serous surface gliding easily over that of the adjacent organs. The bladder receives its nervous supply partly from the mesen- teric ganglia of the sympathetic, and partly from the lumbar portion of the spinal cord: it has therefore nerve-filaments from both the cerebro-spinal and sympathetic systems. The sphincter vesicae is in health in a state of tonic contraction which results in retaining the urine in the bladder. This act is entirely involuntary and uncon- scious and is performed in a perfect manner both during the waking and sleeping hours. When it is desired to evacuate the bladder this sphincter is relaxed by an act of the will conveyed through the cerebro-spinal fibers, but this relaxation once accomplished, the further act by which the organ is emptied is performed without the intervention of the will. The experiments of Kupressow demon- strate conclusively that the nervous center which presides over con- traction and relaxation of the sphincter vesicae is located in the lum- bar region of the spinal cord. And it may be accepted that with other functions of a protective nature the spinal cord maintains the normal action of the urinary organ. There has been considerable discussion among different authors as to whether closure of the vesical urethral orifice is a voluntary or 648 DISEASES OF WOMEN. an involuntary act. Witte and Rosenthal maintain that the closure is due to '• tonicity from nerve force," which resists the urine press- ure. Kupressow holds the same view, basing his opinion on a se- ries of experiments which he made, and further maintains that the sphincter vesicae is at the neck of the bladder to eject the urine completely out of the urethra, in place of standing guard and hold- ing the vesical outlet closed. By others it is claimed that this musculo-elastic ring hinders the entrance of urine into the urethra, but that the tension of the bladder-walls when the organ is filled overbalances this elasticity, and a drop of urine escaping into the urethra brings the necessity for urination to the senses, and the act then becomes a voluntary one. It has been found, however, in cases of urethro-cystic vaginal fist- ula, where the upper part of the urethra and neck of the bladder were totally destroyed, that, after the healing of the parts, the an- terior or lower end of the urethra was practically able to control the urine. The act of emptying the bladder is a very important and inter- esting process, and is not so simple as might at first be imagined. As the organ has three openings and is emptied by the concentric contraction of its muscular coat, the urine is not only expelled through the urethra, but there is a tendency to regurgitation or backward pressure of the fluid into the ureters. The backward flow is effectually prevented by a very complete and interesting ar- rangement. The protection is threefold : First, by the oblique direc- tion that the ureters take in piercing the vesical wall; second, by the two muscular slips already mentioned, that pass from the sphincter vesicae to the insertions of the ureters. As the bladder gradually fills these slips are tightly drawn, and thus partially or wholly close the ureteric orifices. Moreover, it may be presumed that as these muscular fasciculi have their origin in the vesical neck, they act most vigorously during urination, when the bladder pressure tends to cause regurgitation into the ureters. Their greatest use is, in all probability, during the act of micturition. This view is borne out by the fact that these little muscles are in a rudimentary condition in the female, the urethra being shorter and the force necessary to empty the bladder much less than in the male; and further, by the well-known fact that when the hypertrophy of the muscular walls of the female bladder does occur, these fasciculi are proportionately enlarged. Third, by a ligamentous band, not described in the text- books of anatomy, which runs from one ureteric opening to the other, inclosing their vesical ends, and is known as the inter-ureteric FUNCTION OF THE BLADDER. 649 ligament. Its mode of action is this: as the bladder gradually fills, the openings of the ureters are carried farther apart, and with them the 'ends of the ligament. Being elastic it yields to a certain extent, and after a time, being able to yield no more, pulls upon both openings, closing them more or less completely. During urin- ation the tension of the ligament gradually decreases, and then the muscular fasciculi and the oblique direction in which the ureters enter the bladder come into play, the ligament being of use only during filling and distention. If from any cause the bladder is not emptied at the proper time, the organ is not only injured by overdistention, but more serious results may follow if the retention continues for some time ; although the bladder is too full to receive any more urine, the kidneys con- tinue to secrete until not only the bladder, but also the ureters, renal pelves, and kidney-tubes become overfilled. When the press- ure on the urinary side of the Malpighian tuft equals that of the blood-stream in the glomerulus, secretion of urine at once ceases, and we have a mechanical suppression. After death the bladder, ureters, and renal pelves are found to be greatly distended, and the kidney pale, of a bluish, pearly color in the cortex, and oozing urine from the cut surface. Maas and Punier (" New York Medical Record," October 1,1881) have performed experiments on animals and men which demon- strate to their satisfaction that the bladder, whether healthy or dis- eased, as well as the urethra, possesses the faculty of absorption in a greater or less degree, varying with the substance used. Their methods when experimenting on animals were as follows: The bladder was fully exposed, both ureters tied about half an inch above their termination, then divided above the ligatures, and the urine conducted outside of the body by means of glass cannulae in- troduced into the central ends. The bladder was then evacuated by a catheter through which the solution experimented with was in- jected, the catheter withdrawn, and a ligature drawn tightly around the urethra between the prostate gland and the neck of the bladder; sometimes after tying the ureters and urethra the bladder was emp- tied by a Pravaz syringe, the medicated solution injected through the cannula of the latter and the puncture closed by ligature. In a second series of experiments the abdominal cavity was not opened, but after drawing off the urine the solution was injected through the catheter, and the mouth of the latter plugged. The substances used were ferrocyanide of potassium, salicylate of soda, cyanide of potassium, strychnine, atropine, curare, apomorphia, and 650 DISEASES OF WOMEN. pilocarpin. All of these substances were absorbed, but some so slowly that their physiological action was not manifested ; thus atro- pine seemed to have no effect upon the animal, but a small quantity of its urine collected during the continuance of the experiment and instilled into the eye of another animal rapidly caused dilatation of the pupil. The diseased bladder was also found capable of absorb- ing the same substances. In their experiments on man, Maas and Punier used iodide of potassium and pilocarpin. As regards the excretion of the former, they call attention to the fact that in some individuals it rapidly passes off by the urine, in others by the saliva, and in others by only one of these paths to the exclusion of the other. The method used was the following : Taking only individuals with healthy bladders, the latter were evacuated by a Nelaton catheter, after which in twenty-eight cases they injected fifty grammes of a ten-per-cent so- lution of iodide of potassium, following this up in thirteen other cases with an injection of one or two centigrammes of muriate of pilocarpin half an hour later. The iodide was detected in the saliva in fifty-seven per cent of the first, and seventy-seven per cent of the second series, but usually in small quantities only. The dis- eased bladder was found to absorb much more promptly; iodide of potassium was detected in the saliva when only 2*0 were used. A solution of 0*4 morphine in 2'0 of distilled water used in this way, acted very plainly as an anodyne. Pilocarpin made up into a bougie with cocoa-butter, and introduced into the urethra (both healthy and diseased), manifested its specific effects. L. Schafer found that after producing vesico-vaginal fistulae in animals there was increase of from two to three per cent, and some- times from four to five per cent, in the amount of urine passed over that passed before the fistulae were made; and he feels convinced that under normal conditions of urinary secretion the amount of urine in the bladder is gradually diminished by a slight though reg- ular absorption of its watery elements. If this be true, we may look to a too rapid absorption as one of the causes of gravel and urinary calculi. On the other hand, however, Susini found that after injecting potassium iodide and belladonna into his own bladder, and retaining them for many hours, no trace of the former was found in the saliva, and no appearance of the specific action of the latter was made man- ifest. Ailing agrees with Susini, and the experiments of P. Dubelt also support this view. After careful consideration of the evidence pro and con, I am strongly inclined to the view that the bladder FUNCTION OF THE BLADDER. 651 does n<>t absorb anything, save possibly a little water, unless its epithelial surface is displaced or destroyed. When abrasion does occur, absorption is rapid and its effects marked. The fact that the mucous membrane of the bladder is able to absorb liquids after ero- sion of its epithelium throws much light on the cause of some of those peculiar constitutional symptoms accompanying chronic cysti- tis, and known by some authors as ammonaemia. The inner surface of the bladder is lubricated by a very thin se- cretion of mucus. This can be demonstrated by putting some fresh, normal urine in a clean bottle. In a short time a slight hazy cloud will settle to the bottom. When examined microscopically it will be found to'consist of a few epithelial scales and mucous fibrillae— long, fine, and often interlacing. In disease this secretion becomes greatly increased, and is then thick, viscid, and ropy. The normal secretion when tested chemically is found to contain an abundance of the earthy and alkaline phosphates. A healthy woman urinates from four to six times in every twen- ty-four hours, and passes in all from thirty-five to sixty ounces of urine, the average being about forty-five ounces. The amount passed varies much with the season of the year, more being passed in winter than in summer; it varies also with the amount of fluid ingesta, rest, and exercise. Neither limpid nor concentrated urine are well borne by the bladder. The pressure of the urine in the bladder being of importance in both health and disease, I deem it advisable to give here the results of some experiments by Schatz, Odelbrecht, Hegar, and Dubois. These experiments were made with the manometer, an instrument which by means of a column of mercury may be adapted to regis- ter the exact pressure in the bladder. They found the pressure to be from twelve to sixteen inches while standing, in the recumbent posture it was only from four to six inches. The pressure in the recumbent position Dubois be- lieved to be due not to visceral pressure from above, but to the nat- ural tonicity of the distended organ; for in the cadaver, after re- moving the other viscera, the pressure in the bladder indicated four inches, plainly due to the elasticity of the organ itself. The same has been observed in cystocele, in which the visceral pressure is also absent. The pressure is about the same in both sexes, and at all ages. It was found to rise from one haK to one inch with each inspiration, and to fall about the same with each expiration. In laughing, coughing, etc., it rose as high as from twenty to sixty inches. In 43 652 DISEASES OF WOMEN, diseases of the spinal cord, such as myelitis, and after injuries to the vertebrae, Dubois found a marked decrease in bladder pressure. These curious observations on the varying degrees of pressure arising from change of posture are not without value. They help one to understand why, in some diseases of the bladder, patients should maintain the recumbent position. CHAPTER XXXYII. FUNCTIONAL DISEASES OF THE BLADDER. It has been the rule among pathologists to class under the head of functional diseases all those in which no lesion of structure was discoverable in the organs concerned. Although we are still obliged to accept this nomenclature, the progress of pathological knowledge in the past few years has weeded out many of the so-called functional affections: and as this knowledge advances, and new and efficient means for observation and study arise, we shall be able to root out many more, thus doing away with much of the vagueness and uncer- tainty in which this class of affections is shrouded. But even with the improved facilities for diagnosis at our command, there are still many diseases in this list. Owing to the obscurity at present sur- rounding the subject of reflex or sympathetic disorders, i. e., the abnormal condition of an organ or organs, near or distant, affecting the function or nutrition of another organ, we are obliged to put these affections in this class also. Under this head then will be considered: I. Derangements of function in which there is no recognizable organic lesion. II. Derangements of function due to diseases of the nutritive and nervous systems, and to abnormal conditions of the urine re- sulting therefrom. III. Derangements of function due to inflammatory and other affections of the pelvic organs, such as metritis and pelvic perito- tonitis. It will be observed that in this arrangement of the subject, al- though a number of structural diseases are considered, they all stand in a causative relation to the disturbed action of the bladder, the latter being free from any organic lesion, and only disturbed in the discharge of its duty by influences outside of itself. Before discussing these functional disorders in detail, it will be 654 DISEASES OF WOMEN. necessary to fix clearly in the mind their various manifestations ; these are: frequent urination, or polyuria; difficult urination and re- tention, or ischuria; painful urination, or dysuria; pain after urina- tion, or vesical tenesmus; and incontinence of urine, or enuresis. These deranged actions may also be due to organic diseases of the bladder, but they will at present only be discussed in connection with the three classes of functional derangements of that organ just referred to: I. Derangements of function in which there is no recognized organic lesion. There are five of these derangements which demand special consideration. 1. Neuroses, pure and simple. 2. Derangements due to hysteria. 3. Derangements due to disorders of the sexual function. 4. Derangements due to malaria. 5. Derangements due to ovarian affections. 1. Neuroses.—By this term I refer to purely nervous affections of this organ. They are rather rare, it is true, but that they do ex- ist there is no doubt, for there are certain conditions that seem to depend on no other known pathological cause. We learn from the books that vesical neuralgia is of this class. It is known by a variety of names, each taking as its key-note some peculiar manifestation or symptom, as irritable bladder, cystospasm, cystoplegia, and neuralgia vesicae. The term irritability so commonly used in speaking of the healthy organ must not be confounded with the condition known as irritable bladder. The former refers to a certain property that the viscus possesses, by means of which it is able to respond to certain stimuli, while the latter refers to an abnormal condition of sensation, viz., super-sensibility, or hyperaesthesia. 2. Derangements due to Hysteria.—Hysteria holds a prominent place among the causes of functional derangement of the bladder, the vesical affection being probably only a fragment of a general neurosis. Acute and chronic diseases of the brain and spinal cord also produce various vesical difficulties of this nature, but these will be discussed under another class. Any one who has suffered the mortification of an involuntary evacuation of urine from fear will understand how the brain and nervous system can influence the bladder. In the variety of conditions grouped under the head of hysteria, it is often observed that frequent urination is a prominent symptom. The cause, in many cases, is the peculiar character of the urine se- FUNCTIONAL DISEASES OF THE BLADDER. 655 creted in this disturbed condition of the nervous system. The lim- pid urine of hysterical patients is deficient in solids, the watery por- tion being greatly in excess. This unnatural composition renders the urine irritating to the bladder so that it can not be long retained. The quantity of urine secreted is, at certain times, excessive, which, together with its irritating quahty, renders urination necessarily very frequent. But apart from the frequent urination which occurs in severe attacks of hysteria due to the conditions just mentioned, cases are often seen of frequent micturition which can only be accounted for by the state of the nerves which govern the action of the bladder. When the quantity and composition of the urine are normal, and the patient can retain it without pain or distress during the night, but has to pass it every hour or two during the day, it may safely be presumed that the trouble is functional, and due to a disordered state of the nervous system. The only condition which resembles this history is occasionally seen in prolapsus uteri, the patient being free from trouble while reclining, but having to urinate frequently when in the erect position. Hysterical patients frequently suffer from retention of urine. Some of them complain for a time of difficulty in emptying the bladder, and finally fail to do so altogether. At other times they suddenly find that they can not urinate. There are conflicting views regarding the cause of this retention, some believing that such patients can not urinate, and others that they will not. Those who believe that the trouble is feigned and not real, do so on the ground that in this morbid state of the nervous system the patients enjoy catheterization, which would be distressing to any one of healthy mind and body. Others claim that in the extreme sexual excite- ment which occurs in some cases of hysteria, the chronic erection of the clitoris makes pressure upon the urethra, and prevents the flow of the urine through the canal which is at that time com- pressed. I am satisfied that both kinds of cases occur. There are those who complain of retention when they know that the doctor will use the catheter, but they can urinate easily when they please. Others I have seen who were suffering from excessive and painful disten- tion of the bladder and would have gladly relieved themselves if they could. 3. Derangements due to Disorders of the Sexual Function.—An- other class which resembles the hysterical patients in the frequency of urination, but differs in every other respect, is found in those 656 DISEASES OF WOMEN. who suffer from the habit of masturbation. The constant conges- tion and irritability of the pelvic organs, caused and kept up by the unnatural and excessive exercise of the sexual function give rise to frequent urination. Such patients complain of general weakness, which is not accounted for by any organic disease of the general system. Nor is there disease of the bladder; it is simply enfeebled and irritable like the rest of the pelvic organs. To make a correct and positive diagnosis in such cases is by no means easy, because it ne- cessitates our detecting the habit of masturbation, and this is usually one of the most difficult tasks for the diagnostician. It is not al- ways prudent to question the patient regarding the habit; and even when that is done they frequently fail to comprehend the question, or they answer falsely in the negative. The physician is thus gen- erally left to guess at the truth of the matter. The symptoms developed by masturbation are depression of the nervous system, manifested by lassitude, sadness, or emotional ex- pressions of joy and sorrow, those affected with this habit being easily affected to smiles or tears. The eyes are dreamy and heavy, and the pupils dilated. Such subjects are excitable, irritable, and easily ex- hausted. They often have headaches. Nutrition is apparently good in some cases, as is shown by the fair supply of flesh; still, they often suffer from acute indigestion, although at times the appetite is re- markably good. The bowels are usually constipated, and the mus- cles soft and flabby. The exhalations from the skin are some- times changed, so that a peculiar odor is noticeable about such persons. This odor can not be described, but, when once recognized, is easily remembered. In this variety of functional derangement of the bladder, as well as in all the other varieties of neurotic affections, the symptoms vary in severity to a great extent in the same individual. The trouble is by no means regular and constant in its manifestations, as in organic diseases. Whatever disturbs the nervous system will increase the disorder. The rule is that frequent urination is the prominent symp- tom, but occasionally painful micturition is complained of. It is then simply a slight scalding pain, experienced when the urine is passing over the irritable or chafed mucous membrane about the meatus urinarius. 4. Derangements due to Malaria.—Another cause which I believe acts through the nervous system is malaria. The effect of malarial poison on the bladder and urethra is very peculiar. The trouble produced in this way has been called urethral fever, and is described as an inflammation of the mucous membrane of that canal. It mio-ht FUNCTIONAL DISEASES OF THE BLADDER. 657 more properly be called malarial fever of the urethra. As I have observed this affection, the bladder and urethra are usually both affected, but I do not consider the disease one of a well-defined in- flammatory character. There are usually symptoms of malaria pres- ent, but not necessarily chill and fever. On the contrary, I believe that I have observed the affection more frequently in remittent than in intermittent fever, and very often, where the constitutional symp- toms were not more than a slight derangement of the digestive organs, with moderate elevation of temperature in the after-part of the day. The symptoms vary, but usually are as follows: The patient com- plains of frequent desire to urinate, and some vesical tenesmus; se- vere burning pain on passing water, with stinging and burning in the urethra after urination. The history of such cases resembles acute gonorrhoeal urethritis so far as the abruptness of the attack and the tenderness and pain of the urethra are concerned, but there is usually no discharge, or, at least, very little. In many cases the suffering is greatest in the afternoon and early part of the night. Under proper treatment the disease disappears as promptly as it comes on. 5. Derangements due to Ovarian Affections.—In disease of the ovaries we sometimes find that the bladder suffers very much from deranged nerve action. The clearest and best account of this form of functional bladder trouble is given by Fothergill in his paper on '•Ovarian Dyspepsia," published in the "American Journal of Ob- stetrics," January, 1878. In speaking of the derangement of the stomach and pelvic organs, he says: " It soon became clear that there was some condition existing which stood in a causative relation to both the dyspepsia and the uterine disturbance. That condition was quickly seen to be a state of vascular excitement in one or both ova- ries, usually the left ovary. This condition Barnes terms ' oophoria.' In this state there is always more or less pain constantly in the iliac fossa, more rarely on the right, much aggravated at the catamenial periods, wdien the pain shoots from the turgid ovary down the thigh of the corresponding side along the genito-crural nerve. This pain- ful state is otherwise known as 'ovarian dysmenorrhcea.' When pressure is made over this tender ovary during the catamenial flow, acute pain is experienced. Pressure also elicits pain during the inter- menstrual interval. At the same time that acute pain is felt, evi- dence is furnished of emotional perturbation; the patient feels as if about to faint, or ' feels queer all over,' as some express it, and the changes in the patient's countenance speak of something more than 65 S DISEASES OF WOMEN. more pain, pure and simple. It is evident there is a wave of nerve- perturbation set up, which excites more than the sensation of pain. Commonly the patient feels sick after the momentary pressure, and asks to be permitted to sit down, alleging that she feels sick and faint. If a careful physical examination be made, it will be found that there is an enlarged and tender ovary, which may sometimes be caught betwixt the finger in the vagina and the fingers of the other hand applied to the abdominal wall of the ovary. Such manipula- tion elicits manifestations of acute suffering from the patient. Fre- quently the rectus muscle over the tender ovary is hard and rigid, so as to place the organ as perfectly at rest as is possible; just as we see the rectus to stiffen and become rigid over the liver when there is an hepatic abscess, and thus to secure rest, as regards movement, for that viscus. . . . " Not rarely, too, there is set up a very distressing condition, viz., that of recurring orgasm. This occurs most commonly during sleep —' the period par excellence of reflex excitability.' In more aggra- vated cases it also occurs during the waking moments, and this it does without any reference to psychical conditions. " The centers of the pelvic viscera lie near together in the cord, and the condition of one is readily communicated to another. The brief recurrent orgasm affects the bladder-centers, and the call to make water is sudden and imperative, and must be attended to at once, or a certain penalty be paid for non-attention. This last is not a common condition, fortunately, but it is a source of great suffering, bodily and mental, when it does occur. The condition of the ovary also acts reflexly upon the uterus, and keeps it in a state of persistent erection and high vascularity, with the normal phenomena attendant thereupon." It is evident that this form of bladder trouble can only be re- lieved by treatment of the ovarian disease, for which bromide of potassium and counter-irritation are very serviceable, with, of course, attention to the general health. Symptomatology.—In all of these nervous affections of the urin- ary organs, pain and a feeling of weight and uneasiness in the region of the bladder are usually present. Still, the most constant and dis- tressing symptom is the frequent and painful desire to micturate, which the patient tries to relieve by frequent urination, a few drops only being passed at a time. Of course, there are varying grades of this affection, in some of which these symptoms are by no means so troublesome. In some extreme cases, when a little urine collects in the bladder, the pain and irritability are so intense that it is spurted FUNCTIONAL DISEASES OF THE BLADDER. 659 out bv a very forcible and painful contraction of the organ. The sense of weight and bearing down are most intense in the upright position. The pains may be confined to the neck or base of the bladder, or they may shoot in all directions. The pain in micturition may be present at the beginning, but is usually most severe during and after the completion of the act. The local pain and distress, with the frequent urination and un- rest, react upon the general nervous system, thereby greatly aggra- vating the original disorder. This lowered systemic condition in turn affects the local disorder, and so the one is continually aggra- vating the other. In this way the patient, if not relieved, goes on from bad to worse, until the host of phenomena characteristic of nervous prostration and general ill-health are developed. In certain cases the sufferers are by no means so badly circum- stanced, but time and neglect tend to produce these results sooner or later. In some cases, again, the suffering gradually disappears, and the patient is restored to health without much aid from treat- ment. The trouble appears to wear itself out. Diagnosis.—The symptoms I have given are by no means pathog- nomonic of these affections, the same being produced by organic disease of the bladder, calculi, and various other causes. The diag- nosis must be made by exclusion. The first thing to do is to make a careful microscopical and chemical analysis of the urine. Not only can local organic trouble be thus eliminated, but important knowl- edge as to the state of the general system obtained. If no urinary abnormality is discovered, a careful external and internal examination of the organ itself should be made. A finger should first be passed into the vagina, and an endeavor made to ascer- tain, by pressure on the vesico-vaginal septum, whether there is any abnormal sensitiveness of the vesical base or neck, or of both. Then the sensibility of the mucous membrane should be tested by the in- troduction of a sound. If sufficient cause be not found in either the urine or the bladder, the case may be set down as one of pure neurosis, to be treated as I shall hereafter describe. Systemic conditions, such as hysteria or chlorosis, should be considered, as they point to a tendency to neu- rotic difficulties, liable to be localized. Prognosis.—As a rule, the prognosis is favorable. This, how- ever, is not always the case. The longer the affection has lasted, the more difficult it is to cure. Most cases may be cured in a few weeks' time, and even the most obstinate in a few months. The danger to the patient lies in the fact that continuance of the disorder is liable 660 DISEASES OF WOMEN. to bring on an organic lesion, and, whether this results or not, the reaction on the general system tends, in the worst cases, to produce hypochondria-is or even melancholia. Causation.—These nervous affections of the bladder occur most frequently in those of the nervous temperament. A highly devel- oped nervous system predisposes one to nervous affections of all kinds. Especially is this the case if the subject is not well sustained by a vigorous nutritive system. Those in whom the emotional ele- ments predominate in the mental composition are more liable to nervous affections of the bladder than those of the more intellectual type. The exciting causes include all influences which depress or ex haust the nervous system. Mental taxation or excitement which tends to increase the excitability of the nervous system may derange the function of the bladder. Constitutional diseases which lower the tone of the whole organization also tend to produce the affections now under discussion. It is not possible to give any satisfactory explanation of the reason why the innervation of the bladder becomes deranged in some per- sons from causes which are in others inoperative. It may be that those who are most susceptible to this cause are so because of some inherited sensitiveness of the pelvic organs which responds to the disturbing influences. This appears to be the case with those who suffer from irritation of the bladder caused by ovarian disease. This is apparent from the fact that one affected with disease of the ovaries will suffer from derangement of the function of the stomach, while another having a similar ovarian affection will suffer most from fre- quent urination. Regarding the causative relations of malaria to irritation of the bladder, all that can be said at the present time is that this materies morbi appears to act upon that viscus through the nervous system. Treatment.—This may be classed as general and local. In pure neuroses, attention should be first directed to improving the general condition of the patient. Cheerful company should be provided at meals and at other times, and there should be exercise suited to the strength of the patient, daily ablution, and proper regulation of diet. This latter should be simple and nourishing, and of a kind calculated to produce as little urea and urinary solids as possible. In cases where the urine is limpid, the opposite course is to be pursued. Pastry, irritating condiments, and stimulants, except in rare cases, should be prohibited. The exception to this is where a condition of the system calling for stimulation exists. In such cases the irrita- FUNCTIONAL DISEASES OF THE BLADDER. 661 tion of the bladder produced by their use may be more than counter- balanced by the good they do the general system. Tea is better than coffee, but neither is to be used in any great quantity. The condition of the urinary secretion must be carefully watched, and any abnormality quickly and judiciously corrected. Where there is any tendency to excessive acidity, the effervescing waters, rich in carbonic-acid gas, will be found of use. The bowels should be kept moderately well open, but should never be irritated with active cathartic agents. Tonics and medicinal stimulants are often of great value when judiciously exhibited. Strychnia in very small doses does not, as might be supposed, aggravate the irritable condition of these organs. The nerve-tone being below par, strychnia, by gradually increasing it, is of great service. In large doses it is undoubtedly hurtful, and should never be long continued. Quinine, iron, and the various sim- ple and compound vegetable bitters act well in the cases where their exhibition is indicated. If the irritation is extreme, various soothing emulsions and de- coctions may be given by the mouth. Of these, preparations of marshmallow, triticum repens, acacia, pareira brava, and buchu act well. Emulsio-amygdalae is much used and highly recommended by the German authors. Some objections have been raised to the use of these drugs on the score that they increase the flow of urine, thus aggravating the local irritability. The fact is, however, that the presence of fairly normal urine in the bladder in moderate quantity seems to relieve rather than increase its irritable condition. The local treatment may be as follows: A cupful of warm hop- tea, containing from twenty to forty drops of laudanum, may be injected into the rectum. Suppositories containing opium may often be used with benefit. With the opium or morphine in the supposi- tories may be combined belladonna, atropine, or hyoscyamus. Mor- phine in the form of Magendie's solution may be injected directly into the bladder. There seems to be no especial advantage in this mode of administering anodynes, hypodermic injections of the drug acting as well, if not better. Emulsions, decoctions, and infusions of cannabis Indica, hyoscyamus, belladonna, and other like drugs may be used by the mouth, as the case may require. Good effects have followed the use of rectal injections containing chloral hydrate (grains 15 to water ^i or ^ij)- If maJ a^so De given by the mouth, but does not usually act so quickly or have such a direct local effect. 662 DISEASES OF WOMEN. The injection into the bladder of a solution containing morphine, followed by cauterization of the mucous membrane, is highly spoken of by Braxton Hicks. He claims in this way to deaden the reflex irritability of the membrane. I must insist on this—that opium shall be used in such cases with great care, and never continued long. If this rule is neglected, it will lead many nervous patients to contract the opium habit, which disease is worse than irritable bladder. Debout recommends the use of bromide of potassium by the mouth, and also in suppository, combining with it in the latter tinct- ure of opium and belladonna. I prefer hydrobromic acid to the bromide of potassium. When the trouble is due to masturbation, moral and mental in- fluences must be brought to bear, as well as medication and regula- tion of diet and habits. In these cases the bromides will be of serv- ice. If all other treatment fails to accomplish the desired result, resort should be had to mechanical means, viz., the rapid and forcible dila- tation of the urethra. Some authors, indeed, think so highly of this method that they boldly assert that time spent in medication is time lost. Astonishing and very gratifying results have certainly followed its use in a number of cases. Hewetson reports in the "Lancet" (page 4, vol. xii, 1875) that in this manner he cured a case of cysto- spasm of fifteen years' duration. This procedure is spoken of in the highest terms by Teale (" Lancet," page 27, vol. xi, 1875), as also by Spiegleberg, Tillaux, and others. In the cases where this treatment gives relief, I believe that there is some inflammatory condition present, or at least something more than a neurosis. When due to malaria, the treatment is usually simple and satis- factory. Quinine in full doses, as recommended by Bricheleau (" Arch. gen. de med."), for one day, and then in small doses before meals for a week, will usually cut the trouble short, and prevent its return. The digestive organs require attention when they are out of order, as they usually are. If due to hysteria, the original disease should be treated, not, however, neglecting the local trouble. When accompanying acute or chronic systemic diseases, it is only relieved when the original disease is cured, although in the mean time the annoyance may be greatly alleviated by the treatment already recommended. FUNCTIONAL DISEASES OF THE BLADDER. 663 H-LUSTEATIVE CASES OF FUNCTIONAL DISEASES OF THE BLADDER, LN WHICH THEKE IS NO RECOGNIZABLE ORGANIC LESION. Neuralgia of the Urethra and Neck of the Bladder.—A married lady, who had never been pregnant, was first seen when she was twenty-six years of age; she had then been three years married. She was well developed, and, although of a marked nervous tempera- ment, had always enjoyed good health. From puberty onward she had suffered pain at her menstrual periods, but not of severe charac- ter. When she was twenty-four years old she was chilled while rid- ing a long distance on a cold day, which was followed by frequent and painful urination. This was somewhat relieved by rest and diuretics. From that time she was subject to violent attacks of spas- modic pain in the urethra and bladder. The pain was of a sharp, lancinating character, generally coming on before and after her men- strual period; it was, however, brought on at any time by nervous excitement or great fatigue. During the pain there was some diffi- culty in urinating, but the pain was neither relieved nor increased by the act. The duration of the pain varied, but usually did not last more than twenty-four hours. At times she became almost frantic, so great was the suffering. Large doses of opium would relieve her, but, as it caused very distressing after-effects, she avoided taking it, except when the attacks were exceptionally severe and prolonged. When she first came under my care she had a flexion of the uterus, with slight general tenderness of the pelvic organs, which accounted for her mild dysmenorrhoea, and I presumed that that might be the cause of the neuralgic pains in the bladder and urethra. She was treated for the uterine affection, and obtained complete relief from the painful menstruation and tenderness of the pelvic organs gener- ally, but no relief was obtained from the periodic attacks of pain in the urethra and bladder. She acknowledged that it was not quite so severe at her menstrual periods, but was " bad enough in all con- science," as she expressed it. Careful and repeated examinations of the urine were made when she had pain, and when she was free from it, but no trace of any renal, vesical, or urethral disease was obtained. The urethra and neck of the bladder were examined with the endoscope several times, but were found to be normal. Suspecting that the neuralgic pain— for such it apparently was—might be due to malaria, she was given fifteen grains of quinine within a period of eight hours, followed by Fowler's solution of arsenic in doses of three minims after each meal. The arsenic treatment was continued for several weeks, and 664 DISEASES OF WOMEN. gave her some relief, the attacks being less violent, but still she suffered greatly. Moderate dilatation of the urethra was then practiced. This ag- gravated the trouble. Several different remedial agents, including opium, hot water, aconite, infusion of hops and belladonna, were in- jected into the bladder, but none of them gave any relief. The citrate of iron and quinia in five-grain-doses was then prescribed to be taken before meals, and Parrish's compound sirup of the phos- phates in drachm doses to be taken after meals. When the pain came on she was directed to take every three hours a drachm of camphor-water containing eight grains of muriate of ammonia, and to use a vaginal douche of hot water. This treatment usually re- sulted in mitigating the pain, but did not completely abolish it. Thirty minims of the compound spirits of ether and five minims of the tincture of cannabis Indica every four hours were substituted for the camphor-water and muriate of ammonia and with good effect. Under this treatment her attacks were far less frequent, and the re- lief from pain was prompt. She was so much pleased with her im- provement that she took a trip through the West and returned quite well, and has remained so for the past eight years. More re- cently I have had a case which resembled this one in many respects, particularly as regards the character of the pain and its causation, in which a four-per-cent solution of muriate of cocaine instilled into the urethra and bladder gave relief. A Peculiar Form of Neuralgia not yet described, excited by a Desire to Pass Water and by Micturition. (By Dr. Putegnat, of Luneville. (Gaz. Hebdom de med. et chirurg., April 15, 1864.)— The following two cases, out of six published by the author, will give an idea of this peculiar neuralgia, which consists on the one hand, in a special sensation in the bladder, and on the other, in symptoms of a neurosis of the ulnar nerve. M. X., aged fifty, with chestnut hair, of a nervous and san- guine temperament, very abstemious, in affluent circumstances, lead- ing a very active fife, occupying very healthy apartments, free from all diathesis, except a slight rheumatic affection, liable to coryza in cold, damp weather, has never had any other nervous complaint be- yond headache and occasional gastralgia after eating dressed salads or raw fruit. From time to time, at varying intervals of weeks, months, and even years, without any apparent physical or moral cause, in all electric, barometric, and thermometric conditions of the atmosphere, as soon as his bladder is full, and he has a strong desire to pass FUNCTIONAL DISEASES OF THE BLADDER. 665 water, he feels along the urinary passages, especially in the perinaeum a peculiar sensation of numbness, not very painful, but acute, burn- ing, lancinating, and unpleasant from the accompanying sense of prostration. This strange sensation next affects the shoulders, comes down both arms, along the course of the ulnar nerve only, and gives rise in the forearm, the little and the ring fingers, to the same sensation as when the ulnar nerve is strongly compressed at the elbow. The pain is more acute on the left than on the right side, lasts about twenty or thirty seconds, and after diminishing gradually, disappears without leaving any trace behind it. M. X., of Luneville; living in healthy rooms; very active, easily moved and excited ; subject to headaches and to rheumatic pains; free from any diathesis; very abstemious ; complains, for several successive days, but at irregular intervals, and without any known cause, of a strange sensation along the outer border of the left forearm, on the inner side of the thumb, and the outer surface of the index-finger especially. This sensation he compares to the one produced in the last two fingers of the hand by compression of the ulnar nerve at the elbow. The painful sensation only comes on whenever he has a strong desire to pass water, persists during micturition, and ceases com- pletely immediately afterward. On analyzing the six cases of the author, we find four of them to have occurred in females. The mean age of the patients is forty- six ; the oldest being fifty-two, and the youngest thirty-six years old. They are all in easy circumstances; five occupy healthy apart- ments, the sixth only living in damp rooms on the ground floor. Three patients have had gastralgia; the fourth sciatica, and great troubles have shaken his nervous system; the fifth is subject to vio- lent headaches; and the sixth, a female, seems to have epileptiform seizures, and has a double neuralgia. From the above, then, it may be concluded that neuralgia and great nervous excitability are pre- disposing causes of this strange neuralgic affection. In one of the four female patients the catamenia had ceased ; in three they had not, and in two of these the neuralgia showed itself before and during the menstrual periods. Uterine congestion seems then to be a predisposing cause also. Four of the six patients had had rheumatic pains ; but the other two having never suffered from such pains, this can not be consid- ered as the exciting cause of the neuralgic affection. The desire to pass water, and especially the act of micturition, brings on the sensation, which only appears at those stated times, 666 DISEASES OF WOMEN. and it reaches its maximum intensity at the beginning of the mic- turition. It has all the characters of neuralgia, and can even aggra- vate, as in one case, an already pre-existing neuralgia—that of the median nerve. As to the precise seat of the sensations, we find them affecting the four extremities of one patient, but the upper limbs only of the re- maining five. In three cases they simulate to perfection neuralgia of the ulnar; and in two they are felt in the tips of all the fingers. In one case they coincide with and intensify pains in the course of the median ; and lastly, as in the first case we have given above they are felt in the distribution of the left radial nerve. The first patient complains of pain in both shoulders, especially the left; the fourth, of pain in both arms and hands, but chiefly in both breasts, and in the left breast more than the right; the sixth, again, of pain in both forearms and hands, but more marked on the left side. Hence, the left side of the body would seem to be either the only one affected, or the one most affected. The patients always distinguished clearly the special painful sen- sations felt in the urinary passages from the normal sensations due to a distention of the bladder and the subsequent desire to pass water. Retention of Urine Due to Hysteria.—A single lady, thirty-one years of age, of delicate organization and pronounced nervous tem- perament, yet very quiet and self possessed in manner, suffered for some time with difficulty of urination. At times she could urinate very well, at others she was obliged to try repeatedly before she succeeded. She was a lady of high culture and liberal education, but was not interestedly occupied, and hence she had much time for introspection. She called her physician who prescribed remedies, but finding that they did not give her relief, made an examination of the pelvic organs but could find no cause for her inability to urinate with facil- ity. Soon after she was taken with complete retention which was re- lieved by the catheter. This continued for weeks, requiring the doctor to visit her three times a day, and occasionally at night, to pass the catheter. For some reason which was not very evident and could hardly be due to weakness or suffering, she remained in bed most of the period during which the catheter was used. Be- coming weary of such close attention, the doctor tried letting her wait, to see if a full distention of the bladder would have any good effect. This caused her so much pain that the doctor felt somewhat FUNCTIONAL DISEASES OF THE BLADDER. 667 mortified at his want of feeling in permitting her to suffer. Dur- ing this time he had tried a number of remedies, but without effect. At this stage of the history I was called in consultation; I could find no evidence of any organic disease, local or general. The urine wras found upon examination to be normal. I suggested to the attending physician that the trouble was hysteria, but he as- sured me that she was singularly free from all evidences of that affection. Indeed, he had found her a remarkably calm and sensible lady, and very free from nervousness of every kind. The impression that 1 received was that there was a very decided hysterical element in the case, and I advised full doses of bromide of potassium and a sitz-bath when she desired to urinate. I also recommended that she should go to Saratoga, and drink Hathorn water. She did this, and the water gave her diarrhoea, and her retention was immedi- ately relieved. Frequent Urination Due to Hysteria.—A lady twenty-three years of age, in very good general health, and living in very easy circum- stances, had some disappointment which caused her much distress. She had faintings of a mild character which alarmed her mother and called forth much sympathy. About this time she began to suffer from frequent urination. This did not yield to the treatment employed by the family physician, and she was brought to my office for advice. Her health was at times excellent, but she was greatly annoyed by this frequent urination. The urine was normal except at times when it was of a very light color. She could sleep all night without being disturbed by a desire to urinate. If by chance she did not go to sleep immediately on retiring she was obliged to urin- ate every few minutes, and if she was awakened in the night she had to urinate many times before she could sleep again. Any little mental excitement, such as going to church or to the theatre, would bring on the trouble, so that she had to give up all public duties and pleasures. Systematic exercise and occupation, cold baths, bromide of sodium, and a full assurance on my part that she would soon recover, helped her greatly. She was commanded in a very decided way to resist the inclination to such frequent urin- ation, and she obeyed orders. Soon after this her attention was attracted in another and more interesting direction, and she recovered completely. Frequent Urination from Perverted Sexual Function.—A girl nineteen years of age who had a good general organization and en- joyed good health up to puberty at fourteen, sought advice regard- ing impatience of her bladder. She was obliged to return home u 668 DISEASES OF WOMEN. from boarding-school because she had to urinate so often that she could not attend to her studies and recitations. Her general nutri- tion was good, she menstruated regularly, freely, and without acute pain. Her nervous system was depressed. She was sometimes lan- guid, low spirited and fretful, at other times she was bright and dis- posed to be cheerful. Her manner was rather timid and excited. Her hands were clammy, and her eyes dull, and had dark streaks under them. Her chief symptom was the frequent urination which persisted but was much worse at times than at others. Occa- sionally she would pass the night without getting up more than once or twice, but during the day she was often obliged to urinate every half-hour. There was very little pain except occasionally a little smarting at the meatus. She complained of heat and burning about the vulva and occasional aching in the region of the ovaries. She was easily fatigued and had backache, especially on standing and walking—leucorrhoea troubled her only at times. I suspected at first that she had either cystic and urethral con- gestion, or else hysteria giving rise to excessive renal secretion of limpid urine, but an examination of the quantity and composition of the urine proved the contrary. She was put in charge of a very competent nurse who was directed to find out the habits of the patient. The report of the attendant was that she had begun to indulge in masturbation soon after puberty, and that the habit had gradually grown upon her. Her nurse surprised her by telling her the cause of her suffering, and readily gained her consent to make all due efforts to recover her self-control. By care, occupation, and exercise out-of-doors, and the moral control of her nurse, she began to im- prove. Bromide of sodium was given when she was very restless and irritable, but no other medication, except the free use of bathing. In about two months the frequent urination had disappeared, al- though she would occasionally have a day or a night when she suf- fered in that way a little. She now has two children, and enjoys life very well, being free from her former symptoms and no doubt cured of her former habit. Frequent and Difficult Urination from Sexual Continence.—The patient, a strong and active lady in good circumstances, was married at twenty-one years of age, and had her first baby before she was twenty-two. She nursed the child for eighteen months. Her menses came on when the child was one year old. About three years after her marriage, her husband, a strong, vigorous man, died FUNCTIONAL DISEASES OF THE BLADDER. 669 of pneumonia. Several months after the loss of her husband she began to suffer at times from frequent urination, and also had some difficulty in voiding the urine, requiring voluntary efforts. These attacks would pass off, and she would be comfortable for days, when the same irritation of the bladder would return. She was always made worse by excitement, often being kept awake nearly all night after spending the evening in company. Her symptoms became so troublesome that she sought advice of a physician, who treated her for cystitis by giving medicines of va- rious kinds. AVhen she first came under my observation I found her in perfect health in every way. The urine was normal, and caused no pain when she passed it. I was easily able to exclude all diseases except deranged innervation from a possible malarial influ- ence. The periodical character of the attacks favored this view of the case, but the use of the anti-malarial remedies gave no relief. I then ordered her to take more active exercise and a limited quantity of plain food, to bathe frequently, and to avoid excitement as far as possible. Bromide of sodium was also given when her suffering was most severe. She improved on this treatment for a time, in fact she became so much better that I lost sight of her for nearly a year. She returned to say that her former symptoms had returned, and were about as troublesome as before. The same treat- ment was employed but did not help her very much. She was now rather nervous and restless, and disposed to be emotional. Three months afterward she was married, and left the city on an extended wedding-tour. Upon her return she reported herself as perfectly well. A Case of Malarial Irritation of the Bladder in the Female. (By Henry X. Leake, M. D., Dallas, Texas. Abstract of a paper read before the Texas State Medical Association.) I desire to record an observation, which I have recently made, exemplifying the eifect that the malarial poison may exert upon the female blad- der; an observation which may appear commonplace since, as is well known, it has not escaped mention by Prof. Skene in his excel- lent work on the " Diseases of the Bladder and Urethra in the Female" as well as by other authors of equal or less prominence, who have attended to the same subject. Nevertheless, considering the mere allusions by these writers to irritation of the bladder in women, which may be caused by the presence of malaria in the system, on account, doubtless, of the rare occurrence of this affection, it may be questioned whether the latter has been sufficiently individualized as a distinct and independent 670 DISEASES OF WOMEN. malady, deserving especial prominence in the nosology of diseases of the bladder, which seriously disturb the functions of this sensitive viscus. There is the additional reason, also, for reporting the ex- perience which I have had of this peculiar and interesting disorder, in the fact that much obscurity yet surrounds the entire subject of disturbance of the functions of this organ in the female, the integrity of which is so vital to the comfort, happiness, and safety of the in- dividual. Moreover, such conditions often tax the diagnostic acumen of the physician to the utmost, and even wThen by the exclusive method, rigorously employed, many causes of irritation of the bladder may be eliminated from the problem in hand, there will yet remain in particular cases, other causes which may elude-discovery, thus ob- scuring the pathogeny and defeating every measure of treatment which is attempted. About March 1st, of the present year, a lady, whose health has been uninterruptedly good, thirty-seven years of age, the mother of six children, the last of which being an infant of four months, ap- plied to me for treatment for what she considered the ailment to be, incontinence of urine. She stated that the condition had come on gradually, at the first amounting to a mere frequency of urina- tion during the day, without any attendant pain or other symptom which attracted her attention. This frequency had increased, how- ever, to such an extent as to seriously embarrass her in the perform- ance of domestic duties, and prevent her from visiting friends, or doing necessary shopping. Moreover, she soon became troubled at night, often rising six or, perhaps, a dozen times, in obedience to the urgent calls for micturition. The amount of urine passed at each discharge was not large, but exceeded in quantity that ordi- narily retained in cases of acute cystitis, which the affection in many respects closely resembled. There were no deposits in the urine worth noting. It appeared to be somewhat higher colored than normal. There was also a superabundance of mucus, in the form of large flocculi, but no pus or blood. As the case progressed, the desire to evacute the bladder was preceded by a sharp twinge of pain, which the patient averred was " low down at the very neck of the bladder," but which was imme- diately relieved on emptying the viscus. There was no tenderness at any point except a slight pain experienced when the neck of the bladder was firmly pressed toward the pelvis. The frequency of micturition increased to almost constant drib- FUNCTIONAL DISEASES OF THE BLADDER. 671 bling from the bladder, both daily and nocturnally the cloud of mucus in the urine was much augmented, and while the color ap- peared to remain unchanged, there was evidently a large excretion of solid matter composed probably of phosphates. The uneasiness elicited at the neck of the bladder by pressure on this part soon changed to actual soreness. At the end of the second week the case had passed into one of apparently serious import, and was operating with telling effect on the vitality and mental equipoise of the patient. The tripod of treatment, namely, rest, opium, and alkalies, upon which Yan Buren and Keyes cogently protest the successful manage- ment of cystitis rest, was relied on to relieve what I now feared was a case of this distressing disease, the cause of which I could not then determine. The constitutional effect of belladonna was evoked also to mitigate the symptoms, and finally hot-water vaginal injections were employed for their well-known analgesic and anti- phlogistic effects upon the pelvic viscera. Such measures gave only temporary relief, the features of the case resuming their original character whenever the effect of medi- cation—which was occasionally suspended to ascertain the status quo of the disease—had passed off. At the beginning of the third week from the first appearance of the symptoms, the patient complained of slight chilliness toward evening, and it was observed that this was followed by fever, the thermometer in the mouth registering 101.° These symptoms were interpreted to indicate the constitutional expression of .the local in- flammation existing in the bladder. Hence, no special attention was directed toward them. The chilliness was repeated, however, on the third evening, and on the fourth day at the same hour reappeared as the prodrome of a marked rigor, followed by an abrupt rise of temperature of 103° succeeded by sweating and a return to the normal temperature m about four hours, thus clearly demonstrating a well-defined periodicity of the febrile movement. Suspicion being now aroused as to the essential nature of the case, the patient was promptly placed on ten-grain doses of the sul- phate of quinine, to be taken every four hours with mercurial and saline purgatives, the latter being indicated by the appearance of the tongue and the confined state of the bowels, which was due not alto- gether to the opium administered, since this physical modifier had been exhibited both freely and simultaneously. The substitution of the quinine for the treatment previously pursued, like the fabled wand of the magician, broke the spell of 672 DISEASES OF WOMEN. enchantment, which, by its subtle and potent influence had held the patient with relentless grasp for three weeks and had trans- formed a hopeful and contented disposition into one of melancholy and apprehension. At the end of four days from the administration of the first dose of quinine the patient was virtually convalescent. During this period no opiate was employed nor any other medicine but quinine taken, save an occasional dose of neutral mixture, chiefly for its su- dorific effect. Nevertheless the irritation of the bladder did not re- turn, and the close of the week found the patient, although debili- tated by the trying ordeal through which she had passed, enabled to resume her accustomed duties. Periodical Attacks of Frequent and Painful Urination and Vesical Tenesmus caused by Malaria.—About two years ago a patient came to my college clinic complaining as follows : In the afternoon of each day she experienced a sense of heat and burning in the bladder and urethra, with a frequent and irresistible desire to urinate. Evacua- tion of the bladder, attended with a great deal of smarting and pain in the urethra, did not give complete relief but left some vesical tenesmus which increased in severity as the bladder became dis- tended. These symptoms persisted during the night and kept her awake, but toward morning her sufferings entirely left her, and she became quite comfortable until the next afternoon. This condition had existed for nearly two months, and accordingly her digestion be- came impaired and her strength diminished. This was attributed by her to the want of sleep, and no doubt in part was due to this cause. The urine was examined, and found to be normal except that it contained a slight excess of phosphates. She was carefully exam- ined, and no evidence of organic disease was found. While she al- ways enjoyed full health and had been a vigorous woman, she had had an attack of malarial fever about six months before I saw her, and about the time this bladder trouble came on she said she had symp- toms of her former ague. From the facts in her history I ventured to state to my class that this was a functional derangement of the bladder and urethra caused by malaria, which would promptly yield to judicious doses of quinine. I accordingly prescribed twenty grains of quinine to be taken between early morning and noon, to be followed by two-grain doses before meals with four drops of Fowler's solution of arsenic after meals. She was ordered to report at the clinic the following week. She did so, and declared that she had been perfectly well since the first day she took the medicine. The quinine and arsenic in small doses were continued for three FUNCTIONAL DISEASES OF THE BLADDER. 673 weeks, at the end of which time she reported herself as having been well and free from all irritation of the urinary organs. No change in the character of the urine could have occurred to produce such marked periodicity in the functional derangement of the bladder and urethra; moreover, the urine was found to be nor- mal, and she completely recovered on the use of quinine. Vesical Tenesmus and Frequent Urination due to Prolapsus and In- flammation of the Ovaries.—In prolapsus of the ovaries and inflamma- tory affections of these organs irritation of the bladder often occurs. This is illustrated by the following case: A young girl of twenty-one was brought to me suffering from great distress in the pelvis, which was much aggravated by standing or walking. Her suffering was constant, but was tolerable when she remained in the recumbent position. She began to complain about six months before I saw her, and about the same time she found that she was obliged to urinate too often, and that there was an un- easy feeling in the bladder most of the time, a feeling as if the bladder had not been fully evacuated. She was much worse at her menstrual periods. Upon a thor- ough examination I found both ovaries prolapsed, slightly enlarged, and exceeding tender. In every other respect she was perfectly well. In consultation with her physician, a course of treatment for the ovarian disease was decided upon. This was fully and faithfully tried for over one year, but at the end of that time she was wTorse. She was then quite impatient, being very nervous and irritable from her confinement and suffering. Her parents and friends were quite weary of seeing her suffer. Her bladder irritation was no better; in fact it was a great source of suffering. She could not urinate without getting up, and the erect position increased her ovarian pain. The ovaries were still prolapsed and just as tender, in fact, more so than they had been. The complete failure of treatment so far indicated that removal of the ovaries was the only thing that promised to give her relief. Accordingly the ovaries were removed, and she made a rapid recov- ery from the operation and was completely relieved not only from her ovarian pain but also from the frequent urination and vesical tenesmus. It should be stated that at no time was there any evidence of cystitis found upon frequent and careful examinations. CHAPTER XXXVIII. FUNCTIONAL DISEASES OF THE BLADDER (CONTINUED). Having considered the vesical derangements in which there is no recognizable organic lesion, and which may be local neuroses, or may be due to hysteria, disorder of the sexual function, malarial or ovarian affections, I will now invite attention to the second class of these disorders. I. Derangements of function due to diseases of the nutritive and nervous systems, or to abnormal conditions of the urine which re- sult therefrom. This class naturally subdivides itself into: 1. Derangements occurring in both acute and chronic diseases. 2. Derangements due to consequent abnormal conditions of the urine. 1. Of the derangements which occur in the course of acute dis- eases, such as retention and incontinence of urine and frequent urin- ation, nothing more than the mere mention is necessary. They rarely require any treatment, except possibly in the case of reten- tion, when catheterization is to be employed, and they cease as soon as the acute stage is passed. Those, however, which are due to chronic affections of the nutritive and nervous systems are more permanent, and often tax the resources of the physician to the utmost. The two most important are : (a) Paralysis of the bladder, and, (b) Incontinence of urine. (a) Paralysis of the Bladder.—This affection has also been de- scribed under the names of weakness or palsy of the bladder, and vesical atony. It occurs in two forms: First, from causes residino- in the organ itself; second, from those due to outside influences. As affections in the first form will be fully described in another place I shall here simply mention them. They are: Fatty degenera- tion and atrophy of the muscidar walls of the bladder, a common FUNCTIONAL DISEASES OF THE BLADDER. 675 cause of paralysis of this viscus in old women; overstrain of the muscular structure from prolonged retention, voluntary or involun- tary ; displacements and inflammations of neighboring organs affect- ins; its position or nutrition; and abdominal and pelvic tumors. In fevers of a serious type the power of nerve conduction may be either lost or impaired, and a partial or total vesical paralysis re- sult, with overdistention and dribbling of urine. The second form is due to influences acting from without the bladder, and includes acute and chronic meningitis; apoplexies of the brain or spinal cord; sopor; delirium ; myelitis of the lower part of the spinal cord ; inflammation of any kind primarily affect- ing or involving in its results either the lumbar nerves or ganglia; endarteritis deformans of the pelvic arteries ; lumbar or renal ab- scesses ; blows or fall upon the loins, supra-pubic region, or head; shock or disease of the vesical or lumbar nerves from the prolonged use of opium or poisoning by it, and also shock due to overdisten- tion of the organ itself. Symptomatology.—Except in cases of injury of the brain and apoplexies, the invasion of the disease is usually very gradual. This is especially the case in the aged, and sometimes, though rarely, in young people. The patient first observes that the urine is expelled from the bladder with less force than usual; that the act of empty- ing the bladder is more slowly accomplished, and that after a time the organ is unable to expel its contents without considerable strain- ing and aid from the abdominal muscles. At a later date, if the disease goes on unchecked, the stream is less and less forcibly ejected, intermits, and the bladder, after much straining, is but partially emptied. Finally, partial or complete retention follows. The female bladder seems to be capable of more distention than that of the male. Lieven, in a case of supposed ovarian tumor, re- moved by catheterization about nine pints of urine. The patient was a woman thirty-three years of age. The fundus of the bladder reached as high as the ensiform cartilage. I once saw a case exactly like this, except that the bladder only reached to about two inches above the umbilicus. More than a gallon has been drawn off by Hofmeier and others. A peculiarly interesting experiment bearing upon the dilatability of the bladder was made by Budge. He found that section of the lower part of the spinal cord, when the bladder was considerably distended, allowed increased reflex action of the sphincter, and enormous distention then took place—even more than could be pro- duced by force, after death. This is especially interesting in rela- 676 DISEASES OF WOMEN. tion to vesical paralysis and retention due to injury or disease of the lumbar portion of the spinal cord. In some cases of overdistention the resistance of the sphincter is overcome somewhat, and a constant dribbling of urine takes place. It has been called by some authors incontinentia parodoxa. These cases are liable to be mistaken for those of pure incontinence. In rare cases rupture of the bladder may take place ; more com- monly dilatation of the ureters and hydronephrosis. If the condi- tion of vesical distention be not soon relieved, vesical catarrh, true inflammation, ulceration, and death take place. In cases due to in- jury or disease of the spinal cord, low down, there seems to be a paralysis or peculiar condition of the nerves presiding over the nu- trition of the vesical mucous membrane, and destructive changes are not uncommon. Diagnosis.—The diagnosis though easy, is sometimes not made, owing to careless observation or ignorance. When called to a case where there is supposed distention of the bladder, the abdomen should first be examined to see if there are signs of a tumor, and then a catheter should be passed if that be possible, to determine whether an abnormal amount of urine is present. If this is the case, and the tumor gradually subsides as the urine flows, the diag- nosis is at once made. When, however, a catheter can not be passed into the viscus, fluctuation should be sought both through the vagina and on the surface of the tumor. If the diagnosis be still obscure, the aspirator-needle should be passed into the tumor, and its fluid contents carefully tested. The age of the patient, the duration of the disease, and its time and method of invasion will aid in settling the question. The trouble may, however, occur at almost any age, and the fact that a little urine has been passed at short intervals will tend to deceive. In the early stages of the disease an idea can be gained as to its progress by carefully noting the amount of urine passed at each micturition, the amount passed in twenty-four hours, the length of intervals between urination, the force of the stream, whether the bladder is fully or but partially emptied, and whether the stream intermits. The urine should be examined often, else cystitis may get a firm foothold before its existence is recognized. In drawing off the urine for testing or other purposes, the catheter should be absolutely clean. Incontinentia paradoxa must be differentiated from incontinence due to mechanical causes, such as abnormal urine, or the pressure of neighboring organs upon the bladder. FUNCTIONAL DISEASES OF THE BLADDER. 677 Prognosis.—If the disease be uncomplicated the prognosis is good. Paralysis of the organ accompanying the fevers, dysentery, peritonitis, and the like, usually disappears with the cure of the original disease. If the paralysis be accompanied by disease of the bladder-walls, or if it occurs in weak, debilitated constitutions, or has been of long duration, or occurs in old age, the prognosis is not good. A cure, if effected at all, will be only after long and tedious treatment. When due to centric causes or to serious spinal disease or injury, or when it occurs in old people, or with meningitis, or with sys- temic trouble, the prognosis is very grave indeed. Causation.—Deranged innervation due to the central lesion already mentioned, either cerebral or spinal, may be regarded as the principal cause of this affection. If the paralysis has been of long duration nutritive changes may occur in the bladder, but as these will be discussed under the appropriate head I need say noth- ing of them here. Treatment.—In all cases where there is fear of vesical distention, the bladder should be emptied at stated intervals. By way of helping the patient to pass water herself, hot hip-baths may be tried and fomentations over the bladder. The sound of water falling from one vessel into another often accomplishes the same result. If these means do not succeed the catheter must be used. And here attention may be called to a very important practical point in connection with the use of the catheter. When the blad- der has become very much distended it can not be thoroughly emp- tied unless pressure is made upon the abdominal walls; if this press- ure is made while the catheter is in the bladder, and then discontin- ued, air will be drawn through the catheter into the bladder and decomposition of the urine will thus be favored. Marked distention can usually be relieved by the catheter. In some cases, however, the bladder rises up into the abdomen and puts the urethra upon the stretch, thus changing the direction of its axis from the normal to one from below directly upward, the canal being nearly parallel to the posterior surface of the pubic symphy- sis. In these cases passing the catheter will tax the skill somewhat. Great care must be used to avoid injuring the urethra. In emptying a greatly distended bladder a binder should be ap- plied to the abdomen and tightened gradually as the urine flows. It is not safe to draw off all the urine at once. It is better to take away about half, and then after a time to draw off more, until the organ is empty. Syncope and even death, which is said to have 678 DISEASES OF WOMEN. occurred in these cases after rapid emptying of the organ, are prob- ably due to the sudden removal of the pressure on the abdominal organs, which so deranges the circulation as to cause these serious results. The sudden removal of pressure from the vesical walls, which that pressure rendered ansemic, now allows intense conges- tion, and the vesical walls being paralyzed catarrh and cystitis result. Therefore, for many reasons, a distended bladder should be emptied slowly. When, for any reason, a catheter can not be introduced into the bladder, hot hip-baths should be again tried, and opium given in suf- ficient amount to relieve pain and any spasmodic action that may exist. If, after this, there is failure to enter the bladder (and it is only in very rare cases that this occurs), recourse should be had to the aspirator, and after having punctured the bladder, the urine should be drawn slowly and carefully, in the manner already de- scribed. In commencing vesical paralysis, and when incontinentia para- doxa exists or has existed, the patient should be taught to use the catheter herself several times daily until the vesical power returns. It is of the utmost importance that the catheter be absolutely clean. After each time that it is used it should be thoroughly rinsed in a chlorine solution, and put away in carbolized oil or vaseline. A great deal of vesical catarrh is undoubtedly lighted up by foul cath- eters. This is especially the case in hospitals, where the same in- strument is often used on a number of patients. In cases of commencing or established paralysis the effect of the induced electric current may be tried. One pole thoroughly insu- lated up to the point to be used should be placed in the bladder, and the other over the pubic symphysis and loins, letting the cur- rent flow in various directions, through, over, and into, the affected organ. The German authors, especially Winckel, by whom this method is highly recommended in this and like affections, say that the sitting should last but about five minutes. Forcibly distending the urethra and washing out the bladder with a solution containing salicylic acid has been tried and recom- mended. I can not see the expediency of this unless vesical catarrh exists; and even then washing must be done gently and carefully, and without previous dilatation of the urethra. Attention should be paid to the general health. The food should be good and nourishing, and the alimentary canal kept in a proper condition to receive and digest it. Wines (especially champagne), beer, and ale may be of use. I can at least say if stimulants are FUNCTIONAL DISEASES OF THE BLADDER. 679 ever given in diseases of the bladder it should be in cases like these now under consideration. These patients are usually more com- fortable in the standing or sitting, than in the prone posture, be- cause then the weight of the abdominal viscera replaces to a cer- tain extent the natural tonicity of the organ. As they are usually worse in winter than in summer it is advisable, if the case is chronic and the patient able to bear transportation and rich enough to meet the expense, to send her to a moderately warm climate during the winter months. This will apply in most of the diseases of the bladder. If the trouble be purely atonic, camphor or musk may be used internally. Tincture of cantharides, in from five to twenty drop doses, tliree times a day, has been recommended as a vesical excit- ant. I can not indorse its use without the caution that besides the tendency to irritate the kidneys and produce congestion and nephritis, it may light up a severe cystitis. In these cases it may produce serious trouble without causing much pain to give warning of the danger, as the paralysis lessens the sensitiveness of the blad- der, so that destruction of tissue may occur without producing the usual pain and suffering. Strychnia has been extensively used in this complaint, and with good results in some cases. Its failure to do good in many in- stances is undoubtedly due to the fact that it was not given in suffi- ciently large doses. It may be safely pushed as high as the one- twentieth of a grain three times a day, stopping for a few days if any of its characteristic symptoms appear. It has also been used hvpodermically in the neighborhood of the bladder. Ergot has been found useful in cases where the paralysis was due to exposure to cold, or prolonged retention from any cause. The fresh powder has been recommended, and may be given in doses of from eight to sixteen grains, four or five times daily. It is more pleasant and probably more effective to give its equivalent of the fluid extract. Alliers has used it with decided success in cases of vesical paralysis due to centric troubles, such as apoplexy. He has used as much as fortv-five grains in the twentv-four hours. It is highly spoken of also by Roth, Jacksch, and others. Rutenberg (" Wienner Med. Wochenschrift," 1875, Xo. 37) has recommended, in cases where there is destruction of muscular tissue or incurable paralysis from any cause, to make an opening into the bladder just above the pubic symphysis, keeping the fistula open, and closing the urethra by operative procedures. The urine can thus be retained, unless the patient bends forward and downward 680 DISEASES OF WOMEN. or hes upon her abdomen. A urinal would, of course, be necessary to protect the patient. I think I should prefer to produce a vesico-vaginal fistula, and adapt an apparatus to receive the urine. (b) Incontinence of Urine.—Enuresis nocturna is usually an affec- tion of childhood, but has been known to persist up to the age of thirty years. In some children it is hereditary, the mother having suffered in early years, and all the children born to her being affected in the same way. Of all cases, these are the most difficult to manage. They often persist until puberty, when they recover of themselves. The subjects of this affection are usually of the weak, nervous type, although apparently healthy children have been known to suffer from it, but usually only at intervals. These cases of incontinence may be divided into two distinct varieties: First, the anaesthetic variety. An excellent example of this class is seen in infants who, up to a certain age, wet the bed and their diapers. In the infant this is not disease ; it is simply a good normal example of this condition; the incontinence in severe fevers illustrates the abnormal phase of the same thing. Second, the hyper- aBsthetic variety, which is really nothing more than irritable bladder. Each variety may exist alone, or both be combined in the one case. In the first variety the retaining power is defective, the resisting power of the sphincter being insufficient to retain the urine or wake the child. When it is put to bed, it sleeps soundly through the night, and the nerve susceptibility to urine-pressure on the neck of the bladder, being lowered beyond the normal degree, fails to wake the little subject and impress it with the necessity of calling the sphincter muscle into action sufficiently to resist the expulsive power of the bladder-walls. In short, in sound sleep the balance between the resisting power of the sphincter and the contractility of the walls of the bladder is disturbed, and the urine flows away without the child's even dreaming of its unfortunate behavior. In other forms of this affection the brain takes cognizance of the desire to urinate, but too late to control the act. This is seen in children who awake crying when urination is but just begun or half finished. In this case the fault probably lies in the vesical nerves. In the second variety there is an irritable condition of the blad- der (vesical hyperesthesia), which renders the expelling power greater than that of resistance or retention, and, while the will and cerebration generally are lost in sleep, the contents of the bladder are unconsciously passed before the subject wakes to resist the act. Closely allied to this is the peculiar affection known as vesical chorea, FUNCTIONAL DISEASES OF THE BLADDER. 681 in which the child while awake, it may be in school, in church, or at play, suddenly experiences the sensation that it is about to make water, but, before it is possible to resist, the urine is forcibly spurted out. There are usually choreic movements of other muscles or groups of muscles. This affection is the most annoying when the little ones are nervous, cross, and fidgety. It may be accompanied by nocturnal enuresis. It is apparently more common in the male than in the female child. An irritable condition of the bladder may coexist with an an- aesthetic condition of the sphincter vesicae—i. e., the two causes of incontinence may be combined. Irritable bladder, it should be remembered, may be due to some systemic condition—that is, a simple neurosis or to abnormal urine, or reflex irritation from anal fissure, ascarides in the rectum, fistula in ano, haemorrhoids, or vulvitis. Enuresis nocturna is not only a filthy habit, and a source of great annoyance to parents, but, moreover, by keeping the genitals wet and irritable, strongly predisposes to masturbation. Then, too, other serious results may happen. The constant wettings are dangerous, in that they may produce many serious complaints from causing the child to " take cold." Prognosis.—In some cases the cure is easily and speedily ef- fected ; in others, the disease cures itself at or just after puberty; but in a few—a very small percentage—no medical or other means seem to aid the sufferer at all. Treatment.—That the treatment is not uniformly satisfactory is seen by the number of remedies that have been tried. The proper way—and I can not call attention to this too often—here, as else- where, is to find the cause producing the disease, if it be discovera- ble, and it generally is. The treatment will, of course, differ in the two classes, and be greatly modified by diathesis and idiosyncrasy. In anaesthesia, local or general, stimulation is indicated. In hyper- assthesia, irritability should be allayed. Winckel, Barclay, and Brugleman speak very highly of the use of the syrupus ferri iodidi, the last-named gentleman having by its use cured a girl perfectly of incontinence in the short space of four- teen days. This result was probably due more to the effect of the medicine on the blood and general system than to any specific action on the bladder. The sirup of the iodide may be given in from ten to thirty minim doses three or four times daily, according to the age of the patient. Although belladonna has been lauded by many as a specific in 682 DISEASES OF WOMEN. this disorder, its success is by no means general. The drug is usually given by the mouth in from five to twenty drop doses of the officinal tincture. It would be better to begin with small doses in young children, and gradually increase them; for, although no serious re- sults may come from its exhibition in the routine dose—ten drops— the parents may be greatly alarmed by the peculiar redness of the skin produced in some cases. It is maintained by some medical men that the good effects are not obtained unless the administration be pushed to the appearance of the scarlet rash. There is, I think, no proof of the correctness of this statement. A combination of belladonna and chloral hydrate has been used and well spoken of. Winckel, however, though using them in cer- tain cases for a long time, and daily increasing the amount of chloral, has had but poor results, and even in those cases where the patients improved the benefit was seldom permanent. These drugs may be given singly or together, in suppository or by the mouth. If given together, they should not be combined until the time when they are administered, lest the chloral lose its power. Narcotics with tinctura ferri chloridi have been recommended by Campbell Black. Winckel speaks well of five to ten drop doses of tinctura thebaica, to a child from ten to fourteen years of age, just before retiring. According to Sauvage, cold baths and cold douches to the spine at night are of great service. Dr. Kelp (" Le Mouvement Med.") reports that he has, on sev- eral occasions, drawn attention to the value of subcutaneous injec- tions of the nitrate of strychnia in the treatment of obstinate cases of nocturnal incontinence. He practices the injections in the neigh- borhood of the sacrum. A single injection of a very small quantity of the drug suffices to arrest the affection for a certain time, and when it reappears the operation can be repeated. His latest paper cites the case of a young woman, eighteen years of age, who had suffered from enuresis every night for several months; it came on after an attack of scarlatina, and persisted in spite of all precautions. The first injection produced a respite of several nights, and the second produced a permanent cure. The patient was a strong, healthy girl, and had never suffered from enuresis previous to the attack of scarlatina. Such a plan of treatment I regard as useful only when there is deranged innervation, characterized by weakness. It would be diffi- cult to get a child to submit to these injections, and I should in any case, whether child or adult, expect the incontinence to return as soon as the strychnia was discontinued. FUNCTIONAL DISEASES OF THE BLADDER. 683 In cases where the vesical irritability is due to abnormality of the urine, such as lithiasis, oxaluria, and acidity, these conditions should be corrected in the manner I have already pointed out. If to ascarides. anal fissure, and that class of rectal trouble, when the cause is removed the result will usually disappear also. In irrita- bility the usual soothing and demulcent drinks, such as have been already recommended, should be used. Oil of sandal-wood has acted remarkably well in some of these cases. Bromide of sodium and tincture of nux vomica have been effectual in some cases. In the anaesthetic variety, where the anaesthesia is more or less marked, special or local and general stimulants should be employed. Narcotics are as hurtful here as they are useful in the hyperaesthetic class. Strychnia by the mouth, in suppository, or hypodermically, often produces good results, as also quinine, whether the presence of malaria is suspected or not. Tonic and astringent injections into the bladder are sometimes of service. In cases of abnormally small bladder, forcibly washing it out, distending the organ a little more each time, is well spoken of. In one such case, where there was irritability, Winckel produced a cure by first injecting a solution of nitrate of silver, and following it with sulphate of morphia. This treatment, however, applies more to the irritable than to the anaes- thetic type. The little patients are very hard to operate upon, and, unless great care is exercised, much mischief may be caused by local treatment. Winckel claims good results from the use of the electric current, applied in the manner I have spoken of under the head of paresis vesicae. When the bed-wetting is due to pure carelessness, laziness, fear, or dread of the cold air in rising, in idiots and half-witted children, much may be gained by proper education. There is a general plan of prophylaxis recommended by common sense, viz., the heartiest meal should be in the middle of the day; but little water should be taken toward evening; the food should be plain and unseasoned; the bowels should be kept regular; no coffee or tea should be allowed; the little patients should be put to bed early, after it is assured that.the bladder is first thoroughly emptied ; they should lie upon a hard bed, with not too much covering; the air in the room should be maintained fresh and pure; the genitals should be kept clean and dry; no places of amusement should be visited after dark; and they should be awakened occasionally to urinate, especially at about the time the parents are going to bed. When it is discovered that they have wet the bed, they should be 45 684 DISEASES OF WOMEN. awakened, and talked to and reasoned with, if they are able to com- prehend wdiat is said and meant. Children should not go to school too early, or stay too long. If the enuresis be due to masturbation, the parents must be cautioned to watch closely, and to use every means in their power to stop it. A child should never be whipped for the offense or misfortune of wetting the bed, unless the inconti- nence be due to pure laziness. Owing to the fact that incontinence is an affection of childhood, and occurs but seldom in women, cases will not be given to illustrate what is said in the text on that subject. This omission is made for the additional reason that partial incontinence due to displacements of the bladder and urethra and from other causes will be discussed further on. ILLUSTRATIVE CASES. Paralysis of the Bladder followed by Incontinence in Case of In- sanity.—This was a single lady, twenty-eight years of age, who had been insane for eight months. I was told that at first she was vio- lent, but had become quiet and rather demented toward the time that I saw her. Her physician had observed for some time that her bowels were obstinately constipated, and the nurse noticed that she had great difficulty in evacuating the bladder. She also appeared to have some discomfort in that region; finally, she went for over twenty-four hours without urinating, and then I was called to see her. I found the bladder greatly distended, and yet I could not see that she had pain or tenderness on that account. The catheter was used, and three and a half pints of urine were removed. After this the catheter had to be used twice in twenty-four hours for five weeks. During this time the usual means were tried to restore the function of the bladder, but without effect. The urine then began to flow constantly. When I heard of this, I presumed that the bladder had become overdistended, and that the nurse who used the catheter had not emptied the bladder. This I found was not the case; the blad- der was empty. The incontinence continued until the patient died of general paralysis. Paralysis of the Bladder from Cerebro-spinal Meningitis.__A girl twelve years old was taken with cerebro-spinal meningitis, and pre- sented the usual clinical history of that affection until the seventh day of the disease, at which time the pain had subsided to a great extent, but her mind, which up to this time had been clear, began to wander. Retention of the urine was noticed by her nurse, who called my attention to the fact. I found the bladder distended, but FUNCTIONAL DISEASES OF THE BLADDER. 685 not greatly so. She was asked if she did not desire to urinate, but she answered in the negative, so far as I could understand her. The catheter was used, and, although the distention was not great, the bladder did not contract well, so that abdominal pressure was neces- sary to make the urine flow through the catheter. The use of the catheter was necessary for some time, during which she improved in her general condition, the mind becoming quite clear. She then began to express at times a desire to urinate, but could not relieve herself. Four days later she succeeded in urinating, but did not completely empty the bladder. She gradually improved, but the catheter was passed once every twenty-four hours for a week longer. The desire to empty the bladder became more and more urgent, and she had pain in the urethra in urinating. An examination of the urine at this time showed that she had cystitis, due, I believe, to the use of the catheter. The cystitis was treated according to my usual methods, and she made a good recovery. Paralysis of the Bladder from Progressive Locomotor Ataxia.—A lady who had been affected with locomotor ataxia for more than a year, came under my care for retention of urine. I found that there was some decomposition of the urine, but nothing else to distinguish the case from paralysis of the bladder, occurring in other cases of disease and injury of the spinal cord. The attendant was advised to use the catheter regularly, and to wash out the bladder with a solution of borax—one drachm of borax to a quart of wrarm water. I learned subsequently that this patient had incontinence of urine before she died. II. Derangements due to Abnormal Conditions of the Urine.—The bladder being made to contain urine, almost constantly uniform in its composition, it at once feels and responds to any abnormality. If the aberration is only occasional, the effects are slight and of short duration ; but, if the abnormality be constant, or almost so, or if the altered urine has a hyperaesthetic surface to deal wdth, the results are more annoying:. Urine which is too acid or too alkaline, too limpid or too greatly concentrated, acts somewhat like a foreign body—it irritates, and the bladder inclines to expel it. Deposits of any of the urinary solids in the viscus may produce an irritable condition, and, if unchecked, lead to organic disease of the bladder. Uric acid, in large or small crystals, in little masses, forming gravel and minute calculi, the amorphous urates, the triple and amorphous phosphates (these, as a rule, however, occurring only in decomposition of the urine), and oxalate of lime may give rise tc 686 DISEASES OF WOMEN. considerable trouble. There are some other deposits, such as cystine, that are of such rare occurrence that they need not be mentioned in this list. In any of these cases, but especially when there is a de- posit of uric acid, there may be one of two things resulting; and, in order to treat the case properly, they must be borne in mind: First, a real excess of the salt in the urine; and second, a condition of the secretion, where, whether the amount of salt present be nor- mal, or less or more than normal, it will be precipitated in the blad- der. As an example of the first may be mentioned some cases of dys- pepsia, when, owing to a defect in either primary or secondary as- similation, the salt or salts are eliminated by the kidneys greatly in excess of the normal. Here a normal or even an abnormal amount of water in the secretion could not hold them in solution, and they are consequently precipitated. As an example of the second may be taken some cases of hepatic disease, in which, although the uric acid is eliminated in abnormally small amount, it is precipitated on account of the deficiency of water, excessive acidity, and possibly too rapid absorption of the watery element of the urine while in the bladder. In some cases with an excess of salts, there may be excessive acidity and lack of water. Some forms of dyspepsia are notable examples of this, and as low nerve condition frequently accompanies these disorders, the abnormal urine meets in the bladder with an irritable mucous membrane. In these cases the acidity is quite as hurtful as the deposit. Deposits of oxalate of lime in the bladder are not so common (except in lime-water regions) as those of uric acid. In cases of the persistent deposit of oxalate of lime in the urine, known as oxaluria, there is usually marked irritability of the bladder. This has been ascribed by some to the presence of minute octahedra of this salt irritating the mucous membrane. It is more than likely, however, that the derangement of the general nervous system, always existing in these cases, stands as a propter rather than a post hoc, and that the bladder difficulty is but a local manifestation of the general dis- ease, and consequently a pure neurosis. That the urine of oxaluria does possess irritant properties there is but little doubt, but it is hardly likely that the symptoms here occurring would be produced unless there was already an abnormal condition of the vesical mucous membrane. Many authors hold that the high specific gravity of a single speci- men of urine must not be taken as an evidence of concentration, or FUNCTIONAL DISEASES OF THE BLADDER. 687 the low gravity of excessive limpidity of the twenty-four hours' urine. This is very true in regard to the total amount passed in a day; but as the bladder has to do each time only with the urine in it at that time, it will be well in these cases to examine several spec- imens in a day, rather than to depend for information on the reac- tion of the total amount of urine passed. Urine may irritate the same patient at one time from being too limpid, and at another time from being too highly concentrated. These variations must be carefully watched and treated. A bladder that is irritable at all times and with urine of varying reactions, may be set down as one affected with a pure neurosis, if no organic cause be found, for the urine could not work the mischief continu- ally, if normal at certain periods. Symptomatology.—Patients suffering from this affection usually complain of frequent urination and vesical tenesmus. In some cases there is smarting pain in the urethra during the passing of water and for some time after, and there is a sense of heat in the bladder and a desire to urinate which are not fully relieved when the bladder is empty. This last-named symptom belongs more especially to those cases in which the urine salts are in excess. When the urine is defective in the salts, that is, when the urine is limpid, the only symptom present is frequent urination. It will be observed that these symptoms are the same as those presented in a variety of affections, and hence can not be depended upon in making a diagnosis. Diagnosis.—The diagnosis must be made by excluding all other conditions which give rise to this derangement of function, and by re- peated examinations of the urine, which will show its abnormal state. Prognosis.—The relief of this class of cases will depend upon the possibility of correcting the constitutional affections which pro- duce the pathological state of the urine. In case the abnormalities of the urine persist for a long time cystitis and urethritis may be produced. I am sure that I have seen cystitis which could be traced to long continued abnormal states of the urine. Causation.—In discussing the pathology of this class of func- tional derangements the causes which produce them have been fully brought out, so that they need not be repeated here. Treatment.—In cases of concentration of the urine clue to acute febrile action, the patient should be liberally supplied with cooling drinks; and as in these affections the urine is generally too acid, the slightly alkaline, effervescing wTaters will be found useful. 688 DISEASES OF WOMEN. In digestive troubles, with excessive acidity or saline deposit, at- tention should be paid to diet, bathing, and regularity of the bow- els, as well as the taking of a proper amount of exercise. Where deposits of uric acid take place there is usually some defect in either primary or secondary assimilation. This should be sought out and remedied. In excessive acidity with deposits of uric acid, the alka- line carbonates act in a double way ; first by neutralizing the acid- ity of the urine, and second by acting on the liver to lessen the amount of uric acid produced. The following is a very pleasant and efficient prescription in these cases. IJ. Potassii bicarbonatis, Potassii citratis......................aa 3 ss. Syrupi simplicis.................... 3 iv. M. ---- Sig. Take 3 i in half a tumbler of water, adding 3 ij of lemon- juice. Drink while effervescing. The late Prof. Armor gave some very excellent advice regarding the management of such cases, which I will reproduce in his own words: " When the urine is acid in any of the forms of cystic irritation, great relief is experienced from the use of alkalies, especially when administered in an infusion of buchu. I regard buchu as a remedy of undoubted efficacy in all eases of vesical irritability. It seems to possess similar properties over the urinary tract that bismuth does over the intestinal, and is an admirable vehicle in which to adminis- ter the various alkalies. The citrate of potash with buchu is an excel- lent combination where we desire the joint action of these remedies. The liquor of potash, the bicarbonate and the iodide of potash also possess a high degree of utility in the class of cases referred to, and their therapeutic action is certainly never disturbed by administer- ing them in an infusion of buchu. " In irritable conditions of the bladder associated with a gouty and lithic-acid diathesis, the carbonate of lithium is a remedy of un- doubted efficacy. It perhaps excels the preparations of potash in rendering uric acid and the urates soluble." The following is the formula of a prescription which answers well: p. Lithiae carbonatis.....................3 ij. Acidi benzoic....................... 3 iij. Sodii boratis................ ....... 3 j. Aquae dest.......................... 3 iv. M. Sig. One teaspoonful in a large glass of water. FUNCTIONAL DISEASES OF THE BLADDER. 689 Limpid urine is usually due to some general nervous trouble or cerebral disease. In such cases treatment should be directed to the original disease. Deposits of amorphous or triple phosphates are rare, unless there is some organic disease of the bladder. Where the deposits are not due to decomposition, some decided nerve trouble is usually pres- ent, and here, as in limpidity, the attention must be turned to treat- ment of the general trouble. In oxaluria attention must be paid to the moral, mental, and physical condition, and time must not be wasted in treating mere symptoms. In the way of medication, the following prescription is looked upon by many as almost specific in these cases : 1$. Acidi nitro-muriatici diluti................ 3 v-vj. Tincturae nucis vomicae................... 3 iij. Olei gaultheriae......................... lUxij. Aquae ad............................... § iv. M. ---- Sig.— 3 i in water before each meal. In some cases the pure non-diluted acid, freshly made up, acts better than the dilute. It should be given in smaller doses than the dilute, and in plenty of water at the time of taking it. In all cases of urinary deposits, water should be freely taken, and the greatest attention paid to general hygiene and to mental and moral surroundings. Many of the slightly alkaline mineral-spring waters will be found of use, acting gently on the liver, flushing the kidneys and urinary organs, and slightly relaxing the bowels. A considerable quantity should be taken in the course of the day when the stomach is empty. ILLUSTRATIVE CASES. Irritation of the Bladder from Abnormal Urine.—A patient forty three years old, large and stout, had menstruated scantily for sev- eral months and, as the flow diminished in quantity and duration, she gained in flesh but not in strength. She had a very good appe- tite and lived very well, but she did not feel in her usual health. She noticed a gradual disinclination to mental and physical activity. Backache, headache, and wandering pains here and there, occasionally annoyed her. After these symptoms had continued for a time urin- ation became more frequent and at times slightly painful. She noticed also that there was a sediment in the urine. These symp- toms caused her to seek advice from the fear that she had Bright's disease. She was found to possess a very good organization; and there was no organic disease of any kind present. All the evi- 690 DISEASES OF WOMEN. dences of excrementitious plethora were well expressed in the abun- dant adipose tissue, coated tongue, constipation, muddy appear- ance of the eyes, full slow pulse, shortness of breath on exertion, depression of spirits, disposition to sleep, and at times sleepless- ness. The urine was examined, and found to be slightly alkaline. The specific gravity was 1030. There was neither albumen nor casts. The salts of the urine were in excess, but as a quantitative analysis was not made the exact composition of the urine was not obtained. The diagnosis of general excrementitious plethora from imperfect elimination was made, and the frequent urination was at- tributed to the abnormal condition of the urine. Ten grains of pil. hydrarg. and one grain of ipecac were given at bed-time and a Seid- litz powder an hour before breakfast the next morning. This was repeated in five days. The quantity of food was diminished—she had been taking ex- tra diet to make her stronger—milk was the chief article permitted, with a very little animal food once a day. A Turkish bath twice a week and gradually increased out-of-door exercise. The bowels were kept rather free by giving a dose of Congress water an hour before breakfast every morning. Under this treatment she im- proved in every way. The irritation of the bladder subsided, and has not returned. The urine is now normal. Frequent Urination from Abnormal Urine.—An unmarried lady, thirty years old, of good constitution, very ambitious and energetic, overtaxed herself during the winter, and toward the end of the season, began to suffer from frequent urination and a sense of burn- ing heat in the bladder and urethra after urinating. After a time these symptoms became very annoying, and as she was a nervous, sensitive person, she suffered quite severely. She was found to be quite out of health. Her appetite was poor and her digestion im- paired ; she was constipated, and suffered from rheumatic pains in her joints, and in the back of her neck. In short, she gave a fairly good history of dyspepsia and neuraesthenia plus the irritation of the bladder which was her chief source of discomfort. The urine was diminished in quantity, dark in color, very acid, ai d of high specific gravity ; no albumen or casts were found. She had been quite free from any affections of the pelvic organs, the present dis- turbance of the bladder being the only suffering she had ever had in that regard. My first impression was that she had cystitis, but there were no products of inflammation found in the urine, and therefore the diag- nosis was made as stated above. FUNCTIONAL DISEASES OF THE BLADDER. 691 Peptonized milk was ordered with raw eggs, and, in addition, barley gruel, clear soups, and bread. Two drops of liquor ammoniae in a wine-glass of water were given every two hours until the urine became normal. Her bowels were kept regular by small doses of Rochelle salts and cream-of-tartar taken in the morning. Rest was insisted upon, and massage every third day. As soon as the urine became less acid and dense, she obtained some relief, but was not restored to her usual condition. It was not until her general health had been improved that the urine became normal and the irritation of the bladder finally left. An interesting point in the treatment was observed. For a time she was partially relieved by the alkaline remedies, but, when she ceased taking them, the irrita- tion of the bladder returned. When her general health was restored by rest and tonics the urine became normal, and the irritation of the bladder disappeared entirely. At the present time I have a lady under treatment for specific disease of the uterus; during the last four weeks she has had irrita- tion, causing frequent urination. She obtains relief by drinking very freely of lithia water. » Case of Baruria (by Dr. Samuel West).—The patient, aged thirty- nine, complained, after catching cold, of pains and aching in her limbs, which became severe enough after a week to keep her in bed. AVhen admitted, these pains continued, but there was swelling of joints. The temperature wras 100°, and she perspired freely, but the sweat did not smell sour. The urine had a specific gravity of 1040, and yielded copious crystals of nitrate of urea, with nitric acid. Her appetite had been for some days almost absent, and in the hospital she took but a little milk or beef-tea. For two days the condition of the urine was the same, and the percentage of urea 5-l. This per- centage gradually fell to normal, and, as it did so, all the patient's * symptoms disappeared. The case was regarded as one of baruria. The account of the case given by Prout wras summarized and com- pared with the present case, and reference was made to other authors, by some of whom the existence of the affection was questioned, while by others it was not referred to. A somewhat similar case, the result of overfeeding and constipation, has been described, in which like symptoms were associated with a high percentage of urea, and disappeared when the amount became normal. III. Derangements of Function due to Affections of the Pelvic Organs other than the Bladder.—Functional diseases of the bladder, caused by disorders of the neighboring pelvic organs, are frequently 692 DISEASES OF WOMEN. met with in practice. In this class the vesical trouble is secondary to some primary and more important affection, but the derangement of its function is often the most prominent and troublesome symp- tom ; hence it is important to understand its relation to the primary disease, in order to make a correct diagnosis, and to treat such cases properly. This class of functional disorders frequently resembles in history some of the organic diseases of the bladder, so that care is necessary to distinguish the one from the other. What I may say upon the subject will have reference to diagnosis only. When wre know that the bladder trouble is due to disease of some other organ, attention is at once turned to the primary affection. These facts must be borne in mind, and the symptoms not mistaken for the disease. Diseases of the rectum affect the bladder sympathetically. Irri- tation and pain in the rectum from any cause affect the bladder more or less. Chronic haemorrhoids will cause frequent urination, and so will rectal fissure, especially after defecation. Abscesses in the neighborhood of the rectum will frequently cause retention of urine. One very interesting case of this kind occurred in the practice of my friend Dr. Cushing. The patient had an abscess in the neigh- borhood of the rectum which caused retention of the urine, and this in turn caused acute renal disease. After the bladder had been emptied and kept from overdistention for some time, the urine was examined and found to contain albumen and casts. She made a rapid recovery, and all evidence of kidney-disease soon disappeared. Yery troublesome vesical irritation may come from ascarides. The itching of the anus and rectum, caused by these troublesome little worms, keeps up an almost constant desire to urinate. Chil- dren are most troubled with these parasites, but women often suffer in the same way. Marion Sims points out the interesting fact that almost all cases of vaginismus are accompanied by an irritable condition of the blad- der, and that, as the terminal fibers of the hymen often extend from the meatus to the vesical neck, cystospasm may in these cases be due to reflex nerve irritation. An attempt to catheterize these patients is as liable to cause spasm of the bladder as an analogous attempt to examine the uterus would be to produce vaginismus. In these cases the hymen should be excised, and the vaginismus treated after the usual methods. Acute pelvic peritonitis and cellulitis cause great distress in many cases by their effect on the bladder. A constant desire to urinate, without the ability to make sufficient straining effort to accomplish FUNCTIONAL DISEASES OF THE BLADDER. 693 the object, is very often observed in all these acute pelvic inflamma- tions. Thedisturbance of the bladder is, of course, only a symptom of the primary and more important trouble, and simply requires to be mentioned here. The after-effects of pelvic peritonitis are what I especially desire to call attention to at present. The adhesions formed by the products of the inflammation of the pelvic peritonaeum are in some cases sufficient to prevent the normal filling of the bladder, and frequent urination then becomes a necessity. This derangement of function generally exists alone. The urine is retained without trouble up to a certain amount; it is passed without pain, and no vesical tenesmus follows evacuation. Unless the contraction of the bladder is great, and the frequent necessity to urinate very troublesome, patients rarely consult a phy- sician for it. Paralysis of the bladder with retention may be caused by a pecul- iar condition of oedema, by which the detrusors are rendered power- less to act. It is usually caused by disease of the cervix uteri, para- metritis, or peritonitis. CHAPTER XXXIX. METHODS • OF EXPLORATION OF THE BLADDER AND URETHRA. Preparatory to the study of organic diseases of the bladder and urethra, I desire to call attention to the methods and means of ex- ploring the bladder and urethra, and to some of the physical signs of disease obtained thereby. In all cystic affections the urine should be carefully examined, both chemically and microscopically. It is not necessary for me to describe the methods to be employed in this examination; they will be found in the various books published on that subject. If an examination of the urine does not make the diagnosis clear, attention should be directed to a physical exploration of the bladder and urethra. For this purpose either a digital or an endoscopic ex- amination may be made. Digital examination per vaginam is one of the most valuable means of investigating the bladder and urethra. By this and by the bimanual touch the physical signs of many of the affections of these organs can be readily obtained. The method of making these examinations is exactly the same as practiced in examining the uterus. The vaginal touch reveals the position of the bladder and urethra, the degree of their sensitiveness, the location of tenderness, if any is present, the increase or diminu- tion of elasticity, and the state of their walls, as regards thickening or irregularity. Distortions of the urethra from neoplasms or the products of inflammation can also be detected in this way. The bimanual touch will show whether the bladder is full, empty, or partially distended, and any foreign body of considerable size can be felt in the bladder in case the abdominal walls are not too rigid. As a means of detecting stone in the bladder of women, the biman- ual touch is the easiest, safest, and surest of all methods of explora- tion. The presence of neoplasms can be discovered in this way, although their composition can not be clearly made out. In some cases it is necessary to give an anaesthetic to relax the parts before METHODS OF EXPLORATION. 695 a satisfactory bimanual examination can be made. There are many advantages gained in anaesthetizing the patient while making a bi- manual examination, but some of the most important signs may be lost by the unconsciousness of the patient, such, for instance, as the location of tenderness. On that account I prefer in critical cases to make an examination both without and with anaesthesia. It is also well, when the object is to search for foreign bodies, like stone or tumors of any kind, to have a few ounces of urine in the bladder, unless that much gives the patient pain. The longer I practice the more I depend upon this method of examination. Another method of examination is by means of the endoscope. For this purpose I devised and have employed for years an endo- scope which has proved of great service. This instrument is com- posed of three parts. A glass tube (a, Fig. 226) is shaped like the ordinary test tube nearly the whole length of the inside of the glass tube, and about one third of its circumference. To one end of this arrangement the mirror is attached at an angle of about 100°. At the other end a delicate handle projects at an obtuse angle. This part of the instru- ment looks like a section of a tube that has been divided into three equal parts by longitudinal section, with a mirror attached at one end and a handle at the other. This piece is made perfectly black on the inside, and answers two purposes—it holds the mirror, and, when placed in position for use, darkens one side of the glass tube. It will be seen that the mirror can be moved forward or back- ward, and turned around ; so that when the tube is introduced into the urethra or bladder, the exposed internal surfaces can be brought into view by moving the mirror while the tube remains stationary. Fig. 225, shows the glass tube placed inside of a fenestrated hard-rubber speculum; and Fig. 227 shows the glass tube inside of a speculum that is open and beveled at the end. These specula are 696 DISEASES OF WOMEN. used in making applications to the urethra and bladder, as will be described hereafter. The method of using this instrument is as follows : The tube, with the mirror inside, is introduced into the urethra, and bladder also if an examination of the lowTer portion of the latter be desired. Light is then thrown into the tube by the aid of a concave mirror. This shows that portion of the interior of the urethra or bladder which is opposite the mirror and in contact with the tube, and by moving the mirror backward and forward all the parts to be exam- ined are brought into view in regular succession. Sunlight may be used, and when it can be favorably controlled it answers better than any other method of illumination. It very often happens, however, that the light is insufficient. Dark, cloudy days, or the unfavorable position of the office-window, often make it impossible to employ sunlight for endoscopic examinations. On this account I prefer to use gaslight. For this purpose I employ a gas-bracket, which is movable in every direction, and which can be fixed in any position desired. By this means the light is easily ad- justed to the position of the patient on the examination table. An argand burner with the ordinary condensing attachment is used, which gives a very strong, yet soft, steady light. There is one ob- jection to the condenser, and that is the difficulty of getting the light in the exact place where it is needed. On this account I pre- fer the ordinary argand burner with the glass chimney, such as ocu- lists employ with the ophthalmoscope. The color of the mucous membrane lining the urethra and blad- der has already been described ; but it must be borne in mind that the endoscope modifies the color to some extent. This is especially so when examining the urethra. If a large-sized tube is used, the parts are put upon the stretch and the pressure of the glass on the mucous membrane interrupts the capillary circulation to some ex- tent, and renders the color as seen in the mirror a pale pinkish white. This when understood does not interfere with the examina- tion, as it only tends to make the contrast between the normal and the diseased tissues more marked. The only condition where the endoscope might lead to error is in acute general congestion of the urethra. The pressure of the instrument causes the cono-estion to disappear in part, and gives the idea that there is less hyperaemia than there really is. In such cases I use the speculum or the ordi- nary endoscope (Fig. 227), and thereby remove all possibility of error. By a little practice in managing the light, sufficient dexterity to METHOD OF EXPLORATION. 697 examine the urethra and neck of the bladder thoroughly and satis- factorily can soon be acquired. The cystoscope of Nitze and Leiter is the only instrument for thoroughly investigating the bladder. Bruck, of Breslau, first dis- covered the principles of the instrument, and Nitze and Leiter per- Water-pipes. Fig. 227a. fected it. Dr. Willy Meyer gave a description of this instrument in " The New York Medical Journal," April 21, 1888 : "The cystoscope (Fig. 227a) consists of a silver tube of the shape of a catheter, in the short beak of which a platinum wire is fastened. The latter is made incandescent by means of an electric current which passes through it, and then darts its rays upon the wall of the bladder through an oval window in the concavity of the beak, covered with transparent quartz. To convey the current of electricity to the platinum, an insulated wire runs through the whole length of the shank; the metal of the tube forms the connection with the opposite pole. No cold water current is needed. Accord- ing to Nitze's design, a telescope is introduced into the shank of the cystoscope. It enlarges and magnifies the spot coming into sight. Without this telescope we should not see much more at the time than a spot about the size of a pea; with it wre are enabled to in- spect a portion as large as a silver dollar, and even more. " At the junction of beak and shank, corresponding to the con- cave side, a rectangular prism is cemented in, the hypotenuse-plane of which acts as a mirror on account of the total reflection of the rays. Thus a diminished, inverted real picture arises in the shank of that wall of the bladder which is situated at a right angle to the longitudinal axis of the instrument, and opposite the prism. It is again inverted by means of the lenses of the telescope, and thrown to the outer end of it, where the examining person looks at the now upright picture through the magnifying ocular of the telescope. 698 DISEASES OF WOMEN. " If the fundus of the bladder is to be inspected with this in- strument, it must be turned ISO0, and its handle deeply depressed between the thighs of the patient, the latter being in the recum- bent (lithotomy) position—the best for examination with the cysto- scope. " This manipulation may sometimes be very painful. To avoid this, a second instrument (Fig. 227b) is made with the window for Telescope. Wall of the bladder. Fig. 227b. Water-pipes. the incandescent platinum on the convex side of the beak. There is another window at the end of the straight tube through which the observer looks with the telescope. Of course, there is no prism. " Leiter's cystoscope shows the old pattern with the improvements mentioned. A key near the handle can be made to make or break the current by turning to the right or left upon or from an ivory plate. The shank of the instrument is somewhat short ; its telescope diminishes the part in view a trifle." Fig. 227c. Before using the cystoscope, the beak should be put in water, and the light tested to see that it is in working order. Glycerin should be used to lubricate the instrument. The bladder must be washed, provided the urine is bloody or cloudy with mucus, and then be partially distended with from five to six ounces of clear water. If the urine is quite clear, no preliminary washing is neces- sary. METHODS OF EXPLORATION. 699 W. Donald Xapier has invented a probe that is of use in detect- ing foreign bodies in the bladder. No dilatation of the urethra is needed for its use. It consists of a beaked sound, the vesical end of which is covered with pure metallic lead. This, having been care- fully polished with soft leather, is dipped into a one-per-cent solu- tion of nitrate of silver, which gives it a beautiful black coating. Before use it should be carefully examined with a lens to see that its surface is perfect. When introduced into the bladder, if any hard body be present, such as a calculus, against which it strikes, an obvious impression is made upon the polished surface. Exploration of the bladder by dilatation of the urethra is a most valuable means of diagnosis. It may be employed in various de- grees. The urethra may be enlarged only sufficiently to admit a fair-sized endoscopic tube, or it may be dilated sufficiently to admit the finger. I will first give the methods that are commonly in use, aud then explain the plan I usually adopt. Although there are rec- ords of bloodless dilatation of the urethra as far back as 1502 (Beni- vienni), 1506 (Marcus Sanctus), and 1561 (Franco), up to a late date the operation was not a common one. Franco used an instrument of his own for effecting dilatation. In the early part of the present century, dilatation by means of the compressed sponge and Weisse's metal dilator was somewhat used, but more for the extraction of cal- culi and foreign bodies than for purposes of diagnosis. To Simon, however, belongs the honor of improving the means employed, and introducing the subject to the profession. His method is this : He makes a single incision superiorly, or two slight lateral ones, in the wall of the meatus, about one tenth of an inch in depth. He also snips the urethro-vaginal septum to the depth of about one fifth of an inch. This is done to relax and prevent irregu- lar tearing of the meatal portion of the urethra, which is the most rigid and undilatable part of the canal. He next introduces a hard-rubber speculum, shaped somewhat like a cone, the cut end of which is protected by a rounded piece of wood within. His largest speculum has a diameter of nearly one inch; his smallest about one third of an inch. After the introduc- tion of the largest one, the finger can be readily passed into the bladder, and the whole of its interior explored, save the antero-later- al portion, which is high up, and difficult to reach. The narrowest urethra may in this manner be sufficiently dilated in from five to ten minutes. Simon found that, without any bad results following, an adult woman could bear the introduction of a speculum having a circum- •JrU 700 DISEASES OF WOMEN. ference of two and a half inches, and, when the necessity for marked dilatation was urgent and possibly resulting incontinence of com- paratively little importance, a cone having a circumference as high as two and eight tenths inches might be employed. In girls, specula having a circumference of from TSS inch to 2-52 inches may be used. For most diagnostic and therapeutic pur- poses, instruments not large enough to produce incontinence are usu- ally sufficient. Winckel has used Simon's method seven times, and has had ex- cellent results; and he says that, although the incisions made at the meatus are sometimes opened still further, and that a fresh one may appear under the clitoris, it is of little moment, as the presence of the dilator stops all haemorrhage, and the incisions heal readily. In none of Winckel's cases, although he watched them for weeks, was there any incontinence. Heath, in digital dilatation, found usually a tearing of the mucous membrane under the pubic arch, and incon- tinence was generally present for at least twenty-four hours. Instead of incising the meatus, I generally dilate it slowly, using for this pur- pose the bivalve urethral speculum (Fig. 228). When used as a dilator, I cover the blades with a piece of soft- I'.ig. 228.—Bivalve urethral speculum (Skene). t r rubber tubing. Notwithstanding the testimony to the contrary, I am sure that dilatation of the urethra to any great extent is dangerous. There is danger of lacerating the urethra and causing incontinence, which can not be easily cured. Great care should therefore be exercised in dilatation, and it should not be resorted to at all unless there is some marked indication for it. In cases where extreme dilatation of the urethra does not prove sufficient for the desired end, the method of opening into the blad- der through the vaginal wall, as recommended by Simon, may be tried. He makes an incision from right to left into the anterior vaginal wall just in front of the os uteri. From the center of this incision another is carried forward about one inch in length in the line of the urethra, thus forming a T-incision. Fine tenacula are then fastened into the bladder-wall through the incision, and, with one hand pressing the abdomen, and by traction on the tenacula, the bladder is pulled down through the incision and opened. After all necessary procedures are completed, the edges should be carefully METHODS OF EXPLORATION. 701 sacured by sutures, and the parts will heal kindly. The bladder-walls coapt readily and accurately. It will be understood that this important operation is only to be perfonned for the purpose of detecting and removing foreign bodies and abnormal growths from the bladder, and possibly to close vesico- intestinal fistulae. Rapid dilatation of the urethra is chiefly useful for the purpose of allowing the extraction of foreign bodies and moderate-sized cal- culi, for cauterizing the mucous membrane, for opening haemato- celes (Spiegelberg), for allowing the introduction of endoscopic tubes of large size in diagnosticating cystitis, calculi (vesical and ureteral), ulceration, vesico-intestinal fistula, polypi, and papilloma, and for the local treatment of these. Incision into the bladder, on the other hand, is useful in cases where calculi or other bodies are too large for safe removal by the urethra, the removal of tumors situated high up anteriorly or antero- laterally, in operations of various kinds where the urethra precludes free movement and good illumination, as in sewing up large vesico- intestinal fistulae. I may observe, in passing, that, in performing operations through the incision, artificial light might be thrown into the bladder by means of a small curved endoscopic tube and concave mirror in the urethra. In cases of cystitis and vesical ulceration, this operation has been performed by Sims, Emmet, Bozeman, Simpson, Hegar, and Simon, to prevent the stagnation and decomposition of urine in the diseased organ. Catheterization of the ureters has been performed by Simon and Winckel, but, as it is diOcult, not without danger, and of little prac- tical value, I shall not dwell upon it here. In connection with the subject of physical exploration, I give here a list of the various instruments that 1 find of use in examin- ing and operating upon the bladder and urethra. They are as fol- lows : Two Skene's Sims's specula. One Folsom's speculum (modification). One Skene's reflux catheter for urethra. Two silver probes. One sponge-holder (steel). One knife. One Blake's polypus-snare (ear). One Allen's polypus-forceps (ear). Two glass pipettes, six inches long. 702 DISEASES OF WOMEN. Two head-mirrors on same strap, three and one half inches and one and one half inch. Skene's bivalve urethral specula. Ordinary urethral endoscopes, modified by Skene. Two rectal endoscopes (long and short), with fenestrated rubber specula. Three urethral endoscopes (JSos. 13,15,17, American), with bev- eled rubber specula. Two beveled urethral endoscopes (Nos. 19, 21, American), with fenestrated rubber specula. One brush for cleaning endoscopes. Having described the important methods to be employed in phys ical exploration of the bladder, I now pass to a consideration of the organic diseases of the bladder and urethra. CHAPTER XL. ORGANIC DISEASES OF THE BLADDER. Having treated of the methods of physical exploration of the bladder and urethra, I now invite attention to the organic diseases of these organs, and shall first describe those which affect the blad- der. These may conveniently be divided into three classes: I. Inflammatory; II. Non-inflammatory; and III. Neoplasms, hyperplasia, and atrophy. I. Inflammation of the bladder, or cystitis: Under this head I shall include all forms of deranged nutrition which produce disorders of function, temporary or permanent lesions of structure, and the morbid material known as the " products of in- flammation." Well-defined typical inflammation presents during its course cer- tain peculiarities which are characteristic of the affection, and with- out the existence of which the disorder can not be called true in- flammation. Inflammation, however, varies in character with the tissue or organ involved and the extent or intensity of the disease; and, while there is really but one process of inflammation, as that process is often interrupted, prolonged, or modified in various ways, its products must necessarily vary greatly. Its divers grades or forms are distinguished as acute, chronic, catarrhal, interstitial, suppurative, croupous, diphtheritic, and gon- orrhaeal. Before entering upon the consideration of cystitis in its many forms, I desire to speak of hyperaemia and haemorrhage of the blad- der. This latter affection might more properly, perhaps, be consid- ered under another head, but it is so closely connected with hyper- aemia and inflammation that I prefer to treat it here. Hyperemia.—In all cases the first perceptible departure from the normal is a derangement of circulation. Hyperaemia of the mucous membrane is observed, and with it disorders of innervation, as is evi- denced by derangement of function and sensation, 704 DISEASES OF "WOMEN. In hyperaemia of the mucous membrane of the bladder the blood- vessels are distended, and, becoming prominent and apparently more numerous, give to it a bright-red color. The arteries are the first to be affected. If the hyperaemia is not marked, or is produced by some transient cause and not aggravated, it may pass off in a short time, and leave the membrane in its normal condition. If it is of a high grade, however, rupture of some of the vessels may occur, the haemorrhage taking place either on the free surface of the membrane or beneath its epithelial layer. Should this condition continue, the hyperaemia which began in the arteries extends to the venous side of the circulation, and the vessels become more prominently and uni- formly distended. The congestion may also begin on the venous and extend to the arterial side, as in sudden interference with portal circulation. As a rule, however, it begins in the arteries. A clear distinction must be made between the acute congestion of which I am now speaking, and which is chiefly confined to the smaller vessels, and passive congestion with a varicose or haemor- rhoidal condition of the veins about the neck of the bladder. This haemorrhoidal condition I will speak of later. Symptomatology.—The symptoms of acute congestion of the bladder, as a rule, occur suddenly. Frequent but painless urination is the principal symptom. There is often a sense of heat and heavi- ness in the region of the bladder, which is greatly aggravated by standing or walking. When the urethra is involved, the patient complains that the urine " scalds " her. The general system is not disturbed—i. e., the pulse and tempera- ture remain normal. The physical signs are mostly negative. The composition of the urine is unchanged, save that there may be an excess of mucus and a few blood-globules present. There may be some tenderness on pressure over the bladder. The endoscope (when there is an opportunity to use it, which is very rare in this trouble) shows an increased redness of the mucous membrane, with occasion- ally an excess of mucus on its surface. Diagnosis.—The diagnosis has to be made by exclusion, the nat- ural history of the affection having in it nothing pathognomonic. It is liable to be confounded with sympathetic or other functional derangement of the bladder, caused by sudden dislocations of the uterus or by pelvic inflammation, such as pelvic peritonitis and its results. The former can be excluded by an examination of the pel- vic organs, and the latter by the constitutional symptoms of inflam- mation and the signs of such pelvic disease. Causes.—The causes of hyperaemia of the bladder are exposure ORGANIC DISEASES OF THE BLADDER. 705 to cold (especially during the menstrual period), wetting the feet, overtaxation in walking or using the sewing-machine, excessive vene- real indulgence, constipation of the bowels from torpor of the portal circulation, the excessive use of stimulants, and the use of improper articles of food. Treatment.—The treatment should be directed to equalizing the circulation. Diaphoretics, warm, stimulating foot baths, hot applica- tions over the epigastrium, and, above all, rest in the recumbent position. If the bowels are confined, they should be emptied by saline laxatives. When there is much irritation of the bladder, caus- ing frequent urination and vesical tenesmus, pulv. doveri with cam- phor should be given, or suppositories of belladonna and morphine introduced into the vagina. Under this treatment the trouble will usually pass off in a short time. It may, however, go on to the de- velopment of cystitis. Occasionally bleeding occurs in active or acute congestion of the bladder, and that leads me to speak of haemorrhage from the bladder. Haemorrhage from the Bladder.—Haemorrhage from the bladder, or (if I may be allowed to coin a word) cystorrhagia, is usually due to some important disease of the bladder, and is, therefore, rather a symptom than a disease. For this reason I will at present confine my remarks to haemorrhage when caused by acute congestion, which I have just considered, or to varicose veins of the bladder. The bleeding may take place from the free surface of the mucous membrane, and mingle at once with the urine or coagulate in the bladder. It may also take place beneath the surface of the mucous membrane, and form ecchymoses, like the spots seen beneath the skin in purpura. We may also have a condition known as haemo- globinuria, in which only the coloring matter of the blood is found in the urine ; in such a case we should, of course, find no blood-cor- puscles. t The quantity of blood varies greatly in different diseases, and in the same disease in different persons. In congestion of the bladder blood-globules will often be found in the urine only on microscopic examination, while at other times the urine will have the appearance of being all blood. Again, the blood may coagulate, and be passed in clots, or the coagula may remain in the bladder, finally break down, and be passed as a chocolate-colored or blackish matter. Symptomatology.—The symptoms of haemorrhage do not differ from those of congestion or the onset of cystitis, except when small clots form, distending the urethra, and causing pain in urinating. It 706 DISEASES OF WOMEN". is very rare that bleeding from these causes is sufficient to prostrate the patient. As bleeding may take place at any point in the urinary tract, it is important always to locate the haemorrhage. AVhen coming from the bladder in any quantity, it is usually passed in small clots, and is seldom so intimately mixed with the urine as when it comes from the kidneys or ureters. This statement is not exact, and at best gives but a probable idea of the true facts. To complete the diag- nosis, we must resort to something more trustworthy. Sir Flenry Thompson gives a very ingenious method for determining as to whether pus found in the urine comes from the kidneys or bladder, and Van Buren and Keyes advise the same plan for detecting the source of haemorrhage. The method is this : " A soft catheter is gently introduced first within the neck of the bladder, the urine drawn off, and the cavity washed out very gently with tepid water. If the water can not be made to flow away clear, the inference is that the blood comes from the cavity of the bladder. If it will flow away clear, then the cath- eter is closed for a few moments, the patient being at rest, and the few drachms of urine which collect may be drawn off and exam- ined. The bladder is now again washed out, and if, after a single washing, the second flow of injection is clear, while the drachm of urine w agea tnirtj-SlX. Married five years, and a widow three years, of a marked nervous temperament. Has never been pregnant. Menstruation always normal, and general health fair in early life. Her general system has been much reduced by nursing her husband, who died of phthisis. Nervous system also much im- paired. When first seen, all the functions except those of the blad- der were performed well. She suffered night and day from frequent urination, but there was no pain either during or after the act, unless she tried to hold her water for a few hours, when there was great pain after the completion of evacuation. Nervous excitement, pleasant or unpleasant, made the trouble much worse. Her urine was normal. On examination, complete retroversion of the uterus was found, with shortening of the anterior vaginal wall; the bladder was much contracted, but otherwise normal. The uterus was restored to its place, and held there by a pessary. Hydrobromic acid in thirty-min- im doses was given four times a day. She made a rapid recovery. The next is a case of vesical tenesmus and partial retention from a sudden retroversion of the uterus. Mrs. G., aged forty-three, the mother of four children. Widow for several years. She was a strong, healthy lady, and had been on her feet all day attending to her household duties, and in the even- ing, while hanging some pictures, slipped from a chair, and fell heavily to the floor, striking on her feet. She was at once seized with a desire to urinate, and soon after pelvic tenesmus came on. The desire to urinate wTas constant, and, after strong expulsive NOX-IXFLAMMATORY DISEASES OF THE BLADDER. 763 efforts, she was able to pass a little urine from time to time, but without relief. The bowels became distended and tympanitic. On the following day she was ordered anodynes, but they gave very little relief. On the next day she was examined, and the uterus was found to be completely retroverted, and the bladder full, but not overdis- tended. Replacing the uterus gave her great relief at once, and she has remained well and free from all bladder trouble since the acci- dent occurred, some two years ago. This was a case of acute retro- version of the uterus, producing an intensely painful affection in a normal bladder. (c) Dislocation Forward.—Forward dislocation of the bladder, unless it be through the open abdominal walls, is very rare. Some change in its shape from pressure of organs or tumors from behind may occur, but this is really not a true displacement, except in some rare and marked cases. The most frequent cause is pressure from the anteverted and enlarged uterus in either the virgin or puerperal state. Anteversion of the uterus usually causes frequent urination, perhaps as much so as prolapsus; but whether this frequency is due to the fundus uteri resting on the bladder, or to the supersensitive- ness of the whole pelvic organs, which usually accompanies this dis- location, I have not always been able to determine. I have been in- clined to the belief that the latter was the case. In this displace- ment (anteversion) the uterus is generally enlarged and elevated, so that the body and fundus rest upon the bladder, and impede its dis- tention. True dislocation of the bladder forward is the rarest of all dis- locations, only three cases being on record. It has been variously called ectopia of the unfissured bladder, ectopia vesicae totalis, and prolapsus vesicae completus per fissuram tegumentorum abdominis. The first name is too vague, the last best of all, but rather lengthy for every-day use. The three cases on record are by G-. Yrolik, Stoll, and Lichten- heim. In all these the bladder was protruded through a small slit in the abdominal wall, and appeared as a bright-red, rounded tumor at the lower and anterior part of the abdomen. In Lichtenheim's case only was the tumor reducible. The pubic bones were separated about two inches. The urine could be retained perfectly, and the patient was able to micturate in a small stream. Microscopical ex- amination of the outer covering of the bladder-walls proved it to be mucous membrane, like that lining the interior of the organ. In G. Vrolik's case, according to Winckel, there is doubt as to 50 761 DISEASES OF WOMEN. whether it was a true vesical ectopia. He believes it to have been a gaping of the fissured abdominal walls over a dilated urachus, the latter communicating with the bladder by a small opening. In Lichtenheim's patient no operative measures were thought of, for, beyond a little excessive secretion of the external surface, no trouble was experienced. If, however, from the protrusion of the tumor or other cause, difficulty in passing or retaining urine be pres- ent, an attempt should be made to close the abdominal fissure. If it be large, two or more flaps may be needed to accomplish the de- sired result. The operation is very like that for fissure, already de- scribed, only more simple. If an operation is not desired or consented to, the patient should wear a concave compress, and, by attention to bandaging, keep the surface of the organ in as nearly a normal condition as possible. (d) Lateral Displacements.—Lateral displacement of the bladder is not very often met with. It is generally due to inguinal or fem- oral hernia, tumors at the side and base of the organ, and contract- ing pelvic adhesions. There is generally more or less distortion of the urethra that may hinder the outflow of urine or prevent the easy introduction of a catheter. Irritability may result, but it is not so common as in the other varieties, the organ being generally but slightly displaced, and, soon getting used to the disturbing cause arising from the malposition, produces but little disturbance. One case of this kind I have seen which was of interest. The patient was a young lady, who had had a pelvic peritonitis, which left her with pelvic tenesmus, ovarian pain, and some vesical tenes- mus and difficulty in emptying the bladder. One of my assistants, while examining her, found a fluctuating tumor on the left side, which he supposed to be an ovarian cyst, but which proved to be a left lateral displacement of the bladder fixed in its malposition by adhesions. Causation.—Its causes are of two kinds—predisposing and excit- ing. Of the predisposing, the most common are a loose, flabby con- dition of the vesico-vaginal septum, excessive venosity of same (these may be due to pregnancy or to a general systemic condition), ab- normally capacious vagina, unusually large introitus vaginse, total or partial loss of perineal body, and the tendency of the bladder to pouch inferiorly as age advances. As exciting causes, we have violent expulsive efforts, as in def- ecation, lifting heavy weights, and especially child-bearing. The latter is probably one of its most common causes, for not only do we have expulsive efforts of the most violent kind, but a lax, spongy NON-INFLAMMATORY DISEASES OF THE BLADDER. 765 condition of the vesico-vaginal septum—i. e., the anterior vaginal and posterior vesical walls, which are pushed downward before the advancing head. Another common cause is prolapsus uteri, though in many cases the cystocele precedes the prolapse of the womb. Whichever is the cause, the one aggravates the other. In slight prolapse of the uterus, the vesical symptoms are only those of irritation; and it is a strange fact that the irritation is often as great in the first degree • of prolapse as in the third. Other less frequent causes of cystocele may be tumors in the posterior vesical or anterior vaginal wall, stone in the bladder, vesi- cal diverticuli, violent efforts at urination, and marked pressure from above. The bladder begins to sag inferiorly as age advances, and conse- quently the tendency to prolapsus advances, as does the age. The number of pregnancies may, however, have more to do with the fre- quency than the tendency to pouching in old age. (e) Dislocation Downward.—I have reserved this malposition to the last, because it is the most important. There are various grades of the dislocation, the most marked of which is known as cystocele vaginalis. Pathology.—This affection may be conveniently divided into three grades. In the first, there is but a slight bagging of the or- gan. In the second, about one half the bladder lies below the nor- mal level of the anterior vaginal wall, giving the organ an hour- glass shape, the urethra entering the upper segment just above the point of partial constriction. In the third or highest grade, the whole bladder lies below the level of the normal anterior vaginal wall. The urethra in these cases has a direction from above back- ward and downward. The ureters in the last two grades are so bent and obstructed by pressure, that dilatation and hydronephrosis may result. Such instances are given by Phillips, Froreiss, Virchow, Braun, and Winckel. The vesico-uterine pouch is, in cases of marked vesical and uterine prolapse, greatly increased in size, and may contain a loop of intestine. In some rare cases it may become constricted superiorly, and exist as a closed sac. In chronic cases the vesical mucous membrane becomes hyper- trophied, and, in the lower segment especially, congested and oedem- atous. To this may be superadded cystitis and ulceration, which often follow in cases of long standing. Symptomatology.—In the first grade of downward dislocation 76Q DISEASES OF WOMEN. the symptoms are those of irritable bladder, such as frequent and sometimes painful urination. When the displacement has existed for a considerable time, the bladder seems to accommodate itself to the new relations, and the calls to urinate become less frequent. In cases in which the prolapsus of the bladder is slight and there is dila- tation or prolapsus of the upper third of the urethra, partial inconti- nence occurs, a very annoying symptom. Every time the patient coughs, lifts a heavy weight, steps suddenly down from the curb- stone into the street, or even indulges in a hearty laugh, there is a sudden escape of urine. In complete prolapsus of the uterus and bladder, we find instead of frequent urination, difficult urination, and in the worst cases, re- tention. Partial retention always occurs in the marked cases, and the urine remaining in the bladder decomposes, and in time causes cystitis, which greatly aggravates the patient's sufferings. Such cases are very like those occurring in old men, and due to retained urine by reason of an enlarged prostate gland. There is usually a dragging pain experienced in the region of the umbilicus, which is due to traction on the urachal cord, and also a constant sense of pain and uneasiness, due partly to the vesical and partly to the uterine malposition. To fully empty the bladder in the worst cases, it is necessary to relax the parts by lying down, and then force out the urine by press- ure on the vaginal tumor. Cystitis is a common secondary affection, and is due to decompo- sition of the retained urine, and to chronic congestion with oedema and hypertrophy of the mucous membrane. Winckel's experience has, however, differed from that of most observers, he having failed to find a single instance of cystitis in sixty-eight cases of cys- tocele. From pressure on the ureters there may result dilatation and hydronephrosis, and if marked or long-continued, uraemia. There may also be set up that condition known as pericystitis, and the lower vesical segment be rendered irreducible owing to the formation of adhesions. If cystocele occurs in a patient already suffering from cystitis, the original trouble is of course greatly aggravated. Cystocele may interfere with delivery during childbirth. In one such case, McKee, being unable to push a catheter into the bladder, punctured the tumor with a lancet, and delivery was rap- idly accomplished. In another case, a certain physician mistook the vesical tumor for the bag of waters, and punctured it. NON-INFLAMMATORY DISEASES OF THE BLADDER. 767 Diagnosis.—This is readily made. The patient should be laid upon her back, with the thighs flexed on the body. If the tumor is already down it should be examined carefully, and also the position and condition of the neighboring organs. If possible, a catheter should be passed into the bladder, to ascertain if it enters the tumor and the direction it takes in so doing should be observed. The tumor should be slightly compressed, and notice taken whether the urine flows from it through the catheter. An attempt should also be made to try to reduce it. The urine should be carefully ex- amined for pus, mucus, albumen, epithelial elements, and the amount of urea should be determined. Prognosis.—The prognosis is generally good ; but in giving an opinion the degree of dislocation, the size of the tumor, the condi- tion of its mucous membrane, whether it is reducible or not, the age of the patient, and the gravity of the producing cause, must all be taken into consideration. In young patients, Sims, Simon, Hegar, Verf, and others claim to have obtained radical cures. Some of these cures were not, how- ever, lasting. Scanzoni claimed that he had never seen an opera- tion for this displacement that resulted in a permanent success, and that his own operations were by no means satisfactory. My own experience entirely accords with that of Scanzoni. Treatment.—The treatment consists in reposition and retention. The former is easy, the latter hard to accomplish, as prolapsus uteri and cystocele generally go hand in hand; one can not be treated without the other. Having pushed the uterus up into position, emptied the bladder and replaced it, some mechanical ^B^. means should be sought to retain B J^Sm^L For the purpose of support- J^P^^^^_^| ■bLs3B^L/57 vised the pessary shown in Fig. w^ ^^^^^c-^^^^S^ accomplish the obiect fairly well Fl°- Jss.-Peasary for prolapsus of the , , -i.i . bladder (Skene). The main portion, a, When the pelvic floor IS not m- surrounds the cervix uteri, and b sup- l'lired ports the bladder and upper portion of J * . the urethra. The other part, c c, joins This pessary is adapted and the main portion in front of the uterus, introduced in the Same Way as a and rests on the posterior walls of the J vagina. retroversion pessary, an account of which will be found under the head of the treatment of retro- version. 7G8 DISEASES OF WOMEN. The facility of introduction and removal is one of the minor, but by no means unimportant, qualities of this pessary. Several sizes are made, which answer in most of the forms of displacement of the bladder; but a case will occasionally occur in which it is necessary to first take measurements, and have the in- Fig. 236.—Pessary holding up the bladder. strument made exactly to suit. This can be easily done. The pa- tient is placed on her left side, and after introducing the speculum, the uterus and bladder are restored to their proper positions ; then a thin strip of sheet lead is bent to the size and shape of the ante- rior walls of the vagina and cervix uteri. This form will enable the instrument-maker to produce the required size and shape of the pessary. I have also devised another form which suits some cases. It is like the retroversion pessary which I use, but the sides anteriorly are made more curved and very much thicker than the ordinary one, Fig. 237. Should a pessary fail to accom- plish the desired result and the case grow gradually worse and the de- FlG- 237.—Modification of the retrover- mand for relief become more urgent, l^ bESSr?' ™d m prolapsus ot NON-INFLAMMATORY DISEASES OF THE BLADDER. 769 the operation may be performed which is described on page 866 and illustrated in Fig. 249, Plate IV. HERNIA OF THE BLADDEH. This injury was first recognized by Dr. Paul F. Munde, and described by him in the " American Journal of Obstetrics," June, 1890, page 614. That it may have been observed by others is pos- sible, but it was evidently not understood until thoroughly investi- gated by Munde. Guided by the light which he has thrown upon the subject, I have been able to comprehend a number of cases which were previously obscure, and which, not knowing better, I had classified as cases of prolapsus of the bladder. The pathology is the same as in all hernial protrusions. There is first a giving way of the anterior muscular wall of the vagina in the median line, and then the bladder, covered only wdth the vagi- nal mucous membrane, protrudes into the vagina. Causation.—There are three causes which I have observed in the cases which have come under my observation: The first, which occurs less commonly now than formerly, is removal of a part of the vaginal wall, colporrhaphy. In time the scar-tissue stretches at the site of the operation, and the bladder protrudes at the point at which muscular tissue is deficient. The second cause is, apparently, a laceration of the muscular tissue in the median line during labor. When the hernia is caused in this way the urethra and lateral walls are in proper position, but at the point of hernia the muscular tissue and fascia are absent. The remaining cause is atrophy of the muscular tissue. This I believe to occur, because it has been found in women past the meno- pause who have not had children, and who have not been subjected to any injury which could have produced muscular laceration. Symptomatology.—The symptoms, so far as I have observed them, are the same as in prolapsus of the bladder. Physical Signs.—The physical signs are, wdien understood, quite diagnostic. AVhen the perinseum is retracted, the hernia appears as a smooth, hemispherical body, around the base of which the vaginal walls are in normal position. With a sound in the bladder, the thin vaginal wall, which is reduced to mucous membrane only, is appar- ent to the touch. If any doubt exist about the diagnosis, the results of treatment will determine whether the condition is that of hernia or of prolapse. If it be a prolapsus, which has been treated by the use of a tampon or pessary, with rest in a recumbent position, there will be a noticeable contraction of the vaginal wall and a temporary 16^ DISEASES OF WOMEN. relief; but no such change occurs as a result of this treatment in case of hernia. Treatment.—Having failed to relieve hernia by any of the oper- ations recommended for prolapse, I wras driven to try an operation which gave me good results, and that, too, before I understood the true pathology of the affection. The operation consists in making a small opening in the vaginal wall at the junction of the urethra and bladder, and at the lower margin of the hernia. Through this opening a probe is passed and pushed up to the upper margin of the hernia, between the vaginal wall and the bladder. A delicate forceps is then introduced into the tunnel made by the probe, and its blades are spread forcibly apart. The vaginal wall and bladder are then completely separated to the extent of the hernial opening in the muscular layer of the vagina. The probe or forceps is held in place and upward pressure is made with it. This keeps the bladder in place while traction is made upon the vaginal mucous membrane at its upper part. This brings the lateral edges of the muscular layer of the vagina together and develops a ridge of mucous membrane. Sutures are now intro- duced to hold the parts in position. The mechanism of this proceeding is the same as in making a tuck. The ridge or tuck of mucous membrane projects into the vagina like the segment of a circle, but soon flattens out and over- hangs the line of sutures. Care should be taken not to make the sutures tight enough to strangle the tissues, but only sufficiently so to hold them together until they unite. I have operated in a number of cases, and the immediate results are all that could be desired. I have had an opportunity to observe but four cases long enough to determine whether the cure is permanent or not. In one of these, done five years ago, the hernia shows no disposition to return. The same is true of all the cases that I have operated upon. The first operation was done five years ago, and the last, one year. Dr. Munde, in his paper on this subject, commends the opera- tion of Stolz, which consists in the removal of the circular portion of the mucous membrane which covers the hernia, and the bring- ing of the parts together at one central point with a purse-string suture. I have tried this operation in three cases, and have found that, while it appeared to answer the purpose, the scar gave way in time and the hernia returned. In fact, the worst case of hernia of the bladder that I ever saw followed a similar operation, which wras done for prolapsus. NON-INFLAMMATORY DISEASES OF THE BLADDER. 769* ILLUSTRATIVE CASES. A patient who had had a number of children suffered from a pro- lapse of the bladder and laceration of the perinseum. I performed Xoeggerath's operation for the relief of cystocele, and obtained a good result so far as relieving her for a time. She returned four years afterward, suffering as much as ever. I found that the scar left after removing the section of the anterior vaginal wall had become stretched and thinned out, so that the bladder protruded. I vivified the vaginal wall all around the outer edge of the scar, and brought the surfaces together and obtained good union. Two years after this I found the hernia had again returned. This led me to devise the operation which I have described above, and which has given me far more satisfaction. Hernia following Stolz's Operation.—A patient fifty-nine years old had a prolapsus of the bladder and a laceration of the perinseum of sixteen years' standing. I performed Stolz's operation and restored the perinseum. She was apparently cured, but two years afterward I saw her again, when I found what I believed to be a return of the prolapsus, but I now know that she had a vesical hernia. Frequent Urination due to Prolapsus of the Bladder.—The patient was thirty-two years old, and had given birth to five children. She had always been well and strong, and at the time that I saw her she was in very good general health. After her last confinement, one year previous, she began to suffer from frequent urination. At first she obtained relief from emptying the bladder, but subsequently the desire to urinate, though not very urgent, was constant wdien she was upon her feet. On lying down she obtained relief and retained the urine all night, but upon rising and going about the tenesmus re- turned. By digital examination I detected a prolapsus of the bladder, but only in a slight degree. There was considerable relaxation of the pelvic floor and of the vaginal walls, but no laceration of either. In all other respects she was quite well. The urine was normal. She was ordered to rest for a few days, most of the time reclining, and to use vaginal injec- tions night and morning of sulphate of zinc, sixty grains to the quart of warm water. Afterward a pessary was used shaped like Graily Hewett's anteversion pessary, but having the anterior bars thickened. 770 DISEASES OF WOMEN. Immediate relief was given by the pessary, and she was able to walk and stand as she used to in former times. The zinc-douche was kept up once a day, and she was cautioned against walking or standing too long. At the end of six weeks the pessary was re- moved to see if she could do without it. In a few days the old symptoms began to return, and the pessary was replaced to her en- tire relief. From this time onward the pessary was changed once a month for a smaller one. Seven months afterward the instrument was removed, and the injections of the zinc solution continued for one month longer. She had no further trouble. Prolapsus of the Bladder caused by Laceration of the Perinaeum.— This lady was forty-one years old, of large form, and had an excel- lent constitution ; she had two daughters, the youngest seven years of age. For nearly six years she had suffered from vesical tenesmus and frequent urination. These symptoms were greatly aggravated by the erect position. In fact, for a long time she was quite comfort- able while sitting or lying down, especially the latter. Her symp- toms gradually increased, and within the past two years she has had partial incontinence. Any sudden motion such as is caused by cry- ing or sneezing would cause a spurt of urine which wras most dis- tressing to her. She became quite helpless although in perfect health. Being unable to stand or walk for any length of time and having partial incontinence she remained in the house all the time. She had been treated with all kinds of drugs, but, as might have been expected, without any relief. I found that she had a laceration of the perinseum, and also a bilateral laceration of the cervix uteri. The bladder was prolapsed and the upper third of the urethra pre- sented the usual signs of the ordinary cystocele. She was admitted to my private hospital, and after having been submitted to prepara- tory treatment the cervix was restored. While she was recovering from that operation the bladder was kept in place by the tampon, and astringent vaginal injections were used. One month later the pelvic floor was restored, and as much tissue brought together as pos- sible. After the operation the pelvic floor was kept well sup- ported with a compress and T-bandage. The astringent injections were continued. Six weeks from the last operation she was per- mitted to take exercise, but the pelvic floor was supported for two months longer. After restoring the pelvic floor it was necessary to use the catheter to draw the urine; that excited some irritation of the bladder, but this was relieved by injections of borax and water. She made a perfect recovery, and has remained quite well for more than four years. NON-INFLAMMATORY DISEASES OF THE BLADDER. 771 Cases of Displacement of the Bladder due to Displacement of the Uterus and Causing Retention of Urine.—(D. Berry Hart, M. D., " Ob- stet. Jour.," Great Britain and Ireland, August 3, 1880): Case I.—A. B., aged eighteen, was seen in Prof. Simpson's out- patient clinic, on account of white discharge and pain on making water. Ocular examination of the external parts showed a recent laceration of the hymen and glairy discharge from the ostium vaginse. On vaginal examination the cervix was found normal in all respects, except that the os looked downward and forward ; bimanually, a fluc- tuating tumor, reaching up a little above the level of the pelvic brim, was felt in front of the partially retroverted unimpregnated uterus. The catheter introduced drew off twenty-seven ounces of urine. Case II.—Mrs. C. wras admitted to Prof. Simpson's ward on ac- count of retention of urine, necessitating catheterism ; bimanual ex- amination showed a large tumor in the hollow of the sacrum, marked elevation of the os uteri above the symphysis, and a fluctuating tumor in the hypogastric region, reaching almost as high as the umbilicus. This physical examination and the history of four months amenor- rhoea made the diagnosis of retroversion of the gravid uterus per- fectly plain. What concerns us here, however, is that the bladder contained only about twenty-three ounces of urine, a less amount than in the previous instance. Case III.—Along with Prof. Simpson I saw at the Maternity Hospital a patient with rigidity of os uteri, supposed to necessitate early application of the long forceps; supra-pubic inspection and palpation revealed a fluctuating tumor bluntly triangular in shape, with the apex down. Exact measurements showed that vertically it extended four inches, and transversely for about the same distance. The catheter passed deeply up, and drew off only two ounces and a half of clear urine, and some time afterward the same apparent dis- tention occurred, wrhen three ounces and a half were removed. Af- ter the bladder was thus emptied, the furrow between cervix and uterus could be felt two fingers' breadth above the symphysis pubis. These three cases are typical instances, and evidently call for expla- nation. In the first case narrated the bladder was simply distended. It had pushed the intestines up, tilted the uterus back, but its posterior wall was still in its normal position. The peritonseum was still on the summit of the bladder, but, of course, was stripped to a certain extent from the lower part of the posterior aspect of the anterior abdominal wall. Thus the bladder, though its summit was only at the level of the brim, was considerably distended. INow, in the 772 DISEASES OF WOMEN. retroversion of the gravid uterus, the bladder was certainly distended, supra pubic palpation, however, misled as to the amount of disten- tion, and for the following reason : The cervix uteri was tilted high up behind the symphysis pubis, and consequently the blad- der, to whose posterior angle the cervix is attached, was swung up, as it were, into the abdominal cavity, a movement permitted by the anatomical relations behind the pubis. The peritoneal relations were the same as in Case I. In the third case, the bladder was, of course, drawn up, as I have already shown,* and its relations were as follows: In front it touched the anterior abdominal wall; behind, the child's head, the cervix, of course, intervening. In this way the anterior and posterior vesical walls were in contact, and thus a film of urine, as it were, gave the appearance of distention. As I have before pointed out, the peritonaeum is stripped off the bladder more or less.f The conclusions advanced are : 1. The retro-pubic anatomical attachments of the bladder admit of its distention and passage up- ward. 2. Supra-pubic palpation gives no sure indication of the amount of urinary distention. 3. When the summit of the blad- der is above the pubis, it may be (a), a pure distention (Case I); (b), distention plus a tilting up (Case II); (c), drawing up of the blad- der, with almost no distention (Case III). The reason why gynecologists use a long gum-elastic catheter is very evident. I have already described the empty bladder in the non- parturient female as forming a Y-shaped figure on vertical section. During parturition, however, the urethra is elongated, and forms with the bladder, on vertical section, a continuous tube. % Only that part of the bladder above the pubis is available for the recep- tion of urine, so that in this way the path for the catheter to travel is increased. In Braune's section of a woman in labor, the distance for the catheter to travel is about four and a half inches, more than twice what it is normally. In the last place, the distended female adult bladder is quite comparable in its anatomical relations to the distended fetal one. This may point to the explanation that the ultimate changes which convert the urinary bladder from an abdominal organ into a pelvic one is chiefly in the bony pelvis itself. Retrocession and Forward Transposition of the Uterus.__The vari- ous forms of displacement of the bladder described thus far are usu- * "Edinburgh Medical Journal," April, 1879. f "Edinburgh Medical Journal," September, 1879, "Edinburgh Obstetrical Transac- tions " (Part II, p. 142). % See " Die Lage des Foetus," Braune, Tab. C. NON-INFLAMMATORY DISEASES OF THE BLADDER. 773 ally associated with uterine dislocations, and are familiar to those who have given attention to gynecology. There remains to be no- ticed two forms of displacement of the uterus not generally described by authors, but which markedly disturb the functions of the blad- der, viz., retrocession audi forward transposition. In the first form, the uterus, without any change in the relation of its axis to the plane of the superior pelvic strait, is found to rest far back in the pelvis, and is fixed there. In the second form, the reverse of this exists, the uterus resting just behind the pubes. Figs. 240 and 241, will show these conditions. The best example of retrocession I have ever seen was in a pa- tient who had had a severe pelvic peritonitis sometime before she came to me. The uterus was firmly fixed in the posterior portion of the pelvis, and the bladder was drawn backward, and was exceedingly irritable. This condition caused her great trouble, as she could never Fig. 238.—Forward transposition of the uterus. The bladder will be seen somewhat flat- tened against the pubes, and the urethra pushed out of its axis. completely empty the organ, except when the catheter was used. Owing to the fixation of these organs in their malposition, it was impossible to relieve her from the frequent and difficult urination, and she remained a great sufferer, until she died of phthisis pul- monalis. 774 DISEASES OF WOMEN. To illustrate the forward transposition, I may mention a case that came under my notice several years after she had had an intra- peritoneal pelvic hsematocele. Her physician told me that she had Fig. 239.—Retrocession of the uterus. The vagina is here found lengthened, and the bladder and urethra pulled upward and backward, a, adhesions, b, bladder. severe inflammation following the internal haemorrhage, and nearly lost her life therefrom. She was confined to her bed for many months, and after recovery she suffered from frequent urination. Night and day she was obliged to pass water every two hours, and if she went longer than that, she had pain which was not relieved till some time after emptying the bladder. The uterus was situated at its proper elevation, and was just behind the pubes. The bladder was compressed from before backward, and (as the uterus was firmly fixed in its forward position) of course it could never be fully distended. There was no disease of the bladder, so far as could be ascertained from an examination of the urine, or of the organ itself. No treatment that was employed gave anything more than temporary relief. (/) Inversion of the Bladder.—This affection stands next in rarity of occurrence to complete prolapsus of the bladder through a fissure in the abdominal walls. It is sometimes denominated as extrover- sion of the bladder through the urethra. NON-INFLAMMATORY DISEASES OF THE BLADDER. 775 By some authors it is supposed to be a simple protrusion of the mucous coat of the bladder through the urethra, but by others to be a prolapse of the whole organ. In support of the latter belief is the fact that after death Joubert, Rutly and Leoret found a sinking in or partial inversion of the whole organ. Moreover, Meckel claims to have found under the labia minora, and protruding from the meatus a mass of tissue that on careful examination proved to consist of all the elements of the several coats of the bladder. Burns thinks it much easier for a prolapse of the whole organ to take place than a separation and prolapse of the mucous membrane alone. Streubel, after a careful review of the literature of the sub- ject, was able to find but one case in which the mucous membrane was alone prolapsed. As the posterior vesical wall in the empty organ hes over the vesical opening of the urethra, it is easy to com- prehend how this dislocation might occur from sudden straining efforts, pressure of the overloaded colon, or pressure of a heavy uterus. Vesical tumors with long pedicles coming out through the urethra, by weight or from traction, might produce this result. The process of extroversion is generally slow. De Haen, quoted by Streubel, gives a case, however, where from force, the bladder, rec- tum, and vagina were all prolapsed together. It will be understood that in order to have the bladder turned inside out, the urethra must be abnormally dilated. It may occur at any age. Weinlecher saw it in a child but nine months old; Oliver, in one of sixteen months; Crobs, in one from two to three years; Streubel, in a girl fourteen years old; and Thom- son and Percy, in women aged respectively forty and fifty-two. Symptomatology.—The patients, even before the tumor appears, feel strong pressure in the organ on urination, and may have stop- pages in the stream and retention. After a time these symptoms become aggravated, a small red tumor appears at the meatus, and with each urination enlarges. With the appearance of the tumor comes pain. In some cases, when the desire to urinate is felt, severe contraction of the bladder takes place, but no urine flows. Then suddenly the little tumor disappears inside, and the urine flows freely. With each appearance of the tumor there is considerable constitu- tional disturbance, and after a time the appetite is lost, and the suf- ferers emaciate rapidly. From continual traction on the ureters, they may become inflamed, and also the kidneys, and uraemia super- vene. Blood is sometimes passed with the urine. Cystitis may occur, which increases the suffering and danger. The mucous mem- brane may become hypertrophied, congested, and even oedematous. 776 DISEASES OF WOMEN. The constitutional symptoms bear no relation to the amount of tissue extruded or the area of mucous surface exposed. Diagnosis.—Fortunately, this affection is a rare one, for the diag- nosis is by no means easy. The surface of the tumor should be ex- amined, and the nature of its epithelium carefully noted. Reduc- tion should be tried, and, if successful, examination should be made by the sound in the bladder, and the finger in vagina or rectum (the latter in infants), to ascertain, if possible, whether there be any thick- ening of the membrane or a tumor in the viscus. If on the surface of the protrusion the orifices of the ureters can be found, the diag- nosis is at once settled. Polypoid projections of the mucous mem- brane must be differentiated from protrusion of the viscus itself. Such cases are described by Baillie and Patron. From prolapsus of the urethral mucous membrane, which I shall hereafter describe, this condition is to be differentiated by the absence in the latter of the ureteric openings and the position of the meatus urinarius. In urethral prolapse the orifice is situated either centrally or superiorly, while in vesical protrusion the meatus surrounds the pedicle. In the latter there is a large strong pedicle; in the former none. Treatment.—The treatment naturally divides itself into prophy- lactic and curative. To prevent partial extroversion from becoming complete, narcotics and demulcents should be given by the mouth and rectum, or injected into the bladder. Opium, hyoscyamus, and belladonna may all be tried. Local cauterization and washing out with tonic injections might prove serviceable. These preventive means are usually sufficient, provided the urine is normal and the mucous membrane healthy. If either of these abnormalities exist, they should be corrected. If the tumor is down, its reposition should be attempted. Gentle manipulation with the finger should be tried, and, if the mass can not be put back in this way, a well-oiled blunt catheter should be used, making pressure with it in the direction of the axis of the urethra. If this is very painful, and there are spasmodic contrac- tions of the abdominal muscles, which prevent replacement, the patient should be etherized, and success may then follow. She should be on her back, or in the Sims's position. To prevent prolapse after reduction, the catheter may remain in situ for a time, or the colpeurynter or tampon may be used. Schatz's pessary for urinary incontinence may be employed advantageously, as its use tends to contract the vesical neck. Astringent injections may be used. No operative procedure is required. CHAPTER XLIII. NON-INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED). FOREIGN BODIES IN THE BLADDER. Foreign bodies found in the female bladder are divided into three classes by Winckel, as follows: (a) Those that come from the body, entering the bladder by per- foration. (b) Those which have their origin in the bladder. (c) Those that are introduced from without through the urethra. I will adopt this classification, believing it to be the most natural and convenient. (a) First then, as to those that come from the body, entering the bladder by perforation. That cysts ever originate in the bladder is doubted by some and denied by others. In most cases where they are found in this organ they can be traced to dermoid cysts of the ovary which have found their way into it, thus accounting for the presence of hair, teeth, and other tissues in this viscus. These things are never found there unless such a cyst has opened into the bladder. The contents of these dermoid cysts may become nuclei for calculi, and lead to seri- ous trouble. I think there can be no doubt but that some of the cysts found in the bladder have their origin there. Mucous follicles certainly do exist in the bladder, and are liable to have their orifices blocked or occluded, and by secretion behind the point of obstruction grad- ually form cysts. Interesting cases, where the cysts evidently had their origin in the bladder itself, are related by Paget, Listen, and Campa. It is, however, undoubtedly the fact that most cysts of the bladder have their origin outside that organ. Cysts of the ureters and urachus may open into the bladder. Hydatid cysts have been found, but are less frequently seen in this 61 778 DISEASES OF WOMEN. country than in almost any other. Iceland is especially cursed with them, about one sixth of the population suffering from them in some part of the body. They may appear in the urine, white and pearly in appearance, or be of a dirty yellowish color, from prolonged soak- ing in foul urine. Treatment.—These cysts, or their contents, if giving rise to any trouble, should be treated in the same manner as the neoplasms, of which I shall speak later. In the treatment of hydatid cysts, iodide of potassium has been especially recommended. Having never had occasion to use it for this purpose, I can say very little for or against it. Other Foreign Bodies.—Various parts of the foetus have found their way into the bladder by ulceration during extra-uterine preg- nancy, and pieces of ulcerated intestine, masses of feces, fecal con- cretions, and biliary concretions, are some of the curious things that have been found in this viscus. In gun-shot and other injuries to the pelvic bones, osseous splinters have found their way into the viscus, and been evacuated through the urethra, or have passed into the vagina or rectum by ulceration, or have remained, forming nuclei for calculi. Various parasites may penetrate the walls from the immediate tissue or neighboring organs, or come down from the kidneys, such as the echinococci, already spoken of, the distoma haematobium or the filaria sanguinis hominis. Joints of tape-worm, the ascaris lum- bricoides, and the thread- or seat-worms have also been found here, entering either through a fistulous opening, existing between the bladder and intestine, or through the urethra. In acute destructive change in the kidneys (pyonephrosis and abscess), pus and pieces of renal tissue are not unfrequently carried down into the bladder, and may, by frequent incrustation with the urinary salts, result in the formation of calculi. Of themselves, they give rise to very little, if any, irritation, and are consequently of no importance save in relation to the destructive changes going on in the kidney, of which they tell the story. If such discharges from the kidneys continue for a long time, they cause cystitis. Renal calculi may become dislodged, and be swept down into the bladder, there to enlarge by further incrustations, or pass out through the urethra. Symptomatology.—The symptoms of the various foreign bodies in the bladder differ only in degree. They are at first those of irri- tation ; later those of acute or subacute inflammation. Bodies round, smooth, and soft, are, of course, less irritant than those that are rough NON-INFLAMMATORY DISEASES OF THE BLADDER. 779 or sharp. Cysts, therefore, bits of flesh, and their like, as a rule, give rise to no very severe symptoms, while splinters of bone and calculi occasion much more severe manifestations. Pain and tenes- mus will vary with the character of the offending body. If the mucous surface be abraded or torn, haematuria will result; and, if the foreign body remains in the organ, and continues to irritate it, cystitis will follow, and the patient suffer increased agony. The extension of the inflammation upward, and involvement of one or both kidneys, will give rise to pain in the back, hectic fever, partial or total suppression of urine, and consequent ursemic symp- toms, ending fatally. The urine shows the various appearances of cystitis, of which sufficient has already been said, and also the signs of renal involve- ment, if such be present. Treatment.—Any foreign body, when known to be present in the bladder, should be removed at as early a date as possible. In the adult female this may be readily accomplished by dilatation of the urethra, or, if the body be too large, by Simon's vesico-vaginal section. In cases of fistulous communication between the bladder and in- testine or other organ, an attempt should be made, in the manner already spoken of, to close the opening. Echinococci and other parasites should be treated with the vari- ous remedies recommended for their destruction elsewhere, always, however, removing the offending body from the bladder first, and trying to prevent further invasion by proper medication. If cystitis be present, this will be attended to in the prescribed way. Hydatids in the Bladder.—Dr. J. A. McKennion, of Selma, Ala- bama, reported a case in the " American Medical Weekly," Louisville, Kentucky, in 1874 or 1875. The purport of this report, according to my recollection, is that it was a case which, when first seen, had every indication of cystitis, with great thickening of the walls of the bladder. Frequent micturition caused the patient to exclude her- self from society for two years before a correct diagnosis of the case was formed. She was becoming prostrated from constant dysuria, and, in order to give her quietude, Dr. McKennion says, I attempted to introduce a Sims's catheter, to be retained during the night; but, meeting with an obstruction in the bladder, and, by manipulation with catheter, finding that she was insensible as to the point of the instrument, I concluded that a hydatid formation was present, and designed at once to have it expelled if possible. 780 DISEASES OF WOMEN I would say here one of the strongest arguments in my own mind at the time of hydatid formation was, when force was used to push up the instrument farther, a small amount of fluid escaped, and no blood. I injected into the bladder two drachms of liq. sodas chlor. (French preparation). In about an hour violent spasms of the blad- der occurred, the urethra dilated, and there was expelled into the vessel about a pint of hydatid. The shape and attachment of these resembled the cactus; the sacs were transparent and well defined. There was but slight haemorrhage. This I attributed to the forcible distention of the urethra. It is now over five years since their ex- pulsion, and up to this day my patient has had no more inconven- ience with her bladder. Fortunately, my case was a female, and she is well; this might not have been if it had been one of our own sex.—New York Medical Record, November 20, 1880, p. 588. ib) Bodies having their Origin in the Bladder Itself—Under this head come calculi, which may be of various kinds, as uric acid, triple and amorphous phosphates, oxalate of lime, and cystine. The latter are quite rare. Again, the calculi may consist of more than one of these ingredients. Time will not allow me to enter into the extensive field embrac- ing the etiology and treatment of stone. For a comprehensive study of this matter, I must refer the reader to any one of the many excel- lent works on that subject. Calculus.—I shall only speak of one or two points in connection with calculus that are of especial interest in the study of disease of the female bladder. Stone in the bladder is not so common among women as among men. This, I presume, is owing to the large and easily dilatable urethra of the female, which permits small renal cal- culi to pass out; calculi of the same size in the male being retained in the bladder, and serving as nuclei for larger ones. Symptomatology.—The symptoms are simply those of a foreign body in the bladder, varying with the size, shape, and number of the stones, and also their roughness of surface. Frequent urina- tions, tenesmus, pain before, during, and after urination, some- times incontinence, and always more or less cystitis. Haunaturia is not at all infrequent, and the urine presents all the characters of bladder inflammation, as shown by the presence of pus, epithelium, and, sooner, or later, numerous crystals of the triple and amorphous phosphates. The constitution suffers from the constant pain and frequent urination, and the patient gives all the symptoms of a severe cystitis. Diagnosis.—This is comparatively easy in the female bladder, NON-INFLAMMATORY DISEASES OF THE BLADDER. 781 for between the judicious use of the sound, conjoined manipulation, and the bladder speculum, a stone can hardly escape detection un- less it be very small or completely encysted. Prognosis.—The prognosis in vesical calculus in women is good, provided the kidneys be not seriously disordered. The cystitis usu- ally disappears soon after removal of the foreign body, under proper treatment; and even if renal disease exist, it may also sub- side. Causation.—The causes of stone in the bladder are about the same in both sexes, and so I need not dwell long on this part of the subject. I may call attention to one cause of the formation of stone in the bladder of the female. In cystocele, a mass of mucus or shreds of membrane and triple and amorphous phosphates gradu- ally collect in this abnormal pouch, and form a nucleus for stone. It is a curious fact, too, that women are particularly liable to have stone after the operation for closure of vesico-vaginal fistula. There has been considerable discussion as to whether calculi, discovered soon after this operation, existed undiscovered in the bladder before the operation, or were formed rapidly after it. Henry F. Camp- bell, M. D., of Virginia, relates one case in favor of the former view, and Dr. T. A. Emmet several in favor of the latter. The belief has been advanced that irritation in the bladder mod- ifies the urinary secretion sufficiently to cause deposit of the urin- ary salts, and thus account for the formation of stone after the operation for fistula. It is claimed that reflex nerve action is ex- cited by the operation, the inflammatory action about the edges of the wound, or by cystitis already existing. This idea that the reflex nerve influence modifies the urinary se- cretion sufficiently to result in the formation of stone in these cases, is, I think, hardly tenable; for in hundreds of cases of cystitis, where the reflex action does undoubtedly exist, no stone is formed. Then, too, the secretion is as a rule rendered more watery, instead of concentrated, a condition in which precipitation of the urinary salts would be very unlikely to take place. A middle position on this question seems to me to be the most rational, and stones found after operations for closing fistula might be due to any one of three causes : (a) Calculus already existing in the bladder, escaping detection by being pocketed, or so small as to lie beneath a mucous fold, and rapidly increasing in size after operation, due to the retention of the salts of the urine (deposited by decomposition), that formerly es- caped by means of the fistula. 732 DISEASES OF WOMEN. (b) Calculi, small or large, existing in the kidneys or renal pelves, and washed down after the operation by the increased flow of limpid urine: these, too, increasing in size by incrustation. (c) Calculi, the formation of which commences directly after closure of the wound, due partly to retained products of decomposi- tion, possibly to modified secretion, or to small nuclei swept down from the kidney, or, what is much more likely, to nuclei consisting of pieces of mucous shreds, blood-clots, or possibly incrustations on one or more of the sutures which may be exposed in the bladder. I am quite sure that the formation of calculi after closing a ves- ico-vaginal fistula is favored by the presence of the catheter in the bladder during the healing process. The drainage is imperfect and if the bladder is not frequently washed there is every facility for the deposit of urinary salts and the formation of stone. I am the more persuaded that this explanation is correct from the fact that, since I have permitted my patients to empty the bladder in the natural way after the operation, I have not had a case of stone following this operation. Treatment.—The female bladder presents an inviting field for experiments on the treatment of stone by solvents ; but as the opera- tion here is so easy and its results so good, it seems hardly justifiable to recommend any other method of treatment. In patients, how- ever, who object to the operation, it may be tried. For a full and interesting account of experiments and statistics on the solvent method, I refer to Mr. Roberts's most excellent work on "Urinary and Renal Diseases." The stone being found and its size determined, it may either be removed by cystotomy or crushed. If the stone be small and soft, it may be advisable to crush it, washing out the fragments through the open speculum in the moderately dilated urethra, thus saving the urethral mucous membrane from laceration by the sharp frag- ments; or better still the debris may be removed by Bigelow's method. If much cystitis be present, however, or if the stone be large, it is advisable to perform vaginal cystotomy. In this way a stone of large size may be removed from any part of the bladder, and an opening for drainage is left to act beneficially on the inflamed organ by giving vent to the urine and its sediment. The bladder should be carefully washed out daily with a warm solution of salicylic acid (1 to 600 or 1 to 400). If drainage is desired, care must be taken to keep the incision open, for it closes very readily. I have spoken several times already as to the method of per NON-INFLAMMATORY DISEASES OF THE BLADDER. 783 forming vaginal cystotomy. Emmet dwells especially and justly on the necessity of fixing the vesico-vaginal wall ririnly with a tenacu- lum before commencing the incision, which may be made with cither a knife or scissors. A calculus in the bladder, if interfering with labor, or if liable to be caught between the child's head and the pubes, should, if possible, be pushed up out of the way. This is seldom successful, and as much damage may be done the bladder by the crushing of its walls, it is best to puncture and remove the stone at once in case there is time during the labor and the attendant is prepared to operate. Should it be impossible to operate before labor is completed, it should be done as soon afterward as practi- cable. It should be borne in mind that the vascularity is greater in the puerperal state and hence every preparation should be made to arrest haemorrhage. ILLUSTRATIVE CASES. Foreign Bodies in the Bladder.—By L. H. Dunning, M. D.; read before the " Indiana State Medical Society " : Case I.—Mrs. A., aged thirty-eight, married, a lady of culture and refinement, was delivered, four years previously, of a hydro- cephaloid child. The delivery was instrumental. Whether from long pressure of an abnormally large head, or from maladroit use of instruments, I know not, a vesico-uterine or vaginal fistula re- sulted. The precise location of the original opening of the vaginal or uterine extremity of the fistula I am unable to state, as two operations had been done for its closure, both of which were un- successful. The last operation was done in June, 1883, and in the following December I was consulted in consequence of intense pain and burning in the region of the bladder, and pain at the close of the act of urinating. The patient stated she had, a few weeks previously, passed a small stone by the urethra, and now thought there was another and larger one present. An examination with the sound confirmed her diagnosis. I proceeded to remove the stone, assisted by Dr. S. L. Kilmer. The urethra was dilated with a three-bladed dilator, the stone crushed with a Thompson's lithotrite, and removed with Bigelow's evacuating apparatus. We were both confident all the stone was removed. The patient made a good recovery, but was not entirely relieved of the bladder symp- toms. Id March, 18S4, I was again called to remove a stone, which the patient stated she had felt with the large end of a shawl-pin in- troduced into the bladder through the urethra. This time, assisted by Dr. M. L. Morse, a large quantity of stone was removed in the same manner as at the first operation. The lithotrite was introduced 7S4 DISEASES OF WOMEN. three times, and, the last time it was withdrawn, we found within the grasp of its closed blades a silver-wire suture, with the loop cut, but the twist intact. The whole was coated with a phosphate-of-lime deposit. We now felt confident we had secured the foreign body around which the calculus had collected. The patient stated to us that she had been aware ever since the last operation for fistula that there was a wire left behind, and that she had once visited the sur- geon to have it removed, but it could not be found. There are many other points of exceeding interest connected with this case, but they are not pertinent to this subject, hence will be omitted. There was a band of dense cicatricial tissue extending transversely across the fundus of the bladder. Posterior to this band was a pocket, in the bottom of which was the vesical extremity of the fist- ula. In this pocket lodged the stone, and was evidently made sta- tionary by the suture, which remained partly imbedded in the tissues. That the wire rendered the stone stationary finds support in the fact that, July 18th, four months after the wire was removed, a fourth large calculus had formed in the bladder, and was quite movable. This last calculus was readily crushed, and voluntarily expelled from the bladder along with water freely injected into the organ. Since this fourth stone was removed, there have been no signs or symp- toms of a calculus in the bladder. Case II.—Mr. B., a laborer, aged fifty-seven years, was brought to me, by Dr. Kettring, September 19th, of last year, for the re- moval of a foreign body from the bladder. The patient stated that, about the middle of August, he passed a cigarette-holder into the orifice of the urethra; that it slipped away from him, and passed down into the urethra, and, in his efforts to remove it, pushed it into the bladder. Being a mechanic, he had invented an instrument with which he attempted to remove the body, without success. I sounded the bladder, and found the holder lying obliquely across the organ. I judged it to be about two and one half inches long, and as thick as a small lead-pencil. A Xo. 18-§- sound dropped readily into the bladder, and, since the urethra was of so large a caliber, and the patient had frequently passed his instrument along its track, I concluded to attempt its removal without further dilatation. A Thompson's lithotrite was introduced, and the body seized ; but I was made conscious that the instrument did not grasp it at the end, so I withdrew the lithotrite and introduced a sound, and endeavored to bring the long diameter of the holder in line with the urethra. Now, with but little difficulty, the end was grasped by the blades of the lithotrite, and I proceeded to withdraw the whole. It soon NON-INFLAMMATORY DISEASES OF THE BLADDER. 7$5 became evident that we had not rightly estimated the size of the holder, for, although it, together with the instrument, entered the prostatic portion of the urethra, we had considerable difficulty in making it advance through the membranous portion. However, avoiding much force, but keeping steadily at work, with the aid of Dr. Kettring, I succeeded in withdrawing it to within one inch and a half of the orifice of the urethra. Further than this we could not advance; so the urethra was incised posteriorly down to the end of the holder, and, by applying pressure from behind, made to enter the incision, and was finally entirely withdrawn. We were surprised to see the size of the holder and its breadth when in the grasp of the lithotrite, thirty-five millimetres. There was a moderate amount of haemorrhage from the urethra or bladder; probably from the mem- branous portion of the urethra, since that is the most constricted por- tion of the canal. The bladder was washed out with tepid water, and the patient taken to his home in a closed carriage, the operation having been done at my office on account of the patient's refusing to have it done at home for fear of exposure. Soon after reaching home, the patient had a chill, followed by fever. In the next twenty-four hours he had three chills, each time followed by in- creased fever, the temperature ranging from 102° to 101° F. The urine passed was freely mixed with a considerable quantity of mucus and a little blood. 20th, 1.30 p. m.—Patient seen by Dr. Kettring and myself. Had a temperature of 106°. He voided urine in our presence; it was quite bloody, and, upon close examination, was found to contain a wedge-shaped piece of mucous membrane twelve millimetres long, four millimetres broad, and about two millimetres thick. This was not examined with the glass, but was supposed to be from the mem- branous portion of the urethra, since at that point there wTas the most resistance. There were also voided at this time several small grains of gravel, some as large as wheat-grains Patient complained of con- siderable pain. Bladder was washed out with warm carbolized water. Twenty grains of quinia sul. were given ; one grain opium and ten grains of acetate of potash every four to six hours, and a milk-diet ordered. Further than this, I will not attempt to minutely detail the history of the case, but will simply outline it. In the next twenty- four hours the patient had four chills. The temperature ranged from 101° to 104°, and the pulse from 108 to 120 per minute. Patient perspired profusely, and was at times delirious; great nervousness; prognosis was regarded unfavorable. Whisky, in 3 jss doses, every hour, when the temperature mounted high, was added to the treat- 786 DISEASES OF WOMEN. .ment. Dr. Kettring washed out the bladder twice every day, using for this purpose a soft-rubber catheter and a rubber bag. We de- bated the advisability of this procedure, but found that, by this means, we removed a considerable quantity of turbid urine, small clots of blood, and occasionally small grains of gravel; and further, the cleansing of the bladder seemed to afford the patient relief; so we decided to persist in it as long as its use was indicated. 22d.—Patient slightly delirious; pulse, 112; temperature, 1<»1°; slept moderately well last night; has had no chill since 9 p. m. yes- terday. Dr. Kettring found morphine, gr. one sixth, ar. spts. ammo., 3 jss, very efficient in relieving or aborting the chills. At noon to-day patient-seemed much better; at 9 p. m. temperature had fallen to 100°, and pulse to 90 ; but the urine had accumulated in the blad- der, and had to be removed by catheterization. 23d, 7.30 a. m.—Patient rational; has slept well during the night, and voided urine frequently; pulse is 70, and temperature normal; the nervous symptoms have nearly disappeared ; had symp- toms of a chill last night, which quickly disappeared under the effects of the morphine and ar. spts. of ammo., with the addition of ten drops of chloroform. From this time forward the recovery was uninterrupted. In one week the patient was able to sit up. A few days later he was walk- ing about the streets, and in two weeks after the operation resumed work. Thus happily terminated a case that at one time was exceedingly alarming, in consequence of the intense urethral fever that devel- oped. It would undoubtedly have proved fatal had it not been for the skill and unremitting attention bestowed upon the case by Dr. Kettring. Stone in the Bladder; Lithotrity by a Single Operation. (N. A. Powell, M. D., Edgar, Ontario.)—S. F., aged now five years, first presented symptoms of trouble referable to the urinary organs in October, 1876. Pain, partial incontinence, and the passage of blood and mucus continued from this time, and in January, 1878, a bit of " gravel" the size of a split pea came away. During the following spring the desire for urination became almost constant, and vesical tenesmus was marked. On June 12th, my friend, Dr. Blackstock, of Hillsdale, was called to see her, and on the 13th, under an anaesthetic, he examined, and found a calculus at the neck of the bladder. An operation for its removal was advised, and pending this, anodynes were freely given. On July 9th, the writer, in consult* NON-INFLAMMATORY DISEASES OF THE BLADDER. 787 tion, saw the case for the first and only time. The child was said to be failing very fast; she was much emaciated; was suffering severely, and seemed to gain a respite from her pain only when violently rocked while in the knee-chest position in a cradle. Pulse 140, temperature 102^° F. Chloroform, replaced later by ether, was given, and a stone found jammed into the upper part of the urethra. This was displaced upward, caught in the blades of a smaller Weiss and Thompson lithotrite, and crushed. The scale showed five eighths of an inch separation of the blades. Further comminution of the fragments was effected by means of long polypus forceps. Evacua- tion was accomplished by the same, aided by the frequent injection and aspiration of warm water through a large-sized Eustachian catheter, to which a strong rubber bulb had been attached. This last was the best substitute at hand for Bigelow's or Clover's appa- ratus. The vagina was too small to admit a finger without undue stretching, but water could be retained in the bladder by pressure upon the urethra. The first calculus being removed, suprapubic pressure brought two other and smaller ones within reach, and these were treated as the first had been. The distance between the outer surfaces of the blades of the forceps used when grasping the largest fragment re- moved was three tenths of an inch; this, then, was the limit of urethral dilatation. The lithotrite was used for crushing five times, the forceps twenty or thirty times. The time occupied was one hour and a quarter. The bladder being washed and aspirated till, as nearly as possible, freed of its solid contents, the child was put to bed with hot applications over the pubes and to the extremities, and a full anodyne was given. The detritus collected at the time of operation weighed 241 grains; subsequently seven grains more were obtained from the strained urine. For the history of the case after this, I am indebted to notes kindly sent me by Dr. Blackstock or his assistant Mr. Gould, who, with my students Messrs. Shepherd and Bremmer, gave assistance during the operation. " Partial control of the urine returned on the day following the lithotrity, and complete control, except during the night, after tliree days. The desire to void urine occurred about every hour for several days, and at the end of a week, about every third hour. Slight haematuria was noticed for two days." Under date August 27th, I hear that "the child's general health is good. She is gaining in flesh, and has no symptoms of her former trouble." The above case would a year ago, hardly have merited transcrip- 788 DISEASES OF WOMEN. tion from the case-book of a country physician to the pages of a medical journal. But since the appearance of Dr. Bigelow's paper on litholapaxy * the whole subject of the tolerance of the urinary bladder for prolonged instrumentation has come up for reconsid- eration, and this is offered in evidence. From Civiale down, all lithotritists, so far as the writer's knowl- edge extends, have held that the visits of a lithotrite to the interior of a bladder must be strictly limited in point of time. Though ex- perts may, at times, have given themselves more latitude, they have always taught others not to exceed five minutes for any one crush- ing. Of late years, also, the tendency has been to confine the opera- tion within narrow and yet more narrow limits, treating by it only such moderate sized stones as could be got rid of in from two to four sittings. It remained for the Harvard professor to demonstrate that the calculus-containing bladder of an etherized man might be manipulated for one, two, or more hours, and yet not resent it by cystitis or subsequent atony ; provided that no sharp fragments were left in it to do outrage to its lining membrane. Although the case just given occurred in a female child instead of in an adult male, it seems to support Dr. Bigelow's conclusions as to vesical tolerance. Surely the delicate tissue of a child's bladder is ill adapted for pro- longed contact with instruments, while the proportion of the organ covered by peritonaeum in the child being greater than in the adult, there would seem to be a greater danger of serous inflammation. Yet, here all irritation promptly subsided when the irritant was re- moved, although its removal took one hour and a quarter. May we not expect like results when even large stones are crushed in the male bladder, and evacuated by the new method \ Statistics so far —seventeen cases, sixteen successful—seem to point that way. It may be asked why the urethra was not more widely dilated in this case? My answer is that too large a proportion of those thus treated have been made dribblers for life by it. The case with which stretching may be accomplished, and the free access which it gives to the bladder, will strongly tempt a surgeon who does not look beyond the operation he has to do at the future life of his patient. Prof. Simon, of Heidelberg, made y many accurate meas- urements to determine the extent to which the adult female urethra may be dilated without the risk of incontinence. His limit is in width, eight tenths of an inch; in circumference, 6'3 cen., (=2'4 inches). This would allow a finger to pass, but not a finger plus a * " American Journal of Medical Sciences," January, 1878. f Translation in " New York Medical Journal," October, 1875. NON-INFLAMMATORY DISEASES OF THE BLADDER. 789 pair of forceps. Mr. J. R. Lane thinks no stone larger than an acorn should be removed entire through the urethra of an adult female, and none larger than a bean through that of a child. Dr. Hunter McGuire, of Eichmond, Va., states that many cases of so- called successful operations by dilatation and extraction have, to his personal knowledge, been followed by incontinence. Rapid dilata- tion, however, seems to be less dangerous than slow. In proof of this, I may, in conclusion, mention that I have knowledge of the case of a girl, aged twelve years, into whose bladder a pair of sequestrum forceps was pushed, a calculus seized and extracted vi et armis, dilating and lacerating the urethra as it came. The stone was as large as a pigeon's egg. Absolute incontinence existed for twelve days, but was followed by recovery. Stone sacculated in the Bladder of a Female. (By Charles Will- iams, F. P. C. S., Ed., Surgeon to the Norfolk and Norwich Hos- pital).—Cases in which a vesical calculus is impacted in a cyst situated in the walls of the bladder are so extremely rare that I consider it a duty to record this very interesting example : A fine, healthy girl, aged three years, living in Norwich, came under the care of the late Mr. George Hutchison in the year 1873, having for several months previously suffered from very decided symptoms of stone in the bladder. It had been noticed by her mother that from the time of her birth she had experienced diffi- culty, as well as occasionally severe pain in passing urine, and that sometimes she voided blood mixed with it, and was in the habit of straining so violently as to produce prolapsus of the rectum. On sounding the bladder, which was an unusually capacious one, it was with some difficulty that a calculus could be detected. At the wish of the parents Mr. Hutchison resolved to remove the stone by dilatation. Mr. W. H. Day assisted at the operation, and I was requested to administer chloroform. The urethra was freely and quickly dilated with Weiss's trivalve dilator. There was considera- ble trouble to find the stone, and when found a still greater trouble to seize it with the forceps, (and it was particularly noticed that, although the patient was thoroughly under the influence of the anaesthetic, the getting hold of the stone with the forceps occasioned severe straining); the blades could not be made to grip the calcu- lus ; they continually slipped off, bringing away pieces of the stone. At last it became absolutely necessary to ascertain what occasioned the difficulty. For this purpose the urethra was still further dilated, and the neck of the bladder was also divided with a probe-pointed bistoury. The stone could now be felt with the point of the finger 790 DISEASES OF WOMEN. immovably fixed in the floor of the bladder on the patient's left. It appeared to be of the size of a pigeon's egg, and was inclosed in a sac, through the neck of which a small portion protruded into the vesical cavity, and it was off this nodule that the forceps so continu- ously slipped. Many efforts were made to dislodge it—first with a scoop, then with the finger, which could barely reach it, and next with the forceps; they all proved unsuccessful. Several portions were broken off the uncovered portion, but the main piece was left in situ, as it was considered undesirable to make any further at- tempt to remove it, the patient having been a long time under the influence of chloroform, and apparently in a very exhausted con- dition. The next day the child had voided very little urine. A catheter was introduced, and a small quantity of sanguineous urine flowed out. She was very drowsy, and had been so since the operation. When aroused she took milk and brandy very freely, but immedi- ately afterward became drowsy again. She did not appear to have recovered from the influence of the chloroform. The next day she died. No post-mortem examination was permitted. I am induced to believe that this child died of chronic chloroform- poisoning, and not from the effects of the operation, which was by no means roughly performed, and that there was very little blood lost. She never thoroughly revived, but became comatose, and died in that condition. It is difficult to imagine what could have given rise to the formation of the sac. There never was an obstruction to the escape of the urine, such as stricture or prostatic enlargement might engender, for neither existed. We are taught that a cyst is usually formed by the straining necessary to expel the urine; the mucous membrane is forced between the bands of muscular fibers, hypertrophied in consequence of the strain to which they are sub- jected. Nothing of the sort can apply in this case, and it is not easy to believe that the stone was the cause of the cyst, which it might have been, had it been situated close to the neck of the bladder. When impacted in this situation, the very pressure to which a stone is subjected by the constant and long-continued action of the bladder to expel it, causes the mucous membrane to ulcerate through, and the stone is in due time forced into a cavity, which enlarges as the stone grows, and in this way it may form a tumor in the vagina. An effort is then made by nature to contract the opening, which in this child was nearly accomplished ; but the calculus was far from the neck of the bladder, and could barely be touched with the point of the finger, so that a different explanation of the formation of the NON-INFLAMMATORY DISEASES OF THE BLADDER. 791 cyst is required ; and as no examination was allowed to be made, it seems to me to be almost impossible to suggest in what way the sac was formed. Sabulous matter, or a few urinary crystals, may prob- ably have been deposited originally in a mucous follicle, lacuna, or fossa, and gradually augmented in quantity, and in this way the sac inclosing the calculus may have been produced. The mother of the girl at four years of age suffered from stone, which was removed by the late Dr. Edward Lubbock; it was the size and shape of a wal- nut. She has suffered from incontinence since that time. I believe that it would have been very much better to have re- moved this stone by cystotomy. Had the patient lived she would have suffered from injured urethra. (c) Foreign Bodies introduced into the Bladder through the Urethra. —Of these it may be truly said that " their name is legion," for in the literature of the subject we find recorded a most numerous and diverse list of objects found in the bladder of the female. Some of these objects were forced into the bladder by accidents, such as falls or blows; others were intentionally introduced into the urethra for the purpose of masturbation, and then pushed or drawn into the bladder. The same may occur in auto-catheterization, the instru- ment being sometimes broken off in the bladder, and at others, drawn bodily into the viscus. Hysterical and foolish women, with or without the intention of masturbating, have passed all manner of things into the bladder, as pins, needles, matches, sand, charcoal, bits of glass, bodkins, and tooth-brush handles. Masturbators have also forced in various articles, such as twigs, small wax candles, penholders, nails, pencils, and the like. Cathe- ters and clay-pipe stems, that have been used for purposes of cathe- terization, have been broken off and left in the bladder. Pessaries, which have been badly fitted, or worn too long, have passed by ulceration from the vagina into the bladder. Symptomatology.—The symptoms need not be given in detail, as they are the same as those caused by any foreign body, usually aggra- vated, however, if the body be sharp and have jagged edges. Bleed- ing is not uncommon, and pain varies in amount and severity with the kind, size, and shape of the foreign body. Hysterical women have been known to conceal the pain and tenesmus for a long time. If the bodies be small and blunt, they may give rise to but little pain or tenesmus, and, remaining in the bladder undisturbed, form nuclei for calculi. I doubt if a modification of the urinary secretion by reflex nerve influence (excited by these bodies) is necessary to 792 DISEASES OF WOMEN. cause incrustation, or form calculi. The hypersecretion of mucus and decomposition of urine is all that is required. Treatment.—The treatment of a foreign body in the bladder is summed up in two words—remove it. This must first be tried through the urethra. A pair of forceps (those known as the alli- gator forceps being the best) are guided to the object, which is to be seized and removed. If this is difficult, the operation may be done through the speculum. If the bodies be small, they may possibly be washed out. If they are so situated that their removal by the urethra is impossible, vaginal cystotomy may be performed, and the foreign bodies thus removed, using such after treatment as will re- lieve any cystitis, which may have been produced, CHAPTER XLIV. NON-INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED). RUPTURE OF THE BLADDER. Rupture of the bladder may be classified according to its loca- tion and extent, as follows: I. Complete and incomplete. II. (a) Occurring at a point where the bladder is covered with peritonaeum. (b) Where the bladder is not covered with peritonaeum. I. In the complete rupture all the coats of the organ are divided, while in the incomplete variety one coat at least remains undivided. Pathology.—The complete form of rupture is the most common, and the location at which it most frequently occurs is the posterior and upper part; that is, the part where the walls of the bladder are the thinnest, and probably where there is the greatest exposure to the causes of the injury. There is another reason given why rupture is more frequent where the bladder is covered with peritonaeum, and that is because the peritoneal covering is not so elastic as the other coats. When the laceration occurs within the limits of the peritoneal coat, and is complete, the urine escapes into the peritoneal cavity, and produces shock and peritonitis, which usually prove fatal. In rupture at any point not covered with peritonaeum, infiltra- tion of urine takes place in the tissues beneath, not within, the peri- tonaeum. This infiltration is sometimes very great, extending from the cellular tissue of the pelvis to the labia and thighs. The clinical history of these two varieties differs in its char- acteristics because of the fact just mentioned—that in the one va- riety the urine escapes through the rupture into the peritoneal cavity, while in the other the urine infiltrates the tissues in and about the pelvis. 52 701 DISEASES OF WOMEN1. In the one, peritonitis is speedily developed, as a rule, and gen- erally proves fatal; in the other, the progress is slower, and the chief danger is from septicaemia. There is another class of cases having a pathological history which holds an intermediate position between the two already described. In this class the history points to the fact that the rupture has been at a point destitute of peritonaeum, or else the rupture has been incomplete, not involving the peritonaeum. This gives rise to symptoms of severe internal injury, but less severe than in complete rupture, which is followed by a sudden giv- ing way and escape of urine into the peritoneal cavity, and subse- quent peritonitis. This opening into the peritoneal cavity at a pe- riod remote from the injury, is due to pressure or ulceration or sloughing, which completes the rupture. Symptomatology.—-The symptoms of rupture of the bladder are ordinarily developed as follows: There is usually shock in a matked degree, and if the pelvic bones are broken—a frequent complication of this injury—the patient is unable to move after having rallied from the shock. Severe pain is felt in the hypogastric region, and a continual desire to urinate, without the power to void the smallest quantity of urine, or possibly but a few drops mixed with blood. The constitutional symptoms indicate great prostration, which rapidly ensues. The patient has an anxious look, the countenance is pale, the pulse feeble and fluttering, respiration sighing, skin clammy; the abdomen in a short time becomes tympanitic. There is also a rise in temperature after a time, but during the shock the temperature may be sub-normal; delirium, convulsions, and coma may occur, and death may take place in a few hours in severe cases, or it may be delayed a few days. A fatal result occurs sooner in complete than in incomplete rupture. If the patient survives the shock or collapse, life may be en- dangered by the development of peritonitis or septicaemia. The physical signs of rupture are few and by no means reliable. I must therefore give more attention to the clinical history and symptoms, incidentally bringing out the only physical signs obtainable, such as the empty state of the bladder found when that viscus has not been emptied in several hours, and the withdrawal of a small quantity of bloody urine by means of the catheter. The surgeon is not able to make a certain diagnosis in all cases, as the symptoms are not always pathognomonic. The statement of the patient that she received a blow over the hypogastrium, or that while in the act of straining she felt something give way, are valu- NON-INFLAMMATORY DISEASES OF THE BLADDER. 795 able as evidence when acute pain and other symptoms of rupture follow. The evidence obtained from the use of the catheter is of value, especially when it is known that the patient had not urinated for several hours prior to the accident. Under these circumstances when the bladder may contain a small quantity of bloody urine or when the bladder is empty, there is strong evidence of the bladder being lacerated. But the evidence pointing to rupture is by no means always certain. And again very often signs and symptoms which the diagnostician depends upon most are absent, and those that are present are liable to mislead. This is very unfortunate, but true. The diagnosis is especially ob- scure when there has been a long interval between the receipt of the injury and the development of characteristic symptoms. It is there- fore necessary to watch a patient in whom there is suspicion that rupture of the bladder may have occurred. The symptoms may be for a time concealed and then develop rapidly. The first symptoms may be delayed or be obscure and not attract attention, because the vesical rupture may be involved with other injuries whose symp- toms for the time hide the more dangerous lesions. As a rule, it is rare to find any external signs or mark of injury on examination of the abdomen. When much depends on the history given by the patient regarding the nature of the accident and the condition of the bladder at the time, it frequently happens that she is not able to answer questions correctly, because of the shock and the fact that this accident often occurs while the patient is intoxicated. Strange as it may appear, in exceptional cases the patient may have no difficulty in urinating, and indeed may pass a large quan- tity of water. Cases have been recorded where the patient regained the power of voluntary urination after the catheter was passed for the first time. Although it is important to make a diagnosis early in all cases, yet it is of equal importance to know whether the rupture is com- plete or incomplete. This can be done by noting the fact that in the one case there will be infiltration of the urine into the cellular tissue of the pelvis, and in the other such infiltration is absent. It is often necessary to pass the catheter both for diagnosis and treatment, and great care should be taken in its introduction, for sometimes by using too much force it is accidently pushed through the viscus into the abdominal cavity. Prognosis.—The chances of recovery are not favorable, espe- cially when the urine passes into the peritoneal cavity through a 796 DISEASES OF WOMEN. rupture high up. When the rupture is incomplete or does not in- volve the peritoneal coat and treatment is early employed, the pros- pects of saving the life of the patient are encouraging. Causation.—The predisposing causes of rupture are certain con- ditions of the walls of the bladder, such as atrophy, fatty degenera- tion, ulceration, and sacculation; overdistention from stricture or other causes, and alcoholic intoxication which favors overdisten- tion, and exposure to the exciting causes of the accident. The empty bladder may be lacerated in connection with injuries of the other pelvic organs, but it is a fact that in the majority of cases the bladder has been less or more distended at the time of the accident. It should be borne in mind, however, that rupture has occurred a great many times when the bladder was normal and not overdis- tended, there being no predisposing conditions present that could be recognized. The most common determining causes are blows over the region of the bladder. These may be sustained in a variety of ways, such as direct blows or knocks, falling from a height upon something which violently strikes upon the hypogas- trium. Rupture often occurs in connection with severe injuries which fracture the pelvic veins. In such cases it is not possible to say whether the rupture occurring under such circumstances is due to the direct blow or to laceration by pieces of the broken bones. Rupture has occurred sufficiently often in the puerperal state to warrant placing this condition in the list of predisposing causes. One can see how a distended bladder might be ruptured during the violent labor-pains or the contortions of instrumental and manual delivery, and this accident has occurred in that way. In a number of cases, however, the rupture has not taken place un- til after delivery, showing that the labor gave rise to retention, and that to rupture. So far, then, as the puerperal state is related to rupture of the bladder it may be said that a full bladder may be ruptured by the direct violence done during delivery, but quite as often retention occurs in the puerperal state, and the rupture is caused by overdistention. In a similar way rupture has occurred in displacement of the uterus which caused retention of the urine. The bladder has frequently been wounded during ovariotomy and hysterectomy when there were adhesions, but this accident does not come under the head of rupture now under consideration. Treatment.—The first indications are to relieve pain and shock if either is present. These objects can be attained usually by opium and stimulants. If there is infiltration of urine into the pelvic cellular tissue the urine should be removed by puncturing or incis- NON-INFLAMMATORY DISEASES OF THE BLADDER. 797 ing the parts affected. Next, and most important of all, the bladder should be continuously kept empty by retaining the catheter in the bladder. The catheter should be a flexible one of soft rubber with a perfect eye very near the end. It should be made to enter the bladder only far enough to secure perfect drainage and not far enough to disturb the wound in the bladder. Yaginal cystotomy has been recommended as a means of drainage, but I feel sure that the catheter is a simpler, and certainly as reliable a means of accom- plishing the object. The management of the graver cases, in which the rupture opens into the peritoneal cavity, must be of the most heroic character in order to be effectual. The great object is to cleanse the peritoneal cavity of urine and blood. This has been done when the case was seen early, by pass- ing the catheter into the peritoneal cavity through the rent in the bladder. When this can be done easily it may answer that purpose, and the patient may be treated by rest and opium; but, unless the catheter passes without much effort and the one catheterization is sufficient, this method should not be persisted in. Laparotomy appears to offer the best chances in these very for- midable cases. If the patient is seen early, and before extensive peritonitis has been established, I believe the best that can be done is to open the abdominal cavity, and thoroughly remove all blood and urine that have accumulated. When this has been accom- plished the wound in the bladder should be accurately closed with sutures. In case the edges of the wound are very irregular, and will not fit together accurately, they should be trimmed suffi- ciently to give a clean and complete coaptation. The after-treat- ment should then consist in draining the bladder, as already mentioned, and managing the patient as in laparotomy for any purpose. ILLUSTRATIVE CASES. Case of Rupture of Female Bladder associated with Abortion (by T. Lawrie Gentles, L. F. P. S. G., Derby).—On October 13th I was requested, at 3 a. m., to visit a woman in a neighboring street, who was said by the messenger (her husband) "to have had a mishap." On reaching the house I found a well-made woman of thirty-six lying on her left side in bed, vomiting large quantities of a dark- brown, pungent-smelling liquid. The pillows were drenched with the fluid, so also was the carpet in front of the bed, and on the walls opposite to the patient were stains of a similar nature. There was also half a pint of vomit in the chamber-vessel. The woman was in 79S DISEASES OF WOMEN. a state of collapse; a cold, clammy perspiration stood on her face, her hands and feet were like ice, and her pulse was imperceptible. There was no one in the house except her husband and two little children, the latter occupying the same bed as the patient; while, to add still more to the ghastliness of the scene, the younger of the children (a babe of nine months) was vainly endeavoring to reach its dying mother's breast in order to obtain its usual nourishment. I made a rapid examination by the vagina, but found a closed os uteri, and no marked traces of haemorrhage. I observed, however, .that the abdomen was greatly distended. I tried to administer some ammonia, but the patient was unable to swallow; she gave me one agonizing look of dread, moved her lips as if to speak, and then died, the death taking place within a quarter of an hour after my arrival at the house. My first impression was that the woman had died of internal haemorrhage; the only things which seemed to militate against this being the redness of the lips and the copious vomiting. This idea of haemorrhage seemed also confirmed by what the husband said at the bedside—viz., that " his wife had had a good many clots come from her, and that her linen was very much stained." I refused, of course, to give any certificate, and communicated with the coroner. In collecting evidence for the inquest, the follow- ing facts were clearly brought out; first, that the woman was a drinker; secondly, that she had had a drinking-bout for some days; and thirdly, that she had had occasional difficulty in passing urine. In regard to the first two points, the husband's evidence was most conclusive, and showed clearly that v/hen the poor woman had one of her drinking-fits on, she would not only consume large quantities of beer (her favorite drink), but also all the spirituous liquors she could lay her hands on. In regard to the third point, the hus- band also made clear the fact that his wife had often suffered from retention of urine, but, "so far, had always got over it." At the inquest, further details of evidence brought to light the fact that the woman had complained of pain in her belly for two or three days previous to death. She had, however, been " up and down stairs " until 1 p. m. of the day preceding her death; but when her husband came home at 6 p. m., he found her in great pain, and was told by his wife that "she had been losing blood." A good many clots were in the chamber-vessel, and these he threw away into the ash- pit. The pain getting no better, and finding that his wife was - altering for the worse," he came for a medical man as already stated. NON-INFLAMMATORY DISEASES OF THE BLADDER. 799 At the autopsy there were no external signs of violence found, except a slight abrasion on the forehead, and another on the lower lip, and a small bruise on the inner side of the right thigh, none of which were of recent date. On cutting through the abdominal walls, the great depth of fat and its extreme " wateriness" arrested our at- tention, the knife going through the tissue with a distinct " swish." Suspecting an accumulation of fluid in the abdominal cavity, a small incision was made at first. No sooner was this done than a reddish- brown liquid began to well up. Some of this was drawn off, and the opening enlarged, when nearly six pints of fluid were removed. The stomach and intestines, having been carefully examined, were then taken out, in order to facilitate further search for the lesion. The first thing which we noticed was a pint of blood lying in the pelvic basin ; and, on making more minute search, a rent was discovered in the posterior wall of the bladder—a rent large enough to admit four lingers. Here, then, was the cause of death. There were some fresh adhesions on each side of the bladder and the pelvic walls; there were also similar adhesions between the bladder and uterus. All these adhesions, however, were extremely soft, and broke with the slightest pressure. The walls of the bladder itself also seemed much thinner than usual. No flakes of lymph could be discovered in the fluid removed from the abdominal cavity, and neither did the peritonaeum exhibit any great degree of vascularity. It may be, however, I think, safely affirmed that a large portion of the fluid found was effused from an irritated peritonaeum, the other portion of the fluid being, of course, urine from the ruptured bladder. On opening the uterus, signs of recent delivery presented them- selves ; on observing which I asked my son to tell the husband to rake up "the clots" from the ash-pit. The husband did so, and one of the " clots " was found to be a foetus, three inches in length. Now comes the question : When did the rupture of the bladder occur, and had uterine action anything to do with it ? Supposing that the "pains in the belly," of which the woman complained for two or three days before death were the commencement of the abortion, it is reasonable to infer that, when true expulsive efforts on the part of the uterus began, these efforts would be aided by the action of the abdominal muscles; and, supposing still further, that the bladder was at that time distended to its fullest capacity, it is perfectly possible that the pressure of the abdominal muscles would be the "last straw" necessary to produce the fatal lesion. I am, therefore, inclined to think that the rupture took place in the after- noon of the 12th. I ought to have stated that, although, when the 800 DISEASES OF WOMEN. husband came home at 6 p. m. on that day he found his wife in bed, she, nevertheless, " kept getting out of bed, trying to pass urine, but could not." There can be little doubt that the alcoholic condition of the patient would rob her of her sense of attending to the calls of nature; and it is melancholy to think that, if she had only been seen earlier, a simple catheterism might have saved her. As a piece of concurrent evidence of the habits of the patient, it may be stated that the liver was a genuine " nutmeg"; that the kidneys were thoroughly disorganized (the cortical substance being rarely distinguishable); and that the spleen was exceedingly soft. The heart was small and fatty. The lungs wrere fairly healthy, but there were extensive adhesions in the right pleural cavity. The head was not examined.—British Medical Journal, January 6, 1883. Cases of Rupture treated by Laparotomy.—(A. G. Walter.)—Ten hours after a severe injury, no urine was found by the catheter. The abdomen was opened in the linea alba by an incision beginning one inch below the umbilicus and terminating one inch above the pubes, to the extent of six inches. The intestines were found inflated, their peritoneal coat, as well as that fining the interior of the ab- dominal walls, already showing evident marks of congestion. A soft sponge was then cautiously introduced into the abdomen, with which the extravasated fluid, consisting of urine and blood, was carefully removed from the pelvis and between the convolutions of the bowels, amounting to nearly a pint. A rent was found at the fundus of the bladder, two inches in extent. The cavity of the ab- domen being cleansed of the noxious agent, the wound of the blad- der was left to itself, as no urine was seen to escape from it. The abdominal wound was closed by strong Carlsbad needles, secured by silver wire (only skin and fascia being stitched, while the peritonaeum was left untouched); a flannel bandage encircled the whole abdomen. The patient, awakening from the anaesthetic sleep, felt relieved of pain and the desire to urinate, so distressing before the operation; vomiting did not return; opium in one-grain doses was ordered; abstinence of drink and perfect quietude of body, with retention of the catheter, were strictly insisted upon. He soon began to doze, had a comfortable night, was free from pain the next morning, com- plaining only of soreness in the abdomen, without tympanites, sick- ness, or calls to urinate; thirst less urgent. The treatment being vigorously continued, for drinks iced barley-water, water only in very small quantities, with pieces of ice, being allowed. No un- pleasant symptom followed; urine in small quantities, but free of NON-INFLAMMATORY DISEASES OF THE BLADDER. 801 the admixture of blood, passing by the catheter. On the third day the intervals between the doses of opium were lengthened to two hours; on the fifth, to three, and thus gradually decreased as all signs of inflammation had passed. At the end of a week the abdominal wound appeared to be closed by first intention; the stitches, however, were not removed till a week later. The gum-elastic catheter was replaced by a new one every two days, and was not withdrawn for two weeks after the injury had been received, and then only for a short time. At the expiration of two weeks, with the absence of all pain and tenderness, opium was omitted. The intestines were re- lieved by warm-water injections on the tenth day, when mild nour- ishment was ordered. Between the second and third week the catheter was permanently withdrawn, and only introduced every four hours for the evacuation of urine. After the third week, the patient left his bed. He has remained well, working at his trade, and feeling no impediment in his urinary organs. (Alfred Willett).—An incision some five to six inches in length, from the umbilicus to the pubes, was made in the mesial line and carried through the parietes. All bleeding points having been se- cured, the peritonaeum was opened, and at once several ounces of dull, brownish fluid, with strong urinous odor, escaped. The intes- tines were greatly distended, and instantly bulged out through the wound. The peritonaeum generally was highly injected, and adja- cent surfaces were glued together. Passing my hand into the pelvis I detected a laceration of the bladder. The coils of gut were only slightly more adherent here than in the abdomen proper; I satis- fied myself that there was no protrusion of bowel into the lacerated bladder. The omentum was raised from off the intestines, and so much of the latter as lay in the pelvis was drawn up, laid upon the upper part of the patient's abdomen, and protected from harm and chill by flannels wrung out of moderately hot water. There was about half a pint of bloody, urinous fluid in the pelvis, and when this had been sponged away, a rent of the bladder some three and one half inches in extent was exposed. It extended diagonally across the fundus, having a direction from before backward and from right to left. The appearance was that of a nearly straight tear through all the coats of the bladder, except at its most dependent parts, where it was jagged and uneven. The bladder was flaccid, but, of course, quite empty, and at the site of rupture its walls were fully half an inch in thickness. I brought the torn edges easily in apposition, and united them by eight interrupted sutures of fine Chinese silk. The sutures were placed at intervals of rather less than half an inch, and seemed S02 DISEASES OF WOMEN. to close the rent completely. Before returning the intestines I cleaned out the abdomen as thoroughly as I was able ; but the mes- entery of the gut lying outside the abdomen acted as a transverse diaphragm, and I was disappointed to find on replacing these coils that some of the fluid had been pent up above it. Owing to gaseous distention, very considerable difficulty was experienced in replacing all the intestines within the abdomen, and I was quite unable to in- troduce my hand and cleanse the upper part of the peritoneal cavity as satisfactorily as I could have wished ; but the patient's shoulders were raised in order to make the pelvis more dependent, and all fluid that found its way there was removed. The intestines that had been lying out of the abdomen during the operation were sponged over with warm water and carefully cleansed before returning them. So extreme was their distention that to enable me to introduce sutures, and close the external wound, Mr. Langton, who assisted me, was obliged to spread out his hand and restrain the bowels from forcing their way through the wound, withdrawing his hand gradually as the successive sutures, also of Chinese silk, were tightened. Through the lower angle of the abdominal wound I passed a carbolized drain- age-tube into the pelvis, securing it to the edge of the external wound, which was then dressed precisely as after ovariotomy. A Thompson's catheter was introduced and retained in the bladder. On being replaced in bed, hot bottles were placed beside the patient, and he was well covered up. The wound in the abdominal parietes was found on the autopsy to be adherent almost along its whole line; not much swelling of abdomen. The intestines immediately behind the wound were adherent to it. All the coils of intestine in the lower half of the abdomen were adherent to each other and to the abdominal walls by recent lymph. The intestines in contact with the bladder were adherent to it. There were about two ounces of bloody fluid at the back of the peritoneal cavity; about an ounce of this lay just above the bladder. The opening in the bladder was everywhere well closed, except between the posterior two stitches, where there was an orifice through which water injected per urethram escaped very freely. Even here there appeared to be an attempt at repair. Elsewhere the edges of the wound were adherent. There was very little sign of inflammation in the interior of the viscus. (Christopher Heath).—Man, aged forty-seven. Pubes being shaved and washed with carbolic lotion, an incision was made in the middle line just above the pubes for two inches, and the tissues divided down to the peritonaeum, which appeared blue, the recti mus- cles, which were firmly contracted, being held aside by retractors NON-INFLAMMATORY DISEASES OF THE BLADDER. 803 with difficulty. The peritonaeum was then picked up and a cut made into it, when a gush of fluid, like that drawn off by the catheter, came out. A large quantity of clots was then taken out from the peritoneal cavity. The finger introduced into the peritoneal cavity found a long rent in the posterior wall of the bladder high up. This was sewed up by a continuous catgut suture firmly tied at both ends. The clots were removed as far as possible from the peritonaeum, and the cavity sponged out after injection with warm water, and a long large-sized drainage-tube was inserted at the lower angle of the wound, the upper part of the wound being brought together by deep and superficial sutures. A catheter was passed into the bladder, to which was afterward attached some India-rubber tubing leading into a vessel under the bed. Hot poultices were applied to the abdomen, and one grain of opium was administered every four hours. The fur- ther history shows great relief and improvement, but on the fourth day after the operation the patient became rapidly worse and died. Autopsy.—Small intestines considerably distended. For two inches around the abdominal wound the intestines were adherent by recent lymph to each other, and to the abdominal parietes. Above and on each side of these adhesions there was no trace of peritonitis. On tearing away these adhesions some coils of intestines were seen lying over the pelvis glued together, and to adjacent parts by recent blood- stained lymph. On lifting these coils upward, the recto-vesical pouch of peritonaeum was exposed, containing about six ounces of clotted blood, black in color, and moderately offensive odor. There was a rent in the mid line of the posterior wall of the bladder two inches in length, extending upward as high as the apex. The lower third of the rent was gaping; the edges of the rest were approxi- mated by the catgut suture, the lower end of which was free and loose. CHAPTER XLY. NON-INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED). NEOPLASMS, HYPERPLASIA, ATROPHY. Owing to the very imperfect facilities for observing the internal surface of the bladder during life, the study of vesical neoplasms up to within a few years was chiefly post-mortem, and of course their therapeutics was almost nil. At the present time, however, by means of the endoscope, the microscope, and the operation of cystotomy, more accurate methods of diagnosis and of rational and successful treatment have been developed. The neoplasms of the bladder may be classified as follows : Benign.—Myxoma, fibroma, myoma, myo-fibroma, tubercle. Malignant.—Epithelioma, encephaloid, scirrhus, sarcoma. Tumors of the bladder and deposits in its walls are by no means common, and those of a benign nature are less common than those that are malignant. There has been some dispute as to whether some of these neoplasms are malignant. This is especially the case in regard to the villous growth, the German and some English authorities ranking them as essentially malignant, while some American authors, as Van Buren and Keyes, deny in toto that they have any such property. More will be said of this when I come to the class in which I have placed them ; not that I am satis- fied that they are malignant, but for lack of positive evidence of the new idea, temporarily at least, I adhere to the old one. Benign Growths.—Myxomata, Mucous Polypi, and Polypoid Hy- pertrophies, while having nearly the same anatomical characters, are really different affections as regards etiology, symptomatology, prog- nosis, and treatment. Mucous polypi are isolated hypertrophies of the mucous mem- brane, varying in size, and giving rise to trouble only in proportion to their size. They may exist at birth, or be developed at any time during life being more common, however, in youth and middle NON-INFLAMMATORY DISEASES OF THE BLADDER. 805 age. The mucous membrane covering them is thickened and pulpy, and that about their base and in their immediate neighborhood is somewhat thickened, and more vascular than normal. If the polypi are situated at or near the neck, or in other portions of the bladder, where their long, narrow pedicles admit of a blocking of the urethra, the entire mucous membrane of the organ suffers, as in all cases of retention and decomposition of urine. If the obstruction is great, and the organ requires spasmodic and irregular muscular effort to empty it, there will be, sooner or later, not only cystitis, but mus- cular as well as mucous hypertrophy. These growths may be as small as the head of a pin, or as large as a goose-egg; they consist of hypertrophied and hyperplastic connective tissue, covered by soft, pulpy, hyperplastic mucous membrane, that bleeds easily on touch. They may coexist with uterine fibroids. Their favorite seat is the posterior wall of the bladder. General polypoid hypertrophy of the mucous membrane con- sists in an irregular thickening of the mucous membrane through- out, accompanied as a rule by hypertrophy of the muscular and serous coats. There is an increased blood-supply, the membrane be- ing bright red in color, the capillaries dilated, and the whole mass bleeding easily on the touch. It has somewhat the appearance of fresh granulations. Upon the free surface of the mucous membrane, there is, as we should expect, an excessive cell proliferation, these cells being in a transitional condition, i. e., occupying the position between imperfect and perfect, and not all of the same degree of perfection or imperfection of development. There may be either serous or gelatinous infiltration, giving it a heavy, sodden look. Upon the surface are often found incrustations of the urinary salts. It appears to me that there has been an undue complexity of classification of this subject, especially among the German patho- logists, some of whose differences are too minute to be of any prac- tical value from either a pathological, diagnostic, or remedial point of view. Tumors which they call villous or papilloma vesicae are, in many, if not all respects, identical with the so-called polypoid hyper- trophy of the vesical mucous membrane. For all practical purposes they are essentially the same. They have been described as enlarged papillae, the vessels of which are dilated, and their walls thinned. They only differ from the polypoid hypertrophy in increase of vascularity, and the fact that they are usually limited to the trigone. Underlying and about them is a thin, wavy stroma of connective tissue, that becomes in- creased as the disease advances. 806 DISEASES OF WOMEN. The surface of these growths varies very much in different cases ; in some looking like large granulations, in others having more body, being more compact, and looking somewhat like a raspberry or mul- berry. Occasionally, they are slightly pedunculated. Their surface has an epithelium resembling the superficial layer of the bladder, unless proliferation is very rapid, when the cells lose their identity, and take a multiplicity of forms, to which may be attributed, perhaps, their having sometimes been mistaken for cancer cells when found in the urine. Fatty degeneration of the most superficial cells is by no means uncommon. As the villi increase in size and number, the connective-tissue stroma, while increasing about their base, dimin- ishes in the prolongations themselves, leaving little besides a mass of tortuous, thin-walled, dilated vessels hanging free in the bladder. The rest of the mucous membrane is usually soft and hyperplastic, and, if there be any stoppage to the free outflow of urine, inflamma- tion may coexist, with incrustations, and possibly dilatation of the ureters. The muscular coat is also usually slightly hypertrophied. Fibroid tumors and myo-fibromata are very rarely found in the bladder. When they do exist they have all the characters of the fibroma or myo-fibroma found elsewhere, and give rise to the same changes in the vesical walls and ureters that other tumors do, viz., retention with hypertrophy, or dilatation, cystitis, and inflammation of the ureter. They may have their seat in any part of the bladder- wall, and occur at any period of life. Symptomatology.—The symptoms of vesical neoplasms are di- visible into local and constitutional; the former being by far the more important. The local symptoms, if the tumors be of any size, are those produced by a foreign body in the organ, viz., irritation, and sooner or later inflammation. Obstruction to urination sometimes occurs when the tumors are in a position to block the urethra, and by the sloughing off or de- tachment of small fragments, which may or may not be incrusted. These are forced into the urethra, and obstruct the outflow of urine. Pain in one form or another is almost always present. It may consist of a simple uneasiness in the hypogastric region, or amount to actual pain. It may have its seat in the hypogastric region in the perinaeum, or more rarely at the end of the urethra. It may also be felt in the loins, or along the thigh and knee. It is usually more intense, as all the symptoms are, during the menstrual flow. This is not so in all cases. Frequent urination and vesical tenesmus are as a rule present, NON-INFLAMMATORY DISEASES OF THE BLADDER. 807 but are not proportionate to the size of the tumor, a very small neo- plasm often giving rise to most intense spasm. Haemorrhage is by no means infrequent, and in some cases is very severe and not readily checked ; in others it is slight, simply tinging the urine or imparting to it a smoky appearance, that is characteristic of the presence of a small amount of blood or blood- coloring matter in acid urine. When the haemorrhage is extensive, and the bladder is distended by the fluid or clotted blood, retention of urine is apt to occur, and sometimes obstructive suppression, that may lead to most serious results. Haematuria is as liable to occur with the benign as with the ma- lignant growths, and consequently is of little value in differential diagnosis. The effects of prolonged or repeated haemorrhage upon the constitution are often most serious, and the patients are apt to be anaemic and also cachectic in appearance. I have had one case in which haemorrhage was the only symptom present. The presence of the foreign body in the organ soon gives rise to inflammation, which is seriously aggravated if retention accompany it. The urine is then found loaded with mucus, muco-purulent or purulent matter, epithelial scales, tissue shreds, bits of tumor, and the triple and amorphous phosphates. Intense and repeated vesical tenesmus aggravates the inflamed condition of the membrane, and after a time leads to muscular hyper- trophy and increased haemorrhage. In these cases, as in cystitis from any other cause, dilatation of the ureters, with a traveling upward of the inflammation and destruc- tion of the kidney, may result. This dilatation and the evil after- results are more apt to occur if the neoplasm be of sufficient size to obstruct the free outflow of urine, as at every spasmodic and forcible contraction of the hypertrophied organ some urine is dammed back in the ureters, dilating them gradually. When the ureteric openings are dilated, so that urine regurgitates at each vesical contraction, serious lesions result, as ureteritis, pyonephrosis, renal abscess, or, if the process be slow, gradual renal atrophy, uraemia, and finally death. The general system may or may not suffer severely for a long time. In most cases it does. The usual train of symptoms, such as loss of sleep, disorder of digestion, sweating, and blood contamina- tion are developed in regular sequence. The patients become thin. and have a worn, anxious expression, and, as I have already said, are apt to be both anaemic and cachectic. If renal troubles complicate this affection, casts, renal cells, and 808 DISEASES OF WOMEN. albumen may appear in the urine. In renal abscess-atrophy, or pyo- nephrosis, however, the urine may be examined for weeks without showing any renal tissue, casts, or epithelium, there being simply an abundance of pus. Diagnosis.—The diagnosis of vesical neoplasms is made chiefly by physical signs. The methods employed in their investigation may be arranged under two heads. Direct.—Bimanual touch, speculum, endoscope, curette, catheter, palpation. Indirect.—Urine. Direct.—An intelligent employment of the methods classed under the first head is all that is necessary to make a clear diagnosis in some cases. The bimanual touch will reveal the presence of the tumor, if it is of any great size, and also its size and fixation in one place. This fixed position is of much importance as distinguishing a neoplasm from other foreign bodies, stone, for example, which is movable, and can be pushed from one side of the bladder to the other. The use of the endoscope will show at once the appearance of the tumor, if it is favorably located, and by scraping away a little with the curette (through the speculum), its nature may be discov- ered by a microscopical examination. The use of the catheter or finger in the bladder, or one in the bladder and the other in the vagina, may be resorted to in cases where the diagnosis is difficult. But these are extremely painful manipulations, are not free from danger, and, consequently, should not be resorted to unless there is failure by other means. Indirect.—An examination of the urine in these cases will lead to the suspicion of the presence of some neoplasm in the bladder, from the occurrence of tissue shreds and bits of the tumor in this fluid. A piece of tumor will sometimes become detached and be expelled with the urine, and by careful searching it may be found. This can be placed under the microscope, and thus the examiner may be able to tell exactly what kind of a growth exists. Prognosis.—With our present means for exploring and operat- ing upon the inside of the female bladder, the prognosis of benign neoplasms is very good, if the operation for removal be performed early enough in the disease. Operation, however, at any time gives promise of good result. There is danger of relapse, as we learn from the cases of Simon, Hutchinson, and others. If the operation be carefully done, even incontinence of urine may be avoided, and complete, and permanent recovery follow. Without operation patients have lived as long as NON-INFLAMMATORY DISEASES OF THE BLADDER. 809 nineteen years, in some cases suffering but little; and it may be well to say that not all of these cases are accompanied by cystitis, a little pus and blood in the urine at intervals, with occasional frag- ments of tumor, being all that is found. Causation.—The causes of these neoplasms are very obscure, in- deed, no definite facts can be adduced in favor of any of the causes given by the various authors. Some speak of them as due to the irritation of calculi, calculous fragments, and incrustations. These, however, may be readily secondary to and produced by the neo- plasm, being the effect rather than the cause. Moreover, it is known that while persons carrying foreign bodies of various kinds in the bladder for a length of time, are very apt to have cystitis, neo- plasms are seldom found, and are very rare under any circumstances. Some authors look, with a show of reason, I think, to the irrita- tion from blood transudations into the bladder-walls, as a cause. This is borne out by two well-authenticated cases occurring, one in the practice of Hutchinson, of England, the other in that of Winckel, of Germany. The etiology of these neoplasms needs further care- ful study, before any cause or causes can be pronounced upon with certainty. The free and intelligent use of the modern means of physical exploration in all affections of the female bladder will in a few years throw much light upon this subject. Treatment.—There is really but one form of treatment for these benign neoplasms, viz., removal. The method will differ with the size of the growth. If the tumor be not of large size, it may be seen, reached, and removed through the urethra. This may be accomplished by twisting it off by means of a pair of forceps, ligating its pedicle, and allowing it to slough off or by passing the wire of the galvano-cautery around it. If the pedicle be not suffi- ciently distinct, or the mass too soft to come away in mass, it may be broken down and removed in pieces, either by the finger and for- ceps, or by the curette and forceps. The haemorrhage, which as a rule is not great, may be controlled by injections of iced water, ice to the pubes, and sometimes by tamponing the vagina. Some oper- ators have found it necessary to apply directly to the bleeding sur- face the liquor ferri sesqni-chloridi (Braxton Hicks). The after treatment consists in washing out the organ thoroughly yet carefully with warm water to which may be added salicylic acid (1 part to 60). The pain may be controlled by opium, either by the mouth or rectum. The urine should be kept slightly alkaline, and under no circumstances allowed to remain in the bladder long enough to decompose and irritate or overdistend it. 53 810 DISEASES OF WOMEN. If the tumor is too large to admit of removal per urethram Si- mon's operation should be resorted to. Also in cases where the tumor is so situated as to be beyond the operator's reach through the ure- thra. I have already fully described this operation. A T-incision is made into the anterior vaginal wall, the bladder opened, inverted through the opening, and the tumor is thus brought into easy posi- tion for any operative procedure. When removed, its base may be cauterized, and the bladder replaced. When the surface has entirely healed, the wound in the vesico-vaginal septum may be closed. Union soon takes place in most of these cases, if not interfered with. The after treatment should be the same as when the tumor is removed through the urethra. I need hardly say that when the general system is below par, it should be attended to. Polypus of the Bladder.—Dr. Godson showed a polypus which he had recently removed from a woman aged sixty, who was under his care in St. Bartholomew's Hospital. He first saw her a year ago, when she complained of bleeding from the vagina. The uterus and vagina were found healthy, there had been no recurrence of the haemorrhage until a week since when the patient again presented herself. On examination a tumor the size of a walnut was found at the orifice of the vagina. It had at first sight the aspect of a firm fibrinous clot; it was discovered, however, to protrude from the urethra, and to be connected by a narrow pedicle with the fun- dus of the bladder, which organ it partially inverted. Dr. Godson applied a catgut ligature, and separated it with scissors. A micro- scopical examination showed it to consist of fibro-cellular tissue, with a few muscular fibers covered over with mucous membrane. Such polypi are of extreme rarity, and it was fortunate that the subject of it was a woman.—{Obstetrical Journal, April 1879, p. 28). Excision of Papilloma of Bladder.—M. C, aged thirty-four, was admitted to the St. Mary's Hospital, under the care of Mr. Norton, suffering from the effect of long-continued haemorrhage of the bladder. On examination per urethram} a tumor one inch square, coated with phosphatic calculus, but not much raised above the mucous membrane, was discovered occupying the trigone about half an inch from the sphincter. It was evident that the tumor must be removed, and the patient submitted to the risks attendant upon a severe operation, or she must be left to endure the tortures brought about by the contractions of the bladder upon the growth after micturition, and with the certainty of an early death from haemor- NON-INFLAMMATORY DISEASES OF THE BLADDER. 811 rhage or from blood-poisoning. It was impossible to remove the growth through the urethra, and it was decided to cut the mass away by opening the vagina. It was considered that the growth could not be cleared without cutting through the urethra, and the opera- tion was performed as follows: The spring-scissors were inserted, one blade into the bladder nearly up to the tumor and the other into the vagina, and closed; the front wall of the vagina was then incised centrally to within half an inch of the uterus, and the vaginal wall, which was found not to be incorporated with the growth was dissected from the bladder; the growth was then seized with the vulsellum forceps, and drawn forward, and was then excised by the scissors and removed. Bleeding was averted by the actual cautery, and the lateral flaps of the vagina approximated by sutures. To prevent further haemorrhage a catheter was inserted, and the bladder compressed by plugging the vagina; no haemorrhage of importance took place. The temperature remained below normal, and the pulse rose to 120. Severe vomiting persisted until the tenth day after the operation, when she was considered out of danger. On the twelfth day, when apparently in health, she vomited, and shortly afterward fell asleep, in which sleep she died from syncope. At the autopsy the wound was green, and sloughing upon the surface, but healthy immediately beneath. No peritonitis or cellulitis was present, or any thrombosis of vesical, pelvic, or iliac veins. A microscopical examination showed the tumor to be a papilloma. Since writing this case Mr. Norton had operated upon a second case of tumor of the bladder, wmich had completely recovered from the effects of the operation.—The Medical Press and Circular, May U, 1879; and Medical Record, July 26, 1879, pp 82 and 83. Tubercle of the Bladder.—Tubercle of the female bladder is a comparatively rare affection. Winckel, of Germany, in 2,505 autopsies, found it but four times. Though not often existing as an accompaniment of pulmonary tuberculosis, it does not occur alone, but is usually accompanied by similar deposits in the intestines, kidneys, fiver, and elsewhere. It is usually found in early life, though cases have been recorded where it occurred as late as the 6ixty-fifth year. The favorite site for its first appearance is at the vesical neck, or about the meatus urinarius, these places being rich in minute glands and follicles. The deposits appear as minute white or yellowish white points on a red, indurated base. After a time, owing to their coalescing and breaking down, large spots of ulceration result. With these deposits in the bladder there are very apt to be simi 812 DISEASES OF WOMEN. Iar deposits in the kidneys and ureters, giving rise to destruction of the former and tubercular pyelitis in the latter. Symptomatology.—The symptoms are at first those of irrita- tion, and later of true cystitis, with ulceration, induration, and hypertrophy. Diagnosis.—The diagnosis may be made by means of the endo- scope, if there is opportunity to make early and repeated examina- tions. If by chance the deposits are located at the neck of the bladder, where they can be seen and watched going on to ulcera- tion, the diagnosis is not impossible. The history of the case and the presence of the tubercular diathesis will also aid in the final conclusions. The urine examined by the microscope is found to contain a granular matter mixed with the pus of cystitis which is sooner or later produced. In case the microscopist is fortunate in finding the bacillus tuberculosis the diagnosis is sure. Prognosis.—The prognosis is bad, as there usually exists serious trouble of the same nature elsewhere, and as local treatment accom- plishes very little, the end comes much sooner if the kidneys and ureters are involved in the disease. Treatment.—Local treatment is out of the question, except such as may allay the irritation or inflammation to a certain extent, and prevent undue pain and spasm. This is not readily done. Daily cleansing of the viscus with warm water; opium, and belladonna suppositories, or enemata of atropine, are the best methods of treat- ment. Warmth, attention to diet, general tonics, cod-liver oil, and the various remedies used in phthisis pulmonalis should be advised. Malignant Growths.—These are not common, although occurring more often than the benign growths. They are usually secondary, and may be of different varieties, as sarcoma, scirrhus, encephaloid, epithelial, villous, and even colloid cancer. Sarcoma, scirrhus, colloid, and epithelial are very rare; encephaloid and villous are more common. Symptomatology.—The symptoms are the same as those of the benign tumors, differing only in the greater extent and severity of the pain, and, as a rule, less haemorrhage. The condition of the gen- eral system is usually low, the patient soon becoming feeble and cachectic. Cancerous deposits in the kidney and extension of the inflammation up the ureters, may produce renal destruction and consequent uraemia. Diagnosis.—The only means of making an absolute diagnosis is by using the endoscope, and removing a bit of the tumor with NON-INFLAMMATORY DISEASES OF THE BLADDER. 813 the curette, and submitting it to a microscopical examination. Sarcoma and scirrhus may exist either as distinct tumors or as diffused indurations. The encephaloid variety usually grows rap- idly, and is very soft, and easily broken down. I have already said that cancer of neighboring organs may open into the bladder and produce most serious results, sooner or later involving the bladder- tissue in the destructive process. In any case, adhesion to the neighboring organs takes place, and the disease is liable to extend. Thrombosis of the veins of the vesical neck is apt to occur and lead to embolus elsewhere. Peritonitis is a frequent accompaniment. The favorite seat of cancer, especially of the villous form, is at the trigone. Some authors deny the existence of villous cancer, saying that it is simply a luxuriant growth of vesical papilloma, and base their opinion upon the nature of its structure and certain facts in its clinical history. " They never lead to secondary can- cerous deposits elsewhere. They do not spontaneously ulcerate. The lymphatic glands are not implicated. There is no characteristic cachexia. When they kill, death seems due purely to loss of blood and exhaustion from pain."— Van Buren and Keyes, p. 257. Most German authors claim that this growth is malignant, and think that in drawing deductions, such as I have given above, the observers saw only cases of simple non-malignant papilloma. Causation.—Nothing is known about the causes of malignant disease of the bladder, except that which is known about malignant disease elsewhere, consequently, that subject need not be discussed here. Treatment.—If the disease is not too far advanced, extirpation or breaking down of the tumor may be advisable, but except in the case of epithelioma, and the so-called villous cancer, but little good is to be hoped for. When removal is not advisable, we must look to narcotics and tonics to prolong the patient's life and relieve the intense pain and tenesmus. If the tumor is generally distributed throughout the bladder, or has its origin in a neighboring organ, extirpation is out of the question. Sarcomatous Tumor of the Bladder.—Dr. L. A. Stimson, at a society meeting, exhibited a tumor of the bladder removed from a gentleman sixty-three years of age. When admitted to the Presbyterian Hos- pital in the early part of October, the patient complained of frequent and painful passage of bloody urine. His first attack occured in the eariy part of July, and two or three weeks after a fall from a buggy. 811 DISEASES OF WOMEN. For the previous four years he gave a history of attacks of so-called bilious colic, which in connection with his bladder trouble gave rise to the suspicion, in the mind of Dr. Stimson, of renal colic, and the possible existence of vesical calculus. After unavailing efforts to reduce the irritability of the bladder the patient was sounded for stone with negative results. A subsequent examination was also of a negative character. The use of the searcher was followed each time by blood in the urine for two or three days consecutively. Examination per rectum revealed enlargement of the prostate, and fulness and doughiness about the bladder, which condition was sup- posed to be due to cystitis. The existence of a tumor was suspected, but the suspicion could not be confirmed, inasmuch as the condition of the patient forbade bimanual exploration. Ruling out the prob- ability of the existence of a tumor of the bladder, pyelitis was thought of as a cause for his trouble. The patient died rather suddenly without a positive diagnosis having been made. At the autopsy, and before the body was opened, bimanual palpation was performed, and the existence of a tumor was made out. On open- ing the bladder the morbid growth, which proved to be a sarcoma, three inches in diameter, was attached by a pedicle as thick as the finger to the posterior surface of the bladder, about four inches above the neck of the organ. HYPERPLASIA. Hyperplasia of the bladder may be partial or total; may be con- fined to the muscular, mucous, or connective tissue. In usino- the term hyperplasia reference is usually made to an increased thickness of the muscular walls alone. There usually coexists with this con- dition (which is partly hypertrophy, partly hyperplasia) increase in thickness of the various other structures of the organ. This may or may not be the case, and when existing it is more hyperplasia than hypertrophy. The terms partial and total have been used to convey the idea of hypertrophy of a part or parts of the muscular tissue, and do not usually refer to the number of coats involved. The truth is, however, that one part of the muscular tissue of the organ seldom becomes hypertrophied to any extent without involving the other parts; the increase in one part simply being greater than in another. This affection is much less frequent in the female than in the male, owing to her exemption from the more common causes of it. Any obstruction to the outflow of urine, as tumors of the urethra or bladder, partly or wholly blocking the passage; cystocele, by NON-INFLAMMATORY DISEASES OF THE BLADDER. 815 preventing complete evacuation ; inflammatory or nervous troubles, causing unusually active muscular contraction, continuing for some time ; all these may produce muscular hyperplasia. Inflammation of the mucous membrane is almost always present; sooner or later, that membrane becomes to a certain extent thickened, and may go as far as the production of tufty, polypoid hyperplasia. Van Buren and Keyes state that Civiale mentions hypertrophy, chiefly of the anterior vesical wall, due to chronic inflammation or tubercular in- filtration—evidently not simple hypertrophy. As the production of hypertrophy is almost always due to some obstruction to the outflow of the urine, dilatation after a time oc- curs, producing eccentric hyperplasia. When dilatation does not occur, but hyperplasia alone, the condition is produced which is known as concentric hyperplasia. In these cases of muscular hyper- trophy in which great force is required to expel the urine, pouches are sometimes formed, usually at the inferior fundus, caused by the pushing of the mucous membrane between the enlarged muscular fibers. These diverticula are comparatively rare in the female. A sagging or dislocation of the entire posterior inferior bladder-wall need not be discussed here, as it has been already disposed of. Symptomatology.—In concentric hyperplasia there is usually vesi- cal spasm, some pain, and forcible ejection of urine. A certain amount of cystitis almost always accompanies this affection, and surely aggravates the original disorder, by which it is itself further aggravated. In the eccentric form the symptoms are almost the same, there being sometimes superadded those of overdistention. Diagnosis.—This is readily made by introducing the finger into the vagina and the sound into the bladder, by which means the ca- pacity of the organ can be measured and the thickness of its walls ascertained. It is not unusual in the concentric form for the sound to be forcibly expelled from the bladder by a sudden contraction of that organ. The capacity of the viscus can be further measured by noting the amount of urine passed at each micturition, or by inject- ing into it some bland solution, such as salt and lukewarm water. Treatment.—The treatment must be directed to the removal of the cause when that is possible. If due to stricture of the urethra or the presence of tumors, their removal is to be considered; if to cystocele, replacement, and retention in place by a proper pessary, and other measures of which I have spoken fully in a previous chapter, must be adopted. When existing in the eccentric form an abdominal belt, cold baths, cold douches to the hips, astringent injections into the blad- 816 DISEASES OF WOMEN. der, and electricity, should be tried, having first, where possible", removed the cause, and palliated or cured the aggravating complica- tions. Daily catheterization, in cases of obstruction to the outflow of urine, or where, without obstruction there is liability to over- distention, is of great importance, and should be practiced. ATROPHY. So far as I know this is not a common disease. Its recognition during life being by no means easy, and but little attention being paid to the bladder in autopsies, very little knowledge of its fre- quency is had. I am inclined to believe, however, that it exists oftener than is commonly supposed. Its causes may be ranged under two heads, viz., constitutional and local. Constitutional.—In most women from fifty years of age upward a degenerative change takes place in the bladder, as in the other pelvic organs, and this is a perfectly natural process. In this con- dition the several coats are found proportionally changed, the three sometimes forming a wall not much thicker than fine writing-paper. This, however, is extreme and uncommon. The process causing atrophy is one of fatty and granular degeneration, and often at this age the epithelial cells of the bladder found in the urine are fatty and granular, as is also the case in both the vesical and vaginal epi- thelium of some women just after parturition. Walls thus thinned by the degenerative changes of age are of course much more liable to be still further altered by various causes, such as paralysis or overdistention. Winckel attributes the cysto- cele of aged women to atrophy of the bladder-walls, and the result- ing retention of urine. In soft, flabby and debilitated women, and also in men, an atro- phied condition of the bladder-walls often exists, and may lead to rupture. " Bonnet, Hauf, and Hunter (quoted by Pitha), give ex- amples of sudden rupture of the bladder in young persons from this cause (atrophy). Civiale gives the caution of avoiding pressure on the bladder-walls during catheterization, for fear of perforation." — Van Buren and Keyes. Local Causes.—Extreme distention of the bladder, leading to temporary or permanent paralysis, or paralysis with resulting over- distention, may lead to fatty degeneration and atrophy, as well as inflammatory trouble. Interrupted nutrition, due to shutting off the circulation, is the usual method of causation. Nutritive changes may also be due to lack of, or to perverted, innervation caused by NON-INFLAMMATORY DISEASES OF THE BLADDER. 817 disease or injuries of the spinal cord. When atrophy occurs in women under fifty years of age, who are in otherwise good health, and of good constitution, I believe that it is due to habitual over- distention of the bladder from retention of urine. Treatment.—Daily use of the catheter, strychnia in pretty full doses, electricity, building up of the general system, and gentle washing out of the organ with warm medicated solutions, may be tried. But little can be done when the degeneration is due to age. Atrophy of the Bladder from the Habit of retaining the Urine for a Long Time.—The lady was thirty-three years of age, large, and well developed, except that her heart and arteries were rather small. Her uterus was also undersized. She began to menstruate at fifteen years of age, and her menses were irregular in recurrence and dura- tion, and always attended with pain. Early in life she became a school-teacher, and had followed that profession up to the time that I saw her. She fell into the habit of retaining her urine for long periods, and for several years urinated only twice in each twenty- four hours. For some time she had noticed a growmg difficulty in emptying her bladder, and five months before consulting me she found that she had lost the power of urinating altogether. Her physician used the catheter regularly for a time, and then taught her to use it herself. Under this treatment, with tonics and seda- tives, she gradually regained a partial control of her bladder; but with it came an irritable condition of that organ and the urethra, which caused an almost constant desire to urinate. When I examined her I found slight prolapsus of the base of the bladder, and, by passing a sound into it, and a finger in the vagina, I found the posterior bladder-wall quite thin. There were also in- dications of a slight catarrh of the organ, doubtless brought on by the continued overdistention and prolonged use of the catheter. She told me that she had to make strong efforts to pass urine, and that it came away in interrupted jets. My impression of this case is, that her constant neglect of the bladder function caused overdistention, which led to atrophy and further distention. The use of the catheter permitted the organ to partially regain its muscular power, and also excited some catarrh. Passing the urine in spurts or jets was due, I presume, to the volun- tary muscular efforts. CHAPTER XLVL DISEASES OF THE URETHRA AND URETHRAL GLANDS. Having finished the consideration of the diseases which affect the bladder, I now invite attention to those which affect the ure- thra and its glands. These may be divided into two classes: I. Functional diseases. II. Organic diseases. I. FUNCTIONAL DISEASES OF THE URETHRA. I know of but one form of affection which properly comes under this head, and that is commonly denominated neuralgia. A case will be occasionally met in which there are pain and tenderness of the urethra, with frequent desire to urinate, and pain in doing so. In short, there is a history of subacute urethritis; but, upon the most careful examination that can be made, with all the means at one's command, there will be failure to find any lesions to account for the symptoms present. To this condition the name neuralgia has been applied, rather improperly, no doubt. From my own observation of this affection, in which there are well-marked symptoms, with no apparent anatomical lesions, I have been led to the conclusion that it is a disease of the nerves of the part—one of the neuroses, as they are called. It is quite possible, however, that progress in the diag- nosis of urethral diseases may yet enable diagnosticians to find lesions other than of the nerves to account for the symptoms presented by the disease in question. But for the present it must be classed among the neuroses. So far as I know, it is an affection peculiar to young women. 1 have only seen it among young married women of marked nervous temperament, and who have not borne children. In some of the cases observed, it was associated with an irritable condition of the introitus vulvae. DISEASES OF THE URETHRA AND URETHRAL GLANDS. 819 The symptoms are such as occur in a great variety of pathologi- cal conditions, and are, therefore, of little value in guiding to a cor- rect idea of the real trouble; and, as there are no diagnostic physical signs present, the diagnosis must be made by exclusion. The most thorough examination of the urine should be made, and the urethra and neighboring organs should be carefully investigated. Perhaps the greatest liability to error lies in mistaking this condition for reflex irritation of the urethra and bladder, arising from ovarian, uterine, or rectal disease. Careful inquiry into the condition of those organs should therefore be made before concluding that the disease is of the urethra itself. The affection is fortunately rare as well as obscure. I will, there- fore, relate the history of some cases, which will give the facts as they were observed clinically. ILLUSTRATIVE CASES. One case was that of a lady of a highly nervous temperament, whose parents died of tuberculosis. She was twenty-six years of age, and had been married three years. From the time of her marriage she began to suffer from painful menstruation and uterine leucor- rhoea. She attributed her trouble to getting cold while driving in an open carriage behind a fast horse. She had an anteflexion of the uterus and cervical endometritis. The right ovary was large, tender, and prolapsed. Before, during, and after her menses she had smart- ing and burning pain in the urethra, wdth a feeling of spasmodic contraction, which sometimes rendered urination difficult and pain- ful. In the interval between the menstrual periods she had tender- ness of the urethra and discomfort in passing urine. The urethra was repeatedly examined throughout its whole extent with the endoscope, but no disease could be found, only tenderness and spasmodic action. She derived relief from suppositories of morphine and bella- donna, but, when last seen, she still had attacks of the same trouble. It was supposed, at first, that the urethral trouble was due to the disease of the uterus, but the former persisted after the latter was relieved. Another case was that of a lady, aged twenty-nine, who had been married for seven years, but had never been pregnant. She wTas of a highly nervous temperament, but her general health had always been good. She began to menstruate at fourteen years of age, and con- tinued to do so regularly, but scantily. For several years she had suffered from backache and slight uterine leucorrhoea, and coitus had 820 DISEASES OF WOMEN. always been painful. She had frequent and painful urination. The uterus was small—in fact, all the reproductive organs were under- sized. There was marked tenderness of the introitus vulvae. The remains of the hymen were very tender, and at the meatus urinarius and on the vestibule there were a number of quite small papillomata (of the same color as the mucous membrane) that were also exceed ingly tender. These were destroyed by an application of equal parts of carbolic acid and tincture of iodine, and the leucorrhoea was ar- rested by the usual treatment. This relieved her of ail the symptoms except those of the urinary organs. Her urine was examined repeat- edly, and was found to be normal. The urethra was also investi- gated, but nothing wrong was found there except that the papillae appeared to be unusually prominent. I learned that if she retained the urine for an hour or two the desire to urinate passed off, and did not return until the bladder was fully distended. When she did urinate, the desire to empty the bladder continued—i. e., she had vesical tenesmus—but, if she indulged this feeling by passing the urine repeatedly, this tenesmus continued; while, if she resisted the desire, it gradually subsided. This proved conclusively that the cause of the frequent urination was the condition of the urethra. Quite a variety of agents, which I need not give in detail here, were tried in this case. Suffice it to say that she only derived bene- fit from coating the entire mucous membrane of the urethra with dry subnitrate of bismuth once a day for a week, and then applying equal parts of tincture of aconite and aqueous extract of opium twice a week for a time. The bismuth was made into an emulsion with water and a little acacia, and applied with the pipette. A steel sound was also passed once a week, and allowed to remain in place for about five minutes. This gave pain at the time, but relief fol- lowed. During the local treatment she took nourishing food, iron, and arsenic. She may be said to have recovered ; but overtaxation, mental or physical, would bring back the trouble in a slight degree for a short time. II. ORGANIC DISEASES OF THE URETHRA. This class may be subdivided into ten groups. 1. Inflammation or urethritis. 2. Granular erosion. 3. Vesico-urethral fissure. 4. Neoplasms. 5. Dilatation. ORGANIC DISEASES OF THE URETHRA. 821 6. Dislocation. 7. Prolapsus. 8. Stricture. 9. Foreign bodies. 10. Fistula. 1. Inflammation of the Urethra, or Urethritis.—This is of three varieties (a) acute, (b) chronic, and (c) gonorrhoeal. Acute urethritis, though not a very frequent disease among women, is a very distressing one, and often difficult to relieve. In many cases it will be found to depend upon a specific cause, that is, gonorrhoea ; and I would treat this subject as gonorrhoea in women, were it not that it is often difficult to tell a specific or venereal ure- thritis from simple inflammation of that portion of mucous mem- brane. There is a difference in the history when correct testimony is obtained from the patient. Simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease; while the gonorrhoeal variety comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. The chief symptom in both varieties is painful urination. Sharp scalding is produced by the urine passing over the tender surface. There is often a frequent desire to urinate, but not so urgent as in cystitis. In some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. In quite a number of cases I have noticed haemorrhage. That the blood comes from the urethra is known by the fact that it is not intimately mixed with the urine ; and after micturition it will ooze from the meatus urinarius. An examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. Occasionally, there is a discharge seen coming from the urethra, but if the parts have been recently bathed this may not be apparent. Introducing the finger into the vagina, and pressing upon the urethra from above downward, the discharge can be started, unless the pa- tient has passed water immediately before. The appearance of the discharge corresponds to that of gonorrhoea in its various stages. An examination of the discharge with the microscope may reveal the presence of the gonococcus, and, if so, that will determine the nature of the urethritis. The absence of that germ is not positive proof that the inflammation is not gonorrhoeal, unless frequent and skilled examinations fail to find it. Cystitis, which is liable to be confounded with urethritis, may be excluded by using the catheter, and after letting urine flow for a 822 DISEASES OF WOMEN. time collecting the remainder for examination. The mucous mem- brane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. The instrument can not be used in all cases, owing to the acute tenderness of the parts. Bleeding is very likely to occur at the examination, simply from the contact of the endoscope. The treatment of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. This will suffice in most cases of acute disease; but when it assumes the sub- acute form from the beginning, then the use of injections becomes necessary. Dr. Avery Segur, of Brooklyn, finds that the discharge of gonor- rhoea is markedly lessened, and sometimes cured, by ten-grain doses of salicylic acid, given in solution several times a day. I have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. For this purpose I use a catheter made like the fluted roller of a crimping-machine, the appearance of which is doubtless familiar, Fig. 240. Inside the cath- Fig. 240.—Skene's reflux catheter. eter there is a small supply-tube, which conveys the water to the rounded point of the instrument. Behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. By this arrangement the water as it flows back through the grooves is brought in contact with every portion of the mucous membrane. The instrument is passed up to the neck of the bladder, and a fountain syringe attached to it, and the water as it flows away is caught in a cup. The injection of solutions of nitrate of silver, sulphate of zinc, and the like, will often prove useful. It must be borne in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where but very slight force is employed while injecting. I use a large pipette, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. When the case is of long standing, and the neck of the bladder appears to be involved also, I use a mild injec- tion of one or two grains of nitrate of silver to the ounce, and inject ORGANIC DISEASES OF THE URETHRA. 823 it through the urethra with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. In acute urethritis the most efficient treatment that I have found is to wash out the urethra with the reflux catheter two or three times a day, and then introduce a suppository of iodoform in cocoa-butter, or bismuth and cocoa-butter. In old cases, which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. While the bougie is passed once or twice a week, I apply to the vaginal portion of the urethra oleate of mercury or the unguentum hydrargyri. This will often suffice to stop the gleety dis- charge, as well as remove the thickening of the urethral walls. The case reported by Dr. Howard, which will be found at the close of the consideration of the diseases affecting the urethral glands, would seem to indicate that a gonorrhoeal urethritis in which these glands are involved may continue indefinitely unless appropriate treatment is directed to them. Treatment of Chronic Urethritis and Spasm of the Bladder.—Dur- ing the past ten years Weiser has adopted a new method of treat- ment in chronic gonorrhoea, and out of twenty-five cases he has suc- ceeded in curing all but one. The latter was afterward advised to consult Dr. Greenfeld, who, by means of the endoscope, discovered granulations in the urethra, which being cauterized, the man got well after several weeks' treatment. Weiser first passes an elastic or metallic catheter into the bladder, and, after thoroughly evacuating the viscus, injects into it by means of a clysopompe, or, preferably, an irrigator, a solution of sulphate of zinc, 2 to 3, and tannin, 0-5 in 500 of water, at a temperature of 26° P. The catheter is then withdrawn, and the patient directed to empty his bladder, thus bring- ing the medicated solution in thorough contact with the whole of the urethra. This method is effectual in all cases when no granulations exist. The latter require the application of caustics. The author has, however, omitted to state how long the treat- ment must be continued. In cases with associated cystitis three to four drops of nitrite of amyl should be added to the above solution, the former being a very active disinfectant—one or two drops added to a bottle of urine serving to prevent the development of ammonia in the latter for a couple of years. When strictures are present they should be treated with metallic sounds. For the relief of cysto- spasms, the above-mentioned solution may also be employed ; one or two injections a day, continued for an average period of three months, usually suffice to entirely cure this condition. Frictions 824 DISEASES OF WOMEN. with cold water and lukewarm (2G° P.) sitz-baths may be employed as adjuvants.—" Mittheilungen des Wiener Med., Do