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'    *■  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 


(( 


ti 


<( 


(t 


i( 


l« 

(( 

(( 

« 

i( 

« 

(( 

(( 

« 

(( 

u 

ii 

< 

<( 

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 


(( 


(t 


«( 


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 


(( 


(( 


«( 


(( 


« 


K 


« 


<( 


«i 


«( 


780 


INDEX, 


« 


« 


(( 


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 


u 

(t 

«l 

<i 

(C 

u 

i( 

li 

(( 

it 

u 


(t 


FINIS. 


i 


i