tt v< •■ vy.v.y.y.;.-.;. m r'/.v.v,- mm W9M fti.tY %} ytftm 7m NATIONS- LIBRARY OF ^DIClNf NLH DDSfiDQbfl M SURGEON GENERAL'S OFFICE LIBRARY. Section, _ ____ __________________ 3—1639 NLM005800684 TREATISE ON THE DISEASES OF WOMEN FOR THE USE OF STUDENTS AND PRACTITIONERS BY ALEXANDER J. C.jjKENE, M. D., LL.D. Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. 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, of the Obstetrical and Gynecological Society of Paris, and of the Leipzig Obstetrical Society ; Honorary Member of the Edinburgh 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 THIRD EDITION, REVISED AND ENLARGED WITH 290 ENGRAVINGS AND 4 PLATES IN COLORS LIBRARY SURGEON GENERAL'S OFFICE f r / C '!/¥-¥- NEW YORK D. APPLETON AND COMPANY 1898 WP SQzr-t 13-JS Copyright, 1888, 1892, 1897, By D. APPLETON AND COMl-ANY. TO THOMAS KEITH, M. D., LL. D., F. R. C. S. E., THIS WORK IS DEDICATED AS A TRIBUTE 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 THIRD EDITIOK In no department of medicine have more rapid and greater strides been made during the present decade than in gynecology. During this period many things new and useful have been added to the science and the art, while much that is both old and new deserves to be forgotten. To preserve and present to the student and practitioner that which his own experience and that of the highest authorities in this country and abroad have demonstrated to be worthy of their confidence, has been the author's aim in the preparation of this edition. In the discussion of injuries of the pelvic floor he has en- deavored to rearrange the varieties so that they could be more clearly comprehended. The surgical treatment has been simplified and otherwise improved, and more fully illustrated by drawings from the living subject and the cadaver. Vaginal and abdominal hysterectomy have been brought fully up to date, and complete descriptions and illustrations given of the approved methods of performing these operations. The control of haemorrhage in all surgical procedures by com- pression and electric heat has been made practical and perfect in all its details, so that it now in the author's practice takes the place of the ligature. This contribution to surgery is believed to be of great value not alone to the gynecologist, but to the general sur- geon as well. The surgical treatment of uterine displacements is fully consid- ered and its true value estimated. The use of the endoscope and cystoscope is so described as to bring these instruments more completely within the grasp of the V VI DISEASES OF WOMEN. general practitioner, thus enabling him to make diagnoses other- wise impossible. The illustrations have been in charge of Robert L. Dickinson, M. D., who has given up much time to the development of accurate and artistic drawing of medical subjects. Prof. Joseph H. Raymond, who is associated with the author in teaching gynecology, has had entire charge of carrying the work through the press. To these gentlemen, and to the profession at large, sincere thanks are here tendered by 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. New 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. Vll 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 facts which he may seek. X PREFACE. The author has ventured to give his own views and methods pertaining to practical matters, believing that while they may differ 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. II. Ray- mond, who has rendered valuable aid in the preparation of the work, and Dr. It. L. Dickinson, who has made the drawings for the original illustrations. The Author. TABLE OF CONTENTS. I.—Methods of Observation ..... II.—Development of the Fallopian Tubes, Uterus, and Vagina III.—Menstruation and its Derangements and Chlorosis IV.—Flexions of the Uterus .... V.—Diseases of the External Organs of Generation VI.—Diseases of the Vagina .... VII.—Injuries to the Pelvic Floor from Parturition and Causes ...... VIII.—Fistula in Ano and Coccyodynia . IX.—Inflammatory Affections of the Uterus X.—Corporeal Endometritis .... XL—Subinvolution . .... XII.—Sclerosis of the Uterus .... XIII.—Membranous Dysmenorrhcea XIV.—Lacerations of the Cervix Uteri . XV.—Cicatrices of the Cervix Uteri and Vagina XVI.—Inversion of the Uterus .... XVII.—Dislocations of the Uterus XVIII.—Retroversion of the Uterus XIX.—Abuse of Pessaries ..... XX.—Hypertrophy of the Cervix Uteri XXI.—Fibroma of the Uterus .... XXII.—Malignant Disease of the Uterus XXIIL—The Menopause ..... XXIV.—Senile Endometritis ..... XXV.—Diseases of the Ovaries .... XXVI.—Diseases of the Ovaries (Co?Mnued) XXVII.—Neoplasms of the Ovaries .... XXVIII.—Cystic Tumors of the Ovaries—Symptomatology and ical Signs ...... XXIX.—Ovariotomy ...... xi xii DISEASES OF WOMEN. CHAPTER PAGE XXX.—Illustrative Cases of Ovarian Neoplasms . . . 568 XXXI.—Diseases of the Fallopian Tubes . 5n(5 XXXII.—Pelvic Cellulitis ....... 596 XXXIII.—Pelvic Peritonitis ....... 620 XXXIV.—Pelvic Hematocele ...... 637 XXXV.—Ectopic Gestation ....... 649 XXXVI.—Diseases of the Urinary Organs—Anatomy and Develop- ment of the Bladder and Urethra .... 659 XXXVII.—Malformations of the Bladder and Urethra . . 072 XXXVIII.—Function of the Bladder ...... 697 XXXIX.—Functional Diseases of the Bladder .... 702 XL.—Functional Diseases of the Bladder (Continued) . . 723 XLI.—Methods of Exploration of the Bladder and Urethra . 743 XL1I.—Organic Diseases of the Bladder .... 754 XLIII.—Organic Diseases of the Bladder (Continued)—Treatment of Cystitis—Croupous and Diphtheritic Cystitis—Cystitis with Epidermoid Concretions ..... 788 XLIV.—Non-Inflammatory Diseases of the Bladder—Dislocation of the Bladder ....... 812 XLV.—Foreign Bodies in the Bladder ..... 831 XLVI.—Rupture of the Bladder ...... 847 XLVII.—Neoplasms, Hyperplasia, and Atrophy of the Bladder . 858 XLVIII.—Patency of Gartner's Duct—Diseases of the Urethra and Urethral Glands ...... 873 XLIX.—Dilatation, Dislocation, and Prolapsus of the Urethra . 908 L.—Stricture, Foreign Bodies, and Incomplete Fistula of the Urethra ........ 927 LI.—Diseases of the Glands of the Female Urethra . . 938 LII.—Vesical and Urethral Fistulje ..... 951 LIIL—Diseases and Injuries of the Ureters .... 9G8 INDEX TO ILLUSTRATIONS. FIO. 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. Midler's ducts 20 21, 22, 23, Coalescence of ducts Disappearance of septum Appearance of fundus and cervix 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 section 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 30. Anteflexion of body and cervix—third variety 37. Operation for imperfect invagination ; the incision 38. " " " sutures in position xiii xiv DISEASES OF WOMEN. FIG, PAGE 39. Elliott's uterine adjuster ..... 67 40. Glass stem, with soft-rubber base 69 41. Extreme anteflexion ..... 72 42. Skene's hysterotome ..... 75 43. External genitals of a woman who has borne children 78 44. The superficial veins of the perinaeum (Savage) 80 45. External genitals of a virgin .... 81 46. Cribriform hymen ..... 82 47. Annular hymen ....-• 82 48. Fimbriate hymen . 82 49. Rectum continuous with allantois (bladder) and duct of I duller ( vagina' (Schroeder) ...... 82 50. The depression has extended inward (Schroeder) 83 51. The cloaca is dividing (Schroeder) 83 52. The perineal body is completely formed (Schroeder) . 83 53. The upper part has contracted (Schroeder) . 83 54. Spurious hermaphroditism (Simpson). 84 55. Length of vagina ..... 100 56. Triangular shape of perineal body 100 57. Sims's vaginal dilator ..... 106 58. The levator ani ...... 117 59. The muscles of the pelvic floor 118 60. Diagrammatic sagittal section of the female pelvis . 119 61. The pelvic floor a suspension bridge . 121 62. So-called rectocele ..... 127 63. Beginning atrophy of perineal body in median ljne . 128 64. Atrophy in median line, with sagging of posterior vaginal a vail 12'.) 65. Sagging of the pelvic floor .... 131 66. Diagram of the sweep of the suture . 131 67, 68. Sutures properly and improperly introduced 134 69. Peaslee's needle . . ... 134 70. Tissue forceps ...... 144 71. Emmet's curved scissors .... 144 72. Emmet's scissors ..... 145 73. First step of perineorrhaphy, denudation begun 145 74. Second step, continuing the strip 140 75. Vivifying complete ..... 147 76. Needle-forceps ...... 147 77. Stitch in place ...... 148 78. The stitches in place ..... 148 79. Laceration with rectocele .... 149 80. Perineal body restored (profile view) . 149 81. Scissors for removing sutures .... 151 82. Complete laceration of perinaeum and sphincter ani . 153 83. do. operation; denudation completed 154 84. do. " sutures in rectal wall introduced 156 85. do. " rectal sutures tied; remaining sutures placed 157 86. Haemorrhoid clamp . , . 160 87. Hard-rubber rectal tube .... 162 88. Denudation for restoration of perinaeum 164 89. Sutures in place...... 165 90. The operation for fistula in ano 171 INDEX TO ILLUSTRATIONS. xv a multipara FIG. 91. Mold of uterine cavity in the virgin (Guyon) 92. " " " " multipara (Guyon) 93. Section of mucous membrane of uterus 94. " through corpus uteri of an infant . 95. " '■ " " of a woman aged eighty-three 96. One of the median columns in the cervical canal (Courty) 97. Section through the mucous membrane of cervix showing cystic eration .... 98. Elongation of the cervix (Winckel) . 99. Hypertrophy of the body of uterus (Winckel) 100. General enlargement of uterus (Winckel) 101. Skene's instillation tube 102. Sims's curette .... 103,104. The two sides of a half membrane from 105. Half a membrane from a virgin 106. A cast from a virgin . 107. Fragments of membrane in the condition in which they pelled ...... 108. A cast which might be taken for a product of conception 109. Bilateral laceration ; unequal division of the cervix 110. Bilateral laceration, with thickening of the everted lips 111. Extensive multiple lacerations 112. Multiple incomplete lacerations 113. Incomplete bilateral laceration 114. " " " in section 115. Crescentic laceration . 116. Skene's hawk-bill scissors .... 117. Operation for laceration of cervix; denudation complete 118. Skene's triangular needles .... 119. Counter-pressure instrument . . • • 120. Operation for laceration; sutures in position 12i « " " " tied 122. Removal of crescentic-shaped piece (seen in section) 123, 124. Method of bringing the sides of the section together 125, 126. Another method of closing the gap 127. Partial inversion (Thomas) .... 128. Complete inversion (Thomas). 129. Polypus simulating partial inversion (Thomas) 130. Polypus simulating complete inversion (Thomas) . 131. Byrne's method of reduction of inversion . 132. Cup pessary to exercise gradual pressure (Thomas) . 133. Replacement of uterus by dilatation through abdomen (Thomas). 134. Section of pelvis showing its inclination and the axis of the inlet 135. The normal range of the uterine axis (Van der Warker) . 136. Diagram of the uterine ligaments . 137. Section through right broad ligament 138. Section of pelvis, with the slings of the uterus 139. Diagram of the uterus slung between the broad ligaments 140. The normal inclination of the pelvis and the transmission of for above ..■•••■ 141. The three degrees of prolapsus . 142. Prolapsus uteri with cystocele . are often ex- PAGE 177 177 ITS 179 180 181 degen- ce from 291 293 297 xvi DISEASES OF WOMEN. FIG. 143. The shallow pelvis with lessened inclination of brim 144. Increased inclination of inlet 145. Uterus replaced, with pessary in position 146. Stem pessary, modification of Cutter's 147. The three degrees of retroversion 148. Retroversion of the second degree 149. Retroversion with imperfect invagination of cervix 150. Apparent imperfect invagination 151. The same uterus with its lips drawn back into place 152. The three steps in replacing the retroverted uterus by means of sponge holders ....... 153. Albert Smith pessary ...... 154. Method of measuring the length of the pessary 155. Diagram of pessary in situ on looking through Sims's speculum 156. Slight invagination of cervix posteriorly with suitable pessary 157. Decided invagination of cervix posteriorly fitted with a suitable pessary 158. What the pessary does not do 159. How the pessary acts .... 160. Second step ; the uterus falls into the pessary 161. The knee-chest position 162. Ventral suspension . .' . 163. Fibroid on posterior wall of uterus simulating retroflexion 164. Prolapsed and adherent ovary simulating retroversion 165. Overcurved pessary making pressure on angle 166. Extreme retroflexion (Barnes) 167. Uterus with defective walls; the supra-vaginal portion of the elongated (after Winckel) 168. Stem of pessary ulcerating through cervix . 169. Stem cutting through body of uterus 170. High rectocele due to improper pessary 171. Displacement caused by a badly adjusted pessary . 172. Hypertrophy of the cervix .... 173. The first step; splitting the cervix . 174. The double flaps of the amputation . 175. Diagram of the pieces removed 176. The sutures in place ..... 177. The sutures tied ..... 178, 179. Interstitial fibromata (Winckel). 180. Subperitoneal and submucous fibromata (Winckel) . 181, 182. Enlargement due to subinvolution compared with that from growth of a fibroma (after Winckel) 183. Uterine electrode ..... 184. Ecraseur ...... 185. Wall of uterus caught in ecraseur-wire and removed 186. Abdominal hysterectomy (Kelly); line of incision . 187. " " " ovarian vessels and round ligament tied 188. Cancer of both lips (Winckel) 189. Cleveland ligature forceps 190. Vaginal hysterectomy—clamp operation : Speculum in place 191. do. Cervix severed from vaginal wall 192. do. Forceps pushed through pouch of Douglas 193. do. Forceps draws tube forward INDEX TO ILLUSTRATIONS. XVH FIG. 194. 195. 196. 197. 198. 199. 200. 201 204. 205. 206. 207. 208. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222, 223. 224. 225. 226. 227. 228. 229. 230. 231. 232. 233. 234. 235. 236. 237. 238. 239. 240. 241. 242. 243. 244. 245. Vaginal hysterectomy—clamp operation: Forceps turns broad ligament do. Tube and ovary rolled forward do. Uterine artery clamped do. Placing gauze Vaginal hysterectomy by morcellement Vaginal hysterectomy by author's electric haemostatic forceps: Beef mus- cle seized in forceps do. Artery closed .... -203. do. Haemostatic forceps .... do. Transformer for heating forceps do. Hand-driven dynamos do. Cautery incisions about cervix do. Vagina and wound after removal of uterus The fundus uteri and ovaries seen through the pelvic brim (His) The ovary and its ligaments (Henle) . The ovarian, uterine, and vaginal arteries (Hyrtl) Cyst-regions of ovary (Bland-Sutton) Section of the ovary of a bitch (Waldeyer) . Ovary displaced and bound down by adhesions Left ovary, one large cyst (Farre) Compound and proliferating cyst (Farre) Multilocular cyst (Hooper) Papillary cystoma of ovary (Winckel) Dermoid cyst of ovary (Winckel) Fibroma affecting both ovaries (Winckel) . Area of dullness in large ovarian tumor xVrea of dullness in ascites Cautery clamp .... Keith's short compression-forceps Keith's long compression-forceps Keith's needle ..... Keith's ligature-forceps Keith's modification of Spencer Wells's clamp Position of operator, assistants, and accessories in ovariotomy Diagrammatic transverse section of the pelvis (Luschka) Section through sacrum, symphysis, and ischia Pelvic abscess opening obliquely downward Pelvic abscess opening obliquely upward The pelvic peritonaeum, looking into the brim The reflections and pouches of the pelvic peritonaeum (Hodge) Retroverted uterus bound back by peritoneal adhesions (Winckel Subperitoneal pelvic haematocele Intra-peritoneal pelvic haematocele . Diagram of the bladder to show corpus and fundus Base and neck of the bladder (Savage) Urethra laid open with probes distending Skene's glands (posterior wall divided) ..... Urethra laid open with probes in Skene's glands (anterior wall divided) . Transverse section of urethra with gland on either side Longitudinal section of urethral glands The meatus everted, showing the mouths of the glands The relations of the ureters (Garrigues) XV111 DISEASES OF WOMEN. FIG. 246. Extroversion of the bladder . 247. Linear cicatrix 248. Bladder covered by deep flaps 249. Diagram of the result of the operation 250-252 Skene's endoscope 253. Urethroscope with electric light 254. Principle of the Nitze-Leiter cystoscope 255. Diagram of cystoscope 256. Leiter cystoscope 257. Skene's modification of cystoscope . 258. " " " " for ureteral catheterization 259. Skene's bivalve urethral speculum . 260. Fountain-syringe for washing bladder 261. Skene's instillation-tube .... 262. Skene's urinal cup-pessary .... 263. Holt's catheter, with its modification 264. Skene's modification of Goodman's self-retaining catheter 265. Retroversion of the gravid uterus (Schatz) . 266. Skene's pessary for prolapsus of the bladder 267. Pessary holding up the bladder 268. Modification of the retroversion pessary, used in prolapsus of the 269. Forward transposition of the uterus . 270. Retrocession of the uterus .... 271. Skene's reflux catheter .... 272. Skene's fissure probe and knife 273. Skene's urethral speculum .... 274. Skene's modification of Folsom's nasal speculum . 275. Allen's polypus forceps .... 276. Blake's polypus snare ..... 277. Dilatation of middle third of the urethra 278. Skene's button-hole scissors .... 279. Dislocation of upper third of urethra 280. Complete dislocation with dilatation 283. Sims's tenaculum ..... 284. Operation for vesico-vaginal fistula; paring the edges 285. Sims's sponge-holder . 286. Emmet's needles 287. Curved track of the needle . 288. Operation for vesico-vaginal fistula; 289. Two sutures tied 290. Kelly's ureteral catheter the sutures in place bladder Plate I. Operation for laceration of cervix uteri. II. Vaginal hysterectomy with the author's haemostatic cautery forceps. III. Abdominal hysterectomy with the author's haemostatic cautery forceps. IV. Inflammation of the urethral glands. IV. Operation for prolapsus of bladder and urethra. Note.—All illustrations not credited are from original drawings by Robert L. Dickinson, M. D., or were prepared under his supervision, excepting cuts of instru- ments and Figs. 93, 94, 95, 97, 242, and 243, by J. M. Van Cott, M. D., and Figs 240 and 241, by A. H. P. Leuf, M. D. DISEASES OF WOMEN. CHAPTER I. METHODS OF OBSERVATION. A thorough familiarity with the means and methods of investi- gation is the first requisite in acquiring knowledge. The art of observation, which is simply the systematic use of the mental and physical faculties to obtain facts, should be made an essential part of the preliminary training of every student of medicine. From this point of view, the subject which we have to consider resolves itself into two divisions: first, the ways and means of investigation; and, second, the objects to be studied. Before approaching the study of gynecology, it is taken for granted that much experience and practice have been attained by the student in the art of investigation. The experience of every- day life, from infancy onward, and the ordinary school education obtained before beginning the study of medicine, tend to develop and cultivate the perceptive faculties. Still, the physician and surgeon require special training in the art of observation. To accurately note the structure, form, color, general proportions, and expressions of the human body in health, is the first lesson which every student of medicine should learn. This is the most important step toward the attainment of a practical knowledge regarding the functions of the human body, and its deformities, diseases, and injuries. The correct, rapid, and thorough observer has from the outset great advantages. Important and necessary as this branch of education is, it is almost wholly neglected in schools and colleges. The chief occupation of teachers appears to be to impart knowledge already in existence, rather than to qualify the student to observe and think for himself. Special attention should be given to this art of observation, be- cause it is the key to science and the first exercise in practice. The systematic way in which knowledge is presented in books and by oral instruction enables the student to acquire facts in all branches 2 1 2 DISEASES OF WOMEN. of learning, and to classify them. The mental training obtained in the study of mathematics and logic prepares men to make reasonable deductions from the facts obtained ; but in institutions of learning, thorough training in the art of observation is seldom given. This lack of preliminary education adds greatly to the labors of the student, because he is obliged to acquire knowledge while he is not in possession of the means of obtaining it, and it is mainly be- cause of this defect that practitioners of medicine are led into error in making diagnoses. They fail to observe all the facts, and hence their deductions are liable to be incorrect. Acute, clear perception is a gift which all do not possess in a high degree, but it can be cultivated by those of ordinary intelli- gence, and it should be by those who intend to practice medicine. The practical study of the elements of natural science, which should constitute a large share of the early education of those destined for the profession of medicine, aids much in cultivating the faculties concerned in observation. So also the arts, especially drawing, painting, and sculpture, help to qualify for the actual in professional life. The trained eye and hand of the artist are most valuable in acquiring the art of medicine and surgery, and a share of the days of youth spent at an art-school will save much time and perplexity in the medical school as well as in subsequent professional life. The first lesson is to obtain a familiarity with the general appear- ance of the body in health, its structure and the uses of the various organs, the process of development, the slight deviations from the ideal or highest type which occur within the range of health, and finally the relations of the being to his environment or conditions of life. A portion of this subject will be fully discussed in the chapter on the development and structure of the sexual organs of woman, and the conditions of life which are suitable to her development, growth, and maintenance. Subsequently the derangements of the body from disease and injury will come in for the greater portion of time and attention. Here it is that the highest perceptive power is needed, and the most painstaking attention to observation. The fact should be kept clearly in mind that a knowledge of the science of medicine does not give skill in the art of practice, how- ever much it may help in acquiring that art. Men profoundly versed in the science of medicine may be poor practitioners; and others, whose knowledge of the science is very limited, may attain some reputation in practice; but the best qualified physician is he who knows most of both the science and the art. The subject for present consideration is the method of investigation to be adopted METHODS OF OBSERVATION. 3 in practicing the art of gynecology. Before beginning the actual work of examining patients, it is necessary to know how to do so. There are several methods of investigating the sick and injured given in text-books and taught in the medical schools, but most of these are better adapted to general practice than to special depart- ments of medicine. The methods which I desire to present here are circumscribed, and perhaps less complicated, because they are limited to the diseases peculiar to women. In examining patients it is well to first settle definitely in the mind the object to be attained and how to attain it. • Some rational system of investigation should be mastered in all its details before undertak- ing actual practice. To engage in clinical study without such prepara- tion is like trying to read a language without knowing its alphabet. The system advised is : first, to obtain all the facts regarding the case in hand ; second, to arrange these facts in their natural relation to one another; and, finally, to make deductions from the data thus obtained. These suggestions will be easily remembered in the follow- ing order and association : observation, classification of things observed, and conditions indicated by the sum of the information obtained. The examination of a patient should begin by a general inspec- tion ; and, in order to make that inquiry complete and profitable, certain questions should be raised in the mind of the examiner ; such, for example, as, "What is the general appearance of the patient under observation ? "What size ? Regular or defective in general outline ? Lean or corpulent ? What temperament ? Is the face pale or flushed ? Languid or vigorous ? Sad or cheerful ? Calm or excited ? Intel- ligent or stupid ? "What diathesis is indicated, if any % In short, does the general physiognomy indicate health or disease ? All these interrogations are made while 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 organiza- tion in mind, the observer is able to scan a given case, and detect any deviation from that standard of healthy formation and appearance. The artist, in looking at a picture or statue, does not necessarily question every line of the drawing or form by itself, but his trained eve 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 4 DISEASES OF WOMEN. pertaining to a given subject are placed side by side, is a fair illus- tration of this kind of classification. Facts and ideas can be arranged in the mind upon precisely the same principle. The advantage of classification is that it aids comprehension and memory. By recall- ing 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 history 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 inherited tendencies to dis- ease, known as diathesis. 3. Evidences of disease, expressed in the face, either acute or chronic. 4. The temperament; 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 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. METHODS OF OBSERVATION. 5 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 inquiry are the condition of the functions and the structure of the organs under examination. Perverted function of the cerebro-spinal divis- ion of the nervous system is manifested through derangements of sensation and motion, and abnormal states of the organic nerves are 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- 6 DISEASES OF WOMEN. 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; second, deranged functions of the organs affected; and, third, modified loco- motion. 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 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 history of that function ? And, finally, is menstruation attended with de- rangements of any of the other functions of the body? METHODS OF OBSERVATION. 7 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 with 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 phys- ical 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: 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, 8 DISEASES OF WOMEN. 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. 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 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.) 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 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 the bimanual method, as it is termed—that is, while one or two fingers are introduced into the vagina, the fingers of the other hand are placed upon the abdomen at the pelvic inlet, and by pressure the parts are brought down to within near reach of the finger in the vagina. Fig. 2 illustrates the mode of making this examination. This method 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 METHODS OF OBSERVATION. 9 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 Fig. 2.—Bimanual examination. 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, owring 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 importance to make an accurate diagnosis that can not otherwise be made. Dilatation of the urethra sufficient to admit the finger has 3 10 DISEASES OF WOMEN. been practiced and advised for the purpose of aiding in the explora- tion of the pelvic organs, but the information gained in this way does not compensate for the suffering and danger ; hence the prac- tice 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 j-n j 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 *ig. 4.—(Jusco s bivalve speculum. r 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 speculum, and only then, when it is impracticable to place the pa- tient upon the table. A housewife's cutting board placed beneath the mattress will greatly aid in the examination. 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 METHODS OF OBSERVATION. 13 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 perinaeum 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. 7). By moving the hand forward, the blade is made to point backward 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 upper orlower 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 per- inaeum 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 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 Fig. 13.—Jenks's sound. arrangement being such that the examiner can run the sheath toward or 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 easier and safer, 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 Kecamier 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. 17 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. 17), sea-tangle, and tupelo (Fig. 18) are in general use. It is seldom that tents are required for purposes of examination 4 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 go 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.—When the parts to be touched in examination are very tender great advantage is gained by the use of cocaine. A two-and-a-half-per-cent solution is safe, and can be made efficient bv repeated or prolonged application to the vulva with the McKesson and Bobbins glass pyrozone atomizer, and to the cervix uteri with a pipette. "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 sufficiently unsatisfactory to leave a doubt in the mind, then ether should be given to the extent Fi<;. 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. of complete anaesthesia. The relaxation which this affords simpli- fies all investigations in a very marked degree. In the investiga- tion of the pelvic organs of insane women and in virgins who cer- tainly 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- 20 DISEASES OF WOMEN. der which holds one hundred gallons. V>y 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. I have long employed a modifi- cation of this apparatus for ether inhalation and I find it superior to the inhalers in general use. Fig. 18a and the accompanying de- scription shows its mechanism and mode of acting. 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 facili- tate the memorizing of the objects to be investigated, I have ar- ranged 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. Presence or absence of fixation of pelvic organs; swelling or tumors 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. METHODS OF OBSERVATION. 21 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. 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 injury 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. 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 examination. Mobility of the uterus with or without moving abnormal growths in 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. CHAPTER II. DEVELOPMENT OF THE FALLOPIAN TUBES. UTEKUS, AND VAGINA. 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 Fig. 19.—Muller's Fig. 20.—Coalescence of are separated by a ducts. ducts. septum formed from their coalescent walls, so that the united portion shows a right and left cavity. These two cavities are soon converted Fig. 21.—Disappearance of Fig. 22. — Appearance of • , ,-i septum. fundus and cervix. int0 one> thQ 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 Muller's ducts form the Fallopian tubes (Fig. 21). From this time to the fifth month there oo DEVELOPMENT OF THE FALLOPIAN TUBES, ETC. 2IS 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 Muller'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. 24. 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- gjze becoming more nearly equal to the ;raSion.rSeCti0n'SCant cervix. The palma plicata disappears Fig. 23.—Infan- tile uterus. Fig. 24. — Palma plicata extend- ing nearly to fundus. 24 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 dov/n 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 hody, 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 Fig. 26. Fig. 27. Fig. 28. Figs. 26-28.—Virgin uterus (Sappey): 26, anterior view ; 27, median section; 28, trans- verse section. 26. 1, body; 2, 2, angles; 3, cervix; 4, site of the os internum; 5, vaginal portion of the cervix; 6, external os. 27. 1, 1, anterior surface; 2, vesico- uterine cul-de-sac ; 3, 3, posterior surface; 6, isthmus; 7, cavity of body; 8, cavity of the cervix; 9, os internum; 10, anterior lip of os externum; 11, posterior lip. 28. 1, cavity of body; 4, 4, cornua; 5, os internum; 6, cavity of cervix; 7, arbor vitae of the cervix ; 8, os externum. 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 FALLOPIAN TUBES, ETC. 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 a 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 hvpertrophy of the uterus, and classed with the malformations. 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 Muller'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. 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. 33). 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 body and fundus (Fig. 31). The uterus bif undalis 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 FALLOPIAN TUBES, ETC. uterus bifundalis (Fig. 32) the horns, though not united, are well developed and present outlines more nearly like the normal body of the uterus, while the part which forms the cervix is completely developed. Entire absence of the uterus is per- haps unknown, unless in mon- strosities in whom the lower part of the trunk is wanting. Rudimentary uterus is seen occasionally. As most fre- quently found, it presents a very small cervix slightly, if at ... • , i i • i Fig. 32.—Uterus bifundalis unicollis. all, invaginated, and in place of the body of the uterus one or two small solid masses are found from a quarter to half an inch in thickness and about the same in length. Fig. 3S. —Uterus duplex (Cruveilhier). Left walls developed in consequence of pregnancy. The effect of malformations as manifested during functional life is quite remarkable. In some there is not the slightest deviation from health in the function of the sexual organs. In others the •2$ DISEASES OF WOMEN. 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 malformation does not materially affect the function of the uterus, while in 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 the"n 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 the left uterus was a virgin one. She was attended in her confine- ments by three different physicians, none of whom made any refer- DEVELOPMENT OF THE FALLOPIAN TUBES, ETC. 21) 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 diacr- 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- corrhoea 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 Muller's ducts, these rudiments made half a revolution, thus bringing one in front of the other. CHAPTER III. MENSTRUATION AND ITS DERANGEMENTS, ANT) CHLOROSIS. Menstruation is the function of the uterus that especially claims the attention of the gynecologist, though it is only a subordinate part of the great process of reproduction. Professor Stevenson, of the University of Aberdeen, describes the physiology of menstruation as a nutritive and active innervation wave that periodically runs to the pelvic organs, attaining its height at the beginning of utero-gestation, or, in the absence of gestation, at the beginning of menstruation. This nutritive material is eliminated when 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 affect only the epithelial layer. Be this as it may, there appears to be a general agreement among the authorities of the present time that degeneration and exfoliation occur to an extent sufficient 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. 30 MENSTRUATION AND ITS DERANGEMENTS. 31 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 developed, 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. 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 32 DISEASES OF WOMEN. 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. formal structure and functional activity of the nerves which preside over the action of the sexual organs. i. 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 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 dull and sleepy, and had a feeling of fullness in the head and slight headache. 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 suffering 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 MENSTRUATION AND ITS DERANGEMENTS. 33 all her symptoms were increased. From this time on her men- strual flow returned regularly, but did not increase in duration or quantity. At each recurring menstrual period her suffering in- creased 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 remained for three months. During that time she took morphine liberally. From this time her suffering dur- ing 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 convulsions 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.—Having 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 posi- tively 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 re- vealed nothing of value, but, in using the sound through it, I could pass that instrument 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, M'hile 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 5 34 DISEASES OF WOMEN. 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 outline 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 represented 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, 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 aggra- vates the difficulty. This patient 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 leadino- influence in causing menstruation. Rudimentary Uterus Bicornis; Entire Absence of Menstruation.__ When first examined, this lady was thirty years old, below the MENSTRUATION AND ITS DERANGEMENTS. 35 average size, but well formed, and presented, to outward appear- ances, 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 peri- odically or not she did not know. At no time was her suffering sufficient to interrupt 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 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 puberty, 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 men- struation, even in an imperfect way, was impossible. This case is placed in contrast with the preceding one to show that when arrest 30 DISEASES OF WOMEN. of development and growth is such as to render functional action entirely impossible, affair 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 imperfect 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 improved by Treatment.—The patient was a young woman of full size and well formed, and of a sanguine, nervous temperament, and a re- markably 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 connection with her scanty menstruation. Treatment.—At her next period she was directed to take a tea- spoonful every three hours of the following mixture : Ammon. mur., 3 ij; aquae camph., 5 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 teaspoonful 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 MENSTRUATION AND ITS DERANGEMENTS. 3- 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 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, and for about one year the menstrual flow lasted from two and a 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 38 DISEASES OF WOMEN. 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 intrauterine stem-pessary for six weeks. She 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 Menstrua- tion; all the Symptoms increased by Local Treatment.—This was a single woman, twenty-two years old, the daughter of wealthy and educated parents. She was tall, spare, and of nervous tempera- ment. Before puberty she acquired the habit of self-abuse while at school. While her general system was not developed, and while weak, irritable, dyspeptic, and subject to severe headaches she be- gan 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 oc- casions five months elapsed. The flow was usually normal in MENSTRUATION AND ITS DERANGEMENTS. 39 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 sufficiently 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. Be- fore 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 was 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 alter- nating periods of mental and physical exercise and rest. Every afternoon she took thirty grains of bromide of sodium, and during her menstrual periods thirty grains three times a day with eight drops of tincture of cannabis Indica. Laxatives were given to regu- late 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 treatment she improved in every respect. She still suf- fers at her monthly periods, and the menstrual function is still irregular. 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 40 DISEASES OF WOMEN. consequences are far more disastrous than the same practice when begun after puberty and completed growth. Chlorosis.—Closely associated with this subject is chlorosis, a condition involving menstrual derangements due to the same de- fect of the uterus, being associated with lesions of the general system. Chlorosis 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 organization presenting invariably certain character- istics of structure which are unfavorable to high functional activity, and which predispose to certain forms of disease. Some authori- ties, French mostly, believe that chlorosis is a disease of the organic nervous system which appears at puberty and presents certain changes of nutrition, especially 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-develop- ment, rather than from some well-defined disease. The German pathologists hold that in chlorosis there is an arrest of growth of the circulatory and genital systems; the heart and blood-vessels be- ing undersized and the sexual organs also. This certainly cor- responds to the facts as observed clinically, and if to this be added that peculiar condition of the organic nervous system, which is un- defined but probably structural, a type of organization 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 development and growth, and in which there is a state of the organic nervous system which is also below the normal and incapable of exercising 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. 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- MENSTRUATION AND ITS' DERANGEMENTS. 41 fled 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 system suffer because of the undersize of the uterus and, pre- sumably in some cases, the ovaries also, together with the im- perfect 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 sub- jects are the outcome of their anatomical peculiarities. Whether this be the proper description of chlorosis or not, it is the expres- sion in brief of the prominent features of chlorotic subjects, and agrees with the facts observed in practice. The reason, I presume, •for the different opinions held has grown out of the fact that some have accepted the mal-nutrition which is so often seen in the chlorotic, and the consequences thereof, as the disease itself; where- as these derangements of the nutritive and sexual systems are the outcome of the anatomical imperfections. The chief object in dis- cussing the subject here is, because chlorotic women necessarily suffer from deranged and imperfect menstruation, and they natu- rally fall into the care of the gynecologist, and without some defi- nite 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- 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 42 DISEASES OF WOMEN. 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 re- mained 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, ex- cept that the mucous membrane was anaemic. 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- rhoea. 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.—Y\\. hydrarg., gr. x ; pulv. ipecac, gr. j, were given MENSTRUATION AND ITS DERANGEMENTS. 43 at bedtime, followed by a saline laxative in the mornino-. 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; aquae font., 3 ij. This improved her appetite, and her strength increased. When she had finished the first mixture, the following was given : Ferri iodid., 3j ; quiniaa sulph., gr. x ; ext. belladonna?, gr. ij, in pil. Xo. 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., 1 j ; aquas font, 3 ij ; one teaspoonful, after meals, in water. During the follow- ing six weeks she took the pills one week, and the next week the tincture of iodine mixture, alternating regularly. The menses ap- peared 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.; strychniae sulph., gr. ss.; liq. potass, arsenit., 3 j ; tr. colomb., 1 j ; aquae font., § ij. Teaspoon- ful, in water, after meals. This mixture she continued to take for six weeks longer, omitting it occasionally for a few days. Dur- ing 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 nu- tritious food in great variety, 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. For 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. Ameniia 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 malnutrition and the consequent imperfect menstruation which she had. This is the history of the great majority of such cases when they 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- 44 DISEASES OF WOMEN. 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 schoolgirl, 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., 3 j ; 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: Ijfc Hydrarg. chloridi corrosivi...................gr. j. Liquor arsenici chloridi......................f 3 j. Tr. ferri chloridi, Acid, hydrochloric, diluti.................aa f 3 iv. Syrupi simplicis.............................^ i j. 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. II. 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 recom- mended was continued, except that she occasionally indulged her fancy for sweets. MENSTRUATION AND ITS DERANGEMENTS. 45 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 life 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 now 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 believe that she would, had she been neglected, as most of these cases are. In my clinical records 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. Those who had no treatment until after puberty, and were suffering from all the symptoms of typical cases were improved by treatment, so 46 DISEASES OF WOMEN. 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 during 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 amenorrhcea, 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 wras 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 ex- treme 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 appropriately 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 MENSTRUATION AND ITS DERANGEMENTS. 47 example of this is 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 48 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 who 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 MENSTRUATION AND ITS DERANGEMENTS. 4;, whom the menses are delayed, and quiet conntry 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 was 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 6 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. Her 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 ceased taking thena 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 leucorrhoea, but no menstrual flow. She was ordered to take lessons in horseback-riding, and to walk for half an MENSTRUATION AND ITS DERANGEMENTS. 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., ill iij ; vini ipecac, m ij, in a wine-glass of warm water. This improved her appetite. After meals she took a teaspoonful of the following: Tr. ferri chlor., 3iij; %• ar- senic, hydrochlor., 3 j ; spiritus limonis, 3 ss; syr. simp., § j ; aquae font., ^ ij. 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. during most of that time she took tonics containing some form of iron. Citrate of iron and quinine, iodide of iron and whisky, p<>- 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., v\ ij, every three hours in a small glass of Vichy water. She was 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. MENSTRUATION AND ITS DERANGEMENTS. 53 I ordered the following: Strychniae sulphatis, gr. ss; tr. cannabis Indie, 3 ij; tr. card, comp., I j ; aquae font., 3 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 meais, 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 UTERES. 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 54 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 stao-es 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, anteflexion of the cervix (Fig. 34a); Fig. 34a.—First variety; anteflexion of cervix. 58 DISEASES OF WOMEN. second, anteflexion of the body (Fig. 35; ; and, third, ante- flexion of both body and cervix (Fig. 36). Pathology. — Flexion of any 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, At the point of flexion the On the side to which On Fig. 35.—Second variety; anteflexion of body of uterus. which need not be noticed here. tissues of the uterine walls are deficient the organ is bent the wall is compressed and attenuated 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. The menstrual fluid, in place of escaping passively, is expelled, perhaps, by spasmodic contractions. The submucous stratum of fibrous tissue is in some cases abnormally dense and resists the swell- ing of physiological congestion and this causes pain. These patho- logical 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, anteflexion of the first two varieties often pro- gresses to the 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 remove the uterus from the bddy, 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 60 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 hypersemia of the uterus, or endometritis, promptly increases the dysmenorrhea, and gives rise to new symptoms. Leucorrhoea, 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 dysmenorrhoea which begins at puberty may continue, and increase but little through life. 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 dysmenorrhoea 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. Owing to the fact that all imperfectly developed organs are less able to resist the causes of disease, 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 FLEXIONS OF THE UTERUS. 61 the touch and the uterine probe. The touch may indicate that the cervix is in its normal position, or is anteflexed, the os pointing toward the introitus in the same way that we find it in retroversion. The vaginal portion of the anterior wall of the cervix is much shorter than the posterior. Carrying the finger along the < anterior vaginal wall, the body of the uterus can usually be felt bending for- ward. The bimanual examination reveals the deformed condition of the uterus in lean patients, whose abdominal parietes are yield- ing ; 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 impossi- ble 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 with a probang. In this way the canal is par- tially 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. Causation.—There are several causes of flexion, and this may account for the different opinions held by authors on this subject. The errors, I presume, come from investigators accepting the cause found in a limited number of instances as applying to all cases of flexion. Some of the more important causes assigned may be briefly noticed. Rokitansky considered that the peculiar density and arrange- ment of the mucous membrane of the cervix and lower part of the corpus uteri formed one of the chief supports of the organ, and gave it its slight anterior inclination ; consequently, he looked upon the pathological state of this layer as the basis in the development of uterine flexions. He thought the uterus bent upon itself, from cir- cumscribed atrophy of one of its walls, arising from inflammation. He claimed that the glands of the mucous membrane, becoming dis- 62 DISEASES OF WOMEN. tended from imprisoned secretions, so pressed upon the other tissues as to cause atrophy at that part. When the distended glands rupt- ured and collapsed, the part rendered thus defective permitted the uterus to bend upon itself. Several eminent writers on this subject, Dr. Ludwig Joseph being the most recent, after careful observa- tions, have been unable to discover this peculiar condition of the mucous membrane and its submucous layer to which Rokitansky alludes. If they are correct, further discussion of this supposed cause is useless. Should Rokitansky be right, the cause he favors would chiefly affect cases of acquired flexion; while the majority of cases occur before we have any evidence that inflammation pre- ceded it. Virchow attributes the primary cause of flexion to congenital shortness of the anterior uterine ligaments, which drag the body of the uterus forward, or flex it. The uterus being held in this posi- tion, pressure results, which leads to atrophy of the tissues, and thus all the conditions of flexion are present. Klob, who is one of the best authorities on uterine pathology, doubts the views expressed by Yirchow, and states that with the nor- mal firmness of the tissues the uterus is not likely to be deflected by the cause in question. He also calls attention, as a reason against the theory of Yirchow, to the fact that false membranes or short liga- ments, which would incline and fix the fundus forward, would ne. cessarily cause pressure on the fundus of the bladder. This would cause the bladder to distend more in its lowest portion, which would press the lower part of the cervix uteri backward, and in place of producing flexion would cause anteversion. Klob admits that the cause assigned by Yirchow may produce or maintain flexion, but only when there is defect of tissue in the uterus itself, arising from some preceding cause. The relation of the bladder to the uterus is looked on by some writers, including Yirchow and Ludwig Joseph, as of some impor- tance in the etiology of flexion. The uterus is known to make a descent corresponding to the variations in the shape of the bladder, which in foetal and infant life changes from the elongated fusiform to the short ovoid shape, and its fundus, thus approaching the floor of the pelvis, draws the attached uterus with it. As the cervix uteri is closely attached to the posterior surface of the bladder, it will be readily understood that perverted development in the con- nections of the two organs might lead to flexion. The only causes which I consider worthy of discussion in con- nection with anteflexion, when it occurs as a primary or uncompli- FLEXIONS OF THE UTERUS. 63 cated disease, are: 1. Malformation resulting from arrested or im- perfect development. Flexion arising from this cause may be classed among the congenital deformities. 2. Deformities arising from in- flammation and degeneration of the uterine walls on one side. This will include atrophy of the anterior uterine wall at the os internum from inflammation and distention of the cervical glands; also fatty degeneration in advanced life, and excessive involution after parturi- tion, by which one of the uterine walls is weakened at the junction of the cervix and body. These may be called acquired flexions. I purposely omit a number of conditions usually given as causes of flexions, such as metritis, enlargement of the corpus uteri, preg- nancy, uterine tumors, abdominal tumors, accumulations of fluid in ntero, ascites, fecal accumulations, and adhesions from inflammatory exudations. Several of these causes, such as pregnancy, produce flexion so very seldom that they may be treated as exceptions to the ordinary laws of pathology, and are of no practical importance. The others named are more important than the flexions which they pro- duce, and I should prefer to discuss flexion occurring under such circumstances as a complication of the primary affection. It is, to say the least of it, objectionable classification, to discuss the primary and most important disease as the cause of a consecutive affection, and one which does not always follow. Regarding the first cause—imperfect development—I can readily see how flexion might occur therefrom. During the time when in- vagination of the lower portion of the cervix and upper part of the vagina takes place, the process is liable to progress farther on one side than on the other. Should the posterior vaginal wall become reflected much higher than the anterior, the attachment of the vagi- na, being lower on the anterior surface of the cervix, would naturally pull it forward. From the fact that this malformation at the junc- tion of the uterus and vagina is present in the vast majority of cases of anteflexion of the cervix, I have looked upon it as one important cause. If this arrangement should tend, as it probably does, to bring the cervix forward so as to flex the uterus to a slight degree previ- ous to its complete development, the pressure at the point of flex- ion would arrest the growth at that point, and then the wall would become more attenuated still, and flexion of the body would be produced. Imperfect development may cause flexion in another way. The infantile uterus, having little strength of tissue to support itself, might readily become flexed, and so remain during the period of secondary development. I am aware that good authorities, such as 64 DISEASES OF WOMEN. Klob, state that previous to puberty the uterus is neither bent back- ward nor forward; but other observers have found the infantile uterus anteflexed in many cases, and one can readily understand why the organ might remain so. The position in sitting at school and in sewing so often maintained by girls, constipation, and improper cloth- ing, all tend to retard development and hence produce flexion. The uterus might readily increase in size at all parts except the portion compressed at the point of flexion. Flexion occurs also from excessive development of the cervix. The unnaturally long cervix pressing upon the posterior wall of the vagina is inclined forward, while the body of the uterus remains in its normal axis. This produces slight flexion, which in time becomes greater, on the principle that the deformity, once established, tends to increase. When flexion is caused by inflammation, the explanation given by Rokitansky and already referred to, applies in some cases of ac- quired flexion. Irregular involution is doubtless one of the causes of flexion when it occurs after confinement or miscarriage. If press- ure was brought to bear on the cervix, fundus, or both, so as to favor flexion, involution might go on beyond the normal limits at the point of pressure. Treatment.—A brief review of the various plans of treatment will, I believe, show that while they are of great value, and capable of giving relief in many cases, still it will be found that they do not fully equal all demands. The use of extra-uterine pessaries will re- lieve some of the prominent symptoms, but will not overcome the deformity. Intra-uterine pessaries, while they sustain the uterus in its normal shape, are objectionable in some respects; they are often difficult to introduce, are not easily held in position, and are liable in some cases to cause so much irritation as to make their prolonged use dangerous to life. The surgical methods which have for their object only to relieve the symptoms or evil consequences of flexion, are chiefly dilatation and division of one wall of the cervix. Dilatation is certainly of much value, but the improvement is often, indeed generally, only temporary. Division of one side of the cervix answers the same purpose as dilatation, and the effect is not more lasting. But neither of these modes of treatment overcomes the deformity altogether, and seldom permanently cures the troublesome symptoms. The merit of dividing the cervical wall appears to me to be, that it may correct the conditions of the flexion which cause sterility, and when that is accomplished, and pregnancy follows, the development of the uterus FLEXIONS OF THE UTERUS. 65 during gestation permanently cures the malformation as a rule. If pregnancy does not follow, the patient is not always improved, ex- cept temporarily, by the treatment. The objects to be attained in the treatment of flexions of the uterus are, to straighten the organ and to keep it so until the defect- ive portions of its walls become developed sufficiently to render it self-sustaining. Should the means used fail to overcome the de- formity, the next aim should be to relieve the patient from the con- sequences of the flexion by other means, such as dilating the canal of the uterus, or dividing the posterior wall of the cervix after the manner of Sims. The means to be used in the management of flexion must be adapted to each case, and hence the subject resolves itself into, first, the treatment of flexion of the cervix; second, flexion of the body of the uterus ; and, third, flexion of both. It follows, naturally, that the treatment of flexion of both the body and cervix—i. e., the third form mentioned—should include the treatment of the first and second forms. The treatment of flexion is as follows: When the vaginal por- tion of the cervix is unusually long and conical, amputation may be called for, and is often followed by very satisfactory results. In the majority of cases a less important operation will answer. By clip- ping out a Y-shaped piece in each lateral edge of the os, and extend- ing upward from an eighth to a fourth of an inch, a few of the circular fibers are divided. This permits the longitudinal fibers to contract, and thus shortens the vaginal portion of the cervix. By far the most frequent and important lesion that occurs in the connection of the uterus and vagina is the imperfect invagination of the anterior wall of the cervix, which has been described under the head of pathology. To overcome this deformity, I have adopted the following plan of treatment: The patient is placed on her left side, and Sims's speculum is introduced. The anterior lip of the cervix uteri is seized with a tenaculum, and the cervix drawn back- ward toward the hollow of the sacrum. This puts the anterior column of the vagina on the stretch, at the point where it is reflected on the cervix. The vaginal wall is then divided transversely with the scissors, about three fourths of an inch from the os uteri, the incision being from a quarter to three eighths of an inch deep (Fig. 37). The vaginal wall is dissected up, so that when the incised portion is put upon the stretch the sides will come together. In other words, the upper and lower edges of the incised central por- tion of the vaginal wall are drawn apart, and the sides brought together to fill the space, so that the transverse incision now ap- 66 DISEASES OF WOMEN. pears as a longitudinal one. Sutures are introduced, to keep the parts together till they unite (Fig. 38). l'iu. 37.—Operation for imperfect invagination. The incision. If the uterus is slightly below its normal level, and inclined to retroversion (a condition not uncommon in anteflexion), much benefit will be obtained by introducing a double-lever pessary, largest at its posterior extremity. This will hold up the uterus, and, by making Fig. 38.—Operation for imperfect invagination. Sutures in position. pressure in the posterior vaginal cul-de-sac, draw the cervix back- ward, and thus hold the edges of the wound together and favor union. The effect of this simple and safe operation is to bring the anterior wall of the cervix farther down into the vagina, and permit it to extend backward more toward the axis of the pel- vis, where it ought to be. This plan of treatment I have found to be sufficient for the relief of flexion of the cervix uteri in many FLEXIONS OF THE UTERUS. 67 The treatment of flexion of the body of the uterus requires first that the organ should be made straight, and then that it should be kept straight, as already stated. The first ob- ject can be accomplished most easily by the use p of Elliott's uterine adjuster (Fig. 39). I am in- debted to Dr. T. G. Thomas for the knowledge of the method of using this instrument. It is similar to a uterine bougie, with a round metallic disk at its end. By turning this disk, the point of the instrument can be bent forward or back- ward at the will of the operator. In using it to straighten the flexed uterus the instrument is carried forward and passed into the uterus; the disk at the end is then turned in the reverse di- rection, and the instrument, carrying the body of the uterus "with it, is bent in the opposite direction until the body and cervix uteri are brought into line with each other. There are certain precautions necessary in using this instru- ment to straighten a flexed uterus, but these will be brought out in the history of cases which fol- low. In straightening the uterus with Elliott's ad- juster it is useful to bend the uterine body back- ward beyond the line of the cervix when this can be done without causing much pain. The stretch- ing of the wall of the uterus at the point of flex- ion stimulates nutrition and gives strength to the weak part. By repeating this treatment many times, much relief is given, and much progress made toward finally overcoming the deformity. To keep the uterus straight in anteflexion of the body, two of the many methods commended I have found useful—the first being the use of a retroversion pessary to draw the uterus back- ward, as suggested by Emmet, in order to bring the cervix on a line with the body of the uterus. The other means is the intra-uterine stem with a vaginal pessary to keep it in position ; the glass or hard-rubber stem and a closed ring pessary of soft rubber answers very well (see Fig. 40). In using the intra-uterine stem the greatest possible care should 39.—Elliott's uter- ine adjuster. ^ 68 DISEASES OF WOMEN. be employed because of the great danger of exciting inflammation. Before resorting to the use of this instrument all congestion and irritability should be subdued as far as possible, and the uterus should be trained to tolerate a foreign body in its cavity. To accomplish this, all the ordinary means for the relief of metritis should be employed. Cocaine, which has proved to be of great value in other departments of surgery, is a great help to the gyne- cologist, especially in the management of the class of cases now under consideration. By the use of this agent the extreme liyperaesthesia, which renders the use of the sound not only painful but dangerous, can be completely overcome. When I first began to use cocaine I was fearful that, while the sound or adjuster could be used without pain under the effects of this local anaesthetic, there might be as much danger of causing inflammation as there would be without it; but experience has proved that my fears were groundless. I prefer a two-per-cent solution, and depend upon repeated applications to produce the desired effect. This is a safe way of using cocaine. At the time of using tli3 solution it should be at about the temperature of the body, and it should be introduced with a pipette. I apply it to the canal of the cervix and os internum, and in a few minutes pass the sound just beyond the internal os. If this causes much pain, I make another application and try the sound again; and if it can be easily introduced, I permit it to remain in the canal for a minute or two. At the next treatment I repeat the application and use a larger sound, and, if this is well tolerated, I pass the pipette into the cavity of the body and apply the cocaine. If that causes no pain, I use the Elliott adjuster and straighten the uterus, if I can do so without causing suffering. At each subsequent use of the adjuster I apply cocaine until the tenderness disappears. Then the cocaine is omit- ted, and if the sensitiveness does not return I feel sure that the stem pessary will be tolerated. I am inclined to think that cocaine aids in relieving inflamma- tion. Its immediate effect is to relieve congestion, and although the hyperaemia returns after the effect passes off, I do not believe that it does so to the original extent. Defects of the canal of the uterus are frequently associated with flexion. In some cases the whole canal of the cervix is too nar- row, and in others there is a stricture at the internal os. To over- come these defects, and to aid in correcting the flexion, several methods have been employed, the chief among them being incision and dilatation. When the constriction is at the external os uteri, FLEXIONS OF THE UTERUS. 69 Fig. 40.—Glass stem, with soft rubber base. I prefer incision followed by dilatation, easy and gradual, or forci- ble. The first consists in passing graduated sounds, the other in using the uterine dilator (see Fig. 16). I prefer the forcible dilatation when there are no contra-indica- tions, such as extreme sensitiveness; but I do not approve of carry- ing the dilatation beyond that which is sufficient to admit a NTo. 12 or 16 English sound. The extreme dilatation practiced by some, which is carried to a point sufficient to ad- mit the index-finger, is dangerous and un- necessary. In cases complicated with endo- metritis, adenoma, or stenosis at the internal os, I employ free dilatation, curetting, and packing with gauze. This treatment has been successful in so many cases that I now give it first place. If the flexion returns after this the stem pessary can be employed. A fuller account of this is given in the treat- ment of corporeal endometritis. Finally, it may be noted that success in the treatment of flexions depends upon the careful use of the means suggested, avoiding, as far as possible, the ever-present danger of exciting inflammation, which may make matters far worse. And much depends upon the age of the patient. It is always more easy to correct deformities in the young than in those of more advanced life. It should also be borne in mind that there is a tendency for the flexion and all con- sequent symptoms to return unless utero-gestation follows. On this account I have classified the results of my treatment in married women under two heads, viz., relieved, and cured. The former em- braces those who have been relieved from dysmenorrhoea, but have remained sterile, and the latter those who have been relieved and have home children. Ninety per cent have been relieved or cured of dysmenorrhoea, and about fifty per cent cured of sterility. Comparing my results with those of other gynecologists, I have reason to be quite in favor of the treatment that I have employed. Sims's operation—that is, dividing the cervical wall posteriorly and keeping it open—was the treatment of anteflexion years ago, and I followed that practice for a long time, but abandoned it in favor of the methods given above. Hearing very little about it now and for ten years past, I presume that it has fallen into disuse. About seven years ago Professor E. C. Dudley, of Chicago, in- 70 DISEASES OF WOMEN. troduced to the profession a modification of Sims's operation that found favor with many. The doctor's description of his operation is as follows: " Under ether the uterus is exposed by Sims's speculum. The uterine canal is dilated by means of Palmer's or a light Ellinger's dilator sufficiently to permit the introduction of a dull spoon curette. The object of the curettement is to remove any granula- tions that may give rise to hypersecretion or menorrhagia. " The endometrium is then thoroughly irrigated with hot ster- ilized water. Then the cervix is divided backward in the median line considerably past the utero-vaginal attachment. The cut sur- faces are held apart by means of two tenacula—one in the hand of the operator and the other in the hand of an assistant—while the incision is somewhat deepened by means of a scalpel, especially on the side of the cervical canal. " On each side the surface thus incised is now folded upon itself and secured by silkworm-gut sutures. These sutures are not intro- duced in such a manner as to stitch the intra-cervical to the vaginal margin of the cut surface, but the cut surface is folded upon itself in a direction at right angles to this—i. e., on either side of that point at the margin of the os externum where the backward incision is commenced—and is stitched to the very angle of the incision so that the cut surface is folded upon itself, not from within outward, but from before backward. Thereby the os externum is carried directly back to the angle of the incision. " Already the cervix has commenced to point backward in its normal direction toward the hollow of the sacrum, instead of for- ward toward the vaginal outlet. Then the anterior lip of the cervix is caught with a tenaculum and partially removed. " This incision should extend to the os externum, but not into it. " Sutures are used for the purpose of folding the exposed sur- face upon itself from side to side. The removal of a portion of the anterior lip is not only not a mutilation, but it may even correct a deformity, because in anteflexion the anterior lip is often elongated in consequence of the relatively greater pressure exerted upon the posterior lip by the posterior vaginal wall." While I know that this operation is a great improvement upon the Sims operation, I must say that I prefer the methods of treat- ment already given. FLEXIONS OF THE UTERUS. 71 ILLUSTRATIVE CASES. Anteflexion of the Cervix Uteri, Sims's Operation. (Relieved.)__ This patient was a strong, healthy lady, who began to menstruate at the age of fourteen years. She continued in good health, and the menses were normal, except that she had more discomfort than be- longs to perfect health. About the age of eighteen menstruation became more painful, and she had some backache and occasional leucorrhoea. These symptoms increased but little until she was married, at twenty-two years of age. Then she began to have dysmenorrhoea, and occasional menorrhagia. The leucorrhoea and backache became more persistent and her strength failed. The pain at the menstrual period was not very severe; in fact, it was not at all like the violent pain often present in flexion of the body of the uterus, but it made her life quite miserable at that time. About eighteen months after her marriage she first applied for treatment, when the above symptoms were related. The os externum pointed toward the vulva, and the vaginal por- tion of the cervix was slightly flattened from below upward. The invagination of the cervix anteriorly was nearly normal, but not in proportion to that of the posterior wall, which appeared to be ex- cessive. The body of the uterus was in its normal position ; the sound could not be passed until the cervix was dragged backward and brought in a line with the body. She was treated for a time to relieve her congestion and cervical endometritis, and then the posterior wall of the cervix was divided according to Sims's method. When the edges of the wound healed, there was considerable inversion of the mucous membrane, showing that it was redundant. The protruding portions were trimmed off, and then the results of the operation were quite satisfactory in ap- pearance. She was relieved of all her symptoms, for a time at least, but remained sterile, although the canal was large enough, and the sound could be passed. Three years afterward she was seen, and then she was complaining of leucorrhoea and occasional pelvic pains. This case was treated fifteen years ago, and is the last one in which I have performed Sims's operation or any of its modifications for flexion. Extreme Anteflexion of the Cervix Uteri; Dysmenorrhoea. (Re- covery.)—The patient was first seen at the age of twenty-five. Her past history was that of good health. Menstruation occurred first at fifteen, and from that time onward was normal, except that it was accompanied with pain. During the first few years after puberty 72 DISEASES OF WOMEN. the pain was slight, but it gradually increased until it was suffi- ciently severe to unfit her for everything during the menstrual period. Her general health began to fail; she lost flesh, and became very nervous and irritable, and it was on this account that she sought relief. I found that the anterior wall of the cervix uteri was on a line with the anterior wall of the vagina, and the os pointed toward the pubes. The posterior wall of the cervix projected into the va- gina far more than normal; in fact, the cervix was hooked upward. The body and fundus were in the normal position. Fig. 41 will give an idea of this form of flex- ion. It gave the impression that in the descent of the uterus the anterior wall of the cervix had been arrested in its progress by the vaginal wall, while the posterior wall of the uterus descended beyond the normal extent. It was very difficult to pass the sound; to do so, the uterus had to be raised up in the pelvis and partially retroverted. Drawing the cervix forcibly backward toward the sacrum developed a band of the anterior wall, which ran from the extreme end of the cervix upward and forward about an inch and a half, and there blended with the vaginal wall. It was easily seen that this abnormal attachment of the vagina was the cause of the flexion of the cervix. Preparatory treatment was employed for a short time, to reduce congestion, and then the operation, already described, to correct the invagination of the cervix, was performed. The ridge of anterior vaginal wall was divided a little less than an inch from the cervix, and then very gentle traction was sufficient to draw the cervix back into its proper relations with the body of the uterus. The wound, which was made at right angles to the axis of the vagina, became parallel to it, when the cervix was carried back into its normal po- sition. It was closed with silk sutures, carried deep down into the wall of the vagina, to make sure that the deeper portions of the wound were coaptated. When the sutures were tied, the invagina- tion was seen to be complete, and the cervix was carried well back, quite as far as it should be; there was also a noticeable traction on the sutures, because the cervix inclined to flex forward again. To correct this, a stem-pessary was introduced, which extended about half-way up the cavity of the body of the uterus. This was held in position at first with a marine lint tampon, and when the wound healed the stem was held in place by the retaining pessary. The FLEXIONS OF THE UTERUS. 73 operation was done without ether, and the patient did not complain of pain, except when the stem was introduced into the uterus. Ten days after the operation the sutures were removed and the union was complete ; the stem was still left in place. After another week had gone, there was considerable congestion in the canal, indi- cated by a free discharge. The stem was removed, and an applica- tion of tannin and glycerin made. After the sutures were removed, the douche of borax and warm water was used daily, and once a week the stem was removed and the canal painted with tannin and glycerin. The next menstrual period was without the severe pain which she suffered before the treatment. Still there were backache and pelvic tenesmus. The stem was left in place during menstrua- tion and for three weeks after, but during that time it was removed every week, and the application of tannin made. The second menstruation after the operation, the first after the removal of the stem, was painless. Subsequently there was no re- currence of the flexion, and her menstruation has continued regu- lar and without pain. It is now three years since she was treated, and she remains well and free from dysmenorrhoea. I may add here, that in all cases of anteflexion of the cervix, due to imperfect vagination, the treatment given above has been suc- cessful. Anteflexion of the Body and Cervix Uteri with Prolapsus. (Recov- ery.)—This patient was a little below the medium size, but was strong and active. She began to menstruate at thirteen, and con- tinued to do so rather irregularly. She generally went over time a varying number of days. From the first, menstruation was painful, the pain gradually increasing from month to month and year to year. This pain was characteristic of flexion; it began before the flow, diminished when the flow was well established, and subsided entirely on the second day. The pain was referred to the uterus, and was intermittent. From puberty to about twenty-one years of age her health was perfect between the menstrual periods. She then began to suffer from backache, leucorrhoea, occasional ovarian pain, and gradually her digestion became impaired, and the nervous system fretted. She was first seen at the age of twenty-four, when the above history was obtained. It was evident that all her symptoms were increasing in severity; general congestion and tenderness of the vagina, uterus, and ovaries, were found at the examination. The os externum pointed toward the vulva, and the fundus could be felt through the anterior wall of the vagina. The cervix was normal in 71 DISEASES OF WOMEN. size, and projected into the vagina in due proportions, anteriorly and posteriorly. The uterus rested low down in the pelvis, and the cer- vix appeared to be bent forward by the pressure upon the pelvic floor. These signs, obtained by touch, were all confirmed by the sound and speculum. The sound was passed through the os internum with difficulty at first. There was no change in the structures of the uterus except the flexion ; the congestion was well marked, and there was slight leucorrhoea, indicating that cervical endometritis was being developed. The treatment of this patient consisted in remedies to improve digestion. Bromide of sodium was given to quiet her nervous sys- tem. Locally, the hot-water douche was employed; the os exter- num was dilated, and tincture of iodine applied to the cervical canal; the uterus was raised to its proper elevation, and held there at first with a tampon, and afterward with a small Peaslee's pessary. The following week the internal os was dilated, until it admitted a No. 10 sound, and the iodine was also repeated. This caused much pain, and compelled the patient to rest in bed a few days, during which time the hot douche was continued. After this, the uterus was made straight by using Elliott's adjuster once a week. The douche and iodine were continued, and this completed the plan of treatment. For six months this course of local treatment was followed out, the constitutional treatment being varied as the symptoms changed. The tenderness and congestion first disappeared, and the pain dur- ing menstruation gradually became less and less, and finally ceased entirely. The patient remained under observation two months longer, and then married, and seven months later her physician reported to me that she was four months pregnant. Anteflexion of the Body of the Uterus; Stenosis at the Os Inter- num, treated with Stem-Pessary. (Recovery.)—This patient-had good health, but was of a highly nervous temperament, a condition which had been increased by a severe and prolonged education. She be- gan to menstruate at fifteen, and had dysmenorrhoea from the beginning. She managed to get along by resting at the menstrual periods, and bearing her suffering as best she could, but at the age of twenty-eight gave up, and sought advice. Her general health at that time was impaired, and she was quite despondent. When first examined, the usual signs of anteflexion of the body of the uterus were found. The cervix was also slightly bent forward. The canal of the uterus was of full size, except at the internal os; FLEXIONS OF THE UTERUS. 75 a small probe only could be passed at that point. The uterus was quite tender, and there was some catarrh of the cervical mucous membrane. Tonic and sedative treatment was begun, and the strict- ure was incised on two sides, with the hysterotome. After this, a sound was passed twice a week for a time. The pa- tient was much relieved by this treatment, but still suffered pain at the menstraal periods. The pain returned to a certain extent, at each menstruation, and at the end of a year treatment had to be re- Fig. 42.—Skene's hysterotome. newed. At that time the patient appeared to be as badly off as when first seen. Dilatation of the canal and straightening the uterus with Elliott's adjuster gave some relief. More thorough treatment was advised, but she would not consent to give her whole time to it. Four years later the patient returned in much worse condition than when first treated. The tissues of the uterus were much hard- er, and there was more tenderness. Great pain was experienced upon passing the sound, and any effort to straighten the uterus was un- bearable. Sleeplessness was now a prominent symptom, and she ^as obliged to take morphine at the menstrual periods. I prescribed the rest-treatment, with tonics, bromides, massage, and the hot-water douche, and the application of tincture of iodine to the cervix uteri and the upper part of the vagina. When the general health had been improved by two months of this treatment, the cervical canal was dilated, under the use of cocaine, until it ad- mitted a No. 12 sound. The uterus was then straightened with the Elliott adjuster, and a glass stem-pessary introduced. Although she was kept quiet after the introduction of the stem, the suffering was so great that at the end of two hours it had to be removed. The general treatment was resumed for about four days, and the stem was again used ; this time it was worn for five days, but had to be again removed, owing to the pain it caused. The irritation was again subdued by the hot douche and cocaine applied to the canal of the cervix, and occasionally an application of iodine and carbolic acid was made. A week later the stem was used again; it then caused lb DISEASES OF WOMEN. less pain, but she had to remain in bed, and there was still consid- erable distress. There was also a marked leucorrhceal discharge. It was necessary to remove the instrument about every five days, and treat the cervical endometritis. Three weeks passed before the patient could be trusted to walk around, and it was two months longer before she could walk out and ride without causing pain. The dysmenorrhoea was less severe each month, and finally subsided entirely. The stem was worn altogether about four months; during all that time the case had to be watched and treated for a recurring endometritis, but finally the recovery was complete. Two years have passed since the treatment was completed, and the patient remains well. The chances are, however, that the flexion will recur. It will be noticed that the stem caused much irritation, and re- quired constant watching. This I find is the case very often. There are few patients who will tolerate the stem unless great care is tak- en, and they are treated the moment that symptoms appear. The longer the trouble has existed, the more difficult it is to use the stem. The uterus becomes more dense in structure and more sensi- tive in old cases, and the results of treatment are not very satisfac- tory. This is the rule, and there are not many exceptions to it. The patient whose case I have just described is one of the oldest that I have ever successfully treated for flexion. All the cases here given are intended to show the different forms of flexion, and the various methods of treatment employed. It will be seen that my object is not to use one method of treatment in all forms, but to adapt the treatment to the peculiar requirements of each case. Finally, I may add that I have succeeded in relieving all cases of flexion, of whatever form or degree, temporarily at least, by the treatment described, excepting when there were complications, such as ovarian disease, or the results of old inflammations. A consider- able number have entirely recovered, and borne children. CHAPTER V. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. ANATOMY. The Pudendum.—The pudendum comprises all those parts that are situated at the outer and lower portion of the pelvis. It is bounded above by the lower part of the abdomen, on either side bv the thighs, and below by the perinseum. In general outline it is wedge-shaped, the edge being downward. The several parts are the mons veneris, the labia majora and minora, the clitoris, and the hymen. The mons veneris is a mass of tissue which covers the sym- physis pubis, and occupies the triangular space formed by the junc- tion of the abdomen and thighs; it is composed of fatty tissue and rather thick integument, which, after puberty, is covered with hair. At its lower border it is divided into two folds by the upper por- tion of the urogenital fissure. The labia majora are two prominent rounded folds of integument, continuous above with the mons vene- ris, which extend downward to the perinaeum. They are formed by integument covered with hair on the outer side; the inner sur- face is more like mucous membrane in general appearance, but it contains sebaceous glands instead of mucous follicles. The tissues of the labia beneath the skin are, connective tissue, elastic elements, and fatty lobules with underlying adipose structure. The vascular supply is abundant, forming a venous plexus. The labia minora, also called the nymphse, are two small folds of mucous membrane, situated upon the inner sides of the labia majora, and extending downward until they meet posteriorly, and form the thin circular band, the fourchette or fraenulum vulvae, which extends across at the posterior part of the opening of the vagina outside of the hymen. The outer surfaces of the labia minora are continuous with the labia majora, and the inner surfaces with the mucous mem- brane of the vestibule. 7S DISEASES OF WOMEN. The clitoris is analogous to the penis, but possesses neither corpus spongiosum nor urethra; it is erectile in structure, and is described as having three parts—the crura, corpus, and glans. The crura are Fig. 43.—The external genitals of a woman who has borne children. oblong, spindle-shaped processes, formed by the bifurcation of the corpus ; they are attached to the rami of the ischium and pubes. The corpus is located in the median line beneath the pubic arch, and terminates anteriorly in a rounded extremity, the glans. The relations of the clitoris and the labia minora are as follows: Each labium divides anteriorly into two folds, which surround the glans clitoridis, the superior folds meeting to form the preputium clitoridis ; the inferior folds being attached to the glans, and forming the fraenum. The vestibule is the triangular, smooth surface, bounded above by the clitoris, on either side by the nymphse, and below by the an- DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 79 t-rior vaginal wall. Just above the junction of the vestibule and vagina the meatus urinarius is situated. It is distinguished by its projection beyond the general surface of the vestibule. The hymen is a thin semi-lunar fold covered on both external and internal sur- faces with mucous membrane, and stretches across the posterior part of the orifice of the vagina. It is a continuation of the vagina (Budin). In fact, the hymen covers the orifice of the vagina, closing it completely, except a small, crescentic opening just below the mea- tus urinarius. It varies in different subjects in regard to its shape, hence the above description can only be taken as that of the typical form—the deviations from this type will be referred to in connec- tion with the pathological conditions of the hymen. The meatus urinarius is situated in the median line, at the junc. tion of the lower margin of the vestibule and the margin of the an- terior wall, about three quarters of an inch below the clitoris. It is kept closed by the muscular tissue of the urethra, and presents a puckered appearance and projects slightly beyond the general plane of the vestibule. The line of junction between skin and mucous membrane runs along the base of the inner aspect of the labium majus, passes down beside the base of the outer aspect of the hymen, and through the fossa navicularis. The deeper structures of the external parts of generation are mostly glands and blood-vessels with connective tissue—the arrange- ment of the two latter giving the characteristics of erectile tissue. The glands are of two kinds, the sebaceous and mucous. The sebaceous glands are abundant in the tissues of the nyinphae; they furnish a yellowish-white secretion, which has a peculiar odor. In those who are not quite cleanly in their habits this secretion accumu- lates beneath the upper folds of the nympha?, around the glans cli- toridis. The mucous glands are of two varieties—the glandulae vestibu- lares majores and the gland ulae vestibulares minores. The glandulae vestibulares minores are about six in number, and are situated about the meatus urinarius; they are of the compound racemose variety, and have short ducts with large orifices. Some- times one or more of these ducts is found, much enlarged, and look- ing like a cul-de-sac, large enough to admit the point of a small catheter. The glandulae vestibulares majores are two in number and about the size of a pea, and are of a reddish-yellow coior. They are situ- ated at the posterior extremity of the bulbi vestibuli, and are par- 80 DISEASES OF WOMEN. tially included in the bulbi, or, more properly speaking, the glands and the bulbi overlap each other. They, like the glandulae minores, are of the compound racemose variety, and their acini open into a duct, more than half an inch in length, which is wide where it leaves the gland, but becomes nar- FiG. 44.—The superficial veins of the perinaeum (Savage); c, corpus clitoridis; 1, 2, 3, corpus cavernosum urethrse; 5, anterior superfical perineal veins; 7, dorsalis clito- ridis vein; 8, 9, 10, pudic vein and primary branches; d, tuberosity of ischium; o, coccyx; 6, vulvo-vaginal gland; a, anterior border of gluteus maximus muscle; b, superficial sphincter and muscle; ff, erector clitoridis muscle; h, left cms cli- toridis. rower toward its orifice. These ducts, in their course, run along the inner side of the vaginal bulbs, and terminate in front of the hymen, about midway from the base of the vestibule and the posterior border of the hymen, or its remains. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 81 The remaining deeper structures of the pudendum of special in- terest are cellular tissue and two masses of blood-vessels, known as the bulbi vestibuli vaginae. These bulbs of the vaginal vestibule are, when distended with blood, about an inch long; they are located on each side between the vestibule and the pubic arch. They are composed of reticulated veins and erectile tissue. The upper ends Fig. 45.—External genitals of virgin. of these bulbs are pointed, and communicate, by an intervening small plexus, the pars intermedia, with the vessels of the glans cli- toridis (Fig. 4-4). The orificium vaginas differs greatly in size and general appear- ance in the virgin, in those accustomed to sexual intercourse, and in those who have borne children (see Figs. -13 and 45). 8 «2 DISEASES OF WOMEN. In virgins the hymen is present, as a rule, and its upper crescen- tic border, with its concavity looking toward the urethral opening, forms the vaginal orifice. There is a considerable variation in the shape of the hymen, and, though there are deviations from the nor- mal type, they are not of necessity morbid states, but rather pecul- iarities of formation. The most common of these are the hymen cribriformis (Fig. 4<>\ which has a number of small openings ; the Fig. 46.—Cribriform hymen. Fig. 47.—Annular hymen (}-). Fig. 48.—Fimbriate hymen. hymen annularis (Fig. 47), which has one small central opening; the hymen fimbriatus (Fig. 48), so called because it is fringed some- what like the extremity of a Fallopian tube. The hymen is usually lacerated in several places during the first coitus, but in some instances this does not take place. Cases have been seen in married women in whom the hy- men is very elastic and distensible. Hyrtl men- tions one specimen, in the museum at Halle, where the hymen is perfect though the woman had given birth to a seven-months' child. The x carunculae myrtiformes are a number of iso- ¥'0t^'X^l !ated elevations .of m"°°»s tissue about the ori- lantois (bladder) and nee of the vagina, which most authors claim Sfd^it t0 be th* ™°*™ of the laeerated hymen. of skin which grows Schroeder has pointed out that these elevations IXls^eTrr116 °r ca™c»^ are produced by child-bearing, and not by simple laceration of the hymen. Clinical observations confirm the views of Schroeder. Development and Malformations of the Vulva.—During the second month of fetal life the rectum, allantois, and Muller's ducts com- municate, but there is as yet no opening of these to the exterior (Fig. 49). DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 83 Fig. 50.—The depression has extended inward and become continuous with the rectum and allantois, forming the cloaca (CI). Fig. 51.—The cloaca is dividing into urogen- ital sinus (Su) and anus by downward growth of perineal septum. Later on, about the tenth week, the genital cleft forms ; this is a depression in the skin which gradually extends deeper and deeper until it communicates with the allantois and the rectum, and becomes the cloaca (Fig. 50). The structure which lies between the rectum and the allantois grows in a down- ward direction, dividing the cloaca into two parts ; that which is situated anteriorly is the urogenital sinus into which Muller's ducts open ; the posterior part becomes the anus, while the lower end of this downward growth forms the perinaeum (Fig. 51). The upper portion of the urogenital sinus, becoming more and more contracted, forms the urethra, the lower part remaining as the vestibule (Figs. 52 and 53). As has elsewhere been stated, the ducts of Miiller unite to form the vagina. The clitoris is formed from the genital eminence, and the labia minora from the edges of the geni- tal cleft. From this brief consideration of the manner of formation and development of the external genital organs their malfor- mations are the more readily understood. Thus, if the depression which is known as the genital cleft fails to be formed, complete atresia of the vulva results. If the partition between the rectum and vagina is not developed, the condition known as atresia of the anus results. From the description already given, it will be seen that this is nothing more than the continuance of the cloaca. In other cases the urethra fails to be developed, and there is then a persistence of the urogenital sinus, or what is commonly known as hypospadias. Hermaphroditism.—In hermaphroditism both ovaries and testi- cles, or one of each, exist in the same individual; these cases are extremely rare, though they have been observed and described by llildebrandt, Bannon, and others. In false or pseudo-hermaphro- ditism a condition exists in which the external genitals appear to Fig. 52.—The perineal body is completely formed (Schroeder). Fig. 53.—The upper part of the urogenital sinus has contracted into the urethra; the lower portion persists as the vestibule (Su) (Schroeder). 84 DISEASES OF WOMEN. belong to the opposite sex. Thus, the clitoris may be so hvpertro- phied as to resemble a penis, and the labia minora be so closely in apposition as to be mistaken for a scrotum; or, on the other hand, the individual may be in reality a male, in whom the condition of hypospadias may exist, and thus the appearances seem to indicate a female. A case is reported by Otto, in which the external genitals of the individual so resembled those of a female that he lived as the wife of three husbands without the fact that he was a male being discovered; and then the mys- tery was only solved by medical examination. Fig. 54 represents the appearance of the organs in this remarkable case. In these cases of false hermaphroditism careful examination will settle any doubts which may have aris- en. The parts simulating both scrotum and labia, when exam- ined, will, if the individual is a male, contain the testicles ; and, if a female, no such body will be found. It is, of course, to be borne in mind, that owing to the non- descent of the testicle, no body might be found, and still the individual be a male, and, on the other hand, that a prolapsed ovary might be mistaken for a testicle. A digital examination should also be made through the rectum for the uterus and ovaries. If the age of puberty has ar- rived, the presence or absence of menstruation will be a valuable diagnostic sign, and great aid may be derived from a study of the other portions of the body, as the breasts and the face, in order to detect the beginning beard, or the voice, to distinguish its tones. It is, of course, very important to make a correct diagnosis; but when this is done, the physician's duty is at an end, so far as being of any service to the patient. Fig. 54.—Spurious hermaphroditism (Simp- son), case of hypospadias in the male making the external organs simulate those of the female : a, a, lobes of scro- tum ; b, imperforate penis, 1£ inch long; e, perineal fissure, l\ inch deep, lined with mucous membrane, at bottom of which the urethral orifice, d, is seen ; c, the split urethra with openings, f, of glands beside it. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 85 DISEASES OF THE PUDENDUM. Vulvitis.—Primary inflammation of the vulva is quite rare, if the specific form and the vulvitis of children are excluded. In nearly all the cases that have come under my observation the inflam- mation of the vulva has been secondary to and caused by some pre- existing affection. "When it is due to gonorrhoea, syphilis, cancer of the uterus, or vaginitis, it must necessarily be treated as a complica- tion of these diseases, rather than as an affection in and of itself. Uncomplicated vulvitis may occur in several forms—as a sim- ple erythema, a purulent inflammation, or as a follicular inflam- mation. The erythematous variety is characterized by a general redness of the vulva, limited to the mucous surfaces, though sometimes it ex- tends to the skin. It is usually transient, passing away without much treatment. The purulent form is more defined. The parts are red, and cov- ered with a copious formation of pus. The epithelium rapidly ex- foliates, leaving a raw-looking surface. Occasionally only small patches of ulceration are to be seen, but these are neither large nor are they deep, as a rule. In follicular vulvitis the mucous membrane generally is not much changed in appearance; sometimes it has a deeper color, but the whole surface is studded with small, red points, which on close in- vestigation are found to be the orifices of mucous follicles. The size and number of these inflamed spots vary in different cases. In this and in the purulent form the discharge is increased by a free secretion from the mucous and sebaceous glands, and this gives rise to a very disagreeable odor. There is also in most cases consid- erable pruritus. Causation.—In regard to the causes of vulvitis, it is evident that the strumous diathesis and the lymphatic temperament predispose to it. All the cases that I have seen, which could not be traced to some pre-existing or specific cause, have been in strumous or phleg- matic women. Age also has its influence. The purulent variety occurs in chil- dren, while the follicular form occurs most frequently in the aged. Symptomatology.—These are not diagnostic. The discharge, heat, tenderness, and pruritus are the chief symptoms, but they all occur when the vulvitis is associated with vaginitis, and similar symptoms occur in many of the eruptive diseases of the vulva. Physical Signs.—These are the same as those presented by in- 86 DISEASES OF WOMEN. flammation of mucous membranes generally, and hence need not be given here. Diagnosis.—This is made by inspection, and a careful exclusion of all other affections, such as eruptive, specific, or malignant disease. Treatment.—The chief objects, in the management of vulvitis, are to keep the parts clean, and to separate the inflamed surfaces. This is difficult to do in children, and hence the complete relief of this affection in the young is not by any means easily effected. In vulvitis of women I have of late years relied upon frequent washing with a solution of borax or boracic acid, two or three times in the twenty-four hours, and then after drying the parts, ap- plying thoroughly a dry powder of subgallate of bismuth, oxide of zinc, or iodoform. This method answers very well if the patient has a nurse who can carefully employ the treatment. Equally good results have been obtained by applying to the parts, after bath- ing thoroughly, a solution of sulphate of zinc, three or four grains, three ounces of water, and one ounce of fluid extract of hydrastis Canadensis, or nitrate of silver, two grains to the ounce of water. After applying either of these lotions, a small pledget of absorb- ent cotton should be placed between the labia, to keep the surfaces apart, and to absorb the purulent discharge. Inflammation of the Vulvo-vaginal Glands. — Inflammation of these glands in the great majority of cases is due to vulvitis. The inflammation extends into the ducts and finally to the glands them- selves. While this is sometimes the result in simple vulvitis, it is far more likely to occur when the inflammation is gonorrhceal. In some cases the inflammation does not extend beyond the duct, the gland itself escaping, and then there is but little discomfort experi- enced by the patient unless the purulent discharge keeps up a cir- cumscribed inflammation of the vulva around the opening of the ducts. When the glands are involved, the symptoms are those of an inflammation of the deeper structures. The closing of the ducts of these glands may result in the formation of cysts, by the retention of the secretion. Symptomatology.—The patient will usually detect the inflamma- tory condition before the physician is consulted. This portion of the pudendum will be hot, sensitive, and painful; pruritus may also be present. Physical Signs.—By inspection of the parts, redness around the mouths of the ducts will be found. The openings of these ducts are to be sought for, about the middle of the ostium vaginae, one on DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 87 each side, just in front of the hymen, or the carunculse myrtiformes. By palpation a hard, circumscribed tumor will be found at the loca- tion of the gland. Prognosis.—The inflammation may gradually subside, or result in the formation of an abscess. If an abscess forms it will pursue the same course, and be recognized in the same manner as an ab- scess elsewhere. The pus may discharge through the duct, or it may require surgical interference. Rarely the pus remains encysted for a long period. The inflammation may confine itself to the duct and not extend to the gland. In this case it will cause but little trouble, pain and pruritus being present for a short time, and disappearing with the subsidence of the inflammation, or the inflammation may result in adhesion of the wall of the duct, and, by occluding its lumen, prevent the escape of the secretion of the gland, and cause a cyst by its retention. Not infrequently the walls of such a cyst become inflamed, and an abscess results. Treatment.—The inflammation of these glands is to be treated in the same manner as is recommended for the treatment of in- flammation of the labia majora. When a cyst forms, and its contents can not be evacuated through the duct by pressure, it may be dissected out. Although the great- est care may be exercised, this can not always be done; in that case. the cyst-wall, after being exposed by dividing the mucous mem- brane, may be opened freely, the contents of the sac removed, the wall of the sac thoroughly cauterized with carbolic acid, and the cavity permitted to heal from the bottom by granulation, its walls being kept separated by packing with cotton in order to prevent its closing, and again filling. Inflammation and Abscess of the Labia Majora.—This inflamma- tion occurs in the connective tissue, which constitutes the greater part of the labia. It is often associated with vulvitis, or may be due to the secretions of the vagina, which are of an irritant char- acter. Blows or other injuries may also excite an inflammation in these tissues. This inflammation is characterized by redness and swelling; the latter is not circumscribed, as in the inflammation of the vuivo-vaginal glands, but is more diffuse. Like that, however, it is painful, and accompanied with pruritus. When a swelling is formed in one of the labia, it may be due to simple inflammation, or it may be a hernia, an ovary, or a hematocele. Treatment.—The means employed for the treatment of inflam- mation of connective tissue elsewhere are indicated here. These are rest, evaporating lotions containing opium for the relief of the S8 DISEASES OF WOMEN. pain, salines, and flaxseed-poultices if the inflammation does not subside. If an abscess forms, it should be opened as soon as the presence of pus is determined ; the opening of the abscess, and the subsequent treatment of the wound, should be managed on strictly antiseptic principles. Varicose Veins of the Vulva.—The veins about the vulva, like those in other portions of the body, may take on a varicose condi- tion. This commonly occurs in those who have borne children ; and, indeed, pregnancy appears to stand in a causative relation thereto, although cases undoubtedly do occur in those who have never been pregnant. Causation.—Anything which obstructs the venous circulation will, by increasing the intravenous pressure, tend to produce this varicose condition, whether it be a pregnant uterus, a tumor, or, as mentioned by Winckel, the straining at stool, in case of obstinate constipation. Symptomatology.—A patient may have well-marked varicose veins of the vulva, and yet be entirely unaware of the fact. Or a sense of heat and irritation may be experienced of so disagreeable a nature as to cause her to consult a physician, when the presence of varicose veins may be recognized. In still other cases the full- ness due to the swelling is so great as to attract her attention, though other symptoms may be absent. Physical Signs.—Upon examination, in slight cases, the varicose condition of the veins is observed. There may, however, in more aggravated cases be so much tumefaction of the labia and other parts as to mask this peculiar condition of the veins. Holden describes a case in which a tumor existed as large as the head of a child. The diagnosis in these cases is to be made by excluding the other affections, by the methods which are elsewhere described. Treatment.—But little can be done in the way of radical treat- ment for this condition. The bowels should be attended to, so that there may not be constipation and the accompanying straining at stool. If the varicosity is marked, and shows a tendency to increase, some relief may be obtained by a pad, so applied as to give the veins the support which they lack by reason of the weakness of their walls. It should be constantly borne in mind that, when these veins assume a marked varicose condition, there is a possibility of their becoming so distended during pregnancy as to rupture at the time of delivery. Wounds of the Pudendum.—These injuries are of three kinds—in- cised, punctured, and contused. They are of great interest, owing DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 89 to the profuse haemorrhage which usually occurs when the vessels of the bulbi vestibulares are wounded. Superficial wounds of the labia are not usually important; it is only when the larger vessels of the bulbi are opened that profuse and dangerous haemorrhage occurs. Incised and punctured wounds are usually caused by falling upon cutting instruments. I have not had any personal experience with such injuries. All I know about them I have gathered from Sir James Y. Simpson's obstetric work. He calls attention to several fatal cases of this injury, death occurring from haemorrhage. He also states that several of these fatal cases were supposed to be caused by criminal intent. I remember, when a boy, reading an account of a gypsy woman, in Scotland, who died from pudendal haemorrhage, and her husband was tried for her murder. The defense set up was, that the wound was caused by striking against a stick while squatting down to urinate, in the woods, where they were encamped. Thomas records a case, not fatal, I believe, which was caused by a piece of china, from the breaking of a pot de chambre. Symptomatology.—The symptoms are pain and profuse haemor- rhage, following an injury to these parts. The bleeding is suffi- ciently alarming to require an examination, when the character of the injury is at once detected. Causation.—The causes are traumatic, and need not be discussed. Treatment.—The treatment, commended by most authors, is to use cold applications and astringents, such as persulphate of iron and tannin, and if these are not sufficient, to enlarge the wound, pack it with antiseptic cotton, and apply pressure. To make the pressure effectual, the vagina should be tamponed, and a compress and band- age applied. I am satisfied that this kind of treatment must prove very un- satisfactory. Although I have had but little experience with acci- dental injuries of the pudendum, I have repeatedly encountered pro- fuse bleeding from vessels of the bulb, wounded while removing morbid growths from the pudendum. In such cases I have found it most satisfactory to ligate the bleeding points, taking up the ves- sels en masse when several of them were wounded; when it has heen difficult to find the vessels and secure them in the deep wounds, I have passed a strong suture from the outer side of the labia into the vagina, and returned it so that it would include the bleeding vessels in its grasp when tightly tied. This controls the bleeding for the time, but occasionally it will start again, when the ligature becomes loosened, which it is likely to do in a few hours. When 90 DISEASES OF WOMEN. this occurs, the ligature should be tightened. If there is no subse- quent bleeding, the suture can be removed at the end of twenty-four hours. I am sure that this is the most surgical as well as the mo>t satisfactory way of managing haemorrhage in this region. Styptics and pressure, in some cases, will only conceal the bleeding, but not arrest it; the blood will burrow in the soft tissues and complicate the injury, and also make ligature of the vessels more difficult. Contused Wounds of the Pudendum.—These are of two degrees of severity. A slight bruise, causing rupture of only a few small ves- sels (which very soon stop bleeding), gives rise to an ecchymosis, which quickly disappears. Occasionally inflammation follows and an abscess develops, which is managed in the usual way. Contused wounds, which rupture the large vessels of the bulbi vestibulares, or varicose veins of the labia, if any such exist, produce pudendal haematocele—i. e., an accumulation of blood in the loose cellular tissue of the parts. The pathology of this injury is the same as that of bruises or contused wounds generally. There are laceration of the vessels, and haemorrhage into the cellular tissue. In contusion of the pudendum there are two conditions which conspire to make the injury grave in character—the large size of the vessels wounded, and the loose character of the cellular tissue, which admits of a very large accumulation of blood. The size of the haematocele depends upon the size of the vessels lacerated. In case the vessel is small, the bleeding may be controlled by the pressure from the blood in the tissues; but when large varicose ves- sels or the vessels of the bulb of the vestibule are lacerated, the size of the haematocele is very great. I have seen one nearly as large as the two fists. The course and termination of haematocele vary. If the blood- clot is small, it may disappear by absorption, without causing much discomfort, after the first pain of the injury subsides; but when the accumulation of blood is large, then inflammation follows, which may terminate in sloughing or suppuration, and finally septicaemia. Symptomatology.—The symptoms are pain following the injury, and then a feeling of fullness, heat, and sometimes throbbing. In one case that came under my observation the pressure was sufficient to prevent urination, and it was very difficult to pass the catheter. The attention of the patient being directed to the location of the injury, the swelling is discovered by the touch. Physical Signs.—The physical signs vary in the different stages of the disease. At first, the tumor is elastic and like a local oedema, except that it does not pit on pressure. After the blood has coagu- DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 91 lated the parts are denser and slightly irregular, or slightly nodu- lar ; discoloration of the skin occurs in twenty-four hours, or less. (Edema of the skin also appears. Diagnosis.—In regard to the diagnosis, it may be said that pudendal haematocele can hardly be confounded with any of the diseases of the pudendum, except pudendal hernia, and the mode of development and physical signs of the two affections are so unlike that the differentiation is easy. Causation.—The causes of pudendal haematocele are predispos- ing and^exciting. Varicose conditions of the vessels, degeneration of the vessel-walls, and marked engorgement from any cause which interrupts the venous circulation, render the vessels more liable to rupture when subjected to any injury. Pregnancy predisposes to rupture of the pudendal vessels, and labor is one of the most prominent of the exciting causes, but the present discussion of this affection is limited to causes occurring in the non-puerperal state. The reader will find a very full account of this affection, as it occurs in labor, in a monograph by Prof. Fordyce Barker. In regard to the exciting causes of the affection, it may be said, in brief, that they are always traumatic. Direct blows are the usual means by which the vessels are ruptured ; indirect injuries— from a fall, for instance—might produce rupture of the pudendal vessels, but I have not seen any cases in which the injury was caused in that way. Treatment.—When the patient is seen immediately, and while haemorrhage is still going on, an effort may be made to arrest the bleeding by pressure; but if this fails after a short trial, it is best to lay the parts open, and secure the bleeding vessels in the way already described. This is quite an important operation, and requires that the patient should be anaesthetized, but the results fully justify the means. The advantages of this treatment are threefold: the bleed- ing is controlled effectually, and in the safest way, providing the surgeon is called while the bleeding is still going on ; the extent of inflammatory action is greatly lessened or wholly avoided; and the dangers of septicaemia are guarded against by clearing out the blood- clots and securing free drainage. The rule is, however, that the surgeon is not called until the stage of bleeding is past; it is then well to wait till the patient has recovered from the loss of blood, and reaction from the shock, if there has been any, has set in, and then lay open the haematocele, turn out the clots, tie any vessels that may bleed, secure free drainage, and use ordinary surgical dressing. I 92 DISEASES OF WOMEN. am sure that this course of treatment is the best, being by far the safest in guarding against fatal septicaemia, and securing a more prompt convalescence, with infinitely less danger to the tissues of the pudendum. ILLUSTRATIVE CASK. Pudendal Haematoma.—A dissipated woman, about forty years of age, was brought into the Long Island College Hospital, after having received a brutal beating from her husband. She had a number of bruises about her head and face, and complained of pain in the puden- dum. On examination, an enormous swelling was found in the region of the right labium. Pressure was made by means of bandages, and the swelling, due, no doubt, to haemorrhage, was controlled so that it did not increase. She had considerable fever and depression from her injuries, but was rallied by means of stimulants and quinine. At the end of forty-eight hours after her admission the ecchymosis was so marked, and pressure upon the tissues so great, that slough- ing was apprehended ; even if that should not take place, the exten- sive inflammation and suppuration, which necessarily must follow, would have placed the patient's life in great danger from septicaemia, and made convalescence, at least, very tedious. It was therefore decided to operate, which was done as follows: An incision about four inches long was made on the inner side of the tumor with the thermo-cautery knife. Proceeding slowly with the instrument at a dull-red heat, no haemorrhage was excited by the incision. The clot, a very large one, was turned out, and, just as soon as the pressure was removed, bleeding started at several points in the deeper portion of the wound. The bleeding vessels were caught up by compression-forceps and ligated, and the general oozing which kept up was controlled by the cautery. The wound was then packed with lint, which was held in place by a bandage; the dressing was changed night and morning, the quantity of lint being reduced as the cavity contracted. She made an excellent recovery, and left the hospital in two weeks from the time of the operation. Hernia of the Pudendum.—Two varieties of hernia may occur in the vulva—one known as anterior-labial, and the other as poste- rior-labial. The former, which is sometimes described as inguinal labial hernia^ consists in the passage of the dislocated organ by the side of the round ligament into a labium majus. The sac may con- tain intestine, omentum, ovary, Fallopian tube, or uterus. WTinckel found six cases of this variety of hernia in 5,600 private patients ex- amined by him; in one case an ovary was found in the left side • DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 93 in a second, each ovary in a hernial sac ; in a third, the uterus ; and in a fourth, the pregnant uterus. The second variety, known also as vagino-labial hernia, occurs much less frequently. Winckel has seen but two cases, and says that the hernia passes down in front of the broad ligament into an open- ing in the pelvic fascia and levator ani, and appears at the posterior extremity of one of the labia majora. Diagnosis.—This is not difficult, if due caution and care be ex- ercised. If the patient bears down, the size of the tumor will be increased. If she be placed in the knee-chest position, the hernia can be readily reduced, going back with a gurgling sound. When she assumes an upright position, the reduced tumor will again return. Treatment.—This consists in reducing the hernia, and retaining the organ in place by means of a properly-applied truss. Vaginal Enterocele.—This is a form of hernia in which the intes- tines descend into the pelvic cavity, and may pass down either in front of or behind one of the broad ligaments. The hernia is usually composed of small intestine alone, though it may contain omentum alone, or both intestine and omentum to- gether. Cases have been recorded in which the large intestine came down instead of the small one. Yaginal enterocele is usually explained in the following manner: The intestine, having found its way into Douglas's cul-de-sac, pushes it downward, and gradually causes the vagina to bulge inward. This may increase to such a degree that, finally, the tumor may appear at the vulva and even protrude from it. Diagnosis.—This is not difficult if the examination is made with care, though serious errors have been made by surgeons, the tumor being considered an abscess, and opened by the knife. A vaginal enterocele may be recognized by the following char- acteristics : It becomes smaller on pressure; increases in size when the patient coughs or bears down ; is resonant on percussion—though, if the contents are omentum, this sign would not be present—and is easily returned if the patient be placed in the knee-chest position. It may be mistaken for an abscess, a prolapsus of the vagina, an ovarian cyst, or a dropsy of the Fallopian tubes. Causation.—Parturition is considered as the most common cause of the hernia, the intestines being pressed down against the relaxed pelvic tissues by the expulsive pain of labor. When occurring in nulliparous patients, it is usually due to falls or to violent straining efforts. '.>-* DISEASES OF WOMEN. Treatment.—Inasmuch as the sac of this variety of hernia is not liable to constriction, strangulation rarely occurs. The tumor will disappear if the patient is placed in the knee-chest position, and its retention may usually be accomplished by a pessary that will keep the vaginal wall tense. This will at least prevent the protrusion of the hernia from the vulva, though it is doubtful if any treatment will prevent entirely the entrance of the intestines into the pelvic cavity. The existence of this hernia should be borne in mind in case the patient becomes pregnant, for under such circumstances labor is often impeded by the enterocele, which, coming down in advance of the presenting part, offers a serious obstacle to its progress. Hydrocele of the Round Ligament.—In order to understand the condition which is present in hydrocele, it is necessary to recall the anatomical relations of the round ligaments and the labia majora. The labia, it will be remembered, are the analogues of the male scrotum, and the round ligament of the spermatic cord. These liga- ments terminate in the labia majora, and are covered by an offshoot from the peritonaeum, the increased serous secretion formed by this membrane constituting hydrocele. Although the peritoneal sac does not ordinarily extend into the inguinal canal, still it may do so, and intestine or an ovary may en- ter this pouch. Hydrocele of the round ligament is liable to be confounded with hernia. The tumor will be translucent if it be hydrocele, and this, together with the history, will be sufficient to make the diagnosis. An aspirator needle may be employed to make the diagnosis more certain. It is an exceedingly rare disease, and one that I have never seen. Treatment.—The fluid contents of the sac should be withdrawn by aspiration, and tincture of iodine injected. Hyperesthesia of the Vulva.—This disease, as the name implies, is characterized by a supersensitiveness of the vulva. Pruritus is absent, and on examination of the parts affected no redness or other external manifestation of the disease is visible. When, however, the examining finger comes in contact with the hyperaesthetic part, the patient complains of pain, which is sometimes so great as to cause her to cry out. Indeed, the sensitiveness is occasionally so exaggerated as to keep the patient from consulting her physician until it becomes absolutely intolerable. Sexual intercourse is equally painful, and becomes in aggravated cases impossible. This affection must not be confounded with vaginismus, or with other conditions of increased sensitiveness of the vulva due to in- flammatorv conditions. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 95 Causation.—The causes which produce this hyperaesthetic con- dition of the vulva, when not due to inflammation or the presence of urethral tumors, are difficult to recognize. At the menopause the affection seems more likely to occur than at any other period of life, and women of weak mental and physical powers are more often its subjects than those who are strong both in mind and body. Treatment.—Various methods of treatment have been suggested, but so far as my own experience is concerned they have been in most instances unsatisfactory. The sensitive tissue has been dis- sected off and relief obtained for a time, the hyperaesthesia return- ing, however, as before the operation. Nitric acid has been ap- plied, but without a cure resulting. The best that we can probably do for our patients is to build them up with tonics and nutritious food, and, if possible, to send them away so that they can have the benefit of a change of air and of scene, and at the same time be re- moved from the irritation of sexual intercourse, which of necessity aggravates and perpetuates the hyperaesthesia. I have repeatedly been able to relieve the hyperaesthesia, temporarily, by the applica- tion of cocaine in a four-per-cent solution. This will also be found useful when making examinations in cases of sensitive vulva, or in passing the sound into a sensitive uterus. Pruritus Vulvae.—This condition is a symptom rather than a dis- ease in and of itself, and yet it is such a prominent one in many cases as to justify its description as an independent affection. Pathology.—Pruritus consists essentially in an irritable condition of the nerves of the part affected. Although this is ordinarily the vulva, it may be and often is the vagina and the anus, and even the integument of the abdomen and thighs may be involved. Symptomatology.—The patient notices an itching of the parts affected, which is at first relieved by scratching or rubbing, but later this relief is but temporary, and the friction aggravates the original trouble, until an eruption of an irritating nature appears, from which at a still later period there is an exudation, which, by the nails used in scratching, or in other ways, is carried to other portions of the body, and seems by its irritant nature to excite a similar trouble there. The itching and the burning sensations become at times in- tolerable, and the patient is debarred from the society of her friends. In some instances the annoyance and suffering are increased at night, and in order to obtain sleep hypnotics have to be administered. Physical Signs.—The signs vary according to the affections which cause the irritation. These are described above in speaking of the pathology. In some cases there are no definite signs present. 96 DISEASES OF WOMEN. Causation.—It is more than probable that pruritus is always secondary to some other trouble. A due appreciation of this fact is necessary for the institution of proper treatment, as, if it is lost sight of, and that which is in reality only a symptom is regarded as a disease, the pruritus will continue almost indefinitely, and in its chronic form will resist all remedial measures. Leucorrhoea is very commonly as- sociated with pruritus, and appears to stand in a causative relation thereto. Other irritating fluids may also produce the same result. Of these the most common are diabetic urine and the discharges from an ulcerating cancer of the uterus. The leucorrhoeal discharge which is most likely to produce pruritus is that from a uterus which is the seat of endometritis, either cervical or corporeal. The presence of parasites may also account for the existence of pruritus. Treatment.—From the principle already laid down that pruritus is to be regarded as a symptom of some pre-existing disease, the de- tection of this disease will first demand attention, and when discov- ered treatment appropriate thereto should follow. If there be an endometritis, the discharge from which irritates the vulva or other parts, and causes pruritus, the inflammation should be treated as advised elsewhere. A pledget of absorbent cotton placed against the os, to receive the discharge, will be of great benefit; this should, of course, be renewed sufficiently often. Yaginal douches containing acetate of lead or carbolic acid will often give great relief. Subnitrate of bis- muth may be dusted on to prevent friction of the labia against each other; this sometimes relieves the pruritus. I have found this to be one of the best local applications in the pruritus caused by diabe- tes ; in such cases I direct the patient to keep the urine from coming in contact with the parts, as far as possible, when urinating, and to dry the pudendum and dust it over with subnitrate of bismuth. By adding an equal quantity of prepared chalk to the bismuth, it makes a powder that is more easily used. Very satisfactory results can be obtained in the management of cases where the pruritus is caused by some appreciable disease of the organs. The greatest difficulties are experienced, however, in the treatment of that form of pruritus which occurs without any lesion of structure or accompanying affections to account for it. That there are some morbid changes in the tissues, in the violent pruritus which is experienced, is no doubt true, but so far they have not been demonstrated by pathologists, and hence the majority of authors con- sider that this affection is a neurosis. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 97 In the majority of cases of this kind that have come under my observation, the skin has been bleached, in spots appearing whiter than the normal skin. It has also lost the normal elasticitv. To the touch it seems harder and less flexible, but what these changes are, and whether they are related to the pruritus, are questions which have not yet been answered. The pathology and causation of this affection are both obscure, and the treatment is equally unsatisfactory. Many of these cases prove to be incurable, and in some it is not possible to give the patient complete relief by any local treatment. This has led to the use of a great variety of agents, but none of them has proved to be reliable in all cases. The remedies that have given the best results in my practice are bichloride of mercury and emulsion of bitter almonds, one grain to the ounce ; this is applied to the parts affected twice a day. A powder composed of one grain of morphine to two grains of chalk, to be applied night and morning; equal parts of tincture of opium, iodine, and aconite, and eight per cent of carbolic acid, applied once a day—all of these have been tried, and each one has proved serviceable to some extent, but there are cases which resist all these remedies. The bichloride of mercury mixture, used alone, has been of the most service in the largest number of cases. Where it fails, I have used a solution of iodoform in ether; this is applied by means of an atomizer, and by using strong air-pressure the solution is forced into all the folds of the mucous membrane; the ether soon evaporates, and leaves a fine coating of the iodoform over the whole surface. This nearly always relieves, and if applied frequently is curative in some cases. I have also used carbolic acid and tincture of iodine, equal parts, and this nearly always gives relief for a day or more. In the following case this application relieved the pruritus permanently: The patient had passed the menopause, and, although she had not borne children, her health had always been good. Dr. Fordyce Barker, whom she consulted, sent her to me, telling her at the same time that I could not cure her, but would give her as much relief as possible. I tried the usual remedies, with no benefit. I then used the carbolic acid and iodine, but found it difficult to apply to all the irregularities of the surface. I applied it with the atomizer, using a high pressure, so that the solution was forced into the tissues, and a deeper effect obtained than I had expected. The result of this was, that the patient suffered greatly. The first effect was sharp pain, followed very soon by relief from the itching, and numbness of the parts; in short, the anaesthetic effect of the carbolic acid was 9 98 DISEASES OF WOMEN. obtained in a marked degree. Following this there were great irri- tation and pain ; the epithelial layers of the skin and mucous mem- brane came off as if they had been blistered, and there was much sensitiveness. During this, while the patient was suffering the most pain, she said that it caused far less suffering than the itching. When she recovered from the treatment the itching did not return for several weeks, and then only in a slight degree. I made the same application once again to several spots where there was severe itching, being careful not to cover more than a very small area. It was not necessary to apply the remedy the third time. She completely recovered, and remained well for one year at least; and I presume she has had no relapse, as I should probably have heard from her if she had. Eruptions of the Vulva.—The vulva may be the seat of eczema, either acute or chronic, herpes, prurigo, erysipelas, and diphtheria. Eczema here as elsewhere consists of vesicles, or a somewhat reddened skin, from which a serous fluid escapes. This dries, and oftentimes a thick crust forms, under which pus may accumulate. If the attack does not become chronic, this crust falls off in one or two weeks, exposing a new and tender epidermis beneath. If, on the other hand, the affection becomes chronic, the tissues become thickened by exudation, and at the same time dry, and lose their suppleness. This condition is very liable to extend to the thighs and to the integument about the mons veneris and anus. In herpes, vesicles are also present, but they are not accompanied by any redness or inflammation of the surrounding tissues. These vesicles may rupture and scales result, but, like herpetic eruptions on the lips, they are of short duration, and soon disappear. In prurigo, small papules are seen on the affected parts. Kiilm describes them as having a small, dark spot in the center, which is depressed, and containing a tenacious, reddish, gland-like mass at- tached to the bottom of the papilla. Treatment.—In the acute form of eczema, in which there is free transudation of serum, I use subnitrate of bismuth or powdered soap- stone, with three to five per cent of carbolic acid. When the parts are dry, I employ oxide-of-zinc ointment, carbolic-acid ointment, or glycerine and borax. In chronic forms of eczema, applications of nitrate of silver, twenty grains to the ounce of water, may be made. This may be done once or twice a week. The herpetic eruption will disappear without treatment, and the only indication is to keep the affected parts protected from friction. Prurigo may be cured, according to Kiihn, by removing these DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 99 tenacious masses which have been described as situated at the bottom of the papillae. The vulva is sometimes the seat of erysipelatous and diphtheritic inflammation. Erysipelas is rare in adult fife, and indeed may be said to occur most frequently in the very earliest infancy. In its local treatment sugar-of-lead lotions may be applied, and internally tonics and stimulants. The prescription which has given me the most satisfaction is as follows: Borax, one drachm; tincture of opium, one ounce; glycerin, three drachms; and water, three ounces. The parts should be kept constantly moistened with this. Diphtheria of the vulva occurs in some cases when the exudation exists in the pharynx or larynx, and rarely as an independent disease. Its treatment is constitutional. Noma, or gangrene of the vulva, is perhaps best considered in connection with the eruptive diseases. The first indication is a swelling of one of the labia majora, which becomes of a grayish- green color, followed by vesicles; the color changes to brown, and gangrene rapidly sets in. Causation.—Noma occurs in children whose general health is poor, either from insufficient and improper food, or from having lived in squalid tenement-houses; or, indeed, from both combined. It may also occur as a complication of one of the contagious diseases— scarlet fever, measles, or small-pox. The prognosis in noma is very grave. Treatment.—This should be directed to sustaining the failing powers of the patient. For this purpose quinine, iron, and stimu- lants should be freely administered, and antiseptic dressings applied to the affected parts. It has been recommended to excise the gan- grenous tissue, and to apply the actual cautery to the underlying parts. CHAPTEK VI. DISEASES OF THE VAGINA. Anatomy of the Vagina.—The vagina is the continuation of the genital tract from the uterus to the vulva. It is curved to coincide with the axis of the pelvic excavation; this, to some extent, renders it much shorter in front than behind. The anterior wall is about two inches long, while the posterior is nearly twice that length. The anterior wall is further shortened by the cervix uteri, which joins the vagina much nearer to the vul- va in front. Fig. 55 shows the comparative length of the vagina in front and behind. The vagina is attached above to the cervix, about midway be- tween the body of the uterus and the termination of the cervix uteri. Below, it unites with the floor of the pelvis and the structures which form the vulva. Anteriorly, it is united to the bladder and urethra ; to the former loosely, and to the latter so firmly that it is almost impossible to separate these structures even by dissection. Posteriorly, the vagina and rectum are united and form the recto-vaginal septum. Below, they are sepa- rated by the sphincter-ani and trailversus-perinei muscles and cellular tissue. Fig. 56 shows the triangle formed by the bifurcation of the two canals and the divided muscles between them. The vesico-vaginal septum is the most resist- Fig. 55.—Length of vagina, less in front than behind. Fig. 56.—Triangular shape of perineal body. 100 DISEASES OF THE VAGINA. 101 ant portion of the vaginal walls, and, when put upon the stretch, feels like a cord lying beneath the mucous layer; this is called the anterior column of the vagina. The vaginal walls are composed of three coats—an external, mid- dle, and internal; the external consists of fibrous, elastic, and areo- lar tissue; the middle of unstriped muscular fiber; and the inter- nal of mucous membrane. The muscular coat is continuous with the middle coat of the uterus, and the two are alike in structure, and in the fact that they both undergo extraordinary hypertrophy during utero-gestation. The mucous membrane of the vagina is continuous with the endometrium, but differs from the latter in structure to a marked extent. It is arranged in transverse folds, which are most prominent anteriorly, and is studded with papillae and covered with pavement epithelium. In general structure the mucous membrane of the vagina resembles very much the skin. This is noticeable in cases of prolapsus, in which the membrane, by being exposed, be- comes dry and its epithelium hardened. The structure of this membrane is like the skin to some extent— its secretion is serous and of acid reaction. There has been some discussion among anatomists regarding the presence or absence of muciparous glands in this vaginal membrane. The fact is that they are abundant in the lower third, but nearly absent in the middle and upper thirds. The vagina is developed like the uterus, from Muller's ducts, and is liable to malformations from arrest or defects of development. Malformations of the Vagina.—Imperforate hymen has been al- ready discussed under the head of menstrual disorders due to mal- formations of the sexual organs generally. Double vagina usually occurs in connection with double uterus, and in such cases no harm to the patient is likely to result. Perpetuation of the septum between the most dependent por- tions of Muller's ducts has been found. In one patient who came under my observation a thick septum extended from just within the hymen upward about an inch and three quarters. This malforma- tion gave rise to no symptoms, and was not recognized until the birth of her first child, when the attending physician found that it caused some obstruction to delivery. I examined the case about two months after her confinement and found this septum, about a quarter of an inch thick and quite resistant. It was divided by two incis- ions parallel to the axis of the vagina, and about three quarters of au inch apart. The strip thus removed was not the whole of the septum, but it was sufficient, as the ends remained contracted. The 102 DISEASES OF WOMEN. divided edges were brought together with sutures, and healing took place very promptly. Imperforate Vagina.—Absence of the vagina has been described as one of the malformations, but it is doubtful if there is not in these cases a rudiment of vagina, which is imperforate, and hence absent to all intents and purposes. In the most complete case of the kind that I have seen the rectum and bladder were near together. With the finger in the rectum, and a large sound in the bladder, a rather dense cord running upward from the vulva could be felt. The uterus was also rudimentary, and although the patient had passed the period of puberty, and had the outward characteristics of her sex, she had never menstruated. This was evident from the absence of menstrual flow in the uterus and Fallopian tubes. In cases like this nothing can be gained by treatment. So long as there is no excessive menstrual molimen, which would endanger the life of the patient, there should be no interference. Atresia of the Vagina.—This is the more common affection. It may be either complete or partial, congenital or acquired. In the congenital form the atresia may extend the whole length of the vagina, and that condition is generally associated with an un- developed uterus. The incomplete, or partial, atresia is usually at the lower third, but it may occur at the upper or middle portion of the vagina. Congenital atresia occurs under two different conditions. The one is associated with defective development of the uterus or ovaries, or both, sufficient to prevent menstruation altogether. In the other, menstruation takes place, but the flow being obstructed, accumulation occurs in the uterus and sometimes in the Fallopian tubes. These differing conditions require different management. I will therefore consider them separately. Atresia of the vagina, with defective development of the uterus and ovaries, is only of interest with reference to the diagnosis. Noth- ing can be done, nor is there any active demand for treatment. The patient does not suffer, as a rule, except from the consciousness of her deformity, which would only cause mental distress in case she intended to get married. Two such cases have come under my observation. The most typical one was of a good family, strong, but inclined to flesh. She did not change much in general appearance at puberty, but main- tained considerable of the masculine type. She never showed the slightest disposition to menstruate. She was asked by a worthy man to marry, but she was afraid to do so without advice, knowino- DISEASES OF THE VAGINA. 103 that she was " unlike other women." She sought advice, and on ex- amination there was found atresia of the vagina, and apparently the uterus and ovaries were rudimentary. N'othing could be done to help her. She took up nursing as a profession, and has succeeded remarkably well. This case is briefly given in order that this variety may be contrasted with the next form. Atresia associated with fully developed uterus and ovaries may be complete or incomplete. Usually, there is no notice taken of the deformity until puberty arrives, unless the attention of the mother or physician is directed to the pelvic organs for some other reason. There are no symptoms until puberty. Then the patient, after hav- ing undergone the changes characteristic of the period, has all the symptoms of menstruation without the flow. The symptoms, or menstrual molimen, as they are called in their totality, are more marked than in normal menstruation, and great pain, fullness, and tenesmus, come on during the period. The first effort at menstruation is not usually attended with such severe suf- fering, but each succeeding period is worse, and very soon the evi- dences of the accumulated fluid become tangible. Physical Signs.—Inspection of the parts shows a complete closure of the vulva. Combined touch with a straight sound in the bladder and a finger in the rectum, reveals the fact that in absence of the vagina the rectal and vesical walls come together, and are thin and elastic. If the vagina is present, but closed, it is felt between the sound and finger as a firm cord. When the uterus is distended with menstrual fluid, the accumulation causes a tumor, which is elastic and obscurely fluctuating. The signs of partial atresia differ according to the location of the occlusion. When the atresia is in the upper third of the vagina the lower portion of the canal ends in a cul-de-sac. If the atresia is at the lower third, the obstruction is found below, and, by means of the sound in the bladder and the finger in the rectum, the upper portion of the vagina is found distended with menstrual fluid. Causation.—Congenital atresia is produced by some arrest of development or disease during embryonic life. When it is acquired between birth and puberty, it is usually due to acute inflammation occurring in connection with some constitutional disease, such as scarlatina, diphtheria, or measles. Gangrenous vulvitis and vaginitis, which may occur in the course of any of the above-named diseases, may also terminate in atresia. I have seen two cases of partial atresia, caused by some acute inflam- mation during the course of typhoid fever, occurring near the period of puberty. 101 DISEASES OF WOMEN. In the cases which have been acquired after puberty and child- bearing, one was a soldier's wife, who was confined of her first child at a military post on the frontier. Her labor was of three days' duration, and she was finally delivered by craniotomy; there was subsequent sloughing of the vaginal walls, and consequent atresia. Another case of partial atresia was caused by amputation of the cervix for cancer. There was at the time of the operation deep cau- terization of the vaginal walls, which resulted in atresia. One other case was caused by the accidental use of pure carbolic acid, as a vag- inal injection. In this case the adhesions of the vaginal walls were not very firm, and the canal was restored by operation, but there was much trouble experienced in preventing the recurrence of the atresia—a constant tendency to which remained. Prognosis.—In complete atresia there is great difficulty in the operation for its relief, and a constant tendency to contraction of the parts; hence, the hope of complete recovery is, to say the least, very limited. Treatment.—The indications are to restore the vagina by surgical means. This is a difficult procedure, and one that is not very suc- cessful in all cases. The difficulties in the operation, and the ulti- mate success, depend upon whether the atresia is partial or complete. If the portion of the vagina which is closed is limited to a third of the whole canal, reasonable hope of success may be entertained, but I doubt if the vagina was ever fully restored and maintained when complete atresia existed. When there is associated with the atresia imperfect development of the uterus and ovaries, and there is no tendency to menstruation, treatment is not indicated. Such malformed subjects often live quite comfortable and useful lives. There is another class of cases, already referred to in treating of absence of the menstrual function, in which the uterus and vagina are rudimentary, but the ovaries are well developed. In these there is a recurring menstrual molimen, and the general nervous system may become greatly deranged. Ovaro-epilepsy may occur under these conditions. The removal of the ovaries might become neces- sary in such cases in order to arrest the inolination to menstruation, and relieve the constitutional disturbance caused by such unsuccessful efforts. The following is a description of Dupuytren's operation for atresia of the vagina, as described by Courty, with the modifications which M. Puesch has added, which I quote from the work of Dr. Thomas: DISEASES OF THE VAGINA. 105 " After having arranged the woman in a convenient position, the bladder is emptied by means of a male catheter, which is given to an assistant, who holds it turned upward. It is not removed during the operation, except where the obliquity of the part would render it troublesome. The index-finger of the left hand is then carried into the intestine as far as possible, in order to serve as a guide for the bistoury and at the same time as a protection to the rectum. After these preliminary steps the operator, placed between the thighs of the patient, makes a transverse incision at the center of the obsta- cle, or in the vulvar orifice, if the vagina is completely wanting; if the cellular tissue is lax, he can tear with his finger, the sound, or the handle of the bistoury the vesical and rectal walls till he reaches the tumor; if it is tense or too resistant, the surgeon dissects by gentle efforts, separating the tissues with the handle or the finger rather than cutting them, and, if it be necessary, breaking them down at the edges with a button bistoury. In each case he proceeds slowly and carefully, stopping from time to time to examine with the finger and be certain at what distance those organs are situated which it is necessary to avoid. When the canal wThich has been reopened will admit the index-finger easily, and when a more distinct perception of fluctuation announces the proximity of the sanguineous collection, the operator is warranted in plunging a trocar into this, and the pouring out of a sirupy, brown liquid, like the lees of wine, will show that the end has been reached. The pressure upon the uterus is then stopped, a large part of the fluid is allowed to flow away through the canula, and then, substituting for this instrument a per- forated sound, the operator increases the size of the opening by nu- merous incisions upon its sides, and thus renders certain the final result. Afterward he carries a gum-elastic sound into the uterine cavity, and throws through this, but with very little force, several injections of warm water. The dressing having been finished, the parts are sponged and dried, and the patient is placed in bed, pro- tected with cloths, so as to prevent the bedding from being soiled hy the mucous and sanguinolent discharges which flow during the first days." To keep the canal open after this operation is exceedingly diffi- cult; all surgeons testify to this fact. Many things have been tried to accomplish this object, but the best is the glass plug or dilator of Sims (Fig. 57). In one case—the case of acquired atresia referred to under the head of causation—I found that the glass instrument caused much pain, and I used elm-bark cut in fine strips, made into a roll of suitable size, and moistened with carbolized water. This 106 DISEASES OF WOMEN. was removed daily, and, as it expanded after being introduced, it answered in that case very well. The tendency in all these cases is to contraction and return of the atresia; in fact, I The following is from his work on " Diseases of Women,'1 page 34: " The operation for atresia is performed by the bistoury or guarded bistoury, or Pouteau's trocar. The bistoury is to be gener- ally preferred. Pouteau's trocar is resorted to when a considerable part of the lower vagina is absent, and the sac is punctured some- times pretty high up per rectum. This operation is in such cases preferable to vain, painful, and dangerous attempts to bore the thin tissues between the urethra and rectum to make and maintain a new vagina. Such a proceeding results only in vexation. It is far better for the malformed woman to discourage all hopes of maternity. The artificial passage into the rectum is easily kept open, and the men- strual fluid runs off through it." INFLAMMATORY AFFECTIONS OF THE VAGINA. Vaginitis.—The vagina is seldom if ever affected with idiopathic inflammation; vaginitis, therefore, always occurs as the result of some specific cause, or is secondary to some contiguous inflammation, such as endometritis. There are several varieties of vaginitis. Clas- sified according to the intensity and duration of the affection, there are the acute and chronic forms; when classified according to the causation, there is a number of forms, the most important of which are gonorrhoeal, erythematous, sometimes called erysipelatous, and diphtheritic. As a rule, the inflammation is general, involving the whole canal; occasionally it is circumscribed, and then it is found just within the vulva, or else at the upper part. Pathology.—Owing to the anatomical peculiarities of the vagina it is not susceptible of the catarrhal form of inflammation, so com- mon to mucous membranes elsewhere. From the fact that the vag- inal mucous membrane resembles in structure the skin, and that DISEASES OF THE VAGINA. 107 there are few mucous follicles found in it, vaginitis, in its pathology, is more like dermatitis than like the ordinary inflammations of mu- cous membranes. Congestion, transudation of serum, premature ex- foliation of the epithelium, and, in well-deflned cases, the formation of pus, are the characteristic results of acute vaginitis. In the subacute form there is less congestion and less pus, other- wise the inflammatory lesions are the same. This may all be more briefly stated in another form, as follows: Vaginitis occurs either as erythematous, purulent, or exudative—never as purely catarrhal. The morbid appearances in these forms differ. Erythematous vaginitis is characterized by great capillary congestion, which gives the intense redness of this form of inflammation in the first stage. Then, as the disease advances, there is exfoliation of the epithelium. Sometimes the epithelium comes off in thin flakes, resembling in this respect the exfoliation of the cuticle in dermatitis. This leaves the mucous membrane denuded of its epithelium, and gives a glazed appearance to the whole canal. During this time there may be a free serous secretion and some pus found, but these are not profuse in all cases. In purulent vaginitis the lesions are the same as already described. In the exudative forms the characteristic lesions are present; the diphtheritic membrane as in diphtheria, the croupous in that form of inflammation. There are other forms of vaginitis mentioned by some authors, but they are peculiar in regard to causation, while in their pathoh ogy they do not differ materially from those described. Symptomatology.—The symptoms in the acute form are a feeling of internal heat and fullness. These increase in intensity, and pain in the vagina and uterus come on. Vesical and rectal tenesmus are present in severe cases, and urination and defecation are painful. The urine causes violent smarting of the inflamed parts about the vulva with which it comes in contact. So severe is the pain in some cases during and after urination, that the patient resists the inclina- tion until the power of evacuation is lost, and there is retention. There are constitutional disturbances also. At first there is fever, and following that loss of appetite and debility. The discharge is profuse, and sero-purulent in character; it causes excoriation of the external parts, which often extends to the limbs. If great cleanli- ness is not observed, the discharge decomposes and causes a very dis- agreeable odor. In the subacute and chronic forms of vaginitis the symptoms are the same in character, but less in degree; in fact, the annoy- 108 DISEASES OF WOMEN. ing discharge is the only symptom observed in many of these mild cases. Physical Signs.—By inspection of the parts when the labia are separated the characteristic discharge can be seen and recognized. It differs from that of vulvitis in being less tenacious. The mucous glands about the vulva give to the discharge of vulvitis a cohesive- ness which is not found in that of vaginitis. The use of Sims's speculum will show the inflamed appearance of the membrane and the discharge which is present. The anterior and lateral portions only of the walls of the vagina are seen through the Sims speculum, but by watching the folding together of the posterior and anterior walls, as the speculum is with- drawn, the whole canal can be thoroughly inspected. The difference between the signs of acute and sub-acute inflam- mation is simply in the intensity of the congestion, the extent of the canal involved, and the quantity and character of the discharge. To distinguish gonorrhoeal vaginitis from the non-specific forms the microscope alone is sufficient. When there is a question regard- ing the nature or the cause, specimens of the discharge should be examined for the gonococci. Causation.—There is a predisposition to vaginitis in those of delicate health and strumous diathesis, but it is not marked. Judging from my own observations, the common causes of vagi- nitis are gonorrhoeal virus, metritis, especially puerperal, and ery- thematous affections. This applies to the acute form of the affec- tion. Sub-acute and chronic vaginitis may be caused by any inflam- mation in the neighborhood of the canal. Dysentery, for example, causes vaginitis not infrequently. Different fungi have been credited with causing vaginitis, but this is not well settled. When it occurs in connection with the eruptive diseases the cause is, of course, the specific morbid material which produces the constitutional disease. Prognosis.—With proper care vaginitis can be arrested and re- covery secured without any permanent lesions. It is liable to re- cur if caused by gonorrhoea. Sometimes permanent damage is done to the canal when the vaginitis is due to any of the eruptive diseases or diphtheria. Treatment.—In the past, treatment of vaginitis has consisted mainly of the frequent use of medicinal douches. The agents used, and the means and ways of using them, have varied greatly with different practitioners. Very recently a new method of treatment has been brought to the notice of the profession by Dr. Engelmann DISEASES OF THE VAGINA. 109 of St. Louis. His method he terms the dry treatment, which consists in the use of medicinal powders and medicated tampons. A number of years ago I tried this method, in an imperfect and limited way, in the treatment of vaginitis among the insane, and obtained ex- perience enough to know that it is of great value. I find even now, however, that while using certain agents in powdered form, and also the tampon, the discharge from the inflammation and the powder used lodge in the folds of the mucous membrane, and that it is necessary to use a vaginal douche occasionally in order to make the treatment effective. In acute vaginitis I employ what may be called a mixed treat- ment, using the medicinal agents and powder with tampon, and oc- casionally employing the douche in the following way : After cleans- ing the mucous membrane thoroughly with a douche of warm water and borax, a drachm to the quart, I then thoroughly apply sub- nitrate of bismuth and prepared chalk, equal parts, and introduce a tampon of borated cotton, the tampon being so arranged as to thor- oughly keep the vaginal walls apart; at the end of twenty-four hours the tampon is removed, and any accumulation of the discharge and powder is thoroughly removed and the tampon replaced. At the end of the next twenty-four hours the tampon is removed and the douche of borax and water employed, and the dry treatment re- peated. In acute cases where there is much pain, and especially if due to specific cause, I employ iodoform in place of the bismuth. If the trouble does not yield promptly to this treatment I give up the dry dressing, and every third day apply to the entire canal, by means of the atomizer with strong pressure, a solution of nitrate of silver, one grain to the ounce, or sulphate of zinc, one half grain to the ounce. I find that such mild solutions, applied with considerable force with the atomizer, diffuse the application very thoroughly, and produce a'far more marked effect than much stronger solutions used as a douche. The method of application or spraying the canal is as follows: A Sims's speculum is introduced, and when the canal is distended by pressure, the spray is thoroughly applied to the upper portion of the canal and to the anterior and lateral walls, and the posterior wall is sprayed as the speculum is gradually withdrawn. In the inter- vening days between these applications I employ daily, or twice a day, a vaginal douche of a solution of sulphate of zinc, sixty grains to the quart of warm water. In cases thaf can not be so carefully watched and treated, I rely 110 DISEASES OF WOMEN. almost wholly upon the sulphate-of-zinc solution, used as a vaginal douche twice a day at first, and subsequently once a day. This an- swers remarkably well in a great majority of cases, but there is a constant liability to miss a portion of the canal, especially the upper and posterior fornix. To overcome this, an application of the nitrate of silver or sulphate of zinc is to be made to these neglected parts once or twice a week through the speculum. This simple treatment is usually sufficient in all ordinary cases, but whenever the disease is specific in its origin, and is complicated with urethritis and endometritis, then these affections should be treated simultaneously in the ordinary way. If treatment is neglected or discontinued too soon, the vaginitis will recur in a very short time. Vaginismus.—Since the time when Sims first described this affec- tion and its treatment it has been considered by most writers as a distinct affection, and is usually classed as a neurosis of the vagina or hymen. In all the cases which have come under my observation the trouble has been due either to some affection of the muscles of the pelvic floor, or to a hyperaesthesia of the mucous membrane of the vagina. The former will be spoken of in connection with in- juries of the pelvic floor. Hyperaesthesia due to affections of the other pelvic organs, I have always looked upon as a symptom of the preceding disease of the uterus, rectum, or bladder. Viewing the subject from this stand- point, little need be said about it in this connection. The removal of the affections which give rise to it is the chief indication, and is generally sufficient in the way of treatment. It may be mistaken for anal fissure, urethral caruncle, or vaginitis. Occasionally, it is necessary to give relief while the treatment is being employed to remove the cause ; and, in those cases in which the cause can not be removed, efforts should be made to relieve the hyper- aesthesia. This can usually be done by the judicious use of cocaine. Neoplasms of the Vagina.—Many of the neoplasms of the vagina are the same in character as those found elsewhere; as, for example, sarcoma, carcinoma, fibroma, and lipoma. All these are very rare. The diagnosis and treatment of these neoplasms are based upon the same principles as those which guide the practitioner in dealing with such affections when located in other parts of the body. I will, however, give a brief account of some of the more com- mon neoplasms of the vagina: Cysts of the Vagina.—These vary in size from that of a buck- shot to that of a child's head—one case, at least, being on record DISEASES OF THE VAGINA. Ill in which the tumor was of the latter size, and so seriously interfered with labor as to necessitate the evacuation of its contents before the labor could proceed. Kelaton reported a case in which, on analysis, the cyst contents were found to be made up of water, eighteen parts ; albumen, one part and a half; and salts, a half part. Micro- scopical examination has shown the presence of epithelium, pus, cholesterine, nucleated and lymphoid cells in these cysts. Occa- sionally blood and pus are found in the contents. Winckel, who has examined these cysts with great care, states that their walls are made up as follows : The external surface is covered with the ordinary pavement epithelium of the vagina; the thickness of the walls varies between one twenty-fifth and two fifths of an inch—the thinnest portion being formed of connective tissue alone, the thicker with the addition of smooth muscular fibers. The internal surface is usually perfectly smooth, but may show papillae covered with epithelium, which in the majority of cases is cylindri- cal, more rarely simple, or stratified pavement epithelium, or, still more rarely, stratified pavement and cylindrical epithelium in the same cyst. These cysts of the vagina are caused in some cases by a closing and subsequent distention of the vaginal glands. They may also be due to dilated lymph-vessels, to oedema, and to the accumulation of blood after an injury. Cysts most frequently have their origin in distended Gartner's ducts. This has been clearly pointed out by Amand Routh in his most interesting article in Volume XXXV of the " Transactions of the Obstetrical Society of London." Their recognition is not difficult, provided that a careful inspection is made of the vaginal canal. Their treatment is exceedingly simple. It consists in emptying them by an incision through their walls. To prevent refilling, the cyst wall should be removed if possible, and the wound closed. If that is not possible, the portion of the cyst wall left should be destroyed with cautery or caustic, and the cavity packed with gauze to cause healing by granulation. The following case, illustrative of this form of vaginal cyst, I quote from Dr. Routh's article : " Miss C. C, aged twenty-five, first saw me in 1SS9 for coccygo- dynia and bearing down, due to pelvic congestion. She improved rapidly, but over-walked herself in January, 1890, and for a few weeks suffered as before. Two years and a half afterward—Novem- ber, 1S92—she consulted me again for pain over the right ovarian region, and a profuse yellow watery discharge, which was occasion- ally offensive. Walking caused great pain down the right leg and 112 DISEASES OF WOMEN. in the right side. The abdomen was somewhat distended, and the muscles resistent over the right half of the abdomen. Per vagi nam the uterus was mobile, but pushed over to the left by a somewhat elastic mass on the right side of the pelvis, situated apparently be- tween the layers of the broad ligament. Bimanually this mass could be felt to be partly mobile, elastic, tender, and separate from the uterus, which by means of the sound could be moved to some extent independently of the broad-ligament tumor. " In the vaginal wall, running from the base of the right broad ligament, starting from a spot slightly to the right side of the cer- vix, there was an elastic ridge, somewhat irregular in outline, which passed forward and toward the middle line, becoming lost a little to the right of the urethra, about three quarters of an inch behind the base of the vestibule. I could not find out where the discharge came from, though I noticed that the upper part of the vagina was free from discharge, while the vulvar orifice was always moist, and soiled by a somewhat viscid, yellowish, offensive secretion. " A fortnight later the patient suffered severe throbbing pain, and the temperature rose nightly to 101° or 102° F. The vaginal ridge had then become larger, tenser, and more elastic, and evi- dently contained fluid reaching very nearly to the vaginal outlet in the middle line of the vaginal roof. " In a few days the portion of the vaginal cyst near the cervix was found to be more swollen, being about the size of a thumb, but the rest of the vaginal ridge seemed to consist of several cysts, ap- parently intercommunicating. There seemed also to be definite communication between the vaginal cyst and the broad-ligament tumor, from the fact that pressure upon the vaginal cyst caused its contents to pass backward, while straining or coughing immediately refilled it. " The patient went into a nursing home, and was examined under ether. The vaginal cyst was then found to be collapsed along its whole length ; the broad-ligament tumor was very distinctly made out, and was thought to be a broad-ligament parovarian cyst, the vaginal cyst being presumably a patent Gartner's duct communicat- ing with the cyst cavity. At the end of the examination, as the patient was regaining consciousness, she coughed, and bore strongly down, causing a quantity of yellowish offensive pus to come out of a minute hole not previously seen, just beneath and to the right of the urethral orifice at the base of the vestibule. A small probe passed down this abnormal orifice for three quarters of an inch and the passage was laid open as a rectal fistula would be. The DISEASES OF THE VAGINA. 113 openings of Skene's ducts just within the urethral orifice were quite perceptible. " I then opened the main vaginal cyst about two inches up the vagina, but was not able to pass a probe for any distance either backward or forward. " Offensive pus continued for some days to come away from hoth of these places, but mainly from the anterior orifice; indeed, I do not think I really opened the main cyst posteriorly on the first occasion. A few days later I succeeded in passing a probe along the whole canal from the anterior orifice, and subsequently a direc- tor; and, under ether, freely laid open the vaginal cyst by means of a Paquelin's cautery knife, letting out much pus, which welled freely out of the upper end of the incision at the base of the broad liga- ment. "The duct thus laid open was lined by smooth membrane, but no microscopic examination was made. '" A sound passed into this upper opening near the cervix went a distance of five inches upward and outward, and was evidently inside a cyst cavity in the broad ligament. "' The opening was enlarged to admit the finger, which could be passed into the cyst behind the vagina, and could make out that the lining membrane was smooth, and that the cyst was between the layers of the broad ligament. Per rectum the examining finger passed well behind the cyst cavity, and could then detect a sound passed into the parovarian cyst from the vagina. The cavity was washed out with iodized water, and a drainage tube inserted. " For nearly five weeks the purulent fluid continued to come away, speedily losing its offensive odor and becoming daily more watery, and at the upper end the sides of the vaginal cyst tended to unite again over the drainage tube, which was gradually shortened and finally removed, leaving a canal in the vaginal wall about an inch long (March, ISO,",) on the right side of the cervix. "November 7, 1SU3.—A rut or trough is to be felt in the vagi- nal wall to the right of the vaginal portion, leading into a short canal an inch long. The canal now only admits a large sound, and ends in a cul-de-sac. It is lined by a bright red membrane. The uterus lies in its central position, and nothing abnormal can be felt in the right broad-ligament region. The patient feels perfectly well. " This is believed to have been a case of distended Gartner's duct, where the contents finally suppurated. It is probable that at first the vaginal part of the duct was impervious, but had become grad- 10 Ill DISEASES OF WOMEN. ually opened up by the pressure of the contents of the distended portion in the broad ligament where the pain first began. Dr. Routh has been able to find but two other cases of associated broad-ligament and vairinal cvst, one described bv Watts in lssl? and a second by Veit in lssi\ These are as follows : " Watts's patient had a vaginal cyst which bulged from the an- terior vaginal wall in the position of a urethrocele. The urethra was, however, quite normal. " lie laid open the cyst/xv raginam, and to his surprise was able to pass a probe several inches without the slightest resistance. The probe passed to the patient's left side, and its tip was easily felt at a point midway between the umbilicus and the left anterior superior iliac spine. AVatts thought this probe had penetrated to the perito- neal cavity, but I think it pretty clear that, as in my case, it was really between the layers of the broad ligament, where there was almost certainly some distention of the duct not noticed at the time, as it doubtless speedily collapsed when the vaginal cyst was opened. " Veit's case (1SS2) was that of a married multipara, aged forty- seven, who had a large vaginal cyst, which made micturition diffi- cult, owing to pressure upon the urethra. The cyst bulged out between the labia majora as large as a child's head. " The uterus was pushed over to the left by a tense elastic swell- ing in the right broad ligament, which clearly communicated freely with the vaginal cyst. kk The case was treated by incision of the vaginal cyst, draining both it and the broad-ligament cyst, and by cutting out a large piece of the lining membrane of the vaginal cyst to prevent reclosure. Cholesterine crystals were found in the fluid. The epithelium was flattened in type. " The finger could be passed into the broad-ligament cyst, and the ovary could be felt on its posterior and outer surface." Fibroma, Myoma, and Fiijromyoma.—Thoe growths occur but rarely. Like the cysts of which I have already spoken, they vary very much in size; some being so small as only to be recognized by the most careful examination, while others may be so large as to in- terfere seriously with micturition or defecation, or even to so dimin- ish the caliber of the pelvic canal in pregnant women as to prevent the delivery of the child through the natural passage, and to necessi- tate laparotomy. These tumor* are readily recognized bv their den- sity. If there is any doubt in the mind of the practitioner, an aspi- rating needle will at once exclude a cyst or an abscess. If the tumor attains any considerable size so as to interfere with any of the func- DISEASES OF THE VAGINA. 115 tions it should be removed ; or if, though small, it is increasing in size, this would constitute sufficient indication for its removal. This may be done by Paquelin's cautery, if the tumor is sufficiently pedun- culated, or if not, it may be enucleated. Sarcoma.—This is so rare as to need but the simple mention. I ts treatment should, of course, be prompt removal as soon as recog- nized. Carcinoma.—All that I think it necessary to say on this subject has been said in the chapter on Cancer of the Uterus, to which the reader is referred. CHAPTER VII. INJURIES TO THE PELVIC FLOOR FROM PATCTl'RITIOX AND OTHKR CAl'SKS. In order to comprehend fully the nature of the injuries to the pelvic floor and their varied and important pathological relations, it is necessary to review briefly the anatomy and physiology of this structure. The pelvic floor, which is also known by the somewhat indefinite name of perinaeum. comprises the tissues which together occupy the space between the bones of the pelvic outlet. It is composed of muscles, fascia, areolar and elastic tissues. The muscles, which are the chief element in the structure and perform its function, have their origin from the ischium, the pubes, and the coccyx. From these points they extend downward, inward, and backward to the median line, and are united to the terminal ends of the rectum and vagina and to each other from the opposite sides. The levator-ani muscle arises from three points : the first sec- tion from the posterior surface of the os pubis on each side of the symphysis, the third section from the spine of the ischium, and the second or middle portion from the tendinous arc swinging between these two points, this thickening of the obturator fascia being called the " white line." The three parts converge to be inserted into the coccyx, or the recto-coccygeal raphe, though a few fibers are given off to the vagina, perineal body, and sphincter ani. The general course of the muscle is backward in a nearly horizontal direction. It is lined by the anal or levator fascia beneath, while above it is attached to the strong recto-vesical fascia. According to Dr. W. W. Browning (Medical News, June 12, lsi»7) the first part also has its origin from the posterior layer of the triangular ligament, where it blends with the obturator fascia along the descending pubic ramus. Fig. 58 shows the position and attachment of this muscle. The transversus-perinaei muscle arises from the ramus of the ischium, and passes across to the median line, where it joins its fel- low of the opposite side. The coccygeus arises from the spine of 116 INJURIES TO THE PELVIC FLOOR. 117 the ischium, and is inserted into the side of the lower part of the sacrum and side and front of the coccyx. It is understood, of course, that there are two of each of the muscles thus far described, one on each side. The bulbo-cavernosus muscle can be most easily traced Fig. 58.—The levator ani, seen from the ripht after removal of much of the ischium. Lp first section arising from the rear of the pubes; Lf, second part arising from the fascia, or white line ; Li, third, or ischial portion. The sphincter surrounds the anus, and is attached to the coccyx. by taking as its origin the space between the sphincter ani and the orifice of the vagina. From this point its two halves pass upward, one on each side of the vagina. The upper anterior end of each slip of muscle divides into three parts, which are inserted as follows : One into the lower surface of the corpus cavernosum of the clitoris, a US DISEASES OK WOMEN. second into the posterior portion of the bulb, and the third unites with its fellow of the opposite side in the mucous membrane of the vestibule ; and all of them are, through the medium of tendon and fascia, connected to the pubic bones. If this muscle is traced from above downward to the center of the pelvic floor, it will be seen to Fig. 59.—The muscles of the pelvic floor; on one side the superficial muscles, on the other the three parts of the levator (semi-diagrammatic). The ischio-rectal fascia is shown beyond the muscle. have an origin and insertion like that of the anterior fibers of the levator ani ; hence the bulbo-cavernosus and levator ani maybe con- sidered as one muscle. This view is justifiable from the fact that they also contract together, having a similar function. The sphincter-ani muscle, which has a function peculiarly its INJURIES TO THE PELVIC FLOOR. 11! own, is closely united to all the other muscles of the pelvic floor by an interlacing of the muscular fibers and by tendinous and fascial attachments. This muscle arises from the end of the coccyx, and divides to surround the end of the rectum, while its deeper fibers are inserted in the tendinous raphe in the median line between the rectum and vagina. The superficial fibers of this muscle are circu- lar, and attached to the integument. Taking the muscles of the pelvic floor in the aggregate, they form one complete diaphragm of muscular tissue which fills the pel- Fig. 60 — 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. vie outlet. Bv this arrangement the rectum and vagina are held in position, and their terminal ends controlled in the performace of their functions. The muscular attachment of the muscles and va- gina is in part shown by the preceding figures, 5S and 59. The normal elevation of the pelvic floor is illustrated by Fig. 00. V20 DISEASES OF WOMEN. 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 becomes 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 spbincteric 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 levator 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- vis, the muscles, by retraction, distend the sphincter ani to a irreat extent. The dilatation of the vagina is produced by a more passive 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. Regarded as a mechanical structure, the pelvic floor resembles a diaphragm com- posed of muscles and fascia which close the pelvic outlet. Its bor- ders are attached to the bony walls of the pelvis, and it is held at its proper elevation by strong fascia and the levator-ani muscle. Its mechanism is based upon the principles of the suspension bridge, the anchorage being represented by the pelvic bones, the floor representing the bridge and the levator-ani muscle with the powerful fascial layers corresponding to the sustaining cables (see Fig. 01). 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 INJURIES TO THE PELVIC FLOOR. 121 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 diversity of opinions regarding the function of the perinaeum and Fig. 61. 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. AVhere 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 defi- nitely 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 11 122 DISEASES OF WOMEN. 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 organs. This is often seen in cases in which lacerations sufficient to largely impair the function of the pelvic floor have existed for years in 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 perinaeum. The fallacies of this argument are that, although the pelvic organs are held in position by supports that are sufficient to resist ordinary taxation for a given time, they are not able to do so under extraordinary pressure for any length of time unaided by the pelvic floor. Again, the cases cited in which prolapsus does not occur when the perinaeum is lacerated belong to one of the three exceptional 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 perinaeum by inspection of its mucous and tegumentary surfaces, and, if injury to these surfaces is not found, they pronounce the pelvic floor perfect, while the fact is that laceration of the perinaeum 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 supports of the pelvic organs must admit that the pelvic floor is at least indi- rectly concerned in supporting the structures above it. The injuries of the pelvic floor are of two classes : 1. Lacerations of the pelvic floor in the median line. 2. Laceration of the levator-ani muscle and separation of the INJURIES TO THE PELVIC FLOOR. 123 muscular coat of the vagina from the pelvic floor. This injury is an internal transverse laceration. The first class is divided into lacerations extending from the vulva down to the sphincter-ani muscle ; subcutaneous separation of the muscles and fascia; and lacerations extending from the vulva into the rectum, involving the sphincter ani and less or more of the recto-vaginal septum. The first of these—laceration of the pelvic floor in the median line—is the injury most frequently sustained during parturition. Several degrees of this injury are described by authors, but in re- gard to the pathology and treatment there are only two which, in this 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 there- fore presumed to occur most frequently, although this point is not yet 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-perinaei 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 perinaei, and anterior fibers of the levator-ani muscles hold the separated sides of the perineal body and the posterior, unin- jured portion of the pelvic floor upward. At the same time that the posterior portion of the pelvic floor is maintained at its nor- mal elevation, it is often brought forward to compensate for the loss of support caused by the laceration. 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 121 DISEASES OF WOMEN. 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 can be traced to the laceration, except occasional pain in the scar tissue in the injured part. In cases of long standing the posterior vaginal wall becomes prolapsed. This condition has been described as rectocele. The diagnosis is made by inspection. The second form of injury given in the classification is subcu- taneous separation of the muscles and fascia in the median line, usually limited to the transversus perinaei muscle and fascia, but in rare cases involving the sphincter-ani muscle. Years ago, when I first called attention to this subject, I was not aware that the sphincter ani was ever involved in this form of in- jury, but I have seen since then at least three cases in which the sphincter ani was lacerated completely while the integument and mucous membrane of the vagina remained uninjured. The evi- dences that my observations were correct are that there was incon- tinence, the integument on either side was depressed where the lower fibers of the retracted muscles had drawn it inward, and the most careful examination proved beyond a question that the integu- ment had never been lacerated. I am aware of the fact that a com- plete laceration in the median line may unite by first intention, leav- ing the sphincter ani ununited, and that the scar may be so faint as to be easily overlooked, but in the cases I have referred to I am posi- tive from my own examination, and that of my associates, that no such injury to the integument ever occurred. Furthermore, I found in operating that when the integument was divided some thickening of the cellular tissue was apparent, due no doubt to a reparative exudate which occurred at the time of the injury. I also found the ends of the muscle far apart, the lacerated ends being completely healed over by natural processes. In looking back I recall several more cases of this kind, but not having studied them with sufficient care, they are not available for my present purpose. The mucous membrane of the vagina and the skin covering the perinaeum remain normal, but the transversus-perinaei muscles are INJURIES TO THE PELVIC FLOOR. 125 torn apart in the median line. The bulbo-cavernosus muscles are separated from their insertion at the center of the perinaeum, and possibly some of the fibers of the levator-ani muscle are also lacer- ated. There is, in short, a complete laceration of the deeper struc- tures of the perinaeum, the skin and mucous membrane alone re- maining uninjured. The result of this injury is falling of the pelvic floor, and usually prolapsus of the pelvic organs. The func- tion of the pelvic floor is destroyed or impaired as in the injury first described. I believe that this condition has generally been mistaken for functional imperfection of the perinaeum, or relaxation, as it has been called. The fact is, that it is a well-defined anatomical lesion, 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 vaginae. This can be done by the interrupted electric current, or by irritating the labia. In making a vaginal examination, one can observe how actively the muscles of the pelvic floor contract and close the introitus vagi- nae 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 by 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 perinaeum, 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 120 DISEASES OF WOMEN. 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. When the two forms of injury just described have existed for a long time prolapsus of the vaginal walls takes place. The posterior vaginal wall is most frequently displaced and is usually described as a rectocele, but that is incorrect, as will be pointed out in discuss- ing transverse internal lacerations. The third form of injury in the median line extends from the vulva into the rectum, and includes in the solution of continu- ity the sphincter-ani muscle and less or more of the recto-vaginal septum. 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 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 condition would be sought before sufficient time had elapsed for prolapsus 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 por- tion of the pelvic floor, leaving little remaining to settle down- ward. 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 sphincter-ani muscle only, and does not extend upward into the anterior wall of the rectum and the poste- rior 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. INJURIES TO THE PELVIC FLOOR. 127 Injuries of the second class, which are transverse, and have been described as internal lacerations, consist in laceration of the anterior fibers of the levator-ani muscle and fascia, and this is usually attended with separation of the muscular layer of the vaginal wall from the pelvic floor. In some cases the laceration is complete, involving the mucous membrane as well as the muscular coat of the vagina, and in very rare cases the laceration reaches upward and outward as far as the laceration of the levator-ani muscle extends, but as a rule the laceration of the levator ani is subcutaneous—that is to say, not attended with laceration of the mucous membrane of the vaginal wall. The injury of this muscle, I believe, was first described in my early writing on the subject, but if this is an unjust claim on my part I shall be happy to have it corrected. The pathological changes which ultimately take place in the trans- verse lacerations are : A marked sagging of the pelvic floor, which in itself may be perfectly normal in structure. This sagging is appar- ent upon inspection, and, as I have elsewhere pointed out, the diag- nosis of this lac- eration is made from the fact that under stimula- tion the levator- ani muscle fails to perform its function. The action of this muscle is to a large extent vol- untary, and this voluntary power is lost and stimu- lation fails to call it into action. Of course, the continuation of this sagging gives rise to or permits prolapsus of the vaginal walls, uterus, and bladder. Rectocele is also said to follow in this injury, and possibly it may in rare cases, but I am fully assured from careful observation that the so-called rectocele is not a rectocele at all, but a prolapsus of the vaginal wall and a varicose condition of the veins lying between the vagina and the rectum just within or above the pelvic floor. This I have been able to demonstrate, in a vast majority of cases, by an examination which proved that there was no rectal diverticulum pointing toward the vulva, and that pressure upon the so-called rec- Fig. 62.—The so-called rectocele, being a prolapse of the vaginal wall, with varicose veins beneath it. 128 DISEASES OF WOMEN. tocele caused it to disappear as soon as the blood was pressed out of the enlarged veins. This is shown in Fig. (12. An argument which has been made against this by one of my friends, to whom I have explained my views on the subject, is that he has noticed in faecal accumulations the rectocele protruding through the vulva, especially on voluntary efforts being made to evacuate the rectum. This is offset by the fact that in most of such cases I have found that when the rectum is emptied its muscular walls contract and there is no diverticulum left. Of course, the rectum loses its support when the levator-ani muscle is lacerated, and is easily overdistended, and the distention must be toward the vagina and vulva, but is temporary, not permanent, and hence not a rectocele. I may say further in reference to this form of injury that it is followed by pathological changes which give rise to more distressing symptoms than any other. It is in this form of injury that prolapsus more frequently occurs, not only of the uterus and vaginal walls, but also of the bladder; and there is greater liability than in any other injury to the formation of varicose veins around the lower portion of the vagina and rectum, which give rise to no small degree of suffering. In this injury, too, subinvolution of the vagina and uterus most fre- quently occurs. More than that, I believe that there is in addition to the subinvolution of the vagina a certain degree of areolar hyper- plasia, which accounts for the extraordinary thickening of the vagi- nal walls seen in this class; still more, if relief is not obtained there comes a time when atrophic changes of the vaginal walls take place which cause fur- ther changes in the venous cir- culation, and if the injury goes many years with- out repair, atro- phy of the leva- tor - ani muscle occurs, and such changed struc- tures become ab- Fig. 63.—Beginning atrophy of perineal body in the median line. Solutely incura- ble by any meth- od of operating. It is quite a number of years (sixteen or eighteen) since I called attention to the atrophic changes in the muscles which take place in cases of long standing, and though a certain amount INJURIES TO THE PELVIC FLOOR. 129 of temporary relief is obtained by operating, prolapsus of all the pelvic organs recurs. I formerly believed that in connection with transverse lacera- tions a subcutaneous laceration in the median line (Fig. 63) some- times occurred, but I am satisfied now, after more extended obser- vation, that in place of a lacera- tion there is a thinning out and absorption of the tissues in the me- dian line which produces a con- dition similar to that of subcuta- neous laceration. This absorption ifi brought about ^IG" ^'—-Atrophy m t^e median line, with sagging of the pos- & t terior vaginal wall resembling subcutaneous transverse by the sagging of laceration. the pelvic floor, which makes undue traction upon the transversus perinaei muscles and fascia, and as the posterior wall becomes prolapsed additional pressure is made at that point, and hence the absorption or atrophy which takes place in the median line. This change of structure resembles in every particular the lesion of subcutaneous laceration (Fig. 64), but it is only found in cases that have existed for a long time, in which there is marked prolapsus of the vaginal walls and, of course, great sagging of the entire pelvic floor. These facts in regard to pathology have a very important bearing upon the ques- tion of treatment, as will be noted further on. Sijmptomatology.—-The symptoms which are developed by inju- ries 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 have 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. AVhen 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 130 DISEASES OF WOMEN. 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 anaesthetized. 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. In cases complicated with prolapsus of the vaginal walls, blad- der, and uterus the symptoms belonging to these affections are pres- ent. In cases of laceration in the median line involving the sphincter- ani muscle the control of the rectum is lost. This symptom points to the nature of the lesion directly. Physical Signs.—Inspection reveals the structural changes that have taken place in the lacerations in the median line, so that the diagnosis could be easily made by direct examination. Subcutaneous lacerations of the muscles and fascia in the median line are detected by muscle and fascia. These escape notice at the time when they occur unless carefully looked for. They are easily detected, however, by grasping the pelvic floor in the median line between the thumb and finger. By this manipulation it will be found that all the structures, except the mucous membrane of the vagina and integument, have been divided and retracted, and there is noth- ing left of the fascia and muscular structure in the median line excepting the sphincter-ani muscle. The transverse internal laceration, when entirely confined to the muscular structures of the vagina and levator-ani muscle, is not an easy lesion to detect, owing to the fact that a similar condition is produced by sagging of the pelvic floor, following delivery and temporary paralysis. One of the pathological changes which take place in transverse laceration is a marked sagging of the pelvic floor, which in itself may be perfectly normal in structure. This sagging is apparent upon inspection, and the diagnosis of this laceration is made from the fact that under stimulation the levator-ani muscle fails to per- form its function. The action of this muscle is to a large extent voluntary, and this voluntary power is lost and stimulation fails to call it into action. Fig. 65 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 INJURIES TO THE PELVIC FLOOR. 131 ie 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 tl trunk, the downward displace- ment 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 re- ferred to again in connection with atrophy of the muscles, and the differential points will be noted. In the diagnosis of all these injuries, the all-important ques- tion is to determine whether the paralysis is due to overdistention of the muscles and is temporary only, or due to atrophy, and hence permanent. 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 fiber, and no muscular contraction can be induced by stimulation, it is presumptive evi- dence of muscular atrophy; and yet it may be only a temporary loss of muscular power. It is necessary, then, to support the pelvic floor and let the patient rest in the recumbent position 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 present. If by such means the muscular function is even partially restored, the diagnosis is completed, and the indications for further treatment are estab- lished. 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 useless to hope for success in operating. Causation.—The causes of these injuries of the pelvic floor are traumatic (excepting the last one described), that is, overdistention or stretching of the parts during parturition. The exceptions to Fig. 65.—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. 132 DISEASES OF WOMEN. this have already been mentioned, viz., long-continued overdistention from prolapsus of the pelvic organs, extreme constipation, and mal- nutrition 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 apparently 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 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-perinaei, 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 INJURIES TO THE PELVIC FLOOR. 133 drawn upward until the anus is distended an inch or two. AVhile the fetal head was unusually distending the pelvic floor, and while the hand was placed upon the parts to " support the perinaeum," 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 fully exposed to injury as the other muscles which we know are frequently lacerated subcutaneously. In delivery with for- ceps, the levator-ani muscle is frequently injured, I believe. While 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 care- fully watched patients that I had delivered with forceps, 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 pro- lapsus of the pelvic floor, and loss of contractility upon irritating the parts. Treatment.—The object in treating these injuries should be to restore the lacerated muscles by securing union of their severed 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 Avill be made plain by the following: Primary Operation.—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 134 DISEASES OF WOMEN. "mucous membrane. Shin Fig. 66.—Diagram of the sweep of the suture. 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 repre- sented in Fig. 66. The center lines represent the sides of the wound, and the dotted line shows the suture, which describes a circle, the point at which the suture is tied and the opposite point of its circumference 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 coming out at the edges of the wound hold 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 together, whereas, if the suture is passed straight through the tissues, the edges of the wound would curve inward, while the cen- Figs. 67, 68.—Sutures prop- tral parts would not meet. Fig. 67 shows ducednd improperly intro" the Parts adjusted by a proper suture, while Fig. 68 shows the effect of the imperfect one. Again, the suture running deep into the tissues gives addi- tional surety of catching the ends of the muscles so as to reunite them, which is the chief object of the operation. In the primary operation—i. e., the introduction of sutures immediately after the injury occurs—Peaslee's needle is easier to use than the ordinary Fig. 69.—Peaslee's needle. perineal needle. Fig. 69 shows the instrument. This needle, with a handle, and an eye near the point, is armed with a thread 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 INJURIES TO THE PELVIC FLOOR. 135 brings one end of the suture into the tissues. The operation is re- peated on the other side, which completes the introduction of the suture. The only advantage of this needle is that it is easier to man- age 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 operation. 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. Catgut sutures are employed by some, but they are most unsatisfactory. They decompose, and by causing suppuration prevent healing. Apfelstedt recommends the method proposed by Yeit of confin- ing the suture to the perinaeum in the closure of recent tears, on the ground (1) that needle holes in the vagina or rectum favor infection of the wound ; (2) that too many stitches destroy too much tissue ; and (3) that when they are knotted a cavity is likely to be left in the wound. He uses two needles to each thread of silkworm gut or silk ; these are inserted where the wounded surfaces meet, so as to emerge near the perineal wound. The first needle passes two milli- metres below the junction of the two wounded edges of mucosa, and the lowest in the same way, two millimetres above the point where the edges of the wound in the rectal mucosa meet, the lines of the stitches spreading toward the perinaeum like a fan. Six or eight sutures are enough. The middle ones are drawn quite tight, the others but moderately so before being knotted. This method has been used by Apfelstedt since 1892. All the vagino-perineal lacera- tions have healed, and three out of four total lacerations. 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 136 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 perinaeum, 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. 137 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. 12 138 DISEASES OF WOMEN. Regarding the unfavorable conditions of the tissues generally met with, the following are the most important: Contusions.—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. AVhile 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. Haemorrhage.—Haemorrhage 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 haemor- 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 haemorrhage that I have given much thought to the predisposing causes of this bleeding tendency, so marked in some patients. The haemorrhagic diathesis in its most typical form is generally found in men, but a less marked haemorrhagic 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. 139 a hyperaemic 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 haemorrhage in all operations undertaken during such unfavor- able states. The possible haemorrhage 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 hyperaemic 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 haemorrhagic 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 haemorrhage 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 haemorrhage should 14U 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 haemorrhage, 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 haemorrhage 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, checking the bleeding on the principle of acupressure. The sutures can be left in position until the perinaeum 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 haemorrhage 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. 141 in spoiling my operation, for, although I reintroduced the sutures, union did not take place. This haemorrhage 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 142 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 perinaeum. 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. Ariewed 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 perinaeum there are many perplexing difficulties in the wray 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 perinaeum 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. Yarious 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 perinaeum, the vag- INJURIES TO THE PELVIC FLOOR. 143 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 by 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 to secure the free escape of the inflammatory products. DESCRIPTION OF THE OPERATION FOR RUPTURE IN THE MEDIAN LINE. The first part of the operation consists in denuding the sur- faces to be united. The extent to which this should be carried depends upon the character of the injury. If there is no prolap- 144 DISEASES OF WOMEN. sus of the pelvic floor of the posterior vaginal wall (sec Fig. ), it will suffice to denude the surfaces as far as the original laceration extended and no farther. This can be done by tracing the out- line of the scar tissue formed by the healing after the laceration. This scar tissue contracts 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 removed, 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 vaginae is made too small. AVhen 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. 65), 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 Fig. 10.—Tissue forceps. 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 a little higher. The instruments for denuding the parts are a number of sponges fixed in holders, a tissue forceps (see Fig. 70), and Emmet's curved scissors, four in number, two with lesser curves and two with o-reater (see Figs. 71 and 72). These instruments can not be described; they must be seen to be understood. INJURIES TO THE PELVIC FLOOR. 145 The method of operating is as follows: The patient is placed upon the operating-table in the lithotomy position, and the limbs held in a Fig. 72.— Emmet's scissors. Clover crutch or a sheet arranged according to Dickinson's method. An assistant on each side separates the labia to fully expose the parts ; the operator, seated in front of the patient, seizes the tissues with the forceps on the left side as high up as the denudation should ex- tend, and with the scissors removes a strip at the junc- tion of the skin and mucous membrane across to a corre- sponding 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 con- tinuous strip may be taken out from one side to the oth- er and back again until the whole surface is denuded. The three figures will give a better idea of the mode of procedure than this descrip- tion. In case there is prolapsus [L_ of the vagina—and it is there- FlG 73 fore necessary to carry the denudation high up on the vaginal wall—the scissors with the greatest curve should be used at that part of the procedure. When the whole surface has been denuded in the manner de- scribed, it is necessary to make sure that the edges of the wound 13 -First step; denudation begun. 146 DISEASES OF WOMEN. are 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 care- ful sponging will show any irregularity which needs to be trimmed off. By passing the finger over the fresh sur- face, any scar tissue that re- mains can be detected by its density and resistance com- pared with the softness and elasticity of the normal tissue. At this stage of the op- eration attention should be given to haemorrhage. If there are any spurting vessels in the wound they should be controlled by suture or ligature. Fortunately, when such vessels are encountered they are generally at the up- per margin of the wound, and may be controlled by passing a fine suture through the mucous membrane of the vagina and under the ves- sel and then tying it tight enough to stop the bleeding. This has been already noticed under the head of general obser- vations. 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. AVhen 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. 4 and 5 are the sizes used ; No. 5 for the lower suture and Xo. 4 for the upper ones. The needles employed are like the ordinary darning needles, but Second step; continuing the strip. INJURIES TO THE PELVIC FLOOR. 147 curved. The larger needles are armed with No. 5 thread and the smaller with No. 4. To manipulate these needles it is necessary to have a suitable forceps, and for this I have devised the instrument rep- resented by Fig. 76. It is a double forceps. The central portions of the two blades which form the handles are made of spring steel. The j halves cross each other at I about an inch from each end j to form the jaws. At one ! end the jaws are file-faced on ) the upper tip and grooved on j the lower; at the opposite j end the jaws are copper-faced, j The latter 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 intro- duced into the desired groove, the handle is grasped, which closes the jaws and holds the needle perfectly immovable, _ no matter how much pressure „,, „. .. . . , , . , r Fig 75.—Vivifying complete; the vaginal su- inay be brought to bear upon tures on one side are inserted. it. AVhen 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 copper-faced jaws and withdrawn. The advantage of the copper-faced jaws is that they 148 DISLASKS OF WOMKN. Fig. 77. 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. 77. The dotted line represents the suture which describes a circle, and the straight line shows the sides 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 needle. It is then better to pass the needle in through half of the vivified portion, to draw it out and re-insert it at the same point, and 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 intro- duced like the first—each one being passed at a higher point. The fourth suture (see Fig. 78) is introduced through the side. It is then carried through about three eighths of an inch of the vivi- Fig. 78.—The stitches in place; the vaginal sutures tied. fied portion of the vaginal wall, and then passed through the other side. The last suture is passed through both sides, as shown in Fig. 80, the position of the sutures being viewed in profile. INJURIES TO THE PELVIC FLOOR. 149 When more than five sutures are used, the fifth is passed like the fourth, only a little above it. Most operators introduce 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 do- ing, the rectal wall is crowded forward, and is sure to be includ- ed in the suture, and, besides, it is a violation of the rules of antisep- tic surgery to op- erate with dirty fino-ers. Fig. 79.—Laceration with rectocele. (The Fig. 80.—Perineal ^L dotted line gives the normal location body restored 111 many cases of perineal body.) (Profile view.) 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. AVhen 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. 78. 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 and rectal tenesmus, and greatly distress the patient, especially when the bowels move. AVhen 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. AVhile 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: 150 DISH ASKS OF WOMEN. Case of Central Laceration extending to the Sphincter Ani; Uncom- plicated.—The patient, a spare, small woman, in good general health. She had been married nine years, and had one child eight years old. Iler 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 ad- vice. Her menses returned ten months after her confinement and one month after her child was weaned. Six years after her confine- ment she overtaxed her strength, and then her leucorrhoea became more profuse, and she began to suffer from backache and slight pel- vic tenesmus, especially upon standing or walking. She was consti- pated, 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 commen- cing prolapsus of the posterior vaginal wall, but it was only apparent upon separating the labia and causing the patient to cough or make downward pressure. The uterus was below its normal elevation, but not changed in its axis. The leucorrhoea was due to a cervical ca- tarrh, which promptly yielded to treatment. Five days after a menstrual period her bowels were freely moved in the morning by a dose of pulv. glycyrrhizae comp., given at bed- time the night before. On the following evening the bowels moved spontaneously, and, an hour later, an enema of borax and warm water was given to wash out the rectum. Early next mornino- the vagina and pudendum were thoroughly cleansed and disin- fected and 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 marine lint was 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 burnino* in the region of the wound. She took a small cup of tea, and slept several hours during the night. Next 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. INJURIES TO THE PELVIC FLOOR. 151 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 j[ ^\ fact, after the fifth day she had no local treatment. Ii J) Fig. 81.—Scissors for removing sutures. U ^ 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. 81 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 allowed 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 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 vaginal wall and the outer surface of the pelvic floor, running from before backward, formed an angle as represented in the accompanying diagram. Furthermore, when the introitus vaginae was re- tracted with a Sims's speculum and the instrument removed, 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. Subcutaneous Laceration in the Median Line.—The first step in the operation for this injury is to make an incision in the skin from the posterior commissure down to the sphincter-ani muscle, and then remove the scar in the cellular tissue and proceed as in the com- / V>2 DISEASES OF WOMEN. plete laceration just described. In case there is prolapsus of the pos- terior vaginal wall, the redundant skin and mucous membrane should be removed and the vivifying of the tissues completed by removing all scar tissue. 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 sphincter ani, it is necessary to restore the septum before operating upon the perinaeum. 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 other retractor, 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 refer- ring to Fig. S2 an idea may be obtained of the sutures in posi- tion, 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 perinaeum, catgut sutures are employed, and these are tied upon the rectal side! The in- troduction of the sutures is begun above, and each one tied when introduced. The sutures should be No. 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. OPERATION FOE, 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 INJURIES TO THE PELVIC FLOOR. 153 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 Fig. 82.—Complete laceration of the perinaeum and sphincter ani. The depressions on either side of the rectal opening show the separated ends of the torn sphincter. Between the two runs a thin bridge of dense scar tissue. The rectum is drawn toward the pubic arch by a strong levator. Moderate cystocele and rectocele are present. success when it is not—a delusion often indulged in regarding the plastic operations to repair the lesser injuries of the pelvic floor. In order to comprehend the position and relations of the surfaces 154 DISEASES OF WOMEN. 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 Fig. 83.—Complete laceration of perinaeum. Denudation completed. Here the vulva is shown drawn apart much more widely than in Fig. 86. The flap (R) left from the rectocele is raised. The scar tissue between the sphincter ends has been re- moved. The depressions indicate the ends of the sphincter. understood by referring to Fig. 82. 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. AVith the scissors a strip of tissue 'INJURIES TO THE PELVIC FLOOR. 155 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. AVhen this is done, it will some- times 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- vaginal 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 dissection 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. AVhen the vivifying is completed the parts appear as represented in Fig. 83. There are ordinarily two sets of sutures used, one to coaptate the rectal wall and sphincter-ani muscle, and the other to do the same for the perinaeum. The rectal sutures are introduced first. I used 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 out- ward 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 corre- sponding to the course which the needle traversed in the right side. This leaves the ends of the sutures 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 recto-vaginal wall, and finally around the other end of the muscle to a point directly opposite the one where 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 156 DISEASES OF WOMEN. 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. S4 and 85 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- Fig. 84.—Complete laceration of perinaeum through sphincter. The sutures in the rectal wall introduced. For the sake of clearness some have been omitted. vaginal septum has extended so high up that an operation for its restoration is necessary before restoring the sphincter-ani muscle and the perinaeum. Another condition requiring similar treatment is found in cases in which the septum has been extensively lacerated, INJURIES TO THE PELVIC FLOOR. 157 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 wrall 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 Fig. 85.—The rectal sutures have been tied on the rectal side and the ends cut short. The remaining sutures are in place. The flap from the rectocele is lifted by a tenaculum. perinteum, 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- I5S DISEASES OF WOMEN. 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. AVhen 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- sa 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 5 Glycerin....................................... ? ss.; Syrup of acacia and compound tincture of cardamom, of each....................................... ? -j. INJURIES TO THE PELVIC FLOOR. 159 A teaspoonful of this noon and evening before meals. AVhen 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 was 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 comp. 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- 160 DISEASES OF WOMEN. ele was, however, sufficiently restored to give the rectum retaining power, but it did not act as a perfect sphincter muscle. When 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 haemorrhoidal 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. 8G) beneath the forceps, and slowly Fig. 86—Haemorrhoid clamp. INJURIES TO THE PELVIC FLOOR. 161 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 14 162 DISEASES OF WOMEN. 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. s7). Fig. 87.—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 Boft-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. INJURIES TO THE PELVIC FLOOR. 163 closing the escape tube and opening the stop in the fountain syringe, injects the solution of soap and water. AVhen 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. AVhen 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 case 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. Treatment of the Transverse or Internal Lacerations.—Dr. Emmet was the first surgeon to devise an operation for the relief of this 164 DISEASES OF WOMEN. injury. I had long observed and comprehended the transverse or internal injury, but never conceived of any method of remedying it until I heard from Emmet. I found that by supporting the pelvic floor dur- ing convalescence from confine- ment, in cases in which this inju- ry had occurred, some effort to re- pair the injury by natural heal- ing processes was made, and quite successfully in some, but when Fig. 88. the injury per- sisted and the usual pathological changes developed in consequence of this injury, no operation that I had ever tried was really of any service in restoring the structures. As soon as Dr. Emmet gave to the profession his discoveries in this department I saw the great importance of his valuable contribution to this branch of pelvic sur- gery, and I began at once to practice the operation as best I could. I have found that it meets every indication most fully in cases of transverse internal laceration in which the pelvic floor itself is in perfect condition. The operation is not adequate when the pelvic floor has sustained a subcutaneous laceration, or when atrophy has occurred in the median line from stretching—a common complica- tion of the transverse laceration if permitted to exist for any great length of time. In these conditions I find it necessary to modify Dr. Emmet's method of operating in order to obtain the results required. Moreover, I have obtained better results by treating the so-called rectocele somewhat differently from the way in which it is treated by Dr. Emmet. In Emmet's operation we are directed to vivify the tissues up to the most prominent part of the rectocele, and then continue the vivifying upward in the vagina on either side beyond the uppermost portion of the rectocele and as far as the laceration of the levator- ani muscle extends. No tissue is removed in the median line from the posterior commissure down toward the anus. So far as the lat- eral denudation in the vagina and suturing are concerned, I follow the Emmet method. In the median line I remove only tissue INJURIES TO THE PELVIC FLOOR. 165 enough to liberate the vaginal wall from the pelvic floor and then reflect it upward and backward. I then divide the tissues in the median line down to the sphincter-ani muscle, or down to where I find muscular tissue and fascia; in other words, produce by incision a complete median laceration. The angles in the vagina are then brought together by the sutures down to the muscular tissue of the pelvic floor—that is, down to the bulbo-cavernosus and the ends of the transversus muscle on either side. The muscle, fascia, and integument are then closed by sutures from below upward ; the en- larged vessels and cellular tissue are crowded backward toward the rectum and the vaginal wall united to the floor of the pelvis with the sutures, which bring together the lateral edges of the pelvic floor. By this procedure the muscles and fascia in the median line are restored; the muscular wall of the vagina is attached to the pelvic floor as far back as the rectum and upward to the posterior commis- sure. By this method the so-called rectocele is completely disposed of and the posterior wall is held downward and backward in its normal position; in other words, „ \ made to resume its normal rela- tions to the pelvic floor (see Fig. 60). In this way the essential req- uisites are ob- tained : first, the central part of the floor is restored ; the so-called rec- tocele is disposed of without loss of vaginal tissue; the normal relations of the vagina and pelvic floor are established, and the overdistended veins receive more support than can be offered by any other operation known to me. The veins should not be wounded if this can possibly be avoided, either while vivifying the tissues or introducing sutures. If by chance a vein is wounded it should be exsected, or the opening closed with a ligature ; this guards the patient from phlebitis and extravasation. The veins can usually be avoided while suturing by separating them from the vaginal wall Fig. 89. 166 DISEASES OF WOMEN. and pressing them downward and backward while passing the needle. In regard to the arteries which usually lie just beneath the vaginal wall, no harm comes from dividing them if they are ligate* 1 or caught in the sutures; in fact, the closure of the arteries may be beneficial in lessening the blood supply during convalescence, thereby allowing the veins to regain their original caliber. In addition to the ordinary dressing, a compress and bandage should be applied to support the pelvic floor and prevent traction being made upon the internal sutures while the union is taking place. I must remark that I use the prepared silk suture in this as in all operations, and here its advantages are very pronounced. Emmet uses silver wire, and any one who has seen the irritation that comes from a number of such sutures in the lower portion of the vagina and the difficulty of removing them needs no argument to convince him of the superiority of silk sutures. CHAPTER VIII. FISTULA IN ANO AND COCCYODVNIA. 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 line, into the rectum above the sphincter muscle. AVhen 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. 167 168 DISEASES OF WOMEN. 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. AVhat her sul> 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- rhea. 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, but still the function of the sphincter was imperfect. The patient was un- able to retain fluid fasces 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 perinaeum was shorter than normal, and was drawn upward by the action of the sphincter-vaginas muscle FISTULA IN ANO AND COCCYODYNIA. 169 until it nearly closed the introitus vaginae. The rectum appeared to 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 fistulas 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 15 170 DISEASES OF WOMEN. very liable to be impaired. AVhen the fistula is located beneath the mucous membrane only, then a perfect result can always be obtained Air. John Gray (" Lancet," December 11, lss<)) 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 say 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. AVhile 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 FISTULA IN ANO AND COCCYODYNIA. 171 a trial, and I determined to put it to the test of practice as soon as I 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. AVhile 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. 90.—The operation for fistula; the tract laid open and the sutures in place, a, anus; f, outer end of fistula. 172 DISEASES OF WOMEN. 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. 90 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 carbobzed 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, 1S44, 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.—Fain 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. FISTULA IN ANO AND COCCYODYNIA. 173 Physical Signs.—Tenderness upon pressing and moving the coc- cyx is the chief diagnostic sign. Painful haemorrhoids, 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- tore prefer to disarticulate with the knife or scissors, cutting through the cartilage. 174 DISEASES OF WOMEN. AVhile 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 casks. Removal of the Coccyx and Lower Segment of the Sacrum; Recov- ery.—A married lady, twenty-four years of age, wTas 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- FISTULA IN ANO AND COCCYODYNIA. i-s 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. Fissure in Ano.—This patient was suffering from a small fissure or ulcer in one of the folds of the mucous membrane within the grasp of the sphincter-ani muscle. The fissure was exposed with the aid of the rectal speculum. The cautery was placed at the upper end of the 116 DISEASES OF WOMEN. fissure and heated, and then drawn downward through the surface, and the diseased surface was completely but very superficially cau- terized. The cautery in these cases should be very lightly applied to prevent deep destruction of the tissues, which would cause a slough and retard healing. In many cases, when the ulceration is very superficial, I do not touch the parts with the cautery at all; only hold it near enough to produce the effect desired by the radiated heat. CHAPTER IX. INFLAMMATORY AFFECTIONS OF THE UTERUS. 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 triangle, is about two inches ; and it is about one inch in thickness. It is divided into the fundus, body, and cervix, the cervix being about as long as the body and very nearly as thick. The cervix is divided into the iutravaginal and the supravaginal portions, the form- 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. ill Fig. 91.—Mold of uterine cavity in the virgin (Guyon): a, os internum ; d, os externum. Fig. 92.—Mold of uter- ine cavity in the multi- para (Guyon). 178 DISEASES J0lfi^ ■ v,;;^!,!',"--;;'." SiSlW-l' IfSft ; ^-lfo#t ^lips^'i^ '. f$MJjm ffif?-''-' ffelF (■'?/■; ill .Sli ■;$$$:---c -.-:£§ t$''?)'/'j '•'•'''' ''-''■'',' '/'-'X'lv'v';^:: ,^^i:';:%, /• ''';''-' 11^ 'Qf "';;'!'. .#'#§1; BIS ;' '«'. '™!«$llil ^P§>'V • > ■:■ $'tWim ''/■''/''iSwi"^! ,-*' *' " V' lip Ssl?' /'' ■^1^/' '■^^'^li' 'iti '•■'■ i Jm%9j} 'v-',: ' '^vy^.*tio N"^ C^'ML^t.^<«t ^ Fig. 97.—Section through the mucous membrane of the vaginal portion of the cervix showing cystic degeneration. 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. INFLAMMATORY AFFECTIONS OF THE UTERUS. IS' These are the principal pathological conditions observed in the ordinary forms of cervical endometritis. Occasionally the discharge Fig. 99.—Hypertrophy of body of uterus fol- lowing corporeal endo- metritis (Winckel). Fig. 100.—General enlarge- ment of uterus, contrasting with the two preceding fig- ures (Winckel). Fig. 98. —Thickening and elongation of the cervix, as a result of cervical endome- tritis (Winckel). may be muco - purulent, at times it is sero-muco-purulent; but this occurs only in extreme cases, and usually is due to 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 imparons 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 tliev 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 188 DISEASES OF WOMEN. there are usually marked tenderness and dysmenorrhea, 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 occurs 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 leucorrhoeal discharge is diagnostic. It is dense, thick, opaque, and tenacious, while the vaginal leucorrhoea is INFLAMMATORY AFFECTIONS OF THE UTERUS. 189 serous, non-tenacious, and usually purulent. If the disease is long continued backache comes on, the pain being located in the sacral 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 when 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 leucorrhoeal 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 ace 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 190 DISEASES OF WOMEN. 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- INFLAMMATORY AFFECTIONS OF THE UTERUS. 191 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 will at once be inferred that if the first object is attained, the second will follow as a natural consequence; but it may or ma}' 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. 192 DISEASES OF WOMEN. 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. He 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. INFLAMMATORY AFFECTIONS OF THE UTERUS. 193 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 hypereemia 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-cantery 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. 194 DISEASES OF WOMEN. The method of applying these agents is by using the pipette (Fig. 101). Eegarding the agents to be used, a long list might be ^ given, but it will z^^^7^ —— ~~?rnrM':iir" v*Q--^-^yFS^ suffice to say that ^ „ 1A1 01 , . .... ,. . , the safest and most Fig. 101.—Skene s instillation tube. efficient are mild 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 day, but I know that this constant manipulation is irritating, and does more harm than good. Mucous Polypi of the Cervix Uteri.—In connection with erosion of the cervix the glands of the cervical canal sometimes become cystic, and project from the eroded surface. The amount of this projection is occasionally so great that the cysts escape from the canal and hang by pedicles in the vagina. They are not unlike nasal polypi, and are called mucous polypi of the cervix. They are red in color and are semi-transparent. ILLUSTRATIVE CASKS. 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 always 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 leucorrhoeal 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 INFLAMMATORY AFFECTIONS OF THE UTERUS. 195 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 leucorrhoeal 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, 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. 96). 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 196 DISEASES OF WOMEN. 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, 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 leucorrhoeal 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 three 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 was 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 leucorrhoeal 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- INFLAMMATORY AFFECTIONS OF THE UTERUS. 197 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, 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 three months longer. At this time her general health had been considerably restored, the canal of the cervix had returned to its normal size, the leucorrhoeal 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 198 DISEASES OF WOMEN. trouble, the nature of which I could not exactly determine. She recovered from this, but afterward suffered from uterine leucorrh(ea. 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 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 leucorrhoeal discharge, but she began to have backache and pelvic tenesmus, with an occasional sharp pain in the region of the uterus. She also had slight dys- pareunia. She was 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 my 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 profussly 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, leucorrhoeal 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 INFLAMMATORY AFFECTIONS OF THE UTERUS. 199 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, and 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 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 200 DISEASES OF WOMEN. child. At that time she had some difficulty in her labor, and sus- tained a slight laceration of the perinamm; 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 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 perinaeum 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, ahoma'- 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 INFLAMMATORY AFFECTIONS OF THE UTERUS. 201 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. 42) 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, 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 perinaeum 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 dysmenorrhoea, 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- 17 202 DISEASES OF WOMEN. 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 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 dysmenorrhoea 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 hyperaesthesia of the vagina. A speculum examination INFLAMMATORY AFFECTIONS OF THE UTERUS. 203 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 small 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- colored, and very tenacious secretion. This was removed with the curette, but with great difficulty, and quite a free haemorrhage 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 204 DISEASES OF WOMEN. of the cervical canal; this was accomplished by seizing the cervix with a tenaculum, and then passing a small-sized Sims's curette (Fig. 102) up to the internal os, and under strong pressure draw- ing it down and cutting out a deep strip of the mucous membrane. Fig. 102.—Sims's curette. 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 INFLAMMATORY AFFECTIONS OF THE UTERUS. 205 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 New York, who said that she had some falling of the womb, and treated her by tamponing the vagina with cotton, after the method of Boseman, who, I believe, calls this method of treatment " column- 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 Na- 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. 206 DISEASES OF WOMEN. 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 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 haemorrhage, 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 endometritis some widely-differing pathological conditions, such, for example, as the changes in the tissues following the acute puerperal affections of the uterus.* It will be seen by what follows that, although the diagnosis of endometritis is difficult, careful attention to that part of the subject will secure a degree of accuracy which has not been heretofore gen- erally 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 cervi- cal 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 patients with endometritis die of some other affection, hence the inexact knowledge on this subject. 207 2i»s DISEASES OF WOMEN. 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 from 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- CORPOREAL ENDOMETRITIS. 209 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 210 DISEASES OF WOMEN. and amenorrhoea, 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 CORPOREAL ENDOMETRITIS. 211 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 pres- ent time I believe that a more favorable viewr of the matter may be taken. The disease in itself is not dangerous to life, and, when un- complicated, will usually yield to appropriate treatment. There is a decided tendency in many cases for it to return, but even then it can be relieved by removing the cause. Recovery takes place at the menopause or senile endometritis follows. 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, which 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 course5 212 DISEASES OF WOMEN. 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 2 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, Nott, 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. CORPOREAL ENDOMETRITIS. 213 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 214 DISEASES OF WOMEN. 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 danger. Method of Curetting.—The pathological conditions which demand the use of the curette have already been referred to. The instru- ment which I employ 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. Dilatation of the cervical canal should be made rapidly, under anaes- thesia, with Goodell's dilator. This method of immediate dilatation is greatly in advance of the old way of dilating by sponge or sea- tangle tents, which always caused great pain, and sometimes inflam- mation and septic infection. The patient is placed in Sims's position and the cervix caught and held with a tenaculum curved on the flat (see Fig. 6) and the cervix dilated. 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 gynecology, and very satisfactory in its results. Of course, the usual surgical cleanliness should be observed, and the uterus should be washed out with an antiseptic solution and packed with gauze. ILLUSTRATIVE CASES. The patient was thirty-two years of age, who had been married ten years, and had given birth to two children. She made a slow recovery from her last confinement, 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 suffered from backache, pelvic tenesmus, and irritable bladder, with free leucorrhoea, at first like an ordinary cervical secretion in character. Her general condition also became disordered. The CORPOREAL ENDOMETRITIS. 215 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. AVhen first examined I found the uterus large, the in- crease 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 laxative 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 appear to do any good. I passed a medium-sized curette into the uterus, and gently curetted the entire mucous membrane of the body ; this brought away considerable serum and blood, some of which, from its dark color, had evidently been retained for 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 were found, and several shreds that looked like portions of the epithelial layer of a thickened and softened membrane. The curetting seemed to be a failure, so far as obtaining any 216 DISEASES OF WOMEN. 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 Mas a brave lady, and did not complain without cause. There was con- siderable oozing of bloody serum from the uterus after the curet- ting. About five days afterward an examination revealed a copious discharge of cervical secretion, which wras rather dark in color and slightly yellow, as if it contained pus. Very 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 membrane 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 applied to the cervical canal. This treatment seeming ef- fectual, 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 applica- tion 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 leucorrhoea, 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 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 hyperaemic state of the cervical mucous membrane with leucorrhoea; this was treated for about six weeks with one part CORPOREAL ENDOMETRITIS. 217 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 dysmenorrhoea, 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 flow 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 dysmenorrhoea 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 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 18 218 DISEASES OF WOMEN. 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. She was anaesthetized, the cervix fully dilated, and curetting employed. A large quantity of polypoid material was removed, the uterus washed out with a five-per-cent solution of carbolic acid and thirty per cent of glycerin and then packed with gauze, which was removed at the end of three days. The corporeal endometritis was completely relieved. The constitutional treatment was kept up, and an application was made after each menstruation for three months, which arrested the slight catarrh of the cervix. CHAPTER XI. 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 perinaeum or cervix uteri, metritis, or septicaemia. 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 219 220 DISEASES OF WOMEN. 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. When the involution has been arrested by puerperal metritis, the products of the inflammation are found. According to Dr. Noeg- gerath, these products are inflammatory exudations and hyperplasia of the cells of the areolar tissue. Symptomatology.—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 perinaeum 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. When 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- naeum, and septic infection causing either cellulitis, lymphano-itis, or SUBINVOLUTION. 221 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 anaemic, 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 hyperaemia is necessary to the process of involu- tion, and anaemia 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. 222 DISEASES OF WOMEN. 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 James Y. Simpson, and illustrated with cases wrhich 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- SUBINVOLUTION. 223 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 SO to 90 in the minute. She was thin, feeble, and anaemic in appearance. The mammae 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. u 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 weeks 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. u 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 224 DISEASES OF WOMEN. 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 anaemia 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 / 225 226 DISEASES OF WOMEN. 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- SCLEROSIS OF THE UTERUS. 227 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 fikened 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 wTalls 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 228 DISEASES OF WOMEN. 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. Noeggerath, 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. ILLUSTRATIVE CASES. Sclerosis of the Cervix Uteri.—This case, whose history I give, 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- SCLEROSIS OF THE UTERUS. 229 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 laceration. Healing was prompt and complete, and the size of the cervix—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, I have fre- quently seen such favorable changes after operations. 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, and attended with pain. At times she has a menstrual molimen, 230 DISEASES OF WOMEN. 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 di- rection. 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 ex- pansion 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 anaemic, 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 SCLEROSIS OF THE UTERUS. 231 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 anaemic, 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 anaemic 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, I 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, 232 DISEASES OF WOMEN. 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 dysmenorrhoea, 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 anaemic in appearance. It was only by referring to my notes of the case, taken at the SCLEROSIS OF THE UTERUS. 233 first examination, that I could fully realize the change which had taken place. I treated her for a short time in the hope of relieving her dys- menorrhoea 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,, 19 CHAPTER XIII. MEMBRANOUS DYSMENORRHOEA. 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 uterus, 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 234 MEMBRANOUS DYSMENORRHCEA. 235 to their being called the decidua gravida and the decidua menstru- al is, 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 dysmenorrhoea with its changes in normal menstru- ation, the difference is as follows: In normal menstruation, if we accept the views of Dr. Williams, of London, the whole mucous membrane undergoes fatty degeneration, disintegration, and elimina- tion ; whereas in membranous dysmenorrhoea 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. Xo such product or result of inflammation is found elsewhere in the mucous membranes of the body, nor is it necessary that inflammation 236 DISEASES OF WOMEN. of any part of the uterus should be present in order to produce membranous dysmenorrhoea. Associated with this membranous dysmenorrhea 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 dysmenorrhea. 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 MEMBRANOUS DYSMENORRHCEA. 23" 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 dysmenorrhcea due to Fic.s. 103, 104.—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. 105.—Half a membrane from a virgin; from the body of the uterus only. 238 DISEASES OF WOMEN. 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 dysmenorrhoea—that is, that it is due to inflammation, or else the re- sult of gestation—one is left with Fig. 106.—A cast from a virgin, where the cervix is also involved. out any very rational view to offer Fig. 108.—A cast which might be mistaken for a product of concep- tion : m, shaggy interior; «, film of membrane covering it; c, fila- ments from cervix. MEMBRANOUS DYSMENORRHOEA. 239 regarding its causation. While it is not, perhaps, the part of wisdom to discredit the accepted views on any question 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 the cause of this affection, I am in perfect harmony with the views of Dr. Oldham, who was the first to discover " dysmenorrhoea 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 24-0 DISEASES OF WOMEN. gestation, excites this morbid action on the part of the uterus which leads to this abnormal exfoliation of its mucous membrane i 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. 1 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- MEMBRANOUS DYSMENORRHCEA. 241 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 so 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 242 DISEASES OF WOMEN. I have carefully attended to them, restoring displacements and cor- recting flexions, and so on. WThen the canal has been constricted, free dilatation and packing with gauze have been efficient. 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 Dysmenorrhoea 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 MEMBRANOUS DYSMENORRHEA. 243 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- menorrhea 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 water. 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 244 DISEASES OF WOMEN. 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 Dysmenorrhoea 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- rhoea 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- MEMBRANOUS DYSMENORRHEA. 245 caemia; she then miscarried, and the ovum was found to be macer- ated, and probably had been dead in utero for two weeks. She recovered from this and was quite well for about a year, when her dysmenorrhea 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 dysmenorrhoea 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 hare heard that she gave birth to a healthy child.. Case III. Membranous Dysmenorrhoea 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 wTas done for her; but I know positively that she suffered from dysmenorrhoea, 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 dysmenorrhoea. The character of the pain at her menstrual periods then appeared 246 DISEASES OF WOMEN. 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. CHAPTER XIY. LACERATIONS OF THE CERVIX UTERI. 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- 247 248 DISEASES OF WOMEN. 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 LACERATIONS OF THE CERVIX UTERI. 2413 Fig. 109.—Bilateral laceration; unequal division of the cervix. 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. 109). 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 leucorrhoeal 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 uot be brought togeth- er (Fig. 11(0. This superabund- 20 ■^W8'*l^^kL ^BSEN> .^hl . ^SSJ • -5* -. * ^^ ■gNf»v * ^■ntrv4 * W U «■%■»*.. - J^HlJro a " M ^^ v v ^Ifl BS »t * *§| ^kJS fiaT; Jm ^■^^^^jjjjr Fig. 110.—Bilateral laceration, with thickening of the everted lips. 250 DISEASES OF WOMKN. ant tissue is produced by arrest of involution and areolar hyperpla>ia. 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- Fig. 111.—Extensive multiple lacerations. vided into three unequal parts, as seen in Fig. 111. 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. 112). 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. 112.—Multiple incomplete lacerations. LACERATIONS OF THE CERVIX UTERI. 251 A "'■•" •■■ - -'■' J,&f SBiLi c^y IF53I 1 £.^^H^ « idBB V ^>xj^H ^^p ,-*f^^ 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. 113 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 meni- Fic. 113.—Incomplete bilateral laceration. . . , t ., 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. 115. Causation.—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 ©edematous 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 L Fig. 114.—The incomplete bilateral lacera- tion shown in Fig. 113, as seen by sec- tion of the cervix. 252 DISEASES OF WOMEN. 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. 115.—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- LACERATIONS OF THE CERVIX UTERI. 253 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. AVhere 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. AVhen 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 papilloma tous-looking surface. AVhen 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 254 DISEASES OF WOMEN. 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 amesthetic, 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 Fix? 116. ' ' h' 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 PLATE I. FIG.117 PAGE 255. FIG.120 PAGE 258. FIG. 121 PAGE 253. %^-- ■>** PLATE I. Operation for Laceration of the Cervix Lteri. Figure 117. Page 255. Denudation complete. Figure 120. Page 258. The sutures in position. Figure 121. Page 258. The sutures tied. I HTA.I'l ' i ",im ) Mi' i e /.ol'i / :i.■: >i.. "it ,rui^ir'l .'' >-.ryu\hi< yiIT i .IS-1 -miai** )iJ h'yiuw>. yilT LACERATIONS OF THE CERVIX UTERI. 255 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. 116.—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. 117, 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. 118. 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 Fig. us.—Triangular needles. needle - forceps which will give 0 s 3 4 5 6 GEO. TIEMANN &CU. 251} DISEASES OF WOMEN. the desired angle, and is held immovable there, while the operator grasps 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. 119). ( r _^i^vl ^M==-- G.TIEMANN jTcO. d Fig. 119.—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 LACERATIONS OF THE CERVIX UTERI. 257 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 21 258 DISEASES OF WOMEN. hyperaemic, 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. 120 and 121, 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 Ceryix 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, which was formerly very good, became impaired. The appearance of the cervix when first seen is shown by Fig. 110. It was impossible to bring together the edges of the os exter- num, owing to the enlargement of the halves of the cervix. Con- stitutional 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. 122 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. Fi^s. 123 and 124 show the parts brought together with the sutures, and Figs. 125 and 126 show a different method of doing the same operation. Before tying the sutures a piece of muslin saturated with wax was LACERATIONS OF THE CERVIX UTERI. 259 placed between the halves of the cervix, and left there for four days to keep the coaptated parts from meeting. The sutures were Fig. 122. Fig. 124. Fig. 125. Fig. 126. Figs. 125 and 126.—Another method of closing the gap. Fig. 122.—Removal of crescentic shaped piece (seen in section) when the everted lips are thickened. Figs. 123 and 124.—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. Three weeks afterward the cervix was restored in the usual way, and good union was obtained, and the patient subsequently recovered. In cases like this I 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. 260 DISEASES OF WOMEN. 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. 112). 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 anaesthetize 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 afte.' LACERATIONS OF THE CERVIX UTERI. 261 her third one was born. When she came under my observation she had menorrhagia, a poor appetite, and constipation. She was ema- ciated, very anaemic, 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- rluea, 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 202 DISEASES OF WOMEN. the menorrhagia nor the leucorrhoea. Subsequently the covity 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. 115). 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 LACERATIONS OF THE CERVIX UTERI. 263 manner a3 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 injuries. 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 XY. CICATRICES OF THE CERVIX UTERI AND \rAGINA. 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 pain 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 vaginae, 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 principal symptom developed by cica- trices is pain, which is often intermittent or remittent, and is usually increased by exercise. AVhen the scar involves the cii'cumference of 264 CICATRICES OF THE CERVIX UTERI AND VAGINA. 265 the cervix, and the caliber of the canal is reduced below the normal size, dysmenorrhoea occurs in some cases. AA7hen 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 hyperaesthesia 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. Physical Signs.—These I may briefly mention. They are the presence of abnormal tissue, which is usually tender, always indu- rated, less elastic than healthy parts, and sometimes lighter in color, and having a smooth surface. Cicatrices of the vagina are easily detected; those of the cervix are liable to be confounded with sclerosis and incipient malignant disease. The points of distinc- tion are the increase of tissue and abnormal vascularity found in the latter. Treatment.—Knowing the evils which cicatrices give rise to, the first duty of the practitioner is to guard against their 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 natural 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 practicable; if such wounds can be made to heal without the inter- vention 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 266 DISEASES OF WOMEN. that, if the edges of a lacerated wound are held together, the chances of their uniting are better than if left alone. Even should healing take place by granulation, the sutures, preventing the wide separa- tion of the parts, will tend to lessen the size of the cicatrix. AVhen there is so much to be gained by good union, and so much suffering entailed 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. AVhen 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 the treatment of cicatrices the chief indications are to relieve the pain and tenderness of the parts, prevent contractions, and, where deformities exist, to correct them. These requirements can be most promptly and perfectly fulfilled by removing the whole of the cicatrix and bringing together the normal tissues, and obtain- ing as near immediate union as possible. But this radical treat- ment is only called for in rare cases, and is not always practicable, 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. AVhen the scar can not be removed altogether, contrac- tion should be guarded against by preventing it from shortening. In oblong cicatrices, contraction in width rarely gives trouble, while shortening 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. Some- times the contractility of the normal tissues is sufficient to draw the divided edges of the scar apart, so that incising the scar is all that is necessary. AVhen 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 CICATRICES OF THE CERVIX UTERI AND VAGINA. 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 vagin83. I 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. This 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 from day to day the size used, 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. AVhen there is no marked deformity, and pain and tenderness are the only symptoms, great 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 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 20S DISEASES OF WOMEN. touch revealed contraction of the whole vagina, so that the index- finger 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 papilla? 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 further treatment, and finally recovered. Scar in the Vaginal Wall resulting from an Injury sustained during Labor.—I was called to see a lady two months after her con- finement 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 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 CICATRICES OF THE CERVIX UTERI AND VAGINA. 269 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 caustics. 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 on the poste- rior wall of the cervix and vagina. AVhile 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 treatment were often seen years ago, and at the present day they are far too common. 270 DISEASES OF WOMEN. A Band of Scar Tissue just within the Introitus Vaginae, and extending across from Side to Side of the Vagina, due to 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 only be introduced with 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. CHAPTER XYI. INVERSION OF THE UTERUS. 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. 127 and 128. 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- peral state only. In all cases of inversion, at least at the time when this accident occurs, enlargement 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, the shock alone proved fatal. If there is great Fig rtiul inversion (Thom- as). Fig. 128.—Complete version (Thomas). 271 272 DISEASES OF WOMEN. 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 haemorrhage 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 instead 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. While this exploration and re- moval of the placenta—if it is present1—are going on, the left hand is placed upon the abdomen, and the absence of the uterus above is INVERSION OF THE UTERUS. 273 observed, as already stated. Passing the finger 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 uterus are continuous, and that there is no opening into the cavity of the uterus. These signs will suffice for any one who 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. AVhen 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 22 274 DISEASES OF WOMEN. 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. 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 risimukt^gPolcomS- tw0 surfaces wiU glide backward and forward upon piete 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. 129.—Polypus simulating partial inversion (Thorn- INVERSION OF THE UTERUS. 975 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 haemorrhage, 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 have 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 270 DISEASES OF WOMEN. 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; haemorrhage 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 INVERSION OF THE UTERUS. 277 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 perinaeum rigid, so that the pains which ex- pelled the head were most powerful, especially the last one. The moment that the head passed the perinaeum 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 anaesthesia, 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. 278 DISEASES OF WOMEN. The three 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 doctoi 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 anaemic, 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. Yaseline 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. Xo 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 of 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. INVERSION OF THE UTERES. 279 Dr. Thomas has classified these methods as follows: Methods 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 vagina. 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- 280 DISEASES OF WOMEN. ter-pressure. This method of using the left hand combined with the method of Dr. Noeggerath is highly commended by Dr. T. G. Thomas. Dr. Emmet describes his method as follows : " In 18(55 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 were 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 fingers brought together." This method, which appears to me like Yandel'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 is pushed forward by the screw in the handle against the fundus, and in that way makes the required upward pressure. INVERSION OF THE UTERUS. 2S1 Fig. 131.—Byrne's method of reduction. Fig. 131 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. 132) 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. 132.—Cup pessary to exercise gradual pressure (Thomas) 2S2 DISEASES OF WOMEN. 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 sacrum 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 cold 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. 133 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 INVERSION OF THE UTERUS. 2*3 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 k 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 case 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 133.—Replacement of uterus by dilatation through abdomen. (Thomas.) CHAPTER XYII. 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 284 DISLOCATIONS OF THE UTERUS. 2S5 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. 13-1), and it is equidistant from the sides of the pelvis. The position of the uterus varies from time to time, as already Fig. 13-1.—Section of pelvis, showing its inclination and the axis of the inlet. 286 DISEASES OF WOMEN. 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. 135 shows the changes in the position of Fig. 135.—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. Next in the order of inquiry are the anatomical structures by which the uterus is held in position. This requires a consideration of the DISLOCATIONS OF THE UTERUS. 287 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- Fig. 136.—Diagram of the uterine ligaments as seen on looking into the brim. B, bladder. 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 288 DISEASES OF WOMEN. to the sacrum are those peritoneal folds known ligaments. Between the uterus and the bladder. Peft.SfCKi^l-' as the utero-sacral on the sides of the latter, the folds of peritonaeum form the utero-vesiciil ligaments. These ligaments are so called not because they are composed of ligamentous tis- sue, but rather be- cause they perform a function similar to that of litra- ct ments. With the exception of the round ligaments which are com- posed of muscular tissue covered with peritonaeum, the others are made up of double folds of peritonaeum con- taining between these folds areolar 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. 136. 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 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 Fig. 137.—Section through the right broad ligament showing its relation to the uterus, tube, ovary, round ligament, and the vessels in its base. DISLOCATIONS OF THE UTERUS. 2S!> 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 in- tervention of areolar tissue which is found in considerable quantity in this region. From this it will be seen that these ligaments are continuous from side to side, and also from before 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 princi- ple apparent in the an- atomical arrangement of the parts in ques- tion, 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 nor- mal. In short, many cases have been seen clinically in which all the Other means that Jig. 138—Section of pelvis,witti the antero-posterior slings could oossiblvcontrib- of the u*erus; behind, the utero-sacral ligaments; in t ouiu posMon conn 10 front> thg anterior vaginal wall (after a fr0Zen section). ute to supporting the uterus were removed by disease and injuries, and yet the uterus was maintained in position under ordinary circumstances. The most rational idea of the means and ways by which the uterus is main- tained in the pelvis I obtained from the following statement by Dr. Frank P. Foster. Speaking of the supports of the uterus, he says: " Ordinarily, 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 pos- 200 DISEASES OF WOMEN. teriorly, 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 vaginal wall act in supporting the uterus. I would go one step further than Fig. 139.—Diagram of the uterus slung between the broad ligaments in the true pelvis. The round ligament, tube, and ovary are shown on one side only. 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 continu- ous structure extending across the pelvis in its transverse diameter. These structures, taken together, act like " beams " or (to be more mechanically accurate) cables of a suspension bridge, which support to a large extent the uterus in its center. The utero-vesical liga- ments 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 anterior vaginal wall, utero-sacral, vesico-uterine, and broad ligaments. Fig. 138 shows a section of the pelvis with these ligaments and the anterior vaginal wall with the uterus resting upon them. Fig. 139 shows a transverse section of the pelvis just in front of the uterus and broad ligaments, and represents these structures and the manner in which they support the uterus. A similar function may be claimed for the round ligaments, at least so far as their effect in preventing the backward displacement DISLOCATIONS OF THE UTERUS. 291 of the uterus. Some have claimed that the round ligaments have but little supporting power to sustain the uterus in place, while others give it much credit in this direction. Those who believe in Alexander's operation of shortening the round ligaments for the relief of 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 abdo- men, and the abdominal muscles partially divide the greater cavity from the lesser. This is shown in Fig. 140, where the arrow indicates the direction of the force trans- mitted to the pelvis through pres- sure from above. 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 abdo- men is perpendicular, so that the pressure is indirect from above. Some claim that a suction power is exerted upon the pelvic con- tents by the diaphragm. It is said to act like a piston in the cylinder of a pump. There is reason to believe there is something in this ex- planation from the fact that, on examination through a Sims's specu- lum, the uterus is seen to rise and fall with respiration. This motion is to a large extent arrested when the patient 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 Fig. 140.—The normal inclination of the pelvis and the transmission of force from above. 202 DISEASES OF WOMEN. the pelvic organs as surely as if there were some traction or suction action of the diaphragm tending to draw these organs upward. 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 does not directly support the uterus, it indirectly aids in doing so, and i+ 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 always 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, 203 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 only 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 uterus. 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. 141 shows the three degrees, and may convey a clearer idea than further description. Fig. 141.—The three degrees of prolapsus. The upper outline is a little above the normal position. 204 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 complete. 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 toe 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 fiber. 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 hyperemia of the rjarts in these displacements. These changes of the positior- DISLOCATIONS OF THE UTERUS. 295 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 too-ether, 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 perinaeum 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 200' 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. 297 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. 142.—Prolapsus uteri with cystocele. In the second degree of prolapsus, the os points toward the os- tium vagime, 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 wTalls. 24 20 S DISEASES OF WOMEN. J)tagnosis.—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 Fig. 143.—The shallow pelvis with lessened inclination of brim. The direct action of the pressure from above is shown by the arrows. DISLOCATIONS OF THE ETERUS. 200 Fig. 144.—Increased inclination of in- let. Pelvic organs escape pressure. 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. 143) 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. 143) the pelvic organs are constantly under greater pressure than normal, and prolapsus and retroversion are likely to occur. 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 3<>n 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. 1 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. 301 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 suppoi'ts 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 perinaeum 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 3i )2 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 wool is no doubt the best. It is soft and least irritant to the tissues. AVhen 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 either cotton or wool. In some cases lint is irritating to the tissues and can not be long continued. Sometimes I have used wool and lint alternately 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. 303 fer the borated cotton or marine lint alone, using such astringents as may be required in the douche. In many cases there is some loss of the pelvic floor from pre- vious injury. 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 peringeum 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 rub- ber. 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 appre- ciable 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. 142 represents prolapsus in the second degree. Fig. 145 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 perinea] 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 ; -;< >4 DISEASES OF WOMEN used. The rule is that the smallest instrument should be employed that will keep the uterus in place. If too large a pessary is used it Fig. 145.—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 bv the old glass-globe pessary. It certainly is the best instrument that I have DISLOCATIONS OF THE UTERUS. 305 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 twTo 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 peringeum, upon which the pessary de- pends for support, regains its tonicity. By 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- 306 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 Fig. 146.—Stem pessary. ,. •, , . ~ ., . Modification of Cutter's, found to answer best of the stem pessaries is a modification of Cutter's (Fig. 140). 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. 307 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 every year I find less need for them. By a careful and judicious use of the ring and the tampon, aided by 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 luemorrhage may occur if they are not re-enforced writh 308 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. 309 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 1SSG, 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 toward 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- 310 RETROVERSION OF THE UTERUS. 311 ened, but in reality is thrown into folds. The anterior vaginal wall is generally distorted rather than displaced. Its upper end is Fig. 147.—The three degrees of retroversion, erowded 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 312 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. 148.—Retroversion of the second degree. as a rule, be much affected, either in its position or function, though it sometimes is. The pressure of the uterus being removed from behind, 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 cavity, and the ovaries and Fallopian tubes are to some extent carried backward and downward with the uterus. The extent of this displacement varies greatly. In some cases there is complete prolapsus 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. 313 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 which (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 25 314 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 symptoms 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- orrhoea 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. 315 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 may be 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 316 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. 140 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 anterior 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. 150 shows this condition. Fig. 149.—Retroversion with imperfect invag- ination of cervix due to inflammatory products about it. Fig. 150.—Apparent imperfect invagination due to bilateral laceration of cervix: c, c, lips of the cervix. Fig. 151.—The same uterus with its- lips drawn back into place by tenacula. 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 RETROVERSION OF THE UTERUS. 317 by trying 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 brino- the cervix prominently into the vagina and sustain it there. Fig. 151 shows the change effected in the case represented in Fig. 150, 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. 152. By upward press- ure the uterus can he 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- cessary to have the Fig. 152.—The three steps in replacing the retroverted uteru9 by means of sponge-holders. 318 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. 156), and the Sims's speculum used. This alone is sufficient in some cases to effect re- placement. When 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 by 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 I 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 American Gynecological Society held in Boston, in 1877, Dr. E. R. Peaslee RETROVERSION OF THE UTERUS. 319 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 : " I have had no experience with pessaries, at least Mdth 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 office, 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." 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 3*20 DISEASES OF WOMEN. be doing harm by still further damaging the supports of tne 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. 301 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. L* 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 ipiite 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 in 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 322 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 mere 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. 323 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. " 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. ^.-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 PESSARIES. 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 32 + 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 bv 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 maimer 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. 15+), 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. 325 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- m 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. 153), are adapted to the lat- eral vaginal walls a general way, Fig. 154.—The method of measuring the length of the pes- sary ; p, retracted perineal body. in 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- ward curve of the pessary a little short of the extent of this in- antenor vaginal wall Fni. 155.—Diagram of pessary in situ on looking at it in Sims's position, through Sims's speculum. 320 DISEASES OF WOMEN. Fig. 156.—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. 156 and 157 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 pessary which is easily 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. .. „ „ u,„t 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- . •' ] Fig. 157.—Decided invagination of cervix posteriorly ble. It IS then intrO- fitted with a suitable pessary. RETROVERSION OF THE UTERUS. 327 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 perinseum 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 cises 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. 158.—What the pessary as the body of the uterus rises. Here the principle of the lever acts to change the axis of the uterus. This is shown in Figs. 159 and 100. The lever action of the pessary is made more effective by the 32S DISEASES OF WOMEN. ant. p*ss9ry Fig 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 150. The pessary being wedge shaped — that is, narrower in front than behind—is held up- w*n ward by the contraction of the lower portion of the vagina, 159.—How the pessary acts-shown by an(J tne Wedge-action helps the the arrows in the diagram. D x 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. Alexander's Operation.—In recent times, Alex- ander, of Liverpool, has devised a plan for the correction of uterine displacements, which con- sists in shortening the round ligaments. In his presentation of the subject to the British Gyne- cological Society, he said that the operation has now been performed 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 in- cision was to be made upward and outward from the pubic spine, in the direction of the inguinal canal, for one and a half to two or three inches, according to the fatness of the subject. A considerable thickness of subcutaneous fat was 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 liga- Fig. 160.—Second step; the uterus falls into the pessary. RETROVERSION OF THE UTERUS. 329 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. Fig. 161.—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, and 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. 26 330 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 very often, for the reason that most cases 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. In estimating the merits of any surgical procedure one must always bear in mind its disadvantages. I especially call attention to this subject because we hear enough about the success of Alexander's operation and not enough, perhaps, of limitations of its usefulness, if we rely for all our information upon the strongest advocates of this treatment of retro-displacements of the uterus. During my investigations of retro-displacements of the uterus I found the round ligaments defective in some cases. This led me to the conclusion, early in my teaching days, that atrophy or imper- fect development of this ligament was a frequent cause of backward dislocations of the uterus. I have also found that retroflexion oc- curring among nullipara was sometimes accompanied with a defect in the round ligaments, due, I presume, to a lack of development. In those who had acquired retroversion or flexion, I presume, the defect was due to atrophy. Recently I have seen two cases that fully illustrate the point in question. One was a married lady about thirty years of age who had borne two children. For six years she had suffered from a retroflexion of the uterus. For two years she had been tormented with a painful left ovary. She had been treated by several practi- tioners during the six years before coming to me. Finding it im- possible to keep the uterus in place by any support, I determined at once to do a temporary ventral fixation of the uterus. In my bi- RETROVERSION OF THE UTERUS. 331 manual examination I could not feel the round ligaments, and on direct inspection, after opening the abdomen, no trace of them could be found. I subsequently removed the uterus and ovaries at my clinic, and no evidence of the presence of round ligaments could be found. This case was a very fortunate one for investigation. Be- tween the folds of the peritonaeum where this ligament should be found there was nothing but areolar tissue. These two cases were much the same as others that I have examined heretofore. I have consulted with my associates on this subject and have found that their experiences coincide with my own. I have asked Prof. Browning, Professor of Anatomy at the Long Island College Hospital, about this ligament, and he has told me that he finds it ill defined in some of his subjects, and so difficult to demonstrate to his classes that he often ignores it altogether. Dr. Lewis, formerly Professor of Anatomy, and Dr. F. II. Colton, at one time Demon- strator of Anatomy, give me the same account of their observations regarding this ligament. I have observed that in cases of retroversion the round liga- ment is at first stretched, and then atrophy begins first in the mid- dle of the ligament and becomes complete there, M'hile the uterine and abdominal ends are the last to give way. This explains the fact that in doing Alexander's operation the end of the ligaments is sometimes found in the inguinal ring fairly well developed, while there is not a trace of it left in the abdominal cavity except within an inch of the uterus, where a few fibers may or may not be found. Further confirmation of this opinion has been obtained in having seen expert surgeons of large experience fail to find the round liga- ment in a most careful dissection. This, I presume, is a reasonable explanation of the failures that occasionally come to light. There is still another objection to Alexander's operation, namely, that hernia follows in a number of cases. I am fully satisfied that, no matter how carefully one may do an Alexander's operation, the abdominal wall is sometimes weakened at the point where the incision is made and the patient is predisposed to hernia. There is no trouble immediately after the operation, but in after years when the scar tissue is absorbed the wall of the abdomen is weakened and hernia is likely to follow, and it does occur in some cases. I have seen three patients who had hernia following this operation. These cases having been operated upon by experts and having such results compel me to believe that there are many others, for it is hardly possible that all the cases with imperfect results should have come under my observation. 332 DISEASES OF WOMEN. The advocates of this operation claim that it has one great ad- vantage that I have not referred to, and that is, the short time re- quired to cure displacements in this way. I have never found that patients saved time or money by Alexander's operation, if they were curable in the old way. In treating a retroversion the patient is under observation longer, but she is not so long off duty as in undergoing Alexander's operation, and hence does not lose as much time. To the surgeon who likes to operate and does not very well understand other ways of treating displacements, this operation has a wide range of application, and is popular with patients who like to be cured quickly. Still, in all this I find no good reason for modifying my opinion regarding the indication for the employment of Alexander's operation. I am fully satisfied that this operation is valuable, but limited in its usefulness. I now employ it in. one class of cases, namely, retro- version or retroflexion accompanied with prolapsus of the ovaries and without adhesions. In such cases the uterus can be restored to its normal position, but can not be held there by mechanical sup- port, owing to the ovaries being in the way. Such cases are in- curable by the old method of replacement and support, but are promptly relieved by Alexander's operation, providing the round ligaments are all right. To this extent I indorse this operation in the cases referred to, and commend it as a most valuable procedure. It has been brought into disfavor, like many other good things, by being overdone. Ventral Fixation.—This is the name given by Sanger to the operation of fixing the fundus uteri to the abdominal wall. Kelly called it hysterorrhaphy, and later has used the term ventral suspen- sion, but I like the first name best, as it is most comprehensive. The indications for this form of surgical treatment are retroversion or retroflexion complicated with adhesions, atrophy at the junction of the body and cervix, or disease of the ovaries that require ovariotomy. The operation was first performed by Koeberle, as follows : Having had occasion to remove an ovary and tumor, he fixed the stump in the abdominal wound. This is known as the indirect method, and having been found defective has been aban- doned, I believe, in favor of the direct method—that is, stitching the uterus directly to the abdominal wall. A number of different ways of doing this fixation have been practiced by various surgeons. Some vivified the peritonaeum at the points to be united by scrap- ing ; others omitted this. Various ways of introducing the sutures have been practiced. Pozzi's method is the simplest, and as effi- RETROVERSION OF THE UTERUS. 333 cient as any. He uses a continuous suture, which he passes through the muscular layer and peritonaeum of the abdominal wall and through the peritonaeum. The rest of the abdominal wall is closed in the usual way. He uses fine silk. I prefer chromicized catgut. Operating in this way the fixation is permanent, at least it re- mains for a long time, and hence I have looked upon this procedure as objectionable, first, because it is an abnormal condition, and on theoretical grounds it is not good surgery to produce one morbid state to cure another if it can be avoided ; and, in the second place, this fixation of an organ that should be movable quite often causes suffering as bad as, or worse, than the displacement. For these reasons I have not been fully satisfied with this ven- tral fixation described in the books and practiced by surgeons gen. Fig. 16:2.—Ventral suspension. The uterus is swung to the peritonaeum of the anterior abdominal wall by sutures passed under the utero-ovarian ligaments. To the right, beneath, is shown the incision, with one stitch ready for tying; above this, the usual method of passing the stitches through the peritonaeum of the fundus. (From photo- graphs of a cadaver.) erally. I have therefore made the fixations so delicate that in time they give way and leave the uterus free, as it should be. The way of doing this operation is very simple in principle, but requires consider- able skill and care to do it well. The object is to fasten the utero- ovarian ligaments (at their junction with the uterus) to the inner side of the abdominal wall with a chromicized catgut suture. Adhesions are formed between the surfaces thus held together that are strong enough to hold the uterus in place for a while, but will give way in the course of time. During the period of fixation the natural sup- 334 DISEASES OF WOMEN. ports of the uterus regain their strength and hold the organ in place after the artificial fixation has given way. Much care is necessary in selecting the place upon the peritoneal surface where the sutures should be introduced. First, one should measure the width of the uterus at the point where the sutures are to be introduced, and a little more than half of that represents the distance that each suture should be from the median-line incision ; then the distance from the pubic bones upward to where the lower part of the suture should be, about the thickness of the uterus, plus three quarters of an inch from the pubes. This is difficult to illustrate, but Fig. 102 may help to make the description more clear. The uterus should be supported with a properly adapted pessary, and the cervix kept in proper position until union is completed. In fact, I have deemed it advisable to keep the pessary in position for two months, in order to prevent a recurrence of the displacement when the ventral fixation gives way. With this kind of after-care my cases have remained well. That is more than I can say of per- manent fixation, for all the cases occurring in my own practice and seen in the practice of others have suffered less or more when the uterus remained firmly fixed to the abdominal wall. This includes all the surgical treatment of retro-displacements of the uterus that I have found necessary to relieve curable cases. Some other surgical procedures have been tried, but so far as I can discover they possess no advantages over the operations already described. Neither have they been adopted by the profession gen- erally. Dr. William K. Pryor unites the uterus to the bladder by scarification and sutures. I quote the following description of his operation : "' The patient being in Trendelenburg's position, the incision should be carried well down to the pubic articulation. For suture material I would not use silkworm gut because of its permanency, but silk or catgut. The bladder should be empty. The anterior surface of the uterus from its bladder junction to the level of the tubal openings should be scarified in the middle for a width of half an inch. Beginning at a point from the posterior border of the sym- physis not greater than an inch, the peritoneal surface of the bladder should also be gently scarified for a space equal to and opposite that on the uterus. The scarification on both bladder and uterus should be so done as to cause no bleeding. Even though the dimensions of the bladder be greater than those of the uterus, so as to necessarily leave a portion of the bladder undenuded, it matters not. But as the contracted bladder about equals the uterus in length, it will not RETROVERSION OF THE UTERUS. 335 often happen that much surface on the bladder will be left unscari- fied. The suture should then be introduced with a curved needle without cutting edge. Three or four sutures at most will suffice. These are to be all passed under the bladder peritonaeum first, and then the lowest suture under the uterine serosa, and tied to one side. The same with the other sutures in turn. About half an inch apart will suffice to secure accurate coaptation. The sutures are tied in a flat knot and the ends cut short. The abdominal wound is closed in the usual way." Shortening the round ligaments within the peritoneal cavity has * been practiced by A. Palmer Dudley, Polk, Mann, Wylie, and Bode. The former two gentlemen unite the round ligaments in front of the uterus by first vivifying the peritonaeum and then introducing one or more sutures. One very objectionable result in this operation is that the Fallopian tube is bent at an acute angle to the uterus so that it is liable to be occluded at that point. The latter surgeons fold the round ligaments upon themselves, and, having scraped the surface brought in contact, unite them with sutures loosely tied. Many attempts have been made to fix the uterus by the way of the vagina when it could be brought into position. Some of these operations I shall mention here, though I can not recommend them as having any advantages, or even meeting the indications as well as the surgical procedure already described. Metro-elytrorrhaphy.—Byford united the wall of the cervix uteri to the vaginal wall (in front or behind, according to the displace- ment) by vivifying the tissues and uniting the parts with sutures. According to Pozzi, Doleris practiced pre- or retro-cervical colpor- rhaphy, but I have not discovered that the results were satis- factory. • Pelcic Colpo-hysteropaxy.—This is the name given by Pozzi to Freund's operation, which consists in opening through the posterior vaginal wall into the sac of Douglas and suturing the supra-vaginal portion of the cervix to the peritonaeum near the utero-sacral liga- ments. Uniting the Bladder and Uterus by the Way of the Vagina.— Mackenrodt opens the vaginal wall in front of the uterus, and, after dissecting up the peritonaeum and opening it, he removes a portion and unites the remainder to the uterus by a continuous suture run- ning from one tube to the other. The bladder wall is then stitched to the uterus. The operation is the same in principle as Dr. W. K. Pryor's, already described. 336 DISEASES OF WOMEN. Shortening the Round Ligaments through the Vagina.—Winter and Schauta opened into the peritonaeum through the vagina be- tween the uterus and vagina, and fastening the round ligaments where they are given off from the uterus to a point seven or nine centimetres distant. Wortheim called this operation the vaginal Alexander method. Vineberg and Polk have practiced this procedure in a modified form. RETROFLEXION OF THE UTERUS. In the chapter on anteflexion of the uterus the pathology of flexions generally was discussed, and the classification adopted was it becomes bent upon itself—that is, flexed as well as displaced. Owing to this close asso- ciation of retroversion and retroflexion, and the fact that the treat- ment of both has much in common, 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 relations to the vagina. At all events, the cervix is never bent backward. Pathology.—-This is the same as in anteflexion, so far as the uterus is concerned. There is a want of sufficient tissue at the junc- tion of the cervix and body of the uterus, the point where the flexion RETROFLEXION OF THE UTERUS. 337 occurs. In the majority of cases the cervix and upper part of the vagina are farther forward in the pelvis than they should be, and the cervix points forward more than it should, but less so than in re- troversion. This gives rise to a little short- ening of the anterior vaginal wall, or else an undue invagination of the anterior wall of the cervix. Symptom atology.— 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 ill flexion than in ver- ^io. 16i-—Prolapsed and adherent ovary simulating retroflexion. sion. In retroflexion the menstrual function is more frequently disturbed. Dysmenor- rhcea 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 menstrual 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 abdominal muscles are very lax and the vagina long and elastic the uterus can be carried upward with the finger which 338 DISEASES OF WOMEN. is in the vagina, and brought within reach of the hand on the abdo- men—i. e., the uterus can be grasped and examined bimanually. In that case the deformity 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 abdomi- nal 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 signs are a large and prolapsed ovary and a subperitoneal fibroma on the posterior wall of the uterus. These are shown in Figs. D'»3 and 16L 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 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 children, I believe that retroversion occurs first, and if the cervix meets re- sistance from the anterior vaginal wall and bladder in front, the RETROFLEXION OF THE UTERUS. 339 flexion is produced. If the uterus is made to bend a little at the point of flexion, the pressure will cause atrophy at that point, and thereby the flexion will gradually increase. 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 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, and 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 in- creases the flexion by making press- ure upward in place of backward (Fig. 165). Alexander's operation is suggest- ed to the mind by those cases which do not yield readily to treatment, and I presume it would be useful. How- ever, the only cases which resist the usual treatment are those in which the posterior vaginal wall is un- yielding and the uterus can not be straightened by Elliott's adjuster. In such cases there is reason to suppose that the uterus is fixed in its malposition by some old eel- 34-0 DISEASES OF WOMEN. lulitis or peritonitis; and, if so, Alexander's operation would not succeed. It is rather rare that the treatment 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 stein. The stem is then introduced to over- come the flexion and keep the uterus straight, and the pessary 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 Fig. 167.—Uterus with defective walls; the pessary is adapted to keep the the supra-vaginal portion of the cer- utern8 [n .position as well as to hold vix is elongated (after Winckel). . L the stem m place. To recapitulate, the stem corrects the flexion, and the pessary corrects the retroversion besides 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 forward. 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 ante- rior and posterior walls of the uterus at the internal os which per- mits the uterus to bend forward or backward with equal facility. Fig. 167 shows the appearance of such a uterus. Such cases are rare, and have a clinical history very much the same as anteflexion. I can give the best description of the affection by relating the his- tory 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 dysmenorrhoea. The pain at her periods became progressively worse, until she was entirely unfitted for her duties. RETROFLEXION OF THE UTERUS. 341 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 uterus the sound could not be passed until she was anaesthetized. I then found that the os internum was constricted. I incised it and dilated until I could pass a No. 9 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 in flam, nation 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 internum gave the patient great relief from the dysmenorrhoea. The usual treatment for congestion and hyperaesthesia 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. ABUSE 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 uterus, 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. 168. 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 ¥ ig. 168.—Stem of pessary ul- . . „. , n aerating through cervix. cervix by the surgeon, lhe 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 •642 ABUSE OF PESSARIES. 343 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. 169 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- n j ,, ,t Fig. 169.—Stem cutting came more flexed apparently as soon as the through body of uterus6 support was withdrawn. There was relief from the acute symptoms and inflammation caused by the instru- ment, but the dysmenorrhoea was worse than before. Atrophy of the muscular tissue of the vaginal walls 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. 344 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. 170 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 Fig. 170.-High rectocele due to improper pes- protruding mass was at the sary. r ° 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 ABUSE OF PESSARIES. 345 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 free 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 27 346 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 utems 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. 347 the pessary 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 tinie. 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. When I examined her I found the relations of the uterus and supporter as rep- resented in Fig. 171. 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. 171.—Displacement caused by a badly adjusted pessary. 348 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 rub- 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 pessary 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. 349 while she was in the asylum. When 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 vaginal 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 instru- 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 350 DISEASES OF WOMEN. and occasional bleeding from the vagina, still she neglected her self. After a time she cahed 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 she 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 doctor's 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 cases I have in mind now in which the pessaries were imbedded in the posterior vaginal wall, which were treated by sawing out the anterior half or third of the pessary, and then by turning the remaining portions around they were removed without breaking down or dividing the tissues surrounding it. CHAPTER XX. HYPERTROPHY OF THE CERVIX UTERI. This 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. 105). 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 dysmenorrhoea. In the last stage of the affec 351 352 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. 172.—Hypertrophy of the cervix. Q.) 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. 353 helps greatly in determining the extent of the hypertrophic elon- gation. 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. Tradment.—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 ecraseur, 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 iys. — Dia as follows: 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 Fig. 173.—The first step; splitting the cervix. Fig. 174 —The double flaps of the amputation. gram of the pieces removed. 28 351- DISEASES OF WOMEN. high up as the amputation is to be made (Fig. 173). The double flaps are then made with the scalpel in such a way that the two short flaps are on the in- side (Figs. 174 and 17.n. The portions removed arc 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. 17'i shows the sutures as intro- duced, and Fig. 177 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. 176.—The sutures in place. Fig. 177.—The sutures tied. HYPERTROPHY OF THE CERVIX UTERI. 355 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 UTERI'S. This form of neoplasm, which frequently appears in the wall of the uterus, differs materially from growths generally. In many re- spects it is unlike any other neoplasm in genesis, pathology, and natural history. Observations made in recent years have led me to reject the hitherto accepted opinion that fibroma of the uterus is developed during middle life. I am now convinced that it is congenital, and has its genesis in lesions of arrangement of the tissue elements of the middle layer of the uterine wall. The only essential difference in the histological composition of the middle layer of the wall of the uterus and fibroma is in the arrangement of the tissues. The muscular coat of the uterine wall is arranged in three layers, longitudinal, circular, and oblique; but these are all interlaced, so that they form one structure or continuous muscle. In the fibroid neoplasm the fibers are arranged in circular form around a given center, and are cut off or separated from the wall of the uterus by a thin layer of areolar tissue, and do not form part of the uterine wall. It may be said that this tumor is in, but not a part of, the wall of the uterus. Another difference between the structure of the uterus and fibro- ma is, that in the developmental changes that take place in the uterus during gestation the rudimentary muscular cells are formed into muscular filaments, while the tissue elements of fibroma in- crease in quantity but do not change in form or character. It is more of the nature of hyperplasia than degeneration. The evidence that uterine fibromata have their origin in derange- ment of embryonic evolution consists in their having been found, in a rudimentary state, in the infantile uterus and in young subjects, and before their presence had been announced by any signs or symptoms. They are also found occasionally with other congeni- tal lesions of development, such as anteflexion of the uterus. 3ofi FIBROMA OF THE UTERUS. 357 Figs. 178, 179.—Interstitial fibro- mata (Winckel). Furthermore, if they originate in a lesion of arrangement of tissue elements (and this, I believe, is a fact), this must of necessity take place during embryonic life. One can understand how transformation of cell elements and the development of new tissue can take place in the forma- tion of tumors; but lesions of arrange- ment of musculo-fibrous tissue, such as occur in the formation of uterine fibro- mata, is possible only during develop- ment in the embryo. Fibroid, fibrous myoma, fibromyo- ina, and hysteroma are the names that have been used to designate this varie- ty of tumor. I prefer the term fibroma, believing that it is as com- prehensive and indicative of the character of this neoplasm as any. 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 originate in the middle coat of the wall of the uterus, but the direction they take while growing varies in different cases, and this has led to a very clear and useful classifi- cation of fibromata. When the tumor remains imbedded in the middle coat of the wall of the uterus it is called interstitial (Figs. ITS and 170); when it grows toward the outside, sub- peritoneal ; and when it grows toward the cavity of the uterus, submucous. Figs. 178 to ISO will show the three forms classed accord- ing 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 outward between the folds of the broad ligament and drop down deep into the pelvis. It is not until they become quite large that they extend up out of the pelvis. Being surrounded by the folds of the broad ligament they are more firmly fixed in the pelvis than other subperitoneal tumors, and con- sequently cause more displacement of the pelvic organs. The uterus Fio. 180.—Subperitoneal and submucous fibro- mata (Winckel). 358 DISEASES OF WOMEN. and the bladder are usually pushed far over to the opposite side of the pelvis, and the pressure upon the ovaries and pelvic nerves causes the most pain and suffering of all of this class of tumors. They are more likely to cause cellulitis than when located elsewhere. In some cases the tumor drops down very low in the pelvis behind all the pelvic organs. In one case, unusually large, which came under my care, there was a considerable mass behind the rectum which extended down to the perinaeum. 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 down- ward beneath the peritonaeum, necessarily got behind the rectum. The location of fibromata has a marked influence upon the his- tory and treatment; the classification should be clearly understood and kept in mind on this account. Those that grow toward the inside of the uterus may remain broadly attached to the uterine wall, or they may become pedunculated. They may be single, conglomerate, 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 number of masses growing close together and sur- rounded by one capsule. Fibromata vary greatly in shape. When very small they are usually round, but as they grow they sometimes become 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 demarcation 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 form what is 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 for this the morbid growth would be very much like a cir- cumscribed 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. They increase in size during pregnancy, and generally diminish after confinement, and after the menopause they 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 FIBROMA OF THE UTERUS. 359 uterus, in the respect that there is simply an increase of tissue with- out change of structure. The rule is that fibroids do not increase by growth before puberty, and they usually disappear after the menopause, but not 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 tumor begin as soon as the menses stop in all cases. On the contrary, the organic forces which main- tained 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 alto- gether, or returns to its primitive size. 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 expul- sion of the tumor from the uterus may go on until separation is com- plete, the tumor being expelled as is an ovum in miscarriage. The same changes occur in the reverse direction in subperitoneal fibro- mata. 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 abdominal viscera, and a vas- cular communication between the tumor and the parts to which it has become attached has been established. Sometimes such adhe- sions occur in tumors which are not pedunculated, though it is a notable fact that fibromata are the least liable to form adhesions of all the neoplasms. These changes of fibromata in relation to the uterus are aided, perhaps effected wholly, by muscular contraction of the uterus. The process is in the nature of an expulsion, and is the natural way by whicji the uterus endeavors to free itself from such morbid growths. The density of fibromata differs in different cases, and occasion- ally changes in the same case. They sometimes, especially if large. become 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 usually called a fibro-cvst, but there is a difference in pathology be- 360 DISEASES OF WOMEN. tween a fibro-cyst and a fibroma with cyst-like cavities containing hlood, pus, or serum. I have seen two cases of fibroma which gave the physical signs of fibro-cysts. They were both large submucous fibroids, and situ- ated in the body of the uterus, leaving the fundus free. The tumor closed the lower part of the cervix uteri, and the menstrual 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 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. In some rare cases the tissues soften and suppurate, and septicaemia is pro- duced. One such case occurred in my practice and Droved fatal. CHANGES IN THE UTERUS FROM THE EFFECTS OF FIBROMATA. 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: FIBROMA OF THE UTERUS. 361 " Fibromyomas 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 writer, 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 present; in another, on one side glandular, on the opposite side interstitial, endometritis. " For interstitial myomas three groups must be formed : " 1. Where the tumors are separated from the uterine cavitv by a wall one half to one centimetre thick. " 2. Where the tumor is beneath the mucous membrane but does not project. u 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. " In the second group, the deeper layers of the mucous mem- brane were completely transformed into connective-tissue trabecular; at the surface was a greatly dilated capillary network with thick- walled vessels. u 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 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 haemor- 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- 29 ;HJ2 DISEASES OF WOMEN. 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 present in pregnancy. It is simply enlarged but not changed in form. There is often displacement of the uterus, 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. Pressure of the uterus upon surrounding organs may cause derange- ment of function. These effects depend upon the size and location of the tumor, with reference 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 suffer from pressure which may prevent it from distending, or it may be rendered irritable and tender. 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 pelvic 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 inflam- FIBROMA OF THE UTERUS. 363 mation, and I found the tumor impacted in the pelvis and it could not be di.-lodged by any means. The inflammation progressed, and the obstruction of the rectum became complete by the addition to the tumor of the products of the inflammation. In most cases the tumor can be raised up out of the pelvis when it be- comes large enough to give much trouble. The pressure may be 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 formerly 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 transudation from the tumor rather than from the peritonaeum, as in ordinary ascites. The quantity of the fluid is seldom sufficient to cause much distress. 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 tumor. 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 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. 364 DISEASES OF WOMEN. 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 and the complications, such as endometritis in various forms, which determine the haemor- rhagic 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 most liable of all to cause bleeding. A very small tumor of this kind may cause the most persistent and exhausting haemorrhage. The symptoms produced by the pressure of the tumor upon neighboring organs are generally most marked when the tumor occupies the pelvic cavity; then the pressure upon the bladder and rectum causes irritation and func- tional obstruction of these organs, and less or more pelvic tenesmus of a general character. The effect upon the bladder is to render urination very frequent and sometimes difficult or impossible. 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 extend above the brim of the pelvis. The urethra and bladder were car- ried upward, so that the urethra was caught between the tumor and the pubic bones 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 up- ward, the patient being placed in a knee-chest position. Pressure upon the pelvic 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- 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. Very large tumors interfere with free respiration, and the action of the stomach and bowels to some ex- tent. 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 suggested by the fact that hydro-peritonaeum is usually found in connection with oedematous tumors. FIBROMA OF THE UTERUS. 365 Figs. 181 and 182.—Enlargement due to sub- involution compared with that from growth of a fibroma (after Winckel). 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 distortion 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 out line, one side being much larger than the other. In the subperi- toneal variety this deformity is quite marked. The tumor pro- jects 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 inter- stitial, 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 indurated, 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. 1S1 and 1S2 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- pressed, that the sound can not be passed. A flexible bougie may he used under these circumstances, and although it will not posi- tively show the position of the canal, it gives valuable indications of it. When the sound can not be used at all, this valuable sign is not 366 DISEASES OF WOMEN. obtainable, but the fact that the canal in a large uterus will not ad- mit the sound is evidence of fibroma. There is no other condition of enlargement of the uterus in which the sound can not be passed, as a rule. Small fibromata, which occupy the pelvic cavity, present some physical signs which resemble displacements of the uterus, ovarian tumors, tubal pregnancy, the products of former inflammations 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 pregnancv 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 easily distinguished from the products of a pelvic cellulitis, extra- uterine pregnancy, and disease 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 cvst of the uterus by its density, as recognized by the touch but a soft FIBROMA OF THE UTERUS. 367 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.—The causation of uterine fibromata remains as ob- scure as ever. Granting that they are the results of lesion of evolu- tion leaves the question of the derangement of development unset- tled. Heredity may probably have something to do with it. A lesion in the arrangement of the fiber of tissue might be transmitted as surely as the distribution of colors. The fact that these neoplasms prevail in certain families and races favors this theory. Certain facts in regard to age, race, and social relations have been ascer- tained which favor the growth of these neoplasms. The age when fibromata grow is between thirty and thirty-five years. There are many exceptions to this, howTever, but it is rare to have these growths appear before puberty or after the menopause. It may be more correct to say that they never attain any appreciable size before pu- berty 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 so- cial relations is stated by Thomas Addis Emmet as follows: " The development of these growths is retarded by child-bearing, and even by marriage, for the sterile woman is less liable than the 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. He also gives his views regarding the social state as related to the causation of these neoplasms in the following words : "Between the ages of thirty and forty years the unmarried ;>)(;S DISEASES OF WOMEN. 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." From my point of view, the statements of Dr. Emmet given above refer to the growths of fibromata, not to their genesis or de- velopment. 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 occasion suffering, but rarely prove fatal. Many patients are unable to live on until the menopause, when the tumors disappear altogether, or become reduced during the final involution of the uterus so that they are harmless. The complications are, first, haemorrhage, which recurs so often in many cases that it endangers life. Very 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 fibroma, 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 intra-uterine fibroma. The tumor, being in part cut off from the circulation, undergoes necrosis before its expulsion is completed, and causes septicaemia, and death takes place when FIBROMA OF THE UTERUS. 369 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 meters causing obstruction to the flow of urine, renal disease, and finally uraemia. Although there are dangers from all of the com- plications named above, the number of fatal cases is very small 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. AVithin the past few years such means as ovariotomy, hysterectomy, and electrolysis have been employed in the treatment of uterine fibroma, with results which raise the hope that the great majority of these neoplasms will be controlled, and the death-rate from this cause reduced 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. Uterine fibro- mata, when discovered in the rudimentary or latent state, are amen- able to treatment. A careful study of many cases has convinced me that these tumors are disposed to remain in a latent state until they come under conditions favoring their growth, such as sterility, deranged menstruation, and endometritis. In other words, it is more easy to keep a fibroid from beginning to grow than to arrest its growth after it has begun. It is evident that any derangement of the functions of the uterus favors growth of fibromata. It natu- rally follows that the relief of any diseases of the uterus which de- range or interrupt any of its functions will indirectly control the growth of fibromata. This I have demonstrated many times. I have on record a number of cases of imperfect development with small fibroids of the uterus, manifested by irregular and painful menstruation, that upon being relieved of the malformation and impaired nutrition have suffered nothing from the fibroids. Sev- eral patients after being cured have become pregnant, and while the fibromata appeared to increase in three of them during gestation, they reduced in size during post-partum involution of the uterus. In eighteen cases of pregnancy with fibroma of the uterus, seven miscarried and eleven were delivered at full term; two of them were twice delivered safely. The subsequent histories of ten were kept for periods varying from one to four years, and in only one did the fibroma grow to any appreciable extent. 370 DISEASES OF WOMEN. In some of my cases the tumors had attained considerable size before gestation took place, and as they remained stationary, for some time certainly after confinement, it appears that gestation re- tarded their growth. The indications for treatment (when fibromata are rudimentary and latent, and also when they are growing but are small) are to remove all malformations, malpositions, and inflammations, or other curable lesions that may be present; in short, to restore the uterus to its normal structure so that it may perform its functions. AVhen this is accomplished the growth of fibromata is prevented in the great majority of cases. The above may be called the preventive treatment—that is, treatment which prevents growth. When this fails, or in cases hav- ing progressed far enough to cause trouble, the treatment required is of an entirely different character. The ways and means may be said to vary from the simplest medication to the most daring surgery, and each method, if judi- ciously adapted to the requirements 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 effects 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- 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 FIBROMA OF THE UTERUS. 37 \ 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. Electrolysis.—This method takes a high rank among the means of treating fibroma of the uterus. In order to fully comprehend this subject, some knowledge of the elements of electro-physics should be obtained. For this we must refer our readers to the text- books on this subject. Method of applying Electrolysis in the Treatment of Fibroid Tu- mors.—The method of using the current which I have adopted is to pass an electrode into the cavity of the uterus, and insulate that portion of the instrument which rests in the vagina. The other electrode—a broad one—is applied over the abdominal surface where the tumor is located. The electrode in the uterus is con- nected with the negative pole of the battery, and the other with the Fig. 183.—Uterine electrode. positive. The current is then gradually turned on, until it is as strong as the patient can tolerate and is continued for eight or ten minutes. This is repeated every third or fourth day. The electrode which is introduced into the uterus is shaped like a uterine sound. The portion of it which occupies the cavity of the uterus is made of platinum. The rest is copper covered with hard rubber, and over this there is a sheath of rubber, which can be moved for- ward or backward to regulate the length of the portion to be insu- lated, which varies, according to the depth of the canal of the uterus in different cases. Fig. 183 shows this instrument. The electrode which Apostoli uses for the outside of the tumor is composed of sculptors' clay, rolled, cut to a size sufficient to cover the prominent part of the 372 DISEASES OF WOMEN. tumor, and about half or three quarters of an inch thick. The clay is covered with some thin fabric, like cheese-cloth, to keep it to- gether. This is applied over the abdomen, and then a broad me- tallic plate applied over the clay. This answers very well so far as fitting the rounded abdominal surface, and by its own weight it keeps its place and also protects the skin from irritation. It is not very convenient, however. The clay has to be kept wet all the time, in order to be ready for use when needed. It also requires to be made warm in cold weather, and is not very clean to handle. Owing to these inconveniences of the clay, other materials have been used. I employ a sheet of absorbent cotton about half an inch thick when wet, and gently compressed, and over that an electrode made of a number of small metallic plates fastened together with wire. In this way the electrode fits the irregular curves of the ab- dominal walls. Even this is not exactly what I desire. AVhile it is free from the objections of the clay, it does not adapt itself to the body as well as the clay. This leads me to believe that something more convenient than anything now in use may yet be devised. This is the method of using electrolysis in the way which appears to me to be most acceptable, but there are modifications as practiced by some which should be noticed. Some prefer to anaesthetize the patient and use a current stronger than the patient could otherwise bear. This may insure more rapid progress in the treatment, but it is perhaps more dangerous and disagreeable to the* patient. I prefer a current which the patient can tolerate, and continue it longer at a time and repeat the treat- ment oftener. It not infrequently happens that the cervix uteri is displaced, so that the electrode can not be introduced into the uterine cavity. In such cases a needle-pointed electrode should be thrust into the tumor and the current passed in the usual way. Apostoli speaks of this as making an artificial canal in place of the normal one of the uterus. In order to maintain this canal made by the first puncture, the current used must be strong enough to destroy the tissues in imme- diate contact with the instrument. Should the opening close, another puncture can be made at the next treatment. In cases where there is severe menorrhagia Apostoli recommends the introduction of a positive electrode into the uterus, and the use of a current strong enough to slightly char or dry the mucous mem- brane, and in that way arrest the bleeding. This is no doubt good practice when the bleeding can not be arrested by other means such as curetting or the application of astringents. FIBROMA OF THE UTERUS. 373 Menorrhagia, when it is present, can sometimes be helped by treating the endometrium. 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 curette 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 to reach it is sometimes impossible. In such conditions sufficient drainage after treatment is not obtainable, and hence the very great danger. AVhen 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 by dividing the pedicle. When the dilatation of the cervix is complete, and the tumor is expelled from the uterus and 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; it 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 can be lengthened or shortened in a moment (Fig. 184). 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. DISEASES OF WOMEN. is Objections to the wire or chain ecraseur have been raised. There 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 peritoneal 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 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. 185 shows the condition referred to as it oc- curred in my own patient. The inversion of part of the uterus was not detected before the operation was completed, but an ex- amination of the tumor showed that the inverted portion of the uterine 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 reduced by rapidly taking sections of it away with a strong scissors, and then the ecraseur can be used, or if the hemorrhage is not great the base of the tumor should be enucleated. Much care and gentle handling of the enucleating instrument should be employed, because the muscular wall of the uterus at the point of attachment of the tumor may be absorbed, 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. Fir, 183.—Wall of uterus caught in ecrccseur-wire and removed. wall was completely removed. FIBROMA OF THE UTERUS. 375 Intra-uterine fibromata have been treated by enucleation before they became pedunculated, and before the cervix was dilated. Dila- tation or descision of the cervix was made and the tumor enucleated. When the tumor was high up the capsule was incised, and ergot ing a continuous catgut suture for the peritonaeum, interrupted Fig. 187.—Left ovarian vessels tied, left round ligament tied, vesical peritonaeum divided and pushed down and left uterine vessels ligated. Cervix amputated and uterus pulled up and out, exposing right uterine artery, which is clamped an inch above the cervical stump. The two following steps are clamping the right round ligament and right ovarian vessels, when the mass is removed. (Kelly.) silver-wire sutures for the fascia, a buried continuous catgut suture for the subcutaneous fat, and the subcuticular catgut suture for the skin. " The important points accomplished by this method of operat- ing are (a) the great saving of time, and (b) the simple way in which certain serious complications are met. "(a) Tune saved.—According to other methods of operating, naif an hour or an hour, or even more, may be consumed in enu- 380 DISEASES OF WOMEN. cleating the tumors and in getting ready to close up the pelvic and abdominal wounds, while by this method the enucleation is often effected in three or four minutes, and in difficult cases in from ten to fifteen minutes. " The experience of every surgeon will bear me out in insisting upon the importance of saving time at this particular stage of the operation—that is, the stage of enucleation—which is most likely, when prolonged, to produce shock and to be accompanied by ex- cessive loss of blood. " Furthermore, when the enucleation of the disease is completed, all important questions affecting the vital interests of the patient have been answered ; adhesions have been severed, important vessels controlled, intestinal complications dealt with, and tumors developed in situations difficult of access have been removed. In other words, those factors in the case which often demand an alert judgment and the highest surgical skill have all been dealt with; the rest of the operation, closing the pelvic wound and the abdominal incision, fol- lows a certain routine which may with safety be left in the hands of a well-trained assistaUt. '' (b) Complications met.—I have insisted particularly upon the novel way in which serious complications are simplified by this plan of treatment, and I would refer chiefly to two kinds of complica- tions : " First, fibroid tumors located under the peritonaeum of the pel- vic floor; and, " Second, inflammatory masses situated behind the broad liga- ments, with dense adhesions to the pelvic peritonaeum, to the rec- tum, and often to the small intestines. " In the case of the subpelvic peritoneal fibroids, it is astonishing how difficult they are to get at from above, and how easily, on the other hand, they roll out when handled from beneath by this pro- cedure. " I would say the same of the inflammatory cases. Matted masses adherent in all directions which resist enucleation from above are often removed with ease when rolled up from the pelvic floor from below. The adherent structures seem to be unrolled in a natural and easy way, in surprising contrast to the difficulties experienced and the injuries inflicted in gaining the slightest finger-hold in pro- ceeding from above. " To recapitulate: Abdominal hysterectomy by the continuous incision down through one broad ligament across cervix and up through the other broad ligament, is contrasted with hysterectomy FIBROMA OF THE UTERUS. 381 by an incision down to the cervix through one broad ligament, and then down through the other, followed by amputation of the cervix. " The special advantages offered by this method of operating are: " 1. The saving of from sixty to eighty per cent .of the time in the enucleating stage of operation. " 2. The ease with which intra-ligamentary myomnta and myo- mata beneath the pelvic peritonaeum may be enucleated. " 3. The ease with which inflammatory masses posterior to the broad ligament may be enucleated by attacking them from below after dividing the cervix. " 4. The control of a displaced ureter, on the side last opened up, keeping it out of the way of injury by the simple mechanism of the operation." Traction and Morcellation.—Dr. Emmet, I believe, was the first to operate by the method which he calls traction and morcellation. Intra-uterine tumors that have, in the progress of expulsion, di- lated the cervix, but are sessile—that is, attached to the uterus by a broad base—should be removed, be enucleated. That operation is performed as follows: The patient is placed in Sims's position or in the lithotomy position, according to the preference of the operator, and the parts exposed. The capsule is divided at the presenting portion of the tumor with the knife, or, if very vascular, with the cautery. The tumor is seized with a double tenaculum forceps, and, while making traction, the tumor is separated from its attachments by enucleation. A variety of instruments have been invented and used for enucleating, but I have found most of them poorly adapted to the purpose. I use with satisfaction the dry dissector, well known in general surgery, but made larger and longer. The blades are wedge-shaped and rounded on the sides, and one is blunt and the other provided with very fine saw teeth. The blunt blade or end of the instrument is used in operating upon hard tumors when the capsule is easily separated. The blade with the teeth is required when the capsule is more firmly attached to the tumor. It is always easier and better to enucleate the tumor in mass, and yet when one is too large for this it can be reduced by morcellation. Having completed the enucleation, the capsule should be removed if it does not retract but remains dangling in the cavity of the uterus. That is done by gathering together the edges of the opening at its lower part, seizing it in a forceps, twisting it, and then passing the wire loop around its upper portion and removing it with the ecraseur. This is a most important part of the operation. If the capsule 382 DISEASES OF WOMEN. is left it may slough, and give much trouble. Again, packing suffi- cient for drainage is used. This part of the operation should be done quickly, because the uterus contracts in time and makes it diffi- cult to place the packing. ILLUSTRATIVE CASES. Fibroma of the Uterus; Recovery without Treatment.—This case illustrates a class, not by any means large, in which the disease runs its course without causing much discomfort or impairing the health to any great extent, and without being influenced by treatment. The patient was highly nervous and very active, had a good consti- tution, and enjoyed good health. AVhen she was about thirty years old her menstrual flow became more free than formerly. She had up to that time been quite regular and normal in regard to menstru- ation. This slight menorrhagia continued, and occasionally was quite profuse. She also had backache and pelvic tenesmus, which rendered her less active and enduring than in her earlier life. I first saw her professionally when she was thirty-one years of age. She was then single and enjoying fair health. I supposed that she might have a fibroma of the uterus from the history, and suggested that I should find out by examination the exact condition. This she objected to. From this onward she continued about the same. The menor- rhagia continued, and she had at times dysmenorrhoea and leucor- rhoea, but all of these did not impair her health or usefulness suf- ficiently to make her willing to submit to treatment. At forty years of age she married, and then her symptoms increased consid- erably, but in the intermenstrual periods she was fairly well. Four years after her marriage she had an attack of malarial fever of a mild order, and then the menorrhagia and dysmenorrhoea became worse, and I then had an opportunity to examine her, and found that there was a fibroma in the posterior wall of the uterus, probably inter- stitial. She soon recovered from the malaria and its effects, and then her uterine troubles became as they had been formerly. About this time I made an application of iodine to the cavity of the uterus, but as she improved she did not return for further treatment. I saw her occasionally while visiting other members of her family, and heard that she was about the same as formerly. According to her own statement, she was not at any time quite well, but not ill enough to be willing to be treated. AVhen she was forty-nine she again consulted me, and I then found that the men- strual flow had been diminished for over one year, and had been ab- sent altogether for three months. She was quite nervous and rest- FIBROMA OF THE UTERUS. 383 less, just as many are at the menopause. I examined the uterus, and found that the fibroma had almost disappeared. The uterus was much larger, at least twice as large as it should be after the menopause, but not one third the size that it was when I first ex- amined the case. I have seen her since, and find that she is quite well. Interstitial Fibroma of Large Size, complicated with Endometritis; treated by Tincture of Iodine to the Endometrium, Ergot during the Menstrual Period, and Mild Continuous Current of Electricity.—A strong and vigorous lady who had always enjoyed good health until after she was twenty-five years old, was first seen when she was thirty-one. She was married at twenty-six, and soon thereafter began to menstruate too freely; she never was pregnant. AA7hen first seen she was prostrated with a severe menorrhagia. I then ob- tained the facts given above, and also learned that she had suffered from pelvic pain, leucorrhoea, backache, and a gradually increasing menstrual flow until the time I saw her, when she was quite ex- hausted. The uterus and tumor extended upward to half-way be- tween the pubes and umbilicus. Stimulants and ergot were given, but the flow continued, and then the tampon was used, which stopped it. She improved from this time, quite perceptibly, but was pulled down at the next period, though not to so low a point as before. She was then put under treatment for the endometritis. The hot-water douche was tried, and the whole endometrium touched with tincture of iodine. In order to do this it was necessary to dilate the os exter- num, and then by using the pipette, the application could be made very thoroughly. There was at first considerable catarrh of the cer- vix, and for that a few applications of tincture of iodine and carbolic acid, equal parts, were made. Fnder this treatment the menstrual flow became less free, although the tumor increased slightly in size. After remaining under treatment intermittently for about two years, she was induced to place herself under the care of a physician who made the acquaintance of her husband. This gentleman treated her twice a week with a mild continuous current of electricity, which he pa>sed through the tumor by placing one electrode upon the ab- domen and the other upon the back. Three quarters of a year were occupied in this way, but without any improvement; she neither gained nor lost, except that her flow was more free. She returned to my care again, and I resumed the treatment of the endometritis with iodine; I also continued the elec- tricity, but did so by procuring a battery for the patient, and having one of my assistants teach her how to use it. In place of applying 384 DISEASES OF WOMEN. it twice a week, as the doctor had done, she used it every day, and I am satisfied that she used it as effectually as the doctor. This treatment was kept up for two years. AVhenever her menses became very free, or if the leucorrhoea returned, she came for treat- ment, otherwise she used the electricity alone. The tumor had diminished perceptibly, but her general improvement was out of proportion to local changes, excepting that the endometritis was re- lieved. After this she went to live in the country, and was not seen again until she was forty-six years old. I then found that the menses were normal, and that the tumor was very much reduced. When first seen, I could with ease introduce the sound into the uterus seven and a half inches, while at the age of forty-six the cavity of the uterus measured less than four inches. Interstitial Fibroma of the Uterus treated with Ergot; Recovery. —This patient was thirty-four years old, married, and had one child when she was twenty-three years old. After its birth she suffered from leucorrhoea and backache, but did not have any treatment until she was twenty-seven years of age. She then began to menstruate too freely, and was treated by her physician, but without effect. The menorrhagia, while it depressed her, did not disable her alto- gether, so she went about her duties until she noticed a tumor in the abdomen ; she then came to me for advice. I found the uterus en- larged, extending upward to within two inches of the umbilicus. The cavity of the uterus was deflected to the right and backward, and the sound passed to the depth of seven inches. The fibroma occupied the left anterior wall and projected considerably to the left, giving to the whole mass (uterus and tumor) an irregular out- line. There was some endometritis, and the patient was slightly anae- mic, but otherwise her health was good. Half a drachm of fluid extract of ergot was given before meals, for about a month, in the hope that it might incline the tumor toward the cavity of the uterus, and by partially expelling it bring it within reach for the operation of enucleation. At the end of a month there was no change in the position of the tumor; ergot was then used hypoder- mically about twenty minims every third day. This excited strong uterine contractions, which lasted for about an hour or more each time. This treatment was continued for three weeks, but without changing the position of the tumor, though it diminished in size. The hypodermic use of the ergot was then given up, because the patient became tired of the pain it caused. She continued to take the quantity first given by the mouth for seven or eight weeks, and FIBROMA OF THE UTERUS. 385 the tumor continued to decrease in size. The hypodermic use of the ergot was tried again for nearly a month, but was only used every fourth day. At the end of three months all treatment was stopped because the patient's digestion became impaired. She was kept upon tonic treatment for a time until her general condition improved, and again the ergot was resumed, using it hypodermically and by the mouth alternately. The menorrhagia gradually subsided, and at the end of six months the tumor had diminished over two thirds of its former size. The cavity of the uterus was only three and three quarter inches in depth. No further treatment was deemed neces- sary. Three years after the treatment was suspended the patient was in good health, and her menses were regular. The uterus was above the average size, but not much so. The left wall was more than twice the thickness of the other, so that there was a trace of the fibroma remaining, but it was harmless. While the object for which the ergot was originally given was not attained a happier result followed. The ergot so influenced the nutrition of the growth as to cause dropsy. This is a rare effect of ergot, and yet it sometimes is pro- duced in certain cases. Submucous Fibroma; Expulsion by the Natural Efforts; Separation of the Pedicle with the Ecraseur; Recovery.—The patient was un- married and thirty-five years old; she was large, strong, and had always had good health. She began to menstruate at fourteen, and continued to do so in a perfectly normal way until she was twenty- eight years old. At that time the menstrual flow became more free and lasted a little longer. From this time onward, the menstrual now gradually but not regularly increased, until she established a well-marked menorrhagia. This undermined her health consider- ably. She lost flesh, and became quite anaemic. She had charge of a branch of a large business establishment, and was an efficient and trusted employe, but her duties became very trying to her, espe- cially at her menstrual periods, at which times she was obliged to stay at home occasionally. Still she persisted in her work until she was taken ill and confined to her bed. She called in a poorly-quali- fied physician who failed to relieve her; subsequently her employer requested me to take her in charge. I found the uterus enlarged from the pressure of a fibroma, which was evidently intra-uterine. She also had all the signs and symptoms of a pelvic cellulitis in the left, broad ligament. This terminated in resolution, and in about two weeks she was able to be around again. Although still weak, she returned to her duties, but her menorrhagia continued. Every 386 DISEASES OF WOMEN. effort was made by tonics and good food to improve her strength. She was requested to rest at her menstrual periods, and to take ergot and cannabis Indica in moderate doses at such times. She con- tinued to be quite anaemic, but dragged along with her work as best she could. I saw her only occasionally, and found that the tumor did not grow very fast, and she did not lose much in general strength. This went on for six years, when she began to have se- vere pains from uterine contractions; for this I saw her and sug- gested that she should give up the use of ergot. I did not see her again for about five months, when I was called in haste to her, and found her suffering from great expulsive pains. She told me that it was time for her to menstruate, but she had had very little flow, but instead these extreme pains. Examining the abdomen, I found that the size of the uterus was greatly increased, and that in the absence of uterine contractions, there was distinct fluctuation at the upper third of the uterus. I presumed that the fluctuating mass was a cyst which had rapidly developed since the time that I had seen her before. On making a vaginal examination, I found the cervix dilated about two inches and a solid fibroma protruding at the os externum. Opium was given to ease the pain which was ex- hausting her, and at the end of twelve hours I found that although the pains had modified a little, they had continued. The dilatation of the cervix had progressed. The opium was continued in large doses. It was then night, and I desired her to sleep. The night was passed fairly well, she had pains, but slept between them. Next day the opium was suspended and the pains returned with renewed vigor. Toward evening, after having several violent pains, they ceased, but were followed by the most distressing pressure upon the rectum and bladder. There was no cessation to this suffering, and I was called in haste to see her. I found the tumor the size of a fetal head, pressing upon the perinaeum and firmly impacted in the pelvis. The fluctuating mass was still felt in the pelvis but lower down. Her sufferings were such from the complete obstruc- tion of the rectum and bladder that immediate relief was de- manded. She was at once conveyed to a private room in the hospital, and the removal of the tumor effected. The operation was as follows: It was impossible to determine the location or character of the attachment of the tumor, nor could I pass the chain of the ecraseur over it, so firmly was it fixed in the vagina. To avoid incision of the pelvic floor and delivery of the tumor en masse—a very bad method which has been practiced—I determined to diminish the FIBROMA OF THE UTERUS. 387 size of the mass by exsection with the scissors and forceps. It was night, so I had to use artificial light reflected from the head-mirror. Through Sims's speculum it was easy to cut away enough to enable me to determine that the pedicle was not large, and that the chain of the ecraseur could be passed AVhile making this examination, and also while adjusting the chain, there was considerable discharge of dark blood from above the tumor. The pedicle was easily di- vided, and the remains of the tumor were further reduced, so that it could be brought through the vulva without laceration,, The re- moval of the mass was followed by a gush of dark blood, at least a pint in all, and there were several clots which remained in the vagina. These were rapidly removed, and then I could see the distended and empty uterus. The blood had accumulated in the uterus above the tumor, and given rise to the fluctuation and rapid increase in the size of the uterus which I had observed. With the light reflected from the head-mirror I was able to ex- amine the entire cavity of the uterus most thoroughly. By holding the lips of the os externum apart with an elevator and sponge-holder, the view of the interior of the uterus was complete. The site of the attachment of the tumor could be clearly seen, and the gradual contraction of the uterus was also noted. There was nothing of interest in the after-history of the case. The patient made a good recovery, and gradually regained her health and strength. It is now four years since the operation, and she has continued in perfect health. Uterine Fibroma, supposed to be a Uterine Fibro-Cyst; Death from Septicaemia during the Process of Expulsion.—An unmarried lady of somewhat delicate organization came under my observation when she was thirty years of age; she said that five years previously she began to suffer from menorrhagia, and soon afterward began to ob- serve a gradual increase in the size of the abdomen. AVhen first seen, the tumor was about the size of the uterus at the seventh month of gestation; all the physical signs of a submucous fibroma were obtained. Her general health was somewhat impaired, she was anaemic, owing to the menorrhagia, which was not excessive; otherwise she was in fairly good health, and, as her circumstances in life were good, she was able to be around and enjoy life. She was placed upon a general tonic treatment, with the use of ergot and cannabis Indica, which were given at the menstrual period. She continued for three years to do fairly well, occasionally having an attack of menorrhagia, which pulled her down a little, but she readily recovered from this, and went about in her usual way. ;'»ss DISEASES OF WOMEN. She was seen only occasionally, and the general plan of treatment was not changed. About the fourth year after she came under my observation, she had an attack of menorrhagia which was rather more severe than usual, and she took larger doses of ergot, and continued the remedy longer than was her habit. This controlled the menorrhagia but produced severe uterine pain, for which I was called to prescribe. I then carefully examined the tumor and found that it had increased in size considerably from the time 1 had seen her before—about four or five months. I found that the upper portion of the tumor was quite elastic, and that there was distinct fluctuation extending through an area of about five inches. I then suspected a fibro- cyst. Soon after this she was seen by my distinguished friend, Dr. T. G. Thomas, who, without knowing of the patient's history or my own opinion, made the diagnosis of fibro-cyst. During the remainder of that winter and the next spring she had more menorrhagia, and was kept more continually under the influence of ergot; when summer came she had regained some of her former strength, and went to the country, where she remained for several months. She returned in the autumn slightly improved, but about a month afterward began to suffer from severe pains, due to uterine contractions. These pains increased in severity and frequency, until she was unable to leave her room. She then sent for me, when to my surprise I found the cervix uteri fully dilated and the tumor partially expelled from the uterus, occupying and completely filling the vagina. The ergot was suspended, and she was relieved from her severe pain by the use of opium, but the pressure upon the pelvic organs became so great that it was necessary to try and relieve her. The lower por- tion or capsule of the tumor began to slough, and I then determined to remove all of the tumor, or as much of it as possible. In the mean time the uterus as examined through the abdominal wall had not diminished very much in size, and the fluctuation was more marked and more extensive. She was at this time very anaemic, and so weak that I dared not anaesthetize her. So I proceeded without doing so, with the patient in Sims's position, and with the aid of Sims's speculum I rapidly removed all that portion of the tumor which occupied the vagina, using the tenaculum forceps and haemo- static scissors. There was very little haemorrhage, and the patient derived very great relief from the removal of this portion. She was permitted to rest for a few days and ergot was again given, which produced expulsion of another mass about as large as the one that FIBROMA OF THE UTERUS. 3S1» had bjen expelled, this was removed in the same way as the other ■ while removing a portion which extended up into the cervix uteri, about five or six ounces of fluid escaped from the cavity of the uterus. Immediately after this it was found that the fluctuation was greatly lessened, and the size of the tumor, as observed through the abdominal walls, had markedly diminished. She had after this con- siderable fever and disturbance of the stomach, and this, along with her marked anaemia, prostrated her so that nothing could be done for nearly a week but to sustain her. At the end of that time her temperature diminished somewhat, she was able to take nourishment and stimulants, and as considerable more of the tumor had been ex- pelled, a third attempt was made to remove it. I was able to re- move all that portion outside of the cervix; I then endeavored to remove a portion that was still within the grasp of the cervix; as soon as I did this, about four ounces of putrid matter were discharged from the uterus. Although there was not much haemorrhage, and the patient did not complain of pain, she was so much exhausted and her pulse was so feeble that I was obliged to desist, feeling confident that if I undertook to remove the remainder of the tumor, the patient would succumb. The cavity of the uterus was carefully washed out with carbolized water, and the patient put to bed and stimulated and nourished as well as possible. Two days afterward. when she had rallied considerably, I found that the lower por- tion of the cervix had contracted around the tumor, and that it was breaking down and decomposing. I thoroughly and repeatedly washed out the inner cavity of the uterus, and hoped by so doing to control the septicaemia from which she was suffering in a most marked degree. I also felt confident that if I could bring her strength up again that I might be able to remove the whole of the tumor. But this proved to be impossible, although the uterus con- tracted again, in fact, sufficiently expelled the tumor to partially dilate the cervix. She at no time was in any condition to bear so formidable an operation as completing the enucleation of the tumor. The septicaemia still proceeded, and she died about five years from the time that she first came under my observation. On post-mortem examination it was found that a portion of the fibroma as large as a fetal head remained, and was attached at the posterior and right lateral wall of the uterus, and that it closed the cavity very thoroughly by pressure, and that there was still a little fluid in the fundus uteri. It was clearly evident from this, that this obstruction of the canal below and the distention of the cavity of the uterus above, which gave rise to the fluctuation obtained at her 3i»0 DISEASES OF WOMEN. examination, explained the resemblance of the physical signs to those obtained in the uterine fibro-cysts. It is a number of years since this case came under my observa- tion, and I am satisfied that had I known then as much as I know now about the management of such cases I should probably have been able to save her. As it is, I still think that had she sent for me when she returned from the country, and before her strength became so much exhausted from the efforts at expulsion, I might have been able to remove the whole of the tumor; but it was otherwise. A Case of Submucous Fibroma in which Pregnancy progressed to Full Time, and the Tumor was completely expelled about a Week after Confinement.—This case was seen in consultation with Dr. Bodkin, who, when called to attend her in confinement, found a solid tumor which so completely filled the pelvis that he could not reach the os uteri. The labor-pains continued, the membranes ruptured, and the cord became prolapsed. The tumor was recognized as a fibroma which extended down into the cervix and at the same time upward toward the fundus. It was a long, narrow tumor which may have assumed that shape by stretching during the growth of the pregnant uterus. AAre agreed to try to deliver by version. Accordingly, when the patient was anaesthetized the doctor succeeded in pushing up the tumor out of the pelvis, and passing his hand past the tumor and through the os, which was quite dilatable, he turned and delivered. I then took charge of the placenta, which was retained for some time. To facilitate its delivery and at the same time to investigate the tumor, I passed my hand into the uterus and was able to make out by bimanual touch the size and location of the tumor. It was oblong, as already stated, and situated in the anterior wall a little to the left side, and extended from the cervix nearly to the fundus, and evidently was immediately beneath the mucous membrane. The patient did very well considering all things ; she had con- siderable haemorrhage at the time, and the discharge afterward was free and at times offensive, and she had long-continued after-pains. About seven or eight days after her confinement she had an at- tack of tenesmus, and in the hope of obtaining relief she got up to the commode, and by vigorous expulsive efforts expelled the tumor. It was much shrunken, no doubt, but even then the doctor estimated that it was about seven inches in length and three inches in diam- eter. She subsequently did well. In this connection it may be stated that uterine fibromata cause sterility, as a rule, owing perhaps to the endometritis which is usu- FIBROMA OF THE UTERUS. 391 ally present, and when pregnancy takes place miscarriage generally occurs. Still, I have seen at least four cases that went to full time. In all except the one recorded above the tumors were subperitoneal and not large. Extreme Dilatation of the Cervix Uteri and Expulsion of a Sub- mucous Fibroma while only Slightly Pedunculated; The Case diag- nosticated as Inversion of the Uterus; Operation and Recovery.— This patient came to my hospital clinic and gave a history of menor- rhagia for years, and for several months past a metrorrhagia and uterine pain. She was quite anaemic, but had always been well and strong until the excessive menstruation came. She also stated that she visited the outdoor department of the AVoman's Hospital of New York, and the gentleman who saw her said that her womb was turned inside out, that she should enter the hospital for operation, and that her case was a dangerous one. I presumed that the diagnosis made was inversion of the uterus, and on asking the doctor about the case he told me that he believed it to be so. On my first examination I found a tumor in the va- gina which, in size and shape, was exactly like an inverted uterus. The mass was covered with uterine mucous membrane. Absence of the fundus and body of the uterus in the upper part of the pel- vis was observed by the bimanual touch. That portion of the mass which was uppermost was larger than that which is usually found in inversion of the uterus, but in the center of it there was a slight depression which is generally found in inversion. Passing the sound around the tumor gave evidence that the vagina was at- tached to the upper part of the tumor, but by pressing the tumor to one side and separating the vagina from it, I could see that there was uterine mucous membrane above the vagina, which extended upward, inward, and over the tumor. By seizing the tumor and twisting it round upon its axis, I also observed that the upper part of the vagina did not move with it as would have been the case if there had been inversion of the uterus. From these signs I con- cluded that the tumor was a fibroma, with a small but very short pedicle attached to the fundus uteri, and that the cervix and lower portion of the uterus were so completely dilated that the vaginal and uterine walls were continuous. I presume, that in time, the tumor would have dragged the fun- dus uteri downward and produced inversion. This has occurred. In fact, it is not an unusual thing to find a partial inversion of the uterus caused by fibromata during their expulsion. The pedicle was divided with the ecraseur and the tumor re- 392 DISEASES OF WOMEN. moved. The cavity of the uterus then appeared like a cujvshaped dome at the termination of the vagina. A sponge, in a holder, was gently pressed against the fundus uteri, and held there until the uterus contracted, which it did quite slowly. This was done to pre- vent a possible inversion from taking place. The patient recov- ered very promptly. Soft Fibroma; Atrophy of the Muscular Wall of the Uterus at the Point of Attachment of the Tumor; Enucleation after Dilatation of the Cervix Uteri and Partial Expulsion; Recovery.—The patient was forty-nine years old, married, and had had two children, the last one sixteen years before the time when she came under my care. She was a strong, healthy lady, and had been weL until she was about forty-five years of age. At that time she began to menstruate more freely than at any previous time in her life, but being told that it was due to "change of life" she did nothing for it, until she became so weak that she sought advice of a practitioner who treated her locally for ulceration of the cervix which he said she had. She grew worse, the bleeding was more free and lasted longer at each period, and she had a profuse watery discharge at other times. Then uterine pains came on, which she said were like the first pains of labor. This was the history which I obtained when called to sse her the first time. On examination I found the cervix well dilated, and part of a soft fibroma occupying and filling the upper part of the vagina. The pressure gave her much discomfort, and I found that the por- tion in the uterus was quite as large as that which occupied the vagina. Without giving the patient an anaesthetic, I removed all that was outside of the uterus with the ecraseur. There was no pain and very little bleeding caused by the operation. The patient being fatigued by remaining in Sims's position I did nothing more for two days, and at the end of that time the larger part of the mass was expelled from the uterus. It was oblong but not pedun- culated. All that was protruding from the os externum was re- moved with the ecraseur, and the stump was seized with a double tenaculum forceps and enucleated. Traction being made with the forceps the mass was separated from the capsule with a blunt cu- rette. There was very little pain caused until the mass was sepa- rated all round and the deepest attachment was reached. Then the patient began to complain. This was fortunate, because it made me very careful. I simply made steady traction and counter-pressure with the curette. AAThen the mass came away I could see the peri- tonaeum very plainly at the bottom of the cavity. My assistant FIBROMA OF THE UTERUS. 393 also observed it, and recognizing what it was, he naturally was quite anxious. A space, about the size of a twenty-five cent piece was ex- posed. It had not been wounded at all, but appeared as if it had separated from the tumor very easily. To make sure that there was no mistake I examined by the touch and found the parts exactly as they appeared to be on inspection. Submucous Fibroma of Large Size extending through the Uterine Wall to the Peritonaeum; treated first by Partial Exsection with the Galvano-Cautery and Several Years after by Enucleation; Recovery.— This was a hospital case which I saw with Dr. Cushing. The tumor was large, and extended down into the cervix on one side and could be easily reached. The patient was suffering greatly from bleed- ing. Partial excision was made by passing two large curved needles through a section of the tumor, and then passing the wire be- low the needles, and cutting it off by heating the wire. Section after section was removed in this way, until all that portion which could be reached conveniently was removed, about two thirds of the whole, perhaps. The operation was long, and I did not think it prudent to continue the efforts to remove the whole mass. Recov- ery from the operation was without interruption, and the patient was much improved. The menorrhagia subsided, she gained her former strength, and was able to make her living as a laundress. In a few years the tumor had grown again, and all the old symptoms returned and were worse than ever. Dr. Cushing had to see her for several attacks of menorrhagia, Avhich nearly proved fatal. She then came into the hospital. The tumor was nearly as large as it was before, and she Mas extremely feeble and anaemic. There was a cardiac mitral murmur. The officers of the hospital strongly advised that I should not operate, and I wrould have gladly followed their advice, but the patient begged that I should try again to help her, and I agreed to do so. The tumor was low down in the pelvis and projected beyond the opposite side of the cervix. Ether was given, and the pulse improved a little under its influ- ence. The capsule was divided with the thermo-cautery, and sepa- rated from the tumor over its exposed portion. A strong forceps was fixed in the mass, and while strong traction was being made the enucleation was performed with the spoon-saw of Thomas. AVhen I had nearly completed the separation, I noticed that there was very little resistance on the part of the uterine wall at the upper part; I then made a bimanual examination and found that I had passed through the muscular coat of the uterus entirely. I was fearful that if I made any further effort to complete the 394 DISEASES OF WOMEN. enucleation I might wound the peritonaeum. The detached por- tion was separated from the rest, and the operation stopped. The portion left was about the size of a lien's egg. There was not much bleeding, but I can only say that the patient was living when she was put to bed. The uterus contracted fairly well. There was no further haemorrhage, but a free discharge of serum continued for a number of days. I felt sorry that I had not been able to remove the whole of the tumor, but was glad that her life had been spared. She improved slowly in strength, and was able to leave the hospital in three weeks. The heart-murmur, which was presumed to be largely due to her extreme anaemia, proved to be due to mitral in- sufficiency, and although she had no more trouble from menorrhagia, she did not fully regain her strength. She took up her old occu- pation, but it was more than her strength could endure. A little over two years after the operation she died suddenly of heart-fail- ure. The post-mortem revealed the heart lesions which proved fatal. The part of the tumor which was left had not grown, in fact, it probably had diminished. The scar at the point of the deepest enucleation showed that there was no middle coat of the uterus at the side of attachment of the tumor. These facts proved conclusively that in operating I had gone through to the perito- naeum, as I thought I did at the time. The following cases, treated by hysterectomy, are from the woik of Dr. Thomas Keith : Large Solid Fibroid, Weight, Forty-two Pounds; Supra-Vaginal Hysterectomy; Recovery. (Keith).—Mary C, aged twenty-eight, was sent into the Royal Infirmary by Dr. Robertson, of Ardros- san. She had sought relief in many quarters in vain. The tumor was very large, and was first noticed five or six years before. She was wasted about the chest and arms, like a case of old ovarian disease. The abdomen measured forty-nine inches at the umbilicus; the tumor was firm and solid throughout. The ensiform cartilage was turned upward, and the growth extended under the sternum and ribs; close to the sternum there was a large projection the size of a child's head. No trace of the ovaries could be detected. The greater part of the pelvis was occupied by the tumor. There was no dis- tinct cervix, only a small triangular projection drawn to the left side, almost beyond reach of the finger. For several years no great inconvenience had resulted ; menstruation was never in excess, and for the last fifteen months it had entirely ceased; since then, the increase in the tumor had been rapid, and she could do little or noth- FIBROMA OF THE UTERUS. 395 ing owing to its weight. She sat all day knitting; at twenty-eight, her life-prospects were anything but bright. For obvious reasons, this patient was not taken down to the large theatre, but was operated on in the ward, on the 18th of April, 1881. Sulphuric ether was given, and the operation was performed under carbolic-acid spray. The sponges, thirty in number, had been lying for a long time in a five-per-cent solution of carbolic acid; they were washed in hot water, and then put into a two-per- cent solution, and wrung almost dry. These were used over and over again, and were not washed in any fresh solution during the operation. Dr. AVilson was present from Glasgow, and there were about twenty visitors and students. The first incision measured twelve inches ; it terminated four inches above the pubes, so as to avoid the bladder, which was to be elevated on the tumor. On the right side, the broad ligament rose as high as the crest of the ilium. The left broad ligament was largely spread over the half of the tumor as high up as the ribs. The opening was then enlarged to twenty-two inches, and, by dint of hard pushing and patience, the huge mass was slowly moved forward as far as its connection on the left side would permit. The right ovary was easily seen. On searching for the left, it was found to be transformed into a long, tense, umbilical-like cord, seven or eight inches in length. Here and there along this tense band were several small cysts. It was so imbedded in the tumor that it never could have been removed. The right, broad ligament was transfixed by soft-iron wires, secured and divided ; all bleeding from the tumor was prevented by a series of strong-locking forceps. The fibroid was now more easily dealt with. It was drawn for- ward, so as to put on the stretch its enormous connection on the left side. About a dozen powerful-locking forceps, ten inches in length, were now applied to the broad ligament before and behind. The whole was then cut downward, and the mass enucleated as low as possible. A strong, soft-iron ligature embraced the base, which was of great thickness. The tumor was then cut away, the stump showing a section of the cervix in the centei. The forceps were removed one by one, and all bleeding vessels separately tied. Some of these were large, and one threw blood over the assistant's head. There was much trouble in finding some bleeding points among the loose cellular tissue of the huge gap now left. The haemorrhage was mostly venous. All present could see that the condition was full of danger, and that secondary haemorrhage 396 DISEASES OF WOMEN. into this loose tissue was not one of the smallest risks of the opera- tion. When all oozing seemed to have ceased, the stump (the thick- ness of the leg) and the end of the right, broad ligament were se- cured, with much tension, outside; a glass drainage-tube was fixed in above the stump, and the wound closed by forty silk sutures. The operation lasted one hour and three quarters. After much blood and serum had escaped from the tumor, its weight was forty- two pounds. Ten hours after the operation, five ounces and a half of sirupy blood were removed from the pelvis through the tube. The pulse was 94; the temperature 102*2°; rising two hours afterward to 103-4°. During the night, back-pain w7as relieved by injections of morphia. The first day was passed fairly well. In the evening the pulse was 126, 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 104°. On the fourth day, the pulse was 114 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 104°, 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 1876, 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 FIBROMA OF THE UTERUS. 397 her situation, partly from pain and partly from excess at the menstrual periods. She was twenty-nine years of age, and of fairly healthy 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-forcaps 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 wTas uninterrupted. The serre- noeud came away 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, cedematous 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- 398 DISEASES OF WOMEN. 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 pnt 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 FIBROMA OF THE UTERUS. 399 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- 400 DISEASES OF WOMEN. nected with the anode in the uterus, the large dispersing cathode upon the abdomen. At the first sitting a current of 60 milliamperes 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 milliamperes used for six minutes; bleeding, which Lad 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 milliamperes 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 milliamperes for five minutes. Second puncture, May 5th: large platinum stylet introduced to the depth of 4 centimetres ; an intensity of 100 milliamperes 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 mil- liamperes, six minutes; highest portion of the tumor 3^ centimetres below the navel. Fourth sitting, May 24th: 60 milliamperes, 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 milliamperes 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 milliamperes, six minutes; tumor harder, less elastic, much diminished. FIBROMA OF THE UTERUS. 401 June 7th, sixth treatment: large stylet, 8 centimetres, 60 milli- amperes, seven minutes. June 15th, seventh treatment: 60 milliamperes, 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 milliamperes 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 milliamperes was used; then a still higher intensity, from 160 to 200, was applied. The burning, occasionally intense, often decreased to a'minimuin 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 402 DISEASES OF WOMEN. the tumor seemed again to increase; her general condition not hav- ing improved, menstruation still being excessively scant, a mere show, I endeavored to further constitutional improvement, using no internal remedies, as she complained of her stomach, which had been ruined by constant but ineffective medication ; electrolysis was stopped, and negative electro-cauterization resorted to for the pur- pose of increasing the flow. The uterine cavity then measured 11 centimetres. July 1st, negative electro-cauterization ; 100 milliamperes, six minutes. July 12th, 100 milliamperes, eight minutes. July 16th, 150 milliamperes, ten minutes, no discomfort whatsoever being ex- perienced from the intrauterine negative pole. August 6th, menses free, continuing five days; more profuse and better than ever before since first established; she has gained three and a half pounds in the last month ; looks much better; feels well. This treatment was continued, with interruptions, during the sum- mer ; menses more free than they had been for years; her general condition much improved. No medication whatsoever was re- sorted to. CHAPTER XXII. MALIGNANT DISEASE OF THE UTEBUS. A very important, and a very frequent class of diseases is that in- cluded in the above term; and for this, if for no other reason, must we have a clear notion of the terminology so often misapplied. Malignant growths are those which tend to infiltrate and destroy adjacent tissue, to recur after removal, possibly originate remote secondary neoplastic formations, and wmich cause steady deteriora- tion of the general health without regard to location. They are not necessarily " cancers:" Cancer is an " atypical epithelial neoplasm," distinct from growths of the pure connective-tissue type. Its forms are few and pretty well settled and agreed upon. The first is scirrhus, hard, chronic, or fibrous cancer; the second is soft, acute, medullary, or encephaloid cancer; the third is colloid, " gum," or alveolar cancer; but whether epithelioma is a fourth variety or is itself a distinct form is still a mooted question. Epithelioma is often intensely -malignant; and the term " can- croid " is a safe one as it certainly is like a cancer. Another vexed question is whether cancer of the uterus is a local exhibition of a constitutional malady, or is at first local and only later infects the system generally. The same uterus may be the seat of several varieties of carci- noma; or, again, the neoplasm may change from one form into another as well without, as after, surgical interference. Sarcomata are malignant directly in proportion to the lowness of their organization. They are of the embryonal-tissue type. CANCER OF THE CERVIX. The body of the uterus is so seldom the seat of carcinosis that when the unqualified phrase " cancer of the uterus" is used, it 403 404 DISEASES OF WOMEN. means of the cervix. Malignant disease of the corpus will be con- sidered separately. Excepting epithelioma, scirrhus is the most frequent variety, says one class of gynecologists; encephaloid, says the other. They are both right, for I believe the initial stage to be nearly always the hard carcinoma, which subsequently becomes soft and medullary ; and since it is only the later form that is apt to produce symptoms sufficiently marked for the patient to consult a physician, this may account for the supposed rarity of scirrhus, as compared with en- cephaloid cancer of the uterus. With this idea of the development of the neoplasm in view the pathology will be given. Pathology.—One lip of the cervix becomes hard, uneven, and hypertrophied, and the nodules, which (probably) originate in the submucous tissue, subsequently ulcerate through the mucous mem- brane, which is now covered with vascular vegetations, especially near the orifice ; the opposite lip suffers an identical lesion, the cer- vical orifice enlarges and now the whole cervix is covered with veg- etations. The cellular tissue of the vaginal mucosa just beneath this fun- goid mass which projects into the vagina, becomes, in its turn, in- durated, uneven, and granulated, while, simultaneously, the muscu- lar coat of the cervix is being infiltrated with the growth. The mucous ulceration is frequently gangrenous, and a fetid fluid, containing shreds of dead connective tissue and portions of vessels which supplied the necrosed part, bathes the surface at the cervico vaginal junction where the loss of continuity is best marked; and thus a hob-nailed or fungating mass entirely takes the place of what we should normally feel upon a vaginal examination. In very rare cases the carcinomatous mass is removed in toto as a gangrenous slough, and then the ulcerated patch that remains is walled in by normal tissue. . It is to all appearance, a phagedenic ulcer. Microscopically, a section of scirrhus shows small cavities (alve- oli) surrounded by thick fibrous stroma, and in the alveoli are only a few polyhedral cells. An encephaloid section exhibits a delicate and scanty frame- work surrounding large alveoli which are crowded with cells (many of which are fatty) in a milk-white fluid, the " cancer-juice." The section from such a tumor is light in color and mottled. In the ves- sels are plugs made up of cancer-cells and fibrin ; the walls of these vessels are pigmented and fatty. Either variety is melanotic, when the blood pigment in the MALIGNANT DISEASE OF THE UTERUS. 405 stroma and alveoli is so rich as to produce a deep brown or black hue. Finally, one of the rarest forms of carcinoma uteri is colloid can- cer; the difference between it and encephaloid (of which it is a modification) is that the cells enlarge and are filled with colloid ma- terial, the alveoli enlarge also, and as the stroma thins, one cavity communicates with another so that anfractuous spaces are formed filled with a transparent gum like substance. The pathological effects of cancer of the womb are many and important. It may extend to, and perforate through the vesical wall; this occurs oftener than one out of three cases, and cystitis al- ways precedes the rupture. Vesico-vaginal fistulae are by no means uncommon, and here we shall often find severe gangrenous processes attending. Rectitis may be excited and the wall of the rectum be perfo- rated. These are not half so frequent as bladder lesions. When, however, both structures are opened there is a cloacal intercommu- nication of vagina, rectum, and bladder. When stenosis of the ureters results either from external press- ure or from thickening of their walls, we will find the kidney anae- mic and full of urine (hydronephrosis). The cellular tissue of the broad ligament and iliac fossae is infil- trated, and, later, undergoes purulent infiltration, frequently induc- ing peritonitis, while the vessels and lymphatics leading to such purulent collections are the seat of carcinomatous inflammation. The peritonaeum of Douglas's cul-de-sac is pushed upward and pseudo-membranes inclose the uterus both anteriorly and poste- riorly. The subperitoneal connective tissue of the true pelvis is thick, hard, and adherent to the bones ; it may press on, and cause fatty changes in the sciatic and pelvic nerves. The body of the uterus may be infiltrated, the organ being as large as when pregnant. Its walls may measure one and one half inch in thickness. The tubes are rarely involved; and if carcinoma be located at first solely in the cervix the ovaries always escape. When cancer proliferates downward in the vaginal walls it forms numerous nodes, as far as the introitus vaginae, so that a physical examination will become difficult or impossible. 406 DISEASES OF WOMEN. EPITHELIOMA OF THE CERVIX. Cancroid, formerly called rodent ulcer of the cervix, is not so malignant as scirrhus or encephaloid carcinoma. It seems to be of a more local character than the other neoplasms of this group. It appears in one of two forms—as pavement-celled epithelioma or as cylindrical-celled epithelioma. Excepting colloid cancer, this last is the rarest form of uterine neoplasm. Pathology.—Pavement-celled epithelioma begins in the epithelia of the vaginal portion of the cervix, the tumor formed being waxy, slightly vascular in spots, and dry on its surface. The mass is fria- ble (" fragile cancer"), and on pressure we can squeeze out white worm-like plugs, composed of epithelial cells. I have occasionally found this variety to begin within the cervical canal, and extend outward (not downward), so that on exploration the mass could be scooped out, leaving the cervix a mere shell, its exterior or vaginal portion showing few if any signs of new growth. The tumor is lobulated, and, when the lobules compress the ves- sels, gangrene results, and all that part of the cervix that is carcinom- atous may drop off, or a deep, crater-like ulcer is excavated whose edges are always nodular; hence the term " ulcerating epithelioma." Squamous epithelioma extends to the body and fundus, but in general its spread is limited by the nearest chain of lymphatics. Microscopically, a tubular structure is often seen, the tubes being surrounded by a fibrous material, and probably originating from the culs-de sac of the cervical glands. The appearance of the section has given the name " cystic epi- thelioma " to it. When the tumors are crowded with lobulated nests of cells, connected together with epithelial bands, the centers are filled either with colloid matter or a hard mass resembling ordinary callous (such as that on the hand or foot). Cylinder celled epithelioma originates as a pedunculated or ses- sile vascular wart; and, although the dendritic tumor begins in a single spot, it tends toward the vagina in its growth, and spreads downward as the so-called " cauliflower excrescence," often as large as a hen's egg, and not rarely completely filling the vagina. The glands are so distended that the French pathologists call this " adeno-carcinoma." At first the cylinder cells of the cervical mucosa form a soft mass, with a milky juice; thus it is hard to differentiate it from enceph- aloid except by the aid of the microscope. Non-malignant papillomata also resemble these vegetating epi MALIGNANT DISEASE OF THE UTERUS. 407 theliomata, and, without a microscropical examination, whether a cauliflower excrescence is or is not malignant can not be determined. With such an examination the non-malignant is seen to lie upon healthy submucous tissue, the malignant upon unhealthy; the non- malignant is a simple anastomosing framework, while the malignant growth has an alveolar arrangement with cell-nests. This form of cancroid invariably ulcerates; and, though occur- ring late in the disease, this process is rapid and destructive, large vessels often being eroded. Microscopically, it consists of numerous long stems, all intercon- nected, each stem having at its center a vascular loop, the exterior covering being long cylinder cells ; thus it is like an intestinal villus, only longer, and the numerous vessels among the masses of cells per- mit serum to ooze through their walls, and this is the chief source of the watery discharge of this disease. The points of secondary invasion are many; the bones, lungs, liver, bladder, rectum, pelvic nerves, adjacent lymphatics, and the uterus have been the loci of later malignant growth, and in the uterus it occupies the fibro-muscular structure as numerous and par- tially distinct nodules. Symptomatology.—Malignant disease of the womb runs no typi- cal course. As with cancer elsewhere, so here there is a stage where a tumor is forming, and a stage where it ulcerates. During the first of these stages the amount of pain, the leucor- rhoea, and haemorrhage are so slight that few patients will consult the physician about them. And, as I have said, it is probably for this reason that scirrhus is considered a rare form of cancer. And let me say at the very outset that the lancinating pain so often men- tioned all through our literature as strongly symptomatic of carci- noma uteri is exceptionally met with in this disease. A discharge is the earliest symptom in the majority of cases. This discharge may be bloody, watery, or leucorrheal. As a rule it assumes the character of an intense menorrhagia, the patient also bleeding between the menstrual epochs either spontaneously or from sudden exercise or coition. Some women will state that although their change of life occurred a year or so ago, that now they have "commenced again." The bloody discharge may or may not be fetid and grumous, but the organic matter which forms the grumous discharge, and which is continually sloughing away and passing out of the genitals, very seldom causes any septicaemia. Besides, the lymphatics are not here abundant in the immediate neighborhood of the cancerous tumor. 408 DISEASES OF WOMEN. Watery discharges consist chiefly of the clear serum of the blood ; they are usually odorless at first, but soon become mingled with ulcerative debris, and are peculiarly foul smelling. They are seldom or never free from admixture of blood, and there are very few who will not give " bloody water " as one of their chief symptoms. The watery flux is almost characteristic of the cauliflower excres- cence. In many cases the discharge is simply leucorrheal up to the time of ulceration of the cancer, after which the fetid " cancer smell" and molecular masses from the growth indicate the true cause of the discharge. A sudden bright haemorrhage indicates that a medium-sized ar- tery has been opened. The more rapidly the neoplasm forms, and the more extensively it ulcerates, the more profuse and fetid will be the discharge. Excoriations, erosions, erythema, vaginitis, vaginismus, intense pruritus, and similar conditions may result from the passage of these discharges through and over the genitals. Pain is never so prominent a symptom as the discharge, and, according to some, never a symptom so long as the cervix alone is the seat of malignant growth. The character of the pain is described differently by different patients, as dull, boring, gnawing, shooting, and stabbing. The pain shoots in the direction of the parts supplied by branches of the nerve whose main trunk is pressed upon. The back, pelvis, and thighs are the chief regions of this kind of pain. The pain is more acute when the terminal nervous branches are involved than when the trunk alone is compressed; and it is, again, more severe when there is a large amount of neoplastic tissue formed than when ulceration is extensive. The pain of peritonitis, which may be lighted up by the growth, has characters peculiar to itself The amount of tenderness is not always in proportion to the pain. Pain on motion and from coition (dyspareunia) is experienced almost from the onset in neoplasms of the cervix; later on, defeca- tion and urination may produce intolerable suffering. Pain as a symptom may be absent throughout the disease, and the patient only experience weight and bearing down. As the disease progresses, the patient first loses strength, appe- tite, and all cheerfulness of disposition, emaciation following later on. The face assumes an earthy green, or, toward the end, a bronzed MALIGNANT DISEASE OF THE UTERUS. 409 hue, and the temperature may be slightly subnormal. There is som- nolence and headache, but eclampsia is infrequent. The bowels are constipated, as a rule, but irritation or actual cancer of the rectum may cause profuse and exhaustive diarrhoea; haemorrhoids are common. Cystitis, strangury, and retention or in- continence are not infrequent bladder symptoms. When fistulae form, they give rise to their usual symptoms. In one case the first, and, indeed, the symptom on which the diagnosis was made, was a flow of urine from the region of the cervix. The breasts are frequently the seat of sympathetic pain. Toward the close of the disease there is usually a slight febrile move- ment in contrast with the tem- perature in the early stages of the disease. Physical Signs.—Scirrhus carcinoma gives a hard, hob- nailed or nodular feel to the finger during the earliest sta- ges, and the mucosa seems to be immovably fixed on the sub- jacent connective tissue, a con- dition not met with except in malignant growths. When any cancer has ul- cerated (the usual time when the physician sees it), the fin- ger meets a friable, irregular mass, which bleeds upon the slightest provocation, and which is surrounded by a tough, unyielding, irreg- ular zone of infiltrated tissue. If reached, the lips of the cervix are felt to be uneven, thick, and spreading downward like a mushroom. Palpation may further reveal in many cases fistulae, immobility of the womb, changes in the size and position, and infiltrations and indurations in the neighborhood. In scirrhus the womb is felt to be low down in the pelvis. The bowels may have been so constipated that the physician examines for stricture of the rectum before searching for anything else; but in doing this he will directly suspect the true state of affairs, and especially so if the pelvic cellular tissue or neighboring glands be involved. A second physical sign, which is supposed by some to be diag- nostic, is that a sponge tent or uterine dilator fails to dilate a cervix 32 Fig. 188.—Cancer of both lips (Winckel). 410 DISEASES OF WOMEN. Buffering from malignant disease, whereas in all other neoplasms dila- tion will quickly and easily follow its introduction. A third physical sign is indescribable; it is the odor that the finger has after such an examination—an odor produced by nothing else but cancer. A fourth means of physical diagnosis is the speculum, by the use of which we see what has already been described under the head of pathology. Commencing scirrhus is accompanied by a deep pur- plish or livid hue of the entire cervix, and enlarged vessels are seen to ramify about these nodules. The extent of the growth can only be accurately appreciated by this means of examination. Epithelioma of the cervical cavity is often diagnosticated solely by the use of the speculum and curette or probe. Lastly, the microscope may be used not only to diagnosticate the presence or absence of carcinoma, but to decide which variety we have to deal with. It should be stated here that malignancy can not be decided by the microscope, since it is a clinical property. The microscopical appearances of each form have already been described. Diagnosis.—Before treating of the points in which cancer and other lesions of the uterus differ, it is necessary to mention the char- acters that especially distinguish one form of carcinoma from an- other. Scirrhus gives a nodular, hard sensation on palpation, immobility of mucosa upon sub-mucosa, prevents cervical dilatation on using the sponge tent or the uterine dilator, showing less of elasticity in the tissues, and the discharge is scanty. In medullary cancer the grumous discharge containing molecu- lar debris is the prominent symptom. The course of this cancer is the most acute of all. The brittle, crumbling, ulcerated mass is pe- culiar to this form. The uterus is usually fixed and immovable. Epithelioma is accompanied by a more profuse watery discharge than any other variety; and on palpation the finger meets, often, the characteristic cauliflower-like mass. The uterus even late in the disease suffers no fixation, and may be moved without pain. This variety seems more local than the preceding. In all instances when cancer is diagnosticated a microscopical ex- amination will determine what variety we are dealing with ; and to this end a piece of the tumor may be removed by the curette. There are numberless conditions with which cancer in general may be confounded ; the chief of these are : MALIGNANT DISEASE OF THE UTERUS. 411 Sloughing Myomata or Fibrous Polypi.—These may, either of them, simulate cancer ; but they will be attended by fever, which is absent in cancer, and there will be in the discharges shreds of the normal uterine tissue, while in cancer discharges epithelial cells will be prominent. Frequent washings control the former, while cancer remains unmodified thereby. Syphilitic Ulceration.—This not only resembles cancer, but may even produce vesico-recto-vaginal fistulae. Here the history, the age of the patient, the effects of local and constitutional treatment, the discharge, and an examination of a small bit of the tumor will soon allow a diagnosis to be reached. Condylomata.—These will not long be mistaken for cancer. Erosions.—These are numerous; but non-malignant erosions oc- cur in younger patients, produce no constitutional symptoms, leave no portion of the cervix intact, are attended with large, gaping fis- sures, and, on inspection by means of the speculum, large ovula Na- bothi are seen. The discharge does not have the cancerous odor in benign erosions. The points in connection with cancer of the body and cancer of the cervix are considered hereafter. Prognosis.—It is needless to say that the invariable tendency of malignant uterine disease is toward death. The chief question in prognosis, therefore, is of the duration of life. There are no hard and fast rules for the expectation of life, nor do my own statistics or those of others afford definite statements. Three months and three years are the extreme figures given. In general, it may be stated that, after the first marked symptom (some discharge), the patients live a year, except those who have epithelioma or cancroid ; these, as a rule, have eighteen months of life before them. A prognosis should never be made immediately after diagnosti- cating cancer; the physician should wait until the disease pronounces itself a slow or rapid, an uncomplicated or a complicated, a localized or an extending process. Among the complications are hydronephrosis (see pathology), and, consequently, uraemia, cellulitis, and peritonitis, and, less fre- quently, septicaemia, phlebitis with venous thrombosis, embolism, and cancer in adjacent tissues and distant organs, the liver especially. Death may result from simple exhaustion (cancerous marasmus), or from haemorrhage when a large vessel is opened, or from rup- ture of the uterus (rare), or from any of the above-named complica- tions. 412 DISEASES OF WOMEN. Death is sometimes delayed and torturing, and, in the face of its being inevitable, it often seems as though it were a mercy to hasten it. Etiology.—Until puberty the death-rate from cancer is the same in both sexes ; from this period both frequency and death-rate stead- ily increase in the female up to and a little after the menopause, at which period the difference in rate between the sexes is most marked. After the age of fifty there is a tendency for cancer to appear equally often in both sexes. There is no doubt but that there is such a condition as a predispo- sition to malignant disease ; but to what extent this can be inherited or not is not yet determined. It is well known, however, that cer- tain peculiarities of organization predispose to malignant disease. Among these is the cardio-vascular hypoplasia (Yirchow), where the pulmonary arteries are undersized, and which occurs often with the phlegmatic temperament, characterized by an abundant adipose tis- sue and an appearance of health, which is an appearance and noth- ing else. Great differences are met with in authorities as to the frequency of cancer; reliable statistics, however, tell us that the uterus was at- tacked in three thousand cases out of a total of sixty-one thousand seven hundred and fifteen cases of carcinoma (anywhere in the body) in females. The same also afford us proof that the uterus is cancerous three times as often as any other female organ. Heredity has an undoubted influence; I have gathered the sta- tistics of many thousand cases, and find that an inherited taint can be traced in thirteen per cent of all cases on an average. Age is the most potent factor in the etiology. Before puberty, indeed before the age of twenty, cancer is unknown or phenomenal. I have seen two cases—both ending fatally—where the patients were in their twenty-seventh and twenty-eighth year respectively; and the sister of the last named died of cancer of the uterus in her thirty-first year. The ten years following the menopause (forty to fifty) is the period of carcinoma uteri ; the decade following this is the next most eventful period, and third in order stand the ten years preced- ing the climacteric. Race seems to have little or no influence. Perhaps it is pecul- iar to my practice, yet I have seen more cases of carcinoma uteri among Germans than in any other nationality. There is more than an accidental agreement between cancer and the number of children born ; for it will be found that patients with cancer of the uterus will average one third more children than MALIGNANT DISEASE OF THE UTERUS. 413 women free from malignant disease of the womb ; indeed, every case of carcinoma uteri will average five children, a large family at the present time. Prolonged lactation, anti-hygienic surroundings, poor or improper food, exhausting diseases, grief, and anxiety are all more apt to be accompanied by cancer than an opposite condition of affairs; never- theless, seventy-five per cent of cases will give a history of good health up to the development of this neoplasm. It is quite certain that laceration or erosion of the cervix has a causative influence upon cancroid ; hence in suspected epithelioma the previous history must always be elicited. I do not mean that laceration will cause it; but with a latent tendency, an erosion or laceration will often determine the precise point of .eruption of the disease. In recent times pathologists have favored the idea that cancer is dependent upon a certain germ. When this comes to be better un- derstood, it is possible that medical treatment may be sufficient to prevent or to cure this affection. But at the present time our knowl- edge of the disease appears to be limited to the fact that certain or- ganizations are predisposed to cancer disease; and if it should be found in the future that the disease is due to a cancer germ, the fact will still remain that, in order that this germ may be effective in producing cancer, a certain kind of organization or a certain quality of tissue is favorable to the action of this germ. It is known that the tubercle bacilli (and the germ of cancer, if there is one), require a certain kind of tissue to live upon, hence some enjoy an immunity from these maladies, while others are predisposed to them. Some of the diseases due to specific germs attack all alike, the strong and the weak—typhoid fever, for example. It is very differ- ent with such diseases as cancer. Those germs that require special tissue to live upon act locally. The other germs that attack all or- ganizations are general in their action. There are certain things that we know now which obtain almost invariably in cases that develop cancer—such, for example, as the fact, pointed out long ago by Yirchow, that the pulmonary artery is abnormally small in those who die of cancer. I have kept a record of a very large number of cases of cancer of the uterus, mammary glands, and ovaries, and I think I can say that, without exception, I have found the pulmonary circulation defective, and consequently respiration and blood aeration insufficient to a certain degree. The vast majority of subjects, also, have been stout, with a pre- ponderance of adipose and cellular tissue. In fact, they have been 414 DISEASES OF WOMEN. somewhat chlorotic as a rule, and of the lymphatic temperament. In short, while digestion and assimilation have been normal, disas- similation, disintegration, and elimination have been imperfect or sluggish. It would seem, therefore, that this condition of organiza- tion predisposes to malignant disease; and if such is the fact, then much can be done in the way of development and general manage- ment in early life to overcome this peculiar tendency to disease. All that was said in discussing the management of chlorotic and phlegmatic girls wrould apply with equal force to the prevention of cancer. I need not, then, in this connection, dwell upon that part of the subject. The condition of the organization at, toward, or immediately after the menopause especially favors the appearance of cancer. The diagnosis of this condition is based upon the special tem- perament, usually phlegmatic, somewhat chlorotic, it may be, with small circulatory apparatus, at any rate so far as the pulmonary artery is concerned, and hence the imperfect respiration and blood aeration referred to, the superabundance of adipose and cellular tissue, as shown by the general appearance of the patient, with slug- gish excretion or elimination, indicated chiefly by renal and hepatic torpor. These conditions of ultimate nutrition are very often spoken of as lithaemia, and hence I might say that lithaemic patients at this period of life are predisposed to cancer. It will be seen that this condition may be largely due to in- herited temperament and general organization, and yet to a large extent it may be acquired. Some of the modifications of nutrition which have been referred to in discussing the menopause clearly eventuate in this predisposition to malignant disease. Dr. Arthur W. Johnston (in whose opinion I have profound confidence) believes that the chief cause of carcinoma is failure of the trophic nerves, the failure being brought about by some nerve strain or great sorrow. I accept without hesitation the theory re- garding the causative relation of the trophic nerves to cancer, but my clinical experience makes me doubt if nerve strain is the primary cause. I incline to the opinion that failure of the trophic nerves occurs more readily in those organizations which I have described as predisposed to malignant disease. But whether the nerve strain is a necessary element in the causation of cancer or not, the trophic nerves, which preside over all tissue changes, certainly play an im- portant part in the aetiology of cancer, and have a certain bearing on the question of treatment. Treatment.—This may be divided into the medical and surgical. MALIGNANT DISEASE OF THE UTERUS. 415 The first indications in this condition are to improve the character of the tissues, first by diet, and then by every possible means which can favor ultimate nutrition by promoting the depleting processes, or disintegration and elimination. In regard to the matter of diet, I am confident that all the articles of food and drink which retard tissue waste or elimination of worn-out tissues, such as alcohol (especially in-the form of beer), tea, and coffee, should be avoided. Certain observations that I have made lead to the conclusion that beer-drinking people, and to a less extent wine-drinkers, are more subject to cancer. This is an additional reason for my urging the restricted use of such articles through life, and especially at the time when cancer is likely to appear. The excessive use of animal food, while it may not in itself predispose to malignant disease, does so when it is used in ex- cess in connection with alcohol; and those who take sparingly of animal food, I find, can bear a larger amount of alcohol with less injurious effects. And so, in given cases, if I found that they took animal food sparingly, but alcohol in considerable quantity, I should continue the alcohol but diminish the quantity. It is, I presume, on account of this effect of animal food and alcohol in producing a tendency to cancer that milk diet has obtained a considerable repu- tation in the management of malignant disease. Next to diet, every means should be employed to regulate the renewal of tissue ; and, first, by getting clear of waste material. Diet having been properly adjusted, and food given in quantities that can be easily and thoroughly digested, will insure the best pos- sible supply of tissue. Then if, by the means at command, free disintegration and elimination can be secured, much will be accom- plished toward preventing the appearance of cancer. The bowels should be kept regular, and yet not unnecessarily free. The kid- neys should be made to do their whole duty, and the intestinal secretions, including hepatic secretion, should be carefully looked after. The skin also requires attention ; and here I believe the Turkish bath is of value, especially to those who have not sufficient exercise to induce free, healthful perspiration. A Turkish bath once or twice a week, with thorough massage, will greatly improve the ultimate nutrition. Exercise should be carefully regulated. It is a rare thing to see cancer in an active person who does not carry a superabundance of adipose tissue, and who takes a sufficient amount of muscular exercise, and yet not too much. If diet, exer- cise, and eliminating agents be employed to excess, so that the re- newal of tissue is insufficient, and the patient becomes debilitated 416 DISEASES OF WOMEN. and suffers from lack of nutritive supply, the tendency to malignant disease will be favored. Care must always be taken not to overdo the eliminating pro- cess. The balance between waste and repair should be maintained as nearly perfect as possible, the great object being to secure com- plete ultimate nutrition, so that the tissues may not become too old and worn out before they are broken down and thrown off. I am not sure that I will be thoroughly understood when I speak of old tissues, but I apply the term to a condition in which the process of waste and repair is retarded, and the tissues are not broken down and thrown off after they have served their purpose. That is what I mean, and that is the condition which I believe favors the appear- ance of cancer, and the chief thing to be overcome by treatment directed to prevent it. Dr. Johnston's views regarding causation suggest the necessity for the use of agents that may improve the condition of the nervous system. This, of course, is largely accom- plished through improvement of the general nutrition, but nerve tonics, and sedatives if needed, should be employed. This leads up to the consideration of medicinal agents which are supposed to have some influence on the ultimate nutrition, and which have been used in the past, in the hope of preventing cancer or of arresting its progress when it has manifested itself in any location. A number of remedies have been employed in the past, and we may say of most of them that they have been weighed in the bal- ance and found wanting. At one time condurango, Chian turpen- tine, and several others, were lauded for their curative power in can- cer, but they have been found, if not useless, almost so. Those that are used most at the present day, and which still claim some confidence, are prepared chalk and arsenic. In regard to the chalk, which was first used in the form of calcined oyster shells, given in powders, ten to twenty grains, three times a day, there were several theories regarding its action, but whether they were correct or not is unknown. From personal ex- perience I am unable to say that this agent is reliable. As it is a harmless article, I can see no objection to using it; but I would rely far more upon arsenic. Arsenic has a decided influence upon ultimate nutrition, especially of the skin and mucous membranes; and as cancer usually makes its appearance in those tissues, anything that can improve their nutrition must be of some benefit. Such is the fact, based upon the therapeutic action of arsenic, and the same thing is observed clinically. On this account I have employed this remedy in the management of the conditions which I believe pre- MALIGNANT DISEASE OF THE UTERUS. 417 dispose to cancer and in cases where cancer actually had appeared, and with benefit. On the same principle I have employed mercury and iodine, a favorite prescription being small doses of chloride of mercury with arsenic, continued for a time and then changed for iodine and arsenic. Small doses of the latter, and also of the mer- cury, should be employed, as it is a long-continued action which gives the result. These are the remedies that at the present time are most effica- cious, and I believe that if persistently continued, and if begun early in the course of the disease, but more especially if employed when there is an apparent tendency to the disease, they are poten- tial preventives—at any rate, the best there are. AVhen cancer is present, I need hardly say that surgical treatment is indicated, and is the only treatment that promises any relief. Within the past few years much has been said with reference to the effect of pyoctanin, an aniline preparation. This, I am satisfied, is of some value in arresting the progress of the disease when ap- plied locally, but this belongs to the domain of surgery. What effect it may have when given internally is not decided. A word may be said regarding the treatment of cancer by local applications in the way of plasters and caustics, and so on. This, of course, is surgical treatment, and the most barbarous kind of sur- gery, and so nothing further need be said on that subject. It sometimes happens that, after the surgeon has done his best for the relief of malignant disease, his efforts fail, and the patient falls into the hands of the physician in her last days. There is only one word to say on that subject. Under these circumstances the physician's first and only duty is to give relief and add to the com- fort of the patient as far as possible. Opium is the agent which alone can do this, and I believe in the free use of it in the manage- ment of such cases—doses sufficient to relieve pain. I may add that I believe that not only does opium relieve pain in cancer, but it re- tards the progress of the disease. I have an idea that the habitual use of opium prevents cancer to a limited extent. All that has been said in this connection applies equally to can- cer of the uterus, ovaries, or mammary glands, which covers the whole field of the gynaecologist. Surgical Treatment.—Complete removal of all the diseased tis- sues is the classical treatment of cancer of the cervix uteri. In the past this was accomplished in several ways—by caustics, amputation with the knife, ablation with the curette and thermo-cautery, and in recent years with the galvano-cautery by Byrne's method. 33 418 DISEASES OF WOMEN. Since vaginal hysterectomy has been perfected, the vast majority of surgeons prefer to remove the entire uterus when cancer is found in any part of the cervix or body. Having had ample opportunities for observing the safety and superior results, immediate and ultimate, of Dr. Byrne's operation for cancer of the cervix uteri, I believe that it is preferable and should be adopted. Many surgeons who adopted Byrne's method complained of having trouble with the battery, owing to their not knowing how to keep it in order. There is nothing reasonable or valid in such objection, and now that the electric-light power is in most of the hospitals and houses and can be utilized for running the cautery instruments such objections can no longer be raised. The cautery instruments devised and used by Dr. Byrne are to be found at the instrument makers, and therefore I need not describe them here. The method I prefer giving in the doctor's own words: High Amputation of the Cervix Uteri in Cancer.—" In conditions admitting of high amputation, the following is the method usually resorted to: The uterus is to be exposed and the vaginal walls pro- tected in the manner already described. The diverging volsellum being passed well into the cervical canal, should now be expanded to a proper degree and locked, so as to afford complete control of the uterus during the entire operation. " By alternate traction and upward pressure of the uterus an accurate idea may now be obtained as to the proper point to begin the circular incision, so as to avoid injuring the bladder or opening into the cul-de-sac of Douglas. As to the latter, however, should it be found that the disease has involved the retro-uterine tissues, and that its excision or destruction by the cautery can not be effected without opening into the peritoneal cavity, there need be no hesita- tion in doing so, as I have never known any harm to come from it whether done accidentally or by design. Should it be evident at the outset that the operation, in order to be thorough, must include a portion of the cul-de-sac, it will be better to make the line of in- cision anterior to this, until the cervix has been removed, and leave the excision of the retro-uterine parts by the cautery knife to be the final proceeding. Under these circumstances all that will be needed will be an antiseptic tampon properly applied. " In proceeding to make the circular incision, the cautery knife slightly curved and cold, should be applied close up to the vaginal junction, and from the moment that the current is turned on should be kept in contact with the parts being incised. Before removing the electrode for any purpose, such as change of position or alter- MALIGNANT DISEASE OF THE UTERUS. 419 inu; the curve of the knife, the current should be stopped, and the instrument again placed in position while cool before resuming in- cision. In other words, if the knife, though heated only to a dull red, be applied to parts at all vascular, haemorrhage more or less will certainly follow ; whereas, the cool platinum blade being already in contact with moisture as the current is being transformed into heat, vessels are shrunken or closed even before they are severed. u This is a very important point, and should never be lost sight of in all cautery operations. " The circular incision having been made to the depth say of a quarter of an inch, it will now be observed that by increased trac- tion the uterus may be drawn much farther downward, and by direct- ing the knife upward and inward the amputation may be carried to any desired extent. In cases calling for amputation above the os internum, it will be better to excise and remove the cervix first, then, by dilating the upper canal sufficient to admit the diverging volsellum, once more proceed as in the first instance, taking care, however, to keep within bounds. It will be found that the cupped stump can now be drawn down and made to project as a more or less convex body. " In all cases the dome-shaped electrode should be passed over the entire cavity repeatedly, so as to render the cauterization still more complete. " It is important to add that, in carrying the knife toward the sides of the cervix, circular and other arterial branches are apt to be encountered, and hence, in this locality particularly, a high degree of heat in the platinum blade is to be carefully avoided. As an ad- ditional security against haemorrhage, the convexity of the knife should be pressed against the external surface of each particular section cut, so as to close vessels more effectually. u It is well to state that the metallic parts of the electrode for the distance of about two inches should be covered with a strip of thin flannel, so that the vagina may be protected from injury through the reflected heat." Unfortunately, however, cases occur for whom the operation just described is inapplicable, and yet for whom something maybe done. For such I know no better treatment than that advised by Dr. Byrne. In describing this, he says : " It is well known to all who have had much experience with uteiine cancer that in a very large percentage of the cases met with, whether in private or hospital practice, the disease is found to have already progressed so far that palliative results or a brief respite 420 DISEASES OF WOMEN. from suffering and death is all that can be hoped for from any treat- ment. In such cases, as, for example, when the entire cervix has been destroyed and the corpus uteri as well as the parametric tissues are found to be involved, my course has been as follows : First, to remove all softened and broken-down tissue by the free use of a sharp curette, and having sponged the cavity repeatedly with a mixture of one part of commercial acetic acid, three parts of glycerin, and carbolic acid sufficient to represent eight per cent of the whole, I then pack the cavity with absorbent cotton and allow it to remain for a few minutes or longer as the case may be. On removing this, if all bleeding is found to have ceased, and the cavity fairly dry, cauterization may be proceeded with. If, however, oozing of blood to any extent should still continue, it will be best to pass into the cavity a properly rolled tampon saturated with the above styptic and allowed to remain for forty-eight hours before the application of the cautery. " Cauterization in all such cases should be conducted in the fol- lowing manner : " The diseased organ should be exposed to view, and the vagina protected by a Sims's speculum and an anterior and two lateral re- tractors, and it may be necessary to seize the edges of the excavation by one or more volsella. Before introducing the cautery electrode a wad of absorbent cotton is to be passed into the cavity, held for a moment, and, immediately on being withdrawn, the dome-shaped instrument, brought to a cherry-red heat, is to be rapidly and re- peatedly passed over the bottom of the cavity mainly. The latter is then to be again dried by wads of absorbent cotton held in dress- ing forceps, and cauterization resumed as in the first instance. This process is to be repeated over and over again until the deeper parts of the cavity have become dry and charred, when the sides are to be treated in precisely the same manner and roasted to the same crisp condition. The seat of operation will now present the appear- ance of a perfectly black and dry cavity. All ragged and over- lapping edges are next to be trimmed off by the cautery knife; a firmly rolled tampon of suitable size with thread attached, and satu- rated with the above styptic compound, is now to be placed in the cavity, and, finally, a supporting vaginal tampon is to be applied and the patient removed to bed. The vaginal tampon may be removed on the following day, but the other should be allowed to remain for forty-eight hours or longer. The subsequent treat- ment will consist of vaginal douches twice daily of carbolized water." MALIGNANT DISEASE OF THE UTERUS. 421 CANCER OF THE BODY OF THE UTERUS. This condition is rare as compared with carcinoma of the cervix. Pathology.—In corporeal epithelioma the epithelium of the uterine glands undergoes hypertrophy, and there is formed a fun- gating polypoidal mass, which propagates itself over all the organ, or projects into its cavity, perhaps into the cavity of the cervix. The cancerous mass always ulcerates and leaves wide cavities in the hardened uterine wall. The uterus becomes enlarged. Scirrhus or encephaloid may, in rare cases, be found in the body of the womb, although the best authorities state that there is scarcely an unquestionable case of corporeal encephaloid, and that scirrhus has never been met with. These varieties form beneath the mucosa in the substance of the uterine tissue, and extend outward, causing peritonitis and agglutina- tion with neighboring organs and parts. When they extend inward they are certain to ulcerate. Either form of cancer, when accompanying fibroids, does not seem to modify the latter's characteristics. One case is recorded of cauliflower excrescence of the fundus; this projected out through the cervix down into the vagina. The microscopical appearances in no wise differ from similar neoplasms in the cervix. Symptomatology.—The prominent symptoms of cancer of the cervix are also met with in cancer of the body, but not to the same degree nor appearing in the same order. In cancer of the body pain occurs early, and is severe and parox- ysmal, sometimes remaining at its pitch for two hours. Free menor- rhagia is soon accompanied by a discharge which is profuse, watery, and fetid. In some instances there will be no discharge whatever throughout the disease. The vital forces are early greatly depre- ciated, and marked constitutional disturbance is a prominent early symptom of cancer of the corpus. Physical Signs.—Inspection gives negative results. On palpa- tion (bimanual) the body is felt to be larger and harder than normal. The cervix is usually dilated, but in a few instances has been felt to be normal. Adhesions may firmly hold the uterus in a fixed posi- tion, but in most cases it is freely movable. The probe induces profuse haemorrhage in nearly all cases, and by its use we learn the degree of dilatation of the cavity of the womb. 4:22 DISEASES OF WOMEN. The curette is used to withdraw some of the growth for micro- scopical examination. Diagnosis.—Cancer of the body and cancer of the cervix may be confounded with each other. The points that enable us to dis- tinguish them are these: Cancer of the body is very rare; that of the cervix comparatively common; pain is very early and very severe in cancer of the body ; it is rare or absent in cervical cancel-. Menstruation is deranged from the very onset in cancer of the body ; this is a late symptom when the cervix is attacked. Marked constitutional disturbance and peritonitis—which is often fatal—occur early and more frequently in cases where the body is the seat of malignant growth than when the cervix is involved. There is little or no tenesmus on bimanual examination in cancer of the cervix, while this is marked in cancer of the body. The probe discovers an enlarged corpus in the latter case, while in cancer of the cervix the corpus is normal in size. The adjoining structures are implicated far more frequently, and also earlier in the disease, in cancer of the body than in cancer of the cervix. Prognosis.—The same rules hold good here as in cancer of the cervix. The outlook for recovery is far less favorable, not only from the situation of the growth and the greater likelihood of adjacent tissues being involved, but also from the fact that, as total extirpation is the sole means of treatment, the probability of life after this operation is much less than after amputation, cautery, or scooping. Causation.—The body of the uterus is attacked with cancer very much more frequently in nulliparae than in multiparse, which is in striking contrast with the prevalence of cancer of the cervix. The average age of patients suffering corporeal carcinoma is ten years greater than that of women afflicted with cancer of the cervix. In every other respect the causation is the same as in cervical cancer. Treatment.—Extirpation is the sole means of effecting a cure in cancer of the body^and hysterectomy seems to be followed by far better results in these cases than when performed for cancer of the cervix. This may be accounted for on the ground that in the neigh- borhood of the cervix there is far greater liability to extension of the disease and infiltration downward and laterally. Vaginal Hysterectomy.—While the principles of this operation are the same, the details differ with different surgeons. Some—the French surgeons chiefly—control the uterine and ovarian arteries with clamps ; others use ligatures. I shall describe the operation, and note the most important dif- MALIGNANT DISEASE OF THE UTERUS. 4^3 ferences in the methods of carrying out the various steps of the procedure. Preparation of the Parts for Operat'wn.—The patient being placed in the lithotomy position, the vulva and vagina are thor- oughly cleansed and disinfected and the rectum and bladder com- pletely emptied. If the body of the uterus is alone affected, the cervical canal must be washed out, packed loosely with cotton, and closed with a pair of forceps or with sutures. If the disease involves the cervix, so that the cancerous mass protrudes into the vagina, as much as possible should be removed with the cautery or curette, and then the canal closed in the manner described. The object of this closure of the canal is to keep the wound clean and free from infec- tion during removal of the uterus, and is very important. It is im- portant in such cases to remove all the diseased tissue about and within the cervix before proceeding further in the operation. Retractors should be introduced into the vagina, so as to thor- oughly expose the cervix and upper part of the vagina. The cervix should then be seized with a volsellum forceps and drawn outward and upward, and the posterior vaginal wall be incised, the incision being semicircular and extending half around the cervix and out- ward half an inch or less, according to the size of the cervix. The peritonaeum should be opened from the base of one broad ligament to the other, and the vaginal walls and peritonaeum united with sutures. The anterior vaginal wall is to be next circumcised, and the uterus and bladder separated up to the peritonaeum with the dry dissector or the finger. 1 prefer not to open into the peritoneal cavity in front until the broad ligaments are separated from the uterus up to and including the uterine arteries. The vagina may be separated from the uterus with the knife, scissors, or galvano-cautery. I prefer the cautery. The next step is to either ligate or clamp the broad ligaments and separate them from the uterus. If ligation is determined on, it is done as follows: A ligature is carried around the lower portion of the ligament with a curved needle, Cleveland's ligature forceps (Fig. 189), or an aneurism needle, securely tied, and then divided close up 424 DISEASES OF WOMEN. THE CLAMP OPERATION IN VAOINAL II YSTKKlXJToM Y (Modified from Landau.) Fig. 190.—The speculum in place, the cervix is seized and drawn down- ward, and the incision begun at the junction of the cervix (C) and the vaginal wall. Fig. 191.—The cervix having been severed from the vaginal wall all around, the blad- der stripped off, and the vesico-uterine pouch opened, the body is caught and drawn out through this anterior opening. Fig. 192.—A forceps, guided by the fingers, is pushed through the pouch of Douglas. Fig. 193.—A forceps draws forward into -view the tube (T). F, fundus ; C, cervix. VAGINAL HYSTERECTOMY 4:21 Fig. 194.—Forceps on the ovary (0) turns the broad ligament forward. The uterine artery is clamped. Fig. 195.—The tube and ovary being rolled forward, the ovarian ar- tery is clamped. Fig. 19tl.—The uterine artery can be clamped as soon as the vaginal walls are freed from the cervix. Fig. 197.—Placing the gauze (by the upper hand). The perinaeum is retracted and hand). The perinaeum is the forceps spread apart. to the uterus. The ends of the ligature should be cut off after it is tied to avoid traction, which would be almost sure to loosen it. Successive portions of the ligament are treated in this manner until the whole is separated from the uterus. The other broad ligament is treated in the same manner. The uterus, being now free from its attachments, is removed. The next step is to unite the peritonaeum to the anterior and 426 DISEASES OF WOMEN. posterior vaginal walls with fine catgut sutures. The peritoneal cuts should now be sponged clean. One end of each suture is then eut off and the remaining ends are tied to the opposite sutures, thus Fig. 198.—Vaginal hysterectomy by morcellement. The gray lines show the pieces to be removed in order, each being shown with a forceps fast to it. (Landau.) completely closing the wound, except in the center, where space enough is left to admit a small gauze drain. The vagina is to be loosely packed with gauze, and the operation is completed. Many surgeons prefer silk ligatures, as being more easily handled and more certain to control the vessels; but silk is objectionable for various reasons. It is likely to cause irritation and suppuration, and a longer time is required for the ligatures to come away or be removed, so that by the use of this material the recovery of the patient is delayed. The French Method.—The peculiarity of the French method of performing vaginal hysterectomy consists in the use of pressure forceps instead of ligatures for the control of the blood-vessels. The circumcision of the vagina is performed in the manner already de- scribed, but when the peritonaeum is opened the forceps are applied MALIGNANT DISEASE OF THE UTERUS. 4^7 to the lower part of the broad ligaments. The uterus is then retro- verted—although some surgeons prefer to antevert it—in order to bring the ligaments nearer to the operator, and then the upper por- tions of the ligaments are clamped with forceps. The ligaments are divided between the forceps and the uterus. To prevent unlocking of the forceps the handles are tied together. Gauze is then placed in the wound between the forceps to act as a drain, and either gauze or cotton wrapped around the handles of the forceps to protect the vulva. Landau's full and finely illustrated description of his clamp operation has been simplified in the series of cuts adapted from his work (Figs. 100-1 OS). Method with Electric ILcmostatic Forceps.—Whatever may be claimed as advantages for the ligature, even the modern ligature, that is with much care and trouble made aseptic and can be left in the tissues, has its faults and shortcomings. The catgut ligature is very difficult to sterilize and keep surgically clean, and it is liable to slip and permit haemorrhage. In being disposed of by absorption, or being walled in or encysted, it causes more or less irritation. Dead animal tissue, though sterile, can not be taken care of in a wound without causing some disturbance. Silk, or unspun silk, called silkworm gut, properly prepared, will not decompose, and, being less likely than catgut to slip, has some advantages, but is more objectionable still because it causes irritation, and in the effort to escape or be thrown out enters the abdominal or pelvic viscera and does great damage. There are many cases recorded of serious trouble from ligatures of this kind long after recovery from operations. Nearly twenty years ago I learned from Dr. Thomas Keith his method of treating the pedicle, in ovariotomy, by the clamp and cautery, and I have had ample opportunities to observe that the results are vastly superior to those obtained by any other method. Within the past three years I have discovered that the same method of closing bleeding vessels is applicable in all surgical operations. At the same time I have found that it is no easy matter to use the means which give such excellent results. Naturally, this has in- clined me to seek some simpler, easier way of accomplishing the same object—that is, to arrest bleeding in surgical operation. Hitherto the difficulty in using compression and heat to arrest haemorrhage has occurred in the management of the heat element. The process is as follows: A portion of the end of the vessel, or mass of tissue containing bleeding vessels, is seized in a forceps or clamp and firmly compressed, and while under pressure heat is ap- 428 DISEASES OF WOMEN. plied to the instrument to desiccate or dry the parts but not to char them. In this way the walls of the arteries become united and haem- orrhage is certainly prevented. Heretofore the heat was obtained Section^ Blades .(■ Fig. 199.—Full-size drawing of piece of fresh beef-muscle one fourth inch thick after being seized in forcep blades two minutes with current on. The compressed place is translucent as horn, not charred. The same piece is shown in section. by applying a heavy cautery iron (heated in the fire) to one side of the clamp, but this rendered the procedure difficult and unsatisfac- tory, and limited it to the treatment of the pedicle in ovariotomy. With the determination of improving the process and adapting it to the arrest of haemorrhage in all surgical operations, I have employed electricity to produce the required heat and devised instruments to meet all requirements. I have now per- fected the method so that I believe it to be worthy of the attention of the medical pro- fession. The advantages which may be fairly claimed for this way of controlling bleeding in surgery are, that it is certain and reliable in closing isolated vessels or those imbedded in masses of tissue, like an ovarian tumor pedicle, for example, or the uterine and ovarian arteries in the broad ligament. At the same time that bleeding is arrested all lymphatics are sealed up Fig. 200.—An artery from fresh beef closed solidly by author's method in one half minute. Seen in per- spective and in section. Life size. MALIGNANT DISEASE OF THE UTERUS. 429 which prevents septic absorption. Xerves that accompany the ves- sels are immediately and completely devitalized, and hence there are less pain and irritation in the stump. The heat employed sterilizes the parts involved, and therefore the operation is perfectly aseptic. Of these many advantages, the greatest, I believe, is that it leaves the stump of a pedicle or the end of an artery in a condition re- quiring the least reparatory care, so that recovery is more prompt and uneventful. My impression is that the ends of vessels and tis- sues of pedicles treated in this way become first hydrated and then organized (during the healing process), in the same way that an inflammatory exudate upon a serous membrane becomes vitalized. I asked Dr. Keith about this. He said that he did not know exactly what became of the stump of the pedicle treated in this way, but he did know very surely that it gave no trouble or anxiety to patients or the surgeon. In this my experience fully agrees with his. I have never known trouble of any kind to occur after an operation that could be attributed to this method of controlling haemorrhage. Although fully satisfied with the results obtained by compression and heat as a haemostatic, I have long been annoyed by the practi- cal difficulties in its employment, as already stated. While thinking of how to overcome these difficulties, my attention was called to the use of electricity in cooking and in heating laundry smoothing irons. It then occurred to me to adapt the same heating power to surgical instruments, such as the clamp and forceps. My requirements in this regard were explained to Louis M. Pignolet, an electrician who has given much attention to electricity as used in medicine and surgery. He at once took up the study of the subject with enthusiasm and soon produced the instruments and appliances required. The following is Mr. Pignolet's description, with illustrations of the instruments in question : " The construction of the haemostatic forceps is plainly shown by the illustration, of which Fig. 201 is a side view, Fig. 202 a section of the jaw on an enlarged scale, and Fig. 203 a top view of the chamber in the jaw, also on an enlarged scale, showing the arrange- ment of the heating wire. The chamber is formed by attaching a flat, case (A) of sheet metal to the inner side of one of the jaws (B) of an ordinary compression forceps, in such a manner as to form a water-tight chamber. This increases the size of the jaw but little, as the case is less than an eighth of an inch deep and has the same length and width as the jaw, so that the instrument appears like an ordinary compression forceps. 430 DISEASES OF WOMEN. " The wire (C) for heating the sheet-metal face of the jaw is of platinum or other suitable metal, and zigzags back and forth from side to side in passing through the chamber. A fireproof material, which is also an electrical insula- tor, separates and insulates the wire from the sides of the chamber. The space between the wire and the back of the chamber is several times greater than that between the wire and the front, so that the heat from the wire can pass much more easily to the front than to the back. One end of the wire is electrical- ly connected to the instrument, and the other to a copper wire (E) passing out of the chamber through an insulating bushing (F) in the back of the jaw. The copper wire extends back to the handle of the in- strument, and is insulated by a waterproof covering. Terminals are provided at the end of the copper wire and the handle of the forceps for making connections with the flexible wires or cables which convey the electric current to the instrument. The path of the current is through the copper wire, the wire in the chamber, and one blade of the forceps. The copper wire and the blade present but little resistance Fig. 202. Fig. 201. Fig. 203. to the electricity and are but slightly (if appreciably) heated by the passage of the current. On the other hand, the wire in the cham- ber offers considerable resistance to the current and is heated by it MALIGNANT DISEASE OF THE UTERUS. 431 To a greater or less degree, according to the strength of the current and the resistance of the wire. " By this method of construction the heat is concentrated upon the inner surface of the jaw of the forceps or clamp—the mechan- ism of which remains precisely the same—and but little is expended uselessly in heating the other parts of the instrument. The elec- trical energy necessary for heating the jaw is therefore reduced to the smallest possible quantity, and varies from ten to thirty watts, according to the size of the forceps. " The required degree of heat, which varies from 170° to 190° F., is attained very quickly, owing to the closeness of the heating wire to the face of the jaw and the thinness of the sheet metal com- posing the face. Furthermore, the instrument can be sterilized in the same manner as the ordinary forceps without damage. '' On this principle, forceps of various shapes, from the largest to the smallest sizes, are heated, as the general formation of the instru- ments is not modified by the heating attachments. " The method of construction described is advantageous, for it simplifies the instrument by dispensing with the extra copper wire that would be required if one end of the heating wire were not connected to the forceps; but if desired, the heating wire may be connected to a second insulated copper wire so that no current would flow through the blades of the forceps. " The heat developed in the forceps depends upon the strength of the electric current and the resistance of the heating wire. The current required to properly heat each forceps may be ascertained by trial and marked upon the instrument; or all the forceps (both large and small) may be so constructed as to be heated to the re- quired degree by a current of a predetermined strength, by suitably proportioning the resistance of the heating wire. A small ampere meter included in the electric circuit measures the current re- ceived by the forceps, and enables the current to be regulated to suit by means of a rheostat or other controlling device. The heat of the jaw is thus controlled with certainty, as the current required by each forceps is known, as explained above. " The length of time during which the forceps should be heated varies from thirty seconds to two minutes and a half, depending upon the thickness of the tissues compressed between the jaws of the instrument. It is advantageous to give the forceps a slight ex- cess of current for a few seconds at the commencement, as this hastens the desiccation of the tissues and shortens the time of appli- cation. If, for example, ten amperes be the current required to 432 DISEASES OF WOMEN. heat the forceps to the proper degree, start with twelve amperes and decrease to ten amperes after the lapse of a quarter or a third of the time during which the current is to be applied. " As the forceps require less electrical energy than the average cautery electrode, the current from a small storage battery or a suitable primary battery, such as the excellent battery of Dr. Byrne, can be used for heating them, but the current from electric-light mains is preferable, as it is not subject to failure, and the care and attention necessary to keep a battery in working order are avoided. " Alternating current of the pressure used for lighting buildings can be converted into a current of lower pressure adapted for the forceps, as well as cautery knives and examining lamps, by means of a small transformer capable of giving current of different strengths and pressures. The current is generated in a coil of wire called the ' secondary' by the inductive action of the lighting cur- rent passing through an adjacent coil called the ' primary.' The two coils are carefully insulated from each other, so that there is no danger from the comparatively high-pressure lighting current, as it can not pass from the primary to the secondary. A further ad- vantage of the transformer is that it increases the quantity of cur- rent available as well as reduces the pressure, so that a current of large quantity but low pressure can be obtained without overloading the smallest electric-light wire used. " The pressure is varied to suit the forceps or other device by cutting a sufficient number of the turns of secondary wire in or out of the circuit by a switch, or by altering the strength of the inductive action upon the secondary coil by moving it to a place where the action is stronger or weaker, as a greater or less pressure is desired. " A convenient form of transformer, constructed according to the latter method, is illustrated by Fig. 204. The flexible cable convey- ing the electric-light current is connected to the binding posts, A, the cautery electrode to B, and the incandescent lamp to C. The cur- rent is regulated by sliding the knobs (D and E) which control the cautery and lamp coils respectively toward the center of the instru- ment to increase the pressure and quantity, and vice versa. If the electric-light current be continuous, it can be converted into an alternating current suitable for operating a transformer by a small rotary converter. " The current from the electric mains can be used directly, with- out the intervention of a transformer, if it be controlled by a rhe- ostat ; but this is not advisable, for the high pressure of the current MALIGNANT DISEASE OF THE UTERUS. 433 mi wqqU OlTATBOMMvlI a'aOHTuA MHT HTTW YMOT0:UMT87lT J AKIW Y .oi'DflO^ Y5R>1 rrjAQr^T^ .. .' '■""■ '" ' • >■ .\ i ■ .S8£ s^eq 3'>3 .9iu^B igwoJ baaaoiqnioa odi bns bou^aool u>9d graved 9*mxr'j~; te-rrt 9ilT 89«/rt tnoniB^il bi>nd 9il3 lo llfiii i9vn;l no v™vo bw odui 9iif 9vonm oT .qn i9flgirl q-.rrro bno^aa B be'Am 91IJ ^nolBnojial od bluov/ blod bnooga aidf .ainafu orh iHiv/ bbia aiiH .fnornfi^if b£o*id -nli Wr>bia oivloq ■'„-■"* MALIGNANT DISEASE OF THE UTERUS. 435 Fig. 206.—Cautery incisions about the cervix. being used and the length of time that it should be continued. When one is doubtful about this, the forceps may be removed and the parts inspected, and, if need be, the forceps should be reapplied and the heat continued long enough to obtain the desired effect. The ligament is divided with knife or scissors between the forceps and the uterus as far up as the vessels have been closed. The lower portion of the ligament on the other side is treated in the same way. The uterus is drawn down, and the remaining portions of the ligaments are treated in sections until the uterus is com- pletely made free. The operation may be briefly described by say- ing that it is performed in the same way as when forceps is used to control the bleeding, with the difference that instead of leaving the forceps on long enough for the compression alone to arrest the haemorrhage, the heat completes the haemostasis and the forceps is removed at once. Peritonaeum. pn controlling haemorrhage from small arteries my observa- tions have been limited to such operations as amputation of the mammary gland and small ves- sels in divided adhesions in ab- dominal operations. The for- ceps employed for this purpose is in form the same as the ordi- nary artery forceps, and is used in the same way. The artery is seized and held firmly, and the electrical connection made and continued until the end of the compressed vessel is desiccated. This takes very little more time than applying a ligature; in fact, it takes less time when the vessel is in a deep cavity and not easy to get at. In the manage- ment of small bleeding vessels in the abdomen or down in the pel- vic cavity this electrically heated forceps is very useful and con- venient, and saves much time, trouble, and anxiety. I'p to the present time I have not practiced this method of con- Suture through peritonaeum /■..j. and through >£§('• vaginal wall above cau- terized edge. Fig. 20'7.—Diagram of vagina and wound after removal of uterus. The suture passes through the peritonaeum and the vaginal wall beyond the cautery cut, and is tied ; then is tied to its fellow on the opposite wall. 436 DISEASES OF WOMEN. trolling the haemorrhage in doing abdominal hysterectomy, but I am confident that it can be employed satisfactorily in that operation. After-treatment.—The after-treatment will depend upon what method of operating has been selected. In all cases rest and, it necessary, a cathartic are to be prescribed. If pain is marked and the stomach irritable, opium and warm water may be given by the rectum. For the first few days the food should be fluid; on the third day the bowels should be moved by a saline cathartic, and by an enema of glycerin and water. The gauze packing is left in the vagina for five or six days by most operators. If the operation has been done with ligatures, I prefer to change the gauze at the end of forty-eight hours. When forceps are used I remove the gauze at the end of thirty-six or forty-eight hours, and introduce a gauze drain, which is to be changed at the end of two or three days, and replaced if there is much suppuration. If the wound unites without much suppuration, a douche can be used, but without the least force, for five or six days, and continued daily until all the discharges have ceased. After-treatment of cases operated upon by my method : The vagina is loosely packed with gauze, which is removed at the end of forty-eight hours, and if there is any discharge it is not replaced. After the fourth or fifth day the vaginal douche of borax and water may be used, and repeated daily if there is any discharge. At the end of a week the wound is, as a rule, completely healed, and no further local treatment is necessary. SARCOMA OF THE UTERUS. Fibroplastic tumors, or " recurrent fibroids," are neoplasms of the embryonic tissue type whose seat is usually in the body of the uterus. Pathology.—The connective tissue is the origin of uterine sar- coma ; and immediately beneath the epithelium this tissue forms nodules or ridges which bulge out the softened and somewhat dis- integrated mucosa into the uterine cavity. Since the projections are often polypoidal, pedunculated, soft, and medullary in consistence, rapid in their growth, and vascular, it is easy to see how they can be mistaken for carcinoma. Indeed, Klebs has found a profuse epithelial growth upon sarcomatous nod- ules of the uterus and then the growths seem to have joined. The uterus may be greatly distended by the fungus-like growth. When the mucous membrane is wholly disintegrated, the uterus PLATE III. See page 435. Abdominal Hysterectomy with the Author's Hemostatic Cautery Forceps. A, first seizure, safeguarding the ovarian artery; I>, second seizure, grasping the artery of the round ligament; C, third seizure, securing the uterine artery. PLATE III. Forceps Ota/ on ovarian artery. .Ovary. / Tube. / Ovarian artery.. ^ ,- Round ligament. iJ^^r WW/ V/ w'L 1%1b ^■i^^ F<«!iflriLv^fl^l Ijfifi jfcj F*^! ^^. K /'J mm 0Hm 1^2 ■•■Rk—^KJim^I ill 1 MALIGNANT DISEASE OE THE UTERUS. 437 may be perforated, and in rare instances the sarcoma may prolifer- ate out through the abdomen. In other cases the growth is deeper, less diffuse, and more nodu- lar. It begins anywhere in the uteriue tissue between the submu- cous layer and the peritoneal investment and forms a hard, roundish mass like a fibroid. This may assume a fungoid or polypoid form and hang down in the uterine cavity; as in cancer, so here, the soft may be a later stage of the hard sarcoma. Possibly a degenerating fibroid of the uterus may be associated with a sarcoma; or, as it then would be called, a fibro-sarcoma. As to the effects, the vagina, peritonaeum, Fallopian tubes, and ovaries may be invaded by sarcomatous masses. The uterus is often inverted, either from an easily dilated cervix or from weakening or palsy of the uterine muscle. Symptonudology.—The classical symptoms of malignant disease— pain, haemorrhage, and discharge—are met in cases of sarcoma uteri. Pain, however, occurs late, if at all, and seems to have often been confounded with nterine tenesmus, which is a common symp- tom. At times there may be severe pain from pressure on the rec- tum and bladder. Menorrhagia is an early symptom: or if the disease is in those who have passed the menopause, menstruation seems to have re- turned. Later, there is a discharge resembling the rice-water stools of cholera which is only faintly suggestive of the cancerous odor. But as the neoplasm ulcerates, the discharge is as fetid as that of carcinoma, and in it are pale-gray shreds, which upon microscopical examination at once reveal the true nature of the growth. A cachexia is very slowly and gradually developed, yet finally it is as marked as in cancer. Pliysicid Signs.—Palpation reveals a soft, friable, pedunculated tumor which may be felt to spring from the body of the uterus. The os, through which this tumor is forced, is dilated, softened, and irregular. The finger or the sponge-tent may be used to dilate the cervical canal when the mass has not yet made its way down to the os internum. Bimanual palpation shows the uterus to be large, sometimes reaching halfway to the umbilicus, and oftentimes as irregular as when the seat of fibromata. The sound shows the extent of the enlargements; its use causes intense menorrhagia. The curette is useful to obtain scrapings for microscopic exami- nation. 438 DISEASES OF WOMEN. Diagnosis.—Sarcoma may be mistaken for carcinoma; but in the latter disease pain is a far more frequent, early, and severe symptom; the discharge is fetid almost from the very onset; the cervix is most difficult to dilate with a sponge-tent; the constitu- tional symptoms are more severe; and the duration of the disease is rarely over a year. These symptoms are in contrast with what occurs in sarcoma. Finally, a microscopic examination of some of the scrapings will always be necessary before determining the diagnosis. Prognosis.—Although a patient with sarcoma of the uterus lives on the average three or four years after the tumor is fairly devel- oped, yet the outlook for ultimate recovery is most grave, all cases slowly but surely tending toward a fatal issue. Sarcoma tends to reappear after most careful removal, although the time elapsing between removal and recurrence is much longer than in the case of carcinoma. The prognosis will greatly depend upon an examination of the scrapings: when these show scanty stroma with an abundance of cell elements, the course will probably be as rapid as that of enceph- aloid cancer; but when the cells are few and the fibrous tissue is abundant, life may be prolonged for six or eight years. Among the complications are septicaemia, anaemia, peritonitis, and sarcomatous nodules in adjacent organs. Causation.—Age is the chief predisposing cause; half of all the cases occur between the ages of forty and fifty, and before thirty or after sixty sarcoma is extremely rare. In cancer I referred to the occurrence of the disease in those who had borne many children ; but sarcoma seems to develop in sterile wombs in nearly fifty per cent of the recorded cases. It is a mooted question whether traumatism and uterine inflam- mation have any influence in the causation of sarcomata. Treatment.—When pedunculated tumors project into or out through the cervix, the sharp spoon or the galvano-cautery, or even the finger-nail, may be used to remove them. Then carbolic or nitric acid may be applied to the base of the tumor. AVhen the growth is not sessile but apparently superficial, thor- ough curetting and the application of nitric or carbolic acid are advocated. Deep sarcomata can only be treated by extirpation of the uterus. CHAPTER XXIII. THE MENOPAUSE. The menopause marks the dividing line between middle life and the beginning of old age. The permanent suspension of the menstrual function is known by several names, such as critical time, climacteric or climacteria, turn of life, and menopause, the latter term being the most express- ive and preferable. The natural history of the final cessation of menstruation varies so much in different individuals that it is difficult to accurately give a typical account of it. The time when it occurs ranges from forty to fifty years of age, the average in this country being about forty- five. The menopause coming early or late depends apparently upon the delicacy or health and vigor of individuals. There is a popular idea that those who begin early should stop early, but, according to my observations, those who reach the period of puberty betimes because of good health and strength, and who continue healthy, are likely to maintain the menstrual function later in life, providing that all the sexual functions are normally exercised throughout middle life. The question has been raised as to whether celibates do not reach the menopause earlier than fruitful women, but I have not yet ob- tained facts sufficient to answer this definitely. In women of good health, to whom the change comes without complications, I have observed that in one class the menstrual flow becomes less free and shorter in duration, then a period may be missed, to be followed by a recurrence or two, and then it finally ends. In others the inter- menstrual period is lengthened to five or six weeks, and the flow when it does come is free, often profuse, and lasts longer than usual. The time from the waning until the final cessation of men- struation varies from six months to two years or longer. The menopause being an event which is natural to woman, there is nothing in its occurrence which should cause ill health; still it is attended by certain phenomena indicating special modifications 439 440 DISEASES OF WOMEN. of the organization which disturb the comfort and general activity of the most healthy women, though not to a degree that can be called ill health. Many increase in flesh, become less inclined to mental and physical activity, and show signs of excrementitious plethora. There is usually constipation, often due to deranged secre- tions, and the nervous and vascular systems are more or less dis- turbed. Very often functional heart trouble, irregular action and palpitation of the heart, with a feeling of impending danger, are the common symptoms. These are frequently associated with inter- costal neuralgia of the left side. Grave apprehensions on the part of the patient are excited by these symptoms. Similar indications appear in amenorrhoea in young subjects. This points to the fact that cessation of the menses has a peculiar influence upon the innervation of the circulatory system. The flushings of the face, " hot flashes," from vaso-motor derangement, annoy them sometimes very much. Fullness of the head and occa- sionally headache and drowsiness during the day, and disturbed sleep at night, are frequently noticed. In other cases the appetite fails slightly, and there is no gain in weight, perhaps a slight loss of flesh. The same disturbed circulation is generally present, but there is, on the other hand, increased nerve excitability. Complaint is made of restlessness, and a number of minor symptoms, such as im- paired memory from lack of interest and concentration, are observed and often dreaded. These are the usual symptoms which attend the menopause in healthy women living under favorable circum- stances. Comparing the menopause with puberty shows that they are almost exact opposites, the one being a development of structure and establishment of function, the other a decay of structure and suspension of function. One marked difference is noticeable : men- struation is complete and perfect from the beginning. Established after all the structural conditions are matured, it is maintained in full effect. The menopause comes gradually as the decline of the structures progresses. Atrophy of the sexual organs from impaired nutrition is the anatomical change that directly leads up to the menopause. The ovaries, having all along been breaking down to a certain extent, at each ovulation arrive at a condition of senile atrophy, and no longer exert their full influence in the economy. There is not now the demand for so large a blood supply, and the uterus shares in the lowered nutrition. The ovaries first arrive at the stage of atrophy through a gradual breaking down of the tissues, which causes in- THE MENOPAUSE. 441 competence. This, no doubt, is the most important factor in the causation of the menopause, but it is only one of several. There is, furthermore, an atrophy or lowered nutrition of the spinal centers and organic nerves which govern the sexual organs at this time of life, and the brain also to some extent withdraws its influence from them. Simultaneously with these changes the uterus becomes atro- phied, the degeneration progressing slowly. There is at first anae- mia of the uterus, which is apparent in the pallor of the vaginal and cervical mucous membranes. The whole organ gradual Iv di- minishes, until finally it approximates to the infantile in form and size, although the senile uterus is a little larger than that of a child. When these anatomical changes are completed menstruation ends, but the atrophic diminution continues for some time after the menopause. Leith Xapier, in his elaborate work on the Menopause, gives as the cause the general atrophic condition which comes on in senility. I have always taught that it was the result of the atrophic changes in the sexual system and in the nerve centers which preside over it. I do not believe, as Napier claims, that it is due to the general atro- phic condition of the entire organization. As already stated, the menopause occurs in consequence of a de- cline or atrophy of the sexual organs, nutritive supply, and innerva- tion ; hence there should be a harmonious falling off in all the structures concerned in the functions of the sexual organs. When that is the case the change of life is free from anything that re- quires the attention of the physician ; but when the nutritive changes which precede the suspension of the menstrual function progress faster in one portion of the economy than in another, morbid disturbances arise. It follows that certain affections which occur at the menopause are due to deranged nutrition and prema- ture deterioration of that portion of the cerebro-spinal sympathetic systems which govern the sexual organs. Others are due to prema- ture or delayed atrophic or destructive changes in the sexual organs themselves. Varying forms of derangements may arise from these causes. For example : Withdrawal of the mental influence may cause sup- pression of the menses before the sexual organs are atrophied, and an over-devotion to matters sexual may cause menstruation to con- tinue in an imperfect way after the wasting of the uterus and ova- ries takes place to some extent. On the other hand, degeneration of the ovaries and uterus may cause suppression of the menses while the cerebro-spinal structures may still be perfect and function- 442 DISEASES OF WOMEN. ally active. Certain diseases of the sexual organs may keep up a modified form of menstruation after the nutrition of the nervous system has begun to decline. AVhen this latter condition prevails, the nervous and nutritive systems have a drain imposed upon them which they are incapable of sustaining, and consequently sutler de- rangement. On the contrary, while the nutritive and nervous systems remain healthy and active there is a necessity for men- struation, and if (owing to atrophy or malnutrition of the sexual organs) menstruation is suspended the general economy is sure to be deranged. The derangements and disorders incident to the menopause may be classified, according to the way in which they are manifested, under three heads : premature or delayed menopause, and constitu- tional derangements accompanying or following the menopause. The latter is subdivided into nutritive and nervous disorders conse- quent upon the suspension or undue continuance of this function. Premature Menopause.—The function of menstruation may be suddenly suspended, or it may gradually subside and end completely at too early an age. The abrupt ending of menstruation being the most unnatural, gives rise to the greater disturbance of the general health. The causes of premature menopause are of two classes: diseases and injuries of the sexual organs, and diseases of the nutri tive and nervous systems. By recalling the conditions necessary to normal menstruation, given in the chapter on Menstruation, it will be seen how these causes are operative. The disorders of the sexual organs which cause a premature menopause are degenerative disease of both ovaries, double ovariotomy, and loss of the uterus or injuries to it, which lead to its premature atrophy. Of the lat- ter, the most conspicuous are hysterectomy, the ovaries being left; puerperal metritis, which results in superinvolution ; and extensive lacerations followed by the formation of much scar tissue. Opera- tions for the relief of deep bilateral lacerations, requiring removal of large portions of uterine tissue, may lead to atrophy. This has been noticed by several observers in late years. Removal of the ovaries may be taken as the principal cause of abrupt menopause. Ovaries that are slowly destroyed by disease bring about the menopause more gradually. This is made quite apparent from the clinical facts, that those who have well-defined destructive diseases of the ovaries menstruate imperfectly for some time, and suffer very little from the menopause when it is completed by the removal of the ovaries and tubes, because the change comes more like the natural way. Premature menopause caused abruptly THE MENOPAUSE. 443 by removal of functionally competent ovaries and tubes, removal of the uterus, or diseases and injuries of the uterus, which incapacitate that organ for performing its functions, give rise to such marked derangement of the general health as to demand special considera- tion. Fortunately, the ovaries are not sacrificed so often now as in the near past, when they were removed in the vain hope of reliev- iirg certain neuroses, incurable dysmenorrhoea, and uterine fibrom- ata. It is strange that Napier makes no allusion to induced meno- pause. Symptoms.—The effect of the removal of the normal ovaries in middle life is to derange the nervous, nutritive, and circulatory systems. The clinical history appears in many cases to partake of the characteristics of neurasthenia, nervous irritability, and derange- ment of the emotions. Great muscular and nerve weakness, indi- cated by continual weariness, soon appears. In some there is decided nervous irritability (that which is known as nervousness), with a dis- position to try to do much, but who become easily fatigued. There is mental depression, indicated by sighing and lamenting over real pains and debility, and imaginary evils that are present or impending. Much of this depression and emotional disturbanced comes from a consciousness of being sexually impotent. The nervous systemic disturbance is manifested by headache, pain in the neck and back, pain in the limbs, tenderness of the skin, strange wandering pains, and queer feelings in the head and elsewhere. These symptoms are the same in kind as those found in connection with the meno- pause at the right age for it; but in cases of premature arrest of menstruation the disturbances, mental and physical, are greatly ex- aggerated. Dr. Savage * calls attention to some of the mental troubles com- plained of by such patients. They fancy, he says, that something has burst in the head or womb; have a sensation as if hot blood were over the brain, and a feeling of deadness or emptiness. AVith the passing away of the sexual functions, querulousness, jealousy, and a fancy that their husbands no longer care for them, not infre- quently occur. All of these symptoms I have frequently observed in my own practice. There are also pelvic tenesmus and pain in the ovarian regions, presumably in the stumps left after the removal of the ovaries. The next symptoms in the history are derangement of the circu- lation, chiefly vaso-motor, due to deranged innervation ; irregular * Medical Press, November 8, 1893. 444 DISEASES OF WOMEN. heart action ; flashes of heat, and cold hands and feet; cold per- spiration followed by hot, dry, feverish skin; numbness of the extremities, most frequently of the left arm; creeping, crawling feelings in the skin, and burning spots here and there. Nutrition is generally impaired, and nervous indigestion is present in all cases as a rule. Assimilation is defective, as the loss of flesh and softened state of the muscles indicate. The skin shows malnutrition in being either dry and hot or cold and clammy. These indications are all more marked at the time when the patient should menstruate. These periodical exacerbations are most distinct at the first. As time goes on the patients adapt themselves to the new order of things gradu- ally. If properly managed, recovery may take place in time, but if left without care they become chronic invalids or insane. Artificial menopause is more often followed by insanity than the normal climacteric. The effect upon sexual instincts of removal of the ovaries in. adolescence has been discussed long and laboriously in the past years, but nothing new has been advanced. Repetition of the two opposite, old, and rather ridiculous ideas—one, that the removal of the ovaries unsexes women, and the other, that it does not affect them at all in this respect—is about all that has been heard on this subject during the last eighteen or twenty years. The fact is, that it does not unsex women, but in time impairs sexual characteristics, and they are, as a rule, finally lost. The passing away of the sexual appetence and the consciousness of being positively sterile often have a most disastrous effect upon the mind, and frequently lead to insanity. I will refer to this again in treating of insanity among women. Treatment.—The first indication is to quiet the mental disturb- ance. Much can be done to relieve the patient's depression by giving hope of recovery. Sedatives are required to give sleep, and nerve tonics, such as are suitable in melancholia, are called for; camphor, lupulin, and in some cases small doses of opium, give relief. The opium should be given with care, and without the patient knowing what she is taking. Lately I have used codeine with better effect than opium gives. The deranged circulation is best managed with a combination of digitalis, strychnine, and bella- donna. Occasional attacks of palpitation of the heart—pain in the cardiac region with difficult respiration—are relieved with nitro- glycerin, strophanthus, and digitalis. Indigestion is generally of the nervous type, and is controlled by gastric sedatives such as bis- muth and oxalate of cerium, or subgallate of bismuth. The spinal THE MENOPAUSE. 445 symptoms are, I presume, due to a hyperaemic or anabolic state, hence the irritability, nervous twitchings, and neuralgic pains. When these are annoying, relief is obtained by dry cupping, alter- nating with hot and cold douches, or sprayings, hot and cold, applied in rapid succession to the lumbar regions. Time is the great factor in restoring the equilibrium, and the main object is to relieve and sustain the patient until the new order of things is established. Enforced Menopause from disease, injury, or removal of the uterus, while the ovaries are left, causes a general derangement which may be termed an exaggerated menstrual molimen. The nutritive preparations for menstruation go on, and when the elimi- native function is not performed there is a temporary plethora. The patient complains of fullness of the head, flushed face, very often headache, and oppression which is felt as weakness and indis- position to engage in mental or phj'sical exercise. The nervous systemic disturbance is manifested by drowsiness, low-spiritedness, and inability to think clearly and quickly. Those of a nervous temperament are irritable, fretful, and, although sleepy at times during the day, often have sleepless nights. Treatment.—The old practitioners employed bloodletting, and with decided benefit. In strong women it might be practiced with advantage at the present time, but it should not be continued at each recurring menstrual period, as the habit of requiring bleeding is easily established. Depletion by other means, like saline cathartics, for example, gives much relief, and mercurials are of great value when the liver and kidneys are inactive. Small repeated doses of mild chloride of mercury, followed by a saline, or natural cathartic waters, act well, and Turkish baths and muscular exercise aid in some cases. The headache often complained of as a painful fullness is best re- lieved by bromide of soda with antipyrine or monobromide of camphor. Piperazine is the best solvent, and gives great relief in the uric-acid saturation which is often present and causes neuralgic, rheumatic, and gouty symptoms. The diet should consist of milk, eggs, vegetables, and fruit, with very little animal food. The quan- tity of food should be limited ; underfeeding rather than full diet should be the rule. Some women have a craving for alcoholic drinks, but these should be prohibited. The indications for treatment are based upon the fact that the function of the sexual organs is suspended before the nervous and nutritive systems have been prepared for the change in the economy. The nutritive activities are out of proportion to the demand, and 44b' DISEASES OF WOMEN. therefore the supply should be diminished. If it is not, the nutri- tive processes become deranged. These derangements should be treated in the usual way. The disorders of the nervous system arising from enforced meno- pause from the causes now being considered are also twofold. There is in one class an exalted nerve force, which, no longer finding an outlet through the demands of the sexual system, gives rise to nerv- ous derangements which should be relieved by sedatives, and diver- sion of the nerve forces in some other direction by mental occupa- tion. AVomen who have given their best mental energies to the exercise of the sexual system suffer most from premature meno- pause. There is another class who suffer from nervous exhaustion or debility. They manifest nervous excitability with loss of power; they are called nervous patients. All such require rest, tonics, and good nourishment. Whenever the nervous system is specially dis- turbed at the menopause the greatest care is required to keep its disorders from going from bad to worse. There is a tendency to develop diseases of the nervous system in many forms, and if there is any inherited tendency to insanity it will be brought out under these circumstances. Delayed Menopause.—The menstrual function is sometimes con- tinued to an advanced age in strong, healthy women, but so long as the function is normal there is no reason for being alarmed. It is only when the menses continue beyond the usual time for the meno- pause and there is some derangement in that function, or the gen- eral health is impaired, that attention should be given to the subject. Efforts should be made to discover the local or general conditions which cause these derangements. When the flow is profuse and irregular in recurrence, there is usually some local cause for it that can be easily discovered. It may be said, in brief, that any neoplasm, subinvolution, or old injuries of the uterus may keep up menstruation beyond its normal limit. Scar tissue in the cervix uteri, either from injuries or from the use of caustics, apparently prevents the final atrophy of the uterus by keeping up a continuous irritation. This is the only way that one can account for the relief obtained in such cases by dilat- ing the canal of the cervix. A number of cases of recovery from painful menstruation and delayed menopause have been reported cured by this form of treatment. Fterine fibroids and subinvolu- tion, as well as scar tissue of the uterus, all belong to the domain of surgery, and are only referred to here as belonging to causation. THE MENOPAUSE. 447 Delayed menopause is also caused by certain constitutional conditions, such as hepatic, cardiac, and renal disease, and also certain blood states which, if they do not favor a continuation of menstruation long after the time for change of life, certainly cause menorrhagia about the time for the menopause. Menorrhagia and delayed menopause are not infrequent in cases of mitral insuffi- ciency. The effect of this cardiac lesion upon the circulation is to keep up a continued hyperaemia of the pelvic organs, and this often causes women to go on menstruating when they are old enough to have the menopause, and when they can ill afford to keep up that function. The diagnosis is easily made by the physician who makes his examination sufficiently thorough. The treatment consists in trying to improve the circulation. At the menstrual period the patient should be kept in the recumbent position as long as it can be borne with comfort. She should rest, not necessarily upon her back, but on either side that is most com- fortable. Massage and hot-water douches, which I do not hesitate to recommend if the flow is excessive, will sometimes control this condition. Digitalis and aromatic sulphuric acid in medium doses will frequently give great relief, and they are far better borne than hydrastis canadensis or ergot in those cases of cardiac disease. Hepatic disease, such as the engorgement and enlargement oc- curring in chronic malarial poisoning, not rarely causes menorrhagia in young women, and is very apt to delay the menopause. This no doubt is also due to the deranged portal circulation, which keeps up the pelvic engorgement. The treatment, of course, should be such as the physician employs in chronic malaria. It will suffice to add here that, in addition to the use of the alkaloids of cinchona bark and arsenic, I have found the most marked benefit from the use of iodine. I give five drops of the tincture in water, with enough of the iodide of soda to make a clear solution. The formida is : Tinc- ture of iodine, two drachms; iodide of sodium, half a drachm; simple sirup, one ounce ; water, two ounces. Dose, one drachm after meals, well diluted. To this I very often add two or three drops of Fowler's solution. Of course, attention to the bowels and general nutrition should be fully given. The premature menopause has been referred to as arising from certain constitutional affections, notably tuberculosis, and so on. N'othing need here be said about this, as suppression of menstrua- tion is a conservative matter and requires no direct attention. It may be well to add also that in case the physician can not find any disturbance of the nutritive or nervous system to account for the 443 DISEASES OF WOMEN. delayed menopause, it is evident that the cause is local, and such patients, of course, should be relegated to the domain of surgery. ILLUSTRATIVE CASES A Case illustrating the Normal Menopause.—A lady who had a very good constitution, and, with the exception of having had some acute diseases in early life, had enjoyed uniform good health. She had borne five children, and after the birth of the last one she men- struated regularly and perfectly. AVhen she was forty-six years old the menstrual flow began to diminish in quantity and duration, varying a little in this respect from time to time. In six months from the time that the change began, the duration of the flow was reduced from five days to two. She then missed two periods, and then the flow returned and lasted three days, and was a little freer. Then she went for four months, when there was a slight show for part of a day, and that was the end. During the time when the gradual diminution of the flow was taking place she became somewhat languid, and indisposed to her usual mental and physical activity. Her appetite was not quite as good as formerly. While languid when undisturbed, she was easily roused by any excitement. Her face would become flushed, her hands and feet clammy, and she was nervous and irritable. AVhen these feelino-s passed away she felt annoyed to think that she could not control herself as in times past, and would become a little de- spondent. All these symptoms were more pronounced at the men- strual periods. AVhen suffering most she felt that if she could have a free menstrual flow it would relieve her. These feelings continued to annoy her until the flow ceased entirely, and for about nine months afterward, but they diminished in severity, and finally left her altogether. After the cessation of the flow she gained considerable flesh, and her former mental and physical activity returned, and her health has been excellent ever since. When the diminution in the flow began and her peculiar symp- toms came on, she consulted me about her condition. AVhen told that all could be attributed to the change of life, she pleasantly ac- cepted the situation, and made no change in her mode of life, nor did she take any medicine. This enabled me to obtain the history of the case unmodified by treatment. Premature Menopause caused by Deranged Innervation.—The pa- tient was one having a good organization, but a very marked nervous temperament. She had three children, the youngest of whom was THE MENOPAUSE. 449 five years of age when I first saw her. She was then thirty-six years old. Three years before our first consultation she had many excitino- cares thrust upon her, which affected her nervous system very injuri- ously. Though possessed of means sufficient to secure every luxurv of life, her cares depressed her greatly, and exhausted her nervous system. Her nutrition was impaired to some extent, but still she had the appearance of one in fair health, although she was restless, sleepless, had headache very often, and suffered from wandering neuralgic pains. Iler sufferings in this way had continued for about one year, during which time the menstrual flow was at times scanty, and less in duration than normal. Then the menses stopped altogether for six months, then returned for several months, though scantily, then ceased for two months, returned once, and then again in four months, and then stopped entirely. Five months after the last menstruation was the time that I first saw her. She consulted me because she fancied that if her menses would return her health would improve. To describe her symptoms would be tedious and unprofitable; suffice it to say that she presented typical neurasthenia. There was no organic disease noticeable out- side of the nervous system. Being fully satisfied that if the men- strual function could ever be restored it must be accomplished by restoring the nervous system first, the treatment was directed to that object. Sleep at night was obtained by giving thirty grains of bro- mide of sodium late in the afternoon, and half an ounce of whisky at bedtime. Aconitia, one two-hundredth of a grain, relieved her at- tacks of neuralgia. Massage and general faradization were employed daily, and tonics were given, consisting first of valerianate of zinc, then pyrophosphate of iron and arsenic, and then iodide of iron. Citrate of iron and quinine was also given at times. The form of tonic was changed whenever she became used to that which she was taking, and the most appropriate diet was given. Her general health improved gradually, and in the summer she was able to rest and enjoy life in the country by the sea. Sea bathing was also tried after a time with benefit. About one year of this treatment restored her health, but the menses did not return. In fact, the restoration of that function was despaired of after three months' treatment, when, on examination, it was found that the organs of generation had undergone complete involution. The Menopause delayed by Fungosities of the Endometrium.—This patient was married, and the mother of five children. After the birth of her last child she suffered from uterine leucorrhoea, proba- 35 450 DISEASES OF WOMEN. bly caused by endometritis. She had fair health in spite of that, and menstruated regularly until she was forty-six years old, and then the menstrual flow became more profuse. This continued intermit- tently for nearly one year, when the menses came more frequently, lasted longer, and the flow was quite profuse. Her health failed gradually; she became anaemic, weak, low-spirited, and nervous. Though her flesh remained (she was rather stout), her strength was greatly reduced. Her family physician gave her the usual remedies —lead and opium, ergot, cannabis Indica, and aromatic sulphuric acid—in the hope of controlling the flow, but without effect. Finally she consented, with some reluctance, to an examination, when a large number of polypoid growths were found in the cavity of the uterus. These were removed with the curette, and the flow- ing stopped for six weeks; it then returned for a few days, but was not very free. There was a return of the menstrual flow in two months, very scanty, and another in three months, and that was the end of it. She was then forty-eight years old. After the removal of the fungous growths with the curette, her health improved under tonic treatment, and when last seen, at forty-nine years of age, she was quite well. Excrementitious Plethora, Oppression, and Derangement of the Nervous System from the Menopause.—A strong-looking German lady gave me the following history: She was married and in quite comfortable circumstances. She had six children, the youngest being eleven years old. From the time of her last confinement her health had been good, and she menstruated normally until she was over forty-six years of age. Her menses came then at the proper time, but lasted two weeks, and the flow was too free. After a lapse of three months the menses came again in a diminished de- gree, and again in two months scantily. From the time of her free menstruation, when she was about forty-six years old, her health failed gradually. She had always been a generous liver, and continued to take her nourishment well, but she became languid, indisposed to exertion of any kind, had headaches, was drowsy and sleepy all the time, but often had restless nights. Her mind was disturbed, so that she was depressed in spirits, quite fretful, did and said " queer things" which alarmed her family, and her memory was less reliable than formerly. She had little interest in her for- mer duties and amusements, but occupied her time mostly in think- ing and talking about her feelings. There were flushings of the face at times, which she described as rushing of blood to the head, which she fancied might kill her. There were profuse but brief THE MENOPAUSE. 451 paroxysms of perspiration, which came at times without any phys- ical exertion. She was quite fleshy, and, excepting an anxious ex- pression of the face, had the appearance of good health. The tongue was coated, the bowels constipated, the urine was loaded with phosphates; the pulse full, but slow, and at times irregular; the appetite was not good, but she took food in abundance, and drank wine and beer in the hope of getting strength. She suffered from labored digestion and flatulence, and a sense of fullness in the region of the stomach. The sexual organs had undergone com- plete involution, although the vagina was relaxed and showed some venous congestion. The treatment was first ten grains of blue mass, three grains of calomel, and one grain of ipecac, given at bed-time, followed in the morning with a dose of sulphate of magnesia. This was repeated twice, at intervals of five days, and after that the following mixture was given : Bromide of sodium, half an ounce ; salicylate of sodium, two drachms; wine of colchicum seeds, two drachms; sirup and water enough to make three ounces, and a teaspoonful to be taken before meals. She improved very much on this treatment, and the mixture was continued for about six weeks. After the effects of the mercurial cathartic had passed off she became constipated, and the following pill was given at bed-time : Sulphate of quinine, one grain; extract of belladonna, one eighth of a grain ; and rhu- barb, two grains. AArhen this was not sufficient to move the bowels freely, a glass of Congress water was given an hour before breakfast. AArine and beer were gradually given up, and her diet simplified and reduced in quantity. Exercise in the open air was prescribed, and light, agreeable mental occupation. The progress of the case was quite satisfactory for about two months, then there was a standstill for a time. The medicine was then changed to a mixture of hydrochloric acid, one and a half drachm ; tincture mix vomica, one and a half drachm ; tincture of cannabis Indica, two drachms; tincture of cardamom, one ounce ; and simple sirup, two ounces; one drachm, before meals, in water. The pill at bedtime was continued. This last prescription was given for about two months with an interval of three days after each bottle, when she took the pill only, at night. From this time onward the progress of the case was steady until she finally recovered her former good health. Such a case as this is infrequently seen in practice. The causes being conditions of life favoring derangement of nutrition and slug- gish disintegration, aggravated greatly by the rather abrupt cessation of the menses. Vo2 DISEASES OF WOMEN. Impaired Digestion and Assimilation arising from the Cessation of Menstruation.—This lady was married and the mother of a family, of spare habit and a nervous temperament, but her health had been good in the past. AVhen she was forty years of age her menstrual flow diminished in quantity and duration, and simultaneously her appetite failed, and she lost flesh and strength. Always an active person, she now became restless, nervous, and irritable. Her tongue was clean, but of a deeper color than nor- mal, showing that rapid exfoliation of the epithelium was going on. The bowels were constipated; the urine was abundant and of light color usually. Iler skin was slightly bronzed and usually dry, although she had occasional outbursts of free perspiration. Her pulse was weak, and at times irregular. Her head ached quite often, and she had wandering pains about the chest and abdomen. Her greatest trouble was a feeling of distress in the stomach after eating. Eight months from the time that the menstrual flow began to de- cline it stopped altogether, and two months afterward I first saw her. As the physical condition of this patient was almost exactly the opposite of the preceding case, the treatment was necessarily very different. She was directed to take nutritious food in small quan- tity, six times a day; to rest as much as possible, and have massage at night, which gave better sleep. At first she was given five grains of oxalate of cerium half an hour before meals, and a teaspoonful after meals, in warm water, of a mixture of lactic acid, tincture of columbo, and pepsin wine, and she improved so far as to take food and digest it with less trouble, but her strength did not return as fast as I desired. She was also constipated. A tonic laxative pill was then given before meals, consisting of qninine, belladonna, and compound extract of colocynth; and after meals she was given a teaspoonful of whisky with four drops of tincture of nux vomica and four grains of animal charcoal. This appeared to help her, and this course of tonic treat- ment was continued very faithfully for three months, when she con- sidered herself sufficiently well without further treatment. Two years afterward she was found to be in good health. Circumscribed Inflammation of the Vagina and Cervix Uteri, partly due to the Menopause.—The patient was first seen when she was forty-eight years old. The menses had stopped one year and two months before. Her health was fairly good and always had been, but for some time before the menopause, and all the time after, she had been distressed by a discharge from the vagina of sero-purulent but rather tenacious material, which caused some external irritation. THE MENOPAUSE. 453 There was heat and burning in the pelvis, which became more marked on walking. She had put up with her troubles so long, believing that it was due to change of life and would pass off in time. In fact, she had been told this by her physician. But, in- stead of disappearing, she found that the trouble increased, if indeed it changed at all. Her general health was below par considerably, but there was no organic disease of the organs of nutrition, and yet ultimate nutrition was a little sluggish. The sexual organs had undergone final involution ; the uterus was small, but the os externum was open, and coming from the canal was a tenacious, darkish-colored discharge, not unlike the leu- corrhoea found in young subjects, and heretofore described under the head of " Cervical Endometritis in the Imperfectly Developed Uterus/' The mucous membrane about the external os was eroded in patches, and on the anterior lip of the cervix there were some granular spots that looked as if they were the products of epithelial hyperplasia. The appearance of the vagina was peculiar. In place of the general congestion of a well-marked vaginitis, the mucous membrane was studded with small red points or patches, while the intervening portions of the membrane were pale. The surface of. the membrane was covered with a sero-purulent discharge; at the' vulva there were several patches of congestion larger than those higher up in the vagina. Some of these were of a deep-red and. slightly bluish color. The thought came to me that this might be malignant disease of the cervix just beginning, but this was put aside, because of the duration of the trouble and the fact that I have several times seen this condition after the menopause. I have also frequently seen the same conditions in young insane women who had amenorrhoea. These facts led me to suppose that the inflammatory action was due to impaired nutrition which is pres- ent at the involution of the sexual organs. This low grade of in- flammatory action is no doubt more likely to occur in those who have had some ordinary cervical endometritis and vaginitis before the menopause. The circumscribed red spots looked to me like a few live coals here and there in' the ashes left after the fires of func- tional life and inflammation had subsided. The treatment consisted of general tonics and local astringents; citrate of iron and quinine was given internally, and a teaspoonful of sulphate of zinc in a quart of water for a vaginal douche. The parts about the os externum were touched once with a fifty- 454 DISEASES OF WOMEN. per-cent solution of chloride of zinc. The sulphate-of-zinc injec- tions did very well for a time, but the progress was favored by an occasional application of glycerin and tannic acid. The local improvement did not surpass the general regaining of strength, but kept pace with it. The recovery was permanent and perfect. Pelvic pains of a neuralgic character are common about the change of life, and are often due to it. The following two cases from Tilt will illustrate this form of trouble : Ovario-Uterine Neuralgia.—Miss X. was forty-seven when she first consulted me. She is small,'but well-proportioned. Has been highly nervous all her life. Menstruation was irregular, and there were muco-purulent discharge, vaginitis, and decided ulceration of the cervix, and a most irksome sensation of heat and irritation in the passages. I cured the vaginitis and ulceration by surgical measures, without relieving the vaginal heat and pruritus, so I sent the patient out of town. When she returned, after many months, the pruritus was as bad as ever, and would come on after any excitement or fatigue, or standing about, and would be relieved by resting with the feet higher than the pelvis. This vulvo-vaginal irritation would sometimes disappear on the coming on of a similar pruritus on the palms of the hands and on the soles of the feet, showing that how- ever much the chief seat of neuralgia might be in the womb or vagina, the ultimate nervous expansions in other parts of the body might similarly suffer. When this irritation affects the feet and hands there is nothing to be seen there, and she refrains from scratching them because it would prolong the irritation for hours. As might have been predicted, the symptoms were worse at night, and led to great exhaustion and despondency. I have watched this state of things for twenty years, and at times could give no relief. She was always better for plenty of food and wine, and for such small quantities of citrate of iron and quinine as she could bear. I tried all sorts of injections; tar-water did most good, but it has been repeatedly advisable to discontinue all kinds of injection, for they seemed to do more harm than good. I syringed the vagina with a solution of nitrate of silver and touched the passage with the solid caustic, with questionable benefit. A rectal suppository con- taining a grain of opium and one of extract of belladonna often gave temporary relief, but this remedy could not be relied on. By the sacrifice of her own health many a daughter has well repaid the gift of life; and when my patient lost her mother, who had been long a cripple, requiring anxious and fatiguing nursing, she went THE MENOPAUSE. 455 1 out of town and got fat, and now suffers much less, only havino- a slight return of the old symptoms when she gets weaker and more nervous. Ovario-Uterine Neuralgia.—A very strongly constituted lady, aged forty-seven, is said to have had some acute uterine disease twenty years ago, while residing in France, when forty leeches were ap- plied above the pubis. AVith the exception of not being able to re- tain the urine so well as previously to this attack, health remained so good that every year she was able to take long pedestrian excur- sions with her husband. She never conceived, and menstruation ceased suddenly at forty-four ; in the following months the nose bled very frequently, and the bowels became constipated; for which she went to Homburg and was restored to health. On returning to town, in December, 1868, she took very cold enemata for constipa- tion, which was so great that a wineglass of Friedrichshall water, taken every hour, failed to produce watery motions, and only irri- tated the bladder, apparently causing the strange abdominal sensa- tions which have lasted ever since. The patient feels as if there were a heavy body in the pelvis bearing down upon the rectum, with a burning sensation, referred sometimes to that organ, some- times to the vagina, or to the bladder. AVhen in bed and lying down, with the feet up, she feels comfortable; by the time she has half done dressing the burning sensation begins, and lasts until the bowels have been moved ; soon after this the burning comes back ; it is ag- gravated by standing or sitting, by indigestion, flatulence, constipa- tion, and repletion of the bladder; also by worry and bad news. The sensation is relieved by moderate walking, by lying down, and by regularity of the bowels. Homburg was again tried ; it did good, but on her return the lady was as bad as before, and consulted sev- eral doctors. One attributed the sufferings to stricture of the rec- tum, another to irritation of the bladder, a third to displacement of the womb. The following summer Homburg was tried for a third time, but the waters were soon left off, for they aggravated all the symptoms, and after the patient's return to town Dr. Beale sent her to me. In addition to the pelvic symptoms already described a strong-minded, sharp, matter-of-fact woman was in a state of mental confusion ; her brain felt muddled, and she would sit for hours doz- ing or doing nothing; despondency being doubtless increased by finding herself helpless as a child, after having passed all her life in doing everybody else's business as well as her own. She forgot where she put things; once thought she had taken out a large sum of money in her purse, and that she had lost it, whereas a month 456 DISEASES OF WOMEN. afterward she found it in some out-of-the-way place. On examin- ing, I found the rectum perfectly healthy, notwithstanding the pain and stricture ascribed to it. I was given to understand that marriage had never been concluded, and the vagina was so narrow that I could with difficulty introduce part of my index finger; so I ordered lin- seed tea and laudanum injections, three times a day, and henbane internally. A few days afterward I was able to reach the os uteri. I found the womb exquisitely sensitive; and on sounding the blad- der there was nothing abnormal, except great pain when the sound passed over the urethra, the pain not being caused by inflammation, for the finger in the vagina did not feel the urethra as a hard and round body painful on being pressed. Injections with acetate of lead and laudanum, as well as opium and belladonna rectal supposi- tories, enabled me, a little later, to examine the womb without giv- ing pain ; there was no ulceration and there had been little vaginal discharge. The pain was most.felt at the opening of the vagina, which looked sore, red, and injected, a condition that accounted for a very unusual hardness of the recto-vaginal tissues, a hardness of which the patient was sensible, and complained of as something wrong with " the bridge." This was caused by long-continued con- gestion, although the parts were then without heat or redness. This sore state of the vaginal opening was relieved by the application, twice a day, of zinc ointment, to each ounce of which was added a drachm of diluted hydrocyanic acid. ATaginitis becoming worse, I swabbed the vagina once a week with a solution of nitrate of sil- ver, and ordered alum and zinc injections; suppositories did harm, whether administered by the vagina or the rectum. After thus treating the patient for a few months the sensations of burning and weight had considerably diminished, but were often trouble- some. Digestion was much improved by nitro-muriatic acid and pepsin; pseudo-narcotism and mental disturbance were not relieved by bromide of potassium, but were much reduced by henbane and Indian hemp; and then the patient took, for two months, three times a day, at meals, the twenty-fourth of a grain of arseniate of iron, made into a pill with a fourth of a grain of Indian hemp—a combination suitable alike to the general nervous derangement and to the abdominal neuralgia. This leads me to the question of diag- nosis. There was no organic disease of the bladder or rectum, nor of the womb, neither displacement nor ulceration of this organ. The disease originated in vaginitis, kept up by excessive walking and drastic medicines at the change of life; the vaginitis causing neuralgia of both the sensory and the ganglionic pelvic nerves, the THE MENOPAUSE. 457 neuralgia causing pseudo-narcotism and the other forms of cerebral disturbance that usually attend the menopause; the neuralgic ele- ment of the case being shown by the patient's often feeling the disturbance to ascend, as it were, from the pelvis along the spinal column to the back part of the head, where there was most suffer- ing. There was a gradual recovery of health, and this patient has been able to resume her usual very active life. A long list of diseases has been given as occurring at the meno- pause. This list covers nearly all the ills that flesh is heir to. The majority of these have no relations to the menopause excepting that when there is a predisposition to any disease, the disturbances of the system due to the change would favor the outbreak at that time. No notice need be taken of those affections which are common to all periods of life, the menopause only determining the time of their development. When there exists a predisposition to any of the constitutional diseases, the condition of nutrition at the meno- pause, and the disturbed or unbalanced state of the nervous system, favor the outbreak of these morbid tendencies. CHAPTER XXIV. SENILE ENDOMETRITIS. The prevailing opinion is that cancer is the only disease of the uterus to be looked for after the menopause. There is a decided immunity of the uterus from inflammatory affections in aged women. In the past and present, authorities have agreed in stating that endo- metritis ends in recovery at the change of life. These opinions are true only to a certain extent. I have seen a number of cases of en- dometritis which persisted, in a modified form, after the menopause, and a considerable number in which this affection appeared long after the climacteric. The pathology and natural history of endo- metritis in advanced life differ so from inflammatory affections of the uterus in middle life that I concluded, eighteen or twenty years ago, that senile endometritis was a special, distinct affection worthy of more attention than had been given to it. Fritsch, in Billroth's " Handbuch fur Frauenkrankheiten," treats of this affection, and three or four others have, referred to his contributions, and that is all I can find in the literature; even at the present time there are only four or five authors who make any allusion to it. The subject was first brought to my notice most forcibly in the year 1875. A patient, the relative of a physician, aged sixty-eight, came under my care while suffering from a sero-purulent discharge from the uterus. I made a diagnosis of cancer, but found I was mistaken. She recovered, but I could see that this affection differed from endometritis as it occurs in middle life. From that time I have kept such cases carefully under observation, and I have col- lected facts sufficient to complete the natural history of the disease. Pathology.—The inflammation may be limited to the cervix alone, but as a rule it involves the entire mucosa. WThen it occurs soon after the menopause, and especially if it is a continuation of a cervical endometritis that existed before the menstrual function is Anally suspended, it assumes a catarrhal form modified. As usually seen, it is suppurative, the discharge being sero-purulent. AVhen it 458 SENILE ENDOMETRITIS. 459 begins as a catarrh it gradually progresses to a suppurative form. In the catarrhal form, the discharge, at first a leucorrhoea, diminishes, and changes from the translucent tenacious discharge to a darker glue-like material, associated with a sero-purulent matter. The change results from the atrophy of the glands of Xaboth, which secrete the leucorrhoeal discharge of catarrhal endometritis. The character of the discharge is modified first by the atrophy which follows the menopause, and by changes of structure which are pro- duced by the disease itself. It is not until the senile involution is complete that the pathological anatomy of the disease is fully devel- oped, and shows the characteristics which distinguish this affection from all other forms of endometritis. There is first a general atrophic thinning of the whole mucous membrane. The epithelium changes from ciliated to cylindrical, then pavement, and finally is almost entirely lost. The surface around the os externum becomes irregular, thin, and shows a bluish- red color, which presents a marked contrast to the appearance of erosion seen in endometritis of early life. Granulations of low vitality appear on the endometrium, and minute extravasations of blood occur and are seen as small pigmentation spots. The glands become obliterated entirely by the morbid process, and hence there can be no secretion, but, instead, pus formation. There is molecular death of the structures, but extensive ulceration is rare. During the development of this affection the atrophy of the muscular structure of the cervix proceeds faster than in the mucous membrane of the cervix, and there is an inversion of the membrane which gives a peculiar appearance. Around the os externum there is an elevated bluish-red ring, which stands out in marked contrast to the normal mucous membrane of the vagina. ^Laceration of the cervix uteri frequently accompanies senile inflammation, and when there is much scar tissue present the suffering is more marked. Stricture, partial or complete, at the os internum or externum is frequently formed. Closure of the os internum is caused in some cases by retroflexion of the uterus. In this condition the discharge is intermittent. For a number of days the flow stops, and then a free discharge of offen- sive pus takes place. Complete occlusion of the canal is caused by adhesions of the disintegrated mucous membrane—a result which follows suppurative inflammation of the mucosa, but is rarely, if ever, present in catarrhal forms of inflammation. Pus accumulates above the stricture and distends the body of the uterus, giving rise to a condition which resembles an abscess in pathology, symptoms, and signs. If the stricture is not extensive the pressure will force 460 DISEASES OF WOMEN. it open, pus will be discharged, and there will be repetitions of the closure, accumulation, reopening, and discharge. In most cases it is necessary to open and dilate the canal before relief can be obtained. AVhen the disease has existed long enough to destroy the mucous membrane it may end in cicatrization, but there is a marked tend- ency to continued suppuration. The disease can hardly be called self-limiting. In nearly all the cases that I have seen in which there has been, for a time, a stenosis of the canal, the uterus has become greatly dis- tended and prolapsed or retroverted. The cavity of the uterus measured three inches and a half in one case and four inches in an- other. The senile atrophy may be delayed by the presence of endo- metritis, and the uterus may remain larger than it should be in old age, but that does not account for nor is it like the enlargement from distention. In the enlargement of the cavity from distention with pus the walls become very thin, while in the other the normal thickness of the walls continues. Causation.—A continuation of endometritis, acquired before the menopause, accounts for a certain number of the cases, especially of those in which the disease is limited to the cervix. Some of the severer cases, in which the disease involves the body of the uterus, are caused by displacements, prolapsus, or retroversion, especially retroversion. Prolapsus in a marked degree exposes the cervix to irritation, and, if it continues for long, inflammation and ulceration will appear around the os externum, and the mucous membrane of the canal becomes involved. The atrophy of the cervix is retarded, or else infiltration takes place and keeps the cervix enlarged. These cases are easily controlled in case the displacement can be relieved. Corporeal endometritis is frequently caused by retroversion. The displacement interrupts the escape of the secretion of the mucous membrane; its retention causes decomposition and inflammation of a purulent variety. Stricture at the os internum would cause inflam- mation in the same way as retroversion, and the two are often found together, but in the majority of cases the occlusion is the result of the inflammation. Acute or latent gonorrhoea may cause this form of endometritis, but I am not sure that I have ever seen a case of acute gonorrhoeal endometritis after the menopause. Old neglected cases I have seen several times. Senile vulvitis and vaginitis, due to malnutrition and inattention to cleanliness, extend and cause endometritis in advanced life, but, as the latter very often is the cause of the former, it is difficult to SENILE ENDOMETRITIS. 461 decide in a given case whether the disease began in the uterus or vagina. Fibromata of the uterus act as a very important cause of the affection. Although uterine fibromata frequently disappear after the menopause, the endometritis which accompanies the neoplasm continues, but changes from a catarrhal to a purulent form. One patient who had a small fibroid passed the climacteric, and was free from all uterine disease until she was sixty years old. She then developed an endometritis attended with such a profuse sero-puru- lent discharge that she sought relief of her family physician. He made a diagnosis of cancer, and she was brought to me for operation. I found the remains of the fibroid in the cavity of the uterus. It was removed, and though the serous element of the discharge sub- sided at once, the endometritis persisted, and only yielded to treat- ment after several months. I have often wondered why the surgeons who find so many charges against fibromata, such as their danger to life and health, have never found senile endometritis caused by them. Perhaps they have overlooked this matter, or it may be that these are cases which they have mistaken for cancerous. Fibromata cause endometritis after the menopause by delaying senile atrophy and also by sloughing, which takes place in rare cases. Catarrhal endometritis usually accompanies fibromata and changes to the purulent variety after the menopause, as already stated. Another curious fact is that, although the fibroid that causes the metritis may slough and come away, or become pedunculated and the surgeon remove it, the metritis continues. This is the opposite to that which occurs in middle life. If a fibroid is removed in a young subject, the endometritis usually subsides when this cause is removed. I saw one lady, fifty-four years old, who had a submucous fibroid of the uterus. She had a well-marked endometritis, which was being treated without benefit. The fibroid sloughed and was completely removed. She had septicaemia, from which she recov- ered, but the purulent endometritis persisted, and only yielded to treatment after long-continued efforts. I supposed that the metritis in that case was obstinate owing to its being caused by sepsis, but I found that a like inflammation might be set up with only the pres- ence of a fibroid to account for it. A patient sixty years old had, judging from her history, a catarrh of the uterus at the menopause. It continued in a changed form, and a short time before I saw her she became worse, had more severe pelvic pains and tenesmus, with a very free sero-purulent discharge. I expected to find an endome- tritis and prolapsus, but found a small, pedunculated fibroid that had 4G2 DISEASES OF WOMEN. been expelled from the body of the uterus and occupied the dilated cervix. I removed it, and the patient was relieved and improved, but the endometritis of the purulent form continued, and, although much less severe, was difficult to cure. Symptomedology.—The symptom which first attracts attention is a discharge which varies in character according to the extent and stage of the inflammation. AVhen a cervical endometritis is present at the menopause the characteristic leucorrhoea gradually disappears, or else changes to that of the senile form of the affection. The te- nacious secretion of the cervical glands is replaced by a sero-puru- lent discharge which is more like a vaginal leucorrhoea. The dis- charge, sooner or later, causes a subacute or senile vaginitis and vulvitis. There is so very often prolapsus of the vaginal walls and uterus complicating the metritis that there is pelvic tenesmus and some disturbance of the vesical and rectal functions. These are the chief symptoms in the early stage of this affection when prolapsus is the only complication. AVhen the uterus is retro- verted, and owing to imperfect drainage the products of inflamma- tion accumulate and distend the uterus, there is more pain and the constitutional disturbance is much more defined. There is often a rise of temperature, and the pulse increases. The digestion is de- ranged and ultimate nutrition impaired in cases of long standing. This is due to pain, reflex disturbance, and more especially, perhaps, to a slight chronic sepsis. The malnutrition increases the appear- ance of premature old age, and the dry, bronzed appearance of the skin is suggestive of malignant disease. In cases in which true stenosis takes place at the os internum or at any point in the canal of the cervix, the symptoms are usually very pronounced. The pain is acute, and compels the patient to rest in bed. The pain differs from that of acute pelvic inflammation in being slight at first but gradually increasing, while the pain of acute disease is violent at first and gradually subsides. The constitutional disturbance is more marked in this condition or complication than in any other. There is symptomatic fever. In one of my patients the temperature reached 102° F. I have already stated that stenosis may be the cause or consequence of the metritis. The imprisoned secretion and broken-down tissue cause the inflammation, or the stenosis may be caused by the inflammation. That accounts for the fact that in some cases the distention of the uterus and the symptoms are gradu- ally developed, but in others they come on somewhat more abruptly. Physical Signs.—Inspection shows, in most all cases, patches of inflammatory redness about the vulva which are peculiar to senile SENILE ENDOMETRITIS. 463 vulvitis; the contrast between the red portions and the anaemic ap- pearance of the membrane generally is well defined. AA'ith the aid of the speculum the signs of the same form of vaginitis are observed. Of course the vagina and vulva are not involved in all cases, but as a rule they are. In quite a few it has been limited to the upper part of the vagina, and mostly the vaginal portion of the cervical membrane. The character of the discharge is best studied through the speculum. Its character is of much value as a sign. Indeed, upon this evidence senile endometritis is distinguished from other affections and forms of inflammation, such as cancer and gonorrhoea. The appearance of the discharge differs from uterine leucorrhoea in being less tenacious, owing to the absence in varying degrees of the secretion of the glands of the cervix. The color also indicates the composition to be sero-purulent, and in this it is more like the dis- charge in specific inflammation, and is similar in appearance to that found in the early stage of cancer. The differentiation between the discharge in senile endometritis, specific metritis, and cancer must "be made by the microscope if one would make the distinction at once— i. e., without waiting for the full development of the history. In senile metritis, pus, serum, disintegrated tissue, and changed or broken-down epithelium and bacteria are found. In cancer the dis- charge is sero-sanguinolent, and later in the progress of the disease contains broken-down necrotic tissue and elements of the neoplasm. The gonorrhoeal discharge can be distinguished by the specific germ of that affection. AArithout the aid of the microscope it is impossible to make a positive diagnosis between the specific or non-specific origin of senile endometritis, but fortunately the indications for treatment are the same whatever the cause of the affection may be. The history may show that gonorrhoea is the probable cause, espe- cially if the disease comes on abruptly, was acute at first, and in- volved the vulva and urethra first. The differentiation between this affection and cancer of the cer- vix is made by observing that in cervical endometritis there is the characteristic discharge and degeneration and atrophy of the mucous membrane, and in cancer there is, in addition to the discharge, infil- tration of the tissues—i. e., neoplastic growth. When the disease is fully developed in the body of the uterus the clinical history resem- bles malignant disease, but can be readily diagnosticated by the fact that pus in quantity accumulates in the cavity of the body of the uterus in metritis, while that never occurs in cancer. By aspirating the uterine cavity the material drawn off will be pus, and perhaps a little blood, while in cancer it is serum, blood, and broken-down 464 DISEASES OF WOMEN. cancer tissue. The aspiration is easily made by using a small curved pipette with a rubber bulb at the end. By compressing the bulb and introducing the pipette and removing the pressure, enough ma- terial can be withdrawn to show its character and decide the dia_Conipound and proliferating cyst make up the whole tumor, are (Farre). larger in size and more nearly equal. The general appearance of the mass is of one large cyst- wall containing 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. r>iu DISEASES OF WOMEN. From the general appearance and arrangement it would seem that the cysts included within the major cyst-wall had been de- veloped from the inner cyst-wall, and others still had been de- veloped from the second crop by a process of endogenous pro- liferation. This may or may not be the fact, but it is more Fig. 216.—Muiulocular cyst (Hooper). 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 they 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 cavi- ties of these cysts rarely communicate with each other. Occa- sionally a cyst is found the cavity of which is divided by septa, but associated with such there is always a number of independ- ent 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- NEOPLASMS OF THE OVARIES. 511 trophic increase in the tissues of an ovarian follicle, or of hyper- trophy 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 of either its inner or middle layer. The inner surface or lining membrane of a cyst may develop new structures or pro- liferations. Again, the contents of a cyst may be of a character en- tirely different from the ordinary fluid found in simple or com- pound 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 of the tissue pushes the lining membrane of the cyst before it, and in that way 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 papilhe are sometimes very vascular, and are covered with columnar epithelium. Paroophoritic Cysts.—These cysts, which, as their name implies, are developed in the paroophoron, present, according to Bland Sut- ton, the following differences from obphoritic cysts (the ordinary Fig. 217.—Papillary cystoma of ovary showing proliferation (Winckel). ovarian cysts): They are, as a rule, unilocular; do not affect the shape of the ovary until they have attained an important size ; always burrow between the layers of the mesosalpinx; when large, make their way between the layers of the broad ligament by the side of the uterus, and their interior is beset with warts, which are very vascu- lar, bleed freely, and are frequently calcified. It is to be borne in 512 DISEASES OF WOMEN. mind, however, that although these paroophoritic cysts contain warts or papillomata, still other cysts may also be papillomatous. Dermoid Cysts.—Ovarian dermoids occur much more frequently than is generally thought. According to Olshausen, they form four per cent of all ovarian tumors. In them have been found hair, sebaceous glands, sweat glands, teeth, mammae, horn, nails, bone, unstriped muscle, a well-formed heart, a tongue, a trachea, an eve. and what has been regarded as brain tissue. They occur at almoM every period of life. It is said that they have been found at birth, but Bland Sutton, who has studied the subject of dermoids most thoroughly, is unable to find the evidence of so early a case, lie Fig. 218.—Dermoid cyst of ovary, filled with hair and tallow-like masses (Winckel). refers to an authenticated one in a child of one year and eight months. They have also been found in patients above eighty years of age. Various theories have been advanced to explain their formation. The one which seems to me the most plausible is that of A. AV. Johnstone, M. D., of Cincinnati. lie regards the process as a true parthenogenesis, in which the ovum itself is at fault. For some unexplained and probably inexplicable reason it retains one of its polar cells and goes on, under the stimulus of this male element, to form a human body in a weak and very incomplete way, giving us the great variety of tissues already mentioned as having been found as constituents of dermoids. As a consequence, while the hypertro- phic change which takes place in other ovarian follicles produces ordinary cystomata, that which occurs in a follicle in which exists an ovum that still retains a polar cell will result in the formation of a dermoid. NEOPLASMS OF THE OVARIES. 513 Cysto-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- tomata, 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 Fig. 219.—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. 39 514 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 peritoineiun, 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 layers 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 distinguished. AVhen there has been peritonitis, the cvst-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. 515 gerated in patches. This great vascularity, when it occurs with- out preceding evidence of infiammation, 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 cvst-wall of a pale, grayish-white color, without any recognizable vascularity. This made the cyst very peculiar in appearance and easily 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- 1 ocular 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 1<>20. There are two distinct classes of elements which occur in the contents of these cvsts: the one mucous in its nature, which 516 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, murines, colloid substance, and muco-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 slowly; it first becomes paralbumen, then metalbumen. These are not fixed bodies, but pass on to the condition of peptone. Thus, the albuminous elements which 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.................................. 931.96 Organic substances....................... 59.77 Potass, sulph............................. .08 " chlor..............................59 Sod. nit ................................ 6.2!) " phosph..............................16 " carb................................38 Salts insoluble in water.................... .74 Loss.....................................03 1000.00 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. AAlien 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, 517 cles; globular aggregations of various sizes, scales of epithelium, crystals of cholesterine, and brown pigment were also found. As a rule, 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 -g-.oij-tf inch to 2-.oVu" inch. AVhen acetic 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 be 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 of 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 518 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 which 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. AVhen 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. AVhen 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. Potation 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 cyrtitis are likely to occur. NEOPLASMS OF THE OVARIES. 519 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 may take place instead of gangrene or necrosis. Spontaneous cure has taken place in this way, the tumor shriveling up and disappear- ing. Some very curious things have happened from twisting of the pedicle. Atrophy has taken place so perfectly that the pedicle has been 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. AVhile 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 which clearly indicates the process which takes place. Dragging of the Pedicle gives results similar to twisting. This dragging is produced usually when pregnancy 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 exi>t there. There is another way in which traction of the pedicle may oceur. 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. Rupture 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 520 DISEASES OF WOMEN. cyst may cause death, or the opening may be closed by inflamma- 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 ta"ke 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. 521 flakes of lymph. The original fluid in the cyst is supplanted to a large 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 tilled 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 may 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. 40 CHAPTER XXVIII. CYSTIC TUMORS OF THE OVARIES—SYMPTOMATOLOGY AND 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 sufficiently 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 522 CYSTIC TUMORS OF THE OVARIES. 503 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 the menstrual period, it is due to the process of rupture of the Graafian vesicle. Alenstruation 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 he pain at the menstrual period, which is easily mistaken for dys- menorrhoea. 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 he due to some constitutional condition or some uterine affection, which may accompany the ovarian tumor. AVhen 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. AVhen 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 brat noticed. Here, again, there are no other very well-marked 524 DISEASES OF WOMEN. symptoms. As the tumor increases, the weight and pressure cauee 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 symj)- 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 is 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. Thes-j 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 can be CYSTIC TUMORS OF THE OVARIES. 505 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 anaesthetic 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. Where 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 Thirst 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 cysts 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 he 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 52(i 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 ca.-e. 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 when 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 will not frequently come 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, when 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. 527 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 suffice 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. Differential 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, but quite as often it escapes notice until a much later period. The physical signs which 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, M'hile, if a multiple cystic tumor, the fluctuation may be 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 pelvic organs, and if drawn upward will drag the broad ligament with it. The gross and microscopic appearances and chemical com- 528 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 Fig. 220.—Area of dullness in a large ovarian tumor. There should be no sharp lower limit. The shaded crescent above represents liver dullness. alone is diagnostic. In fact, each of them may be found in other conditions than cystic ovarian tumors; hence arises the difficulty 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 CYSTIC TUMORS OP THE OVARIES. 529 the second stage this is most marked at the lower portion. The in- crease in size may be uniform, the twro sides being alike, or one side may be larger than the other, and in some cases there is an irregu- larity of outline of the tumor which gives a nodular appearance upon Fig. 221.—Area of dullness in ascites, indicated by shaded portion running up to the liver dullness. The tympanitic note about the navel is due to the floating of the intestines. 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 530 DISEASES OF WOMEN. 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 slidinp; about under the abdominal walls. AVhen 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 valu- able negative evidence. Palpation also shows that the tumor is clearly outlined and easily distinguished from the neighboring or- gans in some cases. AVhen the cyst is tense the tumor can be easily outlined, 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 contrasted with the tympanitic resonance of the intestines, will indicate 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- posite. The fluctuating wave will be easily found if the contents of the cyst 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 fingers 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- 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. CYSTIC TUMORS OF THE OVARIES. 531 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 one side and then on the other, it will be observed that while 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 contents 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 desired information on this point. The physical signs of ovarian and other abdominal tumors obtained by laparotomy are, of course, peculiar to each. The descriptions 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 lapa- rotomy as a means of diagnosis in obscure cases, I am as fully aware that it should only be undertaken by one possessing comprehensive knowledge gained by extensive experience. There are certain other affections and conditions which 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 tubercular peritonitis ; cysts of the kidney, liver, or spleen ; enlargement and displacement of the spleen, kidney, or liver; cancerous disease of any of the ab- dominal 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 ovariotomy undertaken when the case was one of pregnancy. In several 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 lack of 532 DISEASES OF WOMEN. attention. One might, in trying to make a diagnosis, mistake the pregnant uterus for an ovarian cyst, but upon opening the abdomen one having knowledge enough to warrant him in undertaking ovari- otomy 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 as, or larger than, the uterus at full term of gestation in doubtful cases. AVhile 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 whether the case is one of ovarian cyst or of pregnancy, time will decide, and there is no valid argument against waiting. 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 oiven, 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 by 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 appropriate 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 CYSTIC TUMORS OF THE OVARIES. 533 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. AVhen 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 534 DISEASES OF WOMEN. 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 very easily recognized at all times. Fortunately it would be no very 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. Affections 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 anaemic 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. AVhen 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 CYSTIC TUMORS OF THE OVARIES. r>35 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 fiuid 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 536 DISEASES OF WOMEN. 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 peritomeum, 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 tin* 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 ovary 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 very 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. L^athology.—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 ovary, 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 some, the tumor was situated in one ligament, displacing the uterus to the opposite side of the pelvis, and, in a lesser degree, the bladder CYSTIC TUMORS OF THE OVARIES. 537 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 intG 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 followTs: 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. AVhen a cystic tumor exists in the abdomen and is firmly fixed below, with no history of inflammation during the 1 41 .-)3$ DISEASES OF WOMEN. 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 suspect 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 fibrocyst 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 CYSTIC TUMORS OF THE OVARIES. 539 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. When 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. 540 DISEASES OF WOMEN. The several methods adopted in operating are as follows: Enu- cleation ranks first, because it is adapted to more cases, perhaps, than any 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 first 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 one or both ligaments. In all such cases it should be tried, and it will succeed well unless there has been inflammatory action which has firmly united the cyst-wall and folds of the ligaments, or the cyst-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 CYSTIC TUMORS OF THE OVARIES. 541 by a continuous catgut suture. The suturing should begin on 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 of 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 he 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 be 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 542 DISEASES OF WOMEN. 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 are, 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 cysts), 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 CYSTIC TUMORS OF THE OVARIES. 543 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 cyst- wall from the capsule as far down as possible. If that can be done, 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 be 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 XXIX. 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. 544 OVARIOTOMY. 545 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 wTell-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. 546 DISEASES OF WOMEN. 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 knowledge 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 thai more failures come from poor operating than from errors in diagnosis. OVARIOTOMY. 547 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 anesthetic, and I am perfectly satisfied with it when it is given in the way 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. 548 DISEASES OF WOMEN. 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. 222.—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. OVARIOTOMY. 549 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 cornplicated 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 550 DISEASES OF WOMEN. 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 two 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 Wells 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 carbohzed 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 OVARIOTOMY. 551 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 which required removal AVhile under preparatory treat- ment the patient's temperature rose to 103^° F., and there was 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 Nervous 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 552 DISEASES OF WOMEN. 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. The Nutritive 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 stomach, 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. These require more care and for a longer time. It sounds well to OVARIOTOMY. 553 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 overcoming 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 nux vomica. belladonna, and rhubarb, will relieve constipation far better than salines. Manugeme/it of the Pouyls.—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 fsecal impaction. The only difficulty is that many patients strongly object to it. AVhen it can be 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- 4*2 554 DISEASES OF WOMEN. 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 anaesthetics. 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, OVARIOTOMY. 555 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 dysmenorrhoea, 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, cither 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 fully 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 70° 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. AVarm ether is also of value in avoiding shock and chilling the patient. This is obtained by using my ether-inhaler, in which the 556 DISEASES OF WOMEN. ether is vaporized in 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 may add here that experience only tends to confirm my confidence in that method of using an anaesthetic such as sulphuric ether. List of Lnstruments and Appliances usually required in the Operation.—Scalpel with fixed handle ; dissecting-forceps; artery- Fig. 223.—Keith's short compression-forceps. forceps; six Keith's compression-forceps (Figs. 223 and 224); 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- OVARIOTOMY. DOT dominal suture (Fig. 225); Peaslee's needles; Keith's fine forceps for carrying the ligatures (Fig. 220) through the pedicle; sutures to —— ■ ---------------- ------------- imj Fig. 225.—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 which is coated with sticking-plaster an inch wide all around; long Fig. 226.—Keith's ligature forceps. 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. 227); curved scissors; concave mirror; counter-pressure instrument for tying ligatures in abdominal cavity; several drainage-tubes of different sizes; piece of Fig. 227.—Keith's modification of Spencer Well's clamp. 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. 558 DISEASES OF WOMEN. 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 ll«—J §P§~E2 e~* ^STAND. WITH INSTRUMENTS AND BASINS,' Fig. 228.—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 OVARIOTOMY. 559 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. Aiaking 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. When 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 5t;o DISEASES OF WOMEN. 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. While 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. When 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 OVARIOTOMY. 561 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 he complicated by a variety of conditions. The chief of these may be mentioned in the order in which they come. When 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. When 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 502 DISEASES OF WOMEN. the detachment is complete. When the cyst is exposed all the par- ietal adhesions should be loosened. This should be done by the hand. When 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 m unilocular 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. When 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 dene the edges of the rubber cloth should be raised so as to direct the fluid into the tub or basin at the side. When 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 writh catch-forceps. Adhesion of the omentum and the abdominal and pelvic viscera OVARIOTOMY. 563 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. When the sponges are removed the position of the bleeding vessels can be seen. When 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. When 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 56-1 DISEASES OF WOMEN. patient is feeble. The tube should be left in until the discharge becomes clear. When 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. When 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. When 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 inrision 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. W. 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- OVARIOTOMY. 565 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 supervenes 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 566 DISEASES OF WOMEN. if there is, the hypodermic is given. Kervous 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, 1 use the following: Magnesiae carb., 3 ij ; magnesias sulph., 3 iij; aquae menth. pip., 5 iij- Of this, a teaspoonful may be given every one, two, or three hours in a dessertspoonful of water. This prescription is used in the Samaritan Hospital in London. A mustard plaster to the pit of the stomach is also useful. When these remedies fail, and the patient complains of burning in the stomach, dessertspoonful doses of iced water may be used. When 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. When 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 OVARIOTOMY. 567 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. While 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. When 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- r,<;S DISEASES OF WOMEN. stores continuity of tissue and at the same time protects the normal surrounding tissue from inflammation and the patient from general septicemia. 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. CHAPTER XXX. ILLUSTRATIVE CASES OF OVARIAN 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. When 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 without success. She lost strength gradually, and it was de- 43 569 5T<) DISEASES OE WOMEN. 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°. When 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. When all bleeding had stopped the wound was closed and dressed in the usual way. 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 so for about a week. The cause of this was not certain. She was discharged from the hospital at the end of the fifth ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 571 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 locomotiom 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 wras 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- 572 DISEASES OF WOMEN. 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 wras 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 ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 573 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- 574 DISEASES OF WOMEN. 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 lOlf ° 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 days immediately succeeding the operation. ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 575 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 rive 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. 576 DISEASES OF WOMEN. 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. When I first saw her she was quite ansemic 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 rallied a little, ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 577 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. Whenever 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 cyst 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. When 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 578 DISEASES OF WOMEN. 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. When 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 by 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. While 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 ligated ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 579 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 wav. 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 days 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 Xo. 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- 580 DISEASES OF WOMEN. 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 cj^st. 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 ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 581 bleeJing 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 easily 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 582 DISEASES OF WOMEN. 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. 1 am wrell 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. Day 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, 1864) there came another case of very large tumor. The patient had been jolted for some hours in a coach, ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 5S3 and, in the hope of relieving the pain thus set up, tapping was per- formed after her arrival. The pain was not relieved, 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 mesem tery hedged in a thick-walled cyst, the base of which was in a coim 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 " Laucet,*' 1S65, 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 p;« tient 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 584 DISEASES OF WOMEN. 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 wTas 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 ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 585 160; 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, IS71. Sul- phuric ether was given. The incision extended from the umbilicus downward eight inches. The wall was much thickened, the peri- toneum 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. Posteriorly, 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 clammy 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 teacupful 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. 44 CHAPTER XXXI. DISEASES OF THE FALLOFIAN 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 a fold of the peritonaeum attached to the broad ligaments, 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 increases 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, peculiar to the tubes alone, ends as a kind of sphincter upon the abdominal orifice. The mucous membrane is lined with 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 organs of generation, shows the closest structural relationships existing be- tween 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 dilatation may exist; and there may be marked difference in length between the two tubes. Two abdominal orifices for a tube may exist, and fimbriae from each may project into the peritoneal cavity. Again, the tube may be dislocated, twisted, bent into knuckles, or may have suffered hernia along with portions of the intestine. 586 DISEASES OF THE FALLOPIAN TUBES. 587 The tubes may open into the womb abnormally low down, which may possibly account for placenta praevia in some cases. J. \Vhitridge "Williams has called attention to a diverticulum extending from the lumen of the tube into its wall, and reaching almost to the peritoneal covering. Such diverticula he has found to he lined with the typical single layer of ciliated epithelium, and to be in all respects like the tube itself. In speaking of this malforma- tion, AVilliams says that these diverticula may hold a causal relation to tubal pregnancy. A fertilized ovum might readily be driven by the action of the cilia into such a cul-de-sac, and there develop. 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 diphtheria) 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 5SS DISEASES OF WOMEN. 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- 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 endo- metritis that the symptoms of salpingitis are merged with those of the primary 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 haem- atocele, but as well marked as in pelvic cellulitis of a mild type. When 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- DISEASES OF THE FALLOPIAN TUBES. 589 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 elon- gated, 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 nine- teen. 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 recovery 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 ozena. 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 sal- pingitis septica including S. pyaemica, ichorosa, purulenta, and diph- theritica, which are due to specific microbes identical with those producing 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- 590 DISEASES OF WOMEN. tions. When the acute symptoms subside, iodine, ichthyol, and mercury have been used locally, and massage and electricity also, with some possible good results. <' When 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. Laparo-salpingotomy as first practiced by Tait and Ilegar is the recognized treatment in these otherwise incurable diseases of the tubes, and the results are very satisfactory. It is not always pos- sible to ascertain whether hydrosalpinx or pyosalpinx exists; hence it is wise to perform laparotomy and remove the diseased tube if it is the seat 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 trust 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 by pseudo-membranes. The thickening results from infiltration. Acute catarrhal salpingitis ordinarily 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 mus- cularis, contain the tubercle bacillus. Symptoniatology.—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 examinations when its immobility, size, tortuosity, and nodular feel, taken in connection with the constitutional condi- tions, causes us to suspect tuberculosis of the tube. Possibly 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. DISEASES OF THE FALLOPIAN TUBES. 591 'M 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 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 evacuation 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 intensity. Etiology.—Intense hyperaemia of the genitals, retroversion, ty- phoid 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. Treedment.—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, 592 DISEASES OF WOMEN. they should be hooked up with the fingers and brought out through the wound, 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 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. The highest authorities agree, at the present time, that when both ovaries and tubes are diseased and require to be removed, the uterus should be removed also. Various reasons are given for this. Some surgeons contend that the operation is more easily performed than when the uterus is left. This is my own opinion, and I prac- tice accordingly in suitable cases. When the adhesions are not very extensive and the disease of the tubes does not extend close to the uterus, a pedicle can be formed and controlled by one ligature, or, better still, the electric haemostatic forceps. I prefer to operate in the old way described above. On the other hand, when the disten- tion of the tubes extends close to the uterus and the adhesions are firm, I remove the uterus also. Kelly's method is the one for which I have preference. The operation is exactly the same as abdominal hysterectomy, already described in treating of uterine fibromata. At the present time I use the haemostatic forceps in- stead of the ligature to control the vessels. In this method of oper- ating the cervix uteri is not removed. Those who believe that the uterus is not only a useless but a dangerous organ after the ovaries have been removed, insist upon complete extirpation of the uterus in all cases requiring double ova- riotomy. Yery much has been said and written on this subject within the past few years, and although many positive opinions have been expressed, I fail to see that they are based upon sufficient clinical observation. For the present I have adopted the following rules of practice: I completely extirpate the uterus in connection with laparo-salpingo DISEASES OF THE FALLOPIAN TUBES. 51*3 ovariotomy when there is septic endometritis present, or any other disease of the uterus that does not promise to disappear when the ovaries are removed, and when there are extensive adhesions and secondary cellulitis of- the broad ligaments—conditions that require after-drainage. When it is possible to determine beforehand that complete extirpation of the uterus is indicated, I circumcise the vagina with the galvano-cautery, and separate the uterus from the bladder up to the peritonaeum before opening the abdomen. 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 ladv, who gave a history of some rather obscure pelvic affection which had existed 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 presumed that this was the whole cause of her suffering. He was able to re- store the uterus to its place, but could not keep it there, because 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 un- able 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 fluctuation. 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 the tube, was repeated a number of times, with this difference, that the accumulation of fluid was less. I regret that I do not have notes of the length of time that the 591 DISEASES OF WOMEN. 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 pa>t doubted if ever pyosalpinx ended in recovery without removal of the tubes, but this case shows that such may occur. The patient was twenty-five years old, and married. 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 uterus 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. Double Pyosalpinx; Amputation with Haemostatic Forceps; Re- covery.—Entered Long Island College Hospital, September 21, lS'.'O. DISEASES OF THE FALLOPIAN TUBES. 595 D. G., native of Norway, and single, began to menstruate at thir- teen years, and regular. Ten months ago came to this country ; had amenorrhea for three months, then menstruated with severe pain for one day ; since then menses have been normal. One month prior to admission was seized with severe pain in the left ovarian region, which gradually extended to the right and across the back. At this time there was a profuse yellowish discharge from the vagina, together with painful and frequent micturition. Diagnosis.—Pyosalpinx (double). Treatment.—September 27, 1896, abdomen was opened, the ova- ries and tubes were freed from adhesions, and the broad-ligament pedicle on either side seized with the long compression forceps, cur- rent turned on and continued for two and a half minutes. The tube and ovary were amputated, when haemostatic forceps were removed and there was no haemorrhage. A number of bleeding points deep down in the pelvis were treated by the method in question. Abdo- men was closed with silk. Time consumed in operation, twenty-five minutes. Convalescence progressive and uneventful. Temperature on third day, 100"5° F.; pulse, 102. This was the highest temperature until the sixteenth day, when it was 102° F. ; the next morning it was down to normal. Cause of rise unknown. Sutures removed on the eighth day ; primary union. Left hospital three weeks after operation. CHAPTER XXXII. PELVIC CELLULITIS. TnE 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 pro- Fig. 229.—Diagrammatic transverse section of the pelvis (Luschka). tity 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 596 PELVIC CELLULITIS. 597 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 liga- ments, comes under the observation of the