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(
\ *
iUSK.\S.I-S !,r \l.
f
' *■ r^ »: '^ i HK
>V i
U'
TREATISE
ON THE
MEDICAL AND SURGICAL
DISEASES OF WOMEN.
WITH THEIR
HOMCEOPATHIO TeEATMENT.
Ijully lllustiiatcfl.
BY
MORTON MONROE EATON, M. D.,
Cincinnati, Ohio.
•■»•
» ' , t ■» ^ - ' -
■ ^ * - ^ ^ • • • ' ' ^ ' '
BOERICKE & TAFEL.
NEW YORK, PHILADELPHIA,
145 Grand Str. 635 Arch Str.
TRUBNER & CO.,
LUDGATK Ujll, E. C. LONDON. ENG.
1880.
"\
Copyright Secure
AND ALL RIGHTS UNDER IT R
BY THE AUTHOR.
i%0
PREFACE.
In conformity to custom, the Author presents some of the reasons which have induced him to present this work to the homoeopathic medical profession.
First. Because he has been for several years repeatedly urged to do so, by prominent homoeopathic physicians of several States, including representative men in the cities of Chicago, St. Louis, New Orleans, Boston, Louisville and Cincinnati.
Secondly/. Because homoeopathic colleges have been obliged to recommend, and homoeopathic physicians and students have been obliged to provide themselves with, allopathic works upon these diseases ; thereby giving a certain amount of sanction to the treatment therein advocated, and causing the use (among otherwise good homoeopathic phy- sicians) of caustics, scarifications, etc., applied to the uterus, to become so common among them as to bring a blush of shame to the face of the true homoeopath. In the use of pessaries and drugs, the homoeopathic profession have also inadvertently been following, in part, their oM-school breth- ren's treatment ; because they largely have been obliged to
IV PREFACE,
study the description, etiology, diagnosis, pathology, and prognosis of these diseases frtm their books. The homcBo- pjithic books which we have had upon the diseases of women, though written by gentlemen of high standing, do not seem to meet all the requirements of the profession, though excellent, so far as they go.
Thirdly. Because it seems time that homocopathists should have complete text books on all branches of medical education ; the large increase in the number of homoeopathic physicians from year to year justifying the expectation^ that erelong we may rival the old school in numbers, as we now do in the intelligence and wealth of our patrons.
Fourthly. Because the homoeopathic physicians of Illinois and Ohio, in their State societies, and of the North-west, in the Western Academy, have honored him with their con- fidence, and shown their respect by giving him prominence in regard to these diseases, and because he has had a large experience in their treatment for over twenty years, in hospital and private practice (allopalhic and homoeopathic).
He has endeavored to make this work as complete as possible. How far he has succeeded, the profession must judge. He believes the works upon the diseases of women, by Thomas and Emmet, of the old school, are ordinarily considered complete; but he finds that Prof. Thomas* omits in his index, Lacerations of the Cervix Uteri; and Prof. Emmet f omits Areolar hyperplasia of the uterus, Hydatids of the uterus, Rectocele, Sterility, Inflammation of the uterus, in all forms, except as he refers to congestive hypertrophy. Abor- tion, Pudendal hemorrhage and Pudendal hiematocele. And
♦Thomas' Diseases of Women. t Emmet's Prin. an<l Prac. of Gvn.
PREFACE. V
both Profs. Thomas «ind Emmet omit Hysteralgia, Puerperal fever, Puerperal phlebitis, Mammary Abscess, Cervicitis, Sympathetic Affections, and Nymphomania, as well as Puer- peral mania. He is hopeful that this work will not be found less complete.
Neither Dawson's improved Sims' speculum nor Wocher's bi-valve speculum are mentioned in either of these works, or those of any other author on Diseases of Women (so far as he is aware), and they need but to be seen to be appre- ciated as decided improvements. Cutler's suture cutter and forceps, his own improvement of the London Abdominal Supporter, his needle holder, and wire holder and twister, for vaginal fistulse, have not heretofore been presented to the profession.
He has spared no pains or expense to have his illustra- tions perfect and complete. In this he is greatly indebted to Mr. John H. Bogart, designer and engraver, of this city. He has not attempted to make a Materia Medica, but has named such remedies as he has found beneficial, and given the prominent homoeopathic indications for their use in each disease, gleaning somewhat from other authors, as well as his own experience.
The Author, in conclusion, would express his thanks to Drs. S. R. Beckwith, of Cincinnati; W. H. Hunt, of Cov- ington, Ky. ; M. B. Pearman, of St. Louis; T. P. Wilson, of Ann Arbor, and others, for valuable suggestions.
Respectfully,
M. M. EATON.
ClNCnSNATI, O.,
U. 8. A.
TABLE OF CONTENTS.
■^
CHAPTER I.
I'AOK.
iNTRODUCnON, 17
CHAPTER II.
General Diagnosis, 21
CHAPTER in.
Normal Menstruation, and Amenorrh(£a, 31
CHAPTER IV. Menorrhagia and Metrorrhagia, 41
CHAPTER V.
Dysmenorrhea, or Painful Menstruation, 46
CHAPTER VI.
Vicarious Menstruation, 56
CHAPTER VH.
Inflammation of the Female Genitalia, 60
CHAPTER VIII. Metritis, 77
CHAPTER IX.
Areolar Hyperplasia of the Uterus; or, Chronic Parenchyma- tous Metritis, . 87
vni TABLE OF CONTENTS,
CHAPTER X.
Paoi
Perimetritis— Pelvic Cellulitis— Pelvic Abscess, . .11
CHAPTER XI. Child- BED Fever — Puerperal Peritonitis, Puerperal Metritis,
METRO-PHLEBITIS, AND PERITONITIS, 12
CHAPTER XII. HoM(EOPATHic Remedies, 13
CHAPTER XIII. Instruments, 14
CHAPTER XIV.
Induration and Hypertrophy of the Cervix Uteri — Vaginismus
AND DySPAREUNIA, 16
CHAPTER XV. Ulceration of the Os Uteri, 17
CHAPTER XVI.
Vaginitis— Adhesions in the Vagina from Inflammation— Diph- theritic Inflammation of the Vagina— Peri- Vaginitis Phleg- MONOSA Dissecans, 18
CHAPTER XVII.
Imperforate Hymen— Atresia of the Hymen (Congenital and Acquired) — H^matometra, Etc., 19
CHAPTER XVni. Uterine Hemorrhage, 20
CHAPTER XIX.
Cervicitis and Endo-cervicitis, or Catarrh of the Cervix, . 21:
CHAPTER XX.
Endo-Metritis, 211
CHAPTER XXI. Leucorrhgea— Whites, 24(
TABLE OF CONTENTS. IX
.CHAPTER XXII.
Page.
Barrenness and Sterility, 249
CHAPTER XXm. Diseases of the Ovaries, 265
CHAPTER XXIV. Ovarian Tumors, 275
CHAPTER XXV.
Ovariotomy, 312
CHAPTER XXVI. Uterine Fibroma— Myoma— Fibrous Tumors of the Uterus, . 342
CHAPTER XXVn.
Uterine Polypi — Veoei'ations of the Endometrium — Uterine Hydatids —Vascular Polypi — Placental and Granular Pol- ypi, Etc., 362
CHAPTER XXVIII. Moles in the Uterus, 375
CHAPTER XXIX. Catarrh op the Uterus and Vagina, 380
CHAPTER XXX. Hernia of the Ovary— Hernia of the Uterus, or Hysterooele, 885
CHAPTER XXXI.
Prolapse of the Vagina, Cystocele, Rectocele, Enterocele, and Ovariocele, . . . . 389
CHAPTER XXXH. Papillary Tumors of the Uterus and Ovaries, and CJoccyoodynia, 395
CHATTER XXXIII.
Cancer and Cauliflower Excrescence of the Uterus — Carci- noma, Sarcoma, Etc., 400
CHAPTER XXXIV.
Femoral Hernia, Inguinal Hernia, Labial Hernia, Vaginal
Hernia, and Hydroc!ele, 404
X TABLE OF CONTENTS.
CHAPTER XXXV.
Pagx.
Htdrohetra — Pruritus VuLViE— Abscess op the Labia — Cysts op THE Vagina — Fibroids op the Vagina— Polypi op the Vagina — Prolapse of the Ovaries, 406
CHAPTER XXXVI. Abortion, 421
CHAPTER XXXVII.
Cysts of the Broad Ligament and Diseases of the Fallopian Tubes, 487
CHAPTER XXXVin.
Diseases of the Urethra— Urethritih, Caruncles of the Ure- thra, Irritable Urethral Carunculu£, Ulceration, Fissures OF THE Neck of the Bladder, or Meatus Urinarius Internus, Lacerations of the Uretbra from Dilatation, Prolapse op the Urethra, Urethral Polypi, Etc., 446
CHAPTER XXXTX. Tuberculosis of the Vagina— Stenosis of the Uterus, . . 451
CHAPTER XL. Cystitis in Women, 455
CHAPTER XLL Stone in the Bladder and Ureters, 462
CHAPTER XLH.
Sympathetic Effects of Diseases of the Uterus* and its Append- ages, 472
CHAPTER XLm.
Pudendal Hemorrhage — Pudendal Hjematocele — ^Thrombus — Rup- ture OF the Bulbs of the Vestibule, 490
CHAPTER XLIV. Puberty — And the Cumacterio Period, 494
CHAPTER XLV. Atresia of the Vagina, and Cervix Uteri— H^kmatometra, Etc., 602
TABLE OF CONTENTS. XI
CHAPTER XLVI.
Page.
Fistula— Vesico- VAGINAL Fistula — Recto- vaginal Fibtula— Recto- •VE8ICAL Fistula — Vesico-cervical Fistula— Urethbo-vaginal Fistula— Intestino- VAGINAL Fistula — Ureto- vaginal Fistula — Vbbico-uterine Fistula — Peritoneo-vaginal Fistula— Perineo- vaginal Fistula— Blind Vaginal Fistula— Fistula in Ano, . 611
CHAPTER XLVn. Lac!Erations op the Cervix Uteri, 539
CHAPTER XLVm. Displacements of the UteruSi 552
CHAPTER XLIX.
Different Forms of Displacements of the Uterus— Inversion of THE Uterus, 663
CHAPTER L. Retro-version and Retro-flexion of the Uterus^ ... 678
CHAPTER LI.
Ante-version and Ante-flexion of the Uterus, . . . .593
CHAPTER LH.
Prolapsus Uteri and Procidentia, : 605
CHAPTER LHI.
Laceration of the Vagina— Laceration of the Perineum — Ulcer- ation (Tuberculous, Cancerous, and Syphilitic), . . 629
CHAPTER LTV.
Extra-uterine Gestation, 642
CHAPTER LV.
Strangury, Dysuria, Ischuria, Retention of Urine, Suppression OF Urine, Enuresis, Etc., 646
CHAPTER LVI.
Gonorrh(ea in Women, 650
CHAPTER LVII.
Syphilis in Women, 655
CHAPTER LVIII. Diseases and Difficulties of Pregnancy, 660
XII TABLE OF CONTENTS.
CHAPTER LIX.
Page
Vomiting ix Pregnancy, 675
CHAPTER LX. Puerperal Mania, 68^
CHAPTER LXI.
Diseased and Deformed Nipples— Milk Fever — Abscess of the Breast— Tumors op the Breast, Cancer, and Amputation of the Breast, 69:
CHAPTER LXn.
Phlegmasia Dolens — Puerperal Phlebitis, or Milk leg, . 70J
CHAPTER LXIH. Hypertrophy, and Sub-involution of the Uterus, . . .70!
CHAPTER LXIV. Hematocele, Pelvic Hjematoma, 'J'hrombus, Etc , 71 1
CHAPTER LXV.
Elephantiasis, or Hypertrophy of the Clitoris, Labia Majora, AND Labia IMinora, Hermaphrodites, Nonentities, Tumors of THE Labia, Etc., 72:
CHAPTER LXVL
Extirpation of the Uterus — Ablation of the Uterus, Hyster- otomy, Etc., 72
CHAPTER LXVn.
Hysteralgi A — Neuralgia Uteri — Irritable Uterus — Ascites in Women, 73<
CHAPTER LXVIH. Bathing — Vaginal Washes— Stomatitis Materna, ... 74^
CHAPTER LXIX.
Nymphomania {The *^ Fureur Uterine'' of the French) — Atrophy and Hyper-involution of the Uterus — Absence of the Uterus — Malformation of the Uterus— Anesthetics, . . .75^
CHAPTER LXX. Hysteria, 76'
ILLUSTRATIONS
Alpliabetlcally Arranareilt
ABSENCE of the uterus, . .
Ante-yersion of the uterus, .
Ante-flexion " •*
Antiseptic spray apparatus,
Applicator sponge tent, . . " uterine, Emmet's,
" «' Palmers,
Artery forceps,
Asbton's perineum needle, .
Aspirator, Tiemann & Co.'s, " Dieulafoy's, . . .
Atresia of the TRgina, . . .
Page.
opp. 723
** 698
" 599
" 156
. . 360
. . 806
. . 715
. . 322
opp. 150
158
154
503
((
((
BABCOCK supporter, ..... opp. 146 Battery, Faradic, 38, 160, 714
*' combination, 38
Bed swing, 339
Bi-vaWe speculum, yaginal, . . opp. 143
" " urethral, .... 446
Bony peWis, female, . . . opp, title-page.
Bozeman's teua'culum, opp. 158
*' curved scissors, 523
'' straight scalpel, 630
CALLENDER'S drainage canula, opp. 158 Canula drainage, . . . 833, and " 158
Catlieter, reversible, 457
" self-retaining, .... opp. 1,08 Cervix uteri, hypertrophy of, ... . 102 elongation of, , . . opp. 009 anjputated (two tigs.), 109
double, 755
(^Invir examination, 22
Civiale's lithotriptor, opp. 147
a
It
Page. Clamps for pedicle of ovarian tu- mors, opp. 101
Clamp, Tbomns*, »* 101
*' Dftwson's improved, 321
" Spencer Wells' original, opp. 101
" *' " new (three figs.),*' 101
Clitoris, hypertrophy of, ... . " 723
Combination battery, 38
Complete procidentia uteri, . . opp. 611 " inversion of the uterus, " 503
Counter pressure hook, 521
Curved scissors, 530
" «♦ Bozeman's, 523
" " long, 146
" '* Emmet's, 720
Cutler's suture cutter and forceps, . . 535
DAWSON'S pedicle clamp, improved, 321 <' Sims' speculum, . . opp. 142
Depressor, vaginal, 522
Dieulafoy's aspirator, opp. 154
Dilator, uterine, "147
" sponge tent, "153
" vaginal, " 145
Double t-enaculum forceps, 323
*' uterus, 754
" cervix uteri, 755
*' uterus and vngina 503
Drainage tubes, .... 333, and opp. 158 Dressing forceps, uterine, . . . . ** 144
EATON'S needle-holder in use, . . .527 " i' i{ ... opp. 145
" wire holder and twister, . " 145
XIV
ILL USTRA TIONS.
Page. Eaton's wire holder and twister,
applied, opp. 145
" improjed London sup- porter, ** 167
Ecri\seur, Edwards', 869
Edwards' Ecraseur, 869
Elastic pessaries, 149
*' abdominal supporters, . opp. 157
Electrode, intra-uterine, 714
Electrolysis needles (one fig.), . . . 160 *' " (seven figs.), . . 870
Elevation of the uterus, .... opp. 718 Elevator, Elliott's uterine, ..." 159 Elliott's uterine elevator, ..." 159 Elongation of the cervix uteri, . *' 609 Emmet's sponge tent applicator, 597, 866
** curved scissors, 726
" spuiigc dilator, .... opp. 158
*' " holder, 826
" counter pressure hook, . . .521
'* speculum, • . . 685
Enlargement of the clitoris, . . opp. 728 Enucleators, Sims' (three figs.), . . . 865
Endoscope, urethral, 446
Examination chair, 22
Exploring trocar, opp. 154
Extirpated uterus, 788, 784
FARADIC batUries, ... 88, 160, 714
Female form, opp. title page.
«* pelvis, bony, . . " ** " Fibroma of the uterus, . . . 848, 852, 854
*' <* cervix, ; 848
'* uterine, subserous, 848
*' " submucous, .... 848
«» « 852, 854
Fibroids, syringe for iigecting, . . . 171
Fistula, vaginal 524, 526, 527
" " opp. 585
Forceps, vulsellum, " 154
" Nelaton's tumor, ... •• 156
" pedicle 865
*' straight lithotomy, . . opp. 147
" «* needle, 626
" artery, 822
" double tenaculum, 828
'* uterine dressing, 184
** ** ... opp. 144
«* Greenhalgh's, 208
'* Cutler's suture, 585
Paox. Front view of uterine organs, . opp. 17 Furguson's mirror speculum, . . '* 143
GREENHALGH'S forceps, 208
H.£MATOCELE, recto-vaginal, opp. 718
Hsematometra (two figs.), 508
Hermaphrodite, opp. 728
Hypertrophy of the uterus 710
»* of the clitoris, .... opp. 728 " ** labia majora, . ** 720
«* " *< minora, . " 725
«* " cervix uteri 162
Hysterotome, White's, opp. 144
" Simpson's, .... " 144
IMPROVED London abdominal sup-
porter, opp. 157
Imp'd Peaslee penneum needles, " 14€
Inflatable pessary, 14S
Inhaler, Lente's modified, . . . opp. 15C
Intra-uterine electrode, 714
Inversion of the uterus, .... opp. 66£
LACERATION of the perineum, . . 63€ ^' of the perineum, adjusted, 63^ " *' •* sutures placed, 68^
Lente's inhaler, opp. 15(
Ligature cutter, 58£
Ligatures, 169, 84(
Lithotomy forceps, opp. 141
Lithotriptor, *' 141
Little's antiseptic spray apparatus, ** 15(
** trocar, •* \h\
London abdominal supporter (old), " 151 »* ** " improved, ** 161
Long curved scissors, 14(
«* « trocar, Vll
a *i a (uterine), . . . . 61(
M'INTOSH'S supporter, 15(
Mirror speculum, opp. 14J
Mucous polypi, uterine, 85:
NEEDLE HOLDER, Eaton's, 627, opp. Hi
" »* Sims', 62(
** " curved, . . opp. 14i
" " straight, . . . . 62<
Needles, Pease's, 141
** suture, curved, .... opp 151
ILLUSTRATIONS,
XV
M
it u
Page. Needles, suture, full curved, . . " 168
" perineum, " 166
" *• Ashton's, . ..." 166
a i( Peaslee'simproTed, « 166
" open-eyed, 826
" electrolysis, 160
" " (seven figs.), . . 870
Nelaton's pedicle forceps, 866
" tumor forceps, .... opp. 166 Nelson's tri-valve speculum, . . *' 148
Nonentity. •* 728
Nott's depressor, 622
OLD WOMAN'S uterus, 27
" " vagina, 27
Old London abdominal supporter, opp. 167
Open-eyed needle, 826
Operating tables, 819. 708
Operation for lacerations of perineum, 686 << vesico-vaginal fistula, opp. 686
«* 624, 626, 627
Original speculum, Sims', . . . opp. 142
" clamp, Spencer Wells', . " 161
** London supporter, ..." 157
Os uteri, virgin, 26
" ** old woman's, 27
PALMER'S uterine dilator, . . . opp. 147
" applicator, 616
Peaslee's perineum needles, . . opp. 156
Pease's needle (perineum), 148
Pedicle clamps (four figs.), . . . opp. 161 " " Dawson's improved, . . 821
Pelvic haematocele, opp. 718
Pelvis, female, bony, . . . opp. title page.
Pessary, inflatable, 149
" elastic ring, 149
Perineum, operation for restoring lac- eration of, 685
" restored after laceration of, 638
Polypi, mucous uterine, 352
fibrous uterine, . . . 843, 352, 354
Procidentia uteri, opp. 609
" complete, . . . '* 611 Prolapsus uteri, .... opp. G05 and 710
opp. GOG
" G08
<.
(i
QUILL, suture, adjusted, G38
t<
t<
u
Page. RECTO- VAGINAL hasmatcoele, opp. 718
Repositor, White's uterine, 673
Retractor, Emmet's vaginal, .... 685 Retro-version of the uterus, . . opp. 578 Retro-flexion " " . . . ** 580
Reversible catheter, 457
Round elastic pessary, 149
SCALPEL, Boseman's, 686
Scissors, «« 628
" curved, 630, 726
Self-retaining catheter, .... opp. 158 Side view of uterine organs, . . opp. 21
Sims' uterine elevator, " 150
" enuolcators (three figs.), .... 365
needle holder, . > 626
original speculum, .... opp. 142 folding «* . ..." 142
" Dawson's imp. •« . . . . « 142
" vaginal dilator, " 145
" sponge holder, 326
" sponge dilator, opp. 153
<< enuoleators, 847
Simpson's sound, opp. 144
" hysterotome, . . . . " 144
Skene's sound, " 144
" urethral endoscope, 446
Sound, steel, opp. 144
" Simpson's, " 144
*• Skene's, " 144
Speculum, urethral bi-valve, .... 446
" " Skene's, 446
" Sims' (three figs.), . . opp. 142
Wocher's bi-valve, . . " 143 Nelson's tri-valve, . . " 143 Furguson's mirror, . . " 143 Emmet's vaginal, .... 635
Spencer Wells' trocar, 320
" " artery forceps, 322
** ** pedicle clamp (orig'l), opp. 161 <« ii « .i ne^^ (three figs.), " 161
Sphygmograph, 161
Sponge tents, 150
Sponge tent applicator, 3GG
" holder, 597
" dilator, opp. 153
" sponge holder, 32G
Subserous fibroid of uterus, 343
Submucous " " " 343
(t
II
It
((
t(
«
XVI
ILLUSTRATIONS,
Paok.
Swing, hcJ, 339
Sub-iuTolution of the iiteniSf . . . .710
Supporter, Babcock*s, opp. 14G
" old Loudon abdominal, . . ** 157 " impiM Lond. abdM, Eaton's, " 157
" silk elastic, " 157
" Mcintosh's, 150
Suture cutter nnd forceps, 535
" needles, curved, .... opp. 158
" " half curved, . . '* 158
Sutures in cervix uteri (two figs.), . . 1G9
Syringe for injecting uterine fibroids, 171
TABLES, operating, 319, 703
Tenaculum, Boseman's, .... opp. 158
«* double,* 823
Tliomas' pedicle clamp, .... opp. 161 Ticmann & Co.'s aspirator, ... " 163
Trocar, common, 391
" exploring, opp. 154
" long curved, 125
" " »* uterine, 510
»* Spencer Wells', 320
" Little's, opp. 159
Tri-valve speculum. Nelson's, . . opp. 143
Tumor forceps, Nelaton's, 305
" " *« .... opp. 15G
UTERINE organs, normal posi- tion, opp. 17, 21
** dressing forceps, . .184, opp. 144 *» elevator, Elliott's, ... " 159
»* " Sims', " 150
»* repositor, White's, 573
«* fibroids (three figs.), .... 343 " " syringe for injecting, . 171
Page.
Uterine polypi (mucous), 352
" (fibrous), .... 352, 854 *• dilator, Palmer's, .... opp. 145
Uterus, hypertrophy of, ... . 162, 710
" sub-involution of, 710
" virgin, 20
" old woman's, 27
»' double, 503, 754
" extirpated (two figs.), . . 733, 734
" elevation of, opp. 718
" prolapse of, . . opp. 605, 606, 009
«< «' " opp. 710
** versions of, ... . opp. 578, 598 " flexions of, .... " 580, 599 " procidentia of, . . . ** 609, 611
" absence of, opp. 728
** drawn out ill sight, . . . ** 585
VAGINA, old woman's, 27
" atropliy of, opp. 723
" atresia of, 603
" double 503
Vnginal dilator, opp. 146
" pessarioH, 149
** specula (three figs.), . . opp. 142 u «« *< .< . , « 143
Virgin os uteri, 26
Vulsellum forceps, .... opp. 154, 586
AVELLS' artery forceps, 822
*^ pedicle clamps (4 figs.), opp. 161 " trocar, 820
White's uterine repositor, 573
Wire holder and twister, Eaton's, opp. 145 " " *• ** " applied," 145
Wocher's bi- valve speculum, . . . '* 143
18 EA TON ON DISEASES OF WOMEN.
fine flour, and highly seasoned food have driven out of use, almost, the plain bread and milk and mush and milk of our fathers.
Again, the fashion of lacing the chest and upper part of the abdomen has been, perhaps, the most fruitful cause of the long ti-ain of women's ailments and weaknesses. By con- tracting the thorax the action of the heart is impeded, the lungs are prevented from a full expansion, the blood is con- tinually charged with too large a quantity of carbonic acid gas. Oxygen is not received into the blood in sufficient quan- tities to stimulate healthy nerve action, and the result, of course, is lassitude, debility, and disease.
Another injury resulting from lacing the upper part of the abdomen is, that the abdominal organs are thereby displaced downwards, and press heavily upon the uterine organs. These are thereby displaced and inflamed, producing not only the symptoms resulting directly from these conditions, but an immense amount of trouble through reflex action on the cer- obro-spinal and sympathetic nervous systems, thereby derang- ing all the normal functions of the body, and sometimes the mind as well.
The wearing of clothing suspended from the hips aids in producing all the ills just mentioned, as resulting in greater or less degree from lacing. Thin clothing, especially upon the extremities, in winter, conjoined with the previously nien- tioned customs, is not to be forgotten as one cause of female suffering.
And, finally, the cause which, we must recollect, is the great curse of the American ladies is to be found in those means used to prevent pregnancy and produce abortion. The disinclination of so many married ladies to become moth- ers has led them to adopt means for the prevention of concep- tion that have had the effect of producing diseases in them- selves of a serious nature. The various means used to pro- duce abortion have entailed on many a lady life-long suffering.
20 EA TON ON DISEASES Of WOMEN.
It may be well to mention that the early introduction ii society of girls of tender age, the desire of mothers to ma young ladies of their girls when they should be consider children, requiring them to refrain from that active exerci that is so necessary for the full development of muscle a strength; the early marriages so frequently consummate together with the constitutional debility inherited from mol ers already affected with weaknesses dependent upon errc of their diet, clothing, and exercise in early life, — all te to enfeeble the constitution and develop special weakness and diseases.
34 ' EATON ON DISEASES OF WOMEN.
attention to his directions and co-operation in the treatment which is so essential for success in any disease, but more es- pecially in those peculiar to women, as, owing to their deli- cacy, it is necessary that much of the treatment be carried out by themselves. The physician has not the opportunity to frequently examine the case, or apply treatment, as in other aihnents.
The general appearance of the patient is to be studied, and the diathesis noted. The cancerous cachexia, which is indi- cated by the sallow, brownish yellow complexion, combined with the anxious, wearied, sunken countenance, is to be rec- ognized at a glance. The tuberculous cachexia is indicated by the shrunken features, the bright, glassy eye, the hectic cheek, emaciation, with the hopeful condition of mind of the patient, conjoined with the slight or severe cough, which the patient always insists is but a slight cold. The location of the tuberculous matter nuiy be in the lungs, liver, bowels, brain, or other parts of the system. But if we have the tuberculous or cancerous cachexia clearly defined, we must, of course, address the treatment to the general condition of the patient, being assured that unless we are able to bring the system to a better standard of health we will have little reason to hope for a favorable termination of the case, what- ever special ailment the patient may have. To what extent these conditions or diatheses may be removed with proper remedies I will state under their proper chapters.
A question may arise in the mind of the physician as to the propriety of suggesting a physical examination in case the patient is an unmarried lady. Some seem to think these cases should never be subjected to physical examination, and let them suffer on. Now, while I would not propose a phys- ical examination of the virgin as soon as I would in the ciise of a patient that had been married, and would try to avoid the necessity of making an examination, still, if the case seemed to require it very urgently, on account of the long
28 EATON OAT DISEASES OF WOMEN.
ease did we not know this change was peculiar to women after the climacteric period h«as been pjissed several years.
Finally, I will agree with Professor By ford in saying that a tender uterus is a diseased uterus. Normally, it is not tender. It should give no pain to make a thorough examina- tion, either digital or with the speculum or sound. If a care- ful examination gives pain we may be assured that something is wrong; that is, always understanding that a suitable sized speculum is used. A speculum of no considerable size should, of course, be introduced into the virgin vagina.
For these examinations I prefer the uterine sound in- vented by Simpson, though I desire two or three sized probes always at hand. The bi-valve speculum manufactured by Max Wocher & Son, of Cincinnati, is the speculum I gen- erally use; but in some cases we must have the tri-valve. Nelson's is, perhaps, the best. I find little use for the com- mon glass instrument recommended by Furguson. Occasion- ally a case can best be examined with the aid of Sims* slit speculum, but its use requires the aid of an experienced assistant. (See chapter on Instruments.)
The diagnosis of diseases of women has been greatly aided during the past twenty-five years by our distinguished coun- trymen, Drs. Ludlam and Byford, of Chicngo ; Sims' of New York; also, Simpson, of Englan<l; Kiwisch, in German}'; , Huguier, in France; and Zienissen, of Bavaria; though the uterine sound and vnginal speculum were known to the ancients, Soranus having mentioned their use.
Conjoined manipulation seems to have been well under- stood by Puzos, as far back «ns 1750. In the excavations of Pompeii a speculum was found, the three blades of which were expanded by a screw ; but, so far as we can learn, its use was not appreciated until within the last quarter of a century.
Anaesthesia is to be employed in cases that can not be well diagnosed without its use — such cases are those who
30 EA TON ON^ DISEASES OF WOMEN.
fingers of the other hand down into the pelvis from above, pressing just above the pubis, and carrying the abdominiil walls downwards before the fingers into the pelvis. In this way the position and diseases of the uterus mny sometimes be diagnosed.
In cases of enlargement of the uterus from tumors, or in pregnancy, the extended pahn of the hand is laid upon the hypogastric region, in making this examination, instead of pressing down into the pelvis. Rectal examination is some- times necessary to determine the diagnosis of disease in the pelvis. This is especially the case in the diagnosis of retro- version, cellulitis, recto-vaginal ha3matocele, and some of the diseases of the ovary. The student should also bear in mind that hemorrhoids, fissures of the anus, tumors in the rectum, prolapsus of the bowel, etc., may simulate uterine disease or displacement. The second finger should ordinarily be used in making a recbil examination, as it is longer than the other fingers and consequently enables us to reach higher up in the bowel. The finger should, of course, be well smeared with vaseline or some oleaginous substance, as in making a vaginnl examination. In making a rectal examination the patient should lie upon her side, with the thighs flexed upon the abdomen. Over the patient should be thrown a cover. There is no need of any exposure of the person in these examinations unless we have reason to suspect fissures of the anus from having hemorrhage from the rectum and finding no hemoi^- rhoids, and then the parts can be seen through the slit in the cover. In the office we have a cover always at hand about two thirds as large as a sheet, with a slit about five inches long in its center. A slight opening may be made in a sheet and be kept at the house by the patient when we make visits to her there, in cases requiring frequent examination. An ordinary sheet may be used for a cover in an emergency.
32 EATON ON DISEASES OF WOMEN.
napkins, others ten or twelve; some have the flow to last only two or three days, others six or eight; hence, a condition that would be amenorrhoea in one woman, would be a full menstruation in another. The physician should learn the peculiarity of his patient in this regard at first, if possible, that he may better judge the proper amount that should be discharged. The interval also varies much; some mensttniate every three weeks, others every six weeks, and are healthy ; but these are exceptional cases. Another class of exceptional cases are those who never menstrunte, and are still in good health. This cLiss is exceedingly small.
In addition to the absence of the usual menstrual flow, we have various symptoms manifesting themselves in amenor- rhoea. First, pain in the back and loins at about the time the menses should occur; nausea, produced from sympathetic nerve action, occasioned by the congested condition of the uterus, resulting from the failure of menstruation; acute or chronic inflammation of the uterus; anaemia, sometimes result- ing from the vitiated sanguification produced from the genenil demngement of the digestive and assimilative process ; head- ache, dizziness, lassitude, the white tongue, palpitation of the heart, shortness of breath, loss of appetite, and a general atonic condition of the system. This latter condition is known as chlorosis.
Another symptom which has been too little recognised by- authors is congestion of the lungs, and is so frequently a con- dition resulting from amenorrhoea, that I am surprised that more has not been written on the subject. I have frequently^ been consulted in cases that were supposed to be phthisis,' without any doubt (cases which had been so diagnosed by sev- eral physicians), where the cough and emaciation had gradually increased for two or three years, and, in one instance I recall now to my mind, over six years, where I found the history
40 EA TON ON DISEASES OF WOMEN.
leucorrhoen, that sometimes seems to take the place of the menstruation, is not to be stopped by astringent vaginal injec- tions, as is so often done by the allopaths ; but we are to consider that the leucorrhoea is a symptom of the inflamed condition of the endometrium, or vngina, and that remedies to relieve the inflammation will not only restore the mens- trual flow, but will also cure the leucorrhoea as well. Wami clothing, especially to the lower extremities, is to be insisted upon ; suitable bathing and exercise nre not to be forgotten. Going into society is sometimes beneficial. Changing the res- idence from city to country, or vice versa^ stopping hard study, using sea-bathing or rowing, and having cheerful company, etc., with assurance of speedy relief, will do much to restore the normal flow. In those cases where the fear of pregnancy seems to be the cause of the suppression, I know of no rem- edy more efficient than blanks of sugar of milk, with the assurance of the physician that they will certainly bring on menstruatron (if the patient has confidence in her physician, and pregnancy does not really exist). Hysteria in these cases is treated as in others, coupled with the proper remedies to relieve the suppression.
Cantharides is sometimes a useful remedy in amenor- rhoea, given in .low dilutions. The indications for its use in these cases are weakness, irritation of the bladder or urethra, and especial weak sexual strength, absence of all sexual desire, stinging pain in micturition, etc.
42 EA TON ON DISEASES OF WOMEN
symptom of other ailments, though given, by common con- sent, a distinctive name.
istioifHry*
The excessive flow in monorrhagia is due, in some in- stances, to overwork ; again, from a too sedentary life, caus- ing impoverishment of the blood. An inflamed condition of the uterus, in its sub-acute form, tends to promote this difiiculty. This is favored by miscarriages, and we often find this disease as a sequela of abortion. Neglected catarrh of the vagina and uterus also favors monorrhagia. Small granula- tions in the neck of the uterus, as well as all forms of uterine polypi and uterine fibroids, tend to produce excessive flow at the regular period. The anaemic condition of the blood, as well as great fatigue of body or mind, may greatly aggravate the difficulty. My esteemed friend. Prof. Ludlam,* says : "In the early stages of phthisis we sometimes meet with cases of troublesome, and sometimes dangerous, monorrhagia. As a rule, however, it is more liable to occur in the advanced stages of the disease."
This does not accord with m^ experience, and I have taken some pfiins to obtnin the experience of others^ and they agree with me that, in the advanced stages of phthisis, we uniformly have amenorrhoea, instead of monorrhagia; and we think that if a profuse menstrual flow should be present in any excep- tional case of the advanced sUiges of phthisis, it would proba- bly be due to uterine polypus or cancer. We have never seen this complication of a ciise of phthisis.
The capillary congestion that is necessary to the produc- tion of monorrhagia may be produced from such a variety of causes that we always have to go back of the excessive flow to the pndue capillary congestion, and again back to the cause of this congestion.
The cold, that in the fii-st instance produced amenorrhoea,
* *' Clinical Lectures on Diseases of Women,'' R. Ludlam, p. 48.
46 EA TON ON DISEASES OF WOMEN
CHAPTER V.
DYSMENORRHCEA, OR PA/NFUL MENSTRUATION,
«
Dysmenorrhoea is a term used to signify painful men- struation ; but it is not all pain occurring at or about the menstrual period that should be called dysmenorrhoea. Neu- ralgia of the ovaries is a notable instance; here we have severe pain in the ovaries, one or both ; it occurs in some instances only at the njenstrunl epoch, still is neuralgia, anil should be so designated. The true dysinenorrhoeal pain is in the uterus, coming on in pnroxysms, ns a general rule, simu- lating the pains of threatened abortion, while the ovarian neu- ralgia is continuous and darting. The throbbing, tense pain is indicative of ovaritis, and is located in the iliac regions.
Authors generally seem to consider that the condition of the uterus in dysmenorrhoea is one of inflammation, either in the uterine muscular tissues or in the internal membrane. I differ somewhat, and claim that more cases of dysmenorrhoea are caused from retro- or ante-flexion, stenosis, or partial atresia of the cervical canal, than from any other causes; though it is true that the inflammation in some cases, without doubt, pro- duces the pain in the expulsion of the menstrual flow. It also tends to the formation of false membrane, that is formed in some cases, and thrown off at each menstruation from the mu- cous membrane lining the uterus, called nidation. Generally, the pain commences several hours, and in some cases two days, before any flow is established. The agony suffered in some of these cases is teiTible.
Besides the severe pains in the uterus, we may have, in addition, pain in the ovaries, gi'eat tenderness over the hypo* gastric region, and sometimes this tenderness extends over the entire abdomen. This is the case where there is present
50 EATON ON DISEASES OF WOMEN.
duce painful menstruation; but I am inclined to the belief thnt in the great majority of cases displacements of the uterus, with some degree of endo-metritis and stenosis of the cervical canal, are the main causes of dysinenorrhoea.
ProKQoeis*
This must depend much upon the willingness of the pit- tient to submit to proper treatment. As the patients usually feel tolerably well during the interval between the men- strual periods, they are very often disinclined to pursue the necessary treatment. In this case an unfavorable prognoaift is the best we cnn make. But, in case we may have several months to treat the case, the prognosis may be favor- able, ^e are usually justified in prognosing sterility, if let alone, in cases that are severe; with proper treatment we may, in most cases, expect that pregnancy will be possible.
Xreatnieiit«
Whoever achieves success in the treatment of this diflt culty, may feel that he is equal to the task of treating almost any of the diseases of women, for to be successful, the phy- sician must show power of careful discrimination in diag- nosis, decision of character and will, in proceeding to do that for the case which it seems to demand. Perseverance in treatment, proper encouragement to the patient (that he may have her full co-operation), is necessary. This is all impor- tant, as it is generally the case that the patient enjoys quite a good degree of health in the intervals between the mea- strual periods, and it is absolutely necessary that the treat* ment be continued thoroughly during these intervals. Maeh care and judgment need to be exercised in the selectioii of the remedies, and in the surgical or mechanical treatment used. Hence I deem the skill demanded in these cases equab any that is required in any case of gynaecology. These cases are the more embarrassing on account of their being foond
w w "- ^
54 EA TON ON DISEASES OF WOMEN.
Satoacqaent Xreatment*
After a good degree of dilatation of the entire cervical canal is accomplished, I proceed to apply directly to the intra-uterine surface a Solution of Iodine^ making it with five grs. lod. Res.y fifteen grs. Potass. lodid.^ to one oz. of waiter. | This should be further diluted with water if it produces any considerable amount of smarting. This is conveniently ap-j plied with Palmer's uterine applicator. These applications I repeat once in three dnys, keeping the cervix diluted by passing a large bougie daily through the cervical carnal. Omit the treatment four or five days previous to the time for the commencement of the next menstrual period. Vaseline, or Bell, ointment, may be used through the applicator in some cases with advantage.
Internal Medication.
Probably there is no remedy so efficient as Phos.y given in the 2* or 3^ attenuation twice a day, and continuing the treatment for several months ; especially is this efficient ia the membranous form of dysmenorrhoea.
Prof. Carl Schroeder, of Bavaria, says:* "The fact that membranous dysmenorrhoea has been observed in poisoning by phosphorus, favors the view that a profound fatty degen- eration, even in a normal mucous membrane, may bring about the membranous exfoliation."
Cal. carb.y Graf.y lod. of Merc.j PhytolaCj Cocculusy or CaulophyUuMy etc., may sometimes be of much service, when used in accordance with the totality of the symptoms.
Treatment of Rtienmatic Dysmenorrluea*
In the rheumatic condition of the system we will do well to try the effect of Bry. or lihus^ Colch.^ Kali hffd.j etc., according to the peculiarities of the ciise and the homoeo* pathic indications for their use.
^Ziemssen's Cyclopaedia, ** Diseases Female Sex. Organs," p. 335.
5G EATON ON DISEASES OF WOMEN.
CHAPTER VI.
VICARIOUS MENSTRUATION,
By vicarious menstruation is meant the discharge of blood from some of the mucous surfaces other than the uterine, at somewhat regular intervals, accompanied with arrest of the normal catamenial flow. These hemorrhages sometimes take place from the nose, called epistaxis ; from the stomach, called hematemesis ; from the lungs, called hemoptysis ; or from the bowels, either with or without the presence of hemorrhoids. (Leucorrhoea, diarrhoea, etc., also sometimes seem to be vica- rious of menstruation.)
These discharges seem to relieve the system, so that the patient suffers much less than she otherwise would from the suppression of menstruation. These hemorrhages, of courae, occur at other times and from other causes, and are only con- sidered vicarious menstruation when occurring in connection with suppression of the regular flow. When coming on from other difficulties or diseases, they are ordinarily to be ar- rested, while in the case troubled with suppression they are rather to be encouraged (within reasonable limits), and viewed as conducive to health rather than disease. The patient is often greatly alarmed at these hemorrhages, until they are explained to her.
These discharges greatly relieve the hypersemic condition of the circulation induced by the retention in the system of the material usually cast off at the menstrual flow; and, if not relieved in some way, would soon manifest the more dangerous symptoms of congestion of the brain, Jungs, stom- ach, pelvic organs, or bowels. Frequently, in these cases, the uterus appe^irs torpid, showing no increase in size, no
60 EATON ON DISEASES OF IV OMEN.
CHAPTER VII.
INFLAMMATION OF FEMALE GENITALIA.
BtiolOflry.
The female genital organs are probably more subject to inflammation than other parts of the body. This is owing to various causes, some of which I will mention. The most prominent one that suggests itself is cold. The open cloth- ing so commonly w^orn by women oilers little protection to the pelvic organs from severe chnnges of tempemture. Especially is cold injurious at or about the menstrual period. The ovaries, uterus, and vagina are at this period congested, so to speak, though the 1 unction of menstruation is a physio- logical one, and one that is necessary to the health of the female. Still we may speak of the congestion of the parts occurring at this period, and generally a few days i>reviously.
This congestion especially aflects the mucous membrane lining the uterine cavity. Cold baths, taken bv girls and ladies w^hile menstruating, have often (*aused inflammation of the uterine organs. I have seen the inflammation of so high a grade from these causes as to endanger life. I have seen it also produce paraplegia, hemiplegia, jus well as hysterical convulsions.
Sexual Intercourse^ which is resorted to by the lower animals solely for the purpose of reproduction, except in one or two species, is resorted to by man as the most common indulgence of his nature, and is frequently the cause of inflammation of the uterus, and, from the irritation und excitement produced, causes also the eflects of cold to be more severely felt.
The reading of lascivious books, the nature of the asso-
SUB' ACUTE IXFLAMMATION, 65
■
lished and the pntient i.s much broken, down in health, <and perhaps consults the physician on account of this general debility, or under the impression that the difficulty is some- thing entirely different from what is re.ally the matter.
The causes of this disease are somewhat similar to those which produce active inflammation, but owing to the good constitution of the patient, or the small amount of exposure a very acute inflammation is avoided, and in its stead a sub-acute form is established. The sub-acute form is often caused also by the use of cold vaginal injections to prevent conception, and by acid injections for the same purpose. Fre- quent child-bearing is also a fruitful cause of this sub-acute form ; neglect of cleanliness, as well as too frequent bathing, may produce the disease. The wearing of hard vaginal pes- saries, as well as rough, brutal copulation by the husband, or promiscuous sexual intercourse, sub-involution of the uterus, and lacerations of the cervix uteri in confinement, also tend to cause this disease.
The symptoms of sub-acute inflammation may not mani- fest themselves in the parts affected to any great extent, and in some instances there may be no symptoms that point directly to the difficulty, unless we are aware of the fact* that the symptoms indicating sub-acute inflammation are generally in some part of the body somewhat remote from the pelvis, and are caused by reflex nerve action. True, we may some- times have slight tenderness of the vagina or os uteri, or slight tenderness in the ovarian region; but often we have no tenderness. Sometimes we have a slight vaginal dis- charge and sometimes none. On making a physical exami- nntion we find the vagina warmer or colder than natuitil. The secretion instead of being oily and slippery to the feel is often tenacious, and the odor of the vaginal secretion
CHRONIC SUB' ACUTE INFLAMMATION. 71
BOiToanding the pelvic organs as well, often implicating the peritonseal covering, so that it may be considered, as a whole, ander the name of chronic sub-acute, pelvic inflammation. The patients in these cases may be able to go about their usujil avocations a considerable part of the time, though suf- fering much pain. This pain is in the organs themselves, and also in the back, loins, thighs, occiput, top of the head, and under the left breast. Digestion is generally impaired, much flatus in the stomach and bowels is generally pres- ent; and palpitation of the heart and fainting spells are frequently symptoms of this difficulty.
The cause is often obscure. These cases generally come under our care with a history often so long that we need to niake a special appointment of an hour to hear it, and, when we l^m it all, we generally find that the aiTay of treatment, and the names of different physicians who have from time time treated the case, will occupy no small part of the recital ; and as several years have generally elapsed since the patient has been a sufferer, we often find it extremely diffi- cult to decide what was the cause of her trouble in the first instance. Sometimes it is clear that a miscarriage, or con- finement badly managed, was a prime cause, in other cases that a cold taken and neglected at the menstrual period seems to have laid the foundation for the long train of suf- ferings that the patient has endured. Again, injudicious treatment, especially with pessaries, caustics, frequent cold baths, the continuous use of cathartics, etc., seem to have kept up the irritation. Again, unsatisfied sexual passion, ns in the case of those ladies who have married men many years their senior (whose sexual vigor was inadequate to satisfy the wife, though sufficient to excite her); entire eontinence, in cases of the unmarried, at ages ranging from thirty to thirty-five years, has seemed to me to tend to pro-
76 £A TON ON DISEASES OF WOMEN.
I
iolac. dec. J in the l"" or 2^ attenuation, given every three or four hours.
China J Ar8. iod,^ Bry,^ Nux^ Sepia^ Cimidfuga^ BelLy CaL carb.j Ignatiay CanthariSj Hepar sulph.y Cham., etc., are the remedies to select from in each particular case, ns the totality of the symptoms seem to indicate. If we have uter- ine hemorrhage, or absence of menstruation, polypi, cysts, or tumors, we must treat them on the principles laid down under these diseases, which will be treated of specifically under their proper heads. Attention to the administration of suitable diet, that is nourishing and still easy of digestion, is always to be remembered. Cheerful company, change of scene and climate, will sometimes aid materially ; and^ if the patient has lived in a malarious district, we must recollect how much this tends to lower the strength of the nervous system, and produce a condition of chronic congestion, and apply our remedies accordingly.
METRITIS, 81
and bowels, arrest healthy secretion, benumb the system, and prevent the proper action of other remedies.
The same remarks apply with equal force to the hypo- flermic use of Morphia. Its use has become shamefully frequent with some practitioners, and should be discounte- niuiced, because we can relieve our patients in a short time without it; and because it so seriously interferes with the nntunil process of digestion and assimilation; and, worst of all, esbibiishes in many the opium habit. The alarming increase of the habit of opium-eating in this country should cause us to be active in suppressing it, and careful not to aid in its spread. The import duties on opium paid the United States government for the year ending June 30, 1877, were $1,778,347. This gives some idea of the great amount of the drug consumed by opium-eaters in the United Sbites.
Cool lemonade is a means of great relief to the fever, and is much relished by most patients. Cold wattn* may be drank with freedom in small quantities, often repeated. The diet should be very plain, consisting of gruel of corn or out- menl, toast, with a little milk. The entire surface of the body should be frequently sponged with tepid water. Ca- thartic medicine must be positively forbidden, and tepid soap and water enem^e used to move the bowels, in case of want of action in them. I speak of this, not that I expect any homoeopathic physician will prescribe a cathartic in these cases, but knowing that we sometimes have patients who have previously had allopathic treatment, and that they may take a cathartic without asking the physician's advice.
From the swollen condition of the uterus and its pressure against the rectum in these cases, as well as some degree of irritation of the bowel from the spread of the active inflam- mation in the uterus, the patient feels a constant ineffectual desire to evacuate the bowels, which tempts her and her fi lends to use a cathartic. Hence, I make the suggestion to the student to forbid them, unless he knows his patient well
6
^i_
AREOLAR HYPERPLASIA OF THE UTERUS. 89
This effusion in time becomes organized, forming new areolar tissue, or distending the minute cells of this tissue so as to appear increased in its substance. Following this con- dition, further effusion may take place into this tissue of sero-plastic lymph, or of abnormal cell phisma, which may cause induration, or cancerous degeneration of the tissues ; or the hyperplasia may remain (for a long period at least) without resulting in induration or carcinoma. In these cases the uterus is found enlarged, somewhat patulous, often displaced, espe- cially downwards, and often retro-verted or flexed. Constipa- tion is an almost constant symptom in these cases, vesical irritation, strangury, ischuria, etc., being frequent; pain in the loins, back, or thighs, pain at the base of the brain, or on the top of the head, gastric derangements, nervoas or hyster- ical manifestations, etc. This is the train of symptoms point- ing to this condition, especially when the history of the case shows that these symptoms have been present for a long time. Pkin in the pelvis is not very frequently complained of in these cases, and the absence of this pelvic pain is the very point likely to mislead the physician in diagnosis. The symp- toms are largely sympathetic, and embrace, at one time or another, about all the sympathetic effects manifested by any uterine disease. (See Sympathetic Affections.) Of this dis- ea.«e Dr. Thomas * says :
*• One of the most common pathological combinations which confront the gynaecologist is that which I here endeavor, in as concise a manner as possible, to picture. A patient calls upon us for relief of backache; pelvic pains; dragging sen- sation about the loins; ^bearing down pains;' leucorrhoea; menstrual disorder, tending chiefly to excessive flow; throb- bing sensation about the uterus; general feeling of despond- ency, malaise, and weakness ; and irritability about the blad- der and rectum. All these rational signs pointing to the uterus as the probably delinquent organ, a physical explora-
*Thoiiui8's " Diseases of Women," p. 274.
AREOLAR HYPERPLASIA OF THE UTERUS, 91
remained large and indurated without sensitiveness^ or the effused l3rniph might be absorbed, and great diminution in >ize occur with induration. Were this really the case the condition would constitute one of inflammation, even if we restricted ourselves in the use of that ambiguous term to the narrow and precise limits prescribed by Dr. J. Hughes Ben- nett, when he says : * It should be applied only to that per- \'erted alteration of the vascular tissues which produces an exudation of the liquor sanguinis; it is this exudation alone which can be held to unequivocally characterize an in- tbimmation/
'* Examined more recently, however, by the more certain and less theoretical processes of modem science, all this has itime to be looked upon as erroneous. Cases which were formerly regarded as instances of inflammation— -on account of the existence of enlargement, congestion, and tenderness upon pressure — ^the microscope now proves to have been instances •►f excessive growth of the connective tissue of the uterus, with congestion, and resulting hypersesthesia of its nerves.
*• It may result from three entirely different pathological states : first, from interference with retrograde metamorphosis of the puerperal uterus from any cause ; second, from conges- tit>n loug kept up by mechanical causes, such as displace- ment; third, from a formative irritation or state of hyper- nutrition excited by endo-metritis, or the existence of fibrous tumors. Whatever be the originating pathological condition, that which results and which we are now considering con- sists in hyperplasia of connective tissue as its most marked feature, and of congestion and nervous hyperaesthesia as im- portant accompaniments.
*• Every-where throughout the recent and progressive lit- erature of gynaecology the foreshadowing of the advancing change in views with regard to this subject will be recog- Qize<l. The pendulum, swung too far by the hand of Dr. Henry Bennet, is making its inevitable return. That it may
92 EATON ON DISEASES OF WOMEN.
stop on safe middle ground must be the hope of all, determination of blood to a part here noticed, charai by dilatation of the arteries,' with increased flow o through the capillaries, must be distinguished from \ gestion of inflammation, characterized by the accuii and stagnation of red and white corpuscles in the tending to be abnormally adherent to each other and vessels,' says Dr. H. G. Wright,* quoting from Dr. * Tested by this standard' (that of Dr. J. Hughes 1 already (juoted), says Dr. Graily Hewitt,f Hhe uterus tainly Aery little liable to "inflammation;" exudati* transfonnation of such exudations, purulent and otl similar to what may be witnessed in other organs body, being very rarely witnessed in the parenchynif uterus. The morbid processes with which we are as aflecting the tissues of the uterus are, for the mo alterations of growth, irregularities in growth, slight cations, in fact, of the processes which follow each ( due succession in the natural condition of things. Tl "inflammation," used in Dr. J. Hughes Bennett's s the word, certainly fails to convey an adequate idei modifications observed under such circumstances.' growth of connective tissue,' says Klob,;J; ^constitu so-called induration, hitherto considered as a result enchymatous inflammation of the uterus. . . . ] sons mentioned I would also advise a disuse of t] "chronic inflammation."' In a discussion || upon metritis, before the New York Academy of Medici Noeggerath limited the disease to ^growth of cellulai both of the body and neck, occurring only during tl peral state.' Dr. Peaslee preferred * to call the disea.^ consideration congestion, rather than inflammation, it has none of the events of inflammation;' and Di
• " uterine Disorders," p. 218. t " Dis. of Women," p. 363.
t** Op. cit.," p. 129. II " Met!. Record," No. 92, p. 4!
AKEOLAR HYPERPLASIA OF THE UTERUS. 93
oierer expressed the view that ^chronic inflammation of the substance of the non-puerperal uterus is never met with; what has been described as such is hypertrophy of connec- tive tissue, resulting from long continued hyperoemia.'
** These views, which, among men who are in the advance in pA'naecology, are rapidly gaining ground, are not sustained by analogical reasoning, but by anatomical proof. I know^ of nothing which will more surely convince the reader of the neces>itv for an alteration in our nomenclature concerning this condition than a perusal of Scanzoni's* article upon it. This author, .ifter heading his chapter * Chronic Parenchy- matous Inflammation of the Womb,' goes on to say: *The nature of the disease would then be, in an anatomical point i»f view, a hypertrophy of the cellular tissue.' Certainly the * anatomical point of view' is an important one, and it is supported by what we observe from a clinical stand-point.
"So much evil has arisen for pathology and treatment from the use of the term chronic metritis, and so clear a «lemonstration has been made that the condition so called is not one of true inflammation, that some other appellation is not only desirable, but has become absolutely essential. It is incontestable that there is a peculiar condition that affects the uterus which is characterized by distention of blood-vessels from vital or mechanical cause, eflusion of the serum rof the blood, and hypergenesis of connective tis- >ae. To denote this state, gynaecologists have long required a name, for medical nomenclature is as necessary as it is faulty. Lisfranc felt this need when he styled it * engorge- ment;' Hodge, when he entitled it Mrritable uterus;' Bennet, when he called it ^metritis;' and others have also acknoAvl- ♦*<lgeil the necessity; Klob, for example, in * habitual hyper- lemia' and SlifTuse proliferation of connective tissue;' and Kiwisch, in ^nfarctus.'
" The appellations infarctus, engorgement, and hyperaemia
^''Diaeases of Females," Am. ed., p. 181.
94 £A TON ON DISEASES OF WOMEN
only convey a partial idea of the truth ; they only m one elemtent of the condition— congestion — while irritable uterus ignores all structural change in ann another element-^nervous hyperaesthesia. At the sai that the phrase, diffuse proliferation of connective due to hypersemia/ which is employed by Klob, clo fines the pathological condition, it is too long and hurt to answer the purpose of a name to be conventionci ployed. If there be a term now in existence whi really convey the idea truly and completely, it should in the interests of pathology and treatment, as woU of consideration for the overburdened student of nomenclature, be employed in preference to the adoj a new one. Enlargement of an organ, due to the fo of new cells similar to those of the tissue in wliich { developed, has been styled, by VirchoAv, hjq^erplasin^ tradistinction to hypertrophy, which consists in iiur size from distension of cells already existing. As \ dition of the uterus now under consideration is one from over-excitation of the vaso-motor and excito-ii nerves, a * formative irritation,' as Klob styles it, and ing in a numerical hypertrophy, it appears to me t term areolar hyperplasia would more correctly dcsij than any other with which I am acquainted. With a desire to lessen, and not to increase, the labors of \ dent and the perplexities of the gynaecologist, I shjd! fore, replace the confusing term, chronic metritis, by areolar hyperplasia of the uterus.
" If the disease really consists in a proliferation or trophy of the areolar or connective tissue of the utoT not in chronic inflammation, it would certainly be tageous to apply to it some name which would signi fact. ^Areolar hyperplasia'* expresses this fact co
♦Hypertrophy signifies excessive jrrowtli of the elements of a tissu existing; hyiierplasia signifies the development ot new tissue.
AREOLAR HYPERPLASIA OF THE UTERUS, 95
and hence I have employed it. But the only proof of the appropriateness of a newly applied term is its general adop- tion. If this be accepted, I shall feel that good has resulted from my effort; if its approval be not implied by adoption, I shall admit, with regret, that I have only helped to render confusion worse confounded.
** Pathology of Areolar Hyperplasia. — The vast majority of eases are due to interference with that retrograde metn- morphosis occurring in the puerperal uterus, styled involu- tion. To comprehend the pathology of cases thus arising, it will be necessary to consider the physiology of that process as well as the pathological conditions which may affect it.
**It is only within the last quarter of a century that we have understood the process by which the uterus, an organ measuring three inches, in the short space of nine months enlarges so as to contain a child, or even two or three chil- dren, and then, within two months after delivery, undergoes so rapid an absorption as to return to its original size. The credit of elucidating the subject belongs chiefly to Germany, for it is to Virchow, Franz Kilian, Heschl, Kolliker, and Retzius that we are most indebted.
" The important pathological fact, that arrest in a disturb- ance of this process constitutes a condition of disease, ema- nated from Sir James Simpson, who, in 1852, published the first article which drew especial attention to it. Ilis article w;ls entitled, ^ Morbid Deficiency and Morbid Excess in the Involution of the Uterus after Delivery.' Since that time, the condition which now engages us has become generally recog- nized as a uterine state of great frequency and moment.
"To fully comprehend this part of our subject, it is nec- essary to bear in mind the component parts of the healthy oterine parenchyma. It consists of five elements: 1. Fusi- form fiber cells, or, a^ they are termed, the smooth muscu- lar fibers; 2. Round and oval nuclei, which are supposed to be elementary fusiform fiber cells; 3. Amorphous or homo-
96 RATON ON DISEASES OF IVOMEN,
geneoiis ronnooHve tissue, which permeates the parenchj and binds together the fiber cells and nuclei; 4. Fibrillat connective tissue or white fibrous tissue; and, 5. fibrous tissue. These elements, together with nerves, bl< vessels, and lymphatics, make up the tissue of the uteml which is covered by a serous membrane externally andt mucous membrane within.
"No sooner does this structure feel the stimulus of ception than it develops rapidly, partly by growth of alreadr existing structures, and partly by new formations. Tkl round or oval nuclei rai)idly develop into fusiform cells, tm these as rapidly grow into colossal cells, which grow longffl and more powerful ns pregnancy advances. ^A new foimi' tion of muscular fiber also tnkes jdnce/* the connective tism elements grow proi)ortionately, and the blootl-vessels enlarge
^'Parturition occurs, and almost immediately a retrograde evolution begins to restore the uterus to its original eonstit* uency. The fully developed fibers undergo a fatty degen«>' ation; the fat thus formed is absorbed, and the organ rapidh diminishes in size and weight. This fatty degeneration affects the orgnn after the fourth day subsequent to delivery, and.' according to Ileschl, the commencement of a ne\v formatioi of muscular fibers is recognize*! in the fourth week after Irtbor, in the form of nucdei Jind caudate cells. At the end of the eighth week the uterus has returned to its n(W<- mal state.
"Certain untoward influences mny retard or check this process, and the uterus remain fl.Ml)l)y and large, when it is said to be in a state of sub-involution, or arrested retrograde evolution.
"^Thus far Ave have been dealing with facts thoroun'hly ascertained by histological investigations and fidly established by evidence yielded by the microscoi)e. But from this point the pathology of sub-involution is not so satisfactorily settled.
•Arthur Farre: "Cyc. Anat and Phys.," Article Uterus.
AREOLAR HYPERPLASIA OF THE UTERUS. 97
Prof. Simpson declared that the disease was due to the fact that *thi8 retrograde metamorphosis of the uterus has not taken place during the puerperal month, or has taken place only to such an imperfect degree that the uterus is of the size we usually see it have at the end of the first week or so after delivery \ but he entered, if I may judge from the posthumous volume of his work upon Diseases of Women, upon no detailed account of the existing pathological defect in the organ. Since his writing, it appears to have been agreed upon that this consists of persistence of the muscular fibers, characterizing pregnancy, in a state of fatty degener- ation. Thus Dr. Wright* says: ^Pathologically, it closely corresponds with that state of the heart structure so admir- ably described by Dr. Richard Qutain, and commonly known as fatty degeneration/ Dr. Westf expresses himself thus: •Though fatty degeneration of the tissues takes place, yet the removal of the useless material is but imperfectly accom- plished, while the elements of the new uterus are themselves, as soon as produced, subjected to the same alteration.' I search in vain the literature of the pathology of this subject for a basis for these hypotheses. That literature is scanty in the extreme as yet, and the subject awaits extended re- searches before we can speak intelligently of it. The day has passed, however, when we can let probabilities in pathol- ogy pass current for facts.
*• The best, indeed I may say the only, detaile«l account of this condition studied by the microscope, which I have been able to obtain, is one by Dr. Snow Beck,| of London. ' The enlargement of the uterus did not depend so much upon an increase in the size of the contractile fiber-cells as upon nn inererised amount of round and oval globules, with amorphous tissue in the uterine walls. . . . The essential condition of the organ consisted in the elements of the different tissues
•"Ulerine Dwordere," p. 221. t "Dis. of Women," 3d Eng. ed., p. 89.
t" London Obstetrical Trans.," Vol. XIII, p. 239.
7
^ ^
98 EATON ON DISEASES OF WOMEN.
retaining a portion of the natural enlargement cons upon impregnation. But this enlargement was more the increased size and amount of the soft tissue pre the walls of the uterus, as well as at the internal surfn< to the increased size of the contractile fiber-cells/ congestion existed, the blood-vessels being hirge and a complete and continuous system with the capillary r on the inner surface of the uterus. No allusion to derance of muscular fibers is anywhere made, and no i of fatty degeneration occurs.
"The condition of the uterine cavity is important always enlarged, the glands of the cervix are usu<'i larged, and upon the lining membrane of the cavity growths are commonly developed.
" This is all that can with positiveness be said pathology of the early periods of sub-involution in tl ent undeveloped state of the subject.
" The uterus, the study of the tissues of which g? Beck's results, measured 3i inches in length, 2i inche.« the fundus, the walls were 11 inches thick, and the canal was 3 inches deep.
"As time passes the uterine walls diminish in siz tissue grows less vsiscular, the blood-vessels become i and the uterine cavity, assumes smaller dimensions. ] organ does not assume its original size; it remain^ dense, firm, and sensitive, for years presenting the chi istic appearances of the so-called chronic parenchy metritis. Although taking an entirely different view pathology of chronic metritis, Dr. West* signalizes the same fact in the following words : ' It must, howe at once apparent that after inflammation has passed av effects may remain in the larger size and altered struc the womb, and that the very nature of these changes such as to render the repair of the damaged organ b
• " Op. tit.," p. 89.
AREOLAR HYPERPLASIA OF THE UTERUS, 99
likely to occur and slow to be accomplished, and must leave it in a condition peculiarly liable to be aggravated during the fluctuation of circulation and alternations of activity and re- pose to which the female sexual system is liable.' This is just the state to which I allude at the commencement of this chapter, as one existing years after labor, and which, attended by congestion, displacement, catarrh, and granular degenera- tion, is styled chronic metritis. It is, I think, this state which most frequently furnishes instances of areolar hyperplasia to the microscope.
''Let any one patiently and faithfully watch a case of sub- involution for a year or two with reference to this point, as I have repeatedly done, and I can not doubt that he will have the same evidence which makes me so strong in my present belief. Lastly, let it be remembered that, by the French school, no condition of arrest of development is recognized as accounting for it ; these are cases of - post-puerperal metritis,' metritis, according to M. Gallard,* without symptoms, 'chron- ique d'emblee/
^ Does any one claim that between this condition and chronic metritis a difference should be made ? Let him tell me by what means he can at the bedside distinguish one from the other, and I may agree with him. There are no means for such differentiation. If the uterus be very large and the patient recently delivered, the case is termed sub- involution by English writei*s ; if its dimensions have diminished, yeai*s have elapsed since parturition, and the almost universal ac- companiments of the condition, leucorrhoea, granular degen- eration, and displacement be present, it is styled chronic metritis.
"Arrest of involution of the puerperal uterus is an occur- rence of very great frequency. It constitutes the chief cause of all chronic uterine disorders, and for this reason its inipor- tance can not be overestimated. Until this subject receives
« " Op. cit," p. 372.
AREOLAR HYPERPLASIA OF THE UTERUS. 101
exertion, or some other influence creating congestion, will produce a relapse which will convince her of her error. It is astonishing to what an extent enlargement of the cervix as a result of areolar hyperplasia will go. Sometimes this part will equal in size a very small orange, and, filling the vagina, will compress the rectum to such an extent as to interfere with its functions. Uninterfered with by art, the disease has no fixed limits. The increase of uterine weight which it induces usuall}'^ results in displacement. This incresises already existing congestion, and the patient suffers, until the menopause at least, from endo-metritis, granular cervix, and the ordinary symptoms of displacement.
^'In some crises contraction of the exuberant tissue oc- curs, and uterine atrophy, with its accompanying symptoms, takes place.
"Frbquenct. — This affection is one of great frequency, and as it was formerly universally regarded as chronic paren- chymatous metritis, this is one great reason why inflamma- tion of the structure of the ut-erus was thought to be so common. This fact makes its careful study a matter of great moment to the gynsBcologist. I do not hesitate to declare that he who fully masters it, and thoroughly appreciates its frequency and influence, will possess a key to the manage- ment of numerous crises which would in vain be sought for elsewhere.
" PaBDisPOSiNO Causes. — These may be enumemted as —
"A depreciation of the vital forces from any cause;
"Constitutional tendency to tubercle, scrofula, or spa- naemia ;
"Parturition, especially when repeated often and with short intervals ;
"Prolonged nervous depression;
"A torpid condition of the intestines and liver.
" The Exciting Causes are the following : "Overexertion after delivery;
u
u u
AREOLAR HYPERPLASIA OF THE UTERUS, 103
^^ Disordered menstruation ; ^^ Difficulty of locomotion ; "Nervous disorder; " Pain on sexual intercourse ; " Dyspepsia, headache, and languor ; " Leucorrhcea. " If the affection be general or corporeal, graver symptoms oianifest themselves."*^ Chief among these are :
^'A dull, heavy, dragging pain through the pelvis, much
increased by locomotion; ^^ Pain on defecation and coition ; Dull pain beginning several days before menstruation,
and lasting daring that process ; Pain in the mammae, before and during menstruation ; Darkening of the areolae of the breasts ; '^ Nausea and vomiting ; "Oreat nei*vous disturbance;
^' Pressure on the rectum, with tenesmus and hemorrhoids ; ^^ Pressure on the bladder, with vesical tenesmus ; " Sterility.
" Physical Signs op Cervical Hyperplasia. — V«ginal touch will generally discover that the uterus h^is descended in the pelvis so that the cervix will rest upon its floor. The cervix will be found to be lai-ge, swollen, and painful, and the os may admit the ti|i of the finger. If the finger be pbiced under the cervix, and it be lifted up, pain will be usually complained of, and if it be introduced into the rectum so as to press upon the cervix as high as the os internum, it will often reveal a great degree of sensitiveness. Under these circumstances, the direction of the uterine axis will generally be found to be abnormal. The cervix will, in some cases, have moved for-
* It most not be supposed tliat all these symptoms ocx;ur in all or even in the mmjority of cases. In many cases few, and in some almost none of tiieui, vill be reoogniced.
AREOLAR HYPBRPLASIA OF THE UTERUS, 105
between its existence and that of the second stage of areolar hyperplasia, or sclerosis. Scanzoni doubts the possibility of deciding, but it appears to me that the investigjitor will usually succeed in doing so by the following comparison of signs and symptoms:
h\ Cervical Sderom, In Scirrhous Cancer.
•*T1ie patient shows no cachexia. She often does.
'* There is tendency to amenoirhcea. There is tendency to hemorrhage.
''The history usually points to parturition. It does not.
** It lias been preceded by symptoms of It has not.
uterine enlaii^ment.
''The cervix feels like dense fibrous tissue. It feels almost like cartilage.
^ The body is, peiiiape, implicated. It is very rarely so.
*' A sponge-tent softens the tissue.* It leaves it hard and dense.
" The prognosis in hyperplasia of the entire uterus, or of the body alone, is unfavomble with regard to complete cure, though highly favorable with reference to great relief of symptoms and to danger to life. Should the patient be approaching the menopause, it is possible that, after the functions of the uterus cease, atrophy may occur, and relief be obtained. But one can not be sure even of this, for the monthly discharge may give place to metrorrhagia, or all the symptoms may continue, in spite of the menstrual cessation. Under a course of local treatment, combined with one con- ducte<l with special reference to the general system, hope may always be held out that, although restoration of the uterus to lUi normal condition may not be effected, the evils result- ing from the complications of this disease can be so fully controlled that comfort will be obtained. When the neck of the uterus alone is affected, a favorable prognosis may always be made, for^ here there are fewer grave complications to be encountered; such, for example, as corporeal endo-metritis, menorrhagia, etc. The diseased part is likewise more access- ible to local treatment, and is also a much less sensitive and
•This test originated with Spiegelberg.
106 EATON ON DISEASES OF WOMEN.
important part of the organism; I might, indeed, almost say a less important organ, so distinct are the uterine body and neck, physiologically and pathologically. As I have else- Avhere stated, the prognosis will depend, in a great degree, upon the patient. If she be unwilling to sacrifice her incli- nations and pleasures, but half fulfill the directions of the attending physician, and clandestinely expose herself to prejudicial influences, the treatment will accomplish nothing. In the case of a reasonable patient, who appreciates what is at stake, and is anxious to regain her health, it may be regarded as favomble.
««
"Rest. — The patient should be instructed to take much less exercise than usual, to lie upon her bed or lounge for an hour every day, about midday, and to be especially quiet during menstrual periods. It is highly improper to confine her to bed, for many women become restive under the con- finement, and suffer both in mind and body, the sanguineous and nervous systems being impaired by want of fresh air. If the connective tissue be so much affected that the cervix is very painful upon pressure, absolute rest upon the back may become necessary, but my impression is that deprivation of fresh air and exercise ordinarily does more harm than is compensated for by the advantages arising from quietude. Every day she should go, unless deteiTed by some special cause, into the open air; and a limited amount of exercise should be inculcated, as a means of keeping up the general health.
" The uterus should be placed at rest as much as possible. Its natural tendency, under these circumstances, is to fall from its position; consequently, all pressure should be re- moved from its fundus by the use of a skirt-supporter and a well-fitting abdominal bandage."
The use of the abdominal supporter I have found of the
AREOLAR HYPERPLASIA OF THE UTERUS, 107
atmoet benefit; in fact, we doubt if these chronic cases can be successfully treated without its use. We would not dbpense with them on any account. They need to be used with care and judgment, however. They must be made to fit so as to be really supporters of the abdominal viscera, and not compressors of the abdomen. (See improved London Supporter, Plate XII.)
Sexual Intercourse. — Sexual intercourse is harmful in these cases as a rule, and should be prohibited in most cases.
Diet. — The diet should be nourishing, but not stimulat- ing. It should be easily digested and taken in moderation, and at regular times only.
An. iod.j Merc, iodid.y Phyioiae. dee.j Ferrunij Mere. cor.y KaH idro.j Nux. Ars. alb.y Secalej Igncdta^ Iris vers., Ifyase.y VercU. vir.^ etc.^ are indicated remedies in this dis- ease, and the sympathetic affections dependent upon it. Special indications for these remedies may be studied best in works on Materia Medica.
Remedies in Homcbopathic practice are not given according to the name of any disease, and must always be selected ac- cording to the pathogenesis of the drug, and we simply men- tion here the remedies most likely to be indicated to facili- tate the selection of the appropriate one, by the study of each individual case. I have named* the remedies in the order in which they are prominent in regard to the fre- quency of their being indicated.
Some gentle local treatment we have found useful. The warm vaginal injection of water, using a large quantity, with a David9on$ syringe once a day, is of service. We think when there is a displacement of the uterus its reten- tion 01 bUu is usually the thing to attend to at first. The
AREOLAR HYPERPLASIA OF THE UTERUS. 109
Sponge Tents. — A sponge tent covered with glycerine, and placed Tor about six hours in the cervical cnnal, is often very useful. First, it dilates the canal so as to make it easier to apply the Iodine. It compresses the tissues so as to temporarily impede the capillary circulation, and the local application of the glycerine is also of service. In using the sponge tent caution must be exercised that the patient does not take cold. It better always be done at the patient's home, and the sponge should not be allowed to remain more than six or eight houi*s in this class of cases.
PERI-'METRITIS. Ill
There is some little pain from distension of the bladder^ but the sensation is more often described as an uneasy feeling. Slight pressure in the lower portion of the hypogastric region produces pain, while in metritis, endo-metritis, etc., slight pressure causes no pain, but hard pressure om not be en- dured. Oenenilly, in a few days, and sometimes in twenty- four hours, the inflammation extends over the peritonseum, and we have a. case of general peritonitis. In some cases, however, the disease is arrested at once, and no extension of iuflaimmation occurs. The disease may exist as a primary difficulty, or may exist as a complication of, or in connection with, the inflammation of some. of the pelvic organs or vis- cera. The disease may be acute, chronic, or sub-acute. The acute form, though more dangerous, is not so likely to produce effusion as the chronic.
etiology.
It is probable that most primary cases of peri-metritis are the result of cold, generally tiken at the menstrual period, or following surgical operations. But peri-metritis very frequently results from extension of inflammation in the uterus, ovaries, or cellular tissue, and occasionally the Madder.
The treatment must be in accordance with the stage of the disease and the special indications in each particular case. In the early part of the disease Ars. alb., Acon.j Bry,, or Arnica are indicated, while later in the disease Merc, car., Merc, iod.j Kali tod,. Chinas Cimieif., Colocynth.^ or Nnx are the remedies. Rest is necessary. The recumbent posture should be maintained, and warm applications be made to the feet and limbs. Cool, acidulated drinks are often grateful to the patient. The diet should be mild and non-stimulating. Fomentations of hops, or the hop or warm water compress.
PELVIC CELLULITIS, 119
of the tissues, the position of the pelvic organs in the main; aniL in the few osises where we are not satisfied there is not a flexion of the uterus, with digital exuininntion, we can gently introduce the sound, and clear up that much of the diagnosis. I lay it down as a general principle of gynaecolog- ical practice that we should never attempt to introduce the speculum when a digital examination gives any considerable pain. (The tenderness should be first removed by suitable treatment.)
The prognosis of cellulitis will be favorable, in most cases, of acute attacks, if treated promptly and rationally, terminatr ing generally in resolution, leaving the uterus less movable than normal, however, owing to adhesions which usually form at some part of the location of the inflammation. We may also detect the band-like or corded feel of the folds of some portion of the vagina, generally its upper part. These are also caused by adhesions, and may oiTer considemble resistance to the advancement of labor, should gestation occur. In some instances, however, suppuration develops, and a pelvic abscess is formed, and may point in the vagina or find exit through the rectum, the opening of the abscess into the rectum being the more common. Or the abscess may open into the bladder in rare instances (only one case of this kind has come under my personal observation); or we may have blood poisoning from the absorption of the pus, in which case we have rigors and fever, with great nervous prostration, and death may result.
In occasional instances the pus has found exit through the small intestines, owing to adhesions between them and the sac of the abscess; and the pus may follow down the psoas muscle, and open in the groin ; or it may pass through either sciatic fonimen, and burrow under the glutei muscles, or it may become sacculated, and remain for years, caosing a diagnosis of fibroid to be made; or it may be
PUERPERAL PERITONITIS. 136
€k>od air is another necessity in the successful treatment of puerperal peritonitis, or metritis. The old style of keep- ing the patient in a small room, with every crevice carefully closed to prevent the ingress or egress of a breath of air should never be followed; but, on the contrary, see to it that a free supply of fresh air is admitted to the sick-room, and abundant means are secured for the passing out of the impure, poisonous gases, which are always present in great amount. Do not be satisfied with a small opening for the ingress of fresh air ; but have two openings so the air in the room may circulate, taking care that the patient is not in a draft. Let her be well protected with warm coverings, and let these, as well as her personal clothing, be changed often. There is no good, but a positive harm, in allowing the bed- ding and patient's clothing to remain days and weeks with- out change. Let the patient be bathed often, and wiped or sponged off frequently, also, using a little soda in the water when the fever is high, and a little Bay-rum when there is less fever.
Keep most visitors out of the room, and, if possible, awa}' from the house. They often are a positive injury by disturbing needed rest, and exciting alarm by unwise though well-meant solicitude.
The complications of this disease must be treated accord- ing to the peculiar conditions present, and the urgency of the symptoms, taking care not to compound the remedies, using one for a few hours or a day, singly, and then changing to another, which the complication seems to demand; the al- ternation which I have already mentioned being in the giv- ing of some antiseptic remedy in alternation with the one especially indicated in that particular case. I am well aware that some homoeopathic physicians believe nothing in anti- septic treaiment. So far as I can get at their objections to it, they are due to the fact that the term has been used by allopaths. Now, the reason for the faith which is in me is
136 EATON ON DISEASES OF WOMEN
this: I believe that in the genuine case of puerperal peri- tonitis we have a blood poisoning which has a tendency to develop a pyajmic condition of the blood and the conse- quent depression of nervous strength, which develops the Diathesis seu Infedio purvlentd. Now, if this is not indica- tion enough for the giving of antiseptic remedies, then there are no indications for remedies. If we can not give anti- septics, neither can we use any kind of antidotes to poisons, and really an antiseptic is an antidote. If it can be ex- plained in any way which does not show its antidotal quali- ties, I am mistaken.
I will digress just here to remai*k that in the treatment of Scarlatina Maligna, Diphtheria, and Epidemic Cerebro- spinal Meningitis, the need for antiseptics is equally great^ and they prove as eminently beneficial. Without their use I would not take the responsibility of a case of either disease.
homqlOPathic remedies. 137
CHAPTER XII.
HOMCEOPATHJC REMEDIES,
Destrinq to condense as much as possible, we make a few suggestions regarding homoeopathic remedies. We do thisy not to interfere with works upon Materia Medica, or Therapeutics, but that the reader may undersbind the opin- ions we entertain regarding them and their action on the system. Having used them now over ten years, and having previously graduated in allopathy, and practiced it for up- wards of a decade, we may, perhaps, offer some practical hints, and we say, unhesitatingly, that we consider homoeop- athic medication the more speedy and certain curative treat- ment, and we offer our understanding of its modus operandi.
Attenuation. — This term has been so often confounded with potency that many have come to use the two terms as synonymous. This seems to me to be a grave error, and hsis led to much hard feeling on the subject of high and low potencies.
As I understand Hahnemann, in his work on '^Chronic Dise:ises," Vol.. I, when specially teaching the preparation and nomenclature to be used, and as I find Jahr and Griiner's *' Pharmacopoeia," as edited by Hempel, contains the same directions verbatim^* I must conclude there was in the early days of homoeopathy no idea that attenuation and potency were synonymous terms. There, we learn in plain English that the 1^ trituration is to be called the 100^*' potency; that the 2^ attenuation is to be called the 10,000"' potency; and that the 3' attenuation is to be called the 1,000,000*" potency.
* Jfthr and Gniner^s Pharmacopceia, by Chas. J. Hempel, pp. 4, 5, 6, and 7. Also eee tables on pp. 32, 33, ibid.
HOMCEOPATHIC REMEDIES. 141
/ Does any allopathist dare say our theories are unphilosophical or untenable ? Does he call a homoeopathic physician a quack because he has adopted an exclusive dogma, as he says? Then let him seek light in his own U. S. Dispensatory, where I found mine. Let him note the action of the small dose, and compare with the action of the large dose, as there laid down, and he will find enough to convince him of the universality of the law just mentioned. Then let him try in practice the application of this principle, and he will soon be able to declare that he, too, has found, not only joy in believing, but joy in practicing as well.
Plate III.
SrMS- ORIGINAL SPECULUM
■ FOLDING SPECULUM,
DAWSONS SIMS' IMPROVKD SPECULUM.
Plate V.
e
9
SKENE'S SOUND.
r
((
H
do
INSTRUMENTS, 146
great care is taken to warm them by putting them in warm water. When cold they are liable to break, even from slight pressure.
Caution. — The physician should always be sure pregnancy does not exist before he attempts the introduction of the uterine sound.
Celluutis also contra-indicates its employment, even for purposes of diagnosis. The use of the sound, or even any t'onsiderable manipulation with the finger, in cases of cellu- litis, is very likely to awaken an increase of the inflammation.
The use of the sound gives us information of the pres- ence of stenosis of the uterus, tenderness , and flexions of the organ, the size and attachment of fibrous polypi, and some information regarding intra-mural fibroids, etc., etc.
HVSTEROTOMES.
The hysterotome is an instrument for incising the interior of the cervical canal. It is occasionally needed in stenosis of the cervix; Its use must, in these cases, be followed by the daily introduction of the bougie smeared with vaseline to prevent the adhesion of the cut surfaces, and the consequent diminution of the size of the cervical canal. I prefer Simp- son's or White's. (See Plate V.)
baton's needle holder.
In addition to the straight needle holder already mentioned for sewing up longitudinal lacerations and fistulse of the vagina, the g}'niecologist needs an instrument for placing sutures in a transverse lacerntion or fistula. This is accomplished with my needle holder, as can be readily seen from the cut, Plate VI. It enables us to insert the needle into the vaginal tis- <\x%s from above downwards with the same facility with which we use the straight holder in stitching from side to side, for which purpose my hoMer may also be used by grasping the needle further down on the blades.
10
Plate VII.
BABCOCKE SUPPORTER
/NSJ'A'C/Af^NTS, 147
OS uteri inteniuin, as well as externum, had to be ac- complished nipidly.
Occasionally its use facilitates the getting at an internal uterine polypus, where we have but a short time at com- mand. Very rapid dilatation is in most other cases objec- tionable, in that it lacerates the tissues, and, in their healing, causes somewhat of a cicatrix, which interferes with the re- laxation and dilatation of the os in labor subsequently, and may cause stenosis, or exen atresia of the cerA'ical canal, and prevent impregiation, arresting the menstrual flow, and prodacing haematometra.
Hence, wheneA'er rapid dilatation is used, care should be taken to keep up some degree of expansion till the tissues are healed. Passing into the cervix every two days a bougie smeared with Vaseline, is a good way to accomplish this.
PERINEUM NEEDLES.
In operating for lacerated perineum it is most convenient to use Peaslee's improved perineum needles and holder shown in Plate VI, whether we wish to use the quill or ordi- nary interrupted suture. The needles fasten into the han- dle with a thumb-screw, and the eye of the needle is near the point as shown in the cut. This is much more convenient than having the needle screw into the handle. Having the three needles threaded before commencing the operation there is no delay in placing the sutures, as one needle can be taken from the handle and another, all threaded, inserted almost instantly. (See the old form, Plate XI.) In an emergency the largest sized surgeon's curved needles may be used to place interrupted sutures in the lac- erated perineum; but the regular perineum needle is much to be preferred, when Ave can have it, and in placing the quill sutures this, or a similar needle, is absolutely neces- sary. (See chapter on Lacerated Perineum.)
Plate X.
DIEULAFOVS ASPIRATOR.
:XPL0R1NG TRUCAK
Plate XIII.
HALF CURVED SUTURE NEEDLES
I
C TiCMANN
BOZEMAN'S TENACULUM.
CALLENDER'S DRAINAGE CANULA.
SELF-RETAININO CATHtTER.
FULL CURVED SUTURE NEEDLES.
Plate XIV.
178 EATON ON DISEASES OF WOMEN.
It will be judged by the thoughtful student that efforts at connection would prove injurious and tend to prevent recovery. This is the case, and it is better to forbid every effort at sexual congress till the patient is thought to be recovered.
Indlcatfons for Remedies.
Arnica is indicated where the vaginismus has resulted after copulation, or injury of any kind.
Aconite is indicated where there is present vaginismus, with heat and tenderness in the vagina, with a wiry pulse, aching' in the limbs, fever, etc.
BeU., where there is drowsiness, with bearing down pain; pain in the small of the back, a flushed face, etc.
Igrnatia, in the case characterized by weakness, nervous- ness, insomnolence, etc.
Hyosc. is indicated if there is a tendency to hysteria, frequent weeping, immodesty, etc.
196 EATON ON DISEASES OF WOMEN,
together with the mucous layer of the vaginal portion of the cervix. Healing followed, with suppuration.
"The case of Minkiewitsch * was of a more malignant character. In this instance also the vagina was expelled in toto; but the patient died, and, at the autopsy, the posterior vesical and anterior pelvic walls were found gangrenous."
* Minkiewitsch, Ibid.>l>. 41, p. 437.
248 EATON ON DISEASES OF WOMEN,
dyloinula on the genitul organs; burning in the urethra; heudjiche on left side; can not sleep at night; burning pain in left ovary.
Verat. Alb. — Leueorrhani, with violent, copious diarrhoea, nausea, et<.\
Verat. Vir. — Leucorrhoea, with congestive conditions; pupils dilated ; mouth and lips dry ; cases complicated with pneumonitis.
Zinc. — Leucorrhoea. with excessive sexual desire; pain in left ovary ; patient walks in her sleep ; constipation, etc.
264 EATON ON DISEASES OF WOMEN.
Sepia. — Sterility, with acrid leucon^hoea.
Stillingfia. — Sterility, from syphilis or abuse of mercury. Compare with Kali iodatuniy Phytolac. dec, Aurum, etc.
Ustilago. — (Similar in its action to SecaU, CaulophyUum, and Cimicif.)
In cases of vaginismus, conception may follow copula- tion, used under the influence of an anaesthetic. This should be, however, a last resort, and can only be advised when the parents are exceedingly anxious to have offspring. The student will find occasionally a case where every thing seems favorable to conception, and still the patient will remain sterile. In such cases attention to the husband is advisable. The treatment of his case does not, however, come properly under discussion here.
OVARIAN TUMORS, 311
If, on the contrary, it is a dark, thick fluid, we may expect its escape into the peritouiieum will produce serious, and probably fatal, results; and, of course, the operation should not be attempted in this class of cases. I will frankly state that I do not see the advantage of this treatment over tap- ping and injecting a Solution of Iodine; for it strikes me that it is better to evacuate the cyst by aspirating it than to allow it to drain oflF into the abdominal cavity. I think there can be little dispute on this point ; hence, we can not recom- mend rupturing the cyst in any instance.
384 £A TON ON DISEASES OF WOMEN.
Sepia, Cah carb.. Can. sat.,, Cubebs, Copawaj Cimieif.^ Cantharidesy etc., are indicated after the first few days, giv- ing them according to the totality of the symptoms. Cubebsj Can. ind.j CantharideSj or Copaiva are indic^ited for cutting, burning pains in urinating, as is Sepia or CcU. carb.j for the profuse vaginal discharge.
Should the disease progress without abatement Ars.^ Sulph.j or Rhus tox.^ are frequently indicated. (See reme- dies for leuconhiea.)
As adjuncts to the indicated remedies we will mention the warm foot bath, warm water vaginal injections, and the warm sitz bath, used daily or twice a day. The patient should abstain from exercise, and recline a great part of the time. Large quantities of cool water should be drank. The food should be gentle, bland, and non-stimulating.
I
COCCYGOD YNIA. 399
the coccygodynia had disappeared. Her physicians had over- looked the cause of the pain, and had thought it to be in the rectum or coccyx. My error would have been mortifying had I proceeded to divide the attachments of the bone or extirpate it. Sitting in this ease was extremely painful, and defecation she described as almost death. She declared that her genital organs were all right, and she believed her trouble to be piles. By paying no attention to her opinion, and at once making a thorough physical examination, I was able to make a more correct diagnosis and relieve her at once; and I was informed several months afterwards that the relief was permanent. The treatment is often made easy by first mak- ing a correct diagnosis.
CYSTS OF THE VAGINA, 415
Small cysts in the vagina present no symptoms. Large ones offer obstruction to copulation, and when pendulous interfere with walking. I removed one of this kind last year; it protruded as large as a small orange from the vulva. It had been treated as a cystocele by a reputable physician of this city, unsuccessfully.
The main trouble in diagnosis is to distinguish a cyst of the anterior wall of the vagina from a cystocele. This is best accomplished by introducing a flexible catheter into the bladder, and drawing off* all the urine, while we press the tumor well up into the vagina. If it be a cystocele the size of the tumor will then be found materially diminished; if a cyst of the vagina, not altered in size. The vaginal cyst in the posterior wall of the vagina is easily diagnosed from rectocele, with which it is possibly confounded, by combined rectal and vaginal touch.
The treatment of vaginal cysts, when of a size sufficient to incommode the patie^ consist^ in dmwing off* the con- tents of the cysts by means of an ordinary trocar; if the cyst refills (which it is very likely to do) it must be again drawn off*, and the sac injected with dUute Comp. Tr. Iodine. I dilute the Compound Tr. about one-half, and allow it to remain in the sac about ten minutes, and then flow away through the canula of the trocar.
After this is accomplished the sac should be compressed so that its sides may adhere and its cavity be obliterated. In order to accomplish this object the inflatable rubber bag may be inserted into the vagina, and well inflated. In this situation it should be allowed to remain several days, though
420 EATON ON DISEASES OF WOMEN.
Rest and quiet, both to body and mind, should be enjoined. Neuralgic dysmenorrhoea is likely to complicate these cases, and give an indication for Macrotine^ Puis., Cimici/.j Aeon., Ars.y China, or BelL
Should cellulitis complicate the case we are obliged to trust to position and remedies, and we can not use the in- flatable bag in the vagina, as the pressure from it could not be tolerated^ until the cellulitis had been relieved.
436 £A TON ON DISEASES OF WOMEA(.
Mood, suicidal : Aur,
Morose and serious : BelL
Nervous : Asar.^ Cham,^ Chin., Ferr.j OpL
and hysterical feeling: Ferr.
irritable : Cham,j Nux v., OpL
Obstinate and passionate : Bry. Over-sensitiveness : Bell,, Nux v. Quietly disposed : Trill. Restless : Acon.^ Bapt.j DtUc.y Rhus t.
anxiousness : Crocus.
quarrelsome : Dulc.
mental : Bapt.
Short time seems a long while to her : Nux m.
Sighing and sobbing : Iffnat.
Startled easily : Bell.y Cocc.
Stupid, half-jisleep condition : Opu, Secale.
Taciturn : Nit. ac.
Tearful : Puis.
Thinks herself well : Kreos.
she is not nt home : Opi.
Weeps much : Kali c.
444 EATON ON DISEASES OF WOMEN
to the rise of the uterus into the abdomen in pregnancy. Tumors of the tube itself may also cause displacement.
Tuberculosis of the Tubes. — Tuberculosis of the tube sometimes occurs before puberty, and might prove a cause of amenorrhoea; and it may develop at any period of life. I know of no way to make a diagnosis before death. It is most common that tuberculosis in the tubes is accompanied with the disease in some other part or organ, and does not often exist as a primary affection in the tubes.
.-*
4S0 EATON ON DISEASES OF WOMEN.
they can be brought into view through the fistula; or, w6 may apply the sharp point of a stick of Argtnbum #»(. to the bottom of the fissure every three or four days; or, apply the Hydrgr. chlo. mit. dry to them by means of a sound wrapped in cotton. Generally there is some cArame e^ditis in these cases, and the injections of warm water, with castile soap in it, passed through the fistula daily, are of much serv- ice. When the fissure and cystitis are cured, place a catheter in the bladder through the urethra, and let the fistula heal if it will. If we find it will not heal in a few weeks we freshen the edges, and stitch them together, as in an ordinary case of vesico-vaginal fistula.
454 EATON ON DISEASES OF WOMEN
condition woi*se than the first, unless the parts are kept dill ted till healed. With incision, there is more risk of inflammation and septicsemia following.
If the stenosis is complicated with elongation of the cervix to a great degree, it is best to amputate a part of tlie cervix at once, taking care to insert a tent into the os during the healing of the cervix. (See page 169.) The ampubition of the elongated neck may remove all the constricted portion of the cervical canal, and consequently make dilatation unneces- sary. Treatment by means of bougies alone will usually prove curative. The treatment must be carried to the ex- tent of being able to introduce a very large size. Gradual dilatation by bougies or sponge tents is in accordance with nature, and is to be preferred, in all cases, in my opinion. The cicatrix formed after incision, even when it is nmde suc- cessful by dilatation, greatly endangers laceration of the cervix in labor if pregnancy should ensue, and it is to be hoped that incision of the cervix, as a rule, in cases of stenoBis, will soon fall into merited disuse.
CYST/r/S IN WOMEN. 459
to prevent the iiifilti*ation of urine into the cellular tissue, which would lead to cellulitis. This point is in the shape of a triangle with the base upwards, reaching from the ori- fice of one ureter to the other, the apex downwards at the commencement of the urethra. Within this triangle the an- terior wall of the vagina and the posterior wall of the bladder lie in contact. Just outside of the line of the ureters, which are about an inch apart, we have blood- vessels. These we wish, of coui*se, to avoid ; hence the incision should be directiy in the median line, and within the triangle just described.
Having now some understanding of the anatomy of the parts, we proceed with the operation. The patient is placed upon the operating table, and the bladder made slightly tense by injecting into it tepid water; we now administer an anaesthetic, and lay the patient upon the left side. After this we introduce into the bladder a short, grooved staff, bent nearly at right angles, about four inches from the end which we introduce ; this is held in position by an assistant, when we dilate the vagina with a large-sized Sims' speculum, so as to bring into view the anterior wall of the vagina. We now insert the index finger of the left hand into the vagina, and by its side a sharp-pointed bistoury, with its edge di- rected backwards, held in the right hand. We now feel for the staff, and pierce the vaginal and vesical tissues at one thrust, till the point of the bistoury strikes into the groove in the staff about one and one-half inches from the meatus externus. We now press the bistoury upwards, keeping it firmly in the groove of the staff (first noticing that the staff is held in the median line), cutting upwards about an inch. We may now seize each side of the slit tissue with the for- ceps (after withdrawing the bistoury and finger), and with the scissors snip off a fourth of an inch or a little more from each side of the incised surfaces. This makes the opening more oval-shaped, and tends to prevent healing of any con- siderable portion of the cut surfaces.
CYSTITIS IX WOMEX. 461
much the odor of the dark ages, and we can wish for no return of their experiences. The object of using the hot iron is to prevent the closure of the fistula. It can be accom- plished by other means. In fact, it is not often very fast to heal if left to itself; and, as the treatment after establishing the fistula is to wash out the bladder freely by some means daily through the fistula, it is not likely to heal rapidly. We therefore dispense with the hot iron in toto. After curing the cystitis, which may take six months or two years, we close the opening, as in any ordinary accidental vesico-vaginal fistula.
Indlcatlotui for RettiecIleA in Cystitis.
Aconite. — Painful urging to urinate; urine passes drop by drop, is scalding; red or dark colored, with a hot, dry skin ; restlessness, etc. ; fear and alarm.
Arsenicum Alb. — Blood in the urine; burning in ure* thra during micturition; involuntary discharge of urine; gen- enil congestion ; sad moods ; cold, with hot flashes; thirst, etc.
Belladonna- — Congestive condition ; pain in the blad- der; flushed face; sense of fullness in the head; intoler- ance of light.
Cannabis Indieus. — Painful micturition; large amount of mucus in the urine; mucus adheres to the vessel when cold ; excessive sexual desire ; general coldness of the body ; frightful dreams, etc.
Cantliaris. — ^Intolerable tenesmus in the bladder; cut- ting pains in the urethra; bloody urine; constant desire to urinate; retention of urine.
Copaiba. — ^Painful urging to urinate; bloody mucus in urine, with dysentery ; pain in the ovaries, etc.
Digritalis. — Constant urging to urinate ; great weakness ; itching all over the body; coldness of the skin, with palpita- tion of the heart.
Pulsatilla. — Tenesmus in the bladder; urine very offen- sive, bloody and slimy, with amenorrhcea from cold.
. STOXE TX THE BLADDER.
467
we have wjished out, and also observe when no more is discharged.
MtliotCMny.
There are two approved methods of performing this opera- tion, the vaginal and the supra-pubic, the latter being re- sorted to in the male for the removal of stones of such extremely large size that they could not be removed by the perineal operation or by lithotrity.
In women the ease of diagnosis of urinary calculi, together with the great dilatability of the urethra, will make it very seldom necessary to perform the supra-pubic operation ; be- sides, a very large stone may be removed by the vaginal method ; much larger than could be removed entire by the perineum in the male.
If for any reason the supra-pubic operation is advisable in a case where we have atresia of the vagina as a complies tion, or for other rejisons, we make an incision about two and a half inches in length in the median line, commencing at the pubis, the bladder being distended with tepid water previously injected and a sound introduced by an assistant, or at least retained by him, and the urethra compressed to aid in the retention of the water. The sound carried up fibove the pubis will serve as an index to the point at which we should incise the bladder, having previously divided the attachment of the pyramidales and pushing upward the peri- tonteum, and having the dissection carried through the cel- lular tissue. After a small opening is made in the bladder, we next enlarge it towards iti> neck, pass in the lithotomy forceps, seize the stone and extract it. While doing this it is well to have an assistant seize the edges of the bladder with small forceps on either side, and lift them a little out of the wound.
After extracting the stone we should pass in the index finger and feel for more calculi. Several calculi of large siz.e are sometimes found in the bladder at the same time,
STONE IN THE BLADDER,
471
and is followed by bloody urine, burning in the urethra aftof the bloody urine has passed, etc.
Ars. Alb. is indicated where there is alternating heat and cold, thirst, suppression of urine, etc; nausea; great weak- ness; aching in the lower limbs, or over the entire body;, tongue coated white.
BelL — In suppression and retention of urine ; pain in the bladder; urging to urinate; pain in the back; flushed face; dullness of the bmin; dilatation of the pupils; fever; dizzi- ness, etc.
Puis. — From effects of cold at menstrual period, causing amenorrhoea ; suppression of urine; painful micturition; mu- cus in the urine, with leucorrhoea^ indigestion, loss of appe- tite, etc.
Cantharides. — In burning in the urethra; constant urg- ing to urinate; pain in the back of the head and neck.
Dulc. — Urine turbid; burning in the urethra; strangury; consbint desire to urinate ; symptoms worse in damp weather.
Can. Sativa. — Sharp pains in urethra; urine scanty and passed with burning pain; stitches in the urethra; mucus in the urine.
Nux. — Painful urging to urinate; tenacious mucus in the urine ; constipation, hemorrhoids, indigestion, etc.
Opium. — Urine scanty, brown, or cloudy; retention of urine; dulness of intellect; face red and hot; constipation; cold sweat on the face and head.
Cal. Carb. — Urine offensive, dark colored; profuse dia- phoresis; anxiety, with palpibition ; vertigo; deposit of earthy salts in the urine; weakness; in women of fair complexion.
liycopodium. — Gravel, with nephritis, or catarrh of the bladder; symptoms aggravated in the afternoon; red sfmd in the urine ; flatulence, with pjiin in the abdomen.
Sulph. — Worse after midnight; burning in the urethra; urine copious, offensive, excoriating; violent itching m the rectum ; despondent mood ; fretfulness, etc.
SYMPATHETIC AFFECTIONS.
473
nausea, biliousness, constipation, headache, cold hands and feet, pain in the side, palpitation of the heart, amaurosis, painful or frequent micturition, sciatica, pain in the hip or ilio-sacral articulation, chilliness, hot flashes, pain in the top of head or occiput, pain in knee, ringing in the ears, languor, inability to swallow hard substances (caused from spasmodic irritation of the oesophagus, this being produced from uterine disease), sensation of some foreign substance (like a fish bone or pin) in the throat, cough, congestion of the lungs, liver, or other organs, anaemia, chlorosis, pruritus vulvae, etc. We may also have anaesthesia or hyperaesthesia, paraplegia or hemi- plegia, as sympathetic affections.
When any or several of these symptoms are present in a case before us, and we can not find other reasonable expla- nation, we may look for the cause in the uterus or its appendages.
It may be either oi-ganic or functional, the result of inflammation or displacement of the uterus, of tumors of uterus or ovaries, or even of an arrest of normal action, as seen in amenorrhoea, the peculiarity of these cases being, that in many of them they refer no pain directly to the parts or organs primarily affected.
As I have mentioned under the heads of "inflammation," '^ amenorrhoea," "displacements," etc., we have these symp- toms complained of sometimes; but what I wish to impress upon the student's mind is, the fact that we may have these symptoms as a result of uterine disease, and have no sugges- tion from the patient of any uterine difficulty whatever; and many times when inquiry is made, we are rather abruptly told that they are all well in this respect, intimating by voice and manner, at least, that they feel we might better have omitted the question.
Years of experience will cause us to be persistent in ascertaining the true cause of these complaints; and espe- cially so when their history shows them to be chronic, and
k
47-* EATOX OX DISEASES GE n'0,VEX.
I have omitted to mention the mental affections prodneed or ajrjrravated hy uterine diseases. Some of them come under the heail of llv.-teria. othiTs that of Insanity. Under H*->teria, and Pueqieral Mania, may be found more extended remarks on the influeiK-e of uterine dis«»aj?e« upon the brain.
Whether or not it is possible that uterine diseases should produrM* insanity, is to-day somewhat in dispute. We are in- clined to the opinion that they may, but whether it is a direct or reflifX action, or in what way nerve irritation produces in- sanity. I will not attempt to explain further than to suggest that the pnin (?xpmence<l in some of these affections tends to exhaustion of nerve force as well as muscular strength. that the anicmii.- condition produced by the derangements of the functions of digestion, assimilation, and excretion (caused from uterine disejise or otherwise) may seriously affect the bniin subsbmce, as well as tend to produce disease of its meninges. We are still, ns a profession, greatly in the dark in relation to the jKUhological condition in insanity, and till wc know more of it we are neither able to assert or denv theories of its causntion. Still we see no jrood reason whv dis«*as(»s of tin? uterus nuiv not cause insanitv. I think we li.iNc (*videnc(; that thev do, in tlu» fa(*t of the co-existence of insanitv and uterine disease, and the fact that the men- tal aberrations disa])]K»ar many times when the uterine dilli- enlii(s are n^moved. Still this might have been a coinci- d<'ii((j; but there is no more reason to call this a coincidence than in many other diseasc^s wliere the symptoms disappear when the uterine difiicultv is cured.
It s(jems to me in (»ntir(» accord with the economy of na- ture that the l)rain should ho affected bv uterine disease, from the fact of tln^ known influence of the brain upon ges- tation and the fietus itself as well, all the processes of nature, all glandular and muscular action being dependent upon nerve |)ower.
Hence it is reasonable to expect that disease or displace-
SYMPATHETIC AFFECTIONS,
485
Ktloloary and Patlioloary*
These attacks result from apoplexy, softening, or pressure upon the substmee of the spinal cord, medulla oblongata or brain, and from sympathetic action, or irritation in uterine dis- ease. It is only the latter cause which I desire to discuss in this volume. The process is somewhat similar to that which is present in the production of hyperaesthesia,' which 1 have already mentioned, with this difference, that while in hyper- aesthesia there is irritation sufficient to cause tenderness of the nerve only, in paralysis there is irritation sufficient to cause some effusion under the membranes of the cord, and conse- quent pressure is exerted sufficiently to interfere with mo- tion, or both motion and sensation. Why one side is affected, and not both, is not easy to demonstrate. We can not explain this, any more than we can the periodicity of intermittents. We simply observe that it is so. We have to acknowledge that there is a large field before us in the discovery of nerve siction, which is at present almost entirely in darkness to our short-sighted vision. Sudden suppression of the menstruation, or its delayed appearance from taking cold, I have seen develop hemiplegin, which lasted about two weeks, till the menses came on, and the inflammation of the womb had subsided.
Diasrtiosis.
We will suspect paraplegia or hemiplegia (from sympathy with uterine disease), when we find a paralysis of a part of the body ; and the history of the case excludes the probability of its being caused from apoplexy; and an effusioft of blood beneath the membranes of a part of the cord, or medulla oblongata; or of its being caused by softening of the nerve substance of the cord itself. We are justified in making further examination to discover if there is any uterine inflam- mation or displacement in these c<ases. We may find both —
SYMPATHETIC AFFECTIONS,
487
may remain in it three or four hours, when she should be taken out and thoroughly rubbe<l with dry towels and re- placed in her clothing, liaving the temperature of the room up to about 80° for a time, though the air should be fresh by the admission of out-door atmosphere indirectly. The tempera- ture of the room may now be .allowed to go down to 68*^ or 70°. During the time the patient is in the pack, she may drink nil (he cool water she may desire.
On general principles the inflammation of the uterus or the displacements of the org.m should be treated as in other cases where they occur. The hemiplegia or parjiplegia will disappear as the uterine difficulty is removed.
INDIGESTION, TYMPANITES, TORPID ACTION OF THE LIVER AND KIDNEYS AS SYMPATHETIC AFFECTIONS FROM UTERINE DISEASE.
Imperfect digestion is one of the most frequent sympa- thetic affections of uterine disease. It very commonly results from suppression of the menstruation, from dysmenorrhoen. menorrhagia, displacement of the uterus, or inflammation of the uterus in either form, etc., etc.
Tympanites is a result of this imperfect digestion. Torpid or deficient action of the liver and kidnevs sometimes results from the prostration of the nerve strength, induced by uterine disease first affecting the digestion in many instances; in others, affecting the spinal cord primarily, producing debility of nerve power. This weakness of nerve power then causes torpidity of all glandular action, notably in the liver and often affecting the kidneys; this torpidity of the liver, causing constipation, and tending to prevent complete digestion, also thereby causes tympanites.
Nux^ CoLy Merc, iod,^ China j Ars. iod.j Lf/copodium^ Puis., etc., are usually the indicated remedies; though in inflamma-
SYMPATHETIC AFFECTIONS.
489
the entire abdomen, pain in the spinal cord, fever, thirst, pain in the stomach, etc.
Bry. is indicated for constipation with mucous discharges from the bowels, vagina, etc., and in case of indigestion with sharp stitches in the side or head, tenderness of the scalp, sharp pains in the ovaries, pains in the limbs or back of a darting character.
Of course, the most prominent indication is to cure the uterine trouble upon which these diseases depend.
PUDENDAL HEMORRHAGE,
491
or pars intermedia. It is on account of the rupture of these veins around the vulva that the hemorrhage is so profuse in cases of accident to the labia or vulva. They may be acci- dentally ruptured in confinement from distension of the parts by the head of the child, or in the careless use of instru- ments in delivery.
The hemorrhage from the part in cases of incised or punctured w6unds which penetrate deeply enough to injure the bulbs of the vestibule readily make the diagnosis clear.
In cases of Thrombus or pudendal haematocele a sense of fullness, soreness, etc., is complained of in the labia, and on physical examination a tumor is felt, varying in size from a walnut to an orange, near the vulva and distending the labia. If recent, the tumor feels soft or semi-solid. If several weeks have elapsed, the tumor is rather solid in its feel, un- less, suppuration has taken place, in which case the feel is fluctuating, accompanied with tenderness in the part, on pressure.
IMfTerentlal DlaartMMils.
Thrombas of the labia or pudendal haematocele is liable to be confounded with
Abscess of the Labia, Labial Hernia, Inflammation of the Labia, (Edema of the Labia, etc. In abscess of the labia there must be a preceding history of inflammation of the parts — heat, tenderness, swelling, etc. In labial hernia, gurgling in the bowel, which is pro- truded, the possibility of its replacement and its becoming smaller or entirely disappearing after lying down several hours, distinguishes it from pudendal haematocele.
In inflammation of the labia usually both are affected, and the swelling is more uniform, the tenderness and heat much greater than in thrombus or pudendal haematocele.
PUDENDAL HEMATOCELE,
493
of the bloody the pus should be freely evacuated. Brush out the interior of the abscess with a Solution of Iodine^ and apply pressure to cause adhesion of the walls of the abscess.
Thrombus or encysted blood-clot nuiy be left to itself if small. When large, so as to greatly inconvenience the pa- tient, it may be enucleated by first incising the mucous tis- sue, and peeling out the entire tumor, using the fingers and the handle of the scalpel for this purpose.
Remedies indicated in the hemorrhagic diathesis, or for varicose veins, may be given as indicated by homoeopathic pathogenesis.
4W EATON ON DISEASES OF WOMEN.
CHAPTER XLIV.
PUBERTY-^ AND THE CLIMACTERIC PERIOD.
The nge of puberty in girls signifies the time when ovnla- tion and menstruation commences, though they do not always occur simultaneously, ovulation having been known to occur before the establishment of menstruation, as shown by the occurrence of pregnancy before the appearance of the catamenia.
Just how frequently ovulation is established previous to menstruation it is impossible to determine (as but few are exposed to possible impregnation at this age). Still there are reasons to justify the belief that ovulation precedes the appearance of the menstrusil flow for several months in very many cases. The most prominent of these reasons is the uneasiness, pain, bearing down in the pelvis, sometimes accom- panied with baickache and headache, nausea, etc., occurring at intervals, sometimes irregular at first, varying from four to six or eight weeks, gradually becoming more regular in their recurrence every four weeks, when the flow also appeal's. In some enses, however, the flow comes on without these premonitory symptoms, which are indicative of ovulation, either complete or imperfect.
The development of this function is a critical period in a woman's life, a period when her whole being seems to change. The romping, rude girl becomes the reserved, modest young lady. The breasts develop, the whole form becomes rounded and symmetrical. The menbil changes are about as marked as the bodily. Though tfuln ess and comprehension of deep subjects are manifested in place of the careless thoughtless- ness of childhood and want of understanding which usually mark the age of youth.
PUBERTY,
495
Generally this chnnge takes place in girls at about the fourteenth or fifteenth year, sometimes coming on at twelve; or even at nine in warm climates, and is sometimes delayed till seventeen or eighteen years are attained in colder latitudes.
During the intervening period from the time the symp- toms of commencing ovulation first appear to the time men- struation is regularly and fully established, various symptoms are manifested with which the student should become familinr; for, otherwise, he might be led into errors, both of diagnosis and treatment, in frequent instances, entailing upon himself m,uch ridicule (especially on the part of the old ladies), which might be remembered and tbld of him for many years. I will not discuss here the various theories regarding menstruation and ovulation, as this belongs more particularly in the department of physiology ; but will consider the manifestations which this change develops in the system. Dr. Emmet has occupied much space in giving tables indicating the age at which men- struation was developed, the barrenness or fruitfulness of each, etc., etc., which are of interest as statistics, but of no practical value ; as the average age of puberty is shown to be fourteen years, with a variation from ten to twenty-three years of age in exceptional instances.
From all experience we learn that there is no exact time for the period of puberty to become established. It occurs earlier in warm climates than in cold; earlier in cities than in the country, owing to the greater excitation of the nervous system, often 'tis true at the expense of the muscular. Civilization and a luxurious mode of living doubt- less tend to the early development of this function.
As ovulation commences the girl shows more irritability of temper, is peevish and fretful, restless and sometimes sullen; the appetite is capricious, longings for unnatural arti- cles, like chalk, slate pencils, etc., are common. Disorders of digestion are often manifested, eruptions on the skin appear, notably in the form of pimples on the face. Pain and tender-
THE CLIMACTERIC PERIOD.
497
usually suffers from the same train of symptoms as occur in cases of suppression from other causes earlier in life, but with less intensity; sometimes, however, for a few months, the arrest of the flow produces no serious disturbance in the system, and with a few women the change of life produces no effect whatever. These cases of exemption from disturb- ance in the system from cessation of menstruation are the exception; and it is usually found that a very considerable effect is produced, as might be expected, from the reten- tion in the system of more sanguineous fluid than it has been accustomed to.
Generally, as a first effect of the menstrual cessation, the uterus may be felt congested and enlarged, and it is likely the ovaries and entire pelvic viscera are in a measure con- gested also. This congestion and over-fullness of the blood- vessels in the pelvis, especinlly in the uterus, causes irritation of the nerves of these parts, which is communicated to the spinal cord and sympathetic ganglia, which explains some- what the manifestations of diseases peculiarly common at this epoch.
The train of symptoms sometimes developed includes almost if not all the sympathetic and hysterical manifesta- tions to which women are liable, as well as the actual derangement of functions which do occur in these cases. As perhaps the most common result of this congestion, con- tinuing for several months, we have profuse floodings, follow- ing several months of suppression. These floodings are in some cases very exhaustive to the system, and even danger- ous to life.
The next most common disturbance in the system is derangement of digestion, causing pain, colic, heartburn, etc., etc., accompanied sometimes with rliarrhoea, and sometimes with constipation. Backache, headache, neuralgia in various parts of the body, sciatica, etc., are very frequent at this period. This condition of congestion of the parts gradually
32
PUBERTY— AND THE CLIMACTERIC PERIOD.
499
ChinUy etc., should be studied. Puis, or Macrotis are indi- cated for the non-appearance of the menstruation without special symptoms for other remedies. BeU, is indicated for bearing down pains with tenderness of the epigastrium. Sepia J when the patient has a leucorrhoeal discharge. Actm- ttCy in case nervous symptoms predominate, with chilliness or fever. Are. for nausea, complicated with hot flashes. China for weakness, trembling of the limbs, vertigo, etc.
Attention should be given to these cases regarding dress, to see that they wear sufficiently warm clothing about the feet and limbs. Warm foot baths, or the warm hip bath, may often be of service. A useful adjuvant is found also in the mustard plaster to the small of the back and epigas- trium in case much pain is felt in these regions. Horseback exercise is often highly beneficial.
If after several months of trial of remedies the flow is not established and the symptoms are of a serious charac- ter, and the patient having reached an age somewhat ad- vanced beyond that when the catamenia ordinarily appears, it is advisable to institute a sufficient physical examination to determine whether there is an imperforate hymen or an atresia of the vagina or cervix uteri, and, if so, to establish a normal condition. If the parts are found normal, we must wait and continue the use of remedies, and place the patient in favorable hygienic conditions. Sometimes going into company is good in these cases, calculating to divert the mind and restore equilibrium in the nerve forces. Cessation from hard men- tal labor is in some cases a necessity, as the excessive ac- tivity of the brain may so divert the nerve forces in the system as to cause atony of the genitalia, as mentioned in treating of " Vaginismus " and " Amenorrhcea."
Xi^atment of Disorders of tlie Climacteric.
For the condition of suppression of menstruation occunnng in the married, we are debarred from very active measures
PUBERTY— AND THE CLIMACTERIC PERIOD.
501
ion of her acquaintances, though she may pretend to ignore and despise the opinions of others, and does not like to think that old age is approaching. She does not like, therefore, to be told that this is the climacteric period with her.
It becomes the physician s duty to enjoin great care on her part to avoid taking cold ; and exposure to damp, cold atmosphere, especially at night, as well as fatigue, should be avoided. M}*^ opinion is that often the menses disappear before the climacteric period is reached, on account of various causes independent of the natural cessation of ovulation and consequent stoppage of uterine activity ; hence, it is the plan most conducive of good to our patient to keep up the function of menstruation as long as possible. In this way I think much of the tendency to the developmient of uterine tumors, cancer, phthisis, etc., is avoided by maintaining the function of regular menstruation as long as possible, and much of the liability to excessive hemorrhages is also avoided. We also have less development of nervous symptoms, digestive de- rangement, etc., if the function is maintained regularly to the utmost limit. When this is accomplished the system will suffer little from the absence of menstruation. The sexuality is, in a measure, lost ; sexual passion is lost, or much weak- ened, and the uterus becomes ^atrophied ; the vagina shrinks and becomes dry. Under these circumstances the only symp- tom likely to develop will be weakness, showing a" loss of vitality as well as virility. In these circumstances Nux^ China^ Ar8.<, etc., are usually the indicated remedies.
ATRESIA OF THE VAGINA. 603
vagina (see Fig. 47), or it may affect the lower portion only,
or the OS uteri externum or internum msiy be the sent of the
occlusion, or it may affect the entire cervical caiiiil. Either
condition mny develop hiematometra, which
wilt be situated above the location of the
adhesion.
Professor Emmet* relates a case of double uterus and vagina with atresia of one of the vnginse. (See Fig. 48.) He says : "Some years since I was consulted by a woman about nineteen years of age, who had never menstruated regularly, and wished relief from a sense of pressure and bearing down which had existed for several yeiirs. She was exceedingly nervous; I Fio. No. «. had great diiBculty in completing a thor-
ATRSn* OF IHIt V<OIN* ° , . "^ , , ,., .1
wiiK ncKATOMBTu. ough exammatiou, and was not a httle puz- zled to make out a diagnosis. To the left of the viiginawas felt an iiccumuhition of fluid extending as high as the finger could reach, and from the rectum an elastic and nearly globular body could be felt, closely attached to the uterus. After satisfying myself iis to the posi- tion of the tliiid and its connection with the uterus, I unfortunately suggested to introduce an exploring trocar, to ascer- tain the character of the accumulation. It seemed I had already lost my pa- tient's confidence, from the length of time I had taken to form an opinion as to what her difficulty was, so that my fio «
proposition was refused, on the ground onk v*ms*tL«Kii. that she would not be experimented with any longer. I never saw the aise again, and know nothing of her subsequent • Emmet'a Prin. and Pnic. of Gynecology, page 208.
ATRESIA OF THE VAGINA.
505
lishment of the normal passage. This has occurred in my own practice, but I do not recollect it to have been men- tioned by any other work on Diseases of Women. Barnes mentions that in infants and young girls atresia of vagina and hymen may produce serious consequences, and require an operation, on account of the retention of the secretions above the adhesion.
Abrupt flexions of the uterus may cause atresia at the internal os, when accompanied with inflammation and exuda- tion, or granulation. The same may also result from the development of intra-mural fibrous tumors in the cervix, or lower part of the body of the uterus. Inflammation of the vagina in childhood may cause atresia; hence, cases of leu- corrhcea in young giris must not be neglected (as the leucor- rhoea is but. a symptom of vaginitis, endo-cervicitis, or endo- metritis).
Symptoms.
In congenital atresia of the vagina or cervix uteri there is, of course, non-appearance of the catamenia. If the ovaries and uterus are normal the blood is effused, but retained above the point of the atresia, cnlled hcematometra^ nnd gives rise to the symptoms about to be mentioned; and in acquired atresia, haematometra is a result. This arrest of menstrua- tion, or its entire non-appearance, must be present in every case of atresia, w^hether congenitid or acquired (if the uterus and ovaries are normal). But the absence of menstruation does not positively indicate atresia, for it might be caused by absence of the uterus or ovaries, or want of action in these organs.
A physical examination would show the condition at once. If no obstruction was found in the vagina the attempt to pass the uterine sound would reveal the atresia of the cersix if it existed. Just here some care is necessary not to fall into an error in diagnosis, as a contraction of the cervical canal or a flexion of the uterus might offer much obstruction
ATRESIA OF THE VAGINA.
507
Atresia being an organic obstruction, the treatment re quired is mechanical or surgical, though remedies are valuable in the treatment of the conditions of the general system dependent upon the retention of the effused blood and its reabsorption into the circulation. These remedies must be selected in accordance with the symptoms in each case on .the general plan of homoeopathic therapeutics. But for the relief of the atresia an operation is required. Surgeons formerly fell into the error of making small incisions, and making two or three operations to complete the breaking up of the adhesions, and evacuating the haematometra, which allowed of the introduction of air, and the decomposition of the retained blood. At present surgeons are unanimous in the opinion that the operation should be completed at one time, and the retained blood be freely evacuated, followed by a thorough cleansing of the uterus.
Opemtloti for AtretUa or AlHietice of tlie Vagina*
The patient is placed under the influence of Ether comp. while lying upon the back with the thighs flexed upon the abdomen. A lateral incision in now made in cases where there is no depression to indicate the location of the vagina. If there is a depression, make the incision vertical, and reaching from a point about one-half inch below the meatus to within an inch of the anus. We next introduce a steel sound into the urethra. (See Plate V.) It should be about eight inches in length, of large size, and bent at a right angle; about three inches from the expansion of the handle is the best, as it distends the urethra more, if large, and its bent form enables the assistant to hold it more out of the way.
The assistant now seizes the handle of the sound and holds it firmly, as well as steadying the limbs, when the
ATRESIA OF THK CERVIX UTERI,
509
bandage has to be removed for the calls of n;iture. Every twelve hours the dilator should be removed, the ^agimi washed with carbolized warm water and the dilator replaced, till the parts are thoroughly healed.
After the operation is completed and the dilator inserted, the patient should be placed in bed in a room of a temper- ature at 70°, and suibibly wrapped (o maintain the heat of the body. The recuiJibent position should be maintained for about two weeks. The character of the fluid in the htema- tometra merits a word. It is usually of dnrk color and rarely coagulated, owing to the deficiency of fibrine. The quantity varies in different cases, according to the length of time it has been accumulating. Leatherby analyzed forty oz., which gave water 875.4, albumen 69.4, globulin 49.1, hiematosin 2.9, salts 8.0, fat 5.3, extractive 6.7.
Occasionally this fluid undergoes decomposition, and ulcer- ation is established, ventilating the abscess into some of the adjacent cavities. Each cnse of this kind must be treated upon its merits. Generally speaking it is best to proceed with the establishment of the normal opening, if the patient is not in a condition of too great depression, for it is probable that with the establishment of the normal canal the fistulous opening would close by the natural restorative powers of the system. It has formerly been recommended to evacuate the haematometra with a trocar through the rectum, an operation which is open to serious objections, and one entailing more danger than the establishment of the normal vagina, and it is now discarded.
Xreatment of Atresia of tlie Cervix I7terl«
After opening up the vagina, we may find the cervix im- pervious; or it may be closed in cases where the vagina is of normal size The adhesions in the cervix may sometimes be divided by pressing into it the ordinary uterine sound. In other cases, it is necessary to use some instrunitnt
FISTUI.^\ ' 511
CHAPTER XLVI.
FISTULA,
VESIOOVAGINAT. FISTUIx\ — RECTO-VAGINAI. FISTULA — RECTO-VE9ICAL FIS- TULA— VESICOCERVICAL FISTl^LA — URETHRO-V AG INAI. FISTUM — IN- TESTING-VAGINAL FISTULA— tJRETO-V AGIN AL FISTULA — VESICG-UTER INE FISTULA — PERITONEO - VAGINAL FISTULA — PERINEO - VAGINAL FISTULA — BLIND VAGINAL FISTITLA— FISTULA IN AND.
To save space and time, as well as to make clear these various fistulse and their appropriate treatment 1 will discuss them in connection with each other.
Fistula in ano is not peculiar to women, but results from an abscess in the cellular tissue surrounding: the rectum, and is sometimes a result of cellulitis in the female as well as in the male. Fistula in ano may be complete or incomplete, internal or external. In complete fistula in ano there is a fistulous opening from the bowel to the external part of the perineum, or posterior to, or beside, the anus. In incom- plete fistula in ano the opening may only be external, in which case it is termed external fistula in ano; and when it opens into the rectum, and has no external opening, it is called internal, or blind, fistula in ano. When opening an abscess into the vagina, it is termed blind vaginal fistula,
VesicO'Vaffinnl fistula signifies an opening between the bladder and vagina, allowing the urine to pass into the vagina.
VesicfHirethral fistula signifies an opening between the urethra and the vagina, allowing the urine to pass into the vagina, as in vesico- vaginal fistula.
VesicO'Cervical, or vesico-uterine^ fistula indicates a fistulous
VAGINAL FISTUL^E. ^ 513
in the bladder of a calculus, which gets lodged between the head of the child and the pubis. The use of Ergot is to be blamed for many cases of vaginal fistulse, especially when administered to the patient before the os uteri is largely dilated, and before the head of the child has engaged in the superior strait. This agent produces such continuous con- traction of the uterus that unless the conditions of the os uteri and vagina are such as to allow of rapid delivery various injuries are liable to result, the most prominent of which are vesico-vaginal fistula and lacerations of the os uteri and perineum. It may be caused from a pessary cutting its way through, or from its long continued pressure causing an ulcer, and finally a fistula.
Recto-vaginal fistula is more seldom produced than vesico- vaginal, it being found in less than six per cent of the total number of cases of vaginal fistuloe on record. The presence of internal piles serves as a cause of the recto-vaginal fistula. It may also be caused by instruments used in operating for atresia of the vagina. Recto-, vesico-, or urethro-vaginal, fist- ulie may result from accident in the attempt to establish a normal vagina in cases of atresia, or where it is congenitally absent.
The use of the obstetrical forceps has been blamed for producing vaginal fistulse more than any other cause. It is true, a vaginal fistula has followed sometimes after instru- mental delivery with forceps, even when they have been used by skillful and experienced hands; but still it is not clear to my mind that the instruments were the cause of the fistula.
I am of the opinion that the long continued pressure of the head of the child upon the bladder and urethra, for a great length of time, causes the sloughing and the resulting fistuln. My own opinion is (and I know the same opinion is entertained by many eminent obstetricians), that if the forceps were used more frequently, and without
33
VAGINAL FISTULAi 515
nattiralis is established. Falls upon sharp sticks, penetrating the vagina, syphilitic or cancerous ulceration may cause either of these fistulae of the vagina. Ulcerative action in the bladder, or syphilitic, or diphtheritic ulceration in the vagina may also cause them.
Vesico-cervical or vesico-uterine fistula may be caused from laceration of the cervix in confinement, implicating the vesical wall. The vagina and lower part of the cervix heal and the vesico-cervical fistula remains. This is sometimes carelessly termed vesico-uterine fistula.
Generally the first symptom which is noticed in vesico or urethro-vaginal or vesico-cervical fistula is a dribbling of urine from the vagina. This the patient at first supposes is the result of inability to hold it on account of weakness of the parts. Soon she finds that upon attempting to pass her urine little or none passes through the natural outlet, but passes through the vagina, and she takes alarm and con- sults her physician. The diagnosis of the exact nature of the difficulty is made out by a conjoined exploration with a finger of the left hand in the vagina and with the sound in the urethra or bladder. Sometimes the fist- ula is so small as to make it impossible to pass the sound through it, and it then becomes necessary to examine the vagina with a Sims' improved speculum (jis invented by Daw- son), or a trivalve, thus bringing the anterior >vall of the vagina into view, as well as the os uteri. If the urine be found dribbling from the os uteri, this fact is conclusive of its being a case of vesico-cervical fistula.
Recto-vaginal fistula is discovered by the passage of flatus and fecal matter per vaginam. The examination made with a finger in the rectum, and a sound or probe intro- duced through the vaginal opening of the fistula till it pene- trates the bowel through the rectal opening, is necessary to
VAGINAL FISTULjE. 517
•
ficial fistulae the raw edges are kept in a healthy condition by the frequent use of the injections (warm water) and free from the irritation always exerted by a deposit from the urine. Whenever this is done the largest sized artificial opening will often rapidly close of itself." He relates two cases which were sent to the hospital immediately after delivery, who were suffering from fistulae of the vesico-vag- inal variety, of a size large enough to admit x)f the introduc- tion of the index finger into them, which healed rapidly under the treatment of warm vaginal injections.
If there is present any inflammation of the bladder or abnormal condition of the urine, we may introduce the warm water directly into the bladder through the catheter, or by way of the vagina through the fistulous opening. In oases of several months or of years' standing, an operation is usually necessary to cause union of the edges of the fistulae. Sometimes, however, they may be cured by remedies and local applications to stimulate giTinulations.
We must be guided much by the circumstances of the case and the wish of the patient and friends in the treat- ment. We can usually promise a good hope of a cure from an operation, but some patients have a serious objection to an operation who are willing to suffer a great amount of incon- venience and great loss of time, and be put to any amount of expense in order to avoid an operation. In this class of cases it is advisable to make an attempt to cure the case by other means. These measures must have for their end the cleansing of the vagina and the fistula from all phosphatic or other deposits, causing the urine to flow through the normal canal and causing granulations to develop around the fistula, so as to approximate its edges, and, finally, to cause union, thereby obliterating the fistula by this process. It is really aiding nature to pursue the same process which it under- takes so successfully in the recent case, as I have learneil from experience it will do, and as I have quoted from Dr.
VAGINAL FISTULM. 519
dula. This should be repeated four or five times a day till the parts are healed. It is well to use Vaseline over the parts when almost healed, to soften them and prevent the formation of a cicatrix around the point ulcerated.
After the vagina has been healed so that nothing remains abnormal but the fistula, we introduce into the vagina a Dawson's improved Sims' speculum, so as to bring the vag- inal portion of the fistula into view; then with a syringe which has a long, curved ' nozzle inject the bladder through the fistula (if it be vesico-vaginal) with warm soap and water daily. After the free use of the water we pass a sound wrap- ped with cotton saturated with Iodine through the fistula, 15 grs. to the oz., taking pains to apply the Iodine to the margin of the fistula thoroughly, but not so freely as to al- low it to drop into the bladder or vagina.
If the fistula is vesico-cervical, we pass the Iodine up into the cervix to the point of the opening of the fistula, and hold it there for a few moments, turning the patient a little oti to her face, so as to aid the Iodine in passing into the fistula. In case the os uteri is not large, dilate it with sponge tents, so that the sound wrapped with cotton may pass without being compressed, so as to drain off* the Iodine before it reaches the fistula.
In case the fistula is urethro-vaginal, the edges of the fistula may be touched with a brush saturated with the Iodine^ after thoroughly cleansing 'the parts with the warm water and soap, by means of a soft sponge. The strength of the Iodine must be increased if we find after two or three weeks that no granular inflammation is established in the walls of the fistula. After granulations have become well established (and the fistula is a large one) we gain much time by taking two or three stitches with silver wire, to draw the edges of the fistula together. The patient will sometimes be willing to submit to our placing two or three sutures, after she has been treated some time, who would not submit to an operation at first.
VAGINAL FJSTULjE, 621
will most conveniently ilmw the edges together. The stitches should be placed about three-eighths of nn inch apart, and may or may not be set deeply enough to include the vesiciil mucous membrane. I prefer to include this membrane in placing the suture, using the semi-circular vesico-vaginal
Fig. No. 51. — Emmet's Couxtkr-Presscrk Hook.
needle; and have the wire threaded, into the needle, at least eighteen inches long. Seize the needle near the eye with a long-handled pair of straight, slender needle forceps, if the longest diameter of our incision corresponds with the median line; but if the longest diameter of the incision is transverse the vagina, we use our curved needle holder. (See chapter on Instruments; also Plate VI.) This enables us to grasp the needle so as to insert it in a direction corresponding to the median line very conveniently.
By using my needle holder we see clearly what we are doing, as the handle of the holder is to one side of the vagina while we insert the needle. This needle holder is curved simply in the blades which grasp the needle, holding it at right angles, with the handle of the holder, and with its con- cavity directed towards the operator as be holds the needle in the grasp of the holder ready for use. Pierce the tissues on the upper side, about one-fourth of an inch back from the fistula, press it through till about one-half the nee<lle emerges from the fistula ; then let go the end of the needle, and seize it in the portion emerging from the fistula, as far back towards the eye as we can, and draw it through, and then insert the needle in the opposite side by entering the needle into the fistula, and bringing it out one-fourth of an inch to the side of the fistula, opposite the one we at first pierced. Now seize the needle with the forceps and draw it through till it is out- side the body, pressing back the tissues with the counter-
VAGINAL FISTULAE:. 623
fever, Aconite is the indicated remedy at first, usually fol- lowed by Bryonia. Generally these four remedies are the ones required, unless complications arise, which must, of course, be treated according to the most prominent indications.
Operations In ClircMilc Cnaee of Veslco-vaslnal PIstnla.
Chronic cases have to be treated somewhat differently from the recent case. In chronic cases the fistula has be- come incrusted with urinary deposits, and a sort of mucous membrane has formed around the fistula. This must be cut away, and a raw, fresh surface made bfefore the sutures are inserted, in order to secure union by first intention, or even rapid union by granulation. For this purpose the long-handled, curved-bladed scissors are the most convenient. After the preparatory treatment previously mentioned in operations on the recent case, and having cleared the parts from incrusta- tions and applied Calendula wash till the vagina is in a healthy condition, the patient having been for some time kept on her side with a catheter in the urethra to secure the free drainage of the urine from the bladder, that it may not pass through the fistula and keep up the irritation. Due
Fio. No. 53. — BozEMAx's Citrved Scissors.
attention should be given to the general hctalth of the pa- tient, that there may be as much plasticity of the blood as possible; the bowels kept open by injections of water and indicated homoeopathic remedies.
The operator should have four reliable, intelligent assist- ants, and see to it that warm and cold water in suitable ves- sels is at hand, with towels, napkins, rags, si)onges, hema- statics, needles, and other ixistruments he may require, not
VAGINAL FISTULM. 525
hemorrhage would be likely to ensue, and defeat, for a time at least, the success of the operation. T is true, Simon in- cluded the vesical mucous membrane in his incisions; but how he could succeed in preventing troublesome and dan- gerous hemorrhage we can not see. Prof. Peaslee lost a case from this cause. Prof. Emmet came near losing two patients in this manner.
If we should accidentally incise the bladder in making these incisions to freshen the edges of the fistula, we should saturate a handkerchief in a small part of its central portion with liquid Ferri Persulph.^ ami insert it by means of the finger or a sound through the fistula into the bladder, and then pack cotton into its interior till strong pressure is ex- erted against the walls of the fistula, especially the incised portion.
When, however, we have succeeded in freshening the vaginal tissues without cutting the cystic membrane and causing excessive hemorrhage, we may, as soon as the little hemorrhage commonly present is arrested with cold applica- tions, proceed to insert the sutures, as described in the treat- ment of the recent case; and the after treatment is about the same, save that there is no need in these cases of ap- plying any Iodine to the seat of the fistula, for the freshen- ing of its edges has placed it in a condition to heal by what is termed first intention, while in those cases called recent, the union is usually produced by the throwing out of granu- lation, the cases being of several days' standing.
After the operation is completed, wash all blood out of the bladder with the reversible catheter and a syringe. Now, the patient should be placed upon her side in bed, and allowed to come out from under the influence of the anaesthetic. The catheter should be retained, as previously mentioned, and the patient kept upon the side for at least ten days or two weeks. The Calendula wash may gently be injected into the vagina and bladder each day, and the bowels
VAGINAL FISTULjE,
527
silver wire, using the semi-circular vesico-vaginal needle to carry it. Cave must be taken in placing the sutures, thnt we turn back into the urethra the redundancy of tissue which protrudes through the fistula; for, should we cut it away, we would deprive the patient of retentive power in the bladder, as it is this ^^^^^ redundancy of tissue, which serves in place of a true sphincter muscle at the neck of the bladder; and be- sides the cutting away of this ap- parent excess of tissue would very likely cause alarming hemorrhage.
There is, perhaps, more skill re- quired in the placing of the sutures in urethrovnginal fistula than in cases of vesico-vaginal fistulse. The needle must be inserted, so that when the suture is tightened the protruding tissues are turned back into the urethra, and the vaginal membrane is brought together over them. Either the straight or my curved needle holder may be used, as the rent is sit- uated longitudinally or transversely to the axis of the vag- ina— the straight holder being most convenient in inserting the needle from side to side (see Fig. No. 55), and my curved holder if we have to insert it from above downwards, or vice versa. (See Fig. No. 56.) After the wire is inserted the ends of the wire are passed through the eyes of my wire holder and twister (Plate VI), and the wire tightened as we draw gently upon the ends of the wire, and carry the holder down firmly against the vaginal tissuas, at the same time aiding the turning in of the prolapsed vesical tissue with the finger of the left hand while we hold the twister with our rigl)t, at the same time grasping the wires, together
no. No. 56.
VAGINAL FISTCLyE. 529
inul fistula no operation is advised. The application of Kreosote l"" locally, with the internal use of Phytolac. dec.y Thuja^ Merc, cor,^ Nit. acy etc., is most commonly the indi- cated treatment. We may say, incidentciUy, that this plan of treatment is applicable to either form of vnginal fistula caused from syphilitic or cancerous ulceration.
Where the recto-vaginal fistula is the result of direct injury (called trjiumatic lesion) we should at once cleanse the parts thoroughly, and evacuate the bowels freely with enemse. Give remedies to cause a cessation of peristalic action in the bowels, and prevent their moving for a week or so, keeping the patient nourished with beef tea, and mainbiining the horizontal position in bed, that every thing may be favor- able to the healing of the w^ound by first intention. If in three or four days we make a careful examination of the parts, and find they have not healed, .stimulating local appli- cations may be made to the lacerated surfaces to aid in pro- moting adhesive inflammation or granulation ; and the bowels should be still longer kept inactive, and the diet of beef tea continued for perhaps two weeks more. If by this time we find we have failed in securing union of the edges of the wound we had better allow the bowels to move, and restrain them again for two weeks, especially if we find the appear- ance of the fistula indicates that by that time it may become closed. During this time the daily use of warm water vag- inal injections is of great service.
It is advisable to stitch the lacerated tissues together in some instances where they are extensively divided. To do this the patient should lie upon the back, with the thighs flexed upon the abdomen. (See chapter on Lacerated Per- ineum.) The vagina is conveniently dilated with two of Dawson's improved Sims' speculums, one on either side, screwing open the divided blade to give room to examine the laceration, and to take the stitchqs. The same instruments are required as in operating for vesico-vaginal fistula, except
34
VAGINAL FISTULyE. 531
but in a different position. It now forms a wall for the vagina, and partially for the rectum as well; and finally a true mucous membrane is formed over the new vaginal patch of membrane on its rectal side, curing the rectal opening in this >vay. When, however, the opening of the fistula in the rectum is directly opposite the one in the vagina we may at the first operation divide the recto-vaginal septum slightly, hook out the rectal membrane with a tenaculum, slightly freshen the edge of this membrane, place two or three sutures in it, and on the tenth day remove these sutures, and com- plete the operation by closing the vaginal opening of the fistula, as just described.
Time to Operate. — About four or five days after thc^ menstrual period is usually the best time to select for oper- ating upon either variety of vaginal fistulae, and should not be within ten days of the expected commencement of the menstrual period. The reason for this is obvious.
Recto-vesical Fistula.
This form of fistula in the female is very rare, as I have stated, and can not exist independently . of atresia of the vagina. Keeping the patient on her side, Avith a catheter retained in the bladder for several weeks, may effect a cure of tlie cystic portion. It is well to restrain the action of the bowels at the same time. The menstrual flow might then take place through the rectum, if that part of the fistula remained open. We mat/ operate for the atresia first, and afterwards for the fistulne, which would then become vesico-vaginnl and recto-vaginal, and may be treated in a similar manner as when present singly, as a result of severe labor.
Vesioo-cervical, or Vesico-uterine, Fistula.
It has been suggested to artificially cause occlusion of the va^a in this form of fistula, but the operation must
VAGINAL FISTULA, 533
Treatment of Flfttnla In Ano.
This difficulty, arising from an abscess caused by pelvic* cellulitis, is to be treated by remedies and means to cause irri- tation in the cavity of the abscess; and, consequently, closure of both abscess and fistula. Sometimes the injection of dilute Tr. Iodine comp. into the abscess, and repeated every two days, conjoined with pressure against the perineum, cures these cases readily. Merc, CaL carb.j Sepia, Ntix^ etc., are the usually indicated remedies. If all these means fail, free division of the tissues with the bistoury and applying some irritant to the fistula itself, is the means to be used in verv obstinate cases of complete fistula in ano. In incomplete fistula the treatment is similar, except that sometimes it is necessary to make an incomplete internal into a complete fistula in ano, by making an external opening, so as to eva- cuate perfectly all the matter contained in the sac, which is often situated at the extremity of an internal blind fistula, and then to treat the case as in ordinary complete fistula in ano. Sometimes the insertion of a thread into or through the fistula, bringing it out through the anus and tying it, and then moving it from day to day, causes an irritation, which pro- motes the throwing out of granulations; and, consequently, causes a cure of the fistula. In works on surgery this fistula is usually well described, and its treatment fully laid down. I will say, however, that I have cured many cases without a resort to incision, or the use of the seton or ligature, by means of the treatment first suggested.
Resnltii of Treatment of iraarlnal FletnUu
Taken altogether the result is usually satisfactory; much is dependent upon the extent of the loss of tissue from sloughing, and the skill of the physician, as well as the willing- ness of the patient to co-operate in the treatment. Professor
VAGIXAL FlSTULAi, 636
Fourthly. This plan leaves the fistula entirely open till all the sutures are placed, and we have trouble in selecting the right ends to twist together, or get the other wires twisted in with the suture we are attempting to secure.
Simon's Operation. — He places the patient on her back, with the hips at the edge of the table, and resting upon a large, hard pillow — ^uses wide specula ns retractors. He incises the vesical mucous membrane in freshening the edge of the fistula, as I have before mentioned. When possible to do so he draws down the uterus exterior to the body, thereby inverting thfe vagina and bringing the fistula into view, which simplifies the operation materially. (See Plate XVII.) He places two rows of sutures, one to approximate the edges of the fistula, and the other, inserted further back from the lacemtion, to take ofi" any strain on the first sutures. He objects to the retention of the catheter in the bladder.
RemoTal €»f SnCtarefl^
In about ten or twelve days the sutures may be removed. Some opemtors remove them sooner, even as early as five or six days; but we prefer to wait ten or twelve days, so as to secure as firm a union as possible before they are removed. Sometimes there exists a small fistula on the sixth day which
Fig. No. 58. — Cutlkr'b Forceps ahd Sutuke Cutter.
will be healed by gmnulation by the twelfth day; and if we removed the sutures on the sixth day in such a case we would be likely to make the fistula larger by drawing out the wires,
VAGIXAL FISTULA. . 537
Episiorraphy. — Where there is very extensive ulceration of the vaginal walls, and the Ccase is complicated with ex- tensive cicatricle adhesions, episiorraphy is sometimes per- formed. It is comparatively an easy operation, and consists in paring tlie inner surface of the labia majora and stitching the opposite sides together; or catting the margin of the vulva and placing sutures so as to bring its sides together, and thereby obliterate the vaginal outlet. For at least ten days fifter the operation the patient should lie on her stom- ach with a self-retaining catheter in the bladder (which must, of course, be removed and cleansed every two or three days), so as to prevent the urine from accumulating in the vagina before adhesions have formed. The menstrual flow thereafter must pass through the urethra with the urine.
KoLPOKLESis. — Kolpoklesis is- similar to episiorraphy. In this operation the vagina is obliterated higher up, leaving per- viQus as much of the vagina as possible. Professor Simon is the originator of this operation, and claims that over fifty operations have been performed in Germany with success.
Simple Vaginal Fistul-«.
These forms of fistulje open into the vagina, but do not
communicate with either of the natural outlets of the body.
They may be
Blind fistula,
Perineo^vaginal fistula,
Peritoneo-vaginal fistula. The blind vaginal fistula is usually caused from a cellu- lar abscess opening into the vagina. It may be situated on the anterior, posterior, or lateral sides of the vagina, but is most frequent on the lateral or posterior sides. They may be treated by injections of Calendula diluted, or, if chronic, may be injected with Solution of Iodine every two days till granu- lations are developed. Another good way to treat them is to wrap a sound or probe with raw cotton, and, after satur-
LACERATIOSS OF THE CERVIX UTERI, 539
CHAPTER XLVII.
LACERATIONS OF THE CERVIX UTERL
Lacerations of the cervix uteri in labor are of somewhat frequent occurrence, and are, doubtless, one cause of the ar- rest of normal involution of the uterus after confinement, and, consequently, one cause of sub-involution of the organ and of Areolar hyperplasia of the uterus as well. Their agency in the causation of these conditions has until quite lately been ignored or overlooked, and they are still but imperfectly appreciated by the mass of the profession.
Lacerations of the cervix are liable to occur in cases where there is a rigid os uteri in labor, where drugs are ad- ministered to hasten delivery without giving sufficient atten- tion to causing relaxation of the os; also, in the use of for- ceps without first seeing that the os is fully dilatable, or in performing pedalic version and delivery under the same cir- cumstances.
One object of this chapter will be accomplished if we can arrest the attention of the student so as to impress upon his mind the necessity of attention to the dilatability of the OS, before giving Secale cor. to increase labor pains, or using forceps or resorting to pedalic version (except in extreme cases) until the os uteri is fully dilated or dilatable. In this way much may be done to prevent the sad consequen- ces resulting from disregard of these precautions.
Lacerations of the cervix uteri may be slight or exten- sive. They may occur singly or multiple. The laceration may implicate the bladder and cause cervico- or, as it is sometimes called, utero-vesical fistula, or it may exist upon the posterior or lateral aspect of the organ, and affect the peritonaeum so
EATON ON DISEASES OF WOMBff.
LACERATIONS OF THE CERVIX UTERI. 543
at marriage 21.47 years. These aveniges npproximate so closely to those of all women under observation, that it is evi- dent neither the time of puberty nor of marriage had any bearing on the cause of the lesion. These women first came under my observation at about the average age of thirty- three years and four months, the greatest deviation being for those who had sufTei'ed from backward laceration. While the number of cases is too small to give any importance to the circumstance, it is not entirely an accidental one, since it is a form of laceration which would produce the least disturbance, and then only later in life as the vagina becomes changed in shnpe. In one of the columns of the fcible will be found the number of the different forms of laceration, and their relative frequency. It will be seen that the injury on the left side is the most common, and double laceration the next. To es- biblish with some degree of accuracy the character of the labor most likely to result in laceration of the cervix, would be an important advance. I endeavored with great care to ascertain from each of these women the prominent features of the labor in which it was supposed the accident occurred. Nolwithstiinding I had so intelligent a class to deal with, I feel that the information gained is to be accepted only as approximating to the truth. The testimony of a patient as to her labors, and particularly the first one, to be of value, must be confirmed by careful observation on the part of the attending physician. From a jwribn infei-ence I had been pre- pared to learn that rapid labor was the most common cause of laceration of the cervix. The contraiy, however, has proved to be the case, as more than thirty per cent of the lacera- tions were attributed to tedious labor. This proportion would be greatly increased by the addition of the forceps cases, which properly should be placed under the head of tedious labor, since, we may assume, forceps were only employed for delivery after the labor had been prolonged. It will be noted that two instances of laceration occurred from mis-
LACERATIOXS OF THE CERVIX UTERI, 545
the length of time given for any other form of the injury. The proportion of these cases, as we have already noted, is smaller than any other, but the sterility was naturally pro- duced by the greater or less degree of retro-version, which existed as a result of the laceration extending into the pos- terior cul-desac^ and causing contraction of the parts or tissues located posteriorly.
"Menstrual Changes. — The average duration at puberty of the menstrual flow for the 164 women who suffered from laceration of the cervix was 4.78 days, while that on the general average for 2^080 women was 4.82 days. These averages are essentially the same, and, as there was no marked difference in the early history of menstruation, either as to the degree of pain or regularity, it is evident the condition jit puberty would furnish no indication of subsequent liability to this lesion.
" Lacerations through the neck of the uterus are of more frequent occurrence than has been supposed. In fact, I doubt if a woman can give birth to her first child without partial laceration taking place; but if it is slight it heals rapidly and causes no difficulty afterwards. Even most ex- tensive tears are seldom recognized at the time of labor. The tissues are then so soft that, unless the rent has passed beyond the cervix into the vagina and connective tissues, it can scarcely be detected by a mere digital examination. Indeed, the occurrence of the accident, in all probability, will not even be suspected, unless an unusual amount of hemor- rhage should exist.
"Lacerations in the median line are the moat frequent, and those through the anterior lip are move common than those in the posterior one. When in the median line and confined to the cervix, these lacerations generally heal rapidly, leaving scjircely a cicatricial line to mark their course. This is due to the fact that the necessary recumbent position of
35
LACERATIOXS OF THE CERVIX UTERI. 547
"The history of the cases suffering from this form of laceration would indicate that the occurrence of the injury is due to the position of the occiput towards the sacrum. It is very rare for bad effects to remain after laceration either backward or forward, ami when they do occur it is excep- tional. When, however, the laceration is in a lateral direc- tion, and extends beyond the crown of the cervix, a condi- tion at once arises which will defeat all the reparative efforts of nature. In practice, therefore, we have to deal chiefly with the consequences of lateral lacerations, and the effects arc more marked when the lesion is double than when con- fined to either side. Whenever the rent has extended to the vaginjil junction, or beyond, there will exist a tendency for the tissues to roll out from within the uterine canal as soon as the woman assumes the upright position. The posterior lip of the cervix naturally catches on the posterior vaginal wall, as the uterus after a recent delivery is larger than ntituml, and lower in the pelvis from its increased weight. When the flaps formed by the laceration are once separated, their divergency becomes increased by the anterior lip being ci'owded forward in the axis of the vagina. This will be towards the vaginal outlet in the direction presenting the least resistance, while the same force naturally crowds the posterior lip backwards into the cal-de sac. From thus forc- ing the flaps apart a source of irritation is at once established, which arrests the involution of the organ. The angle of lacer- ation soon becomes the seat or starting-point of an erosion, which gradually extends over the everted surfaces. With the increased size and additional weight of the uterus, in- duce<l by congestion, the tissues gradually roll out as far as the neiirhborhood of the internal os. As the laceration frc- quently occurs in consequence of rapid labor, or from its hav- ing been necessary to apply the forceps or to use traction, the perineum is frequently ruptured.
" Sometimes the laceration heals while the woman remains
LACERATIONS OF THE CERVIX UTERI. 649
accident, and is generally situated between the folds of the broad ligament on the side of the laceration. The effect of the cellulitis is to shorten the ligament, and the fundus will be fixed towards the injured side. This causes the parts which have been torn down to the vaginal junction, or beyond, to project into the passage, and as they are covered by a reflex- ion of the vaginal tissue over this part of the uterine body, just above the teripinating point of the laceration, the effect to the eye is a length of cervix on that side equal to the uninjured portion. The apparent os is alwaj's more patulous than in health, and this condition is. readily accounted for from the evident existence of disease within the uterine canal. Moreover, the deception is still mnintained by the passage of the sound in the median line to the fundus, for its use gives no indication of the true condition. The explan- ation is, that the sound pnsses through a patulous os, along the angle of the rent on one side of the cervix to the horn of uterine canal on the opposite side. So <Ieceptive is the condition that I have been frequently consulted as to the pro- priety of amputating an enlarged or enlongated cervix, when if a small portion only of the apparent enlargement had been removed the peritonseal cavity would have been opened. The cervix is never so large ns it seems to be, and the line of junction with the vagina is equally deceptive. It is, therefore, a wise procedure, in any doubtful case, to place the patient for examination on her knees and elbows. On the introduction of the speculum the vagina becotnes distended by atmospheric pressure, and by the aid of gravity the uterus is brought into its proper position. The true line of junction with the vagina will be then well marked, and only the actual length of the cervix will project above the vaginal surface. In a case of Inceration on one side, extending to or beyond tho vaginal junction, the fissure will be detected without diffi- culty in this knee-elbow * position. By the weight of the uterus its axis in the pelvis will be brought in line to cor-
LACERATIONS OF THE CERVIX UTERI. Ml
sometimes very largely caused by them, but not necessarily remedied when the lacenition which is already healed is cut and stitched together.
Rest, good diet, cleanliness, pure air, etc.^ are the neces- sities in these cases, combined with such remedies as are homoeopathically indicated by the symptoms in each partic- ular case. These suggestions apply especially to recent cases. Cleanliness of the parts and healing is to be secured by semi-daily injections into the vagina' of tepid castile soap and water, followed by Calendula water.
The chronic case (if found healed) is certainly better let alone, so far as cutting is concerned. The resulting indura- tion, ulceration, hypertrophy or Areolar hyperplasia, may demand treatment ; but as a laceration, we are of the opin- ion it needs none.
DISPLACEMENTS OF THE UTERUS. 553
well achieved, if the case was properly understood. They seem to proceetl as if there was a division membrane, like the diaphragm, between the pelvis and abdomen. I was told not long since by a medical gentleman of some pretensions that there was such a condition of the anatomy of the parts that the abdominal viscera never could press upon the pel- vic. This he stoutly maintained against the expressed views of sevenil medical gentlemen then present. We can only wonder where he obtained such erroneous ideas. Still, I have seen very many physicians who practice in these ailments as if they believed in this kind of anatomy of the parts.
The ordinary practice in these cases seems about as absurd to me as the former indiscriminate use of venesection, which is now so generally abandoned. I hope that within the next decade the universal use of pessaries will also be given up (as I believe caustic applications will also be), which have had their day of almost universal use by the old school (would that homoeopaths had kept entirely clear of their employment).
Some homoeopaths have gone to the other extreme, of depending entirely upon internal remedies in the treatment of displacements. This practice is about as unwise as the other. Great good is accomplished with the use of homoeo- pathic remedies in this class of cases, by relieving congestion and inflammation, and also in giving tone >and strength to the tissues of the uterus and its appendages. They may also do very much to aid in the treatment of displacements by re- storing the normal functions in tihe liver, kidneys, spleen, etc., which may in some cases be remote causes of the difficulty. But remedies alone are not adequate to rectify a very large proportion of the displacements of the uterus with which we meet. I have taken pains to test this matter, and have had very good opportunities to do so, and did so in good faith, desiring, if possible, to cure without mechanical appliances of any kind.
But I can not commend the reliance upon remedies alone ;
DISPLACEMENTS OF THE UTERUS, 555
become displaced, and fall into the space normally occupied by the uterus. It is easy by studying the Plate to see how women, by compressing the upper portion of the abdomen with corsets and dragging it down with the weight of clothing worn by many fastened about the waist, have pressed the intestines down upon the uterus, and thereby displaced it. Now, if the physician forcibly replaces the organ and presses it upwards with pessaries in the vagina, the uterus is placed between two pressures, one from above, another from below. This double pressure would likely produce a fleanon, or a bending of the organ upon itself, or cause inflammation. Now, it has for many years appeared to me to be a rational and philosophical practice, to lift up the abdominal viscera by some means, and give the uterus room to occupy its normal position. If this is not sensible and philosophical practice, then my judgment is entirely wrong. Holding this view, I deem it of vital importance to study in the outset how this can best be accomplished. Why this idea has been so universally ignored by writers upon the diseases of women I can not conceive. The great aim seems to have been to demonstrate the advantage of some particular pessary to press the uterus forcibly into position, irrespective of the superin- cumbent weight resting upon it.
Dr. Emmet* seems nearly to have grasped the idea, which I had already published in 1878 in the Cincinnati Medical Advance^ viz.: The influence of atmospheric pressure in maintaining the uterus in situ. He says: ^^I often give my patients instructions to assume the position on the knees and elbows at night, and after taking out the instrument [pessary, I suppose, though he does not mention, either di- rectly or indirectly, what he means], to open with the fin- gers the outlet of the vagina while in this position, so that .the uterus may be carried well up into the pelvis by atmos- pheric pressure."
♦ Emmet's Prin. and Prac. Gyoniecology, p. 129, 1879.
DISPLACEMENTS OF THE UTERUS, 557
with as great a force as downwards ; and if we can maintain the abdominal viscera in a position upwards towards the chest, as is effected while the patient is in the knee-elbow position, we may have the assistance of the atmosphere at all times, if we will but admit it into the vagina. How to accomplish this is the next question.
Herein lies the difficulty; but it must be accomplished, or little success will attend our efforts to cure many cases of displacements of the uterus. The gynaecologist must give to this matter personal and careful attention in each patient ; and he must use ingenuity in the application of means to various cases, and secure the co-operation of his patient as well.
There are patients with small abdomens, especially in the spare built, which may baffle the most experienced and skill- ful, in which instances rest in the recumbent position upon tlie side, with a pillow placed under the hips, and a small speculum in the vagina (a part of the time), will be the only alternative; but with those whose abdomens are of some size an elastic .ibdominal supporter (called by my friend. Prof. Ludlam, ahofininahU supporter ^ and sneered at by many others) is the efficient means to accomplish the lifting of the abdominal viscera off from the uterus, and leaving space for it to occupy its normal position. An improvement of the "London Abdominal Supporter," which I have had made by Max Wocher & Son, of Cincinnati, I find the most desira- ble, except in crises of extremely pendulous abdomens, when the silk elastic band is preferable. (See Plate XII.)
In adjusting my supporter care must be taken that it is not too large. It should be small enough so that when adjusted, nearly the whole length of the elastic straps pass- ing around the body is required, as otherwise we have not sufficient elasticity to make them comfortable. The lower straps must always be buckled tighter than the upper, so as to cause pressure upon the extreme lower part of the abdomen.
DISPLACEMENTS OF THE UTERUS, 559
every mechanical appliance in gyncecohgy «nd 9urgery^ ns well \\& every remedy in the materia medica.
Supports op the Uterus. — The uterus is made, by an All- wise Creator, freely movable in the pelvis and lower abdomen to subserve the purpose of gestation; for this reason the folds of peritonaeum, called the broad ligaments, are loose aind freely movable. They, in a state of health, offer no impediment to the rise of the uterus in the abdomen when enlarged from pregnancy or other causes, and can offer little resistance to its displacement downwards, backwards, or for- wards, though they in some measure act as stays to prevent lateral displacement. These^ with the vaginal walls and the connective tissue, have been considered the supports of the uterus. They appear rather flimsy, to say the least, and 1 never felt satisfied that I understood the supports of the uterus till I thought of the influence of atmospheric pressure in sustaining it in its normal position. Whether right or wrong, I present the idea to the profession, hoping its truth or falsity will be demonstrated more fully by others. Of the correctness of the plan of treatment of displacements on the general principles, which I have stated I have no doubt, having verified it by twenty years of trial.
The weight of the abdominal organs must be removed in some manner from pressing upon the uterus, or it is very evident the supports of the uterus will give way. NormaUy the folds of peritonaeum covering the intestines with the con- nective tissue, serve to maintain their weight; but when pressed upon from above with corsets or considerable weight of clothing, the folds stretch out and the intestines rest as a dead weight upon the uterus and bladder. Their treatment has been sometimes better than the theory regarding them.
Physicians have been in the habit of introducing enough atmospheric air, I judge, by their frequent use of the spe- culum and by means of various pessaries used; and when they have made the patient recline most of the time, they
DISPLACEAfES'TS OF THE UTERUS, 561
ments have formed ; but it may sustain the uterus after it is replaced by other means, if the weight of the abdominal vis- cera is removed; and after a time the cellular tissue will become healed, and attached in its normal position.
There are certain symptoms which ;ire generally indica- tive of displacements of the uterus, and which should lead the physician to make a physical examination to determine the nature of the difficulty which may also be produced by inflam- mation, in part, it is true; but when taken in connection with the absence of differential symptoms of heat, fever, etc., pres- ent in inflammation, may be quite characteristic of displace- ments. I will mention pain in the pelvis, a sense of weight or bearing down in the pelvis and lower jiart of the abdo- men, pain in the small of the back, constipation, painful and frequent micturition, pain in the ilinc region, nausea, impaired appetite and digestion, painful menstruation, colicky pains in the abdomen, etc., <'is among these symptoms. When we have a considerable number of these symptoms present in the case, whose history shows that it has been somewhat chronic (and in some recent attacks), we may conclude that there is pres- ent some displacement of the uterus, and feel justified in making a vaginal examination to confirm the diagnosis, and the better to determine the means to be used for its relief.
The diagnosis of the various forms of displacement I will mention under their proper heads.
Falls, jumping from a carriage or from any elevation, lift- ing heavy weights, constipation, neglect to empty the bladder at .suitable intervals, tumors in the walls of the uterus or in its cavity, inflammation of the organ, pregnancy, rising too fioon after confinement or a miscarringe, unskillful attention in confinement, the compression of the abdomen with corsets
36
Plate XVIII.
COMPLETE INVERSION OF THE UTERUa
INVERSION OF THE UTERUS. 563
CHAPTER XLIX.
DIFFERENT FORMS OF DISPLACEMENTS OF THE UTERUS^
INVERSION OF THE UTERUS.
Displacements may be downwardsy backwards^ forwardsn sidewise, or upwards.
Downward displacement of the uterus is termed prolapsus uteri. If complete, so as to appear externally, it is terme<i procidentia (though the terms prolapse and procidentia were formerly used as synonomous).
The displacement of the fundus backwards into the hol- low of the sacrum is termed retro-versiorty and when the uterus is bent backwards upon itself in the form of a half circle, it is termed retro-flexion.
When the fundus is bent heavily forward against the pel- vis, and somewhat prolapsed also, the os being carried back- wards into the hollow of the sacrum, it is termed ante-vermn.
When bent upon itself forwards, it is termed ante-flexion.
When tipped to either side, it is termed lateral version.
When carried too high in the abdomen, it is termed up- ward displacement or elevation.
When turned inside out, it is called inversion of the uterus.
Inversion of the Uterus.
Inversion of the uterus may be partial or complete. (See Plate XVIII.) In partial inversion the fundus is turned into itself. In complete inversion, the entire organ is turned inside out, or completely inverted. In order that inversion may take place, it is necessary that the organ be enlarged. In its normal and unimpregnated state it can not become in- verted. Inversion will not often occur in the practice of
INVEKSIOX OF THE UTERUS. 565
entirely within the vagina. Such eases must be very rare. Generally, the uterus is very large in eases of inversion, and as it is inverted and is pressed downwards, it emerges from i\w OS vaginam and drags with it the vagina and bladder, the broad and round ligaments, the ligaments of the ovary, and in some instances portions of intestine into the cavity of the inver- sion. The rarity of the difficulty may be learned from the remarks of Dr. West.* He says : " No instance of uterine inversion in the recent state has come under my observa- tion." "The Annals of the Dublin Lying-in Hospital and those of the London Maternity Charity illustrate the rarity of the accident, since it was not once met with in a total of 140,000 labors."
It is ordinarily supposed that inversion of the uterus is due to traction made upon an adherent placenbi ; but it may occur independently of this cause. Dr. Schroederf says: "Inversion is doubtless brought about in this way: the uter- ine foundation, or base of the tumor, which consists of normal uterine tissue becomes atrophied (either disappearing or un- dergoing fatty degeneration), by means of the pressure which the tumor exerts. A gap is thus formed in the firm contractile tissue, the tumor sinks into the cavity of the womb, and is driven towards the mouth by its own weight and the con- tmctions of the organ. The os then opens and the tumor sinks into the canal of the cervix, and thus, the adjacent por- tions of the uterine wall being drawn down, a complete ever- sion is gradually accomplished. In some cases, however, after the tumor has sunk a certain distance into the cavitv of the uterus, the inversion is rapidly accomplished by means of uterine contractions."
This is a very good description of the modus operandi of inversions occurring from tumoi's in the fundus. It may
•West, Diseases of Women, p. 231. tZieuissen's Cyelojne«lia, Vol. X. page 215.
INVERSION OF THE UTERUS. 567
IMaiTiKNito.
The diagnosis of a case of inversion is not so easy as might at first be supposed, especially if the case be one of long stiinding. It is most likely in a chronic condition to be mistaken for a fibrous polypus. The fibrous polypus is desti- tute of feeling, while the inverted tUerus is usually somewhat sensitive. This is not always the case, however, as it some- times becomes lost to sensibility. While partially inverted it has much the appearance of a polypus. We can pass the utenne sound into the os two or three inches, and sometimes further, and sweep the sound around the apparent tumor, and seem to feel the attachment of the pedicle at the fundus of the uterus.
Sometimes in these cases we can make out the diagnosis by rectal examination, and be able to pass a finger into the circle formed in the inverted fundus, and feel the sound passed into the bladder. In other instances it is impossible to do this, and we have to rely partially upon the history of the case.
In uterine polypi we usually have a history of frequent and profuse hemorrhages, dating back several years, while in inversion, although we sometimes have much hemorrhage, the time elapsing since its commencement is shorter (generaUy but a few weeks), for if of long duration complete inversion would have occurred. And even here we may be mistaken, for I have known a uterine polypus to produce no hemorrhage till of considerable size. A slight menstruation usually takes place from the surface of the tumor if it be the inverted uterus^ which never occurs from the surface of a fibrous poly- pus. The recent case following confinement is usually easily recognized if complete, by its size, its bleeding surface, or the partially adherent placenta, the shock to the system, taken in connection with the recent delivery of a living child, and the impossibility of a large polypus being retained in the
INVERSrOX OF THE C/TEA*CS. 569
mistaken diagnosis have kept their own counsels; therefore^ I mention no names.
The little effect produced upon some women by inversion of the uterus is truly wonderful, while in others there is a profound impression made upon the system from shock, like that which results from severe traumatic lesions. This shock or depression of nerve force, either with or without hemorrhage, is sometimes so great as to prove suddenly fatal. Even simple depression of the fundus has caused shock from which the patient never rallied.
The symptoms of simple depression are ordinarily pain in the part with some hemorrhage from the uterus. As inver- sion progresses the pain is more and more intense, and hemor- rhage is sometimes profuse, and at other times it is arrested, in great part, as the uterine surface is firmly compressed against the cervix in its descent through the cervical canal. In cases following soon after confinement, the inversion may take place suddenly with but a small amount of pain, but the shock in these cases is very great. A weak pulse, clammy skin, cold extremities, nausea, fainting spells, etc., are the symptoms most frequently present in cises of sud- den and complete inversion, and should cause the physician to at once institute a physical examination ; and, if he does not feel competent to decide the diagnosis and institute prompt and efficient measures of relief, he should call for a consulfaition at once. In complete inversion the uterus is found as a tumor in the vagina, or protruding from the os vaginam, its size ninging according to the condition of the uterus.
Until within the last thirty yeara the replacement of the inverted uterus was thought to be impossible after the lapse of twelve hours. In 1847, Dr. M'Coy,* of Harrisville, Ohio, reported a case he had reduced two days after delivery. In
•Aruer. Jour. Med. Sciences, July, 1847.
578 EATON ON DISEASES OF WOMEN.
CHAPTER L.
RETRO-VERSION AX/) RETRO-FLEXION OF THE UTERUS,
Retro-version and retro-flexion are of frequent occurrence, though often not recognized by the physician, an eiTor of diagnosis being more frequent in retro-flexion than in retro- version. This is my own experience, though Prof. Emmet* gives only twenty-nine cases of flexures of the body of the uterus backwards out of three hundred and forty-five cases of displacements. Hq, however, records one hundred and eighty-two cnses of flexures of the cervix, without saying whether they were backwaixis or forwards. I infer that he found most of these flexures of the cervix backward, which would nirtkc a total of two hundred and eleven cases of backward displacements out of a tobil of three hundred and forty-five cjises. This would approximate my own experi- ence, though I have kept no exact record of cases (never having intended to publish them).* 52.75 per cent of nil flextures he found to be in the cervix, and 47.25 per cent in the body of the uterus. I have found that most flexions were at the juncture of the body and the cervix. Dr. Barnes f says: ''lieiro-ver^ion is not nearly so frequent us rctrojlc'xion'' This is also my experience.
Retro vcn^ion and retroflexion may be congenital or ac- (luirod. By n;t rtwersion is meant the tipping backward.s of the body of the uterus into the hollow of the sacrum. th»' OS being carried forwards nearly or quite against the pubis. so that the axis of the organ is transverse in the pelvis.
Retro-flexion signifies the falling backwards of the fundus
- Eniniot's " Disca.ses of Women," p. 327. H^anics's " Pl.-^onsos of Woinon." p. 5(K>.
RETRO-VERSIOX AXD RETKO-- FLEX/OX. 579
agsiinst the rectum, the os remaining in its normal position or being carried slightly forwards. In these ctises the uterus is in a sort of half-moon shape, its concavity looking down- wards and backwards. Sometimes the uterus js bent upon itself at an almost acute angle, and is still termed retro-flex- ion if its concavity is backwards or downwards or both. Both in retro-version and retro-flexion the fundus of the uterus presses upon the rectum.
Until the present century little was known of displace- ments of the uterus. Simpson and Kiwisch have the honor to have instructed the profession more than any others in regard to displacements, mainly on ciccount of the facility of diagnosis gained by the use of the uterine sound.
Btlolofl^r.
Retro-version and retro-flexion are the result of similar causes, except that the flexure occurs where the uterine tis- sues are flabby and relaxed.
These displacements are usually the result of enlargement of the body of the organ, more particularly upon or within its posterior wall (due to inflammatory action or the development of small tumors in the muscular tissue), and the condition of sub-involution, or enlargement in pregnancy, or from the growth of polypi within its cavity, conjoined with a relaxed condition of the broad ligaments, and also a relaxed condition of the peritonieal folds, which ordinarily support the intestines. This relaxation of the supports of the intestines and the broad ligaments of the uterus tfikes place in pregnancy to allow the uterus to rise in the abdomen; and when the product of con- ception is expelled, and the uterus contracts, these supports to the intestines are left weak and of unusual length ; and if the patient rises too soon after confinement, and the intestines press heavily \\\)o\\ the uterus, this weight of intestines, con- joined with the suh'itivofuted ooiidition of the uterus, and the relaxed condition of the pelvic connective tissue nnd vaginal
580 EATON ON DISEASES OF WOMEN,
walls, together with the distended condition of the colon from jiccumuhition of fecal matter, all tend to produce retro-ver-1 sion or retro-flexion. I should also mention the distension of the bhidder as a cause of retroversion.
In this condition a jolt of the body might bend the fundus of the uterus backwards underneath the promontory of the sacrum, causing either a case of retro-version or retro-flexion; and the pressing downwards of fecal matter in the rectum would increase the flexion or version. This possible effect of the over-distended bhidder should be const^mtly recol- lected.
The student should constantly bear in mind also that not only in retro-version, but especially in retro-flexion, there is some prolapse of the entire organ as well. Many cases of retro-flexion arc overlooked for this reason.
The physician makes a digital or specular examination, and finds the cervix lower in the pelvis than normal, with the OS directed a little forwards, and concludes there is prolapse (as is evident), and so diagnoses the case. He next attempts to replace the organ by pressing the os upwards, and inserts some kind of a pessary to keep it up. This allows the fundus to come downwards more and more, and the patient gets no relief. Another and another pessary is tried without avail. The patient consults other physicians, who try a wad of cot- ton saturated with Glf/cerine, or make local applications to the cervix with a brush (which by this time is much inflamed and enlarged). There is probably by this time considerable dis- charge from the os, indicating endo-cervicitis or endo-metritis.
This rcM'ital possibly looks a little overdrawn to some, hut it is a tiue i)icture of many oases which have come under my observation, and if it was simply loss of time and money to the i)atient it would not be so bad; but it has often broken the constitution of the patient, impaired digestion and nutrition, and caused cellulitis, peri-nietritis, ovaritis, or some ailment which will sooner or later terminate
Plate XX.
RETRO-FLEXION OF THE UTERUS.
682 EA TON OX DISEASES OF WOMEK.
a case of retro-version, but the positive disgnofiis caa only be made by a physic^il examination. In retro-flexion we have a similar train of symptoms, with the exception that there is not so much vesical irritation, the cervix not being carried far enough forwards to irritate the urethra or base of the bladder to any great extent. These symptoms may come on suddenly after some sudden fall or effort at lifting or jumping, constituting an acute case, or they may come on gradually, and be of long duration.
In these latter chronic cases there is usually present a considerable leucorrhoeal discharge, often excoriating in char- acter, producing vaginitis and vulvitis. The derangement of digestion is usually marked, and the patient is troubled with tympanites. The patient has usually had much treat- ment for prolapsus, and is thoroughly discouraged. Often there is a severe cough complained of, frequently caused by the derangement of the stomach, produced by the displace- ment and not connected with any disease of the lungs more than a slight bronchitis, which has resulted from the cough rather than being the cause of it. A thorough physical ex- aniiuation will clear up the diagnosis, and is, of course, nec- essary to rectify the displacement.
In retro-flexion, a vaginal examination reveals the os in its normal position, savi* that it is carried a little forwards and downwards. (I will just here say that the physician should have his patient evacuate the bowels and bladder just pre- vious to the examination, if possible). If she has recently menstruated, and there is no fear of pregnancy in the case, w<» next proceed to introduce the uterine sound, the patient lyiiifr upon the back with the knees drawn up, and covered with a sheet (of course.) We first attempt to pass the in- strument with its concavity forwards, as it would need to be if the uterus was in its normal position; in case the instru- ment is arrested in its course, we turn it over till its cou- i^avity looks backwards; if. then, it will not advance, we
580 EATON ON DISEASES OF WOMEN.
walls, together with the distended condition of the colon from accumulation of fecal matter, all tend to produce retro-ver-1 sion or retro-flexion. I should also mention the distension of the bladder as a cause of retro-version.
In this condition a jolt of the body might bend the fundus of the uterus backwards underneath the promontory of the sacrum, causing either a case of retro-version or retro-flexion ; and the pressing downwards of fecal matter in the rectum would increase the flexion or veraion. This possible effect of the over-distended bladder should be constantly recol- lected.
The student should constantly bear in mind also that not only in retro-version, but especially in retro-flexion, there is some prolapse of the entire organ as well. Many cases of retro-flexion are overlooked for this reason.
The physician makes a digibil or specular examination, and finds the cervix lower in the pelvis than normal, with the OS directed a little forwards, and concludes there is prolapse (as is evident), and so diagnoses the case. He next attempts to replace the organ by pressing the os upwards, and inserts some kind of a pessary to keep it up. This allows the fundus to come (lownwfirds more and more, and the patient gets no relief. Another and another pessary is tried without avail. The patient consults other physicians, who try a wad of cot- ton saturated with Glycerine^ or make local applications to the cervix with a brush (which by this time is much inflamed and enlarged). There is probably by this time considerable dis- charge from the os, indicating endo-cervicitis or endo-metritis.
This recital possibly looks a little overdrawn to some, but it is a true picture of many cases which have come under my observation, and if it was simply loss of time and money to the patient it would not be so bad; but it has often broken the constitution of the patient, impaired digestion and nutrition, and caused cellulitis, peri-metritis, ovnritis, or some ailment which will sooner or later terminate
Plate XX.
RETRO-FLEXION OF THE UTERUS.
594 EATON OjV diseases OF WOMEN.
most iiTational instrument. Experience will at iast teach every one that no permanent benefit is ever derived from its use, that no degree of tolerance is ever established, but that sooner or hiter in almost every case mischief will re- sult. I have long taught that its use in a flexure would be as irrational as the introduction of a straight steel sound into the urethra for the relief of an existing chonlee; the penis might be straightened by force, but tiie cause of the difficulty wouhl certainly not be removed.
" Were wo to straighten out a flexure of the cervix by means of an intra-uterine stem, the end of the instrument would make continued pressure on the posterior walls of the vagina, on account of the want of space in tiie canal. So much disturbance, in American women at least, would be excited in the vagina and uterus, that inflammation would certainly become established if its use were persevered in. Then, as soon as the instrument is removed, tiie neck will return to its original condition.
*' If this instrument be employed with a flexure of the bo<ly of the uterus, the disturbance is likely to be even more nuirkcd. A condition exists which so closely resembles an inflannnatory Kn\i\ tliat tlic slightest provocation is often sutlicieiit to (^<{al)lisll cellulitis, and even general peritonitis.
'' \Vh(Miever, l)v sanction of a merciful Providence, the stem lias been tohn-ated for a time, even in this condition, no more profrress will have l)een made toward removing the (»xistinir cause of the flexiin^ than wouLl be aeeoniplished l)y tli(» sound in a ease of ehordee. Moreover, were its use entirely sueeessfui, so far that the canal remained perfectly straiirlit and patulous afterwards, the cause of the flexure would rcMuaiUj and the pain of mc^nstruation would in all probability be inereas(Ml in eonse(iuenee of such disturbance/
Mv own opinion is, that the use of ncarlv all vaginal j)essaries is open to nearly the same objection. This is em- phatieally true wh(»rc no effort is made to take off* from the
598 EATON ON DISEASES OF WOMEN.
CHAPTER LI.
ANTE-^VERSION AND ANTE^ FLEXION OF THE UTERUS.
Ante-version is the term givea to the position of the uterus when displaced nearly transversely in the pelvis, the OS uteri looking backwards towards the sacrum, and the fun- dus directed towards the pubis, or directly against it and the urethra and bladder. In ante-version the fundus is moved downwards and forwards, and the os carried backwards, or backwards and upwards.
If the case is one of ante-flexion we find the os uteri in a normal position, or a little backwards and downwards, the fundus pressing forwards and bent upon the cervix, and, con- sequently, pressing upon the bladder and carrying it down- wards, as well as causing some prolapse of the anterior wall of the vagina.
Some authors contend that ante-flexion and ante-version of the uterus do not and can not exist. In this position I am sure they are much niisbikeii, as these displacements are of frequent occurrence. 'T is true, the normal position of the uterus is with the fundus slightly inclined forwards. But normally it does not press against the bladder with any considerable force, and does not prolapse the anterior wall of the vagina. Sometimes in ante-flexion the amount of prolapse is very con- siderable, pressing the cervix down against the posterior por- tion of the floor of the pelvis; at other times, the flexure is quite abrupt, and not accompanied with much prolapse. The most common seat of an ante-flexion is at the juncture of the cervix with the fundus.
The effect of ante-version is to cause sterility, dysmenor- rhoea, and dyspareunia. According to the best and most com-
598 EATON ON DISEASES OF WOMEN.
CHAPTER LI.
ANTE-VERSION AND ANTE- FLEXION OF THE UTERUS.
Ante-version is the term given to the position of the uterus when displaced nearly transversely in the pelvis, the OS uteri looking backwards towards the sacrum, and the fun- dus directed towards the pubis, or directly against it and the urethra and bladder. In ante-version the fundus is moved downwards and forwards, and the os carried backwards, or backwards and upwards.
If the case is one of ante-flexion we find the os uteri in a normal position, or a little backwards and downwjirds, the fundus pressing forwards and bent upon the cervix, and, con- sequently, pressing upon the bladder and carrying it down- wards, as w^ell as causing some prolapse of the anterior wall of the vagina.
Some authors contend that ante-flexion and ante-version of the uterus do not and can not exist. In this position I am sure they are niii(*h mistaken, as these displacements are of frequent occurrence. 'T is true, the normal position of the uterus is with tlie fundus slightly inclined forwards. But normally it does not press against the bladder with any considerable force, and does not prolapse the anterior w^all of the vagina. Sometimes in ante-flexion tlie amount of prolapse is very con- siderable, pressing the cervix down against the posterior por- tion of the floor of the pelvis; at other times, the flexure is quite abrui)t, and not accompanied with much prolapse. The most connuon seat of an ante-flexion is at the juncture of the eervix with the fundus.
The effect of ante-version is to cause sterility, dysmenor- rhoea, and dyspareunia. According to the best and most com-
ANTE-FLEXION OF THE UTERUS.
600 EATON ON DISEASES OP WOMEN.
and painful micturition may, however, be due to retro-versioii or inQamfnution of the bladder. Henee, it will require a physical examination Tper vaginam to determine the exact nature of the displacement.
In ante-version we discover by digital examination that the OS uteri is displaced backwards, and looking towards the hollow of the sacrum. The fundus is felt ((hrough the ante- rior vaginal wall) in the upper part of the vagina ;is a globular 'or pear-shaped body, generally pressing the urethra hard against the pubis. The axis of the vagina is changed from an oblique upward direction to one almost transverse from before backwards.
In ante-flexion we find the os generally somewhat lower in the vagina than normal, pointing downwards, but situated a little further backwards than in the natural state. Hie fundus of the uterus may be felt apparently occupying a transverse position at nearly a right angle with the cervix. To positively determine the uterus is ante-flexed, it is nec- essary to introduce the uterine sound (which can be done if there if no possibility of pregnancy). If the sound esters the body of the uterus with the point only sH^tly inclined forwards from the direction necessarily given it in its intro- duction into the cervical canal, we may know that the bunch which we first thought to be the fundus is a tumor in the auterioi- wall of the fundus, an enlarged and displaced ovary, an induration resulting from cellulitis, or a large cystic cal- culus, and not a case of ante-flexion at all. But should we find that the sound is arrested when inserted into the cervix about an inch, and we have to turn it abruptly forwards in order to enter the cavity of the body of the uterus, we may know the c^ase is one of ante-flexion.
Treatment.
The first object to accomplish in the treatment of on/^ version or ante-flexion is to take off* from the uterus the
606 EATON ON DISEASES OF WOMEN.
not discovered, even after their physician has made a vaginal examination (the patient being in the reclining posture).
The patient should stand during the examination, and the physician be well experienced, or eiTor of diagnosis may result.
Ktlol€Hry and PatlicrtfHry*
Upon this topic I must differ in a measure from all who have written on this subject, so far as I am aware. I do this with some reluctance, although I believe I am right, for I well know the slowness with which the profession adopts a new idea in pathology or etiology.
Before offering my own ideas I will quote from the most recent writers upon the subject. Dr. Barnes* says: "The leading fact in the history of prolapse is that of imperfect involution after labor. If this great fact be kept steadily in mind, and the lessons in practice which it dictates be carried out, many cases of prolapse will be prevented altogether, and many more will be arrested in their early and curable stages."
Dr. Emmet f says: ^^The immediate causes of prolapse are threefold — either some growth above the uterus crowds it downward, or there is an increase of weight in the uterus itself, or there is a want of proper support below. The first step in the process is usually to be traced directly to the absence of support for the vaginal walls at the outlet of the passage, from which a further prolapse is soon induced by the increase in weight of the organ, resulting from its mal- position."
'" To whatever cause the increase in size and weight of the uterus may be due, the organ will settle into the pelvis just in proportion to the additional burden" (evidently meaning the weight of tlie uterus).
Now, thiit prolapse is caused almost entirely by sub-invo- lution of the uterus after labor is disproven, from the fact
♦Barnes's "Diseases of Women," page 541. t Emmet on " Diseases of Women," p. 366.
608 EATON ON DISEASES OF WOMEN.
procidentia. Normally the perineum is no more a support of the uteras than is a T bandage. The uterus in its natural position is about four inches above the perineum, at the top of the vaginal cavity ; the vaginal walls are loose and flabby^ distensible with the slightest force. If the vaginal walls stood up like pieces of paste-board, and rested upon the peri- neum, I he taking away of their support might allow of the prolapse of .whatever rested upon them; but such is not their nature. The vagina is rebiined in place by means of its attachment to the cervix uteri above, and to the cellular tis- sue on its sides, which cellular tissue is attached to"* the rectum, bladder and walls of the pelvis. Separate it from the attachments I have named, and it will drop down at once to the vaginal outlet (when the subject is placed erect) .
In so far as the attachment of the vagina to the cellular tissue and uterus is firm and normal, it holds the vagina in sitUj if there is no abnormal weight in or upon it. But, we think, the uterus is sustained mainly by the folds of perito- nieum constituting the broad ligaments, the cellular tissue surrounding it and the vagina, and by ntmospheric pressure coming in through the vagina.
Heavy lifting, tight lacinjr, forcing the intestines down upon the uterus by straining in labor or at stool, and stretch- inj^r and weakening the attaehnients of the intestines serve to produce* prolapse directly.
The conditions present after confinement are enhirgenient of the uterus, it is true ; sometimes a condition of sub-involu- tion is i)r(»sent for a long time, but it does not necessarily produce prolapse or ])rocidentia, as I have seen hundreds of crises where there was sub-involution of the uterus which had been present for years, and complicated with endo-metritis to the extent of causing much suffering, and still there was little or no prolai)se at all.
These cases showed an (Milargement of the uterus to the extent of measuring from three and a half to four inches in
Plate XXV.
PARTIAL PROCIDENTIA UTERI.
PROCIDENTIA, WITH ELONGATION OF THE CERVIX UTERI
610 EATON ON DISEASES OF WOMEN
may become complete, for the vagina is always dilatable if not already relaxed, and the uterus may become completely expelled from the vagina, although there is no laceration of the perineum.
If there was no perineum, and the patient did not wear a T bandage, of course, it would come out a little easier than if they were there to offer resistance. Hence, we have to ac- knowledge that the laceration of the perineum in small part allows of complete procidentia, but we do not concede that it is in any way concerned in causing or allowing of pro- lapse. Sub-involution does not in itself and *a1one cause prolapse, we think; but accompanying some cases is a con- dition of the broad ligaments and abdominal organs caused from inflammation (which often is the cause also of the sub- involution), which tends to produce a downward displace- ment. The sub-involuted condition may co-exist with pro- lapse, but I deny its being the principal cause of it.
In these cases where lacerations occur, there have usuallv been present the most intense expulsive pains. These severe bearing down efforts tend to displace all the abdom- inal viscera downwards in any case of labor, and where they are strong enough to cause a la(*eration of the perineum, or to exhaust the patient, so that forceps have to be used, the downward displacement of the intestines must be consider- able, on account of the straining and the atonic condition produced l)y the general exhaustion incident to labor. Strain- ing at stool from constipation tends to produce prolapse, which may come on gradually, fon^ing down the intestines upon the uterus and w(\'ikening the broad ligaments.
The straining from efforts of the uterus and voluntary muscles of the abdomen to expel a polypus from the uterus may also in the same way cause prolapse. Tight lacing of the chest and upper part of the abdomen tends to force the abdominal organs downwards upon the uterus, and produce prolapse. Dr. Emmet says, page 368: "In early life, even
Plate XXVII.
COMPLETE PROCIDENTIA UTERI.
646 EATON ON DISEASES OF WOMEN.
CHAPTER LV.
•
STRANGURY, DYSURIA, ISCHURIA, RETENTION OF UR/NE^ SUP^
PRESSION OF URINE, ENURESIS, ETC.
Strangury, Dysuria, Ischuria, etc., are terms used to sig- nify a complete or partial retention of urine in the bladder and painful evacuation of it ; while suppression of urine indicates the failure of its secretion in the kidneys. These affections are found in the male as well as the female; but there are i>ertain causes which operate only in the female to produce this condition, and it is these only which we purpose to dis- cuss here.
Displacements of the uterus, which cause the organ to press the urethra tightly against the pubis, as in retro-version, jiiite-vcrsion with some degree of prolapse, ante-flexion, etc., cause painful micturition. These displacements not only cause strangury from pressure, but from the irritation of the urethra caused from the pressure. After confinement wo- men arc often troubled with retention, which in some instances results from irritation produced by the pressure of the child's head against the urethra for a long time, in its passage through the pelvis ; and sometimes from a semi-paralyzed (M)ndition of the muscular fibers, of the bladder, rendering it incapable of contraction. This is increased by over disten- sion, lia])lo to result from a neglect to have it evacuated in due time. Suppression of urine results from want of healthy action in the kidneys, or from obstruction in the ureters; but I can not discuss these conditions here.
660 EATON ON DISEASES OF WOMEN.
CHAPTER LVI.
GONORRHCEA IN WOMEN
It seems, from the earliest accounts which have been re- corded, that gonorrhoea has always existed among all nations. Mosbs speaks of it in the Bible "** as ^^a running issne oat of the flesh." Hippocrates, Herodotus, Celsus, and Cicero speak of the disease. It is treated of especially in works upon venereal diseases ; but it seems to me advisable to mention it here, as the peace of families may at times depend upon the physician's correct understanding of it. Many physi- cians even to-day believe that gonorrhoea arises only from infection, which is a serious error, and liable to cause blame to rest upon the innocent.
£ttoi<Hry*
Gonorrhoea may arise from infection ; that is, from connec- tion with a man affected with the disease, or from the appli- cation of the gonorrhoeal matter to the mucous membnine of the Inbia or vagina with the finger or otherwise. It may also develop from a cold, causing inflammation in the vagina and uretlira, wliich is followed by a discharge of matter which will produce the disease in the male Excessive coitus, want of cleanliness, etc., may also develop the disease. Women may also disease a man, who are themselves free from any symp- tom of the disease, and who have never before had any sexual intercourse. This is asserted by Diday.f Fournier,:}: from his investigations coincides with these views. Out of three hundred and eighty-seven cases of gonorrhoea in men, he
•Leviticus, cha])ter XV.
t Biimstead on Venereal Diseases, page 50. } Ibid.
666 EATON ON DISEASES OF WQMEN.
and the mother may become affected with the disease in its tertiary foim, in this manner, so far as the cutaneous symp- toms are concerned.
I am sure I have seen the primary foi-m developed from the virus rubbed off from the seat of a water-closet. I wns formerly skeptical about this method of infection, but am now fully convinced such may be the fact. I will give one case in illustration.
A young man came to me with a well developed Han- terian chancre upon the dorsum of the penis, about three inches from the glans. He had previously been a p;itient of mine with other diseases, gonorrhoea among the number, and I am confident he would tell me the truth, as he was no ways backward about telling of his liasons. He declared that he had had no sexual intercourse for more than two nionthsy that the sore commenced about a week before I saw him^ and that a domestic where he lived, he had reason to believe, had- the disease. He could not credit my di^ignosis that it wns a chancre, and he neglected treating himself properly till finally convinced by his inability to cure himself, when he again came to me. I then treated him as well as I could. He thought himself cured, and married. His first child was still-born, and covered with syphilitic eruptions. His wife now manifested the disease clearly in its tertiary form. (She had never had primary syphilis.)
This case convinced nie that the disease in a primary form could be contracted without copulation. Since that time, which was some sixteen years ago, I have seen a num- ber of cases, both in the male and female, which have proven more strongly this idea to be correct.
The virus will not, however, be readily absorbed by any surface which is perfectly intact. Some irritation of the mucous or cutaneous surfaces is necessary for its .absorption unless it be allowed to remain in contact with the skin or mucous membrane for a considerable length of time.
(596 EA TON ON DISEASES OF WOMEN.
\\ (Iny or two without suppuration; while the terms mam- mary nbscess, abscess of the breast, and mammitis are ap- ])lie(l to those eases of inflammation of the mammary glan«l which progress for some days, and tend to the development of pus.
Symptoms.
The attack of mammary abscess is ushered in with a chill much like an ordinary intermittent, followed by fever, and generally ending in perspiration. The breasts are swollen, tender, and very hard, especially in some particular part. At first this hardness and tumefaction is confined to a small space in many cases, but gradually, and sometimes rapidly, extends and enlarges, so as to embrace the half, and sometimes the en- tire, breast. Intense pain in the head, forehead, and eyebrows is complained of; the face is flushed; mouth and tongue dry; pulse hard and rapid. The secretions of the kidneys, liver, etc., as well as the mammary glands, are suppressed. There is sometimes delirium; at other times, great despond- ency and fear of death. ^
If the inflammation goes on for several days softening is observed, which gives indication of the formation of pus. This is also signalized by the occurrence of a chill. In a week or so, if not artificially evacuated, the pus finds its way to the surface by ulcerative action, and breaks through the skin in one or several places. This has given rise to the term '^broken breast." During this time the pus is finding its way to the surface the intensity of the pain in the part is very great.
These attacks of inflammation of the breast are not peculiar to the period immediately following delivery, but may occur at any period during lactation, the most usual time, however, being during the first few months. Some- times, 'tis true, they occur during the first week after de- livery, and a little care is necessary then to discriminate between the attack of milk fever, puerperal peritonitis, and
ABSCESS OF THE BREAST. 6d7
inflammation of the breast. The use of ordinary skill and care will, however, make the correct diagnosis easy.
Cold is the most frequent cause of these conditions of the breast, the cold in the breast causing an arrest of the lacteal secretion, or its retention in the lactiferous glands, from obstruction in the tubuK lactiferi^ causes inflammation, enlargement, and tenderness of the breast, as just enumemted.
BelL internally, and locally applied externally to the breast, is the remedy to abort the disease, keeping the breast warm, and applying warmth to the extremities. If in spite of this treatment the disease goes on to suppuration, poultices of flax-seed meal or slippery-elm, applied warm and continuously, are useful in softening the hardness and help- ing to invite the ulceration towards the surface. When the fluctuation is very distinct it is best to lance the abscess, and thoroughly evacuate all the pus, and then apply com- pression in such a way as to cause all the matter to freely pass out and cause adhesions of the walls of the sac. This can sometimes best be done with long strips of adhesive plaster; at other times with bandages, always taking care to leave an opening for the free exit of all pus that may be formed. Merc, tod., Hepar sulph.y or Ars. iodid. are very gen- erally indicated in the suppurative stage; and afterwards we must prescribe remedies according to the particular condition of each case.
Malignant and Non-malignant Tumors of the Breasts, Indu- ration, Gangrene, Hypertrophy, etc.
Various tumors develop in the breast, of both malignant and non-malignant varieties.
Gangrene of the breast is seldom seen, and only occurs in
CANCER OF THE BREAST. 701
09niiptotiis«
The patient usually complains of sharp lancinating pains, occurring mostly at night, in one breast. On examination, there is found an indurated tumor of small size, uneven, and nodulated. The axillary glands of the corresponding side are found enlarged and tender, and the patient exhib- its thjB sallow, tawny complexion characteristic of the can- cerous cachexia. The disease progresses very slowly; by degrees the nipple is found to be more and more re- tracted, the tumor enlarges, and blue veins are seen over its surface.
In some instances, scirrhus commences in the integument of the breast, or the underlying cellulo-adipose tissue. In the former case, it is of very small size, bluish in color, round and movable. When situated in the cellular tissue it is felt deep-seated, though movable, generally oblong and nodulated ; after several months it approaches the surfi\ce, the tumor becomes fixed, the nipple retracts, the skin over it becomes bluish, and sloughing commences, and a foul, irritable fungous opening is established. This results from all forms of scirrhus sooner or later.
Encephaloid or Soft Cancer. — The soft or encephaloid cancer of the breast is much more uncommon than the scirrhous, or hard cancer, just described. This form of cancer develops rapidly in comparison with the hard variety, often in Ji few months attaining the size of a child's head. The tumor commences deep in the substance of the breast, and soon ulcerates, and throws out a sort of fungous growth. The pain is comparatively slight in encephaloid, compared with scirrhus. The constitutional disturbance is, however, marked, and the cancerous cachexia is unmistakable. Death generally brings relief in from six to ten months from the time ulceration commences.
CoUoidj alveolar or gelatiniform, cancer in the breast is
706 EATON ON DISEASES OF WOMEN.
The symptoms in n cnse of phlegmasia dolens, or puer- peral phlebitis, MFC very much the same as in ordinary inflam- matory attacks — the ngor followed by heat, fever, etc. The wiry pulse is sure to be present in the early days of an attack; the pain, however, is only moderate in the pelvis, and is severe in one of the lower limbs.
On examination .of the limb we find it much swollen, especially in its upper part — the foot and ankle remaining normal in most cases, but the calf of the leg is generally somewhat affected. The swelling is hard and slightly clastic to the touch; the color of the integument of the affected limb is white and glossy. The distension of the tissues is sometimes enormous.
For a day or two preceding the swelling of the limb, in some cases, we may feel the inflamed veins in the upper part of the lim^ like cords, as hard as tendons. The swelling is distinguished from dropsy in not pitting on pressure. It is not red and shiny like erysipelas, but white and glossy. As the disease progresses the fever and pain abate, the swelling becomes less tense, the tissues commence to pit on pressure.
In bad cases dark spots appear in several places, varying in size from a half dollar piece to the palm of the hand, and sloughing sometimes takes place. There seems to be a gi-eat variety in the seat of the inflammation, some- times affecting the internal coat of the veins, and giving rise to the formation of pus, in which case the symptoms of pyaemia are manifested. The case then assumes typhoid symptoms, and the outcome is doubtful. In other cases the outer coat of the veins is mostly affected, and the inflamma- tion extending to the cellular tissue, gives rise to a great amount of efl'usion of lymph and serum, though the case may not be as dangerous to life as when the internal coat of the
708 EATON ON DISEASES OF WOMEN
Aconite and Secale cor. are indicated in the outset, either singly or in alternation, followed by Bell, or Bry. Evacuat- ing the bowels with enemas of tepid water, and putting the pa- tient into a warm pack, are very useful adjuncts. We should keep the lower part of the body and limbs well wrapped in flannel. In some cases Merc.j Ars., Rhw, CarboL acidj etc., are indicated.
Indlcatioiui ftMT Remedli
Aconite, for the wiry pulse; chilliness; fever; restless- ness ; dizziness ; dry, hot skin, etc.
Ars. Alb., for great prostration ; alternating heat and cold ; aching of the limbs ; restlessness ; thirst ; nausea ; cede* matous swelling, etc.
Bell., for dullness of sensation; intolerance of light or noise.
Bry., for sharp, cutting pains in the affected limb.
Carb. Ac, in a tendency to suppuration ; great exhaus- tion (used in G"" dilution).
Merc. — Dry, shiny skin; torpidity of the secretions; diarrhoea; weakness, etc.
Rhus. — Exhaustion; pain while still, relieved by motion; inability to move the affected limb, etc.
Secale Cor. — Numbness and coldness of the limbs; diar- rhoea; stupid condition of the brain (Cowporthwaite).
If a slough forms, a poultice of yeast is to be applied; and after the dead tissue is separated Vaseline may be ap- plied to the sore, and the whole lower part of the limb should be bandaged with a roller applied evenly and gently, commencing at the foot, and applying the bandage upwards. The Ihnb should be kept elevated upon a hard piUow.
718 EATON OK DISEASES OF WOMEN.
the vngina and rectum. This is called a retro-uterine, or recto-vaginal, haematocele when the tumor consists of blood. Sometimes we find the mass seems to surround the vnginn, and it is then oiUed periuterine haematocele. In case the tumor occupies the entire posterior part of the pelvis, as represented in Plate XXVIII, it shows that the blood is infiltrated into the cellular tissue.
In case the effusion is into the peritonaeum, and the blood gravitates into Douglas' cui-de'SaCj the tumor is found Iiigher in the posterior part of the pelvis, behind the cei-vix uteri, and feels circumscribed. Sometimes we may feel fluc- tuation, nnd sometimes we can not, depending upon the amount and condition ot the effusion.
When the effusion is into the peritonaeal cavity it may, after filling the lower portion of the abdomen, extend up- wards, even reaching to the umbilicus.
It will be observed by this description so far, that haemat- ocele is only a symptom of an effusion of blood, and that the cause of the eff*usion, and the exact locality of the point from which it comes, is often very obscure. Hence, we name the condition as haematocele, (hough not a disease in itself per so. As time passes the symptoms in most cases moder- ate, Jilthough there may be more tenderness in the vagina for a time, and a considerable febrile condition. In other in- stances we have 'symptoms of acute inflammation in the pelvis, resulting in the formation of a pelvic abscess some- what similar to that occurring in cellulitis. Extreme sensi- tiveness of the stomach is one of the most constant symptoms of these cases. There is also often much cystic irritation, the urine either being passed with difficulty or frequently with much pain. Sometimes the use of the catheter is de- manded in these cases.
Prof. Byford* gives to this accidental hemorrhage the term Metalithmenia, signifying misplaced or vicarious men-
* Byforcl un ** Diseases of Women," p. 101.
720 EATON ON DISEASES OF WOMEN,
history of the case for differential points. The slow growth of ovarian cystoma and its height in the pelvis, with its devel- opment in the nbdomen, will distinguish it from haematocele, being free from the symptoms of faintings and severe pain.
If retro-flexion of the uterus is suspected, we had better make an effort to rectify the misplacement; if menstruation has been recent we may at once pass the sound, and discover in a few moments the nature of the case. I was recently called to see the wife of a physician who had had the counsel of an eminent surgeon a few days before, who had (without the aid of the sound) diagnosed retro-version. I immediately passed the sound, and found the uterus normal in position, and diagnosed a recto-vaginal hsematocele (from the history of the ease and vaginal examination), which was undergoing suppurative inflammatory action. My diagnosis was con- firmed in a few days by the discharge of the abscess into the rectum, followed by relief and health. The violent efforts which this consulting surgeon made to replace this tender haematocele with his fingers was injurious and painful to the patient, and disgraceful to himself.
In pelvic cellulitis the tumor develops more gradually, is more tender on pressure, is generally more diffused, though not always. There is some boat in the vagina in cellulitis, and very little in a recent hiiematocele.
Extra-nterinc pregnancy," either ovarian, tubal, or abdom- inal, may slightly simulate hjcmatoeele. The tubal and ova- rian pregnancy may produce hiematocele from the laceration likely to occMir about the third month, and the luematocele in these cases may contain a fuMiis. This is most likelv to be dis- covered at the autopsy which we wnll have an opportunity to make soon after the laceration occurs.
Generally, the prognosis is favorable. About ninety per cent of these cases recover. We have, however, to fear
HERMftPHRODiTE, OB NONENTITY.
724 EA TON ON DISEASES OF WOMEN.
existed somewhat in excess. These were cases of hyper- trophy from inflammatory action, one in a lady aged about twenty-three, the other over fifty. Neither suffered much inconvenience from the enlargement, except a slight irriUition and soreness at times.
Nymphomania is said to be caused by, and be the cause of, enlargement of the clitoris, but I have not observed it. Dr. C. D. Palmer, of Cincinnati, reported two cases to the Cincinnati Medical Society, at the October meeting, 1879. They were two sisters, in whom menstruation had been en- tirely absent, though they had attained to the Jiges of twenty and twenty-two years respectively. This absence of menstru- ation and a failure to effect its esbiblishment by remedies, led to a physical examination, which revealed the vagina in each, short and small, the clitoris large and long, resembling greatly the penis. No uterus could be found in either. The parents of these persons were first cousins, and both died of phthisis.
A. S. Taylor, in his work on Medical Jurisprudence, reports a case of Prof Mayer's, of Bonn, which is the nearest approach to a true hermaphrodite which I can find on record. The autopsy revealed on the right side a withered testicle with a i)rostai(3 frlniid and ponis; while on the left there was the iit(Mu.<, ovary. Fallopian tube, and vairina.
Around thes(^ cases dustcn's considerable interest, not only on account of their abnormal development, but on account of tlioir k'lral ri<»hts as individuals. — whether tliev niav vote or not. as being a ground for divorce, and regarding the l)aternity and maternity of oftspring claimed to have been horn of such i)eople.
II//l>rrtrophf/ of the labia minora, or ivfmpha*^ is more com- mon. It may also occur as a congenital or acquired deform- ity. Sometimes only one side is enlarged, and sometimes i)(>ih. I have thought that these women were more than ordinarily passionate, and their own testimony corroborates the correctness of the statement. The labia minora extend.
HYPERTROPHY OF THE LABIA MINORA.
Plate XXXI.
HYPERTROPHY
728 EATON ON DISEASES OF WOMEN,
the luinor .'ukI uterus removed from case No. 8 (for which I am under obligation to the publishers of the Lancet and Clinic).
^'I wish to distinctly impress on your mind the fact, tliat in every operation given in this report, the body of the uterus was removed — ^amputated through the neck as close to the vaginal connection as possible without opening the vaginal cavity. The removal of fibroids is secondary, and not the prime object to which I wish to claim your atten- tion. I make this report to give evidence that it may be construed by the profession as favorable or unfavorable to hysterotomy. The question whether a w^oman can bear without a fatal result the complete ablation of her uterus and thereafter enjoy life and health, is the one that an en- lightened profession now desires to have answered either in the affirmative or negative. Then if in the affirmative every individual operator desires to have light from the experience of others — to determine w^iether any special case that may come under his care can possibly survive so formidable a procedure.
" Tal)les of statistics are valuable guides to the formation f)f a correct judfrnient, but at the present time, though there are several extant, they are too loosely put together or in- efficient to estal)lish clearly the legitimacy of the operation. So we fhul that wherever the operation is presented to any of our learned bodies for discussion a great diversity of opinion is expressed, and the preponderance is adverse to its perfbrmanee.
^'If we examine the tables of Dr. Samuel Pozzi, of Paris, published in 1875, we find tabulated all of the reported opera- tions up to that time; l)ut if we examine closely the cases liere tubulated, we discover that the largest number w^ere only gavStrotomy \\\W\ partial operations on the uterus, and in many that organ was not touched by the knife, as when pedunculated, sub-peritoneal, or fibro-cystic tumors were
736 EATON ON DISEASES OF WOMEN.
CHAPTER LXVII.
HYSTERALGIA — NEURALGIA UTERI-^ IRRITABLE UTERUS--
ASCITES IN WOMEN.
The terms hysteralgia^ neuralgia uteri, formerly termed irritable uterus^ etc., indicate a neuralgic condition of the orgnn, which is sometimes very severe, although no organic disease of the parts can be discovered. It is to be diagnosed by the severe pain of a neuralgic character in the uterus, and the occurrence in some other parts of the body of neuralgic pain, and from the fact that physical examination reveals no lesion or displacement of the uterus.
It is notiible that of bite years irritable uterus, hyster- algia, etc., are seldom mentioned, while formerly they were diagnosed almost as frequently as some physicians now diag- nose liver complaint (whenever the disease seems obscure). This is possibly due to the (act that uterine diseases of late years have been better understood than they were formerly. It may liave been the case that diseases of the uterus, which are now^ readily diagnosed and treated, were formerly de- nominated irritable uterus, or hysteralgia, from the fact of jK'iin being suHered in the part, and from the fact that, the phy.sician being unable to discover any abnormal condition of the sul)stance or position of the uterus, no other name seemed appro[»ri;i to. The uterus is liable to be affected with neuralgia as well as the stomach or other parts of the boily, and, cousefiueutly, the physician should recognize the disease when present, and treat it ])roperly, though we know from experience that it is not a very common affection.
Neuralgic dysmenorrhoea is of occasional occurrence, but is not one-tenth as frequent as is generally supposed.
738 EATON ON DISEASES OF WOMEN,
is no leucorrhoea, and where previous to the occurrence of pregnancy the uterine sound had been introduced, without causing any pain, in order to discover if stenosis was the cause of the baiTenness.
As we become more familiar with the diseases and con- ditions of the uterine organs we may discover that all of these painful or supersensitive conditions have a cause aside from nerve irritation. But at present we imagine that the nerve tissue itself is alone affected in some cases of pain in the uterus, giving rise to the propriety of using the terms hffsteralgiaj neuralgia of the ttterus, and irritable uterus.
In diagnosis it is necessary that we do so by exclusion in part — t. e.j by determining that this or that disease is not present, which might cause pain if it existed. These patients are usually fretful, moody, irritable, and disagreeable gener- ally. They frequently manifest hysterical symptoms, mag- nify every thing they speak about, whether good or bad. They are active, but soon tire; are exceedingly lively at times, and again as dispirited as possible.
Xreatment*
This complaint has baffled the best endeavors of many skillful men, and must in some cases continue to be an an- noyance, because we can not always use all the treatment we judge advisable, on account of the nervousness of the patient. As to remedies, they are usually among the follow- ing: Ars. a/b.j Chinay Hyosc,^ Acon.j Ntix^ Ignatia^ Camph.^ Kali brom,^ BelLj etc.
The diet should be strictly low and plain ; stimulants are to be aA'oided. Placing the patient under the influence of an anaesthetic, and dilating the cervical canal with a dilator partially, and then inserting a sponge tent for a few hoars, is sometimes a prompt cure. This overcomes the supersensi- tive condition of the uterus, the same as dilatation of the vag- ina relieves vaginismus.
ASCITES IN WOMEN. 741
these ailments and conditions ; but we will briefly note a few here, in order to save time in reading the rather extended dis- cussion of some of these diseases, which we have made in other places in this work. It would not be a pleasant experience to mistake either of these conditions for ascites, and proceed to tap for its relief; hence a careful diagnosis is desirable.
Ovarian cystoma, fibro-cysts of the ovary, and cysts of the broad ligament, develop from the iliac regions, and not from the entire lower abdominal regions, where ascites is first observed. In these diseases the enlargement is felt when the patient reclines, circumscribed in extent, somewhat fluctuating, but not freely so.
In the advanced stages of these, diseases they more per- fectly simulate ascites than in their smaller development. Here the resonance upon percussion over the superior portion of the abdomen, while the patient is reclining, with dullness on the sides, indicates ascites, while in the case of the cystic tumors the intestines are usually crowded to one side, and there is dullness over the superior part of the abdomen. In ascites the resonance is found in one place at one time, and in another at perhaps the next examination, while in these tumors the resonant portion is found at about the same place at each examination.
The history of the development of the abdominal enlarge- ment is also an aid in the diagnosis. In normal pregnancy there should be an arrest of menstruation, and the enlarge- ment is felt as a circumscribed tumor in the hypogastric region. In the later months of abdominal pregnancy the pulsations of the foetal heart settle the diagnosis, though pregnancy may be complicated with ascites in some cases.
In extra-uterine pregnancy the tumor is felt circumscribed, and can be felt more distinctly when the patient* is reclining upon the back, while in dropsy in its earlier stages the enlargement disappears when reclining. In the later months of extra-uterine, or abdominal, pregnancy the foetal heart's
742 EA TON ON DISEASES OF WOMEN.
throbs again help us in making the correct diagnosis. Uter- ine fibroma, fibroids of the ovary, and enlargement of the uterus from the development of intra-mural fibrous tumors, are hard to the feel, compared to ascites; and as they have no fluctuation they should readily be differentiated from ascites.
We do not deem it within the scope of this department to enter into the general treatment of dropsy. I will barely say that among the remedies I have found useful are Ar%, cdb.j Ars. iodid.j Dig.j China^ Merc, cor.^ Merc, iod.. Kali iod., Sanff.j Sulpk.j etc. Remedies should be our main reliance, administered according to their most prominent homoeopathic indications, or key-note symptoms, if you please.
As there are occasionally cases which bafSe the physi- cian's best endeavors at a cure, palliatives are sometimes de- manded. I do not mean opiates or anodynes ; but I mean that the friends of the patient, the patient herself, as well as our sympathy for suffering humanity, require we should do something to prolong life, and make it as comfortable as possible while it lasts. For this purpose tapping is expedient and ])roi)er. We do not think it wise to recommend or use it, as has been before intimated, till remedies have failed us, and not then, until the patient suffers great inconvenience from the excessive accumulation of fluid, manifested by diffi- culty of motion and respiration, inability to lie down and rest, derangement of digestion, etc., etc.
Operation. — The instrument necessary for this operation is a short trocar. The patient may sit in an easy chair, slightly tipped backwards. The abdomen is now fully ex- ])()sed, and a piece of sheet, about two feet Avide and the full lenj^'th of the sheet, should be passed around the body, after being torn down at each end into three strips within about eighteen inches of the center on each side. These should be interlocked, and held by an assistant on either side.
TAPPING. 743
We now make a puncture into the nbdominal cavity with the trocar, about midway between the pubis and umbilicus, in the median line. After we feel the instrument pass through the tissues we should at once withdraw the stylet, and then press the canula further in to avoid its slipping out. If we did not first withdraw the stylet we might wound the mesentery, or intestines. A large vessel, previ- ously procured, receives the discharge. We now direct the assistants to make traction upon the ends of the bandage to compress the abdomen, in order to force out the liquid, and also to prevent collapse. Previous to the insertion of the trocar it is best to manipulate the bowels to some extent, to cnuse the intestines to rise out of the way, and float on the surface of the fluid, so that they be not wounded.
After the fluid is all drained off the canula is to be with- drawn, and a piece of adhesive plaster placed over the punc- ture. The bandage is now to be slightly relaxed, and pinned. If left too loose, faintncss would be likely to ensue; if too tight, the remaining fluid might be forced out of the perito- nseal cavity between the abdominal* muscles.
By making the puncture in the locnlity mimed there is ordinarily little danger of wounding any blood-vessel. The puncture should not be made very much to one side of the median line, for fear of wounding the epigastric artery. If we wound an artery internally, by mistake, the patient will not long survive. If an artery (epigastric) is wounded ex- ternally we may try compression by plugging the puncture. If this does not suffice we must incise the puncture suffi- ciently to expose the artery, and ligate it.
744 £A TON ON DISEASES OF WOMEN
CHAPTER LXVIIL
BATHING— VAGINAL WASHES— STOMATITIS MATERNA,
Water is like fire — very good in moderate amount, but capable of harm when used to excess. Fire may burn your house, though it is very good in the furnace in moderate amount. Water may drown us, or save our lives.
Bathing is a necessity for health; still, it is possible to bathe too much, and at improper times; and while we may well recommend bathing we have often to caution ladies against bathing too frequently. Much depends upon the temperature of the bath and the health of the person. One patient may requiie frequent bathing for a time, and still it might prove injurious if continued too long. There being such a diversity of opinion regarding bathing and the use of the vaginal syringe, we think it prudent to say a word to the student upon these' subjects, not only as remedial, but as hygienic, agents.
lia thing should be used for purposes of cleanliness, and to keep open the pores of the skin, and allow of the free escape of the insensible perspiration eonstanlly going oft' from the healthy l)ody. For this purpose the Avater used in bath- ing should be of a temperature usually termed tepid or warm, ranging from G0° to 70°. The use of pure soap, a little am- monia or soda in the water is not objectionable, if only used occasionally.
Once a week in cool weather, and once a day in very warm weather, a biith may be allowed the healthy person ; but she should not, as a rule, remain in the bath more than ten minutes. Remaining in the bath an hour or more, as is the practice of some, debilitates the system, and can not be well endured except by those adipose individuals who seem
BATHING. 745
to be benefited by a sort of stew. The lean, nervous person will be injured by it.
On rising from the bath the entire surface of the body should be briskly rubbed with a dry, coarse towel. When the temperature of the bath-room is up to 68® or 70° the cold shower bath may be taken for a moment when first rising from the tepid or warm bath, which should be followed by brisk rubbing, as before mentioned. After drying the body thoroughly warm clothing should be put on, and some brisk exercise at once taken, to keep the blood in active circula- tion. Sitting or riding in cool atmosphere must be avoided after a bath.
Time for Bathing; — The bath may be taken before eating, on first rising in the morning most advantageously, if active exercise can very soon be taken. A patient should not bathe just after a full dinner. It is unsafe to take a warm bath before retiring (the very time many choose). There is much greater danger of taking cold after a bath at this time than when bathing in the morning, and at once engaging in active exercise.
The Sponge Bath. — Sponging the body does not require as much precaution as the full bath. Active exercise after it is advisable, however. The cool sponge bath is most desirable, except in those very feeble patients who would feel chilled by it. This bath must be followed by brisk rubbing until a full glow of the skin is secured.
Medicated baths may at times be of use, as this is but another way of taking medicine into the system. They should only be used of a kind suited to the needs of the patient, and are on no account to be used indiscriminately. In electrical baths, so called, I have little or no confidence.
The Hip and Foot Bath. — The warm hip and foot bath IS sometimes of great service in attracting the circulation to the parts, and is useful in cases of amenorrhoea, especially when caused from sudden cold.
746 £a ton on diseases of women
Vaginal Washes.
As a rule we do not recommend vaginal washes. Many times, when the full bath, or the hip bath, can not conve- niently be taken, the use of the vaginal injection of warm water is desirable for cleanliness of the parts; and they are sometimes useful in allaying irritation of the mucous mem- brane of the vagina, and exert a good effect upon the inte- rior uterine surface through continuity of surface. In using the vaginal syringe the central opening in the tube should be soldered up tightly to prevent the accidental introduction of the water into the uterine cavity. The tube should not be introduced ngainst the os uteri in any case. The fountain syringe of Davidson, or one similar, is most desirable, because it is simple, cheap, and efficient. The quantity of water used should be large, so as to keep the stream running evenly for some time, the patient sitting the while over the chamber, and pumping the water in a steady stream.
Complicated instruments, for giving vaginal injections will be found more beautiful in theory than useful in practice.
Cold vaginal injections are not only detrimenbd, they are dangerous. This sliould be told patients with decided em- phasis. They are a fruitful source of uterine disease. Espe- cially should they never be used immediately after copu- lation (as is done by some to prevent conception). The parts are then in a condition of congestion, and the applica- tion of sudden cold is likely to produce inflammation, and produce a nervous shock to the whole system. Cold water thrown by accident into the uterus, in such a case, may pro- duce death in a short time ; and should death not ensue, the uterine colic induced is sufBciently severe to cause the stoutest nerves to quail. The depression following is equally alarming, coldness of hands and feet, the feeble pulse, the blanched, cadaverous countenance, are sufficient, when once seen, to produce an impression for life upon the beholder.
STOMA Tins MA TERN A. 749
Among remedies for this disease I will mention Ars., Merc, cor.y Borax, Bry,, Chinay Ferrum, Kali chlo., Phy- iolac. dec, etc. Arsenicum emphatically takes the lead, as it is indicated in about every case, and is often the only remedy required. In some cases Ars. may be followed with advantage by some one of the remedies mentioned, when used according to the totality of the symptoms. In cas8s which are pregnant, a valuable palliative remedy is Borax and Honey, held in the mouth and then ejected. Sometimes Pulv. Charcoal is found palliative to the burning in the mouth and stomach in this class of cases.
'50 EATOX OX DISEASES OF WOMEN.
CHAPTER LXIX.
NYMPHOMANIA {^THE'*FUREUR UTkRINR** OF THE FRENCH)'-ATROPHY AND HYPER-INVOLUTION OF THE UTERUS^ ABSENCE OF THE UTERUS'- MALFORMATION OF THE UTERUS— ANAES- THETICS,
Nymphomania consists in an uncontrollable desire in women for sexual congress. The passion becomes after a time insa- tiable and irresistible. At last mental Alienation becomes complete, and no sense of modesty seems to be left. The patient will solicit, and attempt to consummate, the sexual act with any man who comes near her, without regard to those present.
CUoloffy.
The disease is supposed to be usually caused by mas- turbation. This is, doubtless, often the case; bul, we think, not always, as we have personally known of instances where the disease existed in its mildest form, /. ^., where wo would have been unaware of its (»xistonco but for tlu^ voluntarv avowal of the patient (a condition not suspected by friends), where masturbation was denied by the ])ati(»nt.
In those oases it soomod that a highly nervous organiza- tion with ooniplote sexual dove^lopniont, and the excitation of the passions by the reading of exciting works of fiction, the stimulating ofToct of high living, and the caresses of lovers, had (lovelopod the condition, especially as marriage had not boon consummated. In one case it soomod to be caused from the incomph^to attempts at copulation on the part of a husband, many years lior senior, who had become impotent. In another case, where the husband was young, but par- tially impotent. Wo have seen other cases, where the verv
762 EATON ON DISEASES OF WOMEN.
In the treatment of cases of this kind much tact and delicacy is required, as well as firm principles. The patient should at once engage in some manual labor to the full extent of her strength, and this must be continued. CatUhar. 30* should be given, Camph. or Kali bro., Platinum^ Picric ae.y or Veratrum alb., given low, are also efficient remedies. Allow no beaux company to be received, recommend a cold bath daily. Let the patient's diet be very plain and non-stimulating. Let no novels be read, and the occupation of the mind should be secured by the reading of works upon geology, or by the study of mathematics. After a year of this treatment, entrance into society may be allowed, and if a suitable matrimonial alliance can be consummated, sanction it.
Cauterization of the clitoris is a barbarous, and so far as I can learn, a useless, practice in these cases. Clitoridectomy or amputation of the clitoris has also been practiced, and been found unavailing, and is to-day entirely abandoned.
Atrophy op the Uterus, and Hyper-involution.
The uterus may be smaller than normal from infancy, which is termed congenital atrophy, or it may become atro> phied after the delivery of a child, which is termed hyper- involution.
The condition of atrophy of the organ after the cli- macteric period is passed is normal. The girl affected with congenital atrophy of the uterus or ovaries will show less of sexuality in other ways; the breasts are found rudi- mentary, the hair upon the mons veneris is small in amount, resembling a girl of fourteen, when she has attidned to twenty-five or thirty years of age. Sexual passion is feeble or entirely absent. There is usually an absence of men- struation; or, if present, it is scant and irregular. Mental
ATROPHY OF THE UTERUS. 753
disturbances frequently accompany this condition, especially a want of mental capacity is manifest.
Mr. Walter Whitehead* relates a remarkable case of hyper-involution, after confinement, going on to the extent of causing entire absorption of the organ. She became quite indifferent to sexual intercourse, and no examination could detect any uterus remaining.
Htloloffy and Pattiological Anatomy*
One cause of the congenital atrophy of the uterus may be found in some instances in the near blood relation of father and mother. Other causes are the tuberculous or scrofulous diathesis, chlorosis, etc.; but in some instances the cause is obscure, from the fact that the development of other pjirts of the body, cMud the health, appear good. In these cases the walls of the uterus and cervix are thin and flabby, appearing to indicate a want of normal amount of muscular fibre. Ossification of the arteries may cause atrophy of the uterus.
Symptoms.
Absent or scant and irrejjular menstruation; want of energy; chUdish appearance generally^ in cases where the dis- ease is congenital.
The diagnosis is to be made by means of conjoined manip- ulation, one finger of the left hand in the vagina pressing against the os uteri, and the right hand pressing down upon the fiindus through the abdominal walls; or we may pass the uterine sound, when we will find that the flabby condi- tion of the organ present is in striking contnist to its normal stiff* and firm feel; and we find that its length is much less than natural.
♦Brit. Me*l. Jour., Oct., 1872. 48
754 BATON Olf DISEASES OF WOMEN.
Treatment.
The scroTulous or tuberculous patient should be given Phfflolac. dec, Calc, Chi., Arsen., etc., according to their hoiiKeopiithic indications. The chlorotiu ciisc denuinds Mere, eor.^ Ar8. iod., Ferrum, Ignaiia, etc., ordinarily. Electricity is one of the most useful agents, as I have proven in many in- st:mces. Let Ihe positive pole be nttached to the uterine electrode when introduced into the uterus, iind apply the negiitive to the spine, using a very mild primary current for about ten minutes, once in three days. The cool hip bnth is also a useful adjuvant. Use a liberal farinaceous diet, wilh free exercise in the open air.
Absence of the Uterus — Malform.4T!on3 op the Uterus.
Cases of the entire absence of the uterus in women are exceedingly rnre. The organ occasionally exists in a rudi- mentary state, having no cavity, iind being of very small size. Miilformations of the uterus are not so uncommon, though sufficiently so as to be of considerable interest. A septum existing in the organ, dividing it into two about equal parts, is perhaps the most frcrniL'iit iiialforniation. It is a condi- tion freqiit'iitly not rei'Ogriized, ns ini[)rc^- nation may tiike place on one side, and Ihe gestation jind delivery may go on normally; menstruation may go on from the opposite sidt); and this condition riraj' account tor Fi N.1 -"-D ■ those anomalous cases where menstruation
^""^""' continues in spite of pregnancy. Concep-
tion may lake place on tho oiijiositc side from which gestation is already going on. (See Fig. No. 72.)
Tlic se[ilum reprosonled in Iho cut is not always contin- uous down lo the os; still, if only extending down to the internal part of the cervical canal, it makes a double uterus
care and discretion. The question frequently ftrises, whether or not they may be used in cflses of weak lungs or with those who have heart diseiise. On general principles, we say no; still some palpifjition of the heart in women who have uterine disease, does not preclude their use, as'this pal- pitation is usually the result of sympathetic nerve action.
la cases where a severe operation is imperatively de- manded in a lady suifering with some weakness of the lungs or heart, aniesthetics may be used in moderation and with special care. In cases of confirmed phthisis or severe valvulnr lesions of the heart, both the giving of the anaesthetic and the operation may usually be dispensed with, as Hfe must soon ebb aw;iy at best, and it is useless to place the patient's life in imminent peril from an operation under such cir- cumstances.
758 EATON ON DISEASES OF WOMEN.
able, spasmodic symptoms (called hysterical) of being simply pretending.
In many cases the suffering of these patients is intense fVom disease, and they are as unable to control these mani- festations as they would be the agonies of labor. But very few can do it. We therefore bespeak for this class of pa- tients sympathy and kindness, often mingled with firmness, it is true ; still let firmness be mingled with gentleness, at all times, with these patients.
The cause of hysterical manifestations lies primarily in the irritable and weak condition of the nervous system. This may be hereditary or acquired by mentjil or physical labor in undue amount, by dissipation, late hours, loss of sleep, stimu- lating diet (to the neglect of that which is substantial, plain, and nourishing). Disorders of menstruation, frequent child- bearing, mental shocks, etc., may also induce this irritable, weak condition of the nervous system. These causes may be termed predisposing.
Direct causes are to be found in displacements of or inflam- niJition in the uterus or ovaries ; dysmenorrhoea, excessive or entire want of sexual congress; indigestion, causing gastralgia or flatulency, constipation; worms, vaginitis, vaginismus, dys- pareunia, pruritus vulvue, etc. The enlargement of the uterus in gestation, irritation of this organ from sympathetic irrita- tion of the breasts in nursing, disagreeable home associations, sudden colds causing amenorrhcjea, etc., may develop hysteria.
I believe all these causes, and perhaps many more, tend to produce hysteria in those patients who have a high ner- vous organization, and who are debilitated, especially those poorly nourished and of weakly constitution. There is in some an appearance of plethora and vigorous health. In these cases there is a want of proper balance of nerve strength, owing to some of the enumerated direct causes. A
760 EATON ON DISEASES OF WOMEN,
of fatigue, may develop such severe symptoms as to mislead the physician, unless he is aware of the patient's peculiarity in this regard.
Hysterical women are prone to magnify every slight ail- ment which they have. They, perhaps, do suffer more than others, because of the acute sensitiveness of their nerves.
Hysterical Rage or Mania. — Raving and paroxysms of anger followed by sorrow, remorse, Aveeping, and self-con- demnation, is a symptom in some cases. They may, how- ever, laugh in a few moments, and again go into a causeless
rage.
Treatment.
In violent cases, the first thing to do is to see to it that the patient does herself or others no harm. Physical re- straint is often absolutely necessary. A thin piece of a large cork placed between the teeth and then binding the jaws firmly, serves to keep the patient from biting her tongue, and also will enable us to administer remedies, which otherwise we might be unable to do. Sec that the feet are warm, the head cool, etc. Select remedies according to Ihe condition of the patient, as well as the symptoms present at the time. Clniicif. Rac, is an excellent reinedv when we have the history of the patient, showing ovarian pain. Puis. when there is amenorrhoea from cold, with tenderness in iliac refrion. Aconite, Gehenu.or An^cn,, may be indicated by the imlse and the teniperatnre of the skin, etc.
Ljnatid is, perhaps, our best remedy, so far as the purely spasmodic symptoms are concerned. When there is any tendency to conjestion of the hmgs, Verat.viride, Gelsem.^ or Bryonia^ may l)e indicated. Hf/osc. is indicated if there is a tendency to immodesty manifested.
Nux and Colocj/nthis, in alternation, are indicated in flatu- hMicy, and especially when pain centres around the navel. When the flatus is evidentlv in the colon, an enema of w^arm water, f(dlowed in a few^ minutes by one of quite cool, is very
762 EATON ON DISEASES OF WOMEN
Special indlcattonti for Remedleii.
Aconite — Hysterical condition, characterized with fear MS a prominent symptom where the disease developed from fright, or where the prominent symptom is fear, together with tenderness of the uterus or ovaries; the wiry pulse; dizziness on rising, etc.
Asafoetida — Hysterical condition, with burning in the oesophagus; sensation of a lump in the throat, termed ghbiis hysterictis.
Aunim,is indicated in suicidal hysteria.
Bell., is indicated in hysteria when there is a flushed face; redness of the eyes; throbbing headache over the eyes.
Bry., when there are shaip pains in the limbs or chest, worse on motion, with hysterical spasms occurring only at the menstrual period.
Cal. Carb.,is indicated in the leuco-phlegmatic tempera- ment where hysteria is manifested, where leucorrhoea is a complication; patient is very sensitive to cold, etc.
Chamomilla, in hysteria, Avhere a bad temper is a prom- inent symptom as a complication.
Col., is indicated where the hysteria is complicated with cutting pains around the navel; gas in the intestines, etc.
Gelsein., is indicated in hysteria, where there is also an intermittent fever present in the case.
Hyosc, in hysteria, with tendency to immodesty; tears come to the eyes without cause ; hysterical spasms, etc.
I^natia, hysteria, with silent morose condition; angry mood ; comes out of her spasm with deep sighing.
Ipecac, where vomiting precedes or follows the hyster- ical spasm.
Nux Vom., in hysteria with constipation, indigestion, loss of appetite, etc., especially in women who have been drinking much wine or other liquor.
Plios., in tall, slender women with hysteria, having stool
HYSTERIA. 763
which is dry, hard, and narrow ; much gas on the stomach, which is raised after eating.
Puls.9 hysteria at the menstrual periods, with partial amenorrhoea ; pain in the ovaries ; indigestion ; headache, etc.
Secale, in high attenuation is indicated in hysteria with threatened abortion.
Verat. Viride, hysteria, with tenderness of the spinal cord, with profuse perspiration
INDEX
■o~
l(
Page. '• Page.
ABORTION, 421, 075 j Absence of tJie uterus, . 750, 754, op. 723
etiology, 422 ' " " -' ovnries, .... 266, 754
symptoms, 428 ! Ablation of the aterus, 727
conyulsions in, 424 " " " cases requiring 727
diagnosis, 425 1 ** '* " experience in, 727
prognosis, 426 ! Acute inflammation of ihe uierus, . . 77
u tl <.
(I ti
(( i:
treatment, 426
remedies in threatened, . . 430 a cause of uterine diseases, 18
Abdominal dropsy, 739
supporters, . .156, 667, 558 parietes failure of to ad- here after ovariotomy, . 334
gestation, 642
Abnormal conditions, tolerance of, . . 479 ♦♦ menstruation, 34, 56, 242, 498
Abscess of the breast 092, 695
symptoms of, 696
etiology of, 097
treatment of, 097
Abscess of the labia, 406, 410
etiology' of, 411
diagnosis of, 411
treatment of, 412
Abscess in inguinal glands, 052
<' abdominal muscles after
bvariotomy, 335
»' the uterus, 241
Abscess, pelvic, 69, 110, 113, 125, 295, 718
etiology 115
symptoms, 116
prognosis, 119
treatment, 122, 125
Absorption of the uterus, 768
(t
« «
u «
u u it
(i
((
It
((
(( «c
ovaritis, 205
Adhesions in Ihevnginn, .... 186, 190
labia, 186, 190
*• prevention of, . 195 Adenoid tumors of the breast,. . 698, 099 Advancing senile atrophy of female
genitalia, 504
Albuminurin 062
Alveolar cancer of the breast,. . . . 701
Alimentation, rectal, 083
Amenorrhcea, . . . . 31, 82, 228, 242, 499
** symptoms of, 32
etiology of, 34
treatment of, 30
caused from psychical in- fluences, 35
simulating phthisis pul-
monalis 36
causing cough, . 32, 20, 242 exceptional cases of, 32, 20
242
Amputation of the breast, 092
*' cervix uteri, 169
inverted ut«ni8, .... 576 .... '62
ft
t; U
tt ft
«
u (t
it
t;
it (t
(;
** clilorit,
Ansimia,
Anomaloiis ear AnUwptio
INDEX.
767
t<
(I
(I
I*
^i
t<
{i
((
C(
((
(I
i(
»{
«(
1(
«
((
(I
i(
tt
ti
il
(i
i(
«i
li
cc
(«
ii
Page.
Caneer of the uterus, 167, 400
breast, 700
tubes, 439
uterus, scirrhous, . 167, 400 " cnccphaloid, . . 400 breast, colloid, .... 700 scirrhous, . . . 700 melanoid, . . . 700 gelatiniform, . . 701 alveolar, . . . 701
ovary, 387
Cancerous ulceration of vagina, . . . 029
cachexia, .... 24, 630, 701
Cachexia, cancerous, .... 24, 630, 701
" tuberculous, 24
Catnmenia, 31
Carcinoma of the ovaries, 300
" " uterus, 400
" liver, 287
Calculi in the bladder, 462
" ureters, 462, 460
phosphatic, 462
uric acid, 462
causes of, 462
one cause of vesico-vaginal fistula in sonic cases, . . . 463
Causes of female diseases, 17
Caution against uterine injections, . . 216
Cervicitis, 211
Cervical metritis 79
hyperplasia, 103
endo-metritis, 218
Cervix uteri, incisions of, 596
indurations of, 162
hypertrophy of, 162
lacerations of, .115, 530, 550
a cause of hypertrophy, 166
" areolar liyperplasia, 102
artificial atresia of, . . . 532
cancerous diseases of, . . 400 I
stenosis of, 452
atresia of, 502
tumors of, 343
amputation of, 169
Cellulitis, pelvic, 110, 113
description of, 113
symptoms of, 110
chronic, 117.
prognosis of, 110 I
treatment of, 122 |
((
It
li
11
It
11
II
II
II
II
II
II
II
li
ii
II
ii
ii
li
<i
Paoc. Chronic inflammation of female gen- italia, 62, 70, 87
cellulitis 117
" cystitis, 458
" parenchymatous metritis, . . 87
Chancre, Huntcrian, 657
" soft, 657
" hard, 657
Chapter on Instruments, 142
Chancroid sore, 657
Child-bed fever, 126
Chair for examinations, 22
Chlorosis, 82, 764
Chills caused from retro-version of the
uterus, 25
Change of life, 494
Civiale*8 lithotriptor, .... Plate VIII.
Clitoris, amputation of, 752
" elephantiasis of, 723
** hypertrophy of, 723
" cases of, 724
Clitoridectomy, 752
Clamp for pedicle in ovariot- omy, 160, and Plate XV. " Thomas', « '*
♦• ** Spencer Wells', " " " Dawson's improved, . . 321
Climacteric period, 494
•' *' t reatnient of diseases of, . 500
Conjoined manipulation, 28
Cold vaginal injections injurious, 701,746
Colostrum, 694, 695
Combination battery, 38
Complications of metritis, 82
Coccygodynia, 396
Color of the discharge in endo-metritis, 220
«< " " endo-cervicitis,212
Cover for use in examinations, ... 30
Colpeurynter, 45, 350, 364
Colpeurysis, 45
Corporeal hyperplasia of the uterus, . 104
Colic, uterine, ....•• 586
Copulation, injurious effects of, . . . 83 Convulsions in the puerperal state from
albuminuria, 662
" in hysteria, 759
Crabs, 408
Cutler's forceps and suture cutter, . . 535
Cut of fistuln, 524
Curved soissors, 530
768
INDEX,
Page.
Curyed scissors, long 146
Cystitis, 455
symptoms 455
etiology, 456
treatment, 457
Cystocele 389, 891
Plate XVI.
Cystoma ovarii, 298
Cystin calculi, 462
Cysticercus, 856
Cysts of the ovary, 280
" " broad ligament, . .801, 437
•' vaginal 406, 414
" '• pathol. anatomy, . . . 414
" ** etiology, 414
** *• diagnosis, 415
" " treatment, 415
" of the uterus, 356
*• •* ovary, rupture of, ... . 310 '• *' " permanent opening into, 309
DAWSON'S improved Sims' speculum,
Plate 111.
Dead foetus in utero, 29
Denidation, 49
Decidua (nidul), 49
Dermoid cyst^, 267, 277, 278
Diet, Dantam system of, 700
Dilutions, homoeopathic, 138
Diphtheritic inflammation of the
vngina, ISO, 101
Diatliesis sen Infeciio punilenta, . . l;>> luMMonhngic, .... 203, 41»'i
Diapiiosifi, ceneral, 21
of female 'li leases, . . 21 •• of a.lliesions in ovarian tumors, 200 •• .litferential, " " '' 283
" <tt inversion of the uterus,. . . r)»i7 •' (lithcnlties of in inversion of the
nierus ^>^)>^
Displaoenienta of the tubes, . . 439, 443
^* ov.'irit'S o^O
of the uterus, . . oo2, 003 •• symptoms, 501 " etiology, . Atn " treatment, 502
Diseases, female, causes of. 17
Dilator : Emmet's sponge tent), Plate IX.
Palmer's uterine. . . •. . . .140
Diseharge, color of in endo-metritis, . 220
Page Discharge, color of in endo-oerricitis, 212
Diseases of pregnancy, 660
" of the ovaries, 265
" uterus, sympathetic, 472, 487
" tubes, 439
" urethra, 445
•* " treatment of, . . 448
*• sympathetic 472
" of the breasts, 692
Double tenaculum forceps, 323
" uterus 754
" cervix uteri 755
Drainage tube, 333
Dropsy in women, ' . . 739
" " *• diagnosis, .... 740 " *' " treatment, .... 742 " of the Fallopian tubes, . . . 301
Dyspareunia, • 162, 173
" symptoms 173
" etiology, 175
" treatment, 176
Dysuria, 646
" treatment of, 648
Dysmcnorrhoea 4«i
'* diagnosis, 47
" prognosis 50
'* treatment, 50
EATON'S necdle-holdcr, . . 145, 521, 527
Fig. of, Plate VI. Eaton's wire holder and twister, 146, 522
'^ ♦• Fig. of, Plate VI.
Eaton's improved London sui>-
porter, . . .158, C05. See Plate XII. Also uterine displacements.
P^craseur, ".09
Edwards* ecraseur, 300
Eflfects of conception in cases of eudo-
metritis, 223
Effects of uterine disease, 17
Elevators, uterine 150
Elevator, Sims' loO
Elliott's 1;jO
Elevators, uterine See Plate XVI.
Elevation of the uterus 503, 577
Plate XXVIIl. Electrical batteries, . . 38. 150, 160, 714
Electrolysis needles, 100, 37t)
in ovarian cyslouia, . . 309 Electrical bktlis 745
" ID Ireatmenl of ntrophj of
iitcTU 754
** '• " smenorrluBa, 87, 470 ■■ " '■ Bub-in volution, . 7H •■ " " uMrine fibroids, . 34'J
Etongation of oerrii uleri 104
EljtrvpUitj 63G
Elephaatiuig of lbs olitori 723
" " lAbin majoni 728
'■ minom, .... 723
clilorlB, . . Plnla XXIX.
Ubift XXX.
" tninarn.P1aleXXX[.
■ Hytrorrhnphy 30^.393,017.623
BlMticil; of the cod in
il.« pelvis, ... 867 '■ " uterine i issue, 163,800
Eotmet's spange dilator, 161
... Plate IX.
" curred scissora, 720
" ipongo teoL applicntor, . 306, 697
effects of, . .
211,2.)3
TegeUiions of. 352, " grnnnlnltims of,. .
iDt1nmm<uioa of, . 218, 253 EDUcleationorBuliniucous fibroids, 347,1 EnucUator. SiiuB' {tlircc figures), . . i Encephnloid cancpr of tLe brenul, . . 7
EiiUrocele, i
Endoscope, aretlirnl, 4
Enlnrgemenl of Uie clitoris 7
" " labin mnjoni, . . 723
Eiiutesis, 047, 648
Episiorrhaphy,
Ephemera
Ergotino injections In uterine fibroids, 348
Emirpation of Ihe breaal 702
Eigection " " 702
Ritirpation of tbe uterus, . . . 340, 727 EmminntioD tAble, 319
." reolol. 30
Eilrn-uterine pregnane}-, . . .280,042
BicoriDted nipples, 092
BxnminUion of virgins 24
EicessiTC Tenery a ciiuse of sterility, 236
41)
FALSE pregnftncy 875, 498
Fallopian lubes, discnses of, .... 439
" cancer of. 443
" " libramn of, 443
" " displacements of, , . 443
" dropsy of. . . . 439, 801
Faciea ovartana, 263, 285
Faradic battery, 88,160,714
Femoral hernia, 404
Fever, bidro^d 130
" puerperal 120
•■ child-bod, 130
milk, 694
Female genitalia, .... Plates I and 11. udv. senile atrophy o^ 504
FIssurw of the vnginn 630
" " nipple, 692
" anus. 260
•' " nock of tho bladder, . 445
Fibroids, uterine, 292. 302, 342
" " dingnosisfrom pregnnncy, 34ri
" varieties of, 343
" Bjmploms of, 848
" " pPognosiH, 345
" " ■' by sponge lents, 849
" " subserous, 343
" " treatment of; . 347
" " submucous 343
" " treatment by enucleation. 347 operations, 348
'■ •■ It^. 343
" of Ihe cervii nteri 348
" of Ihe FnllopiaD uibea, ... 430 Fibro-cysiB of tlie uterus, . . . 302. 340
Fibroids of (he vugina 406,414
Fibroma, uterine, 302
" vaginal, 406,417
Fibrous tumors of the uUtus, . .342,352 " ovnry, .... 300 " cei'vii, . . 342. 352
vngina,. .400.417
Fitch's supporter, 158
FiatulcD, vagina], 511
" " Sims' "peral.ion for, . 5-11
•' " Simon's " " . 5.15
vesico- vaginal, 511
770
INDEX.
Page.
Fistulas, vesico-vaginal, treatment, . 516, " " " " 520,523
" recto- vaginal, 511
" " treatment^ 628
" vesico»cervical, 511
" *' treatment, 516
" urethro-vaginal, 611
" " treatment, . . . .516, 526
** intestino-vaginal, 511
" " treatment, 532
" recto-vesical, 511
«« " treatment, 532
" ureto-vnginal, 511, 532
" " etiology, . . . . '. . .512
" ** diagnosis, 615
" ♦♦ treatment, 532
Forceps, vulsellum, Plate X.
" lithotomy, Plate VII.
" uterine dressing, . Plate V, 184 " NelatWs tumor, . . . Plate XI.
Front view of uterine organs, . . Plate I.
GANGRENE of the breast, 697
«* " ovary, 268
Gastralgia, 748
Galactocele, 695
Gclatiniform cancer, 701
General diagnosis, 21
Gentleness in examination, 23
Genitalia, inflammation of in female, 62
Gestation, abdominal, 280, 642
*' " dingnosis, . . . 043
•' •' prof]C"osis, . . . 044
" " treatment, . . . 044
" interstitial, ()43
" " diagnosis, . . . 043
*• " prognosis, . . . 044
" " treatment, . . .044
" tubal, . . . ., 440
" extra-uterine, 2S0
Glnndula coc(\vir<^n 31>8
Globus hystericus, 73. IWd
GouorrlKeu in women, 050, 02
'* ♦' etiology, 050
" " '' symptoms. .... 051
♦' " " buboes in 053
♦* '' " " treatment, 053
" " young girls, 053
*' *' treatment, .... 054 Grsinulatious of the cervix uteri, . . 353
Paok.
HiEMATOMETRA, . . 198, 845, 602. 505
** simulating ovarian cystoma, . 294
Haematocele, recto-vaginal, 287
" recto-uterine, 718
" pelvic, 710
" " etiology, 716
" " symptoms, . . . .717
" " diagnosi-s . . . .719
" " prognosis, .... 720
" ** treatment, .... 721
" pudendal, 490
Hef.rtburn, 748
Hernia in women, 404
" of the ovary, 885
* " " treatment of, . . . 888
** " " crural, 386
" " ischiatic, .... 380
" " " vaginal, 386
" " « uterus, "385
" femoral, 404
" inguino-labinl, 404
" inguinal, .' 385, 404
" labial 385, 404, 401
" vaginal, 404
Hemorrhage, 201, 222. 350
uterine,. .201,222,254,500
" " etiology, 202
" " dingnosis, .... 205
« »* treatment, .... 205
" " sponge tents .in, . 340
•♦ pudentlal, 400
" alter ovariotomy 331
'* " '' treat men I of, 332
Hemorrhagic diathesis, 203, 4H3
Hemiplegia, 484
Hermaphrodites, 723
Plate XXIX.
Hemorrhoids, 2«in
Hidrosis 13U
Hip baths, 745
Hidrotid fever, 130
" " varieties of, 130
Hom(Copathic remedies, 137
" " atteifuati(wis of, . 137
*' trituration of, . .138
" dilution of, . . . 138
" *' fluxion process, . 138
" " action of, .... 139
How to make a diagnosis, 21
Ilunterian chancre, 057
Hunleiian abnncre, treatment of, . . O&g
Iljrdromeira ^0(i
Iljrdntids of Lhe brensC, OQQ
" uterus, 352. 353, 350. 872
trentment of. . 372
HynieD, imperrorale 26, 107
■' ntreaiftof. 197
Hyperplasia, areolar, of ulenis, ... 87 '■ oerticnl, ■' ■■ ... 103
" corporeal," '■ ... 104
Hjdrosalpini 301. 439
HjperECMlheBin, 480
" etiology, 480
" pnthology, 481
diagnosis, 482
" prognoBis. 483
Hjdrops. folliculi, 277
" folliciilorum, 208
lubol 430
Hydrocele in women, 404
<' trenlmeiit. ... 405
Hyalerolomy. 727
Hj8t*rotome8, 145, 463
.' Plate V.
Hyslerslgia. 730
Hyp«r.i II volution of the utprui, . 7G0. 7ri2 Byperlropliy of the clitoris. . . . 223. 761 " « ■- Plnlc XXIX.
" labia
.. .' " .. IGO. 210
" " breast, l>98
Hysteria, 757
Hysterical mania. 700
" spisms, 750
" convulsions 769
" pumlysiB, 486
Kyslerocele, 386
INTRODDCnOS, 17
Imperforate hymen, 26, 197
lUTcraioD of the utema, 6C3
« " " etiology,. , , 565
PiOE.
Inversion of Ibe uterus, dingnosis, . . 6GT " " " trenlment, . . 5)i0
Ingninnt hernia, 404
Inguino-labiai hernin 404
Intro-uterine stem, 503
Inverted uteru 563
" " nmpnialion of, 676
" " etiology, 666
" " diagnosis, ....... 607
" " treatment 509
" " errors in (lingncBiis. , . . .^'18 " ■' recent, 570
" " •' operations for, . . 572
" '■ White's method, 573
" " " " Barnes' " 675
" " " " Simpson's '■ 675
" " " " Thomas' " 575
" " Watts' " 675 " '' spontaneous reduction,
9 of..
-577
Injections of iodine in ovnrlan cys-
lomn 304
ergoline iu uterine fibroids. 346
Infractus, 93
Indigestion. 487
Imluralion of theccrrii - . 102
" " " etiology. . . , 156
" " " pathology, , ,105
" " " diagnosis,, . . 160
" ■' " lieatmcnt, 107, 171
" brcnsl, 697
Inflammation of tlie female genilnlin. 60 " " bladder, .... 4.-i5
" ■■ vagina, 180
"• " Fallopian tubes, . 4 S!)
" acute, of female genitalia, 62
chronic, " " 62,67
sub-acute, C2. 64
c, . . 62. 70
" of the breasl 671
" '■ urethra, 445
" diphtheritic, of vagina, . 104
Intestino- vaginal fistula, 511
IiinlnimenlH, chapter on, 142
Inlerstilial pregnancy, 643
" geslalion 043
Injections into the uterus, 171
of wine, in ovarian cystoma, 308
JXDEX.
773
«
(i
it
H
Page. Menstruation, time of cessation, . . . 494
arresr of, 31, 223. 242
suppression of, . .31, 223, 242
symptoms, 32
etiology, 84
prognosis, 36
" treatment, 36
** " caused from psychical
influences, .... 35 ** " simulating plithisis, . 36
" profuse, 41
" excessive, 41
" painful, 46
Method of making vaginal examina- tions, 21
Medicated suppositories, .... 229, 713
Metatithmcnia, 719
Menopause, 496
Medicated baths, 745
Metritis, acute, 77
" " diagnosis, 78
•* cervical, 79
" " treatment, 80
" complications of, 82
tendency to dropsy in, ... 82 amtiurosis caused from, . . 83 sterility «» «« . . 83
abortion " " . . 83
" menstrual derangements
caused from, 84
" remedies in, 84
general effects of, 83
chronic parenchymatous, . . 87
Milk-leg, 705
diagnosis, 706
etiology, 707
" treatment, 708
Milk tumor of breast, 698
" fever 694
4(
41
44
44
«
<4
44
" abscess, 695
" diet,
70
Mono-cysts of the ovary, 298
Morphia, hypodermic injection of, . . 81 " " •* " objections to, 81
Moles in the uterus, 375
" " ** etiology, 375 :
** " " deficiency of spermatoioa [
a cause of, 376
«* « " diagnosis, 376 ,
tt u u prognosis, 376 !
Pagk. Moles in the uterus, treatment, . . . 37«) Mucous polypi of the uterus, .... 302
" pat-ches, ()55
Myoma of the tubes, 439
NEURALGIA of the uterus, .... 736 ** ovaries (see Dysmenorrhoea), 46
Neuromata of the vulvn, 739
Nelaton's tumor forceps, 365
" ... Plate XL
Neck of the bladder, fissures of, . . . 445 Nelson's tri-valve speculum, .... 148
•* . . Plate IV.
Needle-holder, Eaton \s, 145
" " .... Plate VI.
" Sims', 520
Needles, electrolysis, 160, 370
** " in ovarian cystoma, . 809
" Pease's, 148
" suture, Plate XIII.
" open-eyed, 320
Non-malignant tumors of the ovarie^i, 275 " ** " '' uterus, 352, 395
" " " •* breast, 698, 699
Nipple shield (Kent's), 694
" excoriated, ... 692
" fissured, 692
" retracted, 693
Nidation, 46, 49
Nidal decidua, 49
Nonentities, 723
" or hermaphrodites, . . . 723
Plate XXIX.
Normal position of the uterus, . . . 554
" " " '* Plates I and II.
Non-malignant tumors of the breast, 697
" " " " fatty, 700
« " " " fibro-cystic, ... 346
" " of the uterus, 852
" " " " fibroid, 292, 302, 342 " " " " subserous, . . . 843 ** ** " " submucous. . . .343
" " of the labia, 726
" *' of the ovary, 294
" " . " « cystic, 294
" " " ■ " fibro-cystic, . . . 294
" " " " fibroid, 800
'» " of the Fallopian tubes, . . 443
Xott's depressor, .')22
Nursing sore mouth, . 747
774
INDEX.
(;
<(
(4
• i t(
4»
l(
t*
ti
Page. |
Nymphomania, 724, 760 I
etiology, 760 i
symptoms, 761
diagnosis, 761
trcalment, 762
Nymphoe, hypertrophy of, 724 '
OBJECTIONS to abdominal support- ers not tenable, 158
Objections to the ligature in the re- moval of uterine polypi, 307
Occlusion of the Fallopian tubes, . . 439 ** " " " congenital, 442
Oligocysts of the ovary, 298
Open-eyed needle, 326
Opium habit, remarks on, 81
** " statistics of, 81
Operations for stone in the bladder, . 4G7
Operating table, 319, 703
Opisthotonos, 759
Os uteri, ulceration of, 179
** " treatment,. . . 185
virgin, 20
in old age, 27
after lacerations, 162
Ossification of the arteries a cause of
atrophy of the uterus, 753
Ovaries, prolapse of, 417
*♦ *' " treatment, . . . 419
displacements of, 385
hernia of, 385
iciuovjil by operation,
cases of, r»s8
diseases of, lit)')
iiialfoniiatioii of, *J0,") i
rnncer of, '>87
carcinoina of, 000 i
rapillonia of. oUo I
" cncliondronia of, 300 j
osteoma of, 000 |
fibroid tumors of, 300 '
" inflamrnution of, 'J').') 1
" cvstic tumors of, *2'»S
" fibro-cystic tumors of, . . . 208
oligocysts of, 298 \
** dermoid cysts of, 275 '
.t?n ngrene of, 2')8 |
Ovaritis, 205 i
ciironic sub-aetite, 200
etiology, 208
t>
<(
<t
Paok.
Ovaritis, diagtiosis, 268
" treatment, 269
Ovariocentesis, 310
Ovariocele 389
Ovarian cyst, rupture of, 810
" " permanent opening into, 800
" Tumors, 275
" " classification of, 276
" " etiology, 276
" " symptoms, 281
" " differential diagnosis, .... 288
'* ** prognosis, 303
" " treatment, 803
" " diagnosis from cellulitis, . . . 288 " " " from enlarged liver, .... 287
« '( « «* fecal tumors, 287
" " " ** retro-uterine ha^motocele, . 287 « .( .( « abdominal ascites, .... 290 li .« i( « hydatids of the omentum, 291 " " " " cyst of the uterus, .... 294 It .i .( c< dropsy of the amnion, . . 293
u u a u floating kidney, 292
»« 4» 44 li pelvic abscess, 295
4i « .i 14 distended bladder, ... 295
<i « it t< pregnancy, 2Sh
u it ii It extra-uterine pregnancy, . 286
" " »* *' uterine fibroids, 292
" " " *» carcinoma of fundus uteri, . 292
it it «t tt haematometra, 294
.. .. 44 it ^j^g^ qp (1,^» broad ligament, 301
.4 44 .4 tt hydrosalpinx, 301
44 44 .4 tt cysts ol" mesenteric glands, . 302 " " " " fibro-cysL of the uterus, . . 302 u 44 44 comparative diflferential, . . 200
" '• " of adhesions of, 200
** " conditions mistaken for, . . . 289
4< 44 varieties of, 275
*• *• causes of, 270
'• ♦* deraiij^emeiitsof nientruation in, 279
*• " sterility as a cau^se, 279
*' *' sometimes congenital, .... 28t) " '* ♦* " case, . . . 281
" *' rectal examination in, .... 282 ** '' "Stages of development, .... 283
" " treatment, 303
*' " " by io<line injections 304
" " " surgical, 012
•' " " medical, 272
•* " experience in tapping and in- jecting, 805
INDEX.
775
Page. OTarian tumors, use of gum-elastic
tube in, 308
" ** wine as an injection in, . . 308 " " iodine " " " . . 304
" " modus operandi of treatment
by injection, 300
" " electrolysis in treatment, . . 309 " cystoma, spontaneous rupt're of, 310
« fibroids, 300
" cyst, rupture of, 310
u i< permanent opening into, . . 300
OTariotomy, 312
" history of, 312, 313, 314
** objections to, 314
** when should it be performed? . 31.>
*' causes of death from, 310
" when it should be abandoned, . 310
" when improper, 318
" preparatory treatment, . . . .317
** time of the year for, 318
" place, 318
" the operation for, by gastrotomy, 321 *^ different methods of operating, 328
•* vaginal, 33r)
" treatment of the pedicle in, 325, 328
" " after operation, 327,831
" " of pedicle by torsion, .... 329 u tt « |jy tors' n of separate vessels, 329
" " " by the clamp, 329
" « " by ligature, 328
•' hemorrhage after, .... 381, 332 " septicssmia or pyscmia after, . . 832 «* " " *♦ " treatment, 833
" vomiting after, 333
" abscess in abdominal muscles
after, 335
PAINFUL menstruation, 4G
Papilloma of the ovaries, 395
Papillary tumors of the ovaries, 301, 395 " " " uterus, . . .395
« " " " treatment, 396
Paraplegia, 484
** diagnosis, 485
" treatment, 48G
Paralysis, 484
« diagnosis, 485
" treatment, 486
" hysterical, 486
Parenchymatous metritis, 87
Page. Parenchymatous metritis, Dr. Thomas
Pall
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89 90 92 92 92 93 93 95
on,
Dr. H. Bennett on, . . Dr. Oraily Hewitt on. Dr. Noeggeinih oil, . . Dr. Pensloe on, . . . Dr. Kamiiiereron, . . Dr. Kiwisch on, . . . Sir James Simpson on,
pathology of, 95
" Dr. Weston, ... 97
♦* Dr. Snow Beck on, 97
course and termination, 100
predisposing cause, . . 101
exciting ** . . 101
symptoms, 102
physical signs, . • 103, 104
prognosis, 105
treatment, 106
ative treatment in uterine
fibroma, 349
Palmers uterine dilator, 14G
" " " . . Plate VIII.
" " applicator, 715
Patient, efforts of, to mislead tho physi- cian as to her disease, 19
Pains, bearing-ilown, 220
Para-metritis, 113
Paquelin thermo-cautcrc, 460
Pain in the sacral region as a
symptom, 221
** " loins as a symptom, . . . 221
Pcri-metritis, 110,218
" symptoms, 110
" etiology, Ill
" sequelse, 112
" treatment^ Ill
Pelvic cellulitis, 110,113
" " etiology, 115
symptoms, 116
prognosis,, 119
treatment, 122
complications of, ... . 120 caused from lacerated cer- vix uteri, 115
Pedicle of ovarian tumors, . . . 800, 328 " clamp in ovarian tumors, . . 160 Dawson's, . . . . .321
(I
M
a
«
((
** Spencer Wells* original,
Plato XV.
776
INDEX.
Page. Pedicle clamp in ovai*ian tumors, new,
Plate XV. c( It i( « t( K Thomas', Plat© XV. u i» it u objections to, .... 329 u It u u advantages of, . . . 829 " treatment of, in ovariotomy, . . 828
*• <* by crushing, 328
" »' " ligature, 826, 3-28
*« " «* the actual cautery, ... 328 <4 « (( torsion of separate vessels, 329 a (( u transfixing it to the abdo- men, 330
Pediculi, 408, 409
Peri-vaginitis phlegmonosa dissecans, 19o
Pelvic hematoma, 716
" hsematocelc, 716
" " source of the hemorrhage in, 716
" " etiology, 716
" " symptoms, 717
" " differential diagnosis, . . . 719
" " prognosis, 720
" " treatment, 721
" abscess, 110, 29.'), 718
" " etiology, 115
" " symptoms, IIG
" ** prognosis, 119
" " treatment, .... 122, 125, 722
Pcaalee's improved perineum needle, . 147
" « " " Plat<> VI.
Pease's nccdlo, 148
Possarie.«, vnginal, . . 148, 2:^6, 503, 603 i " *' the use of alHloiniiiul support- ers in connection with, . 140
" elastic, 1 10
•• " cnp anil stem, .... 140, 150
" ol\)ociions to, . . ; . 118, 119
Perineum neeilles, 147
" lacerations of, ... . 620, 6:>1
'* *' iliaj^nosis (\'.V2
" *' treatment 038
" " operation for, . . . .034
time of, . . . t)aO «♦ " removal of sutures, . filO
Peri-utorine lifrmatoeele, 718
Perineorrliajihy 012)^
Peritonitis, puerpii :. I. 120
•' '* symptoms, . . .120
" " eliolopy 131
" " pmjrnosis, , . . 132
" '♦ complications, . 132
Pagr. Peritonitis, puerperal, treatment, . . 183
" false 181
Peritoneo-vnginal fistula, . . . 537, 588 " ** " treatment of, 688
Perineovaginal fistula, 687
" " treatment of, . 688
Phlegmasia dolens, 705
" *' diagnosis, 706
" " etiology, 707
" «* treatment, 708
** " post-mortem appearances, 707
Physometra, 295
Placenta previa, 204
Placental polypus, 354
Polypi of the uretlirn, 445
Polypi of the uterus, 852, 854
*• « " fibrous, .... 852, 858, 354
«* " " etiology, 854
" " " diagnosis, 857
" " ** differential diagnosis, . . 860
" " " prognosis 862
" " " treatment, 363
" ** " operation for removal of, 364 " " " use of ecraseur in, . . . 369
" " " vascular, 352
u « u It treatment, • • • . . 372
" " " placental, 864
« " " mucous, 852
« " «♦ hydatid, . . . 352. 353. 356
« «' " cystic, 353, 350
" " " ligature in treatment, . . ?.r>7 * '• " sponge tents in *' 305, 3G'.» '• '• " removal by torsion, . . . 367 " " " treatment of cystic, . . .371 " " *' " " hydatid, . . 372
*' " " (small) treatment, . . . 373
Polypi of the vagina, 406, 417
Potencies 137
Polv-cvsts of the ovary, 200
Pruritus vulvjc, 400,664,670
♦' " etiology, 407
" " diagnosis, 408
" " treatment, 400
Prolapsus uteri, • 563, 6t)5
" *• etiology 600
" ** pathology, 600
" " sym[»toms, 613
" " (.litlereuiial diagnosis. .614 ** " cimsing throat trouble, 29 " '' treatment, 215
INDEX.
lu
Pace. Prolapse of the ovaries, . . 406, 417, 419
" ** vagina, 389
" " *' etiology, ... 889
" " " diagnosis, . . 390
" " *' treatment, . . 391
** » urethra, 446
" " bladder, 389
Procidentia uteri, 563, 605
" " etiology and pal hoi., . 606
«* " symptoms, 613
" ** differential diagnosis, . 614
" " treatment, 515
" " " surgical, . . 623
Processus vaginalis peritonsi, . . . 385
Pregnancy, false, 375, 408
** diseases of, 660, 672
'^ tubal, 4-10, 642
** ** treatment, 442
" extra-uterine, . . . 642, 286
•' '* ** diagnosis, . . 043
" " " prognosis, . . 644
" " " treatment, . . 644
*» abdominal, 642
•* molar, 375
" vomiting in, .... 668, 672
•* " etiology, 673
" <* treatment, 674
" " shall abortion ever be
induced to relieve? 675
Primary syphilis, 657
Pressure, effect of in uterine polypi, . 369
*' atmospheric, 367, 556
" " in treatment of uterine
displacements, 867, 556
Pseudocyesis, 498
Puerperal fever, 126
** mania, 688
'» metritis, 126
". phlebitis, 70ri
*' peritonitis, 120
" " symptoms, 129
" *' etiology, 131
** ** prognosis, 132
** '* complications, 132
'• *' post-mortem appearances. 133
** " treatment, 133
Pudendal hemorrhage, 490
" " treatment, . . . 492
" hematocele, 490
" '• treatment, . . . 492
Paob.
Puberty, 494
" treatment of diseases of, . . 498
Pyosalpinz, 439
Pynemia after ovariotomy, 332
QUILL suture, 637
•' '^ adjusted, 638
" " cut of, ... 688
RAPID dilatation of os uteri, .... 146
Rectal examination, 30
'■ alimentation, 683
Rectocele, 889
Retracted nipples, 693
Retention of urine, 646
" " " treatment, .... 048
Rccto-vnginal fistula, 511
** " " treatment, . 528, 531
*• vesical *« " .511,531
Rectitis as a complication of pelvic
c<»llnlitis 121
Removal of sutures, 585
Retro-uterine hscmatocele, . . . 287, 716
*' " " symptoms, 717
'' ** " differential diagnosis, 719
" *' " prognosis, 720
'• " »' treatment, 721
Recto-vaginal h«*mntocele, . . .716, 287
•' " " symptoms, 717
" « " differential diagnosis, 719
** " ** prognosis, 720
" " ** treatment, 721
Remedies IionKeopathic, 187
Reversible eatheter, 467, 466
Removal of the ovaries for hemorrhage
caused by uterine fibroids, .... 351
Retro-veraion of the uterus, 568, 678, 663
** " *' " etiology, . . 679
'• " " " diagnosis, . . 681
" ♦* *' treatment^ . . 687
" *' '* '* in pregnancy, 589
Retro-flexion of the uterus, . . . 563, 578
♦' «' ** ** etiology, . 579
" ♦' ♦♦ *♦ diagnosis, . 581
** " '• •* treatment. . 587
Remedies in acute ovaritis, 269
" " amenorrhoea, .... 36 " " areolar hyperplasia, . . 107
" " cystitis 461, 467
" " dysnienorrhoea, .... 54
778
INDEX,
PAOR.
Remedies in hjsterift 4G2
" " leucorrhoca, 243
" " menorrhagia, 44
" " metritis, 84
'* ** pelvic cellulitis,. . . . 122
" " peri-mctritis, Ill
" '^ prolapsus uteri, .... 62G « « puerperal mania, ... 601 " " " peritonitis, . 184
" *« »* phlebitis, . . 708
« '* sterility, 261
** ** stomatitis materna, . . 749 '* ^ stone in the bladder, . .470 " " sympathetic affections, . 487 ** " threatened abortion, . . 429
II «* yngtnitis, 217
Round elastic pessary, 149
Rupture or the bulbs of the vestibule, 400 '* spontaneous, of the uterus,
from uterine fibroids, . . 851
SARCOMA of the uterus, . . . 400, 402
Salpingitis, 480
Sclerosis « " ... 100, 105
Scirrhus " •• 400
« « breast, 700
Sero-cystic tumors of the breast, . . 698 Sexual intercourse a cause of infiam-
mation, . 60, 224, 288 <* •» interdicted in pregnancy, 669
Septicapmis, 832
Scptiemia, 382
ScA.tangle tents, 230
Simple vaginal fistula, 537
Sims' operation for vesico-Taginal
fistula, 584 Simon's " " " " 58-|
Sims* Taginnl dilator, Plate VI.
** original speculum, . . . Plate III. 11 a i» 142
" folding " 142
" ** ... Plate III.
** uterine elevator, 159
" •' ** ... Plate XIV.
" enuclcator, 847
Simpson's sound 144
Plate V.
** hysterotome, 145
Plate V.
Sound, uterine, 22
u
i(
4(
4(
U
«(
t(
i(
Paob. Sound, uterine, Skene's, 144
" " " Plate V.
« « steel, 144
•* " " Plate V.
** ** Simpson' 144
" " " .... Plate V.
** hard rubber, 144
Spontaneous rupture of ihe uterus in
uterine fibroid, 346, 362
Spencer Wells' clamp, 160
" " " .... Plate XV.
** " origmal clamp, Plate XV-
trocar, 320
artery forceps, .... 322
Spasms, livstcrical, 750
** puerperal -662, 666
Speculum, Wocher's bi-vnlve, . . . .143
. Plate IV. Nelson's tri-vnlve, . . . ". 148
. Plate IV. Ferguson^s mirror, . . . .143 " " " . Plate IV.
'* Sims' original, 142
" ** " ... Plate III.
" « folding, 142
" ... Plate III.
" ** Dawson's improved, . 142
" «* " " Plate III.
Sponge tents, . . . 150, 280, 349, 350, 365
602. 713
•* "in treatment of fibroids. 849
" " in flexions, 596
'' ** dilator, Emmet's, . . .151 " " «• " Plate IX.
" bath, 745
Sphygmogrnphs, 161
Steps to be taken in making a vaginal
examination, 21
Strangury, .646
etiology, 046
diagnosis, 647
prognosis, 647
trentment, 648
, Stem pessnrios, objections to, . . . . 598
Stmight needle foit-eps, 526
•' lithotomy forceps, . . Pliite VIII.
Stone in the bladder, 462
" " " symptoms, . . . . 463
'* diagnosis 464
** treatment, 464
«i
44
il
((
(*
41
41
4*
INDEX.
779
Page. Stone in the bladder, operation for, . 467 " " " " after treatment, 470
** " " remedies for, .... 470 " ** " remoYal by litliotrity, 466 " ** " " " lithectasy, 465
Stenosis of the uterus. 452
" " cervix uteri, . . 452, 250
" " " *• treatment, 453
Sterility, 249
" as a result of pelyio cellulitis, 120
" diagnosis, 255, 358
" treatment, . . .* 257
Stomatitis materua, 747
" " etiology, .... 747
*' " symptoms, . . . 747
" " diagnosis, .... 747
" " ireotment, . . . 748
Suppression of the urine, 640
" " menstruation, . . 268
Sub-acute inflammation of the
uterus 62, 64
Suppositories, uterine, medicated, 713, 229
Suspended animation. 756
Suture needles, . Plate XIII.
Supports of tlie uterus, 559.
Supporters, abdominal, . 156, 157, 557, 558 *' .... Plate XII.
" Eaton's, 157
•* " . . Plate XII.
*' ** Old London, ... 158
** " " Plate XII. " " Silk elastic, . . . .158
" " " Plate XII.
" " Babcock's uterine, 149
" " M'lutosh's " 150
Sub-acute ovaritis, 266
Subserous fibroids of the uterus, .' . . 343
Submucous " " ** . . . 343
Sub-involution of the uterus, 219, 709, 710
" *♦ " " symptoms, . 710
" " '* " etiology,. .711
*' " " " results . . 709
" " " " treatment, . 712
Success of iodine injections in ovarian
cystoma, 304
Swing bed 338
Symptoms of uterine disease, .... 21
Syphilis in women, 655
" secondary, 655
" tertiary, 655
Page. Syphilis, how contracted, 655
'* symptoms and diagnosis, . . 657
" treatment, 658
Syphilitic ulceration of the vagina, . 629 Syringe for injecting fibroids, .... 171
Sympathetic aflfections, 472, 487
treatment, 477, 486 electricity in, . 479
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TAPPING, 739, 743
Tampon, vaginal 850, 363
Tenesmus, uterine, 220
Tents, sponge, 150, 280, 349, 865, 602, 713
** sea-tangle, 230
" cotton, 229
Tenaculum, Bozeman's, . . . Plate XIII.
Tetanus, 759
Thomas' clnmp, Plate XV.
Thrombus, 490, 716, 722, 726
Tiemann & Co.'s aspirator, . . Plate IX. Tolerance of the system to abnormal
conditions, 479
Trocar, Spencer Wells', 320
'* long curved, 125
" " *' uterine, .... 710
Treatment of acute metritis, .... 80
Tri-valve speculum, Plate IV.
Treatment of ovarian cysts with iodine
injections, 304
" uterine fibroids (submucous)
with sponge tents, . . . 349 *' palliative of uterine polypi, 349
Triturations of remedies, 138
Transmissibility of syphhilis, .... 655
Tumors of the breast, 697
" " " non-malignant, 699
" " " malignant, 692, 700
" « " cancerous, 692. 700
*• " . " fatty, 700
labia, 726
uterus, 852
*' " fibrous, .... 343
" " '* polypoid, ... 352
" vagina, 406, 417
ovarian, 275
Tubal gestation, 440, 643
pregnancy, . . . 440, 043
operation, 443
Tubes, Fallopian, diseases of, ... . 439
cancer of, 448
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780
INDEX,
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Paok. Tubes, Fallopian, displacements of, . 443
Tuberculosis of the uterus, 403
yngina, 451
Fallopian tubes, . 448 Tuberculous ulceration of vagina, . . 629
Tumor forceps Plate XI.
Tympanites, 487
ULCERATION of the vagina 629
" " " cancerous, . 629
" " " syphilitic, . 629
" " urethra, .... 449
" " OS uteri, .... 179
" ** cervix uteri, . .179
*' *' ♦* causes of, 180 «« " " " diagnosis, 183
" " " " treatment, 186
Urine, suppression of, 646
" retention of, 646
Urethritis, 445
Urethro-vftginal fistula, 511
Ureto-vnginal fistula, 511
Uricmia 284, 662
Urethra, diseases of, . 445
" inflammation of, 445
*♦ prolapse of, 445
" ulceration of, 445
'• fissure of, 445
♦* caruncles of, 445
•* polypi of, 445
Urinary calculi, 4»*»*2
" *' caused tVoin spinal injury, 4('»"J Urethral speculum bi-vahe, .... 44(3 Uterus, intl;»mtuation of, .... 77, Vl^\
*' neuralj^ia of, 7:^)<')
" stenosis of 4.VJ
•' " treatment, 4"):!
'* catarrli of, • '>*^<'
" '♦ " etiology, :>S1
*' " " diagnosis 8S1
*' " " treatment, ;iH;5
*' cancer of, 1<37. 4(M>
•' malformation, 750, 7 ')4
" tuberculosis of, 40:',
** abscess in t^ 11
" sub-involution of, '210,700
. 710
t(
symptoms,
" " etiology, . . .711
" " effects of, . . 709
« *' >i(vif inoiiJ , 712
treatment,
Paoe. Uterus, hypertrophy of, . . 162, 219, 709
^* bilocularis, 755
'* irritable, 93, 736
" hyper-involution of, . 265, 259, 750
" hydatids of, 856
*' hydatids of, treatment, .... 372
** supports of, 539
" normal position of, 554
" " " " Plates II and III.
** inversion of, 563
" " " " etiology, 565
" « « « cliagnosis, 567
" " " " treatment, 669
" " ** " " of chronic cases, 571
" " of operation for, 572
'* " " Simpson's operation for, 575
" " " Tliomas' '* " 575
" " " Barnes* " " 675
" " *' Watts' " '♦ 675 " " White's " " 673
♦* " " treatmentby amputation, 576
" " " spontaneous reduction, . 576
♦* " " anomalous cases of, . . 577
" displacements of, 552, 663
•' " ** symptoms, . . 561
" " •' etiology, . . .561
" " ♦* treatment, . . 562
" extirpation of, 727, 346
" '' •' experience in, . . 7*20
** ablation of, 727
•• " " cases of, 7*29
'' prolapse of, 508, (105
'' " " treattnont, lilT)
" procidentia of, 5G3, 005
'' treatment, . . . 015 ♦' retro-flexion of, 563, GOo
" " *' etiology 579
" " diagnosis, . . . 581
" ** " treatment, . . . 587
" retro-version of, . . . 503, 578, 003
" '' * " etiology, .... 570
" " '■• '' diagnosis, . . . 581
" " " " treatment, . . . 587
" lateral flexions, 503, 003
'' ante- version of, 503, 508
" " '' etiology and diagnosis, 500
" '' *' ♦* treatment. 000
*• ante flexion of, 503.508
" " " '' etiology and diagnosis, 590
'* " " '• treatment, 600
s, eUTation of, 563. 776
•' .... Pints XXVIII.
■ papillary Uimon of, 895
c&rciDomB of, 292, 400
fibnMtyst of, 802
tumon or. . . . . 292, 802, S42, 862 polypi of.
IS or.
.400
CDccpbnloid of, 400
... .400
nof, ,
cauliflower eicresoence of, . . . 400
222,254,600
rine orgftns, front *iew, . . . Plnte I.
" aide Tiow, . . . Pint* 11.
" irooar, 610
>■ eleolrode, 'W
" npplioatora, 716
" repositor, WhiW'B, 673
" ilreasiDg forcepe, 184
.... Plate V.
" Houoda, 22
Plate V,
" diaeaaee, aymptoms of, .... 21
■' dilalor 140
" *. Plate VIII.
" olBvator Plate XIV,
•■ simB leo
"... Plate XIV-
" " Elliotl■^ 158
u " "' . . Plate XIV.
•' toncsmuB, S2D
oolio, 5S0
myoma, 342
fibroid 802
atem peaaary objectionable, . 693 cerTii, InceratiouB of, ... ■ 6S9 injeclionB, caution agninil, . .216
polypi 852
" etiology, 854
" morbid anatomy, . . ■ 854
" diagnoata, 3G7
*' diOerential diugnoais, . 360
" trenlmenl> 8C8
" sponge loniB in Irealm'l, 849 " operotiODforremotalor, 864
liydstld 852, 366
moles, 815
fibroma,
tTterine fibroids treated by ergoUoe
injections 848
fihro-cjBl. 291
" polypi, Yusoulnr, 852
" " " treatment of, . . 372
hemorrhage,
. 201, 222, 254, 500
Vngii
Vagi
VAOINAL e
waahea, . . 233, 603, 744, T
OTariolomj, SI
peawirieB, . 148, 230, 698, 61
flitulEe, 6:
simple 51
blind, 51
" other vnrleliea, . . 61
186,219, 21
treatment of, 1'
remediea in 11
diphlheritio II
loa, inflammation of, II
cyatB of, 406, 4!
" " pnthol. anni 4'
" " etinlogy, 4'
" " aymptoms, 4
" " diagnoaia, 4'
" " treatment, 4'
fibroida of, . ' 406, 4
polypi of, 400, 4
cntnrrh of the, 186, SI
prolapse of, S80, 4(
hernia of, 4i
atresia of, 5(
operalioQ for, . . 5'
IS of, .
cancerous ulceration of, . . . syphilitic " " 629,
luberculoaia of,
fissures of,
fistula of,
Vnaoulnr polypi of the uterua, . 3.J2, 3 Vnrietits of uterine fibroids, .' . . .8
Vaginismus, 162, 172, %
" symptoms 1'
" etiology 1'
Vegetal
IS of the endometrium, 3G2. ^HS
782
IXDEX.
Page.
Vcncry, excessive, a cause of sterility, 256
Vesico-vaginnl fistula, 511, 520
'• " *' operations for, . 523
Vcsico-cervical fistula, 511,531
Vesico-uteriue fistula, ....... 631
Vesico-vaginal fistula, artificial, for relief of chronic cystitis, 458
Virgin os uteri, 26
" examination of, 24
Vicarious menstruation, . . .84, 56, 498 " " ti-eatment of, . 58
Vomiting in pregnancy, .... 668, 672 •* •* " diagnosis, . . 674
" " " treatment . . 674
" after ovariotomy, 833
" " " treatment, . 884
Vulvas, pruritus of, . . 406, 409, 664, 670 " neuromata of, 739
Vulsellum forceps, Plato X.
WASHES, vaginal, 233, 603
Weed in the breast, r»95
Wells* clamps, ICO
«« Plate XV.
«i
Page. White's hysterotome, 145
hysterotome Plat-e V.
i(
" treatment of inversion.
. . 578
Watt«» u u a 575
Whites (leucorrboea), 240
Wire holder and twister, Eaton's, . •146 « " " " " Plate VI.
Wocher's bi-valve speculum, .... 143 " " " . . Plate IV.
Womb, inflammation of, 77, 126
" ^ ^ chronic, . . 62, 70
" tumors of, 343
*^ symptoms of disease of, . . . 31 •* (see Uterus.)
YOUNG GIRLS, gonorrhoea in, . . . 653
vaginitis in, 191
*♦ treatment of, . .191 menstruation in, ... . 31 atresia of cervix uteri in, 505 time and symptoms of pu- berty in, 494
treatment of diseases pe- culiar to, 498
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FINIS.
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