Clinical notes on uterine surgery: With Special Reference to Management of the Sterile Condition

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UTERINE SURGERY.

CLINICAL NOTES

UTERINE SURGERY.

MANAGMIOT OF THE STEKILE CONDITION.

BY J. MARION SIMS, A.B.,M.D.

LONDON:
ROBERT HARDWICKE, 192, PICCADILLY.

Cr>X AKD WTMAV,

«>IIIVTA.L, CLA88I0AI., AVD OIHBBAL PBIITTHKR,

OSBAT qUBRV 8TBSBT, I.OJIDOir, W.O.

• •

.• •

• • • • • •

• • • • •

• •

• • •
• • • •

TO

SIR JOSEPH F. OLLIFFE, M.D.

(UNIV. PARIS),

VBLLOW OF THK KOTAL COLLBOB OF PHTSICIAITS (lOHD.) ; PHTSICIAlT TO HBB MAJBSTT'S
BMBA8ST AT PABI8 ; OFFICBB OF THB LBOIOV OF HOHOUB, BTO. BTO.

My dear Sir Joseph,

When I came to Europe, now more than three yeai*s ago,
I had no idea of remaining here permanently. But I found in
you a warm and generous friend, whose wise counsels and noble
libei*ality elevated me at once into a most favourable position. It
was principally through your influence that I was able to reach
the highest circles of practice. Without you my sojourn here
would have been temporary and fruitless.

Let me assure you, my dear Sir Joseph, that it is not only to
you, as a learned and accomplished Physician, whose great talents
and attainments have placed him so deservedly in the foremost
ranks of his Profession ; but it is also to you as a true man of noble
impulses and generous nature ; it is to you as a Friend, when I most
needed a cheering comforting word, that I now come with thb
Volume, and beg you to accept it simply as a token of Gratitude
for the many acts of kindness and friendship which you have so
lavishly bestowed upon me.

J. MARION SIMS.

PREFACE.

TN 1862, I voluntarily left my own country, on
account of its political troubles. Our unfortu-
nate civil war continued much longer than any of us.
North or South, anticipated. In consequence of this
my residence abroad was prolonged far beyond my
original intention. I therefore had time to look over
my note-books, and to cull such facts as illustrate the
method of treating Uterine Disease at the Woman's
Hospital. These facts are strung together in the
form of these " Notes."

Having an innate horror of writing, I have not
tried to make a book ; on the contrary, I have simply
related in detail my various operations, and given the
history of cases in which circumstances led me to
adopt a modified procedure, or for which I have
devised new forms of instruments.

A clinical rei)ort of this sort very naturally divides

VI PREFACE.

itself into groups of cases which may be made illus-
trative of the principles of practice.

In my own country my contributions have generally
been received with kindness; and although I have
reason to hope that they will have a friendly reception
here, still, as I make no literary pretensions, it is
with the greatest diflBdence that I appear as an author
on this side of the Atlantic.

As its title indicates, this collection of " Clinical
Notes " lays no claim whatever to the character of a
systematic work. It is simply a voice from the
Woman's Hospital, which, in all probability, would
never have been heard if I had remained at home. I
wish most sincerely that I could have produced some-
thing more worthy of the position so long held by
mo in that noble Charity ; for to this I owe all that I
know practically of the subjects herein treated.

In looking over this volume, it would seem that I
owe an apology to, and must claim the indulgence of,
my brethren for three things : • —

Ist. A clinical review of personal experience, taken
from note-books, as this has been, must almost of
necessity be written in the first person.

2nd. It may be necessary to excuse to my senior
readers tlio minuteness of detail in which I have

PREFACE. Vll

sometimes indulged ; but, at the same time, I must
plead the necessity of such minuteness for the guid-
ance of ray younger brethren, for whom principally
these pages were penned.

3rd. The illustrations are not all as good as I
would have had them. Most of them are mere
diagrams made by myself. For any inaccuracies I
alone am responsible ; for any artistic value that
they may possess, the credit is wholly due to Ldveill^,
Lackerbauer, and Vien, of Paris ; and to Mr. Orrin
Smith, of London.

A word of explanation on another point. It will be
seen that I have not touched upon the accidents of
parturition, such as fistulae of the bladder, rectum,
and vagina, lacerated perineum, &c. It is only just to
myself to say that I have ignored these for the present,
because I hope, if time and circumstances permit, to
prepare, at no distant day, a fully illustrated mono-
graph on these subjects. To have done them ample
justice here would have interfered, in some sort, with
the plan, and augmented very considerably the size, of
this volume.

In conclusion I beg leave to say that I am under

special obligations to Dr. Thos. T. Pratt for timely

aid ; and * I take this occasion to return my sincere

Vlll rREPACE.

thanks to my fiiend, Mr. Ernest Hart, for useful
suggestions and valuable assistance rendered as these
pages were passing through the press.

r^NDON : 1, Bolton Row, May Fair,
let Janiiary, 1800.

UTERINE SURGERY.

INTRODUCTION.

ERRATA.

Page 88, line 17, fw "it is," rtad "they are."
„ 93, „ 1, /or " would not be only," rtod "would be not only."
„ 102, „ 15, fw "of 08 and cervix," rtad "of the oa and cervix."

UTERINE SURGERY.

INTRODUCTION.

I DO not propose to write a complete monograph on
Uterine Surgery, or on the treatment of sterility,
but simply to interweave the two, while taking a glance
at such surgical difficulties as seem ordinarily to inter-
fere with conception. To make a work of this sort com-
plete would be to write a book on all the diseases of
women, and on some of those of the opposite sex. But
this is not my object, and I shall confine myself to
the consideration of such cases as ordinarily come
under the observation of the practitioner.

An inquiry into the conditions favourable to con-
ception would almost necessarily involve a considera-
tion of those opposed to it ; and this would lead very
naturally to the investigation of the best means of
overcoming such obstacles. This is the order in which
I propose to consider the subject ; but it is not the
one by which my experience was gained. It came by
a very different process.

In the course of treating the diseases of women,
I, like others similariy engaged, found many cases
of sterility accidentally cured simply by curing

B

T'l

2 UTEEINE SUEGEBY.

some uterine affection. After a while I discovered
that they were as various and as varying as the
diseases upon which they depended. Then, by a
classification of all diseases of the uterus just as they
were encountered, I found sterility to be incident to
many of them. These naturally arranged themselves
into two classes; viz., — 1st. Those who had never
conceived; and — 2nd. Those who had; but who for
some reason had ceased to do so for a time, say five
years, or more. The first I called " Natural Sterility ; "
the second, " Acquired Sterility."

In looking over my note-books for a series of years,
I was surprised to see how nearly equal these two
classes were. Sometimes one and then the other
would predominate ; but they were so evenly balanced,
that fi'om 3 to 6 per cent, would cover the variation
either way.

I mean that this is so, taking all cases of uterine
disease as they are promiscuously presented. If we con-
sider the cases of those only who come to consult us
merely on the subject of sterility, without reference
to disease or actual suffering, the first class will, of
course, greatly predominate. But it is by a study of
all, that we deduce the principles that are to guide
our judgment in individual cases. It is by this that
we are able to specify the conditions most opposed to
conception ; and, at the same time, those most favour-
able to it.

The trouble in one case may depend upon mere
contraction of the os ; in another, upon malformation
of the same — in another upon engorgement of the
cervix — in another upon elongation — in another upon
hypertrophy — in another upon simple induration — in

INTEODUOTION. 3

another upon curvature of the canal of the cervix — in
another upon polypus — in another upon a fibroid — in
another upon malposition of the uterus — in another
upon some anatomical, anomaly or malformation of the
vagina — in another upon vitiated secretions of the
cervix — in another upon those of the vagina, the one
generaUy acting mechanicaUy, the other chemicaUy —
in another upon the absence of spermatozoa ; while
others may be compUcated with several of these ano-
maHes, all subjects of study and investigation.

And when we come to analyze these various causes
and complications, they are resolved into one great
general principle, embracing all manner of obstruc-
tions to the free passage of living spermatozoa into
the cavity of the womb. In all curable cases ovula-
tion must be perfect, and the faulty link must be found
in defective fructification, or else all our efibrts are in
vain. If the woman has passed the period of ovula-
tion, of course we can do nothing for her. If the
ovimi never passes into the fallopian tubes, a thing
impossible to determine, it is equally beyond remedy.
We may safely assume a normal menstruation as a sign
of normal ovulation. This being our guide, we may
hope, in the majority of cases, to find some of the
troubles above enumerated, many of which are even-
tually curable.

It is self-evident that if we knew exactly all the
conditions of the uterus and its appendages absolutely
essential to fecundation, it would not be very difficult
to determine, in any given case, in what particular
it differed from the proper standard. And, on the
other hand, if we knew exactly the conditions of the
uterus and appendages absolutely opposed to fecimda-

B 2

4 UTERINE SUBQEBY.

tion, it would not be very difficult to determine at once
the chances of cure.

This is but another way of saying that here, as in
every other department of medicine, knowledge of
both normal action and abnormal condition is essential
to safe and sure methods of treatment.

A few years ago, the subject of conception was
wrapped in the profoundest mystery ; but now,
tlianks to the labours of Martin Barry, of Bischoff, of
Costo, of Pouchet, and other modem physiologists,
its laws are much better understood.

As usual, pathology is here behind its great pioneer,
pliysiology, and yet quite in advance of therapeutics ;
for until a comparatively recent period we had no
rational views on the treatment of the sterile condition ;
und almost all that is now known has emanated from
tlie Edinburgh school. Indeed, little or nothing has
boon added to the labours of M'Intosh and of Simpson ;
and the English language presents us with but one
corn})loto monograph on the subject, — ^that by Dr.
A. K. Gardner,* of New York.

Macintofllit discovered that most of his sterile
f )atients hod a contracted os and cervix ; and he con-
coivod the idea of dilating these by bougies, such as
wore used ordinarily for stricture of the urethra. His
HucccHs was very remarkable, but none of his followers
wore ever able to attain equally good results. Simpson,
Huoing the uncertainty and even danger of dilatation,
had the happy thought of incising the os and cervix

• " ( )ii till) Cmim^ and Cumtivo Treatment of Sterility," by A. K.
CJimlnm', M.I)., iVc, Ni'w York. 1856.
■t Miiointiwh'M '» Path(»logy aiul Piuctice of Physic." 1836.

INTRODUCTION.

to render their enlargement more thorough and more
permanent. The results have not been all that were
hoped for ; but enough has been done to show that we
are at last on the highway of improvement; and it
seems to me that further advances must be made as
heretofore, by means abnost purely surgical.

From any point of view this subject is one of great
importance; for the perpetuation of names and families,
the descent of property, the happiness of individuals,
and occasionally the welfare of the State, and even
the permanence of dynasties and governments, may
depend upon it.

Without further preliminary remarks, let us then
inquire, " What are the conditions essential to Con-
ception ?"

1. — It occurs only during menstrual life.

2. — Menstruation should be such as to show a

healthy state of the uterine cavity.
3. — The OS and cervix uteri should be suflEiciently
open to permit the free exit of the menstrual
flow, and also to admit the ingress of the
spermatozoa.
4. — The cervix should be of proper form, shape,

size, and density.
5. — The uterus should be in a normal position, i.e.,
neither ante-verted, nor retro-verted to any
great degree.
6. — The vagina should be capable of receiving and

of retaining the spermatic fluid.
7. — Semen, with living spermatozoa, should be

deposited in the vagina at the proper time.
8. — The secretions of the cervix and vagina should
not poison or kill the spermatozoa.

6 UTERINE SUBGERY.

I lay these down as postulates, embracing the
general principles or laws most favourable — ^indeed,
essential to fecundation ; and I propose to take them
up seriatim, and to show, from clinical experience,
wherein the sterile condition differs from the fecund,
and to point out, so far as we know, the surest methods
of relief.

But before entering upon this discussion, it will be
well, perhaps, to say something

On THE Method of Uterine Examination. — ^Almost
every physician accustomed to treat the diseases of
women has educated himself to some peculiar method
of examination. I propose here to give my own plan.

Every thorough uterine investigation is naturally
divided into two stages, the first requiring the touch,
the second the sight; the dorsal decubitus for the
one, the left lateral for the other. For the touch
alone, the patient may lie on a sofa or a bed ; but the
one is too low, and the other too soft and yielding, for
a speculum examination. I therefore prefer a common
table, two or three feet wide, and four or five feet long,
covered with a wadded quilt, or blankets folded. This
is a little more formidable, but it is better for both
physician and patient. Indeed, it is essential, if we
wish to make a very thorough examination. The table
being properly prepared, the patient is requested to
loosen all the fastenings of the dress and corsets, so
that there may be nothing to constrict the waist or to
compress the abdomen. While this is being done, the
physician should bathe his hands in warm water, and
wash them well. It may seem odd to insist upon this,
but I do most earnestly ; 1st, because it softens and

UTERINE EXAMINATION. 7

warms the hands ; 2nd, because it insures their clean-
ness ; and 3rd, because it assures our patient against
any dread of contamination by the touch, a thing by
no means to be despised.

All being ready, the patient is now requested to sit
on the edge of the table, and then to he down on the
back, with the head, but not the shoulders, supported
by a pillow, while the feet rest momentarily on a chair.

Many practitioners allow the feet to hang down,
each on a chair, but this is by no means the best plan
for either physician or patient, nor is it the most deli-
cate. As soon as the patient is laid comfortably back
on the table, the surgeon will raise her feet from the
chair, upon which he is now to sit down, and place
them on the edge of the table, with the heels separated
some ten or twelve inches, while the knees are a Uttle
wider apart. This flexure of the thighs and legs in-
sures the relaxation of the abdominal walls. Some
patients will at first, in spite of our entreaties, place
the soles of the feet together, and lot the knees fall
widely apart, while others will unconsciously hold the
knees closely together, and brace the feet firmly out-
wards, each condition being equally opposed to an easy
exploration of the vagina.

The patient once on the back, with the extremities
properly flexed and fixed, must be assured that there
is to be neither pain nor exposure of person ; this last
being more dreaded than the most intense sufifering.

Everything being ready, let the left index finger be
well lubricated, not with sweet oil, which is often
gummy and sticky, nor with grease, which is often
rancid, but with warm water and Castile or other fine
soap, which is a cleaner, cheaper, and better lubricant

H UTERINE SURGERY.

than any other. Pass the finger into the vagina— do
it gently — if otherwise, we may jar tlio nervous system,
and produce involuntary spasmodic action of the abdo-
minal muscles. The patient may become agitated and
alarmed, and wo may perhaps be compelled to pro-
crastinate a very minute examination to some future
time. As the finger passes, let it ascertain if there is
anything abnormal about the ostium vagiuje. Is it
contracted, rigid ? Is the h3rmen present or absent ?
Is it irritable or tender ? Then as to the vagina : Does
it dip down towards the coccyx ? Does it run more in
the direction of the axis of the pelvis ? Is it of normal
temperature ? Is it short ? Is it deep ? Is it nar-
row P Is it capacious ? Does it contain any foreign
body ? If BO, is it something inorganic, previously in-
troduced ? Or, is it something organic, growing on
the walls of the vagina, on the os tincjB, or docs it come
from tho cavity of the uterus ? Is it benign or malig-
nant ? Then what of the womb? Is tlie os open or
closed, large or small ? Is the cervix too long, too
pointed, too small, too large ? Is it indurated or
ulcerated ? Is the body of the organ in its proper
position ? Is it ante-verted, retro-verted, or flexed in
any direction ? Is it larger or smaller than natural ?
Is it of proper form ? Is it indui'ated P Is it fixed or
movable? Is there any complication, ovarian or fibroid?

All of these conditions are ascertainable by the
touch alone. We need no speculum to teU us of the
volume, position, and relations of the uterus and its
appendages.

But I should not omit to say that the mere touch
by the vagina is not alone sufficient.

It is necessary to make pressure with the right hand

UTERINE EXAMlNATtON. 9

on tbe abdomen in tbe hypogastric region at the same
time that the left inilex is carried into the vagina. Tbe
two hands then act conjointly in ascertaining the con-
•dition and relations of the uterus.

Is it in its normal position ? Then the os uteri
will rest on the end of the left index finger, while the
fundus will be distinctly felt by the other hand, in a line
drawn from the os, in the direction of the uml)ilicus.

Is it ante-verted ? Then the os will be very far back
towards the liollow of the sacnun, while the fundus will
"be felt by the index just behind the Bym])hysis pubis,
pressing down upon and perhaps parallel with the
anterior wall of the vagina.

But I repeat that tlie touch by the vagina is not
enough to determine this point positively, and it is

Msential always to make pressure at the same time
irith the other hand, just above the pubes. It will
ftwn be very easy to measure the size and shape of the

10 UTERINE SURGERY.

body of the womb, for it will be held firmly between
the fingers of the two hands, and its outline and irre-
gularities will be ascertamed with as much nicety as if
it were outside of the body. Thus isolated, we deter-
mine its condition as easily as we would that of a pear
wrapped up in a common towel or napkin.

The retro-uterine region, represented here as being
occupied by a small tumour, is quite as easily explored
by the touch alone. To do this, pass the left index
finger to the posterior cul de saCy hook it up behind
the cervix uteri, raise this upwards, draw it forwards,
and at the same time press the outer hand in the
direction of the point of the left index.

In a thin subject, where there is nothing abnormal,
the external fingers and the internal one can be
brought very near together behind the cervix, with-
out pain to the patient or inconvenience to the
operator ; and if there is anything abnormal, this
manipulation is sure to detect it.

We may now and then bo obliged to pass the finger
into the rectum to clear up some doubtful point ; but
this is rarely necessary.

By this method, versions, flexions, fibroid offshoots,
and other irregularities, are readily detected ; and if
at any time there is a doubt about the direction or
depth of the uterine cavity, the sound will at once
clear it up.

Having ascertained all these points by the toucli,
we are ready for the second stage of the examination —
viz., that by the speculum. As before said, for the
digital examination, the dorsal decubitus is preferable ;
but for the speculum, the left lateral semi-prone
position is the best.

UTBEINB EXAMINATION.

11

In 1845 I first used my speculum for vesico-
vaginal fiatxila operations, placing the patient on tlie
knees. I rarely resort to this method now, but
as it may sometimes be necessary in a complicated
case of visico-vaginal fistula, or in some forma of
mdignant disease, I sliall here quote the following
from my first paper on this subject, published in the
American Jownal of Medical Sciences, January, 1852.

" In order to obtain a correct view of the vaginal
canal, I place the patient on ^_^..

a table, about two and a half
by four feet, on her knees,
with the nates elevated and
the head and shoulders
depressed. The knees must
be separated some six or
eight inches, the thighs at
about right angles with the
table, and the clothing all
thoroughly loosened, so that
there shall be no compres-
sion of the abdominal pa-
rietes. An assistant on each
aide lays a hand in the fold
between the glutei muscles
and the thigh, the ends of
the fingers extending quite
to the labia majora ; then by
simultaneously pulling the
nates upwards and outwards,
the 08 externum opens, the
pelvic and abdominal viscera ^'"' ^'

all gravitate towards the epigastric region, the atmo-

12

UTRHINE SURGETtV.

sphere enters the va^na, and by its pressure, soon
stretches this canal out to its utmost limits, affording
an easy view of the os tincae, fistula, &c. To facilitate
tho exhibition of
the parts, the
assistant on the
right side of the
patient intro-
duces into the
vagina the lever
speculum, repre-
sented in fig. 2,
and then, by
hfting the peri-
neum, stretching
the sphincter,
and raising up
the recto-vaginal
septum (fig, 3), it
is as easy to view
t.he whole vaginal canal as it is to examine the fauces,
by tiuuing a mouth widely open up to a strong Hght.

" This method of exhibiting the parts is not only
useful in these cases, but in all aft'cctions of the os
and cervix uteri requiring ocular inspection.

"The most painful organic diseases, such as corroding
ulcer, carcinoma, &c., may be thus exposed without
inflicting the least pain, wliile any local treatment may
be instituted without danger of injuring the healthy
stnictures. By this method also a proper estimate,
anatomically, can be had of the shape and capacity
of the vagina ; for where there is no organic change,
no contraction, and no rigidity of it fi'om sloughs,

UTERINE EXAMINATION, 13

ulcers, or cicatrices, and where the uterus is movable,
this canal immediately swells out to an enormous
extent,"

Thus I wrote in 1852 ; and I have introduced figs,
2 and 3, copied from the Americcm Journal of Medical
Sciences of that date, merely for the purpose of con-
trasting my past and present methods of vaginal
exploration.

Many persons who have never witnessed the use of
my speculimi, doubt the correctness of my explanation
of its rationale as given above. But let such experi-
ment for themselves, and give us a rationale more in
accordance with the laws of natural philosophy, if they
have one. For a successfiil experiment certain con-
ditions are requisite. At the risk of being tedious,
I will reiterate them. Let the experimenter first
loosen all the strings and fastenings of the dress and
corsets, and then place the patient on a table on
her knees, and bend her body forwards till the head is
brought down to the plane of the table, where it may
rest in the two hands, its weight supported on the left
parietal bone, while the elbows are thrown widely out
from the sides. The knees are to be separated eight or
ten inches ; the thighs are to be at about right angles
with the table;
thus the plane of
the table (a6), the
axis of the thighs
(ac), and that of
the body (c6),
would form a
right-angled triangle, of which the thighs and table would
make the right angle, and the body the hypothenuse.

Fig. 4.

14 UTERINE SUBGEEY.

The patient must be taught to maintain unflinchingly
this position ; she must not pitch forwards and make the
pelvian angle (c) obtuse, nor draw the knees up under
the body, making it more acute ; she must not arch the
spine (cb) upwards, for this brings into forcible action
the abdominal muscles, which should be perfectly re-
laxed, with the spine rather curved downwards, as we
see it in sway-backed animals. With these precautions
fully impressed on her, she is to breathe easily, and relax
the muscles of the abdomen. In consequence of this
position quietly retained for a few moments, the mov-
able abdominal and pelvic viscera necessarily gravitate
towards the epigastrium. Now, if the surgeon wiU get
immediately behind his patient and lay his hands on
the nates, and push them gently upwards and back-
wards, taking care that her position is not changed,
he will see the mouth of the vagina open, and at the
same moment hear the air rush into it with a blowing
or hissing sound ; and then if he wiU, with even his
finger, raise the perineum up towards the os coccygis,
he will see the vagina distended like an inflated bladder.
If, however, he will use my speculum instead of the
finger, the cavity of the vagina will be more easily seen.
If he will now remove the instrument (or finger),
and allow the mouth of the vagina to close, and then
if he will let his tired patient fall over on her side, he
win have audible and unmistakable evidence of the
sudden escape of air fi^om the vagina. In private prac-
tice, even with the patient on the side, this is such an
unpleasant occurrence, and so mortifying to a sensitive
person, that I generally keep a catheter by me, to be
placed momentarily in the vagina, that the air may
escape noiselessly. If we fail in the above experiment.

UTEEINE EXAMINATION. 15

it will be because we have omitted some of the condi-
tions essential to success. *

The object of this speculum (whether used with the
patient on the knees or on the side) is to elevate the
perineum and to partially support the posterior wall of
the vagina ; the pressure of the atmosphere with the
gravitation of the viscera does the rest. All other
specula act directly on the walls of the vagina, which
they mechanically distend. This one, as a rule, touches
but a small portion of the posterior wall.

I was led to the invention of this speculum by a sin-
gular incident. As showing from what trifles important
results sometimes spring, I venture to record here the
circumstances. I feel the more justified in this because
my speculum is by some in England, and by a few on
the continent, called by the name of another man, who
had nothing to do with it, except to hand it to the instru-
ment-makers here to be copied, and who in their turn
have been the imconscious agents of doing me a great
wrong. In December, 1845, a lady was riding on a pony
in the suburbs of the city of Montgomery, Alabama,
where I then resided. It took fright and suddenly
jumped from under her — she fell, striking her pelvis
on the ground. I saw her soon afterwards ; her suf-
ferings were very severe. Besides the contusions from
the fall, she complained of rectal and vesical tenesmus.
On examination, I foimd a complete retroversion of
the uterus. I had been taught by lectures and books
that the best method of reducing a recent luxation of
this organ was to place the patient on the knees, and
then act on the uterus through the rectum and vagina.
This lady, covered with a sheet, was so placed across
her bed. I then introduced a finger into the vagina.

UTERINE SmtGERY.

but effected nothing by it. Not wishing to pasa the
finger into tlie Fectum, which is always disagreeable,
and to be avoided if possible, I introduced the middle
and index fingers together into the vagina, and
while I was making efforts to replace the uterus,
all at onco it happened that I could not touch the
uterus, nor even the walls of the vagina, and my fingers
were swept around in the pelvis without touching or
being touched by anything except just where they were
grasped by the mouth of the vagina. Wliile I was
wondering what could be the cause of this anomaly,
my patient said she was relieved from the symptoms
of which she was complaining so seriously but a
few moments before. As she was relieved, although
I did not understand how it was done, my duties
to her were of course at an end. She was large and
heavy; letting her go, I requested her to lie domi.
Being quite exhausted from pain and the uunatm'al
position in which she had been placed, she threw
herself quickly down on her aide, when the sudden
escape of air from the vagina gave a ready solution of
my dilemma, as well as of the rationale of the reduction
of the dislocated uterus, which was now found to be in
its normal position. And what was its rationale ?
Wlien the patient was in the position described, there
being a natural tendency of the pelvic viscera to
gravitate towards the epigastric region, it would
require no great vis a tergo to produce the desired
result in a recent case of this kind. One finger, how-
ever, was not long enough to throw the organ up, nor
were the two ; but when they were both introduced, in
my varying manipulations and strenuous efibrts, the
hand was accidentally turned with its palm downwards.

UTERINE EXAMINATION. 17

wHch thus brought the broad dorsal surface of the
two parallel fingers in contact with the vulvar com-
missure, thereby elevating the perineum and expanding
the sphincter muscle, which allowed the air to rush
into the vagina imder the palmar surface of the fingers,
where, by its mechanical pressure of fifteen pounds to
the square inch, this canal was suddenly dilated like a
balloon, and the uterus replaced by its pressure alone.
Having at this time a patient with a vesico-vaginal
fistula, which I could not understand, I placed her in
the position above described, and used the handle of a
spoon, curved at right angles, to open the vagina,
elevate the perineum, and aUow the air to enter, which
afforded me a complete view, not only of the fistula,
but of the whole vagina ; whereupon this instrument
(page 11, fig. 2) was a self-suggested affair.

During my residence in Alabama, up to 1853, I had
no need of any better form of instrument, or any other
position for its application than that above described ;
but when I went to New York, a larger field of obser-
vation soon proved to me that it was essential to
modify both instrument and position, if they were to
be used in the every-day treatment of the ordinary
affections of the uterus ; for while a patient afflicted
with such a terrible infirmity as vesico-vaginal fistula
is ready and wiUing to be placed in any position, how-
ever fatiguing, a mementos reflection wiU show that
this kneeling posture would be quite out of the ques-
tion in the treatment of the simple forms of uterine
disease, as they occur in the higher grades of life.

With this necessity before me, I went to work to
improve my speculum, and at the same time I dis-
covered that it could be used quite as efficiently with

c

18

CTERLNE HUEGEEY.

tliG pa,tiont on tlie left side as on the knees, Forfl
nearly twenty years I have used no other speculum,
and, whenever, in these pages, I have occasion to speak I
of the speculum, let it be remembered that I allude j
always and only to this on© '
(fig, 6), with the patient
necessarily on the left side.
It is the best speculum for
any purpose, whether it be
for the apphcation of the
simplest dressing, or for the
execution of the most diffi-
cult operation,

I must of course make an
exception in favour of the
cunical ivory speculum, when-
ever it is necessary to apply
the hot iron, a thing rarely
done in America.

The speculum is univalve
or duck-bQled, as some liavo
called it. For the sake of
convenience, two specula of
unequal sizes are attached to the same handle, one
at each extremity. This hantUe may be slightly bent,
as seen in fig. 5, or it may be perfectly straight,
as I formerly used it (fig. 2). The only object
in the slight curvature is to facilitate its leverage
in prolonged operations. The assistant may become
tired of holding on to the distal end, and then it is a
great relief to grasp the shaft in the middle, where it
is gently curved. The object of Iiaving two blades or
specula to one shaft is merely to have tlicm of difforent

UTERINE EXAMINATION. 19

sizes SO as to suit diflferent vaginas ; for there are no
two vaginas exactly alike, any more than there are two
faces precisely alike.

I have one with a blade six inches long, another but
two inches, and another of the ordinary length, an
inch and three quarters wide. But these sizes are
very rarely needed. For ordinary purposes, two instru-
ments, i.e. four blades, are all that we need.

The smallest I call the virgin speculum ; for unhap-
pily we are sometimes compelled to use a speculum on
the unmarried, and then it is proper to have it of such
a suitable size as not to give pain, and not to injure
the hymen. Here one blade is a little less than three
inches long, the other a fraction over ; the first three-
quarters of an inch wide, the other seven-eighths. But
the speculum for ordinary use on the married has the
smaller blade about three and a half inches long, by
about one inch wide. This is the one that we need in
nine cases out of ten.

The other, or larger one, is about four inches long by
an inch and a quarter wide. This will be needed
wherd the vagina is very large. As said before, they
are made much wider ; but they are then apt to pro-
duce pain, a thing always to be avoided.

In all vaginal examinations, it matters not for what
purpose, a speculiun should never be used till we
have by the touch first and fully ascertained the con-
dition of the uterus and its appendages.

This injunction is particularly imperative, and for
the most obvious reasons. 1st, because the size of the
speculum should be always adapted to the capacity of
the vagina ; a small speculum in a large vagina is
comparatively useless ; on the contrary, a large specu-

c 2

20

IJTEHINB SUEGERY.

1 am in a small vagina ia cruelly painfiil. 2nd, because
it should bo passed in the direction of the axis of the
vagina, taking cai-e not to strike it against the cer\-ix
uteri, particularly if this be the seat of granular ero-
sion, of polypus, of cauliflower excrescence, or other
hemorrhagic disease, all of which should be previously
ascertained by the touch.

It has been objected to this speculum, that its use
requires the assistance of a third person. Apart from
its real value, there could be no stronger reason for
its universal adoption. I insist that a third person
should always be present on such occasions. Delicacy
and propriety require it, and public opinion ought to
demand it. I do not mean lay, but professional public ■
opinion. \

I am sure that I never made a vaginal examination,
or used a speculum a dozen times in my life without
the presence of a third person. I have never had a
patient to object who was educated or sensible ; but the
silliest person would see the necessity of it when told
that propriety required it, even if an assistant were not
necessary. The few that have objected to the presence
of another person in the room at the time of a
speculum examination, have done so from the fear of
personal exposure. We are too apt to disregard this
innate feeling of delicacy when we have been much
used to hospital practice ; but we can never make a
mistake if we always cultivate the same gentleness and
kindness towards the poorest hospital patient that we
would use towards the highest princess. I repeat,
then, that we should never in our examinations allow
any exposure of person, not even in hospital practice.
When the touch is made, there can be none, of course,

UTEBINB EXAMINATION.

21

with the patient on the back, and covered with a
sheet. Wlien the speculum is used, we should see
only the neck of the womb and the canal of the
vagina.

I have said that for a speculum examination there is
nothing better than a table covered with a quilt or
blankets folded, and this is hterally true ; but for the
conaultation-room I have a chair which has served
such a good purpose that I introduce it here, that
others may profit by it.

Some twelve or fifteen years ago, Mr. James Holmes,
of Charleston, S.O., was driven to the necessity of in-
venting what he called an " Invalid Chair." The
patient sitting in this
chair (fig, 6), can with
the greatest ease and
without an efibrt poise
the body for any
length of time, at
any angle between the
erect and horizontal
postures. Mr. Holmes
invented this chair
especially for a near
relative of his, who
suffered from pro-
longed attacks of (I
believe) gout or some
other very painiul affection. It is much used in
America, and was even introduced on some lines of
railway as a sleeping-chair. I am thus minute, because
I do not wish to claim it as mine. To adapt it to my
own practice I had it made 24 inches wide instead of 18,

and 30 inches high iustead of 22. I have added legs
or uprights, fl, tt) to support the lower part of the chair
when it is extended in the form of an operating-
table (fig. 7). There is also an elastic cord, h, to
pull these uprights back under the chair when it ia
clianged from a table to a mere chair again. For all

practical purposes it is really no better, as before
said, than a common table ; but any patient would
sit in the chair without nervous agitation, while some
become greatly alarmed at being requested to mount a
table. The patient once seated, ia told that the chair
is only a couch, and she is requested to lean back and
extend it horizontally by her own weight, with perhaps
a Uttle assistance from the nurse who stands at the
back of the chair. I am almost afraid to write these
little things, but I do it only for my younger brethren,
who may need to learn the importance of educating
their patients to feel that everything is being done
that delicacy and propriety require on an occasion
so trying to a sensitive nature.

When the patient lies back and the chair is ex-

UTBErSH flXAMtNATlON.

I

tended in the form of a table, it will be necessary
to draw the pei'3on down to the lower edge of it, c e,
whether for a digital or speculum examination, Afler-
wai'ds the patient moves again up on the centre or
seat of the chair, the uprights «, a are drawn back, and
the chair almost voluntarily assumes its proper form.

For a speculum examination the patient is to lie
on the left side. The thighs are to be flexed at
about right angles with the pelvis, the right being
drawn up a little more than the left. The left arm is
tlirown behind across the back, and the cliest i-otated
forwards, bringing the sternum very nearly in con-
tact with the table, while the spine is fully extended,
with the head resting on the left parietal bone. The
head must not be flexed on the sternum nor the right
shoulder elevated. Indeed, the position must similate
that on the knees as
much as possible, and
for this reason the pa-
tient is rolled over ou
the front, making it a
left lateral semiprone
position. The nurso or
assistant standing at her
back pulls up the riglit
side of the nates with
the left hand, when the
surgeon introduces the
speculum, elevates the
perineum, and gives the
instrument into the
right hand of the assistant, who holds it firmly in the
desired position.

24

CTEEINE SUEGEBT.

Tho introduction of the speculum is a matter of
some importance. It ia done under cover, with the
right index finger as a guide, as seen in fig. 8.

Tha

P

object of this is to prevent the point of the instrument ^fl

fi"om striking againat the ccrvis ^^H

uteri. The finger is not to bo £^ ^^\

withdrawn till wo are sure that

the end of the speculum has

passed beyond the cervix, or is

well turned back towards the

rectum. If the patient breathes

easily, the vagina will be im-
mediately distended by the

pressure of the atmosphere, so

as to bring the neck of the

uterus, the poeterior cul-de-sac,

and the whole of the anterior

wall of the vagina into view,

without the least traction,

pressure, or sufiering. But if

she is alarmed and breathes

hurriedly, or bears down, it will

be otherwise. If the uterus be

retroverted, the os tincse is

easily seen. If it be in a

normal position, there is no

trouble in getting a good view

of it ; but if it be completely '^"' ^**'
antevorted, with a narrow vagina, then it will be
necessary to hook a small tenaculum into the anterior
Up, and pull it gently forwards, as shown in fig. 14,
where the manner of introducing the sponge-tent is
illustrated. The tenaculum is to be but slightly insert^ed

UTBEINB EXAMINATION. 25

into the mucous membrane. It gives no pain, and
produces no bleeding, unless there is great engorge-
ment ; but even then it amounts to nothing. Another
plan of bringing the os tinc39 into view is to draw the
neck forwards by pressure in the anterior cul-de-sac
with this instrument (fig. 10), which I call the uterine
depressor.

I have never known any one accustomed to this
method and these instruments who was willing to revert
to the old plan.

The consideration of other means of exploration,
such as the soimd, tent, &c., I leave till we come to
speak of treatment.

EABLY PREGNANCY. 29

SECTION I.

CONCEPTION OCCUES ONLY DURING MENSTRUAL LIFE.

THIS is SO self-evident, that it might be passed with-
out further notice. I do not know that conception
has ever occurred previously to the appearance of the
menstrual flow. Cases are recorded where it happened
at a very tender age ; but it was always preceded by
the appearance of the function that we are taught to
look upon as evidence of the fitness for conception.
As an example, I may cite the following, which is
perfectly authentic.

Dr. Curtis, of Boston, examined into the particulars
of a case of early pregnancy that occurred in the
poorhouse of that city, and reported " that the girl
Elizabeth Drayton became pregnant twenty-four days
before she was ten years old, and was dehvered of a
fine full-grown male child, weighing fully eight
pounds, when she was ten years eight months and
seven days old. The reputed father of the child is
said to be about fifteen years of age. The mother
menstruated once or twice before conception, was
tolerably healthy during gestation, and had rather a
lingering but quite natural labour.'' *

Conception has occurred at an advanced period, and
even after a supposed change of life.

* Medical Times and Gazette^ April, I8G3, from the Boston Medical
Journal, February 19th, 18G3.

30 OTEBINE SURGERY.

An instance of this sort fell under my observation
in the state of Alabama, in 1840, where an old negro
woman (said to be 58 or 60) became a mother, after
having ceased to have children for more than twenty
years.

I regret exceedingly that I did not investigate this
case more minutely, but in my younger days I did not
feel much interest in the subject. But I now know of
two well-authenticated cases of parturition at the age
of fifty-two.

Many women conceive without menstruating, but
it is always during menstrual life. Most accoucheurs
have doubtless met with such cases.

I know a lady some 36 or 38 years old, who is the
mother of six children, three of whom were bom (at
single births) without the least sign of intermediate
menstruation. She menstruated soon after marriage,
immediately conceived, was safely deUvered at term,
and while nursing found herself pregnant again ; she
then weaned her child, went the fiill term with the
second, was fortunately delivered ; and while suckling
it, became pregnant a third time. She thus bid fair
to have a large family very rapidly, but unfortunately,
after her third confinement, she got some uterine
disease that arrested her child-bearing for several
years.

Dr. Emmet and myself saw a case still more remark-
able than this in 1859. One of the patronesses of the
Woman's Hospital requested me to visit a poor woman,
a protegee of hers, who was supposed to have ovarian
dropsy, which had increased so rapidly that she appre-
hended an early fatal result. On visiting the patient,
she told me that the tumour began to grow not very

CONCEPTION WITHOUT MENSTRUATION. 31

long after the birth of her last and eighth child, which
was now some twelve or thirteen months old. She was
stiU suckling it, and it seemed to be drawing her very
life out of her. She was in bed, greatly prostrated from
want of proper and suflBicient nourishment, and from
the exhaustion of super-lactation, all of which had
been supposed to belong to the rapid growth of the
tumour. Laying my hands on the abdomen for
palpation, I instantly detected foetal movement. I
asked her if she suspected pregnancy ; she said no,
nor had she felt any quickening, although the move-
ments of the child were by no means feeble. The
touch showed the mouth of the womb dilated fully
two inches, with the head presenting. Labour set
in the next day, and she was happily delivered by
Dr. Emmet of a fine vigorous child. This was her
ninth labour in fourteen or fifteen years; and she
told Dr. Emmet, that during the whole of her married
life she had menstruated but three times ; thus, not-
withstanding the accepted views of the profession in
regard to the relation of menstruation to conception,
we find anomalies, which, however, are so rare that
they do not invalidate the rule.

It is a Uttle curious that a woman should have had
eight pregnancies, and have gone the ftiU term of the
ninth, without the least consciousness of a movement
of the foetus.

But there was evidently no malingering, for she
was immediately raised from the deepest despair to
the greatest joy, when her tumour was pronounced
to be a living child to be bom in a few hours. I
have seen several cases of pregnancy where the
mothers were totally unconscious of any movement

UTERINE SURGERY.

on the part of the child. I allude to this as a Bubject
of interest to the profession at large ; for an error in
diagnosis, whether in failing to detect pregnancy when it
exists, or in assorting it where it does not exist, always
injures us as a body, and sometimes inflicts injury on
the subjects of our mistakes.

A lady, married about twenty-three years, and ,
childless, became irregular at forty-three- Her physi-
cians said it was incipient change of life, which was I
doubtless true. After a few months of irregularity,
the menses ceased entirely. With this change many I
women anticipate evil in some fonn or other. This
poor sufferer expected cancer, but instead of that
her physicians detected a pelvic tumour. She was
plied with iodine for a long time, and had flying blisters
alternately over the ihac regions ; but in spite of the
most active moans the tumour continued to grow.
Her case was considered hopeless, and it was thought
advisable for her to return to the place of her nativity
to die amongst her friends. On her arrival in New
York she patiently resigned herself to her fate, and
made all arrangements for her approaching dissolu-
tion. After waiting a month in vain, some of her
friends persuaded her to have other medical advice,
and I saw her. There was not the slightest diffi-
culty in detecting foatal movement and fcetal pulsa-
tion, and when I told her that in two weeks she |
would need baby-clothes instead of a shroud, and a ■
cradle instead of a coffin, she could not believe it. i
During the whole of her pregnancy she was not I
conscious of any motion.

Here the mistake was fraught not only with damage
to the profession, but with loss to the husband, for.

I

EHKOES IN DIAGNOSIS.

33

I

\

engaged in a profitable business, he was compelled to
sell it off at a sacrifice, and to make a long journey
to New York, wlien he should have remained at
home. I have seen many similar mistakes, and that
too since the days of Dr. Kennedy's beautifid work on
Obstetric Auscultation.* We may be in doubt about any
case up to the fii'th month of pregnancy, but never
after that ; for then the beatiog of the foetal heart
■will infallibly guide our judgment. Dr. Routh,f of the
Samaritan Hospital, has detected pregnancy as early
as fi-om the sixth to the tliirteenth week by means of
his vaginoscope, which, coming directly in contact
with the cervix uteri, gives an earUer indication of
the placental souffle than we could get by the stetho-
scope.

Mistakes sometimes occur in the hands of the
beat men in the profession, and then it is the
residt wholly of carelessness. For example, a lady,
thirty-five years old, the mother of several children,
had a small fibroid tumour on one side of the womb.
Her physician, a most accomplished diagnostician,
watched the progress of this tumour, which seemed
to be stationary for a long time. I should remark
that fi-om the time the tumour was observed, the
patient ceased to have children. And so things
went on for five or six years, when the abdomen

" Observations on Obstetric Auacultation ; with Analysia of the
' Evidences of Pregnancy ; wwl an Inquiry into the Proo& of tlie Life
ind Death of the Fcetus in Utero." By Every Kennedy, M.D., &c.
Dublin: Hoilges i Smith. 1833.

" On Some of the ayniptoma of Early Pregnancy." By 0. H. F.
\ Roiith, M.D., ic London: T. RichardH. 1864. Pp. 21.

34 UTBEINE SURGERY.

began to enlarge, and as we sometimes see in ovarian
tumours, the menses ceased. The physician put
her on bromide of potassiimi internally, and tincture
of iodine externally. In spite of this the tumour
continued to enlarge, and her physician brought
her from a neighbouring city to me. I had only
to lay my hands on the abdomen to detect motion,
and with the stethoscope the foetal heart was
easily heard. Now, here the physician, having his
mind full of the fibroid growth from which he had
so long anticipated evil, never made any thorough
investigation of the case after the abdomen began to
enlarge, and the patient, who was a most intelligent
woman, declared she had not for a moment sus-
pected pregnancy, and that she had not experienced
the slightest sensation of motion.

While on this subject, I may mention an opposite
class of cases in which we occasionally make grave
mistakes. A hysterical sterile woman, naturally anxious
for offspring, imagines herself pregnant, denies that
she menstruates, affects a quickening, seems to grow
larger and larger, till at last the fulness of time arrives ;
she goes to bed, and has some irregular colicky pains ;
but nothing more. This is a case of hysterical
monomania, for which no physician could be respon-
sible; but if called to give an opinion, he should
be careful not to be misled by the artful misrepresen-
tations of " a mind diseased.** Young women some-
times honestly imagine themselves pregnant, and phy-
sicians, I am sorry to say, are occasionally deluded into
the support of their whim, notwithstanding the fact
that menstruation returns regularly every twenty-eight
days, and pursues its usual course.

FALSE QUICKENING. 35

An example of this sort occurred at Baden-Baden a
few years ago, under the care of a very eminent physi-
cian, now dead, who allowed his patient to lie in bed
for nine months to prevent a miscarriage, when in fact
she menstruated regularly during the whole time. At
the end of the tenth month another physician was
called in, who said the lady had never been pregnant
at all.

But while many women go through pregnancy with-
out feeling the slightest motion of the foetus, a very
opposite state of things is occasionally met with about
the time of change of life. A woman, forty years of
age or more, becomes irregular; she thinks herself
pregnant; by-and-by, she quickens; she begins to
make baby-clothes ; she tells her intimate fidends of
her interesting condition ; she gradually grows larger ;
the time for confinement arrives ; she is not quite as
large as in her former pregnancies ; nevertheless she
cannot be deceived, for the fi:*equent regular move-
ments of the foetus make it impossible for her to be
otherwise than pregnant. At last she becomes alarmed
at the procrastination of the labour, and sends for her
physician, who finds the abdomen large, but the enlarge-
ment is due to an immense deposit of adipose tissue in
its parietes. He passes his finger into the vagina, and
discovers the uterus in an unimpregnated state ; in-
deed, it may be smaller than usual, for the cervix may
be foimd rather atrophied, and the whole organ gradu-
ally imdergoing the change that we always see when
change of life occurs.

I have seen several cases of this false quickening,
never in a woman under thirty-eight, nor over forty-
eight. They had all borne children, and all had a ten-

D 2

36 UTERINE SUEGEEY.

dency to embonpoint They were all women of cul-
ture, refinement, and of good common sense ; and so
strong in every case was the mental impression of the
sense of quickening, that it was impossible to convince
them that there was no pregnancy. Two of these
ladies returned to me several times in the course of a
year, and insisted that I must be mistaken. I now
regret having dismissed them so peremptorily, as I
thereby lost the opportunity of watching the progress
and termination of this fireak of change of life.

SECTION 11.

MENSTRUATION SHOULD BE SUCH AS TO SHOW A
HEALTHY CONDITION OF THE UTERINE CAVITY.

OF SCANTY MENSTBUATION. 39

SECTION 11.

MENSTRUATION SHOULD BE SUCH AS TO SHOW A HEALTHY
CONDITION OP THE UTERINE CAVITY.

OF Scanty Menstruation. — If asked what constitutes
normal menstruation, I should reply, a painless
uncoagulated flow, returning at intervals of about four
weeks, lasting three, four, five, or six days, and
requiring the use of not more than three, or, at the
farthest, four napkins in the twenty-four hours. It
may vary fi:'om a healthy standard in both quantity
and quality. It may be scanty or profuse, and painful
or not, without regard to quantity. If the flow falls
short of three days' duration, it may be called scanty.
K it continues longer than six or seven days, it may
be profuse, but not always so. It may be very abun-
dant, and last but two or three days ; and, again, it
may continue twelve or fifteen days, and be very
scanty, requiring not more than one napkin in the
twenty-four hours. The explanation of either of these
conditions will generally be found in some organic
deviation fi^om a normal state.

Conception may take place, whether the menstrua-
tion be scanty or profuse. But either extreme is not
very favourable to it, not that the amount of blood
lost is per se an important matter, except as the index
of an organic condition, favourable or otherwise to the
fiilfilment of this great law of nature.

According to modem views, the menstrual fluid is not

40 L'TEEINE SUKGEEY.

a secretion, but an exudation of blood from the lining
membrane of the cavity of the uterus, which acquireB
its peculiar qualities by admixture with the secretions
of the cervix and vagina as it passes outwards.

We often see menstruation so scanty, that it lasts
but a day, or a day and a half, one napkin having per-
haps sufiBced for the whole time. Under such circum-
stances, it has been supposed that there is defective
ovulation ; but this, of course, is mere hypothesis, for
it may or may not be so. It must be admitted, how-
ever, that menstruation is a sign of ovulation, the one
taking place when the other begins, and ceasing when
it stops. With ovulation, we see the uterus suddenly
developed in size, the fit receptacle of a new being.
With change of life we see it gradually returning
to the diminutive proportions that it had before
puberty.

In habitually scanty menstruation, if the patient has
never borne children, we shall generally find the uterus
smaller than usual, with rather a long, pointed, indu-
rated cervix, and if so the os and cervical canal will
necessarily be small. On the contrary, if the patient
has borne children, the uterus may be larger than
natural ; but the history of the case will probably show
that there has been some puerperal trouble of an in-
flammatory character, resulting in imperfect involution
of the organ. In either case I have not derived the
benefit that I had expected fi-om sm-gical means, such
as a cupping pump to the cervix, suction and lacera-
tion of the lining membrane of the uterine cavity,
and the intra-uterine galvanic pessary of Professor
Simpson, which seems to have produced very good
results in his experienced hands, and also in those

OP PEOFUSE MENSTRUATION. 41

of his pupil, Professor Priestly, of King's College
Hospital.

For the general management of this class of cases, I
must refer the student to our systematic works
(Churchill, West, Hewitt, &c., &c.), and at the same
time he should not neglect Faradization, as taught
and practised by Althaus,* of London, and Duchennet
(de Boulogne), of Paris. Nor should he fail to study
the brief monograph of Dr. Chapman, { on cold and
heat in the treatment of the ftmctional diseases of
women.

It is now pretty well imderstood that electricity
judiciously administered is especially valuable as an
emmenagogue in young women, where the menstrual
function has not yet been folly established, in conse-
quence of a torpid state of the vaso-motor nerves of
the ovaries and uterus ; and it has also proved suc-
cessM when the catamenia have been lost after labour,
or in consequence of cold shock or mental anxiety.

Op Pbopusb Menstruation. — The profiiseness of
menstruation is to be judged of not so much by its
duration as by the quantity of blood and the effects of
its loss. Sometimes it wiU be very abundant from its
inception to its termination. Again, it may be violent
for thirty-six or forty-eight hours, and then moderate

* *' A Treatise on Medical Electricity, Theoretical and Practical."
By J. Althaus, M.D. London. 1859. Pp. 298.

t ** De r£lectrisation Localis6e et de son Application H la Patho-
logic et la Th^peutique." Par M. le Docteor Duchenne (de
Boulogne). Paris. Second Edition. 1861. Pp. 89.

X " Functional Diseases of Women," «Smj. By John Chapman,
M.D. London : Trubner & Co. 1863.

42

UTERINE SUBGEEY.

to a normal standard. A very good way to judge of
the quantity lost is by the niimber of napkins needed
to protect tlie person and linen. A change of three
or four napkins in the twenty-four hours is about a
proper number for normal menstruation. If seven or
eight be needed, the flow may be called profuse, and if
a dozen or more, then it may be called a menorrhagia.
In the treatment of menorrhagia, we are by no
means to neglect general constitutional remedies,-^
Some bleed, but I never saw a case in which I thoughtJ
this practice justifiable. All prescribe revulsives, tonics,
chalybeates, mineral acids, ergot, &c., which treatment
is well enough as far as it goes, but does not always
strike at the root of the evil ; and often valuable time is
thus thrown away. I know very well that we may have
menorrhagia from mere debility, from super-lactation,
and from some temporary engorgement of the portal
circulation ; but such cases are not very common, and
not usually obstinate. If there is anything abnormal
in the quantity of blood lost at the menstrual epoch,
there is always a cause for it, and we shall generally
be able to find it out by directing our attention to the
seat and source of the trouble. If the nose bleeds, we
try to stop it by the most direct methods in our power.
If the hemorrhoidal vessels bleed persistently, wo
attack them with the icrosenr, ligatures, nitric acid,
persulphate or perchloride of fron. Why, then, ahoidd
we permit the womb to lose an unnatural quantity
of blood without at once interrogating it on the sub-
ject ? I would not ignore such general means as we
all admit to be available, but I would never put off a
uterine exploration in any confirmed case of abnormal
flow ; for where there is an inveterate menori'hagia.

MENOEEHAGIA — GEANULAE BB08I0N. 43

there will always be some organic cause for it. It may
be due simply to granular erosion ; to engorgement of
the cervix; to fungoid granulations in the cervical
canal, or in the uterine cavity ; to polypi of the os,
the cervix, or the cavity ; to a fibroid tumour, intra-
uterine or intra-mural ; to inversion of the uterus, to
haematocele ; or it may be a sign of some malignant
degeneration, all giving rise to hemorrhage, and each
requiring its own peculiar and appropriate manage-
ment.

I propose to illustrate, firom clinical experience, the
surgical treatment of monorrhagia as it may originate
from one or the other of these soiu*ces. And first, —

Op Mbnoebhagia feom Geanulab Beosion. — One ex-
ample of this will suffice. Mrs. , aged twenty-
eight, of leuco-phlegmatic temperament, confined four
years and a half ago, never weU since, was greatly
exhausted by lactation, and weaned her child at six
months, had very profiise menstruation, lasting eight
days, some leucorrhoea, pelvic pains, dysuria, &c.-
could not walk at all — ^had to be carried up and down-
stairs — was quite anaemic and exhausted, irritable,
peevish, hysterical, crying easily and at trifles — ^had
had the usual constitutional and tonic treatment from
several physicians without improvement — ^the uterus
in proper position was larger than natural — ^the edges
of the OS were covered with luxuriant granular erosions,
which could be seen extending up the canal of the
cervix. To these granulations I applied chromic acid,
which is with me a favourite escharotic. It is more
powerful than the nitrate of silver, and ordinarily per-
fectly painless. It is used thus : — Take a drachm of

44 UTERIKE SUBGEEY.

the salt, which is very deliquescent, and add slowly
a drachm of distilled water ; the salt is instantly dis-
solved and ready for use. Dip a small, pointed, solid
glass rod in the eolntion, let it not take up more than
a drop or two, and then apply it to the granulations
and to them only. It produces no pain, and may be
carried into the canal of the cervix or even further. In
this case it was apphed as far as the os internum two
or three times, at intervals of twelve or fifteen days, i
A nutritious diet, but no medicine, was ordered. In 1
three months the granulations and the menorrhagia
were well, and in three months more conception oc-
curred, and resulted in the birth of a son, after five
years of suffering.

Menoerhaqu feom Fibrocs Engorgement of tub

Cervix. — Mrs. , aged thirty-one, married at twenty

— two children, youngest eight years old — never well
since last labour — menstruation formerly normal, but
for the last seven years and a half it recurs too early, and
lasts often ten days very profusely. Five or six months
ago she had it for three months continuously. She is
quite exsanguious and exhausted ; has had some leucor-
rhcea for the last four or five years. I was consulted aa
much for the removal of her steriUty as for the relief of
the menorrhagia. She had taken chalybeatos, mineral
waters, &c., and had been treated locally with the nitrate
of silver for a very long time without material benefit.
The neck of the womb was the seat of fibrous engorge-
ment, with superficial granular erosion. It was con-
siderably hypertrophied and indurated. The organ
was in its normal position. The thickened indurated
bps of the OS uteri were in consequence of their hyper-

»

MENORBHAGIA — F1BH0U8 ENGORGEMENT. 45

trophy in close apposition, the one against the other,
thus mechanically closing the os, although it was
Targe enough to aJmit a No. 8 bougie. To the granu-
lations on the engorged fibrous cervix I applied the
chromic acid as already described, which healed the
granular surface in two months, but did not in the
least modify the hfemorrhagic tendency. A sponge
tent showed that there was nothing abnormal in the
kvity of the uterus, and I then determined to incise

OB uteri. There were two reasons for this ;
Igt: The bilateral incision of the os uteri would
divide the indurated structure of the cervix through
its whole extent up to the os internum, which would
probably ameliorate the engorgement, and diminish the
haamorrhago. And 2nd : It would separate the com-
pressed lips of the OS uteri sufficiently to permit the
spermatozoa to pass to the cavity of the uterus,
thereby rendering conception possible ; and upon this
taking place I hoped for a complete revolution in the
nutritive functions of the whole organ, and an ultimate
perfect cure.

Accordingly, the opera-
tion of incision of the os
and cervix bilaterally, was
performed on the 1st of
October, 1860. The parts
bealed before the next
menstrual flow, which I
was delighted to find great-
ly reduced in quantity; in-
deed, it was almost natural.
In three months she returned home with a normal
Tnenstruation, The mouth of the womb presented a

46 UTERINE SUEGERY.

totally different appearance from what it did when she
first came under my observation. For instance, when
I first saw her it was a simple httle transverse slit
(fig. 11), with the opposite smfaces closely applied to
each other ; but when she leil it presented an entirely
different appearance : the
two opposite lips of the os
uteri slightly gaping open
(fig. 12), thus rendering it
possible for the semen to
get to the fundus uteri.
Nine months after this
. lady left my care she con-
ceived, and I have since
heard that she was safely
delivered of a fine vigorous
child, after an acquired sterility of about nine years.
The result is most gratifying, inasmuch as a purely
rational surgical treatment effected the cure of both,
menorrhagia and sterility.

Of Menorrhagia from Fdsqoid Granulations. — ■
When an old bum and other chronic ulcers reiuse to
heal, we often find the suppurating surface to be ele-
vated above the level of the somid skin, and we call it
" proud flesh," " exuberant granulation," " fungus,"
or " fungoid granulation." It is usually indolent or
insensible to the touch, except, perhaps, just at the
cicatrizing edge of the cuticle, and it often bleeds easily
on being touched. It is a condition of things very much
like this that wo hero designate "fungoid granula-
tions," as sometimes the source of menorrhagia. These
may be in the canal of the cervix, or in the cavity of the

I

MENORRHAGIA — ^FUNGOID GBANULATIONS. 47

uterus, or in both at the same time ; but it is more
common to find them in one or the other alone, and per-
haps more fi^equently in the former. Wherever located,
they are often the source of an increased flow, which
may be remedied by local treatment. To diagnose
their presence, let us suppose a case of menorrhagia
for investigation. K the touch proves that there is no
polypus or other source of it to be found in the vagina,
then we must look to the cavity of the uterus for it.
If it be from a granular engorged cervix, the specu-
lum at once reveals the cause. But if the os and
cervix be in a healthy condition, then it comes from
some portion of the utero-cervical canal. Formerly we
were left in doubt about the pathology of menorrhagia,
but we now explore the cavity of the unimpregnated
uterus with the greatest facility, and, no longer groping
in the dark, we are able to treat most cases of it imder-
standingly, if not always successfully. Compressed
sponge is a very old surgical appliance, but in uterine
therapeutics it is of comparatively recent date, and I
believe we owe its generahzation here to Dr. Simpson ;
but my own countrymen, Dr. J. P. Batchelder and
Dr. W. 0. Roberts, of New York, have both written
very ably on this subject. Sponge tents are now to
be had at most druggists ; those that we see in the
shops are large, clumsy things, thickly coated with
wax, tallow, or suet. They are difficult to introduce,
and often slip half out of the cervix into the vagina,
there exciting an unnecessary amount of irritation.
To be sure that they are well made, I have them
manufactured under my own supervision. They are
so indispensable nowadays that I may be pardoned for
a little minutidB on the subject. City physicians can

48

UTERINE SUEGEKT.

order them from the druggist, but tlie country prac--!
titioner cannot always do so, and this is my apology
for dwelling on the subject.

The sponge should be of good quality, but not I
too soft and yielding. Of course, it should be tho-
roughly cleaned ; but not bleached, for the bleaching
process deprives it of all elasticity. It should be cut
into slightly tapering conical pieces, from one to two
inches long, some smaller and others much larger than
the thumb. A pointed wire or a slender awl should be
passed through the centre of the long axis of the
sponge, which should then be thoroughly saturated
with a thick mucilage of gum arabic. A small twine
or cord is then to be closely wrapped around the
sponge as it is held stiff by the wire, beginning at the
smaller extremity and gradually winding on to the
larger ; then the wii-e may be withdrawn, and the new-
made tent laid aside to dry. If we are in a hurry it
may be dried in the sun or by a fire, taking care not
to injure the texture of the sponge by too great a
heat.

Wlien it is thoroughly dry, the twine is to be
imwound, and the little circular elevations made by
it on the surface of the tent are to be rubbed down by
fine sand-paper.
Without further
preparation it is
then ready for
use. These dia-
grams represent
the tents about
the size and shape that I usually make them. I never
allow them to project more than an eighth of an inch

SPONGE TESTS.

49

from the 09 uteri into the vagma. Being introduced
without grease, except a httle suet just on the point,
they seldom slip out of position. If, however, there
is a disposition on the part of the cervix to eject
the tent, a small pledget of lint or cotton laid on the
cervix after the tent is introduced, will effectually prevent
this accident. I have seen a great deal of suflenng
produced by sponge tents, and with all due deference
to the dexterity of surgeons, I must insist that this is
■wholly unnecessary. The commercial tents, as said
before, are too large, and being introduced without a
speculum always induce more or less pain. My plan is

Flo. 14 reprommts tbe Bpeanlom elevating the pogtertor wall of Uia
TH^nci ; the tonoonlam liiia(; the ateme b; being hooked intc
it« anterior lip ; and the forceps boldiog the teut, which is
iutnidaced np to the os intomam.

I this : — The patient being on the left side, my speculum
i introduced ; the os uteri is pulled gently forwards by
I delicate tenaculum hooked into the anterior lip.

50

UTEIUNE SUIMiEBY.

which fixes the uterus, while the tent held by the for-
ceps is passed easily and gently into the cervix to the
required depth, without producing the slightest pain.
I make it a point never to introduce a tent that ia
larger than the canal that is to receive it, and thus, if
it be gently done, it is impossible to give pain ; and
why should we ever inflict one single unnecessaiy
pang P

If we have the selection of the time for the intro-
duction of the tent, let it be in the morning, say by or
before ten o'clock. We should explain to the patient, —

Ist : That it may possibly produce a little pain,
which is usually very bearable.

2nd : That it will certainly produce a dirty, dis-
agreeable, bad-smelling, watery discharge, from which
the person and clothing must be protected by napkins,
to be changed as often as necessary. And —

3rd : That it will be necessary to see her in six or
eight hours, to remove the tent, and probably to intro-
duce another, if the cervix be not ab-eady sufficiently
dilated by the first one, to permit the passage of the
index finger freely into the canity of the uterus.

If the second tent be needed, it may be allowed
to remain tiH the next morning. The tent is valu-
able both as a diagnostic and therapeutic agent, but
is to be used with caution. If the second tent fail
to dilate the cervix sufficiently, it is safer, as a general
rule, not to persevere further for the time, but to
wait a few days, and then resort to it again. I am thus
cautious, because I have seen metritis follow its inju-
dicious use. The tents of commerce have a loop of
tape, three or four inches long, fastened to the large
or outer extremity, for their easy removal.

SPONGE TENTS. 51

I use nothing of this sort, because I always expect
to remove the tent myself,

Its removal is a matter of some nicety.

Place the patient on the side as for its introduction ;
apply the speculum, and immediately we see the
sponge projecting from the
cervix and dilated from the
size of b to that of a (fig. 15).
It ^t11 be saturated \vith a
fcetid, serous, or sero-sangui- A
Dolent discharge, which is
to be carefiiUy wiped away.
After this fix a pair of spring
forceps firmly on the centre
of the sponge, for the pur-
pose of removing it. Then let the patient turn over
on her back, with the forcejis still fastened to the
sponge. Now pass the left index finger into the vagina
along the locked blades of the forceps, till it comes in
contact with the sponge. The sponge is not to be
suddenly and quickly withdrawn, but it is to be pulled
gently first to one side and then to the other, taking
care at the same time to support the uterus with the
index finger, which is to be gently carried into tho
cervix by the side of the tent, first on one side, then
on the other, to free its meshes or interstices Irora the
cervical mucous membrane, which interlocks, as it
were, with the substance of the sponge. When the
Bponge has been well loosened all round, and is found
to slip down a little, then we should be ready to thrust
the finger up into the cavity of the womb, as we pull
it away. If the finger does not pass at once and easily,
it is better not to use much force, but, as before stated,
E 2

52 UTERINE SURGERY.

to wait for another opportunity. The removal of the
sponge is always followed by more or less flow of red
blood, showing a laceration of tissue. The finger may
pass the os externum with tolerable ease, and still not
be able to pass the os internum, and here it is better
to procrastinate a complete exploration than to use an
undue degree of force. But if the second joint of the
index passes the os externum, the point of the finger
is already in the cavity of the uterus ; and then, while
we press the finger onwards and upwards we should
make a counter-pressure with the right hand just
above the pubes, grasping the fundus of the uterus
through the parietes of the abdomen, and forcing
it down on the end of the left index, as we would
push a thimble down on it. Were it not for this out-
ward counter-pressure, the uterus would necessarily be
pushed upwards before the index, and we should seldom
reach the fundus. There are good reasons for placing
the patient on the side, and using the speculum for
inspecting the sponge before its removal.

1st : It is satisfactory to know that it has remained
precisely where it was placed.

2nd : It is well to see what amoimt of uterine or
vaginal irritation it has produced.

3rd : As the sponge is saturated with a disagreeable
discharge, it is well to clean it and the vagina tho-
roughly before the manipulations necessary for a com-
plete uterine exploration.

All this accomplished, it is a temptation to almost
any one to pull the sponge away while the patient
lies on the side, with everything so nicely pre-
pared for it and seemingly inviting to it. But I must
specially warn the surgeon against this temptation.

SPONGE TENTS. 53

1st : Because if the sponge be removed under these
circumstances, with the vagina widely open, the air
rushes into the cavity of the uterus, and I am sure
that in my early experience I had the misfortime more
than once to see metritis follow this accident. 2nd :
Because the finger cannot be passed far enough into
the uterine cavity for a thorough exploration, imless
the external counter-pressure be made with the other
hand, which is neither easy nor effectual in any other
position than the dorsal.

Having often to recommend the use of sponge tents,
I shall necessarily be compelled to speak frequently of
them in these pages, and I only regret that they are so
disagreeable as remedies. I never use them if I can
possibly avoid it, and I never apply them without
apologising to my patient for the very unpleasant
effects they produce.

He who gives us an efficient, pleasant, and cheap
substitute for sponge tents, will confer a great boon
on Surgery. I know of no competent substitute, or
I would be too willing to adopt it. Having said so
much on this subject, we may now return to " fungoid
granulations," as a source of menorrhagia.

To show not only the diagnostic value, but the won-
derful therapeutic powers of the tent in such conditions,
let me give a case.

Mrs. , of bilious nervous temperament, aged

thirty-five, as a girl had occasional nervous attacks,
and suffered fi*om painfiil menstruation. She was
married at twenty — was sterile — had yellow fever in
1853 — was compelled to leave the South, and go to
New York on account of her health. She had menorr-
hagia from the time of the yellow fever, in 1853, till I

54 UTEBINE SUItGEIty.

saw her, in 1857. She was scarcely ever clear of a.
show for more than a week or ten days out of a month.
It was not excessive on any one day, but its prolonged
continuance had exhausted her strength and worn out
her nervous system. She could not undergo the least
fatigue — would faint easily, even from emotional
causes ; had tinnitus aurium and palpitation ; and
blindness was such a troublesome symptom, that she
consulted an oculist, who told her that the condition
of her eyes was wholly due to the enfeebled state of
her general healtla. She had taken chalybeates,
tonics, ergot, and sea-bathing, without improvement,
and at last I saw her in September, 1857. I did
not dally a moment with such general constitutional
treatment as would be naturally suggested, but at
once attacked the offending organ. The vagina was
excessively tender to the touch from the ostium
vaginEB to the cervix uteri. This was evidently the
result of an ichorous sero-sanguinolent dischai-ge that
was ever present when the hemorrhage, properly
speaking, ceased. The uterus was retroverted — the
posterior wall consequently bypertrophied ; the os was
very small ; the cervix ratlier long and acuminated, —
which anatomical peculiarities explained her symptoms
previously to marriage and her subsequent sterility.
Prom the history of the case, and from the volume
and general condition of the uterus, I expected to find
an intra-uterine polypus. However, the sponge tent
alone would put all speculation at an end. I should
have said that the irritability of the vagina was so
great that I could only use tlie smallest or virgin-sized
specidiim ; and I was obliged to resort to emollient
vaginal injections and to glycerine applications, for a

SPONGE TENTS.

55

few days, to render any spectdum examination at all
bearable. Tliis done, a very small sponge tent, not
more than an inch long, was passed into the cen-ical
canal. It was worn without inconvenience for twenty-
four hours. It was barely large enough to open the
OS uteri from the size of a No. 3 to that of a No. 8
bougie. But this was enough to permit me to look
into the canal, where
I could plainly see
the source of the mis-
chief. Fig. 16 would
represent the general
outline and relative
position of the uterus

before the sponge tent was used ; while fig. 17 would
show a vertical section of the organ after its removal,
when I could easily
seo the vegetations on
the posterior surface
of the cervical canal,
as shown in the dia-
gram. These could
have been scraped

away with Eecamier's curette ; but I was anxious to
open the canal more largely and further up, into the
cavity of tho uterus, with the view of more easily apply-
ing the curette, and with the hope of clearing away
whatever there might be above the portion that was
visible. Accordingly, I introduced a tent two inches
long, and large enough to fill completely the already
partially-dilated cervix. Of course it passed over the
crop of fungoid granulations, pressing them firmly
down into the very siu-face from which they sprang.

56 UTERINE SURGEBY.

I directed this lady to call again next day. Her
residence was not less than five miles distant fi^om
my own.

On the succeeding day, when she was to have come
to me, a furious storm prevented her going out, and,
as she felt no inconvenience, except from the fetor of
the sponge-tent watery discharge, she determined to
remain at home. But on the next day the weather
continued in the same state, it being the time of the
equinox, and I did not see my patient for seventy-
two hom*s affcer the introduction of the tent. I need
not say how anxious I felt, for I greatly feared the
consequences of its prolonged retention. When I
came to examine the vagina, the stench from the
sponge was almost unbearable, and the patient
declared that it had kept her in a state of nausea for
more than twenty-four hours.

Its removal — ^by no means easy — was followed by a
sudden profuse gush of bright red blood. I was so
much alarmed that I did not dare to resort to the
curette lest I might add to the irritation already set up
in the parts. But of this I satisfied myself that there
were no longer any vegetations in the cervix so far as
could be determined by the touch. I did not permit
this lady to return home for three or four days, but
detained her in New York till I was sure that she was
over the dangers, if any, of the prolonged retention
of the tent. No medicine was given, and nothing
more was done, but she was sent home to await the
return of menstruation.

This came in due time, and lasted three days, instead
of seventeen or eighteen as before, being natural in
appearance and quantity. She was thus cured by the

SPONGE TENTS. 57

sponge tent alone in three days, and subsequently
became a mother.

A sponge tent is to us a sort of necessary evil. We
cannot do without it. It is not to be denied that,
while it is powerful to do good, it may also be equally
powerful to do harm. From a very large experience
of sponge tents in uterine disease, I am now firmly
convinced that we ought never to apply them, imder
any circumstances, in the consulting-room.

Whenever they are to be used, the patient should
make up her mind to remain in-doors, if not in her
bed-room, for a week, and this even when used only for
a day. In hospital practice I do not remember a single
mishap from them, simply because the patients did not
go out and expose themselves to the vicissitudes of
the weather. Whereas, after applying them in the
consulting-room, I formerly had several accidents from
them before I could be convinced of their noxious pro-
perties. However, with ordinary care, the tent is as
safe as any remedy capable of doing good. And, since
I have adopted the plan of treating private patients as
I do hospital ones, by keeping them in-doors during
the time of sponge tenting, I have had no cause to
complain of this agent. This course was forced upon
me by more than one such case as the following : —

Mrs. , aged thirty-four, married twelve years,

the mother of three children, the youngest five years
of age, always had rather proftise menstruation, but
since her last labour it became very profiise, lasting
ten or twelve days, and requiring the use of six or
eight napkins a day, and sometimes many more. She
also had leucorrho6a. She was of plethoric habit,
but began at last to feel the effects of the unnatural

68 OTEHINE SUBGERY.

loss of blood. She had been treated locally and
constitutionally without improvement.

The uterus, somewhat auteverted, was mucli larger
than it should have been, and the os and cervix were
granular. I, like the physician who preceded me,
attempted first the cure of this condition. In the
course of three montlis my patient was better of the
leucorrhcea and granular erosion, but the menstrual
flow was as profuse as ever. I then determined to
explore the cavity of the uterus, expecting to find
there a fibroid or polypoid growth, as the body of the
organ was evidently larger than it should be.
Accordingly, a small tent was introduced, and slie was
directed to return the next day. She did so, having
suffered no inconvenience from it. It was removed,
and a longer and larger one introduced, and she
returned home in a stage, a distance of about four
miles. This was in January, and the ground was
deeply covered with snow. She came to see me the
next day, saying that she was chilly the night before.
She was then feverish, seemed to be quite ill, and
complained of pain in the hypogastrium, nausea, &c.
I removed the tent, but made no effort at uterine
exploration. She returned home, had metro-
peritonitis, was dangerously ill for many weeks, and,
fortunately, eventually recovered, but never again to
place herself iinder my care. Now, if I had visited
this lady at her own residence, and applied the same
treatment, I am very sure that slie would not have had
the serious illnesa that was evidently produced by her
exposure in snow storms, two days in succession,
wliile she rode each day, to and fro, a distance of at
least eight miles, besides the exposure of crossing the

I

SPONGE TENTS. 59

ferry to Brooklyn in a boat heated to, perhaps,
80 degrees, while the temperature outside was not
more than 20° F. During this same winter ('58) I had
two or three other cases similarly unfortunate. I then
resolved not to use sponge tents again on riding or
walking patients, and since then I do not remember an
accident from them — and this is saying a great deal in
favour of their innocuousness. However, I use them
now with greater caution — for instance, when I knew
less about them than I do now, I invariably allowed a
tent to remain twenty-four hours ; on its removal a
second was usually introduced to be worn another
twenty-four hours ; sometimes a third was introduced
for another twenty-four hours ; but generally, indeed
almost always, I subjected the uterus to this treatment
for at least forty-eight hours. Whereas now, as I
have abeady described (page 50), the whole process
should not occupy more than from twelve to twenty-
four hours at any one time.

The power of the sponge tent to modify the uterine
surfaces with which it lies in contact is truly
wonderM. It dilates the neck of the womb ; it
softens it by pressure, and by a sort of serous depletion ;
it reduces the size, not only of the neck, but of the
body of a moderately hypertrophied uterus ; it destroys
not only ftmgoid granulations, but even large mucous
polypi ; and in one instance I saw a sponge tent
destroy wholly a fibrous polypus as large as a pigeon's

egg.

This was accidental, but it demonstrated clearly
what the sponge can do by pressure and capillary
drainage.

When introduced into the cervix, the tent soon

60 UTERINE SUEGERY.

absorbs moisture, and dilates. It may produce a
little pain, but it is of no moment, and ceases
ordinarily when the dirty serous or sero-sanguinolent
discharge begins. The meshes of the sponge and the
surface with which they are in contact become inti-
mately incorporated. The sponge forces itself into
the very structure of the cervix, and the mucous
membrane of the cervix shoots out into the interstices
of the sponge, so that it is somewhat difficult to
separate the two if the tent has been worn for any
length of time. On its removal, there is necessarily
a laceration of the tissue incorporated with it. This
lacerated surface generally heals smoothly over in a
few days after, obliterating every trace of the original
indolent fungoid growth that gave rise to the
menorrhagia. Thus, it seems to perform the duties of
M. Recamier's curette in a most efficient manner, but
I do not pretend that it would always supersede it.

The curette is simply the adjuvant of the tent, and
always to be preceded by it. But there are cases
where their relationship is changed, the sponge
becoming the adjuvant of the curette, and this is
when the fungoid granulations are at the fundus uteri.
Then the sponge is to dilate the cervix for the more
easy application of the curette.

In cases of menorrhagia that resisted all other
treatment, Recamier passed his curette into the
uterine cavity, and raked it out as thoroughly as
possible. This was before the days of sponge tents.
But now we first dilate the cervix, pass the finger into
the cavity, ascertain precisely the seat of the fungoid
growth, pass the curette by the side of the finger, and
thus operate more understandingly.

SPONGE TENTS.

61

Fig. 18 represents the curette that I use; the
handle is malleable and may be bent laterally, or
backwards, or forwards, in the
direction of the dotted lines, a, b.
Thus it can be used with equal \
facility on any portion of the uterine \ •
cavity. \

To show the power of the sponge
to destroy mucous polypi, I will
select one, and only one, of many
cases that I might bring forward.

In November, 1862, I was con-
sulted by a lady in Paris, who was
seemingly a perfect specimen of
health, but she was sterile. Meil-
struation had always been rather
profuse, lasting eight or nine days.

The uterus was retroverted, but,
what would seem contradictory, it
was also anteflected. Sufl&ce it for
the present to say, that the cervical
canal was enlarged by a bilateral
incision. The operation was per-
formed in December, 1862, with the
assistance of Sir Joseph OUiffe.

The parts as usual healed before the next men-
struation, which, however, was not much influenced
by the operation, for it went its usual course of eight
or nine days. After it was over I was examining the
condition of the cervical canal, and to my surprise, I
saw the end of a mucous polypus or enlarged nabothian
gland lying high up in the canal, as shown at a, in
fig. 19. I passed a sponge tent on the morning of

Fig. 18.

62

UTEEINE SUEGERY.

January 20tli, along the canal of the cervix, above and!
beyond the seat of the polypus. In the afternoon 1 1
removed the tent and
introduced a longer and
larger one, and allowed
it to remain till the
next raoming. On its
removal there was no
trace of the polypus to
be found. Menstruation
immediately became
Flu. 19. normal, and baa con-

tinued 80 ever since.
This power of the sponge tent to destroy polypoid
growths was accidentally discovered at the Woman's
Hospital in this way. In 1856 a young immarried
woman entered the hospital with a menorrhagia that
bad bled her quite into a dropsical condition. The
flow was almost continuous, but attended with no
great degree of pain ; she was perfectly ansemic from
loss of blood. She had general anasarca, and was of
a waxy hue. I did not suspect the true character of
her disease; and Dr. Emmet and myself agreed to
give her a nutritious diet, with chalybeates ; and so
she went on bleeding for several days longer, and I
then introduced a sponge tent. The uterus did not
seem to the touch to be enlarged, and it was only two
inches and a half to the fundus. The cervix was small,
and the os was correspondingly so. When the tent
was removed there presented one of the most perfect
specimens of fibroid polypi that I ever saw. The
tliagram (fig. 20) shows its attachment and relations.
It had given me much trouble, and was a nice case

(

4

SPONGE TENTS.

63

for operation, which I might ha%'e performed at the
jnoment, but I was anxious to show it to the Con-
Bulting Board of the Woman's Hospital, and conchided
to put off its removal till the next day, which was the
day for the regular meeting of the Board. Accordingly
I introduced a largo sponge tent, expecting to remove
it on the following day,
and complete the opera-
tion in the presence of
the Board. Singularly,
they did not meet, and
the poor patient with the
Bponge tent was complete-
ly forgotten. I expected
Dr. Emmet to remove the
tent, and he thought I had
done it; and the nurse,
who, by the by, never
forgot a patient, supposed
Ve had left it intentionally,
afterwards, the nurse begged to call my attention
to the young woman with the sponge tent, saying she
thought " it must be rotten by this time, as the other
patients in the same ward with her could not stand
the smell of it any longer." My mortification at such
neglect, added to the dread of serious results to the
poor patient, may well be imagined. However, she
nWas soon on the operating table, complaining of
nothing but the intolerable fetor of the sero-
Banguinolent discharge, which had been going on
constantly for a whole week. The sponge and the
tissue of the cervix seemed to bo thoroughly amal-
^mated, and it was necessary to push the point of the

However, about a week

64 UTERINE SUKOEKY.

finger up between the two, and gradually separate
tliem all round before making traction on the sponge
with the forceps. I never performed a more unpleasant
operation than the removal of the sponge ; the stench
was such as to make one of the nurses vomit, and
even Dr. Emmet was obliged to leave the room. "When
the tent was introduced a week before, the tumour
was accurately measured, its volume, density, and
attachment all definitely settled, and easily so. It waa
a dense, firm, fibrous polypus, about the shape of the
diagram on page 63 — a httle larger, and having
attachment to the fiindus as there represented. My
surprise may be imagined when, on introducing my
finger into the cavity of the uterus, after the removal
of the tent, there was not a vestige of the
tumour to be found. The pressure and drainage by
the sponge had eradicated it entirely. The patient
speedily recovered, and was soon restored to a vigorous
state of health. Notwithstanding the happy result of
this accident, and the valuable principle thereby
established, I would not recommend it as a rule of
practice in fibroid polypi. For the danger of metritis
by the prolonged contact of such an irritant, and the
stiU greater danger of pysemia from the disiut^gi-atlon
of tissue would render it too hazardous. However,
the tent may always be tnisted to destroy fungoid
growths and small mucous, or nabotliian polypi, when
they cannot be easily otherwise removed. Dr. Emmet,
surgeon to the Woman's Hospital, whose experience
with the sponge tent is very large, has the greatest
confidence in its safety as well as efficiency. I have
seen him repeat them day after day, and I have often
heard him say that he has succeeded in doing more for

SEA TANGLE TENT.

65

general hypertrophy of the uterus by this means in a
week than could be accomplished by any and all others
in two or three months.

I have said a good deal about the disgusting dis-
charge produced by the sponge tent. While at
Baden-Baden in the summer of 1863, I had occa-
sion to use a tent, and apologized to the lady
for its bad effects. In her case T had been previously
using glycerine dressings to the womb. As the t€nt
showed a little disposition to slip down, I applied
a pledget of cotton, saturated with Price's glycerine,
over the neck of the uterus, simply because it was
convenient to do so. When I went to remove the
sponge in the afternoon, my patient told rac that the
discharge had no bad odour, and, on examination, I
found the pledget of cotton and tent, after removal,
perfectly devoid of any fetor. I have now often used
this as a disinfectant of the sponge, and find it
infallible in its results. The only objection to it is
that it prevents the sponge from expanding to its
fullest extent. I have used tents of the Laminaria
digitata, and think well of them, but they can never
wholly replace tho sponge tent. There is much
trouble in retaining them properly in place. It is
often necessary to prop them up with a tampon, and
even then they sometimes slip out. Besides this,
they require a much longer time to dilate the cervix.
However, they are a valuable addition to our surgical
resources, and for them we are greatly indebted to the
late Dr. Sloan,* of Ayr, Scotland.

Dr. Greenhalgh has improved the Sea Tangle tent

' GlfW'jow MedicalJonr-ial, ()i>t<.l.,T, l>!f.2.

00 r-TKRIXE SUROERY.

very much, and it happened in this way. He had
some trouble in getting a pair of forceps made specially
for their introduction, and the idea occurred to him to
perforate the lower end of the tent for the insertion of
a stylet, which answered a good purpose. But he
soon discovered that the perforated part dilated more
easily and to a greater degree than the rest of it. He
then had the ])erforation made through the whole
length of the tent, when he found that it acted more
rapidly and more efficiently than before. The tents of
commerce up to this time were tied round with a thread
at the lower end to facilitate their removal. This
interfered with the dilatation, by preventing the ex-
pansion of the tubular perforation below. He then
had the thread fastened to one side of the tent as
shown in the diagram (fig. 21). I agree entirely with

Fig. 21.

Dr. Greenhalgh that the tent should not, as a rule,
exceed two inches in length.

Prepared after Dr. Greenhalgh's plan, it is much
softer when removed from the uterus than the sohd
tent, and the perforation is found to be dilated in
proportion to the expansion of the solid part, thus
serving as a drain to facilitate the escape of any
secretions from the cavity of the uterus. Notwith-
standing all this, I regret to say they do not fulfil all
the indications of the sponge tent, and cannot wholly
replace it.

MKNOttRUAaiA — POI.Yl'US. 67

O*' MENuERHAdu FkOM PoLYPfs. — Haviug spoken
of menorrbiigia as a sequence of granular erosion, of
cervical engorgement, and of fungoid granulation b, we
now come to consider it as a concomitant of polypus.
Accoucbeurs and pathologists have desciibed polypi
as soft, hard, miicoua, glandular, cellular, cystic,
fibrinous, fibro-cellular, fibro-cystic, and fibrous.
These several divisions are anatomically and patho-
logically correct; but, as I am taking only a surgical
view of the subject, I prefer to classify them
topogi'a])hically, that is, not according to their own
structural elements, but simply aceonliug to their
point of origin, which, by the bye, in the simplest
method of arrangement. Thus, I would say that
uterine polypi are naturally divided into three
classes : —

1st. Those growing from or about the os tincse.
2nd. Those growing in the canal of the cervix.
3rd. Those growing in the cavity of tlie uterus.

The first may be fibro-cellular or mucous.

The second are almost always mucous.

The tliird are almost always fibrous.

I propose to give clinical illustrations of these sub-
divisions.

In the first class they may be large or small. If of
the fibro-celhilar variety, they may attain an enormous
size. I have seen them almost as large as the foetal
head at t«rm. If of the mucous variety, they seldom
grow larger than an English walnut, and are usually
somewhat flattened by pressure between the cervix and
the opposite wall of the vagina. To the sight these
seem to be only a congeries of fibro-cellular tissue and

68 UTEEINK SUIiGEIEV.

blood- vessels. Polypi growing from the 03 tinc» are
generally attached to one lip of it. I am not able to
say upon which one they are most frequently found.
They often prevent conception, but not always, for
our medical literature contains numerous examples of
labour complicated with, or obstructed by, very largo
polypi, which could hardly have grown during the
period of gestation.

Their removal is easy enough. They may be cut
off with scissors, or removed by the (?craseur. I
know that fatal hemorrhage has followed the use of
scissors, but it was before the discovery of the styptic
properties of the perchloride of iron by Pravaz. This
was, indeed, a boon to surgery, and Deleau* ha8
rendered a great service in vulgarizing its use.

But, unfortunately, it is a remedy of uncertain
properties. It often contains free acid, and then it
irritates the mucous surface of the vagina. So un-
certain is this preparation in New York, that the
profession there have almost entirely abandoned its
use, substituting for it the solution of the persulphate
of iron (as made by Dr. Squibb, of New York), which
seems to be quite as efficient, and is not so hable to
the same objections. In Paris I could not get the
persulphate of iron, and I was obliged to return to the
use of the perchloride as a styptic. Mx-. Swann,
chemist, Eue Castiglione, procured for me specimens
of the perchloride which purported to be neutral, but
they produced very deleterious effects on the vaginal

• " Traits Pratiqua sur lea Apijlications du Perclilorui'e ite Fur en
Mcdecine." Par M. T. Deleau, Ducteiir en M&lecine, Sec. Paiis :
Adrian Delnhayo, 18(il>.

MENOKRHAGIA — TOLYTUS.

69

epithelium, and at last he got some of Deleau's, and its
effects were aa desired, viz., styptic and unirritating.

We win suppose
a polypus growing
from the postei'ior
lip of the OS tincai,
with a pedicle half
an inch, more or
less, in diameter,
(fig. 22). If it is
to be removed by
scissors, first pre-
pare the styptic by
mixing one part of
' the solution of the
perchloride of iron
with three or four
J.,,. .^., of distilled water ;

then saturate pled-
gets of lint in it, or, what 13 better, take some fine
cotton wool, wet it thoroughly in plain water, squeeze
all the water out, and then wet it in the mixture, and
squeeze it nearly dry.

When all is ready, place the patient in the semi-prone
position, apply the speculum, lay hold of the tumour
with forceps, or a vulsellum, draw it gently forwards,
and cut it off at one stroke with suitable scissors.
Sponge the cut surface a moment, and quickly apply
the lint or cotton previously prepared, and press it
firmly in place with a sponge probang (fig. 23). The
firm pressure of one or two sponge probangs on the
styptic lint or cotton almost instantly checks the
bleeding. Wait a little to be sure of this, and then

70 TTERINE SUIUJERY.

put a tampon of dry cotton over all, merely to secure
the dressing proper in mhi. The patient is put to
bed, the recumbent position is enjoined for a
day or two, and the bladder may or may not
be emptied by the catheter.

On the next day the diy cotton is to be
removed, taking care not to disturb the iron
dressing in contact with the cut siirface.
This adheres closely to it, and is not, as
a general rule, to be removed till it is
loosened and thrown off by the suppurating
process, which takes two, three, or even four
days.

But, when the dry cotton is removed on
the day after the operation, its place is to be
suppHed by a bit of cotton saturated with
Price's glycerine, which is to be renewed
daily till the cut surface be healed. For this
purpose take some fine cotton, as much as
can be easily held in the hollow of the
hand, immerse it in tepid water, and squeeze
it gently under the water till it becomes
perfectly wet ; then press all the water out of it,
and saturate it with Price's glycerine. To do this,
lay the moistened cotton in the palm of the left
hand, spread it out circularly for an inch and a
half in diameter, more or less as may be needed,
scooping it out in the centre — then drop half a
teaspoonful of glycerine on it thus held, and rub it
into the cotton with the point of the finger, then
pour on a little more glycerine, and rub it in,
and so continue till the cotton becomes saturated.
When finished, the cotton should feel soft and pulpy,

Fio. 23.

ME.VOItRHAClA

71

should be about an inch and a half in diameter, and
about half an inch thick.

This dressing is an expensive one, for it will hold
from two to four drachma of glycerine ; but I do not
think there is any substitute for it, and its effects are
such that I consider it cheap in the end.

This glycerolo cotton is thus applied daily till the
first dressing is removed, and then it may be con-
tinued for a few days longer, till the whole surface be
healed.

Glycerine is now fixed in professional estimation as
a most valuable addendum to the domain of surgery ;
and to the philosophic and practical mind of
Demarquay* are we indebted for a complete treatise
on the subject, setting foi'th its properties and
quahties. Its use in uterine surgery occurred to me
some seven or eight years ago, in this way : — To a
case of granular engorgement I wished to apply some
caustic or other ; but, whatever it was, I could not
at once find it. Being very much hurried, I looked
around for some substitute. And it oceun-ed to me to
apply a bit of cotton wet with glyceiine, merely to
protect the os iiteri from contact with the opposite
surface of the vagina, which was also quite granular.
I fully intended to use the caustic on the next day.
But, when my patient returned, she saluted me with,
" Well ! doctor, what effect did you intend the treat-
ment of yesterday to produce ? " Seeing that there
was evidently something out of the way, I was quite
at a loss for a satisfactory reply; and she continued,
"You ought to have told me all about it, for, when I

P«r M. DewiiiriiiiHy. Pnr

72 DTERIN"E SCBGERT.

got home, my linen was so wet that I had to change
it, and the water streamed from me all night in such &
way that I have had to wear napkins to protect my-
self." This was all news to me, and, on examination,
I found the pledget of cotton still wet, lying just as it
was placed on the cei-vix uteri, which, together with
the vagina, had a clean, healthy, and greatly improved
appearance, compared with what it had the day before.
I apphed another similar dressing, to see if it would
produce the same effect. It did, and these dressings
were repeated till the case was entirely cured : since
which time I have used glycerine in this way in all my
surgical operations on the neck of the womb, and in
other cases of organic lesion.

The effect of glycerine thus used is very remarkable.
It has great affinity for water. A bit of cotton
saturated with glycerine, and exposed to the air, will
retain moisture for weeks. When applied to the neck
of the womb as above directed, it seems to set up a
capillary drainage by osmosis, producing a copious
watery discharge, depleting the tissues with which it
lies in contact, and giving them a dry, clean, and
healthy appearance. When such a dressing is applied
to a pyogenic surface on the cervix uteri for twelve
hours or moi'e, aud then removed, the cut or sore will
be as clear of pus as if it were just washed and wiped
dry.

Much has been written on the diagnosis of polypous
tumours. I do not intend to open the subject here,
but I would only say that the Gordian knot is easily
cut, if my method of exploration be adopted; for,
with the patient on the side (or knees, if necessary),
with my speculum everything is brought so plainly

MENORIilUGIA — POLYPDS.

73

into view that there is no possibility of making a
mistake.

Dr. Graily Hewitt and Dr. Greenbalgh have related
cases where physicians were in doubt, and bad even
mistaken a common polypus for carcinoma. I have
seen several cases of mucous polypi slightly protruding
from the cervix that had been treated for granular
erosion by repeated applications of nitrate of silver ;
and a few years ago I saw a woman, forty-eight
years of age, greatly reduced by prolonged haemor-
rhages, who presented almost exactly the cachectic
physiognomy of carcinoma. She had none of the
lancinating pains of cancer, but when the finger was
passed into the vagina, it found a knobby liard growth
occupying the place of the
cervix, and the os could
not be felt.

Wlien the ordinary
speculum was used, this
growth filled up its area,
and all was in doubt. But,
by the use of my speculum,
which left the whole vagina
freely open to inspection,
we found a polypus of
mushroom shape fitting
almost like a cap over the
cervix uteri (fig. 24). The
pedicle was short., and the
tumour fitted so well the
projecting portion of the
is, that it was scarcely movable. The removal of
ihe tumour witli scissors exhibited an os tineas per-

74

UTKRiNE SURGERY.

^

fectly free from all appearance of malignant disease.
A not unfreqiient form of
pol^-pus ia represented by
. 25, This was removed
from a lady who supposed it
was the womb coming out,
because it protruded from
the mouth of the vagina.
When I told her it was a fibro-cellular polypus, she
was greatly alarmed, because she had
lost one of her servants by an opera-
tion of some sort for polypus.

All classifications are more or h
arbitrary. This poh-pus might by
some be classed in my second sub-
division ; but as it grew distinctly from
the edge of the os tinc«, although
some of its fibres took root in the
cervical mucous membrane, I have
put it in the first class.

We often find small polypi in the
canal of the cervix. They vary from
the size of a grain of wheat to that
of a small bean, and are called nabo-
thian polypi. (See fig. 19, page 62.)

They may be very effectually de-
stroyed by the mechanical pressure of
a sponge tent worn for twenty-four
hours, or they may be pulled off by
forceps, or cut off with scissors; I
prefer the latter. We often fail in the
extraction of small mucous or cystic polypi for the
want of a suitable instrument.

)ra- ^^H

bv I

MFNOKTinAfJIA POLYPUS.

75

Dr. McClintock uses a fenestrated forceps for tbese,

ffhich answers admirably. Avulaellum is not suitable

lere, because their tissue is so delicate that it is apt to

p out. Fig. 26 represents Dr. McClintock's polypus

forceps. They compress the pedicle, while the littlo

* polypus lies unhurt in the fenestral opening. But

for larger ones, such as fig. 25, p. 74, Charriere has

made for me forceps of this

Lsort (fig. 27), with which

we seize the pedicle of the

lolyp, when we wish either

I tear it away or cut it off

rith scissors.

But suppose, for some

we wish to remove

polypus by torsion. To

•ender this proces.s perfectly

Vsafc, it is necessary that the

'pedicle be long and slender,

and that the tumour be easily

rotated. This process has

Lbeen applied to the small

Hnabothian polypi and also to

ntra-utennc fibrous polypi

rith slight attachments. Laying hold of the polypus

rith a fenestrated forceps, if of the first variety ; with

.a vulsellum, if of the second, we rotate gently from

left to right, and so continue till all resistance ceases,

when we remove the severed gi'owtli. I am no

Lftdvocate for this plan, unless under very exceptional

Pisirciuustances .

There are but few polypi that cannot be safely
Ircniovetl witli scissors, yt't we luay have reasons fnv

76

UTERINE SUKGERY.

I
I
I

I

not wishing to resort to tbem. The patient may be
so exhausted by repeated and prolonged hfemorrhages,
that we cannot afford to risk the sudden loss of an
additional small quantity of blood ; or from some
theoretical grounds we may prefer not to cut. For
instance, in Paris, surgeons often refuse to perform
the simplest cntting operation wlien there is much
erysipelas about, asserting that a clean cut is more
apt to produce erysipelas, and even pyjemia, than the
lacerated wound of the ^craseur. Be this as it may,
let us suppose that we have to deal with a polypus too
formidable for scissors or for torsion. Our only
resource then is the ccraseur, — and a very sure and
safe one is it : sure in its action and safe in its
consequences. Formerly a ligature was passed round
the pedicle of such tumours, and tightened from time
to time till the mass sloughed away ; but that day has
gone by, never to return.

The removal of a polypus by ligation is really a
dangerous operation, resulting not unfreijuently in
pyemia and death, which seldom indeed happens
when the ecraseur is used.

This admirable instrument has been much abused
by the profession ever since it was first introduced by
its able inventor, Cbassaignac.

It has been used in almost every imaginable way,
and often most inappropriately; for instance, for
fistula in ano, for the removal of simple steatomatous
tumours, for excision of the mamma, for lithotomy,
and even for amputation of the thigh. But the time
is coming, indeed is even here, when the true sui'gcon
will raise it to the dignified position that it merits, by
confining it to such operations as are peculiarly its

MESOBItHAGlA — i'OLYfUS.

own. For tlie ablation of diseased structure in

erectile tissue it cannot be over-estimated. In

Cbassaigiiac's wards in the Larriboisiere Hospital I

I have seen cases wbere maHgnant disease of the tongue

I called for the removal of that organ, which was done

safely by this admirable instrument, and the patients

remained well for a long time afterwards. In the

same wards I have seen more than one ease in which

M. Chassaignac had removed the anus, and a large

portion of the rectum, for cancerous disease, an

- operation that woidd have been utterly impossible by

I any other means, and one of these patients had been

well for more than a year.

These are, fortunately, rare cases, but they prove

the value, efficiency, and safety, of the ^craseur

! under the worst possible conditions. But it is for the

I removal of hemorrhoids and uterine polypi that this

I instrument is to find its most common and appropriate

field of usefulness.

Many modifications have been made of Chassaignac's

I chain ^craseur. M. Maisonneuve uses a stiff but

malleable iron wire, to be pulled through the tissue.

I Dr. Braxton Hicks makes a cord of several fine

threads of wire ; while others fi.x one end of the chain

(Chari'iere and Tieman). I have tried all these, and

' have no hesitation in saying that none of thera are in

practice equal to Chassaignac's original instrument.

It generally cuts through neatly, without drawing out

long shreds of tissue, leaving us uncertain when the

tumour is entii-ely severed, if it be hidden from view,

[ as it must be sometimes. Every little chck of

I Chassaignac's instrument measures for us most

[■ accurately the distance over which the chain passes,

I

I

78 UTKUIiVE SUItOERY.

warning us to rest. Tlie resiatance we eneounier i
tightening it shows us the density of tissue, and i»
the index to move slower or faster. Whereas, every 1
turn of a screw, whether a quarter, half, or whole
revolution, leaves us in doubt whether it is too much
or too little — while it is a power unmeasured and
unappreciated by the sense of feeling. This is
strongly proven by the fact that I have never broken
one of Chassaignac's instruments, while 1 have broken J
two worked by a screw. The same thing has occuiTeAj
in the dextei'ous hands of Dr. Graily Hewitt and of"
Dr. McCUntock.

McClintock, in speaking of the 63raseur for uteiine
polypi, says, " I have generally felt it necessary to
bring the bulk of the tumour beyond the external
genital orifice; and this necessity it is that limits its
range of applicability."* The difficulty of placing the
chain around the pedicle of the tumour while in the
vagina, and the still greater one of applying it within
the uterus, has been heretofore the great barrier to its
universal adoption. But I hope this difficulty is now
overcome. 1 do not think the polypus should ever be
drawn outside for (!crasement, or that there should
be any undue traction made on the uterus while the
^craseur is being worked. My plan is this. The
patient in proper position, the speculum (fig. .5) is
introduced, and we have a complete view of every-
thing in the vagina. If the tumour is in the vagina,
there will not be the least cUfficulty in applying the
chain of the ^craaeur ; but, to do this with facihty, it
is necessaiy to prevent the chain fi'om folding on itself.

■■ Clinik;ai Memoi:

^^^^^V MENOUIIHAGIA — rOLYFUS.

^H

^^re attempt to "carry its loop over and beyond

the ^H

tumour. This was to me a source

A

^^H

of annoyance for a long time, but

1

^^^

at last I liave succeeded in giving

^^^M

the cliain a rigid fixity that makes

h

^^M

it very easy to do this.

^^M

Where the polypus has descended

^^^M

into the vagina, Maisonneuve's wire,

^^H

or Dr. Braxton Hicks's cord of wire,

^^1

answers very well ; but where it

^^H

is intra-uterine, with a contracted

^^M

cervix, we ordinarily fail in their

>,

^^H

application, just as we do with the

^^H

chain of Chassaignac.

^^1

I have added to Cbassaignac's

^^H

instrument a porte-chaine, which

^^H

may be described as a pair of dilating

^^P

forceps with spring blades, which

,

^^H

render the chain stiff, so that it may

\

^^H

be passed straight into the vagina, .

\\

^^1

or into the cavity of the uterus, as

Ljl .

^^^1

easily as we would a sound or a

ir^^

^^H

Bponge probang. After which the

1

^^M

chain is expanded by the blades of j

A

^^^^^M

this porte-chaine. "^B

^^^^^^

Fig. 28 represents the ^craseur ^|

^^^^^^1

with the porte-chaine ready for use. -^^h

^^^^^H

It is carried into the vagina or into ^M

^^^^^H

the cavity of the womb thus HV

^^^^H

arranged; the thumb-piece, l>, ^g^^^i^^

^ ^H

is then pushed forward and •^'

^^H

fastened at tlie desii-ed point

^^1

Iby tho notched rack, which is seen piissiug through ^^H

80

UTERINE SURGERY.

the shaft of the instrument; this movement dilated
the spring blades of the porte-chaine, and expands
the chain to the required extent.
When the chain is made to encircle
the pedicle of the tumour, the
porte-chaine is drawn up into the
shaft of the instrument simply by
elevating the thumb-piece, h, and
pulling it back in a straight line
for three or four inches, while the
instrument is pushed forward along
the chain just as if there had been
no porte - chains present. The
porte-chaine is not wholly removed
from the i5craseur ; it Ues in its
place in the shaft while the opera-
tion is being finished.*

Fig. 29 represents the porte-
chaine detached from the dcraseur,
for the purpose of showing its
mechanism. When the thumb-
piece h is pushed forward, e being
a fixed point as shown in figs.
28 and 30, the joints il d must fiq.29.

of necessity be forced apart, and
this it is that dilates the blades *; c, which, hold-
ing the chain securely in its grooves //, <j ij, carries

* The mecbttnUm of this inatniment has been greatly simplified
aince I pi-esentetl it to the Obstetrical Society in December, 1864,
and published an account of it in the Laiicet, For this improvement
I am indebted to Mr. J. Mnycr, iiiitriimeiit-iQiiker, 51, Gi'Oat
Portland Sti^et

MENORRHAGIA — rOLYPUS.

81

out to the required degree, as represented in
fig. 30.

Fig. 30 shows the angles or joints, dd, projecting
through slots in the sides of the
shaft. The only thing necessary
to insure the perfect working of
the apparatus is to see that the
pivot, p, as sho'iv'n in all three of
the cuts, is quito at the extreme
end of the groove, at the top of
the instrument. If by chance it
should not be, then the joints,
d d, will not have room to expand
and project out of the sides of
the instrument through the slots
made for this purpose.

The chain is worked by a
hidden rack in the handle, tj
(fig. 28). When the button, a,
is pushed towards d, the teeth
of the rack are caught by the
notches in the sides of the two
long shafts that run from /
through the whole length of the
instrument; when it is moved
towards d, then its teeth are
elevated out of these notches,
and the chain and porte-chaine p^^ „

can bo freely pushed up and

down the shaft like the piston-rod of a syringe. Its
machinery is exactly the same as that of Chaasaignac's
inBtnunent, except that it is simplified, hidden from
view, and not in the way of the operator.

82 UTEEINB 8UBGEBY.

Let me illustrate the principle of its applicatiou
by a clinical observation. In February, 18G3,
Dr. Morpain, of Paris, invited me to operate on a
patient of his, who had a polypus as large as a goose's
egg projecting partly from the cavity of the uterua.

Fig. 31 repre-
sents its position,
relations, and
attachment. A
] moment's glance
shows the diffi-
culty of passing
a chain around
the pedicle of

r"..oi. •

a tumour thus
situated. The patient, on a table, was placed in the left
lateral somi-prone position, and, when the speculum was
introduced, it elevated the perineum and posterior wall
of the vagina, and brought completely into view the
tumour, as represented in the engraving.

There is great temptation under such circumstances
to seize the projecting portion of the polypus with a
strong vulsellum or tenaculum, and pull it towards the
OS externum. But this is not the best thing to do,
because it will close up the mouth of the vagina, and
obstruct both sight and manipulation ; for the mouth
of the vagina, oven in favourable cases, would hardly
be forced open more than an inch and a half from the
urethra back to the perineum, and we need all this
space for operating.

Here a small tenaculum was hooked into the tumour
at a, and by it the polypus was pushed gently down-

1

MKNORItHAGlA i'OLYl'US.

83

I

wards and forwards against the anterior wall of
the vagina. It was lield finnly, while the stiffened
chain of the dcraseur was passed along the upper
or posterior surface of the tumour from a up to
the fundus uteri at c This done, the tenaculum
was removed, and the chain ofthe (icraseur opened
out in the cavity of the utems to a sufficient extent
to allow the tumour to pass through it. This was
effected by hooking the tenaculum at b, and raising
the end of the tumour up towards the posterior wall of
the vagina, at the same time that the ^craseur was
pressed in the opposite direction. This movement
placed the middle portion of the chain parallel with
the anterior face of the tumour, while its loop, or
distal portion, still remained stationary at c. It was
thus made to embrace the pedicle, and it only remained
to pull the portc-chaine back at the same moment that
the shaft of the instrument was pushed down on the
chain, which was tightened closely around the pedicle.
The operation was then finished as easily as if the
tumour had been wholly outside the body, and that,
too, without the least strain or traction on the uterus
or surrounding organs.

This operation was done with the assistance of
Dr. Morpain, Sir Joseph Oliffe, and Dr. W". E.
Johnston. Since then (February, 1863) I have had
every reason to feel satisfied with the porte-chaine,
whether tlio polypus was in the uterus or simply in
the vagina.

When I was in Dublin, in August, 18G1,
Dr. M'Ciintock asked me to see a young woman
in the Rotunda Hospital who had an intra-uterine

84

UTERINE SDltGERY.

polypus. It was about the size of a pullet's egg, and
entirely within the cavity of the uterus (fig. 32)J
She was a virgins
the vagina was •
course small, ai
the mouth of
' quite contracted :.l
thus any manipuU^ I
tion was difficult.
We succeeded, how-
ever, in getting a rope of wire on the tumour two
or three times, and succeeded as often in breaking
it ; and thus, for the want of proper machinery, we
were compelled to let the case alone for the time
being. If wo had then had the Cbassaignac instru-
ment with the porte-chaine, there would have been
comparatively Uttle difficulty in removing the tumour
at once.

Intra-uterine polypi grow from the fundus, or from
the anterior or posterior walls of the uterus, but more
frequently from the anterior. I do not remember to
have removed any with simply a lateral attachment.
It has so happened that I have seen more polypi
attached to the anterior than to the posterior face of
the uterine cavity. If observation should establish
this as the rule, it will be very fortunate in a surgical
point of view ; for it is much easier to pass the chain
of the iScraseur around the pedicle of a polypus
attached anteriorly than posteriorly, if it be entirely
intra-uterine. An example of each variety may serve
for clinical illustration. Dr. Morpain'a case already
related is a fair specimen of one variety ; but, as
showing the improved methods of modern surgery, I

MENORRHAGIA — POLYPUa.

85

may be permitted to allude briefly to another similar

In February, 1860, a lady from one of the eastern
States consulted me on account of her sterility. She
was thirty-two years old ; had been married ten
years ; enjoyed very good general health ; had leu-
corrhoea and some pain with menstruation, which
was not profuse. The uterus was in proper position,
but felt larger than natural. I introduced a sponge
tent to ascertain the cause of this hypertrophic
state. On its removal, the finger passed into the
cavity of the uterus detected
a fibrous polypus of the size
of a partridge's egg, attached
anterioriy, as represented in
fig. 33. Another sponge tent
of larger size was introduced,
and, on its removal six or eight
hours afterwards, I succeeded
in passing the chain of the
fcraseur around the pedicle,
when it was easily and quickly
severed. This case strongly
illustrates the present improved methods of explora-
tion ; for here wc could not have determined the
cause of the uterine enlargement but by passing the
finger into the cavity of the organ after dilatation
of the cervix. Indeed, before the use of sponge
tents we could not by any possibility have diagnosed
Buch a case as this. But now we determine with the
minutest accuracy, not only the presence, but the
Bize, position, relations, and attachment of all such
tumours. Before the use of sponge tents, if we

86 ITERINE SUROERY.

8uspect<Hl from rational symptoms an intra-uterine
polypus, we could only wait from month to month —
sometimes from year to year — for it to grow and to
force its way into the vagina, before we could interfere
surgically for its removal. But now we no longer
doubt and procrastinate ; we no longer let our patients
bleed till they become bloodless and dropsical ; but we
ferret out at once the source of mischief, and remove
it from its once secure hiding-place. This is a great
advance in surgery ; and no man of twenty or thirty
years' experience can look back on the days of ergot
and Gooch's canula, and contrast them with the
present time of sponge tents and the ^craseur, without
a thrill of delight at the progress of our noble calling.
Having now given chnical illustrations of polypi
growing from the os, in the canal of the cervix, and in
the cavity of the uterus attached to the anterior wall,
I will continue the series by examples of polypi grow-
ing from the fundus and the posterior wall. As said
before, I do not remember any with a simple lateral
Jittachmcnt.

A. II., aged twenty-six, gave birth to her only child
when she was but fourteen. Had two or tliree mis-
carriages since, at about the third month. Had
menorrhagia for many years, very profuse, painful, and
coagulated, lasting usually ten or twelve days. Had
forcing pains during the whole time of the flow, and,
singularly enough, they were always worse in the
forenoon. This patient was sent to the Woman's
lIos])ital by Professor J. C. Nott, of Mobile. The
womb was in its normal position, and evidently en-
larged. The OS admitted the end of the index finger
to the depth of the nail. She had just menstruated,

MENOKRHAGIA — POLYPUS.

and there was a very profiiae miico-piimlent dischai^e
from the cavity of the uterus. For years her suffer-
ings had been a mystery. A sponge tent unravelled
it in a few hours. She had a fibroid polypus attached
to the fundus by a short, thick
pedicle (fig. 34). It was impos-
sible to place the chain of the
^crasenr around it, through a
comparatively contracted cervical
canal. This was before we had
learned the use of wire as a
substitute for the chain. With a
Gooch's canula I put a strong
fishing-line around the pedicle,
and severed it with the screw
^craseur. It was difficult to get
a cord strong enough to cut
through its fibrous tissue. It snapped a large catgut
guitar-string, and then a silk cord. With Chassaignac'a
^craseur, armed with the porte-chaiue, there would
have been no trouble.

So far I have sjioken only of successful operations ;
but there is such a thing as failure, and oven death,
in consequence. Foi-tunately, these are rare. I have
removed a great many intra-uterine polypi, and all
without accident, except in two instances, which were
followed by pya3raia. One of these recovered, the
other died. This latter was an example of polypus
with attachment to the posterior wall by a thick,
short pedicle. It was the case of a lady about sixty
years old. I was invited to see her by Professor
Metcalfe, of New York. She was the mother of a
large family of grown-up children ; had ceased to

88 ITTERINE SITRfiEBY.

menstruate some ten or twelve years before, but for tbe J
last three or four years had suffered alarming hffiraoiv 1
rhages, which greatly prostrated her. The uterus was ■
felt to be enlarged, but the os was not larger than the
point of a coramon probe. A small sponge tent was
introduced, and on the next day a larger one. This
dilated the canal of the cervix sufficiently, but the oa ]
barely admitted the end of the finger, and felt as I
inelastic as if bound by a wire. Of course, no further
effort could then be made. Eight or ten days after
this we succeeded in dilating the cervix, so as to
explore moat satisfactorily the cavity of the uterus,
when we found a hard fi-
brous polypus, with a broad»
thick pedicle, attached to I
the posterior wall, close to
the fundus (fig. 35). This
was in May, 1862. I failed
to put the chain around the
pedicle. Two weeks after-
wards another series of
sponge tents was followed
by another failure. The
tumour was imfortuuately
lacerated a good deal by the
i'"i,i. 33. vulsellum, which was used

to draw it downwards and
to fix it while efforts were made to pass the chain
around it. Two or three days after this a chill
ushered in an iiTitative fever, which imhappily termi-
nated fiitally. Here a valuable life was lost because
our art did not furnish the proper sui'gical appliances
for relief. With the ^craseur, as now supplied with

I

^

MENOREHAGIA — POLYPUS.

89

I
I

I

the porte-chaine, there is every reason to believe that
we would have succeeded in our first efforts.

In cases like this, occurring in advanced hfe, we
often find it difficult to dilate the 03 externum. The
tent may expand the canal of the cervix to the size of
the finger, while the 03 tineas may not become larger
than a No. 10 bougie. Under these circumstances, if
we attempt to force the finger into the cervix, the
contracted os feels rigid and resisting as if bound
round by a fine wire. And here, instead of repeating
the tents, it is safer and better to divide with the knife
the sharp, well-defined edges of the con-
tracted OS, which will permit the finger to /' '-
pass at once to the cavity of the womb. / y
This diagram (fig. 36) represents the rela- / \

tive expansion of a tent worn for six or /
eight hours, where the canal of the cervix j
was dilated, while the 03 tineas remained \
comparatively contracted : — a, the cervical
portion ; h, the part constricted by the os ;
c, the vaginal portion. "

I have now completed the series that I F'"- 3"-
proposed to give as types of this disease.

Time was when women died of polypi without any
effort being made for their relief. This is not so now.
No delicate operation is easier; none more successful.
Life is sometimes lost because we think the patient so
near death that any interference woidd only accelerate
the fatal issue. Tliis is a great mistake. To save life
where death is imminent, wo are justified in assuming
great responsibilities and even of taking great risks.
I fear that we sometimes hesitate to do our duty by
asking ourselves the question, " How will it affect me

90 UTERINK 8URGBBI.

if I fail?" It has been said of a great Ameiican
iitliotomist that he often refused his skill to bad caaea
because they might spoil the statistics of his un-
paralleled success. J
In December, 1861, Mr. Preterre, an eminenfel
American dentist in Paris, asked me to see Madame
R., in consultation with her physician. She had
menorrhagia for many years, and was extremely
prostrated by it, and by a profuse muco-purulent
vaginal diaeharge, which had been present for six or
eight months whenever the haemorrhage ceased. She
had been seen by many of the most eminent surgeons
in Paris, but no one suggested anything for her relief.
I found the uterus retroverted and greatly enlarged,
the fundus extenfling quite to the hollow of the sacrum,
and seemingly filling up the wliole of tliis region. A I
glance showed at once that it could be but one of twa J
things — a polypus or a fibroid tumour. The oa tincsB i
admitted the end of the index finger. I was anxious J
to determine the natiu-e of the case, and made gentle J
but persistent pressure for some minutes through the J
cei-vix. It gradually yielded to the force, and the 1
finger, gliding into the cavity of the uterus, detected ]
an enormous fibrous polypus, which could not ]
outwards because of the retroflexion. I was obliged 1
to be in London the next morning, but I promised to
return to Paris in a week, for no other purpose than
to apply a sponge tent and remove the polypus for
Madame R. Five or six days after my departure they
telegraphed to me that .she was much worse ; that a
consultation of physicians had decided that it was
now too late to attempt any operation, and therefore
that it was unnecessary for me to return to Paris.

MENOKEHAOIA — POLYPUS.

91

Fortunately, tho telegram was not received, and I

returned to Pans to find my patient in a state of

complete exhaustion. She had a profiise, dirty, offen-

aero-sanguinolent discharge from the vagina,

■vhich poisoned the atmosphere of her apartment.

IHer pulse was small and rapid ; she was quite angemic,

■jUid presented all tho appearances of blood-poisoning.

■ On passing my finger into the vagina, I found it
I entirely filled by an immense fibroid polypus in a state
I of decomposition. She was evidently dying from the

absorption of the detritus of this fetid mass. At my

■visit, a week before, this tumour was wholly

pintra-uterine, but now it filled tho vagina. I infer

that its escape from the cavity of the uterus was due

to powerfid contractions provoked by the forcible

introduction of the finger for exploration, for she

grew worse from the moment of my visit. She

had forcing pains, as of labour, for a while, and

afterwards passed into the low condition in which I

found her. Its pedicle (as is most usual) grow from

the anterior wall. What was to be done ? There was

. assuredly but one course to pursue. If we allowed

I this great mass to remain there and slough away,

Ideath was absolutely certain. Its speedy removal

I gave the only hope of rescue. Her physicians con-

r^cnted to its ^crasement, which occupied ten or twelve

1 minutes. Vaginal washes, wine, and a generous diet

I Boon completed the cure. If I had received the

I telegram, she would certainly have died, and I should

lliave been censured by her friends for hastening the

V&tal issue, injismuch as my previous visit was the

I inauguration of a new phase of her sufferings. If I

■ had been afraid to operate because she was almost in

92 CTEKINE SURGERY. ^^^H

a moribund state, she would unquestionably have been

lost,

I have related this case perhaps too minutely, but
it is to encourage the young man never to falter in the
clear path of duty to his patient, and to show that
extreme exhaustion is no barrier to the mere
operation ; for, when effected by the ^craseur, there
is no danger of haemorrhage, and very little of any
other character.

I have no idea how many polypi Dr. Emmet and
myself have removed at the Woman's Hospital and in
private practice, and the case of Professor Metcalfe
above related is the only fatal one. This great succesa
is certainly due to the fact that we always used the
^craseur or scissors. It would seem that by these the
operation is almost always safe, while by deligation it
is fraught with great danger.

Dr. GraUy Hewitt is wholly opposed to deligation ;
so are many other recent writers. Dr. M'CIintock
has written most clearly and ably on this question.*
He reports ten operations by ligature, of which three
were i'atal, and twenty-four by knife, scissors, or
(Scraseur, without a single death. He says, more-
over (p. 183), that "a very high rate of mortality
followed the use of the hgature in the cases reported
by Dr. R. Lee ; for, of fifty-nine instances where the
ligature was applied, nine of the women died, and two
of these deaths occurred before the removal of the
tumour was effected. . . . Dr. Lee gives thirty-five
other cases where polypi were removed by torsion or
e.Kci6ion, and amongst these there Is no death."

it:," pp. 183—186.

UEKOEEUAOU—

93

I

tr this, it seems to me tliat it would not be only
hazardous, but absolutely culpable in ua ever to resort
to deligation when there is any chance of immediate
ablation either by excision or ^crasement.

Before closing this subject, I may mention that
Dr. J. H, Aveling, of Sheffield, has added
a valuable instrument to our surgical
resources for the removal of polypi on the
principle of ^crasement. It is represented
in fig. 37. The thumb- piece a, is con-
nected with the projection ?* by a rod,
which slides along a groove in the shaft,
which is driven by means of the screw at
the handle of the instrument. When the
extremity c is placed around the pedicle,
the part h is made to sever it by being
forced through till it is entirely lost in the
fenestra! opening in the curved extremity.
Dr. Aveling calls this instrument the
Polyptrite. It is described in the Obstetric
Transactions, vol. 4.

Op Menoehhagia from Pibhods Tcmouks.

■The uterus is particularly prone to the
development of fibroid tumours. They
occur at all ages after puberty. They are
seen in young girls under twenty, and in (.,„ 37
the octogenarian, and may vary from the
size of a pea to tliat of the gravid uterus at full term.
They are in themselves innocuous, except mechanically,
■-9E> when they exert an undue pressure upon the bladder,
Tectum, or pelvic nerves and veins, or when they

■oduce haemorrhages. They frequeutly prevent con-

94

UTERINE SUEOERY.

ception, but not necessarily and invariably so. Theg
are classetl according to the manner of their attachmen^l
to the walls of the uterus — as extra-uterine, intra- 1
uterine, and intra-muraJ.

Extra-uterine fibroids grow from any portion of the I
external surface of the uterus, and may be pedun-
culated ; or they may be sessile, with a broad im-
movable attachment to its outer muscular tissue.

The intra-uterine project into the cavity of the
womb, and, hke the first, may be pedunculated or
sessile ; and here we make a distinction in practice but
not in theory, calling the one a fibroid polypus because
it is [jedunculated, the other a fibroid tumour because
it is sessile, having a broad attachment usually to one
wall of the womb ; the one being remedied with com-
parative ease, the other with gi-eat difficulty.

The intra-mural are so called because they are em-
bedded in the walls of the uterus, being interlaced and
overlapped in all directions by its muscular fibres.

Fibroid tumours interfere mechanically with con-
ception ; for instance, they may antevert or retrovert
the uterus, and throw the os out of its normal
relation with the axis of the vagina. They may
elevate the whole organ high up in the pelvis, so that
the semen may never come in contact with the os even
momentarily. They may compress the canal so as to
produce a mechanical obstruction to the passage of the
semen, or they may produce haemorrhages which would
be fatal to the life of the germ even if vivified. I have,
however, occasionally seen pregnancie.s where there
had been for years largo fibroid tumours.

Of 265 women who had once borne children and
then became sterile, 38 had fibroid tumours of various

MENORRHAGIA — FIBROIDS.

95

sizes, and variously seated — or one in 6^. Two were
fibroids of the posterior lip of the os tincae ; the re-
mainder, of the body of the uterus. Of these,

Six were pedunculated

Twenty were sessile

2 on the anterior wall.
2 on the posterior wall.
1 on the left side.
1 on the right side.

" 2 on the fundus.
5 on the anterior wall — one

very large.
8 on the posterior wall.
5 on the right side— none on

the left.

Nine were intra-mural «

1 in the fundus.
7 in the anterior wall.
1 in the posterior waU, very
large.

One intra-uterine— very large and growing from posterior wall.

Of 250 married women, who had never borne
children, the cause of sterility was found to be com-
plicated with the presence of fibroid tumours in 57,
being at the rate of about one in 4^^. Of these,

Five were pedunculated

f

Twenty-one were sessile

2 on the anterior wall.
2 on the posterior wall.
I 1 on tlio fundus.

8 on the anterior wall — one
of them reaching round to
the right side, and one to
the left.
10 on the posterior wall— one
reaching to the i*ight side,
and one to the left side.

2 on the left side.

1 on the right side, and very
large.

96

UTERINE SUKGERT.

Thirt j-one were intrft-mund

' 3 in the fandas— one veiy
large.
23 in the anterior wall — two
Teiy large.
5 in the posterior wall — two
Tery laige.

None intra-nterine.

In 100 virgins consulting for some uterine disease,
24 had fibroid tumours, or one in 4J. Of these 24,

Three were pedunculated

■i;

2 on the anterior wall — ^both
very large,
on the posterior walL

Five were sesHile

2 on the anterior wall — one

large.
2 on the posterior wall — one

reaching round to left side.
1 on the right lateral wall —

and veiy large.

1 1 in the anterior wall — three
Thirteen were intra-mural . . . < large.

Two intra-uterine

\ 2 in the posterior wall.

{

2 to posterior wall — and both
very large.

One large fibroid attached to sacrum.

The polypoid fibroids are excluded, because they
are considered separately in the previous section on
Polypus. Were they included here, of course the
intra-uterine fibroids would be greatly increased. This
arbitrary arrangement is pathologically incorrect, but
practically right.

To recapitulate — Thus, of 605 cases (100 being
unmarried, and 505 being married and sterile) 119

MBNORRHAOrA — FIBROIDS.

97

had fibroid tumours, either large or small, connected
in some way with the uterus, being nearly one in 5 J.

The following table embraces the whole at a
glance : —

Of ihest 119 cases of
fbroid twmowr : —

14 were pedanoulated . . .

46 were sessile

53 were intra-maral

8 were intra-nterine . . .

1 was sacral

2 were on the posterior

lip (os tincse) . . .

Total

Fimdoa.

Ant.
waU.

Post,
wall.

Left
lateral.

Rigrht
lateral.

Total.

• • •

• « ■

• • •

• • •

1

2

1
2
4

• • •

• • •

• • •

6
15
41

■ • •

5

20
8
3

1
2

1

7

• * •

■ • •

• • •

14

46

53

8

1

2

8

7

62

36

3

8

119

These tables show the great frequency of fibroid
growths in connection with the uterus, a thing long
ago established by West and others. It will be seen
that (62) more than half of the whole number were
seated in or on the anterior wall.

It will be remembered that I have said (page 84)
that we find intra-uterine polypi (which are only
pedimculated fibroid tumours) more frequently attached
to the anterior than to the posterior face of the cavity
of the uterus. I only state the fact without pre-
tending to explain the why or the wherefore.

I give these details simply because I have them, and
not because I attach much value to such statistics.
They are entirely from cases observed in private
practice. Had I now access to the books of the
Woman's Hospital, it is probable that these figures
might be changed, but only relatively. Fortunately

II

irTERINE sUTtnEny.

for my patients but two of tbese 119 cases
verified by post viorisTn evidence. Their diagnosis
rests wholly upon the judgment of an individual,
which is infallible in no man.

But I will claim, what I would allow to any one
else, that the errors of judgment would bo not of fact
but of degree — for instance, here is a case of fibroid
tumour of the anterior wall — it is as large as a Sicily
orange. Of its situation and general outline there can
be no doubt, but there may occasionally be a case in
which we are a little doubtful whether it be intra-
mural or merely sessile. And if the figures above
could be varied in any way, it would be in some sucli
unimportant relation as this.

The diagnosis of fibrous tumours is much more
certain now than it was before the introduction of the
uterine probe by Dr. Simpson, Twenty years ago
how few of us could tell whether the uterus was anto-
verted or retroverted ; whether its enlargement, if
any, depended upon a mere hypertrophy of its proper
tissue, or upon some adventitious growth either
within, upon, or near the organ. Now, however,
we diagnose uterine complications with the utmost
precision — and all by the touch, the tent, and the
probe.

As a rule, the diagnosis of fibroid tumours is not
difficult. We are more apt to fail in detecting small
tumours than large ones, and yet it is easy to map out
very minute nodosities on the surface, or jn the walls
of the womb. The whole secret of this consists in
getting the body of this organ between the left index
finger in the vagina and the right hand in the
hypogastrium, as explained on pages 10 and 11, so

MKNuniMTACirA^FlKROin

119

that every portion of its surface is minutely traversed,
and any deviation from its normal size is accurately
measured.

If it be already anteverted, there is not the least
difficulty in this. If it be retroverted, or even in its
normal position, then it must be brought sufficiently
forward to be grasped between the sensive forces of
the two hands. If the walla of the abdomen are very
thick, there may bo some Uttle obscurity for a while,
but a second effort will usually clear it up. If the
patient holds the breath, and contracts the abdominal
muBcles, we may be compelled tfl etherize her — but
this is rarely necessary. But, suppose we have a tumour
in the pelvis the size of a small orange, or as largo as
the fist. Is it in the uterus ? on the uterus ? or quite
detached from it ? The sound determines the direction
and depth of the uterine cavity, and shows its relation
to the enlargement, and this in conjunction with the
means of palpation already described. But even then
we may be occasionally in doubt wliether the enlarge-
ment is due to something in the cavity of the uterus,
in its walls, or on the outside^ — ^and here the sponge
tent comes to our aid, and enables us to explore the
uterine cavity by the touch.

But suppose we have a tumour in the Douglas

' cul de sac. We ask ourselves the questions — Is it a
reti-oversion or flexion P la it merely hypertrophy of
the posterior wall ? Is it a fibroid, interstitial, sessile,
or pedunculated ? Is it a prolapsed enlarged ovary ?
Is it a collection of pus, of blood, or of fteces ? The
history of the case will give the probable clue to many
of these queries ; but the application of the principles

\ of investigation already laid down can alone accurately
n 2

lOU

solve the real nature of the malady. Longer minute
detail on this point would be profitless. Knough has
been said to show the student that positive knowledge
of this character can be acquired only by the ripe
experience of self-training.

As an iEustration of the seeming diflBculties, but of
the real faciUties of diagnosis, I here resort to my bei
argument — a clinical report.

Mrs. , from the State of Texas, aged twenty-
four, married five years, was sterCe. Her menses
were regular, painless, histing three days. She had
some leucon-hoea, but consulted me on account of her
steiility.

She had been treated by distinguished proft
four of our largest cities, and all, without exception,
told her she had retroversion. On making an
examination, I found the opposite state of things,
viz., a complete anteversion, with a turaoiir filling up
the Douglas cul de sac, and giving to the touch the
exact sensation of density and size of a retroverted,
uterus, with hypertrophy
of posterior wall.

But by the method of
the consentaneous coun-
ter-pressure with the two
hands, the position, size,
and relations of the uterus
and tumour were readily
traced out as shown in this
' diagram (fig. 38). The left
index finger, after explor-
ing anteriorly at a, was
carried on till it passed to the posterior cul de sac at h\

I
I

J

MENOKllILAGJA — FlilUOlllS. 101

then the points of the four fingers of the right hand were
pushed firmlj backwards and downwards, from c to (/,
carrying the abdominal walls from their normal hne at c
deeply in the direction of the dotted line e d. Wlien this
hand was carried as far in this direction as could be done
with convenience to the surgeon and comfort to the
patient, it was held there immovably fixed, while the
index finger of the left at i was made to elevate the
cervix uteri as if to bring the points 6 and d into con-
tact. If the uterus be anteverted, as it waa here, then
the ftindus will be pushed up against the palm of the
outer hand at c, to be grasped, as it were, between the
two opposing forces, and thus accurately measured —
while the same discriminating pressure detects, at the
same time, the presence of the tumour/. To be more
positive on this point, the index finger was pushed
backwards, carrying the posterior wall of the vagina
to g, where it was able to elevate the tumour, passing
it up against the points of the fingers at d, while they
wore still cognizant of the presence of the body of the
uterus as already indicated. Tliis examination made
the case perfectly plain ; but, to fortify these lacts,
the finger was passed into the rectum, which con-
firmed, but added nothing to the evidence of the
previous method. A sound was also passed to the
fundus of the anteverted uterus, which would have
removed all doubt if there had been any.

When I told this lady what the trouble was, she
said it must be impossible that I should be right, when
five or six others, equally entitled to credit, were all
of an opposite opinion.

I told her not to take my opinion alone, but to go
to others if she desired it, and I gave the names of

102 UTERINE SUEGERY.

three or four of our most distinguished accoucheurs in
New York. In two or three days she returned, saying
she did not call on any of the gentlemen I named,
but that she had seen another medical man, of de-
servedly great reputation as a physician, and also of
large experience in the treatment of uterine disease,
and that he pronounced her case undoubtedly one of
retroversion.

Although this case would deceive any superficial
investigator, there was nothing easier than its
diagnosis by the plan of bi-manual palpation. How
often have I seen uterine examinations made by the
vaginal touch alone ! And here is the great mistake.
This is very well to determine the size and relations of
the vagina, and the condition of os and cervix, but so
far as anything else is concerned, it is simply fiitile.
It is merely groping in the dark. The value of the
uterine sound cannot be over-estimated when used
merely for purposes of diagnosis, whatever may be
said of it as a redresser. If we are not able to
determine the position, size, and relations of the
uterus by the touch alone, the sound is infallible in
giving us its depth and direction. If we find a tumour
of any sort either before, behind, or to one side of
what we usually regard as the normal position of this
organ, the probe will instantly tell us if it be the body
of the uterus or not.

I use the sound simply as a probe to measure the
depth of the uterus, and to show in what direction
the fundus lies. For this purpose I have it made of
virgin silver or of annealed copper, silvered. It is also
smaller than Simpson's soimd, and without notches or
marks. It is made malleable because it is necessary

MENOBBOAOIA — FIBBOIDS. 103

to clitmge the curTature with almost every case. It is
smfiller to make it imiversally applicable, whether the
canal and os intemmn be large or small. It is
without indentations or marks, to enable us to keep it
thoroughly clean.

These two diagrams (figs. 39 and 40) represent the
relative difference
between a uterine
probe of malleable
silver or copper
and the ordinary
redresser of hard
German silver.
They represent the
exact size of the in-
struments as found
in the shops.

The small one
can be curved to
pass in the suspect-
ed direction of the
body of the uterus,
and, if properly
done, never gives
pain ; the other,
large and rigid,
often produces great
agony, sometimes
by being too large to pass along a narrow canal, but
oftener by being forced in a wrong direction. Until I
modified the instrument to a simple probe, I dreaded
ever to attempt its use in any case of suspected ante-
flexion. But now the diagnosis of the worst case of

104 UTERINE Hl'ltGETiy.

dysmenoirhoeal anteflexion is aa easy and as pMnless
as that of an old retroflexion with a patulous canal.

I have often had the gi'eatest difficulty with the
German silver sound ; and if I were to say I had seen i
a score of cases in consultation where phyaieianB I
assured me it was utterly impossible to pass the sound,
I would not exaggerate the number in the least. I
have felt and seen so much annoyance on this point
that I may bo pardoned for a little minutise.

The cases that usually give us most trouble are
those of complete anteflexion, with a fibroid in the
anterior wall. One will
serve as an example of
the class. Let this fig. 41
represent an anteflexion
with a fibroid, a, as large
as an almond, in the ante-
rior wall. If we should
attempt to pass the large
German silver sound, in
its fixed position, to the
fundus uteri, it would
inevitably be arrested at b, it matters not how
dexterously we may elevate the fundus with the index
finger to straighten the organ up at the time we make
the effort.

I have seen such excessive pain thus inflicted that
the patient could hardly be persuaded to allow a
repetition of the process. And I have often passed
the small malleable instrument under such circum-
stances when the patient was not aware that it had
been done. We should never inflict pain if it can be
avoided ; nor shoidd we carelessly shock the nervous

MENORHHAGIA — PIBUdlDS-

Bystem of one so delicately organized, and that too, per-
haps, when that organism is so intensified by diseased
action as to exaggerate to an unbearable degree the
slightest movement or even sound.

Valuable as the uterine probe may be for giving us
the direction of the fundus uteri, it is not to be
depended upon alone to measure its depth, if that
should exceed four inches ; and for the simple reason
tliat the curvature necessary to pass it along the
pelvian axes would make it strike against tlie anterior
wall of the uterus before it could reach the ftindus, if
this should be six or eight inches deep.

As an illustratioD , take the following: A woman,
thirty-five years old, the mother of two children, had
been for several years subject to menorrhagia. The
abdomen was about as large as at the full tcnn of
pregnancy. Palpation showed that this was due to

I: Ml enormous tumour, which was either wholly uterine
or uterine and ovarian. A jihysical exploration was

106 UTERINE SURGERY.

necjessary to determine this point. The diagram
(fig. 42) illustrates the diagnosis.

On introducing the uterine probe, it passed four
inches, striking the anterior wall of the uterus on a
line with the upper edge of the pubes ; but was this
truly the whole depth of the organ ? A gum elastic
bougie would settle this point. On making the effort,
it passed easily more than eleven inches into the cavity
of the uterus, measuring from the os tincae. But it ig

Fio. 43.

not always easy to pass a bougie. If it is large
enough not to bend on itself, it may not pass through
some narrow point, and so will deceive us. And if it
be too small, it will bend on itself in the vagina, and
hence it will be diflBcult to pass it at all. To overcome
these objections, take a bougie about No. 6, sometimes
smaller, and run a strong wire in it, and give it a
gentle curvature at the distal end, as shown in the
diagram (fig. 43). Introduce this just within the os
uteri, and then hold the handle of the wire, a, firmly
in one hand, and push the bougie, 6, along it with the
other. The wire thus stiffens the bougie external to
the uterus, but allows it to pass onwards to the cavity,
taking, of course, the easiest route, and measm-ing
accurately its depth. Whether this direction be in
the central axis of the organ, anteriorly or posteriorly,

MENOBEHAGIA — FIBROIDS. 107

would be afterwards determined by the sponge tent.
In this case the bougie passed nearly its whole length
into the cavity of the womb, marking a depth of over
eleven inches. This proved that its enlargement was
due to a fibroid. It was then a question whether this
fibroid was intra-mural or intra-uterine. This was
proved at once by a very singular fact, viz., that the
gum elastic bougie, when introduced into the cavity
of the uterus, could be felt through the thin walls of
the abdomen, and thinner of the uterus, from just
above the pubes, quite to the fundus far above the
umbihcus (see fig. 42). This alone showed that the
tumour projected into the cavity of the uterus from
the posterior wall of that organ. Was it, then, an
enormous fibroid polypus — i. e., an intra-uterine
pedunculated tumour, — or was it a sessile fibrous
tumour, with a broad attachment to the uterine walls ?
The sponge tent was to unravel that mystery. It was
accordingly resorted to ; the finger was then carried
up into the uterus, and the anterior portion of the
organ was found to be free, while on the posterior,
about an inch above the os tincae, we felt a large tense
tumour, having attachments posteriorly at the cervix,
which widened out on either side as the finger was
thrown in fi:ont and around it. The finger detected
its attachment posteriorly below, while the probing
with the elastic bougie demonstrated it above; thus
proving that the tumour grew from the posterior wall
of the uterus, and that it had a base of attachment
along this wall of probably not less than eight or nine
inches. The tumour itself was unusually tense to the
touch, and we concluded to explore it by puncture. In
the presence of Dr. Emmet, Dr. Pratt, and Professor

108

UTERINE SDRaERy.

Elliot, I passed a trocar into it at its lowest point, and
in the direction of its long axis, and there was dis-
charged at once more than twenty ounces of a straw-
coloured serum. The puncture was enlai-ged for two
inches, to prevent its closing. There was at once a
sensible diminution in the size and tension of the
abdomen. The discharge was kept up for some
time; and this, together with occasional injections
into the very fundus of the uterus, with the liquor
ferri persulphatis, diluted with three or four parts of
water, arrested very promi)tly the hjemorrhages, and
the patient was dismissed in two months in a very
comfortable condition, and with strength enough to
walk six or eight miles. Indeed, so far as the hiemor-
rhages were concerned, she was cured. She returned
in a few weeks mth ruddy looks to report that she
was in very good health, although the abdomen was
seemingly as large as ever. It was evidently a fibro-
cystic tumour, its first element remaining in stutu quo,
while its second was destroyed by the puncture and
slitting up of the cyst. Within the course of a year
afterwards this poor woman died of cholerine of a few
hours' duration, which her physician did not think in
any way dependent upon the fibroid tumour.

We all know that fibroids of the uterus are harmless
unless they produce hsemorrhage or press injuriously
on some of the pelvic viscera. I have seen many
cases where there were fibroids larger than the fcetal
head, and the patients were not aware of their exist-
ence, I was consulted in Paris in October, 1863, by
a lady who had been married fifteen years without
offspring, and she wished to know the cause of her
sterility. She had a peduncidated fibroid tumour,

MENOREHAGIA — FlIiROIDS.

109

large cnoiigli to rest on the brim of the pelvis, which
di*ew the uterus forwards and upwards, raising its
fundus much above a level of the pubes. Her health
was perfect in every respect, and she felt no incon-
venience from the tumour, which will doubtless never
shorten her life a day.

Of late years a good deal has been written on the
treatment of fibroid tumours of the uterus.

Professor Channing, of Boston, claims to have
cured many by internal medication ; whUe Dr. Simpson
seems to have great faith in the long-continued use of
the bromide of potassium. Dr. Emmet and myself
have tried this and other constitutional remedies in
the Woman's Hospital and in piivate practice, and I
am sorry to say we have not been as fortunate as the
gentlemen named above. On the contrary, I have
never seen the slightest efFeot produced on such
tumours by any internal medication. Dr. Atlee, of
Philadelphia, and Mr. Baker Brown, of London, have
each attacked uterine fibroids surgically and in a
heroic way.

Dr. Atloc has had a success in enucleation
which has not been equalled by any one else.
'He advocates a total eradication of the adventitious
growth ; while Mr. Baker Brown is satisfied with
maiming or mutilating the tumour by what he terms
a gouging process. His success has also been very
great, not in curing the disease, but in curing its
worst manifestation — hEemorrhage. And with this we
should feel well satisfied ; for, as a general rule, I do
not think wc should interfere with these tumours
unless they endanger life. That there are cases in
■which we must interfere I readily admit ; and the

110

TTERINll SUR(!KUY.

Bucceas of Atloe and Brown will justify such a course.
I have not been so fortunate as they hi sittacking very
large intra-nterine fibroids. I have lost two patients
in the Woman's Hospital as a consequence of operative
procedures ; one from an atteiniit at enucleation, the
other from the removal of a bit of the tumour ; the
one in imitation of Dr. Atlee, the other in imitation of
Mr. Brown, The first was the case of an unmarried
lady, twenty-eight years old. Menstruation occurred
at sixteen, and continued regular and normal for ten
years, when it suddenly became abimdant and painful.
Two years afterwards, in November, 1859, she was
admitted to the Woman's Hospital. The flow was
then profiise, exhausting, and attended with severe
forcing pains, from which she sufi'ered for a whole
week before the menses made their appearance. The
uterus was about the size of the organ at the sixth

month of pregnancy. The os and cervix were small,
while the body of the organ was large, hard, and

MENORRHAGIA FIBROIDS. Ill

roundish. Its outline and relations are represented in
fig. 44. The sound could be passed in the direction
of the uterine cavity for only about four inches, being
arrested at a, by striking against the anterior wall of
the uterus. But the gum elastic bougie showed that
the cavity was more than nine inches deep. Then the
sponge tent demonstrated that the tumour was intra-
uterine, with a broad base of attachment to the
posterior wall, beginning just within the os, at c.
The great pain preceding and attending each period ;
the excessive loss- of blood at the time ; the increasing
prostration ; and the entreaties of the patient deter-
mined me to enucleate the tumour if possible. The
first step towards this was to enlarge the canal of the
cervix, which, as before stated, was very small. For
this purpose it was split Avidely open up to the inser-
tion of the vagina, and even to the os internum. The
haemorrhage was very profuse, but easily checked.
The parts healed before the recurrence of the next
flow, which was in no way modified by the operation.
The forcing pains and the haBmorrhage were quite as
great as before.

After this, the next step of enucleation was taken,
viz., cutting open the capsule of the tumour. Instead
of making a long incision through this from above
downwards, as practised by Dr. Atlee, I simply cut
the capsule transversely at e, making an opening in it
about two inches and a half long, and then passed a
.sound for six or seven inches in the direction of the
dotted line e h, extensively lacerating the cellular
tissue that bound the posterior wall of the uterus and
the tumour together. I now think Dr. Atlee' s plan
of incising the capsule would have been the best.

112

UTERINE SUIlGEltY.

The bleeding was very profiise, but it was wholly from
the first incision, and not from the subsequent lacera-
tion. This was checked by a tampon.

After Miss M. recovered from the efifects of this
operation, it was thought advisable for her to return
to the country, and wait the efforts of nature in forcing
the tumour down through the artificial opening made
in its capsule.

She returned in two or three months with the mouth
of the uterus about two inches and a half in diameter,
and a portion of the tumour projecting through it into
the vagina. The pain and the haemorrhage were rather
worse, whether in consequence of the operation, or in
spite of it, I do not know.

The attachments of' the tumour were now further
incised, and its adhesions extensively broken up, but
unfortunately Miss M. was attacked with diphtheria,
from which she barely escaped with her life. So great
was her prostration from this disease and the haemor-
rhages combined, that she was again removed from the
hospital.

She returned sis months afterwards (in October,
1860), but the hiemorrhages were in no way modified
by the process of enucleation, which had been slowly
going on for months. The uterus had greatly increased
in size, notwithstanding the fact that the tumour, now
filling up the whole vagina, was quite as largo as the
foetal head at full term. Indeed, it seemed that the
removal of the obstmctions at the cervix uteri only,
invited and promoted the growth of the tumour down-
wards, without dislodging any portion of it from the
body of the organ. Its size was so enormous that it
was thought advisable to remove all that portion of it

MENORBHAOIA — FtBllOIPS. 113

that projected through the dilated cervix, preparatory
to the real enucleation and ablation of what occupied
the body of the womb.

Accordingly, a cord was passed around it in the
direction of the dotted line a
(fig. 45), where it was severed,
The hssmorrhage was fearfiil,
and she lost a large amount of
blood before it could be con-
trolled by a tampon. She
scarcely rallied at all from the
effects of the chloroform, and
died of exhaustion in thirty-six
hours afterwards. p^^ ^

I tliink that death in this
case was caused by the unexpected and immense loss
of blood that suddenly took place in the brief space
of time between the severance of the tumour and its
removal from the vagina.

The prolonged use of the chloroform in all proba-
bility exerted a very pernicious influence.

The portion of the tumour removed was so large
that it was with great difficulty extracted from the
vagina.

Indeed, to do this, it was necessary to enlarge the
ostium vaginsj by perineal incisions, one on each side
of the fourchette. A similar case to this was operated
on at the Woman's Hospital the year before.

That part of the tumour projecting into the vagina
was removed by t^craseracnfc, in October, 1859. Our
patient recovered from the effects of the anaisthesia
and the operation, and we expected to enucleate the
remainder of the tumour, when she was suddenly

] ] i in-ERlNB SUmiERT.

attacked with peritonitis, four months afterwards,
wliich carried her off.

In June, 1861, a widow lady, aged 30, who had
been for two years subject to menorrhagia, was ad-
mitted into the Woman's Hospital. These periodical
haemorrhages were profuse and exliausting, and she
had all the evidences of extreme anaimia. The os
tincDB was small, and the cervix firm and indurated,
while the body of the organ was felt to be as large as
the two fists. The depth of the uterus was five inches.
The enlargement and the hasmorrhage were evidently
due to one of two things — either a fibroid tumour
or a polypus. A sponge tent or two enabled the
finger to pass into the uterine cavity, when a very
firm and unusually hard tumour was found project-
ing from the posterior wall of the uterus, having a
broad, strong attachment to its whole posterior
surface.

A puncture was made in that portion of the tumour
nearest the cervix, and a large quantity (eight ounces)
of a clear, limpid, transparent, straw-coloured serum
was evacuated. To make sure of a radical cure, a bit
of the sac of this fibro-cystic growth was removed
with scissors. It was elliptical, and about one inch
and a half long by tfiree quai-ters of an inch wide. This
was done in imitation of Mr. Baker Brown's gouging
process. I had seldom felt so well satisfied with an
operation ; but unfortunately irritative fever set in, and
my patient died of pysemia in the course of twenty
days. These four cases are all that have been sub-
jected to any operation for radical cure in the Woman's ,
Hospital.

Two recovered from the operations, but both died

MENOBHHAGIA — FIBROIDS. 115

within a year afterwards — one from peritonitis; the
other from cholerine of a few hours' duration. Two
died from the immediate effects of operative pro-
cedures — one of these from exhaustion produced by
loss of blood aided by chloroform poisoning ; the other
from pyremia. It may be thus literally stated that two
died and two recovered ; for death in the last two was
due to accidental causes which were most probably
independent of the operations.

The complete eradication of an intra-uterine fibroid
with a broad sessile attachment is exceedingly
hazardous, while the removal of an intra-uterine
fibroid with a peduncular attachment is compara-
tively one of the safest operations in surgery.

But why take so much time with fibroid tumours ?
Could the removal of such immense tumours be fol-
lowed by conception and safe delivery ?

It might very well be a question, whether such a
hazardous operation as the enucleation of a large
fibroid tumour should be performed simply for the
removal of sterility, and when the hfo of the sufferer
was not jeopardized by severe haemorrhages ? But I
could very weU imagine cases where it would be jus-
tifiable. Suppose a dynasty was threatened with
extinction, and the cause of sterility was ascertained
to be an enucleuble fibroid : here the perpetuity of a
good government and the welfare of the State might
depend upon the result. Or suppose an ancient family
of great name, influential position, and large fortune,
desirous of perpetuating these noble heritages in a
hne of direct descent ; would such an operation be
justifiable, if the parties, knowing the risks, were
willing to assume the responsibilities?

116

UTEEIKE SlIltQEKY.

But could we promise the possibility of conc^fi
after all had been successfully done ?

As a rule, while there is menstruation there
ovulation, and any woman that ovulates can be im- ,
pregnated, provided the spermatozoa and the ovum ^
can be brought in contact at the proper time and place,
and under favourable circumstances.

The neck of the uterus may have been destroyed by
slougliing, or by other means ; there may be loss of
the greater part of the vagina ; there may be partial
ati'esia of it ; there may be an ovarian tumour ; there
may be fibroid tumours, pedunculated, sessile, inter- J
stitial, or intra-uterine ; there may have been hxma- j
tocele, pelvic cellulitis, or even carcinoma of the neck ;
of the womb, and yet conception is always
provided menstruation, the sign and symbol of j
ovulation, be such as to warrant a healthy condition i
of the uterine cavity, the nidus of the new being.

Our literature teems with cases of delivery com-'
plicated with fibroid tumours in some part of the J
uterine structure, and our experience and observation ]
teach us that these tumours are a very frequent source 1
of sterility.

But to return to tTie question — " Is conception ]
possible, and safe delivery probable, after the enuclea^ !
tion and removal of a large intra-uterine fibroid ? "
It is not at all uucoramon to see tliis follow the
removal of the intra-uterine pedunculated fibroid,
called polypus — and why not the sessile fibroid, called
intra-uterine fibroid tumour ? But the proof of this
is fortunately not left to hypothesis or analogy. And
the question is answered aflfirmatively by the record of
one of the most interesting cases to be found in

MENOTiRHAGIA — FlltltUIPS.

117

English medical literature, by Mr. Grimsdale,* of
Liverpool, The interest of the subject wiU justify me
in extracting the general features of the case from
Mr. Gnmsdale's published account.

On the 12th October, 1865, Mr. Grimsdale first saw
Margaret West, aged 33 years, a stout healthy looking
woman, married three years ; eleven months after
marriage (say in 1853} dehvered prematurely of a
stni-bom child, profuse flooding, cheeked with diffi-
cidty ; in 1854 conceived again, but miscarried at
three months on Christmas ; this also attended with
great flooding ; menstruation very profuse, but
regular after this till three months ago (say in July,
1858) ; supposed herself pregnant, but there was no
nausea. The uterus was about the size of this organ
at six months, but without the usual elastic feel of
pregnancy. A loud bruit heard all over the tumour,
cervix uteri pushed forward, os open, lips everted,
hard and granular.

Mr. Grimsdale's diagnosis was, " fibroid tumour of
the uterus; probably pregnancy in addition." He
watched her for a fortnight. She had occasional
profuse discharges of blood. On consultation with
Mr. Bickersteth, they agreed that the safety of the
patient demanded the induction of abortion at once.
Sponge tents were used, the cavity probed for seven

* A Case of Artificial Emicleation of a large Fibroid Tumour
of the UleniH ; with Bomo Remarks on the Stirgicol Treatment of
tlieso TumoiirB. By Thoinus F. Oriinsdale, Surgeon to the Lying-
in-Uos]iit&l, atid Lecturer on Diseases of Children, at the Liverpool
Royal Infirmary School of Medicine. — Liverpool Medieo-CKirvrffieal
Journal, Jiinuiiry, 1857.

118 UTERINE SUltOEBY.

inches, the tumour found to be adherent to the whole
extent of the posterior wall.

Mr. Bickerateth made the incision for enucleation
with a straight bistoury through the posterior wall of
the cervix, about three-quarters of an inch within the
canal, and, coming down on the capsule of the
tumour, plunged the knife into it; index finger
passed through incision nearly to the second joint, and
the tumour was thus separated for some distance from
the proper tissue of the uterus. But httle bleeding
followed the incision, which was plugged, the lint
being forced up between the tumour and the uterine
wall.

Ist day after operation. — Pulse 96 ; vagina hot ;
tampon removed ; vagina syringed.

2/id day. — ^Aborted a four months* fcetus and
placenta.

7th day. — But little variation ; vagina syringed
and opening plugged daily.

8th day. — Uterine pains ; watery discharge ; tumour
began to protrude through the artificial opening, which
was dilated a little more ; presenting part of tumour
soft; discharge offensive; pulse 120; coxmtenance
pale, anxious ; tongue dry ; thirst.

During the next week her condition changed a
little for the better. She took beef-tea, opium, ergot,
and had the vagina syringed twice a day. The
tumour gradually dilated the artificial os, when, on the
14th day, the fingers could not reach the uterus ; the
tumour had passed through, so as to fill the upper part
of the vagina. It was soft and sloughy ; pulse 96.

15;/( dfiy. — Much worse ; had a chill this morning ;
since then very low; pulse 112; thready; tongue

119

^17' gl^ay; countenance anxious; very desponding;
ordered brandy and beef-tea. 9 p.m. — Messrs.
Bickersteth, Blower, and Fitzpatrick present ; pulse
a little better, but tliriUing ; tongue as before ;
countenance bad ; put her under the influence of
chloroform, which improved the pulse. ,

Mr. Grimsdale then passed his hand by the side of
the tumour into the cavity in the posterior uterine
wall, and easily separated the few attaclunents that
remained at its middle and lower portions. He found
the great bidk of the tumour soft and sloughy, some-
wliat like the placenta of a cliild dead some time iu
utero, and already separate from the uterus. Pos-
teriorly, and high up near the fundus, some firm fibrous
bands passed from the uterus to the tumour, which
resisted all efforts to break through them ; they
extended over about three square inches of uterme
surface ; there were eight or ten distinct bands — one
as large as the finger flattened out, and containing soft
doughy tissue. Finding it impossible to lacerate
these bands, he held his hand in the uterus till
Mr, Bickersteth went for a large pair of scissors,
which occupied some thirty minutes. Even then the
completion of the operation was difficult and tedious,
for he says — "After contmuous efi'orta for nearly an
hour, I succeeded in dividing entirely its attachments,
and removed the tumour, a sloughy mass about the
size of an ordinary placenta." There was no haemor-
rhage, and in withdrawing the hand and the tumour,
the utenis contracted do^vn exactly as after the
extraction of a placenta, and felt externally to be
about the size of a normally contracted uterus after
an ordinary laboiu-. From this time her restoration to

120 L'TEEINE Sl'BGEBY.

health was gradual, but Buro. In a fortnight all fetid
discliarges had ceased. In two months the uterus had
quite recovered its natural size and position, and on
the sixty-eighth day after the operation she began to ■
menstruate. It lasted four days, painless and normal
in quantity and quality.

So far this case is most interestmg surgically. If 1
Mr, Giimsdale had not removed the decaying, slough-
ing mass as ho did on tlie fifteenth day, his patient
would evidently have died of pyseraia in a very short
time. But, to me, the most interesting part of the
case is to be related.

TliG operation was performed on the 4th November,
1855; the tumour removed on the 20th. Menstruji,- ]
tion returned on the 27th January, 1856 ; again on j
the 25th February ; and she probably menstruated I
again about the 24th or 25th of March, for in a foot-
note in Mr. Grimsdale's report, he says, " Since the
above was in type, I have delivered this patient of a
well-grown eight-and-a-half mouths child, stillborn.
The membranes ruptured suddenly on the 17th -^
December, 185G. There was a slight discharge of
blood soon after, but no pain till the 20th. At this
date the foetal heart-soimds were hoard distinctly.
The OS dilated very slowly ; the presentation was foot- i
ling ; and there was very inefficient expulsive action, I
in the second stage of labour. On the morning of the
22nd I got hold of the left foot, and completed the I
delivery. The child had evidently been dead many
hours, the cuticle of the feet having begun to desqixa-
mate. It measured twenty-one inches in length, and
was plump and well formed. The placenta, large and
healthy-looking, came away immediately, without ]

I

MENORRHAGIA — FIBKOIDS. 121

Eemorrhage. The utenis contracted well and remained

),"

The evident bearing of thia case on the subject
under consideration is my apology, if any were needed,
for giving so minutely its synopsis and sequel. For it
is a direct answer to the question, "Is conception
possible and safe delivery probable after the enucleation
and removal of large fibroid tumours P "

Before dismissing this subject, I may state that
Mr. Baker Brown docs not now mutilate the fibroid,
but satisfies himself with simply incising the os and
cervix uteri. But the most philosophical and, indeed,
the most successful treatment of hi^morrhages from
fibroids is that of Dr. Savage, of the Samaritan
Hospital. He dilates the canal of the cervix with a
sponge tent, and injects the cavity of the uterus with
a solution of iodine, which has been so far both harm-
less and efficient. His formula is this : —

^L Iodine 5 L

lod. Potassium 5 ij.

R«ct. apt. wiuQ 3 ij.

Water 3 vi.

It invariably stops the bleeding, and, he says,
when repeated at each recurrence of the flow, for
five or six months, the tumours undergo a sensible
diminution, and in some instances have entirely dis-
appeared.

I have seen remarkable results from this treatment
of Dr. Savage, and if the experience of others should
be as fortunate as his, he will have substituted a simple,
safe, and most successful method for one fraught with

lubt, difficulty, and danger.

122

UTERINE SDRIJERV.

Dr. Routh* follows the plan of Dr. Savage, but
substitutes a solution of the perchloride of iron for
the iodine. I have used both agents, and the objection
that I make to the iron is, that while it arrests the
bleeding promptly, by coagulation, it takes two or
three days for the uterus to expel the large masses of
coagula, which often provoke very severe forcing pains.
Whereas when the iodine is used the patient complains
only of a Uttle sensation of internal warmth, which is
quite transitory.

It is very probable that the curative process of
Mr. Baker Brown's simple incision of the os, and of
Dr. Savage's iodine injection, and Dr. Routh's iron, all
depend more or less on bringing about a degree of
subacute inflammation in the uterine cavity, for I hear
from Dr. Greenhalgh that ilr. Brown's operation when
successful always produces a great degree of consti-
tutional disturbance, with considerable tenderness
over the whole abdomen, but especially in the uterine
region.

I had the opportunity of making a post-tnortevt
examination in a case of fibroid tumour, alluded to on
page 113, where the removal of a portion of the tumour,
nearly as large as a fcetal head, was followed by a most
marked improvement in the htemorrhage. Indeed,
after this it could not be called a menorrhagia. The
woman died four months afterwards of an acute attack
of peritonitis, lasting but a few days. On opening

* " On some Points connected with Pathology, Dingnosis, and
Treatment of Fibrous Tumours of the Womb ; being the Lctteomian
Lectures," Jsc. By C. H. P. Routh, H.D., iic. Iwjndon ; T. Richards.

MENOERHAUIA — FIBROIDS.

123

the abdomen tbe evidences of this suddenly developed
and rapidly fatal disease were everywhere visible. On
laying open the uterus there were found strong old
adhesions, here and there, firmly uniting the anterior
wall of the uterus to the opposite surface of the
tumour, which grew from the posterior ■wall.

These bands of adhesion were in all probability the
result of the inflammatory action necessarily aefc up in
the part by the recuperative powers of nature after
the ablation of the large vaginal portion of the tumour,
four months before. This probability is reduced to a
certainty when I call to mind the fact that previously
to this operation the hand was several times, for the
purpose of diagnosis, carried into the uterus, and
passed freely and without obstruction between the
contiguous sm-faces of the uterus and tumour, where
they were now found adherent in patches.

This condition of things must, then, have been the
result of the operation four months before, and was
most proltably the cause of the great improvement in
the menstrual flow.

While we admit that good results may follow the
incision of the os and cervix uteri, after Mr. Baker
Brown's plan, and equally good, with less risk, may
follow the injecting process, after that of Dr. Savage,
I believe we are not in accord as to their rationale.
I venture to suggest that they act beneficially by
bringing about the same result, viz., an ondo-metritis,
minus the suppurative stage. If this be so, then we
should adopt the iodine treatment on theoretical as
well as practical grounds, as the one most conducive
to the production of plastic or adhesive inflammation.

Dr. Greenhalgli informs me that he has had five

124 UTEUTKE SUIlGEIiY.

successful cases from tho iodine and sponge-tent treat-
ment, combined with Recamier's method of scraping
out fungous granulations, and that they were all cured
promptly by a single injection for each ; and that both
he and Dr. Savage now use the pure undiluted ofBcinal
tincture of iodine, instead of the solution.

It must not be forgotten that the uterine injection
is to be always and invariably preceded by the use of
the sponge tent; that this is an essential part of the
treatment, and by no means to be neglected, not even
if the canal of the cervix shoiUd appear to be large
enough to permit the easy exit of the fluid. To
Dr. Savage we are particularly indebted for tliis prac-
tice, which renders this operation, once most painful
and hazardous, now simple and safe.

Many years ago I rehnquished the practice of inject-
ing the cavity of the uterus, having seen the most
violent and alarming attacks of uterme colic follow
the injection of but one drop of a bland fluid ; but
now, according to the plan of Dr. Savage, the cavity
of the uterus is made tolerant of any quantity of even
the tmdiluted tincture of iodine.

Op Menorehagia fkom Inversion of the Utehus. —
Inversion of the uterus is fortunately of rare occur-
rence, yet as it may happen at any time and in the
practice of any one, we shall devote some consideration
to it. My countryman, Professor Charles A. Lee,*

" " A Statifitical Inquiry into the CaiiHes, SymptoniH, Patbology,
and Treatment of Inversion of the Womb," By Cbarles A. Lee,
M.D. — Aiiutrican Jotinial of lh« Medical Sciences, October, 1860,
pp. 313 to 363.

MEKORRHAQU — INVERSION.

125

has given u3 a very complete monograph on this
Bubject. He has collected from various sources 148
cases, beginning with the writings of Dr. Robert Lee,
and ending with those of Dr. Tyler Smith and Pro-
fessor White, of Buffalo. I would refer the reader to
this excellent paper for a large amount of most valu-
able information which is condensed into a few pages,

In many cases of inversion the cause is said to be,
puUing on the cord. It sometimes occurs sponta-
neously, especially when the labour has been very rapid.
It doubtless occasionally happens at a period more or
leas remote after confinement. But I am disposed to
believe that an adherent placenta, particularly to the
fundus, is the most frequent direct cause of this
accident, whether the cord be pulled upon or not. Some
five or six years ago, Dr. Lems A. Sayre, Professor
of Surgery in the Bellevue Hospital Medical College,
New York, showed me a case of inverted prolapsed
uterus, which occurred in a woman who had never
borne children. The inversion was evidently the con-
sequence of a fibroid polypus attached to the fundus
by a short thick unyielding pedicle, which, as it passed
through the cervix, must have drawn the fundus with
it. This case excited at the time a good deal of
interest amongst the medical men connected with the
hospital, on account of the obscurity of its history and
the difficulties of its diagnosis. The woman had
passed tlie tijne of menstruation ; she therefore suf-
fered no longer from hasmori'hages, but complained
only of the mechanical inconveniences of the pro-
cidentia.

Dr. McClintock describes a case so exactly similar to
this, thiit Ihe drawing of if in his book (page 98) woiUd

126 UTERINE SUBQEBY.

pass for an accurate representation of Dr. Sayre's
case. j

Dr. Lee's paper containa referencea to several cases
eimilar to these, reported respectively by Browne,*
Higgins.t Oldham, Rigby, Le Blanc, and Velpeau,
the last four in " Ashwell on Diseases of Women,"
pp. 403-6.

Dr. Alexander H. Stevens, of New York, has had
a chronic case of inverted uterus under observation
for more than thirty years. It had existed for some
years before he saw it. His patient suffered from
periodical hfemorrliages, which ceased with change of
life, when the inverted organ diminished in size, as it
always does at this critical period. The fundus is
now not more than half the size that it was during
menstrual life.

Dr. Charles A. Lee J has seen one of twenty -five
years' duration, which had remained undetected till he
was consulted. The patient was then forty-five years
of age. She had had hemorrhages at intervals, and
was quite angemic. In the course of twelve months
afterwards (March, 1858) the menses ceased, her j
health became vigorous, and there was no need of
surgical interference.

Dr. Lee§ quotes one case of congenital inversion, ,
reported to the French Academy of Medicine by |
Dr. Wilharae, of Motz. His paper also contains two

• Dublin Meilicdl Journal, vol. vi p. .33.
+ Edinburgh MtmOUy Jmtnud, July, 1849, p. 889.
J Ajrttncan Journal of the Medical Science", October, 1
case 140.

§ Loc. ciC, p. 323.

MENOnnUAOlA — INVERSION.

127

cases of inversion occurring at an early period of
pregnancy. One of partial inversion, reported by
Dr. Spae in the Noi-thern Journal of Medicine, July,
1845 ; the other of complete inversion at the fifth
month of pregnancy, by Dr. John A, Brady, in the
New York Medical Times, February, 1856. But the
most remarkable case of this sort is that of Dr.
"Woodson,* of Kentucky. The patient, aged twenty-
seven or twenty-eight years, pregnant about four
months, was engaged in washing, some distance from
the house, when violent labour pains came on, and she
■was not able to get home. She was greatly alarmed,
felt the foetus protrude from the vagina, and took hold
of it and forcibly pulled it away, which brought the
uterus entirely out, producing complete inversion.
She tore off most of the placenta which was adherent,
forced the uterus back into the vagina, and did not
call for medical aid for five days afterwards. Dr.
"Woodson then saw her, in consultation with the family
physician ; and found the uterus inverted, lying just
within the vagina, with a portion of decomposed placenta
still adhering. He ordered vaginal washes and an
anodyne for the tune, and on the next day, the sixth
after the accident, he succeeded in replacing the
uterus. Tlie loss of blood was not great or alarming,
although it had continued from the time the accident
occurred.

The replacement of a chronic inversion was formerly

Journal of A« Mfdieal Scieiuvg; October, 1860, Ai-t.
XT., "C<im]Jet« Inversioo of tlio Ut4jnis at four months of Ut<.To-
gMtation. Rcplftcefl nix diiya nfter tlie accident," By E. W.
■WixxWu, M.r>., of Woo<li-illc, Kentucky.

128

TJTERINE SUEOEBY.

thought to be impossible. Now, however, it is proven |
to be not only possible, but quite practicable. Dr.
Tyler Smith* replaced one after twelve years of inver-
sion. It required eight days with the india-rubber
air-ball pessary, conjoined vriih manipulation night and
morning for ten minutes at a time. Dr. Charles
Westt has replaced one of twelve months' standing.
He also used the graduated pressure of an india-rubber
air-ball, after Dr. Tyler Smith's plan. Both of these
cases recovered. Professor Wliite,t of Buffalo, New
York, replaced one of fifteen years' standing. The
operation was done in fifty minutes, under chloroform.
Unfortunately the patient, thirty-two years of age,
died of pci-itonitis sixteen days afterwards. Dr.
Noeggerath,§ of New York, has succeeded in one case
of thirteen years' standing.

This great revolution in practice in the treatment of
chronic inversion is due to Dr. Tyler Smith, who was
the first, I believe, in this country, to demonstrate its
practicability, and to Professor White, who was the
first in America to pei-form this operation succeas-

ftilly.

I have had but two cases of chronic inversion. In
one, the uterus was removed by the ^eraseur ; in the
other it was replaced in five minutes under the influ-
ence of ether. One had existed for nine months, the
other for twelve. One was at the Woman's Hospital ;
the other in private practice. The first case was sent

* Medical Timet and Gazette, April 34tli, 185S.
+ Medictd Times and GoMtU, October 29ti, 1869.
I American Journal of llxe Medical Sciences, July, 18fi8.
5 Ainei-iean Medical Timet, April 26tli, 1803, p 230,

M ENORRHAGIA — INTERS lOK .

120

to the hospital in June, 1859, by Dp. Maxwull, of
Johnstown, New York.

This patientj aged thirty-nine, married five years,
had had one miscarriage and two labours at fiill term,
the last on the 26th December, 1858. She was in
labour nine hours. The pains continued very strong
afler the expulsion of the child. The placenta was
retained. The physician was obliged to remove it,
and, in so doing, remarked that something had come
down which would have to go back again. The
mother of the patient saw a large bleeding mass
protruding, which the physician pushed up into the
vagina. Tho hajmorrhage and the pains continued
for nearly twenty-four hours afterwards. On the next
day another physician was called in, who succeeded in
checking the haimorrhage and relieving the constant
pains. About a month after delivery the hasmorrhage
Suddenly returned with great force, but was controlled
by a tampon. From this time she was never entirely
free from more or less haemorrhage, up to the time of
her admission to the Woman's Hospital. She was so
completely blanched from loss of blood, and so ex-
hausted, that I hardly had a hope of doing anything for
her reUef. I have seldom seen any one recover fixim
such a state of exhaustion. The pulse was very rapid
and feeble, the heart giving full evidence of her anaemic
condition. She could not be raised up in bed without
fainting, and would often faint while in the recumbent
posture. Her recovery from this condition was wholly
due to the extraordinary efforts and attention of Dr.
Emmet, whose eminent ability I have so often men-
tioned in these pages. Ho arrested the flow by a
tampon of the Ii(i. ferri pcrsulphalis of Dr. Squibb;

130 UTERINE SL"RGEEY.

he relieved the disposition to frequent syncope by
elevating the foot of the bed, making it an inclined
plane, and uiviting what little blood she had to the
brain ; while by stimulants, tonics, and good nutrition,
a little by tho stomach and a great deal by the
rectum, we had the happiness of seeing our patient
rally and gain blood and strength enough to undergo
operative procedures. We were afraid of chloroform
in her enfeebled condition. She was therefore cau-
tiously etherized. The hand was then passed into
the vagina, the uterus grasped, and steady efforts
made to replace the organ. These efforts were con-
tinued for nearly four hours. The uterus was partially
replaced ; that is, it was reiuverted to such a degree
as to place the fundus up witliin the os uteri, but it
could not be passed farther. The diagram (fig. 46)
would represent what I mean.
It took but a short time to
reinstate the organ thus far,
but no efforts could do more.
A tampon, with some styptic
lotion, was applied to hold the
uteiiis in ntu. And here is
where I made the great mis-
take. If, instead of the styptic
tampon, I had adopted Dr.
P,Q_ ^ Tyler Smith's plan with the

elastic air-bag, the result might
have been different. A day or two afterwards, when the
tampon was renewed, I was horrified to discover that
the vagina, particularly at its posterior cul-de-sac, had
an ecchimosed appearance, as if it had been stretched
almost to the verge of being ruptured. I am now

MEXOIiltUAGIA — INVERSION.

131

satisfied that we continued our etforts for too long a
time, although they were not made spaamodically.
The tampon was chauged daily, the uterus being
retained as represented in the diagram. There was
no pain, no haemorrhage, and our patient ate and
slept well, and improved rapidly in looks and
strength.

About eighteen days after this (July 12th) Mrs. B.
was placed again under the influence of ether, and
another efl'ort made to replace the uterus ; but after
an hour's time we were obliged to desist. The late
lamented Drs. Valentine Mott and John W. Francis,
of the Consulting Board of the hospital, were both
present at each trial, and they were of the opinion,
that in this case the entire ablation of the organ
would be a safer operation than to make another effort
to reinvert it. A few days afterwards menstruation
came on, was exceedingly proftise, and the fundus was
again forced somewhat into the vagina in spite of the
tampon. The uterus was then pulled down into the
vagina, and a strong ligature was passed round the
cervix, and firmly tightened hj a small screw ^raseur,
with the intention of ultimately removing the organ.
The ligature controlled at onco the hiemorrhage, and
wholly arrested the circulation of the fundus, as mani-
fested by its sudden deep pui'ple colour. But the con-
stitutional disturbance was so intense and alarming,
that we were compelled to remove the ligature ap-
paratus at the end of two hours. The great pain,
excessive nausea, rapid pulse, clammy skin, jactitation
and pinched features were too distressing to be wit-
nessed, much less endured, and so the ligature was
removed, and opiates were freely given tiU she was
K 2

132

lITKlilNF SUIillERV.

entirely relieved. A geceral course of invigorating
treatment was followed. Menstruation in August
lasted eleven days, but tlie flow was not very great
at any time.

After the September menstrual period, one more ]
eflbrt was made to reinvert the uterus ; but we could
effect no more than is shown in the diagram (fig. 46).
After this she and her husband begged to have the
organ removed, as we promised to do it vrith the
ecraaeur without pain.

Accordingly, on the 1st of November, she was I
chloroformed, and the chain of the ^craseur was passed T
round the cer\'ix, near the os, and tightened. When I
the operation was half finished, a link parted. Another
chain was applied, and with this the organ was cut
through ; but the broad ligament on the right side
was fortunately not wholly severed. As the chain
was felt to pass suddenly through the uterine tissue,
I was about to remove it and the severed tumour
together, when all at once the most fearful hiemor-
rhage I ever encountered took place, and in an instant
the vagina was full of arterial blood. If the bleeding
had been from the blood-vessels of that portion of the
broad Ugamont already severed and retracted within
the peritoneal cavity, it would have been beyond
reach, and, of course, our patient would have died
before she could have recovered from the effects
of the chloroform. Fortunately, the bleeding was
from that part of the broad ligament still adherent to
the severed uterus. Quickly drawing it forward, I
passed the fore and middle fingers through the cervix
uteri into the abdominal cavity, and with them com-
pressed the remains of the ligament against the edge

UESOERHAGU — I.WEBSION.

133

of the cervical opening, which promptly arrested the
hsemorrhage. The blood was then sponged out of
the vagina, and the undivided portion of the broad
ligament with the artery was tied ; after which a few
sponge probangs were passed iuto the peritoneal
cavity, and the blood that had found its way there
was carefully removed. It must not be forgotten
that the patient was in the usual lateral serai-prone
position. The divided edges of the cervix were
united by five or six interrupted silver sutures. The
one on the extreme right was made to transfix the
ligated portion of the broad ligament, which had
been drawn through into the vagina. The edges
of the cervix united by the first intention. The
opening through the cervix, before it was closed by
the sutures, wouhl easily have admitted the passage
of three fingers at a time into the peritoneal cavity.
This was rather a fortunate thing under the circum-
Btances, as it afTorded great facihty for sponging out
the blood from the peritoneal cavity. The patient
recovered rapidly. Dr. Emmet gave her opiates at
stated intervals for two or tln-ee days, with good
nutriment. Slie had a small vaginal discharge for a
short time, till the little projecting portion of broad
ligament was removed. Ten days after the operation
the bowels were opened by enemata. Two of the
sutures were cut off close, and left to be permanently
sacculated.

I have occasionally heard from Mrs. R. since the
operation, and she remained iu good health.

This cut (fig. 47) is copied from a drawing made
immediately after the uterus was removed. It shows
that portion of the ligament in which the bleeding

UTERINE aimiiEiiv.

artery was found. The artist has slightly exaggerated'^
the long diameter of the organ.

With my next case I was more fortunate. This
was the case of a lady in Springfield, Massachusetts,
who was attended in her labour by one of the most
eminent of our New England practitioners. I presume
it was an example of spontaneous inversion at a some-
what remote period after confinement, for the character
of the physician is a sufficient guarantee that it could
not have resulted from any mismanagement on his
part ; nor could it have occurred spontaneously at the
time of his attendance without being detected by him.
A few weeks after this lady's delivery, her physician
went abroad. Some months afterwards she called
another physician, who treated her for menorrhagia.
She did not improve ; and by-and-by a consultation
was held, when the case was ascertained to be one of
inversion.

She was then etherized, and efforts at reduction
were made, and continued for an hour without effect.
Two or three weeks after this I was sent for; the

MENOKRHAGIA — IS VERSION.

135

patient was etherized as before, and I was able to
reduce the inverted uterus to its normal relations Ln
less than five minutes. This was in May, 1860, about
twelve months after the labour. The medical brethren
present gave me great credit for the facility -with
which the operation was performed. But its speedy
accomplishment was a little accidental. Introducing
the left hand into the vagina, I grasped the uterus, and
soon restored it to the position represented by fig, 46
(page 130), where the fundus is shown as just within
the 03 uteri. At this moment I changed my hold on
the uterus, and, rather by accident than design, deeply
indented the right comus, a, with the thumb of the
left hand ; the fingers compressed the opposite side of
the organ, b, and wliile the thumb pushed the tissue
in which it was embedded upwards, the fingers rather
acted in a contrary direction on the opposite side ; and
to my great surprise, the uterus jumped, as it were,
out of iny hand, assuming its proper normal position.
I certainly bad not the remotest idea of restoring the
organ under a half-hour's effort.

The case reported by Dr. Noeggerath was reduced
very much on the principle of the above ; but instead
of its being accidental, as ^vith me, he reasoned out the
process after he had failed by the ordinary method.

As before said, we are indebted to Dr. Tyler Smith,
of London, and Professor White, of Buffalo, for our
present success in the treatment of inversion of the
uterus. These two distinguished gentlemen seem to
have worked out the problem about the same time, and
independently of each other. Dr. Tyler Smith takes
the slower method of persistent and gradual pressure
with the air-bag; Dr. White, the more brilliant but

136 UTERINE SDRCEKY.

more dangerous plan of immediate reduction
manipulation) imder the influence of chloroform. I
fear that in my own country we have been too much
captivated by the eclat of sudden success. I am sure
now that it would he safer to combine the plans of
Dr. Tyler Smith and Dr. White.

I would hesitate a long time before removing another
inverted uterus.

Judging from the experience of mytwo cases, the great
tliflBculty seems to be in passing the fundus through
the OS intermun. It was easy enough in each instance
to reinstate the organ to the condition represented by
the diagram (fig. 46). That being the case, I should
infer that there were no peritoneal adhesions to prevent
the completion of the operation.

There is one point that I wish to dwell on par-
ticularly.

Those who follow the plan of my distinguished
countryman Professor Wliito (whom I have imitated),
would do well always to make counter-pressure with
the outer hand over the abdomen, as represented in
this diagram (fig. 48).

In pushing the uterus upwards by the hand in the
vagina, there is certainly some danger of lacerating
the vagina and tearing the uterus asunder from its
attachments at the posterior cul-de-sac. Counter-
pressure will obviate that danger. Another advantage
of counter-pressure is that the fingers pushed down
on the uterus, as the cervix is doubled on itself, assists
very materially in dilating that portion through which
the fundus is to be forced upwards.

From what I have already said, it would appear
that the reduction of an inverted uterus naturally

MENOEEHAGIA — INVEBSION. 137

imdes itself into two stages : the first, that of push-
ing the body of the utenia up within the cervix, as
represented in fig. 46 ; and the second, that of com-
pleting the operation by forcing the fimdua through
the 03 internum. The first stage is accomplished by
directly pressing the body of the litems upwards, and
putting the vagina well on the stretch, which, as
Dr. White* says, "pulls open, first its mouth, then its
neck, and finally, if persevered in, doubles the body
upon itself also ; " the second, by compressing the

fundus laterally, and deeply imbedding the thumb in
the cornus uteri (fig. 46, a), by which means we sUde
one-half of the organ at a time through the os
internum instead of the whole fimdus, which presents
a greater diameter. Pressure antero-postoriorly would
avail nothing, because we would simply compress two
flat unyielding surfaces together ; but the comus can

* Atnerktm Journal of the Medical Seienees. July, 1858, ji. 23,

138

UTERIKE SURGERY.

be dimpled and forced inwards and upwards by the
thumb. It is useless to attempt this manceuvre till
we complete the first sta.ge of the operation.

I do not think that, as a rule, we should continue
our operative procedures more than thirty minutes at
a time. If we fail to restore the organ at once, then
we should introduce an india-rubber air-bag, after the
plan of Dr. Tyler Smith, and wait for our patient to
recover fully before trying again. H

But suppose after proper efforts we fail to restorft ■
the uterus, should we amputate it ?

In the hands of Professor Channing, of Boston, and
Dr. M'Cliutock, of Dublin, amputation of the inverted
uterus has proved to be a very successful operation,
and one to be justified if all legitimate means of
restoration, patiently and perseveringly tried, fail to
reinstate the inverted organ.

But before taking this last resort, I would, rather
than amputate, make longitudinal incisions ft-ora the
08 tincffi along the cei-vix to a point beyond the os
internum, for the purpose of facili-
tating the process of reduction.
'. ^/^ I would make at least three —

one on each side, as represented
in this diagi-am (fig. 49, a a), and
another, sbnilar, on the posterior
surface. 1 say posterior only be-
cause it would be easier to make
it there than on the anterior
^"'- *^- surface, if the patient be on the

left side, with my spectdum as it
is ordinarily used. The object of these incisions would
be to divide the circular fibres of the uterine tissue,

MENORRHAGIA — INVERSION. 1 39

and thereby to remove one of the principal barriers to
the reduction of the fundus.

I hope I have said enough to show that we should
not resort to the operation of amputation till we have
tried persistently and patiently every possible means
for reinstating the organ to its normal position.

The patient in whom I was so fortimate as to
restore the organ after twelve months of inversion,
subsequently conceived; and thus we see the important
bearing of this operation upon the subject of sterility.
Even Dr. Tyler Smith's successful case of reduction
after nearly twelve years of inversion, was followed by
conception ; and these two cases are, I think, suflBcient
to warn us against a too hasty resort to the operation
of amputation.

I have just heard from Dr. Tyler Smith (July 12th,
1865), that his patient "has had several children since
the operation (in 1856), and that the medical man
who attended her in her first confinement after the
reduction of the inversion, says that complete inver-
sion occurred spontaneously after that confinement,
which he readily and at once reduced."

Op Painful Menstruation. — ^Menstruation may be
attended by a general malaise, but should not, as a rule,
be accompanied by any very severe degree of suffering.
If there is much pain, either preceding its irruption
or during the flow, there will generally be a physical
condition to account for it, and this will be of a nature
to obstruct mechanically the egress of the fluid from
the cavity of the womb. The obstruction may be the
result of inflammation and attendant turgescence of
the cervical mucous membrane, whereby this canal

140

DTEBmE SDKGERY.

becomes narrowed merely by the tumefaction of its '
lining coat. But by far the moat frequent cause of
obstruction is purely anatomical and mechanical. For
instance, the os and canal of the cervix uteri may be
preternaturally small, or the cervix may be flexed ;
or these may be complicated with the presence of a
polypuSj or with that of a fibroid tumour, in either the
anterior or posterior wall of the uterus, and occasionally
in the antero-lateral portion. l

Of 250 married women who had never borne chil- I
dren, 129, or more than half, had pain of an abnormal
kind attending the menstrual flow. I have been in
the habit of dividing those into two classes, caUing
the one painfiil, and the other excessively painful or
dysmenorrhoeal. Of these 129, 100 were painfiil, or
1 in 2^ of tho whole number ; 29 were dysmenorrhoeal,
or 1 in 8^. Of the 100 painfiil menstruations, 58
had anteversion, or more properly speaking, ante-
flexion ; 17 of these had fibroid tumours in the I
anterior wall : 25 bad retroversion ; 7 of these had |
fibroid tumours in the posterior wall: and in 17 the
position was normal, one of these having a fibroid
tumour in the fundus. Of the 29 dysmenorrhoeal
cases, 23 had anteversion ; 14 of these had fibroid
tumours in the anterior wall : 3 had retroversion ; aU
of these had fibroid tumours in the posterior wall ;
and in 3 the position was normal. Of the 100 cases
of painful menstruation, the os was normal in but 6,
unnaturally contracted in 90, otherwise abnormal
in 4. Of the 29 cases of dysmenorrhoea, properly
speaking, the os was not normal in a single case,
being contracted in 2G, and otherwise abnormal m the
otlier 3.

PAINFUL MENSTRUATION. 141

The following tabular statement presents the par-
ticulars at a glance : —

Os was normal in but 6

^- Trtrt r • r 1 » contracted in 90

Of 100 cases of painful men- ^ . ^ , . /.,

< Cervix was flexed in 61

stniation,

„ congested in . . . 7
There were polypi in 2

Os was normal in

Of 29 cases of excessively ^ ". ^ , . „«

. ^ , . . . -l Cervix was flexed in 23

painful menstruation,

„ had polypi in 2

„ was congested in . . . 1

From this it would appear that the pain of men-
struation is almost wholly due to mechanical causes,
for of the whole 129, only 8 had engorgement or con-
gestion of the lining membrane of the canal of the
cervix, and some of these were complicated either with
flexure of the cervix, or with fibroid growths in some
portion of the body of the uterus. I would not deny
that menstruation may be painful merely from a con-
gested state of the cervical membrane, where there
is no fibroid growth, no polypus, no contracted os,
and no flexure of the cervix ; but such cases are rare,
while the great majority of dysmenorrhoeal cases have
a contracted os and a narrowed cervical canal or a
flexed one. In some instances the os is not larger
than a pin's head, or it may be large enough to admit
a No. 4 bougie. Again, the os may be quite large
enough, but the canal may be flexed so as to form
a valvular obstruction to the egress of the menstrual
fluid. Sometimes we find the os small and the canal
flexed without painful menstruation, and here the
cervix is not indurated, but soft and elastic to the

142

UTERINE SUHOEHY.

touch. Of the 129 cases of painfiil menstruation, but
20 had the uterus in its normal position, while 81
had anteversion (31 of these with fibroids in anterior
wall), 28 retroversion (10 of these with fibroids).

In a great many cases, in addition to a contraction

or flexure of the canal, the cervix will be long, pointed,

and indurated. If the flexure be

anteriorly, we often find the in-

travaginal portion of the cervix

unequally developed — that is, the

posterior part, from the os to

the insertion of the vagina at a

{fig. 50) may be an inch and a

quarter long, while the anterior,

from the oa to the insertion of

the anterior cul-de-sac at b, may

Fio. 50. not be more than one-third as

long.

The size of the os and the position and relations

of the cervix may be ascertained by the touch, as

already explained (p. 9). But it is well always to

resoi-t to the sound to determine definitely the course,

curvature, and contraction of the canal. To the touch

and the sight the os may seem to be quite large

enough, and then we may find a flexure, perhaps a

very acute one, at the junction of the cervix and body

of the womb, due most probably to the presence of a

small fibroid in the anterior wall of the uterus (fig. 41,

page 104).

According to the facts stated above, it would seem
that the pathology of dysmonon-hoea is yet to be
written. I am fiilly of the opinion that it is simply
a sign or symptom of disease, to be found in some

1

PAINFUL MENSTRUATION. 143

abnormal organic condition. This may be inflamma-
tion, or it may be the cause of inflammation, or it
may exist without it. But whether inflammatory or
not, its action is mechanical. I lay it down as an
axiom, that there can be no dysmenorrhoea, properly
speaking, if the canal of the neck of the womb be
straight, and large enough to permit the free passage of
the menstrual blood. In other words, that there must
be some mechanical obstacle to the egress of the flow
at some point between the os internum and the os
externum, or throughout the whole cervical canal.

Dr. Bennet* says, "I have always taught that
menstruation may be painful, even acutely painful,
from its dawn to its close, without any mischief or
impediment existing of any kind whatever.*' Many
years ago I beUeved all this, simply because Dr.
Bennet and others said so ; but now I do not beUeve
in any such doctrine, because experience has taught
me otherwise. There is no such thing as what is
called "constitutional dysmenorrhoea." There was
a time when we looked upon dropsy as an entity,
a disease in itself; but now we know that it is only
a symptom of various diseases. It is a symptom of
disease of the heart, of the kidneys, of the liver ; or it
may follow haBmorrhages or diarrhoea. So is it with
dysmenorrhoea : it is only a symptom of disease, which
may be inflammation of the cervical mucous membrane ;
retroflexion; anteflexion; fibroid tumour in one wall
of the uterus or the other; contraction of the os
internum or os externum ; flexures of the canal of the
cervix, either acute or gently curved, either at the

* Lancet, June 24, 1865, p. 673.

144

UTERINE SDKGEHY.

OS internum, at the inaertion of the vagina, or extend-
ing throughout the whole length of the canal : all
of which are but so many mechanical causes of ob-
struction, which must be recognized and remedied if
we expect to cure the dysmeuorrhoea. We do not
talk of constitutional toothache, of constitutional colic,
or of constitutional fractures, or constitutional dis-
locations. Nor should we speak of " constitutional
dysmenorrhoea." This is but a high-sounding term
that means absolutely nothing. The fact is, that most
of the diseases of the uterus are as purely surgical
as are those of the eye, and require the same nice
discrimination of the true surgeon. And if we fail
to detect the abnormal condition that produces dis-
eased manifestations, whether of sensation or secretion,
it ia plainly our fault. For of all organs the uterus
is now most subservient to the laws of physical ex-
ploration ; and in every case of diseased action, if we
cannot map out accurately the peculiar condition of
the uterus producing or accompanying it, it is simply
because we do not apply our knowledge of those
physical laws to its investigation.

The treatment of dysmenon'hcea was formerly very
empirical. Deweea cured many cases with his ammo-
niated tincture of guaiacum, but I have not seen any
one who had derived the least benefit from it. The
remedy is so nauseous that I could never get a patient
to persevere with it. I must confess, however, that of
late years, smce I have learned more intimately the
nature of the disease, I have not prescribed it at all.
My fiiend Professor E. D. Fenner,* of New Orleans,

I Met/iea' j\'euj*, 1858.

I'AlSFn. MRNSTRITATI'IM. 145

has been vei'y succesaful with the bichloride of raercuiy
in minute doses ; but I have no experience with the
remedy. Many prescribe belladonna and other nar-
cotics, but they can only produce a merely palliative
effect. The operation of enlarging the canal by
incision ia not always succossfid, but it is the only
procedure from which I have derived the least benefit.
The whole philosophy of the operation consists in
opening the canal and keeping it open, so as to allow
the easy passage of the menstnia! flow. M'Intosh
. dilated the cervix with bougies ; but whoever has
followed him must have been struck with the imcer-
tainty of the result, as well as with its painfulness, to
say nothing of its danger. A priori, it would seem a
trifling thing to pass a bougie along the cervix uteri,
but I have known it to be followed by most serious
results. In 1859, Professor Metcalfe, of New York,
referred one of his sterile dysmenorrhosal cases to ray
care. There was sUght anteversion, with a small
fibroid in the anterior wall. The os was very small ;
the cervix long, pointed, and indurated ; and the canal,
though straiglit, was very narrow. I advised the
operation of incising the os and cervix, which was
objected to by the lady, although Professor Metcalfe
was anxious to have it done. I explained to her the
process of dilatation, and ' she wished to try it.
Accordingly, a small bougie was passed in to the
depth of two inches, and allowed to remain a few
minutes. On the next day a larger one was used, and
in two or three days more a conical bougie was passed,
dilating the os externum to about a No. 9. She com-
plained of a good deal of pain at the time, and there
was a slight laceration of the contracted oa. That.

146

UTERJNK SOnOERY.

night she had a rigor, followed by fever, and a most
intense attack of metro-peritonitis, whicli lasted many
weeks, and from which she barely escaped with her
life. Her recovery was slow and tedious. This was
my last bougie case. I have known several cases of
the same sort in the hands of others in my own
country, and I have seen two in Paris during my short
sojourn there.

In November, 1861, in Paris, a medical friend asked
me to see a case of dysmenoiThoea, which was sterile
after a marriage of eight or nine years. The os and
cervical canal were very small ; the cervix long,
pointed, and indurated. It was just the case for an
operation, or there was nothing to be done. I advised
him to incise the cervix. He was afraid of it, and a
year afterwards he introduced a screw bougie made of
ivory deprived of its earthy constituents, which was
allowed to remain in the cervk, and dilate it mechani-
cally by absorbing moisture, and expanding to twice
its original size. A violent attack of metro-peritonitis
was the consequence, and I saw this lady when she
had been ill about a week. She had a pulse of 140,
and continued in a very dangerous condition for a long
time, but eventually recovered.

The other case of metro-peritonitis from mechanical
dilatation occurred in the hands of one of the most
eminent physicians in Paris. Fortunately the lady
recx)vered after three weeks of fever, attended with
very great suffering.

This experience warns against merely mechanical
dilatation. But it may reasonably be asked, "Is it
more dangerous than splitting up the neck of the
womb ? " I answer, " Yes." I cannot now say how

PAINFUL MEKSTEUATIUN.

147

many hundreds of times (certainly more than five
hundred) the operation of cutting open the os and
cervix has been done by Dr. Emmet and myself at the
Woman's Hospital and in private practice, and I now
remember but a single instance in which it was
followed by inflammatory symptoms, and this resulted
in pelvic cellulitis and abscess. The case was badly
chosen for operation, and if I had known that this
patient had had a pelvic abscess once before, I certainly
should not have operated on her. The house-surgeon
of the hospital inadvertently overlooked this part of
the history of the case, and hence the accident.

Some prefer to dilate the cervix by sponge tents.
Foremost amongst these stand the distinguished names
of Bennet and Tilt. I have tried this method, and
the results were anything but satisfactory. Professor
A. K, Gardner, of New York, has used it most exten-
sively and perseveringly, but has now abandoned the
practice as unfruitful. Dr. Tilt thinks the incision
of the cervix " an unjustifiable operation," * and
objects to it because it produces pain and " flooding to
an alarming, if not to a fatal extent." As to the pain,
I am sure I have seen far more caused by a bougie
than I ever saw by the operation. Indeed the opera^
tion is not a painful one. I have often performed it
on delicate, timid women, who were conscious that
something was being done, but had no idea that it was
a surgical operation. I am opposed to operating on
any rational being without first explaining what is to
be done, and the wherefore. In the cases alluded to
the operations were performed at the suggestion and

* " Uteiine Therapeuticfl," p. 205.
L 2

148

nTEItlNE smtGEBY.

earnest wish of husbands, who feared that they might
not be submitted to if fully explained.

In 1858 I advised this operation in a case of dys-
monorrhceal sterility, sent to me by Dr. Vanderpoel,
of Albany, New York. There was anteflexion, with
slight hypertrophy of the anterior wall, cui'ved canal,
and contracted os. The Doctor had tried the bougie
system for some time without any permanent iraprove-
raent, and, fully satisfied that an operation was neces-
sary, he sent his patient to me. But the very idea of
cutting was so terrible to her imagination that she
went to another physician, who pronounced the opera-
tion " butcherous " and dangerous, and promised to
cure her by dilatation alone. Of course this poor
frightened, nervous sufferer gladly accepted the alter-
native, and at once placed herself under his treatment.
She remained in New York for several months, under-
going daily dilatation, and then returned home without
any permanent benefit. Three months afterwards she
consulted me again, and on examination I found the
uterus just as it was seven or eight months before.
Being now fuUy convinced that the operation afforded
the only hope of relief, she submitted to it. When it
was all over she could hardly believe it, and declared
that she suifered more each time the bougie was used
than she did from the operation.

But so far as mere pain is concerned, it raiglit be
left entirely out of the question in these days of
ansBsthesia. When, however, we come to speak of the
dangers of the procedure, I readily admit that we may
debate that point. If, then, we compare the dangers
of the operation with those of mechanical dilatation, I
do not hesitate a moment to declare the former much

J

PAINFUL MENSTRUATION.

149

the safer, while in permanent results it is infinitely
superior. For while I have frequently known pelvic
cellulitis to follow the use of the bougie and the tent,
I have never seen it but once after the operation ; and
while the bougie and the tent can only produce tem-
porary improvement, we know that the operation is
often followed by a perfect and persistent cure. But
it may be asked, is there no risk in the operation ?
The only trouble that I have encountered is hjemor-
rhago ; but that was in my early operations, and before
experience taught me that there was any danger to be
apprehended. Now, however, I have no such accident,
because I take pains to guard against it. When Dr.
Simpson first published on the subject, he said he
never had haemorrhage or other unfavourable result,
eitlier directly or secondarily ; so that I was em-
boldened to perform the operation at my house, and
allow patients to ride home afterwards. But I was
soon undeceived on this point, for in the short space
of two months I had five cases of lia3morrhage that
were truly alarming. One occurred in a lady residing
in Jersey city, who rode a distance of five miles in
stages after the operation. The bleeding began just
as she arrived at her home. She was, of course, very
much alarmed, and sent immediately for me, and also
for her family physician, who, being near by, soon

I arrived, removed the dressing, retiimponed the vagina,
and arrested the bleeding promptly, before I made
my frightened appearance. The other cases, though
nearer to me, were equally alarming. I then made up
my mind never again to operate on patients in the
consulting-room. I asked Dr. Simpson, when I was
in Edinburgh in August, 1861, if the operation was

ISO UTEEINE SlJIiGEKY.

still as safe in his bands as he had at first represented
it, telling him, at the same time, my experience, when ]
he declared that ho never had any trouble from [

How to account for this difference in our experience I
I could not imagine, unless it should be that I cufc !
more extensively than he did. To satisfy my mind
on this score Dr. Simpson kindly invited me to witness
the operation in his hands. It was the case of a lady |
from some of the British possessions. The os waa I
small ; the canal narrow ; the cendx long, pointed, ,
and indurated. It was precisely the case to justify j
the operation, for the gristly induration of the cervix
rendered any other method quite out of the question.
The operation was performed with the Doctor's usual I
dexterity. Then a camel's-hair pencil, saturated with a
solution of the perchloride of iron, was thrust into the
vagina two or tbi-ee times, and in ten or fifteen minutes
from the time we entered the lady's apartment, we were
again in the street making other visits. He had such
confidence in the operation and in his styptic that he i
did not wait for consequences. Before the operation, ,
he requested me to examine the condition of the cervix
uteri by the touch, and I found it as already described.
Afterwards I repeated the touch, and found the cervix '
as thoroughly divided from the os externum to the os |
internum as it was possible to do it, proving that the
difference in our experience as to hfemorrbage did not
depend upon any difference in the extent of the
operation. I do not pretend to account for the fact,
that the operation is not followed by ha-mon-hage in
Scotland while it is in America ; and I would warn J
my own countrymen to take every precaution against I

I'AIKFUL MEXSTEDATIOX.

151

its occurrence, as it is almost the only accident that
can attend this operation.

I may be pardoned for pressing this subject a httle
ftnther. I look upon this operation, simple as it is,
as one of the great Bxirgical advances of the day ; and
I am so well satisfied of its merits, that I would warn
young men to be careful not to bring it into discredit
by permitting an accidental comphcation that should
never under any circumstances be allowed to take
place. I know a most talented, promising young
physician in my own country, whose reputation was
well nigh ruined by blindly following authority, and
operating with the belief that there was no danger
from bleeding. Having been taught to look upon the
operation as a trifling one, devoid of all risk, he un-
guardedly operated on his patient at his own house,
and allowed her in a few hours afterwards to ride
home, a distance of four or five miles. Hjemorrhage
unfortunately supervened ; the doctor was sent for ;
he was not at home. Some time elapsed before he
could be found, and when he reached his patient she
was in a collapse from loss of blood, from which she
never recovered. This is the only well-authenticated
case of death from ha;morrhage that I have known to
follow this operation. Of course it could not have
happened but for the overweening confidence of the
surgeon in the innocuousncss of the operation, and it
should never happen again. Such an accident as this
may be smotliered up in a great city, but if it occurs
in the hands of a country practitioner, it may wholly
ruin him for ever.

The case above alluded to happened in a small
country village, and the pubUc excitement may be

152 UTEHrNE SUBGEUV.

ima^ned when everybody began to discuss the subject,
and to censure a noble young physician for causing
the sudden death of a citizen, who was supposed to
enjoy the most vigorous health. An eminent professor
of obstetrics testified that the operation was a recog-
nized justifiable one ; that it had been well done, and
that death was the result of a rare and unexpected
accident. This testimony was corroborated by others,
and thus the popular indignation was appeased, and
the young practitioner reinstated in public confi-
dence.

But it may be asked, is there no other danger? I
can only here reiterate what I have before stated, that
out of the hundreds operated on in the Woman's
Hospital and in my private practice, I have seen but
the one case of pelvic cellulitis already noticed, wliich
is the only other risk of the operation that I know of.
While this has occurred but once in my hands from
the operation, it has happened frequently under my
observation as the result of mechanical dilatation by
bougies and sponge tents.

The position I take is this ; that, as a rule, the
operation is less painful than the use of the bougie,
which must be repeated for months ; that it is entirely
devoid of danger from hiemoiTliage, provided we
exercise ordinary prudence in the after-treatment ;
that it is less frequently followed by pelvic inflamma-
tion than eithei" the bougie or the sponge tent ; that
it is more certain and permanent in its results than
either or both ; and that, if we exclude it, there are
great numbers of curable cases wliich would be placed
beyond tbe pale of treatment. Thus, from my stand-
point of view, the operation, when indicated, is always

^

PAINFUL MENSTEOATION.

153

to be preferred to any and all other means of enlarging
the cervical canal.

I am surprised to find that this operation is so
seldom performed in Great Britain out of Edinburgh.
In London it is condemned by the great body of the
pi-ofession, although performed by several eminent
men. But where we find one man to uphold it, we
may point to scores who oppose it. This cannot long
remain so ; for where honesty, intelligence, and earnest
inquiry reign supreme, as they do here, the truth must
and will prevail.

On the Continent, so far as I know, this operation
is almost completely ostracized. When I went to
Paris in September, 1862, a lady of very high position
asked my opinion in reference to her sterility. She
had been man'ied thirteen years without issue. On
examination, I was convinced that conception could
never by any possibility occur unless the neck of the
womb were well opened by incision. AH sorts of
mechanical dilatation had already been fruitlessly em-
ployed, producing metro-peritonitis, and leaving the
OS and cervix as contracted as at the beginning.
When the husband asked rae, " What are the risks
of the operation ? " I replied, " In America or Eng-
land nothing but haemorrhage, and tliat we control.
I cannot say what they would be in Paris, for here
you have erysipelas often following the most trifling
wounds. Ask your own surgeon about it," They
sent for my friend Professor N^laton, who said that
in France the operation would be attended with great
risk to life. Such a decision from such an authority
of course put the operation wholly out of the question
for the time being. However, soon after this I had

154

VTEltlNE SUIKIEIIY.

the good fortune to meet Sir Josejili Olliffe, who-1
invited mc to perform the operation on one of his ]
patients in the upper ranks of life. When I told him j
what I have rehited above, he said he was perfectly ]
familiar with British and American literature on the l
subject, and knowing the safety of the operation,
would assume all responsibility in the matter. Tliia
operation, the first of the sort that I did in Paris, was |
performed on the Slst of October, 1862, for Sir Joseph I
OUiffe. His patient recovered without the slightest 1
trouble; and on the 2nd of December we operated
on the lady whose case was first mentioned. To
guard against any risk from the atmosphere of Paris,
we went to their chflteau, not many leagues from the .
city. The case got well rapidly, as usual, and con- |
ception fortunately occun-ed seven or eight mouths
afterwards. She is now (September, 1865) the happy
mother of two beautiful ctildren, — one a boy, sixteen
months old ; the other a girl, less than a month old ;
and this after a sterile marriage of thirteen years. I
am a little minute in this merely historical part of the
introduction of the operation into France, for I wish
to show that it may be done as well and as safely
there as elsewhere.

My third case was that of a native, and I went with
her to the country to perform the operation. The
next was an American, operated on in Paris; then
another American; and then I began to operate on
natives of France, and in the city of Paris, with the
same fearlessness that I did on Americans.

I may be excused for these minute details ; for as
the operation was condemned by the highest authority
in France, it was important, not so much for myself

FAINTrL MENMTIWATIO.V.

155

as for the advancement of surgery, that I should
exercise every precaution to guard against accident
or xintoward results. I have performed this operation
twenty-four times on the Continent without accident,
except the occurrence of hsemorrhage in one case on
the sixth day after operation, which was promptly
controlled by Sir Joseph OUiffe in my absence. My
patients varied in age from twenty-two to forty.
They were natives of France, Vienna, Frankfort, Eng-
land, Scotland, Ireland, and the United States, The
operations were performed in tiie autumn, winter,
spring, and summer. Twenty were done in Paris,
two near Paris, and two at Baden ; and in all there
was the same I'apid and safe recovery from tlie effects
of the operation as I had always seen in New York.
Of course this small number of successful operations
is not enough trO establish fully its acclimatization and
its claims to nniversal favour there; but they are
certainly sufficient to attract the notice and considera-
tion of the profession in France.

But we were speaking of painful menstruation and
its almost invariable concomitants, contracted os and
narrowed cervical canal ; and having said so much in
a general way about the various methods of over-
coming these, we may now proceed to discuss the plan
of operating, together with the after-treatment neces-
sary to protect against haemorrhage and to ensure a
patulous canal.

For the operation of incising the os and cervix uteri,
wo are indebted to Dr. Simpson. His method is fol-
lowed by most operators, both in my own country and
in this. He places his patient on the left side, intro-
duces the index Bnger of ouo hand into the vagina.

166

UTEKINE SDKGERY.

pushes the fundus uteri up if it be auteverted, pasM
his uterotome (fig. 51) along the cervix through the oa 1
internum, springs the blade, and withdraws the instru-l

ment, cutting open one side of the cer\'i3: ; then rein-J
troducing the instrument, tiio other side is cut in like
manner ; thus making a bilateral incision of the cervix
large enough to allow the index finger to be passed to
the 08 internum ; and, as before stated, he then passes
into the vagina a large camel's-hair pencil, saturated
with a solution of the perchloi-ide of iron.

Dr. Greenhalgh has modified Dr. Simpson's instru-
ment by giving it two blades, which cut through both
sides of the cervix at once, thus ensuring an equilateral
uniformity of section tliat cannot always be predicated
of the single-bladed instrument. His instrument
(fig. 52) is a masterpiece of ingenuity, and answers
well in his practised hands. But I object to both
these methods, because they are done in the dark, and
too much is left to the execution of a machine instead
of tlie judgment of the surgeon.

Suppose it were necessary to amputate an elongated
uvula, — ^by no means an uncommon operation, — would
it be judicious to run one finger down the throat and
guide by it some machine for performing the operation
in the dark ? Or would it be more surgical and more
precise to look into the throat, seize the part with a
proper appliance, and amputate it where our judgment

I'AINFDL MENSTRUATION.

157

would determine to be right and best for the individual
case ? There are operations that must be done by the
touch alone; but we never select this plan
if it be possible to aid the manipulatory
process by the sight.

Besides the objections already urged
against instruments of this class, there is
another to which all instruments on tlie
principle of cutting from above downwards
are obnoxious — viz., that as the uterus is
not fixed, it may glide upwards to .some
extent by the mere centriftigal force of the
expanded blade or blades, and thus we can
never feel altogether certain of the length
and breadth of the cut. Wliether too much
or too little, it is not safely remediable
afterwards.

The operation, as I prefer to perform it,
differs from Dr. Simpson's, not in its aim
and scope, but merely in its mechanical
execution. He and his followers operate in
the dark ; I bring everything plainly into
view. They cut from witliin outwards ; I,
in the contrary direction, from the os ex-
ternum upwards to the cavity of the womb.
They, as a rule, do not tampon the vagina
after the operation ; I always do, for the
double pui'pose of guarding against hsemor-
rhage and ensuring an open os.

I place the patient on the left side, as
for all the operations in uterine surgery.
The speculum (fig. 5, p. 18) is Introduced; a small
tenaculum is hooked into the central portion of the

158 UTERINE SUROERY.

anterior lip of the os tincre; tbo uterus is gently
pulled forwards ; one blade of a pair of cur\'ed
scissors is passed into the canal of the cervix till
the outer one comes almost in contact with the
insertion of the vagina on the side of the cervix,
and the portion tlma embraced is divided at one
blow of tlie scissors. Then tlie opposite side is
in tike manner divided, and the operation is almost
finished (fig. 53). It only remains, while the uterus is I

atiU held in position by the tenaculum, to sponge away
the blood, and pass a narrow-bladed, blunt-pointed
knife (at a proper angle with its handle) and divide
the small amoimt of tissue on each side leading from
the scissor-cuts up to the very cavity of the womb.
The scissors never cut the whole amount of tissue
embraced between the blades. They will spring back
a little, making only a deep notch on each side of the
08. The advantage of cutting the edges of the os J

PAINFUX. MENSTRUATION. 159

With scissors is that we make the incisions perfectly
cqiiilaterat and symmetrical.

Flo. 64,
[1 now often nae aciaBora with ahort straight blruW. but cnrvwi

Fig. 56 represents tlie knife with the blade in proper
-..^^^^ position for cutting the left side of

^"""■^ '"" the canal. To cut the right side, it

I is necessary to turn the blade in

the opposit«3 direction ns shown by
the dotted line. The blade may be
fixed firmly at any angle by the
screw at the end of the handle,
which drives a shaft up into little
holes, as seen in fig. 56, where the
razor-shape of the blade is also
shown. The ojieration is quickly
done, and the judgment
of the surgeon deter-
mines whether the pe-
cuharities of the case
demand more or less cut-
ting. The haBmorrhage
is usually unimportant,
but sometimes it is pro-
** fuse; and I have occa-

Fio. 66. sionally seen it come

ft-ith such a rush that the vagina would be filled

160 UTERINK SIIEGEHT.

before a set of sponges could be washed out. But
there is notliing to be feared. Press one or two
sponge probands (fig. 57) right into the neck of the
uteruB, but at the same time be sure to keep the
organ firmly fixed by the tenaculum ; for if the bleed-
ing be profuse, it is a very awkward and unlucky
thing to let it slip out, particularly if the vagina is lax_
and deep. A minute or two will usually suffice to
control the bleeding by the pressure of the probangs.
When that is done, the dressing may be proceeded
with. Two or three small
pieces of cotton, large
enough when moistened to
fill up the gjiping oa, are
to be thoroughly saturated
with water, then squeezed
BS dry as possible, and after-
wards wetted in a mixture of
one part of Deleau's neutral
solution of the perchloride
of iron with four or five
parts of water, or in Dr.
Fm. 67. Squibb's liq. ferri peraul-

[ThiB cut iB introduced here phatis similarly diluted.

nimply to flhow the mechnnism of ci . . i ii

th/Bpo-ge-hoider. .iid tho p^per Squeezc out the suporfluouB
Bi7fl of the ■ponge. We often nao fluid, and placc a bit of the

too Inriro a Bponire tti be paBged ,. ■ i i> , i

cotton m an angle of the

^

with E

1 the fi

Bhonid hnvB a few itinoh Btnallcr wOUud, preSSiug a pOrtion

of it lip into the cervical
canal, and holding it in place with the sponge pro-
bang. Apply another bit of cotton similarly prepared
on the opposite side, and press it down ^vith anotlier
sponge probang. If necessary, another portion of
cotton may be placed centrally ; then, if there is no

PAINFUL MENSTKDATION. lt»l

bleeding, some cotton wet with water or glycerine, may
be laid over tlie neck of the womb, to be covered with
dry cotton to the extent of supporting the whole
dressing neatly and comfortably in its place. The
patient is put to bed, having been perhaps five or six
minutes on the table. She eats and drinks as usual,
but the recumbent posture is enjoined for a few days.
She may pass water lying, or it may be drawn off.
The only object of the recumbent posture is to ensure
the retention of the dressingiV sllii. I formerly allowed
my patients to sit up and walk about the room the
day after the operation ; but I was so often annoyed
by the supervention of hasmorrhage that I at length
adopted the plan of keeping them down till the spon-
taneous separation of the intra-ccrvical dressing.

On the day after the operation, the whole of the
vaginal portion of the tampon is to be carefully re-
moved, placing the patient in the position as for the
operation, and using the speculum, which must be
introduced so as not to derange the relations of the
dressing. Wlien it is all removed do^vn to the intra-
cervical portion, a wad of cotton saturated with
Price's glycerine, and large enough to cover completely
the cervix and its first dressing, is laid over it, and
the patient again lifted into bed. The action of this,
as already fully explained, is to induce a profuse
watery discharge from the vagina, which keeps the
part cleanly drained of all secretions or exudations
from the decomposition of the blood contained in the
original dressing. This glycerined cotton is to be re-
moved and renewed daily till the suppurative process
throws off the dressing from the neck of the womb.
This will not be under three or four days. In the

162

DTEBINE SUKGBKT.

mean time, the glycerine, by its detergent and antiseptic
properties, keeps everything sweet and clean ; and its
affinity for water, which by osmosis it extracts from
the tissues with which it Ues in contact, keeps the
parts entirely clear of any secretion that might be
re-absorbed and poison the blood, if not thus drained
off by the cheraico-capillary action of the dressing.
No one can thus apply glycerine to the neck of the
womb and not be struck with its pectUiar power
and properties. The intra-cervical dressing will be
loosened on the third day or later, and it may then be
gently removed with forceps. If it adheres obstinately,
let it alone, but cover it and the whole cervix with the
cotton glycerole, and at the nest dressing it may come
away easily. I have frequently provoked bleeding by
a Uttle impatience in removing it prematurely. When
it is once safely out, then the cervix is to be plugged
with a small bit of cotton glycerole, and the whole
covered as before with the same. This dressing is to
be renewed daily till the parts have entirely healed,
which usually takes from twelve to seventeen days,
or perhaps tQl the recurrence of the next menstrual
period. And this reminds me that the operation should
always be performed within from tliree to five days
after a menstrual epoch, so that wc may have time
enough for the healing process to bo wholly completed
before the recurrence of the next period.

There is sometimes great trouble in keeping the
mouth of the womb sufficiently open. It never re-
mains just as we cut it. The tendency of all cicatrizing
wouuds to contract as they heal is wonderfully illus-
trated here. I have often been amazed to find the oa
contracted in a month to one-fourth of the size of the

TAINFUL MENSTRUATION.

163

original incisions. I have frequently seen it cut open
large enough to admit the index-finger up to the os
internum, and then close in a few weeks to such a
degree as not to admit a No. 4 or 5 bougie, and this
in spite of persevering efforts to prevent the contrac-
tion. This is the case where there is great induration
of the cervix, with deposit of fibrous tissue. I have
frequently been compelled to repeat the operation, and
I remember several patients upon whom I have operated
as often as three times in the course of a few months,
and even then the result was not wholly satis factoiy.
These may be called exceptional cases, but it is well to
know that they are not very rare. Even when the os
tincre remains open enough, we may have some trouble
in keeping the contracted portion above of normal
dimensions. This may be the case if there is much of
a flexure, particularly anteriorly. And here I would
recommend the occasional passage of a bougie after
the first week. Dr. Emmet is in the habit of using
the sound as early as the third day after the operation,
passing it into the cavity of the womb, and pressing it
pretty firmly first against one side of the canal and then
against the other in withdrawing it. I have in a few
cases followed his example, but with a little timidity.
Dr. Greenhalgh uses a self-retaining intra-uterine
stem, which is very ingenious, and answers well in liis
hands. Dr. Priestley's instrument* (fig. 58) maybe
found usefiil under those circumstances. Introduced
as an ordinary sound, it is then dilated as shown in
the cut.

Incision of the os often cures dysmenorrhnen ; some-

> Mtdlcal Tiiiiei anil Giuetle. March .'itb, l(*fU,
M 2

164

UTEEINE SURGERY.

times it only modifies it. And again, I have seen cases
where it produced no beneficial
effect whatever. The first men-
strual flow after it is usually
ushered in without the premoni-
tions that had so long harassed
the poor sufferer, and she may
pass through the whole period
with comparative comfort ; but I
think it advisable for such patients
to take very good care of them-
selves at each return of the flow,
and to avoid all unnecessary ex-
posure or fatigue. If there is
pain enough to lie down, I direct
an anodyne by the rectum, and
for this purpose McMunn's elixir
of opium is the very best. It is
less apt to nauseate or to pro-
duce headache tlian crude opium
or any of its alkaloids. It is
more cflBcacious by the rectum
than by the mouth, because it is
more immediately in conjunction
with the nerves of the affected
part.

But suppose the bilateral in-
cision produces no peiinanent
tsm fe [^ k amelioration, are we to give up

™^ ISK the case as beyond the reach of

Fib. 68. in tit

surgery r Uy no means. We
must then re-investigato ; for there may still be
mechanical oljstacle imdetected, or, if detected.

some J
, un- I

PAINFUL MENSTRUATION.

165

relieved by the operation. For instance, dyamenor-
rlicea may persist in consequence of an undetected
polypus, or of acute flexure with contraction of the
canal of the cervix at the os internum ; or it may be
the result of a curvature of the cervix, at the insertion
of the vagina, with elongation of the intravaginal
portion, and a consequent unequal development of its
anterior and posterior segments. I propose to give
examples of each of these classes.

I have on more than one occasion found the pain to
be due to an undetected polypus, so diminutive as to
elude observation. A single illustration will serve as
an example of its class, and at the same time be a
warning and a guide to the inexperienced.

Mrs. , aged thirty-two, married at twenty-four,

sterile, had dysmenorrhcea for some years before
marriage, worse after. Her sufferings were excru-
ciating for about two hours on the second day. She
had in the course of twelve years been treated by
sixty different physicians without permanent benefit, —
the largest number I ever knew any one person to
consult. She had been under the care of many of the
most eminent men in at least five or six of the great
capitals of Europe, besides her consultations at home.
I saw her in January, 1857. Her general health was
good ; her only trouble seemed to be the much-
dreaded dysmenon-hcea.

The uterus was of normal size and in proper position.
Os and cervix both small, but not indurated. I re-
sorted to the sponge tent, but found no polypus, no
fibroid, and no flexure of the canal. Three days after
(January 12), the os presented precisely the same
appearance that it did before the use of the tents.

166

UTERINE SURGERY.

The next menstruation was quite an painful as usual,
if not more so. As the canal was straight, and the
corvix soft, I would hardly have expected severe pain,
although the os was rather small. Yet I did not
know what else to do but to incise the os and cervix,
hoping that some benefit might be derived from it.
Accordingly, the operation was performed on the 22nd
January, and the parts were healed before the next
menstrual period ; but the pain was still the same,
and so continued for three or four montlis, in spite
of treatment. I was now quite perplexed. I had
used the sponge tent and found no polypus. I had
then enlarged the cervical canal without the least im-
provement ; but the symptoms were so evidently those
of mechanical obstruction, that I concluded to make
another exploration of the cavity of the uterus. I
accordingly introduced a small sponge tent, and on
its removal I passed another,
larger and long enough to enter
the cavity of the womb. On
its removal, I had the satisfac-
tion of finding and bringing
away a polypus, which was but
little larger than a common
garden pea. Its attachment
and relations, represented in
the diagram (fig. 59), suggest
at once the rationale of the
symptoms.
The violent agonizing pain al-
Jw. w. ways supervened on the second

day of the flow. When I first
felt the tumour, it was protruding through the os inter-

l'A[NFUI. MENSTRUATION. 167

num after the removal of the tent ; but by the pressure
of the finger it suddenly sHpped upwards, and I could
not touch it again till the finger was gently forced
through the os internum to the fundus, when I fortu-
nately seized it with forceps and brought it away.

My explanation of the pain is this — By the second
day coagula formed above the tumour, which pressed
it do^vnward8, its slender pedicle yielding till it
blocked up completely the os internum just hke a ball-
and-socket valve. Then woidd come the violent
neiu-algic throes continuing for two hours or more,
till the tumour either dilated the contracted part, or
was compelled to retreat again into the uterine cavity
by displaced coagula driven between it and the poste-
rior face of the uterus by the expulsive effort.^ of the
organ.

The case illustrates the necessity of a very thorough
investigation before a correct diagnosis can always
be made out in obscure cases. The leeching, the
physicking, the blistering, the anodynes, the baths,
the mountain excursions, the sea-bathing and sea
voyages that this poor patient suffered and endured
for years are almost incredible. As contemptible as
the little polypus was, it took me nearly four months
(shall I say ?) of empirical observation to find out that
it was the source of all the mischief.

It is now plain enough, but the difficulties of dia-
gnosis may be appreciated when we remember the
history of the case and the great number of dis-
tinguished physicians who were baffled in their honest
efforts to elucidate it.

I have already said that sometimes after the cervical
canal is freely opened by the bilateral incision it con-

168 UTKRINE sritOEIiY.

tracts again, anil the pain of Jysmenorrhoea may be I
just as severe as before the operation, and that this iam
more apt to be the case if there is much flex(ire,r
particularly anteriorly. We shall then in all proba^l
bility be compelled to repeat the operation, and eser»i
cise greater car© in keeping the canal open afterwards.]
We may occasionally find the obstruction at the osM
internum with flexure and contraction, while the lower"!
portion of the canal may be of normal size. This,
however, is by no means common. Yet I have seen
several examples of it, Ita most perfect tj'pe I found _
in a patient of Sir Joseph OUiffe. This lady was abouta
thirty-six years of age, and had suffered from painfiill
menstruation most of her menstrual life. Sir Jo
had dilated the os externum and the cervix up to the
OS internum, but had never been able to pass a sound
through this. One of the most eminent surgeons of
Paris saw her in consultation with Sir Joseph about
four years ago, and, failing to pass the sound, proposed
to enlarge the contracted portion by the use of the
actual cautery ! This treatment was not carried out,
and on my arrival in Paris, in the fall of 1862,,
Dr. OlHffe kindly invited me to see her. I found thea
fundus lying just behind the inner face of the symphyaisJ
pubis, with quite a sharp flexure at the 03 intermunJ
The sound could.be easily passed to the oa internum,r
where it met with an unyielding barrier, and I was
obhged to have a small one made, quite probe-like,
just to suit the case; and even tliis could not be pa
with the patient on the back; but by placing her on theJ
side, using the speculum, and fixing the cervix with i
tenaculum, it passed into the uterine cavity seemingly i
through a dense inelastic ring of fibrous tissue, which 1

RMNFIII, MENSTRUATION.

169

resisted not only the ingi'esa but the egress of the
olive-shaped point of the probe. I at once agreed
with Sir Joseph's opinion that an incision of the part
was the only safe and speedy method of overcoming
the diflficulty/ The neck of the uterus was split bila-
terally, just aa if it Lad been contracted all the way
to the OS tincje. When we
came to cut the gristly
circular band at a (fig. 60),
the blunt - pointed knife
was passed through it with
some little difficulty, and
the cuts on each side were
attended with the peculiar
creaking sensation that
we experience in cutting
through cartilage. The

wound was treated in the usual way, as previously laid
down, and all was well by the time of the next men-
struation. The 03 internum was, after the fourth or
fifth day, forcibly pressed open laterally by the sound,
as practised by Dr. Emmet.

But the pain of menstruation may continue even
after all our best efforts to enlarge the oa internum
as well as the cervical canal by the bilateral incision.
It is then often the consequence of curvature, with
elongation of the vaginal poi-tion of the cervit, ac-
companj-ing anteflexion. When this is the case, we
shall find the os tineas looking in the direction of the
axis of the vagina, the posterior portion of the cervix
from the 08 tincse to the posterior cul-de-sac being two
or three times as long as the anterior, measuring from
the OS to the anterior cul-de-sac. I have repeatedly

170

riTERINT; RUROERY,

performed the bilateral operation on such cases as this
without improvement, and for the best of reasons.
If we take a flexible tube the size of the cervical canal,
and curve it as represented by the dia^am (fig. 61),
it flattens out laterally, and
the inner concave - convex
surfaces, necessarily brought
into close apposition, pre-
sent an almost valvular
mechanical obstacle to the
passage of a fluid iji either
direction. By referring to the
diagi'am, it will be seen at
once that a bilateral incision
could only widen the canal a little transversely, but
not at all antero-posteriorly ; that the curvature would
remain the same, and consequently the distances be-
tween the two opposing surfaces of tlie cervical canal
would in no way be modified by such operation.
Having so often failed, under such circumstances, to
afibrd the relief anticipated from the bilateral incision,
I at last devised and practised the following method.
To remove the flexure of the canal would be to remove
the obstacle to the easy passage of the menstrual flow.
To do this, it is only necessary to split the posterior
portion of the cervix from the o9 tincns in a straight
line backwards, nearly to the insertion of the vagina,
and thus the canal of the cer^nx is made to run in a
straight line from the cavity of the uterus to the
terminus of the incision at a, instead of curving round
to the OS tincae. The method of doing this is very
simple. The patient as usual on the left side ; the
speculum introduced ; the anterior lip of the os tincae

PAINFUL MENSTRUATION. 171

is held by the tenaculum, as so often described ; and
then with a straight pair of scissors the posterior
portion of the cervix is split at one blow, as far as can
be easily and conveniently done by scissors, which
would be about as far as represented by the dotted
line a c, fig. 61. Then the blunt-pointed
knife (fig. 62), bent at a proper angle
with its shaft, and cutting backwards,
is passed up to the cavity of the uterus,
and the parts cut in the direction of the
line a rf, thus straightening out the
canal, and thereby removing the mecha-
nical obstacle due to its flexure.

Fig. 63 is intended to represent the
second stage of the operation. The
uterus is firmly fixed by the tenaculum,
while the razor-shaped blade of the
blunt knife is seen in the act of cutting
the canal backwards. The case is to be
treated on the same general principles
laid down for the management of the
bilateral operation. There is some little
care necessary to avoid cutting through
the vaginal cul-de-sac into the peritoneal
cavity — an impardonable blunder that no
true surgeon could possibly make. The
operation has succeeded admirably in these cases, but
is wholly inapplicable except in just such cases as the
one above described. I have often performed the
operation in this way, and my colleague. Dr. Emmet, has
repeated it more fi'equently than I have ; for the relief
it affords is a great temptation to its performance.

In operating for dysmenorrhoea, we must not lose

172 tlTERINE SURGERY.

sight of doing it in sucli a way as to favour the
chances of conception. How often do wo hear even
medical men say, " If ahe could only have a child it
would cure her." To this I always feel inclined to

reply, "If we could only cure her, she would have a
child." We should remember that the physical causes
tliat obstruct the easy egress of the catamenia, like-
wise obstruct the easy ingress of the spermatozoa ;
and to remove the one is in some degree to relieve
the other. If an inflamed, turgid cervical mucous
membrane is a mechanical barrier to the passage from
one direction, it is equally so to it from the other.
If a contracted os shuts the door to an outlet, it closes
it equally to an inlet. If a cervical canal, flexed to
such a degree as to bring its opposite walls into close
contact, will produce the pain of dysmenorrhoea, it will
as certainly prevent the pain of parturition, but only by
preventing conception. Thus, to treat dysmenorrhoea
successfully, is to treat many, but by no means all,

f'AINFUL MENSTHDATION.

173

I

cases of sterility suecessfiilly. Those who have adopted
the operation of enlarging the canal of the cervix for
the cure of dysmenorrhcea, seem satisfied to rest upon
it alone for the relief of sterility. But more remains
to bo done.

It would seem that I have already said enough on the
subject of dysmenorrhcea, and the operations for its
relief; but as my views pre^usly published* have
been controverted by some of the most eminent medical
men in England, I shall say a few words more.

Dr. Henry Bennet t objects to the operation of in-
cising the cervix, because he thinks he can accomplish
the same result by sponge tents; and Dr. Gream,J
because he thinks the bougie system, as introduced and
practised by M'lntosh, answers every purpose. Dr.
Gream says he has seen a case in which the neck of the
womb was so largely opened that he could easily pass
his finger through it, and touch the membranes of the
ovum, at the third month of gestation. His patient
aborted soon after ; and he thinks the aboi-tion was not
the result of passing the finger into the cavity of the
uterus, but of the inability of the organ to retain its
contents, in consequence of the extensive division of the
circular fibres of the cervix.

This is, I admit, a very rational inference; at all
events we must accept the fact, and inquire into its
cause. Mr. Spencer Wells§ advocates the operation,
but says he has seen several cases in which the cervix was
too largely incised, and the lips of tlie os tincae were in

• laiieel, Marc-Ii 4th and 1 1th. April lat, anH Jnne 3rd, 18C.5.
t Lancel, June 21th, 1865. J r^aneet, April 8tU, 1865.

$ Lanett, Mnv 2Tth, 186.'i.

174

DTBBINE SUBQEEY.

consequence everted, rolled back and almost lost in the
insertion of the vagina. This is certainly a very grave
objection to the operation of bilateral incision. But
I have never seen this accident after the operation, as
performed by my method, and, as before stated,
Dr. Emmet and myself have done it several hundred
times.

Let US) then, inquire why it occasionally follows this
operation in the hands of English surgeons and not
in om's. At first I was dispose;! to believe that the
gentlemen alluded to above had encountered unique and
isolated cases ; but upon inquiry I am now convinced
that this accident does occasionally follow the use of
the metro-tome cach^. It is well to know this fact, so
as to guard against its occurrence.

A short time ago, a friend invited me to see a case of
fibroid of the uterus, attended by sevei-e haemorrhages,
in which he had divided the cervix after the plan of
Mr. Baker Brown. The operation had been done by
some one before, but the bleedings continued, and my
friend, desirous of giving the operation a fair chance,
determined to make a more thorough division of the
cervix, for which purpose he set the blades of the metro-
tome cach^ very widely, so as to cut deeply. The con-
Keqnence was a complete division of the cervix through
the whole of the circular fibres, from the 03 tincEe quite
to the cavity of the utenis, which produced the de-
formity that Mr. Spencer Wells speaks of. After seeing
tliia case, I could no longer doubt. Wliy does this
accident happen after the metro-tome cach^ method of
operating, and not after my plan ? The reason is
obvious enough, if we consider the difference in the
two methods of operating. To illustrate this, let the

PAINFUL MENSTRUATION. 175

diagram (fig. 64) represent the natural size of the uterus.
This outline is taken from Dr. Savage's* picture of a
dissection of a uterus of natural size. I have made

the cervix project a little more into the vagina, as we
usually find it so in the majority of cases requiring
operation.

According to my plan of operating, the dotted line
a b would represent the proportion of cervical tissue
divided by the scissors (page 158), while the dotted
lines acybc would represent the extent of the incisions
made by the blunt-pointed knife (fig. 55, page 159) up

" "Illustrations of the Surgery of the Female Pelvic Orgaiw."
By Henry Savage, JI.D., PliyBician to the Samaritan Hospital for
Women. Plate t*, fip. 3.

176

UTERINE 8UHQEBV.

towards the cavity of the uterus. Now, upon tbis same
diagram, let ua see what would be the nature and
extent of the incisions made by the metro-tome cach^.
We vnW take Dr. Greenhalgh'a instrument, as now
made in Loudon by Weiss, and in Paiis by Cbarrifere,
as being the safest and best of its class. Lay it down
upon this diagram, with the point at the fundus J, and
the shoidder at the os tincEe, hold it firmly as we
would in operating upon a patient, then draw the
blades slowly down, and the extent of their movements
will be shown by the dotted lines e d, fd.

The two methods differ theoretically as well as pi-ac-
tically. The one is based upon the idea that the obstacle
to be overcome usually exists in the lower portion of
the cervical cand ; the other upon the belief that it is
always found at the os internum. Now, by comparing
the incisions made by these two methods, it will be
seen that the metro-tome cachd divides the circular
fibres of the cervix to a greater extent at the os in-
ternum, and throughout the entire cervix, than is done
by my method.

As before said, too large a division of the cervix is
sometimes followed by eversion and rolling back of
the two lips of the os tinca3. But why only some-
times ? Large and small are always relative tenna.
What may be small in one case may bo compara-
tively large in another. The metro-tome cachi5 cuts
60 much, whether the cervix be large or small. We
know very well that the size of the cervix varies
greatly in the unimpregnated uterus, and that in the
class of cases requiring this operation, it is sometima
less than an inch in diameter. Now, if we
instrument that cuts more than this, it must of 1

I

TAINFUL MENSTRUATION. 177

Bity cut through the cervix from side to Bide ; and hence
the danger of the accidents that are said to Bometimea
follow this operation.

I have seen, in Beveral shops, metro-tomea that
could be opened from one and a half to two inches. I
am not going out of the way to caution my younger
brethren against machines of this sort, when I call to
mind the fact that a friend of mine recently used one
of them, and was afterwards glad to see his patient
ultimately recover from the serious consequences of
his rashness. If we must use a metro-tome cach^,
let us take Dr. Greenhalgh's, with its maximum ex-
pansion, as shown in the diagram above.

But why do the lipa of the oa tincse roll back when the
cervix is too extensively incised ? The rationale is this :
The longitudinal fibres of the uterus run down from the
fundus to be inserted or incorporated antero-posteriorly
with the circular fibres of the cer\'ix. These two sets
of muscular fibres are antagonistic in their action
physiologically. In a normal labour, the contraction
of the longitudinal fibres of the body must be accom-
panied or followed by a relaxation of the circular fibres
of the cervix, or the labour could not be finished. They
are as antagonistic as are the flexors and extensors of
the hand. Destroy the power of the one set of muscles
and the other will inevitably take on a tonic contraction,
and draw the hand in the direction of the line of their
action. In the operation of dividing the circular fibres
of the cervix uteri by the metro-tome cach^, if the
whole diameter of the cervix be cut entirely through,
we must of neceBsity cut the whole of its cii'cular
muscular fibres, which destroys their contractility, and
removes the force that bound, as it were, in a bundle

178 UTERINE SUROERY.

the terminal extremities of the longitudinal fibres, which
then take on a tonic rigidity, retracting the divided lips
of the OS tincae, and producing the deformity that, we
must admit, is occasionally seen to follow the metro-
tome cach^ method of operating.

Whether my explanation be correct or not, does not
in the least affect the fact imder consideration ; and the
young surgeon cannot be too careful, for if he should
unfortunately cut too much, there is no remedy for his
mistake. It is far better to cut too Uttle, even at
the risk of being compelled to repeat the operation.

SECTION III.

THE OS AND CERVIX UTERI SHOULD BE SUFFI-
CIENTLY OPEN, NOT ONLY TO PERMIT THE FREE
EXIT OF THE MENSTRUAL FLOW, BUT ALSO TO
ADMIT THE INGRESS OF THE SPERMATOZOA.

X 2

SECTION III.

I

THE OS AND CKRVIX UTURI SHOULD HE SUFFICIENTLy OPEN,
NOT ONLY TO PEKMIT THK FItEE EXIT OF THE MEN-
STRn.VL FLOW, BUT ALSO TO ADMIT THE INGEESS OF
THE SPERMATOZOA.

IN the preceding pages we have followed symptom-
atology to the detection and treatment of organic
disease, but now we propose to ask in what particular
organic structure varies from a normal condition, irre-
spective of rational signs ? It will then be necessary
to inquire into the normal condition and relations of
the uteinis, before speaking of its anomalies, and their
influence on conception.

Anatomists tell us that the uterus is pear-shaped,
and flattened a little antero-posteriorly ; that it
is from two and a half to three inches long; an inch
and a half wide, more or less, at its largest part ; and
about an inch thick ; that it ia divided into fundus,
body, and cei-vix ; that its cavity is from two and a
quarter to two and a half inches long, the canal of the
cervix being a little longer than that of the body ; that
the OS tincse is generally round in the nulliparous
uterus; elliptical and transverse aft«r child-bearing;
and that the cervix is rounded and embraced by the
vagina, which is inserted higher behind than before,
thus making the posterior inti-avaginal portion of the
cervix a little longer than the anterior. But anatomists
do not tell us how far the intravaginal portion of the

182 CTEBINK SUKOEEV.

cei'vix should project into the vagina, or what proportion
it should bear to the supra-vaginal section, which, by
the bye, is an important matter to determine. Not
having time or inchnation to go to the dead-house for
the verification of this point, I shall describe the neck
of the womb as I see it in daily investigations on the
living. I assume that a normal os tincEe, whether
round or transverse and elliptical, should be open, and
filled with a ahppery translucent mucus of slightly
alkaline reaction; that the cervix should be rounded,
truncated, and elastic to the touch; that the intravaginal
portion should be about a fifth or not more than a fourth
of its whole length, i.e., from a quarter to a third ot" an
inch anteriorly, and a fraction more posteriorly ; that
the canal of the cervix should be straight or curved
shghtly forward ; and that the axis of the whole organ
should stand at about right angles with that of the
vagina, being neither anteverted nor retroverted to any
great degree. Any woman with such a state of the
uterus will always conceive in three or four months
after marriage, if everything else is right.

Having laid down this ideal of what the womb should
be, an ideal that has not been imagined, but drawn from
actual observation in the clinique and the consulting-
room, we shall proceed to the examination of the
sterile, miimjiregnated uterus, to see where and how it
may differ from a normal conceptive state. This neces-
sarily embraces anomalies or deviations from a normal
state ; 1st, of the mouth of the womb ; 2nd, of the
cervLx; and .3rd, of the body : and this brings us at
once to the third general subdivision of our subject,
viz., that the os and cervix uteri should be sufficiently
open not only to permit the fi-ee discharge of the

OS TINC^ — ABNORMAL

183

moDstrual flow, but also to admit the ingress of the
spermatozoa.

It might appear, at the first glance, that this pro-
position had been embraced, and sufficiently discussed,
in the preceding article on painful menstruation. But
experience teaches us differently; for instance, how
often do we see sterility where there is no symptom
of disease so far as physical suffering is concerned ?
Menstruation may be perfectly normal, there may be
no back-ache, no vesical tenesmus, no beaiing-down,
no leucorrhcea, indeed, no sign of diseased action ;
and when we come to a physical exploration, we
may even find the uterus of proper size, in a normal
position, and with a straight cervical canal, but
the OS may not be larger than a pin's head, and if
to tliis be added induration of the cervix, the case is
almost necessarily sterile ; for while the os and cervix
are capacious enough to transmit the outward flow, the
03 itself is not capable of admitting the sperm, and
without this there can, of course, be no conception.
This is not theoretical, and I might give numerous
illustrations in proof, but one will suffice.

Mrs. X., of fine form and vigorous health, had been
married many years (thirteen or fourteen) without ofi-
spring. Menstruation regular, normal ; never had leu-
corrhcea, or any other symptom of uterine disease ; and
|)eople wondered why such a fine specimen of womankind
should not become a mother ; and they very generally
and erroneously inferred that it could not be the fault
of such a physical organization. She consulted many
eminent medical men, and took baths and mineral
waters, and cordials, elixirs, and nostrums without
number. She had submitted to bo bougied till an

184

UTEEINK SLTKGKHY.

attack of pelvic cellulitis supervening had well-nigh
cost her her life. Indeed, I never saw any woman so
determined on having offspring, and for that purpose
she was ready to suffer anything and to take any
reasonable risk. On examination, I found the uterus
in proper position, and rather under size; but as men-
struation was perfectly normal, the size of the organ
was not deemed of any great importance. The canal
was straight, but the os was exceedingly si
the cervix felt to the touch like a little round marblej
and almost as hard.

Of course there was but one thing to be done, viz.J
to open the os and cervix by the bilateral operations
This lady, who hatl already Buffered so much froi^
dilatation, thought the operation a small affair com
pared to the result hoped for.

In this case, I was able to say beforehand that sIm
would almost certainly conceive after the operation^
Very often wo can say to one, " Yes, you are almost
sure to conceive; " while to
another we are compelled
to Bay, " Conception is pn
bable ; " to another, " It i
possible ; " and to othert^
"It is impossible."

This diagram (fig. 65) i
presents the relative condiJ
tion of the os and cervixa
The operation was done :
April, and conception
curred in December foUow-J
ing. Here there was no dysmenorrhcea, as aires
remarked. And why ? Simply because there was ngi

us TINCJi^ABNOkMAI..

185

mechaoical obstruction to the flow. The canal of the
cei-vix was small, but straiglit ; and its mucous mem-
brane was not congested. Had it been a little crooked,
there would probably have been pain, for it was very
small. But as small as the os was, it permitted the
easy exit of the menstrual flow, wliile it prevented the
ingress of the sperm. This is proved by the fact that
she was sterile for thirteen or fourteen years, during
which time she tried all sorts of remedies to overcome
it, and then became pregnant in a few months after the
performance of the operation.

I have seen many other similar cases, and a great
many like it artificially pi'oduced by the injudicious use
of potassa fiisa, potassa c. calce, and even nitrate of
silver.

Sometimes the os tincse becomes wholly occluded by
the prolonged use of these agents ; more frequently it
is partially closed, and the cervix always feels indurated.
Whether the induration is due to tlie action of the
remedy, or to tlie inflammation that called for its
application, I ahull not pretend to say ; but I have
always found artificial occlusion of the os to co-exist
with induration of the cervix. This produces a state
of acquired sterility. I have met with it more fre-
quently amongst those who had once borne children,
though I have seen it in those who had not. A marked
example of this was found in the out-door practice of
the Woman's Hospital, in a young unmarried woman
who had had potassa c. calce applied some months
before at one of our dispensaries. When the finger
was introduced into the vagina, the cervix was found
in proper position, but it wa.s perfectly round and liard,
and no os was to be felt. Wlien the speculum was

186 L'TKUIME srUGEItY.

used, we found the os completely bi-idged over by a
dense fibrous bond of union, with a little opening
at each extremity, whicli.
would not admit an
dinary-aized probe. Fig.
represents the appearance
of the OS in this case, and
shows the two little points
a a, whence issued
menstrual flow.

I saw, in consultatii
with Sir Joseph OllifFe in
Paris, in 1803, a lady in
the higher ranks of life, who had been twice married
without offspring, and whose os tincse had been tbua
artificially agglutinated by the prolonged use of the
nitrate of silver during her first marriage.

Wlien this mechanical obstruction to the egress of
the menses is thus artifically produced, we may find
more or less suffering and general malaise attend-
ing the flow, which becomes imusually prolonged,
always very dark-coloured, often of tarry consistence,
and sometimes offensive. The cessation of the flow
is then followed by a dark-brownish fine coffee-
grounds-like mucus, which continues for a few days,
and frequently irritates the parts with which it cornea
in contact. The mechanical obstruction at the os
preventing the easy outlet of the flow, causes a jiartial
retention of the secretions, which thereby undergo
some change, that reacts upon the tissues, and pro-
duces a sort of subacute endo-metritis. Of course the
only remedy is the restoration of the os and cervix to a
normal state, by cutting open the canal and keeping it so.

rnta

OS TINCJ: — .^NORMAL. 187

i speciea of artificial occlusion of the os by caustic
applications is not, I am glad to say, very common, but
I fear it occurs more fi-eqiiently than it should. For-
tunately its effects are easily remedied if they are
recognized.

The cases of it that have fallen under my observation
did not present themselves on account of the sterility
that it engendered, but because of the ordinary symp-
toms of uterine disease from which they suffered.
Several of these, when cured of the organic difficulty,
were rendered fruitful again.

I have repeatedly said that tlie subjects of sterility
are naturally arranged in two great classes ; viz., those
who have never borne children, and those who, having
once conceived, cease, from some cause or other, to
conceive again.

Very perfect illustrations of this last class may be
foimd in those who have had the os xiteri artificially
sealed up by the injudicious use of the potassa fusa or
potassa c. calce. Amongst the cases of this sort that
I have seen, I now call to mind two ladies, who had
been treated by the same physician.

They are important enough in their bearings on this
subdivision of our subject, to give a few particulars.
A lady, aged thirty years, married at twenty-one, had
two children, the youngest six years old. Tliere was
nothing pecular about the labours, but she was subject
to leucorrhoea after the last one, for which slie had
general constitutional treatment, and, after a while, local
applications of the potassa c. calce, nit. arg., &c. Menses
rather profuse but othermso normal, till about two years
ago, they became gradually very tedious and prolonged,
lasting nine or ten dayn, iiii^tead of three or four, as

188

UTERINE SUHiJERY.

they did previously to the ])otaa3a c. calee treatment.
The flow was now scanty, very dark-coloured, ahnost
black, attended with nausea, nervous irritabihty, and a
sense of utter prostration, together with bearing-down,
weight and soreness in the rectum, and neuralgic pains
at the end of the coccyx. She also had great tender-
ness and sensitiveness at the mouth of the vagina.
The fnindus was considerably hypertrophied, the cervix
was also hypertrophied and indurated, and felt more
like a small globe pessary than aiiytliing else; and it
was utterly impossible to detect the os tinciB by the
touch-
Fig. 67 shows about the size and relation of the little
opening throii^li which the menses made their tedious
The canal was

opened by the bilateral
incision. The whole
cervix was of fibrous
hardness, and the re-
sistance to the knile
was veiy great. As
uHual in these cases,
there was butlittle hse-
morrhage, but there
was great trouble in
keeping the os open.
However it remained suflieiently so. The next men-
struation was normal, and in four months she conceived
again, after an acquired sterility of six years, due,
firstly, to granular engorgement, and its attendant
leueorrhoea, and lastly, to the potassa c. calce treat-
ment and its result, occlusion of the os.

I do not object to the use of potassa c. calee judici-

i

; Tixt;*: — abnormal.

189

oiisly applied, Imt it is well for us to know that it is
all-powerful to do mischief, while we intend only to do
good with it. I feel, therefore, justiiied in proasing this
matter a little more on the attention of the reader.

Mr3. M., aged thirty-six, thi'ee children, youngest six
years; some uterine trouble ever since the last labour;
was treated for " ulceration " by potassa e. calce thj-ee
years before I saw her in April, 1856. Her menses,
scanty, dark-coloured, of a tarry appearance, were now
preceded by pain for a week.

It is a waste of time to give general or even local
symptoms.

The uterus was anteverted, the fundus hypertrophied,
the cervix almost as hard as cartilage, and the os was
contracted to a little round point, that could not be
detected by the touch.

The OS was cut opeii ; the next menstruation was
painless and normal, and the enlargement of the fundus
soon subsided as a consequence of the easy exit of the
menses, and conception occurred a few months after-
wards.

But I pass from this class of cases to another,
where the os is open enougli to permit the easy exit of
the flow, but where there may still be a mechanical
obstruction to the ingress of the spermatozoa. It is
not sufficient to say that the mouth of the womli is
large enough, and tliat it admits easily the passage of
a bougie or a sound.

To illustrate my meaning I turn to my note-book.
Mrs. — — , aged thirty-five, two children, youngest ten
years old. She ha<l been in bad health for a long time,
and was treated by a very eminent physician, Dr.
Duane, of Schenectady, who sent her to me in June,

190

LTKlilNE SL'ltCKUY.

1856. The uterus was Jinteverted, and greatly hyper-
trophied, being tiiree inches and tliree quarters to the
fundus ; the cervix was the seat of fibrous engorge-
ment ; the menses were profuse, lasting five or six
days, returning in seventeen ; and she was ansemic
and prostrated.

A course of treatment, local and constitutional, was
agreed upon, and Dr. Duane sent his patient to me
again in the autumn. She was somewhat improved ;
the depth of the uterus was three and a quarter inches
instead of three and three quarters ; and the hyper-
trophy and induration of the cervix were better, but
there was little or no improvement otherwise.

I was at a loss what more to do for her relief, and
felt very sure that her ten years' of sterility was due
not so much to the state of her general health as to
the peculiar conformation of the mouth of the womb,
which certainly prevented the ingress of the sper-
matozoa. Many of us think that a pregnancy will often
modify the nutritive ftinctious of the uterus in such a
way as to remove engorgements, hypertrophic condi-
tions, and even small fibroids. With my mind fiill of
this idea, I asked my patient, rather jocularly, if she
would like to have more offspring. She promptly re-
plied, " No." " Well," said I, " it's difficult for me to
determine what else to do, if you will not consent for
me to rectify the condition of the mouth of the womb,
BO that conception may take place." She did not think
it possible, and hardly believed me to be in earnest.

Now it may be asked what could be the trouble with
the mouth of the womb, when she had had children,
and when she still menstruated without the least diffi-
culty. From the birth of her last chUd she had had

08 TINCU — ADNUKMAL.

.^^^

leucorrhoea, aa a consequence of granular engorgemont
of the cervix.

Dr. Duane liad cured this long ago, and there still
remained, aa previously stated, some hypertrophy of the
cervix. This, too, he had removed, in a great measure,
during the summer, by two small potassa c. oalee
issues, one on each lip of the os tincse. But there still
remained the same mechanical obstruction at the os as
before, which is represented by fig. 68. A crescentic-
shaped os is by no means uncommon. We often see
it in anteversions, and I
have frequently seen it
where the position of
the uterus was normal.
We may have it where
there has never been
conception, or it may
occur after child-bear-
ing, as a consequence of
chronic inflammation of
the cervix, with hyper- Fm.fis.

trophy of the cervical

mucous membrane. Here it presented no barrier what-
ever to an outward flow ; but a glance at the peculiar
projection a from the anterior lip, shows what a perfectly
valvular closure it opposed to any inward flow. When
this little tubercle « was hooked with a small tenaculum
and pulled downwards, so as to open the canal of the
cervix, and permit a view of its cavity, this hypertrophic
condition was seen to extend up along the anterior face
of the cervix for an inch. The c\irvilinear dotted line
c shows the course of the incision by which this was
removed. It was a triangular wedge, as seen in fig. 69,

192

TTKRINE SUBT-EKY.

the apex having reached nearly to the oa intemuin.
There was biit httle bleeding, and this was controlled
at once by the pressure of a sponge probang,
and then by the appUcation of a pledget of
cotton, wet with a solution of the perchloride
of iron.

The wound was healed by the time of the
next menstruation ; and my patient went
home with the os presenting a perfectly yio. m. ^
normal appearance. Notwithstanding her fl

feeble state of health, and the length of time sinctf'
the birth of her last child, conception occurred a
month after the operation. She went the full time,
and was safely delivered by Dr. Duane of a fine boy.
But I am constrained to say that the pregnancy pro-
duced no good effect either constitutionally or locally.
I had occasion to examine the utcnis some four or five
months after dehvery, and its condition was about the
Bame as at the time of conception. The case is valuable
only as illustrating one of the mechanical obstacles
to conception. It is not exceptional, for 1 have seen
other similar cases.

Again, the mouth of the womb may be open enough to
let the menses flow out freely, and it may be even large
enough to admit easily a No. 8 or 10 bougie, and yet be
absolutely closed to the ingress of the spermatozoa; and
that without any excrescence or malformation. This
condition is a very common cause of acquired sterility,
and occurs in this way : Labour is followed by a chronic
inflammation of the cervix, which becomes hypertro-
phied ; the inflammation or granular erosion is cured,
but the hypertrophic condition conjoined with indura-
tion remains, and the two indurated, thickened lips of

OS TlNfMi: — ABNORMAT,.

193

I

the 08 tincfe lie in close apposition, yielding readily to
any fluid passing down, but opposing any passing up
the canal. We too often overlook this cause of sterility,
common as it ia. We are apt to say the mouth of the
womb is all right, because it admits alarge bougie, and
gives free vent from the uterine cavity.

Now, what ia to be done with such a case ? The os is
a straight transverse line,
with the two opposite
borders crowded obsti-
nately against each other
(fig. 70). It is long enough
from side to side, but
antero-posteriorly it has
lost its gaping, graceful
oval form, and although
quite as large as it ought to
be, it is still to all intents
and purposes practically closed. Such an os as this may
be bougied till both surgeon and patient are mutually
tired out, without any result whatever ; and there is
but one thing to do, viz., to incise the cervix as for
dysmonorrhoea. It may seem paradoxical to enlarge
an OS that is already large enough, but the only way
in which I have ever succeeded in causing a permanent
receding of such compressed lips, is by a bilateral
division of the circular fibres of the indurated cervix.

In March, 1859, a lady, twenty-seven years old, con-
sulted me on account of acquired sterility. She had
had one child five years before, — no conception since.
As she and her husband were both in vigorous health,
she wished to know tlie cause of what was to them a
soui'ce of great unhappiness. She had been told by

\'.i\- I'TEltlNr: SUIiOKBV.

her family physician that there was no reason why she
shouhl not conceive. On the contrary, I said that con-
ception was utterly impossible, with the mouth of the
womb as it was, and explained the necessity of a sur-
gical operation. Heing satisBed of its painlessness and
its safety, she submitted to it at once. The cervix waa
hard and gi"istly, but the incisions produced the desired
result of giving the os an elliptical shape.

It required nice care to prevent a contraction of the
OS to its former condition. Fortunately all went on well,
and in leas that twelve months from the date of the
operation the mother was safely dehvered of twi
wliich, she said, made up amply for her lost time.

In fifteen months after this she gave birth to anoti
child, which proved that the mouth of the womb
mained properly open.

I might go on to enumerate various other changes
that take place in the ajipearance and form of the os,
as a result of accident, inflammation, engorgement, or
hypertrophy, any and all of which may in some sort
interfere with the passage of the spermatozoa to the
cavity of tlio uterus. Many of these we will recognize
and remedy, while great numbers, even when fully
understood, will baffle our efforts. /

We all know that a protracted labour with impacted
bead often produces sloughiugs of the vagina, which
result in fistulous openings into the bladder or rectum;
but sometimes we have the impaction in the superior
strait before the head has passed through the cervix, and
then wo may have a sloughing of some part of the cervix
without necessarily a fistulous communication with the
bhidder or rectum. Sometimes we see the anterior lip
destroyed ; again the lateral [lortion of the cervix ;

the

OS TI^X^K ABNORMAL. 195

again the posterior lip ; and a few years ago, Professor
Isaac E. Taylor, of the Bellevue Hospital Medical
College, showed me the entire cervix that had been
thrown off by slough, in consequence of impaction.
In almost all these cases, the cicatrizing process produces
malfonnations of the os that mechanically prevent con-
ception. I might give an immense number of illustra-
tions of these unfortunate cases, drawn from the records
of the Woman's Hospital, but one will suffice.

fig. 71 represents the appearance of a case that was
in the Woman's Hospital
in 1856; the anterior lip
of the 03 tincse was entirely
destroyed, but the poste-
rior being intact, projected
slightly forwards, so as to
hide the small opening
leading to the canal of the
cervix. There was a mi-
nute vesico-vaginal fistula
which was easily cured, Kto. 71.

but the mouth of the

womb remained contracted, puckered, and nvc-r-lnppcd
by the posterior lip in such a way as to form a com-
plete barrier to a subsequent conception.

Professor Fordyce Barker, of the Bellcvuo Hospital
Medical College, sent me a case in 1858, in which the
whole cervix had sloughed off without injury to tho
vagina ; and the cicatrizing process had here produced
a complete obliteration of the os. When the finger was
passed iuto the vagina, we could feel the womb as it
were sitting on this canal, seemingly attached to it by
a narrow neck, but not projecting into it at all. Heix*,
2

19G

UTERINE StTliGEBT.

not only the os, biit the canal of the cervix fraa
obliterated. It was no easy matter to make an opening
through this dense isthmus of fibrous tissue up to the
cavity of the organ. But I fortunately succeeded, and
kept the canal open with an intra-uterine stem for two
months, and the patient left the Hospital; but she re-
turned in two or three months al^erwards, just as she.
was when I first saw her. The operation was repeated
a second and even a third time, and the canal was
eventually obliterated a second and a third time.

But other deformities of the os tincEe may occur of
a less formidable character, still resulting in complete
sterility. As so often said, any organic condition
whatever that tends to prevent the passage of the
spermatozoa, necessarily prevents conception. Wishing
to impress this point on the young surgeon, I shall
continue clinical illustrations of my meaning.

A lady, aged twenty-six years, had had two labours
at full term, the last sLx years ago. This labour waa
violent and very rapid, lasting only half an hour. The
child was large, and the head was probably forced
through the neck of the womb before it was sufficiently
dilated, and the os was, consecpiently, lacerated from
side to side. This healed slowly, but she remained
sterile afterwards.

Fig. 72 represents the ajipearance of the 03 : the
anterior half of the cervix was twice as thick as the
postoi-ior, while the posterior lip of the os over-lapped
the anterior, closing it valvularly and perfectly. The
cervix waa indurated, and the cicatrices resulting from
the laceration and subsequent healing could be dis-
tinctly seen extending laterally fi'om the os to the
insertion of the vagina. This lady was anxious for

i

I

1

i TINOJE — ABNORMAL.

197

more offspring ; and I proposed to cut off the posterior
over-lapping lip of the os, as indicated by the dotted
line ((, which would straighten
the canal and open the door
to the entrance of the sper-
matozoa, that is, if the heal-
ing process could be managed
so as to prevent undue con-
traction. However, she was
fi'ightened at the idea of an
operation, and would have
nothing done.

But it may be said, " Your
views of conception are en- jciu. 72.

tirely too mechanical." The

act of copulation is piu-ely mechanical. It is only
necessary to get the semen into tho proper place at
the proper time. It makes no difference whether the
copulative act bo performed \vith great vigour and
intense erethism, or whetlier it be done feebly, quickly,
and unsatisfactorily ; provided the semen bo deposited
at the mouth of the womb, everything else being as
we would have it. Thus far I accept the charge of
Diechanical views.

To illustrate the principles of tho operation above
suggested, here is a case in point. A widower in the
prime of life, in good health, the father of children,
married a young wife, who at the end of five years
remained sterile. The fault was not with the husband,
as shown by his previous marriage. The iivife's
menstruation was regular, lasted two days, and not
painful to any great degi-ee, except when she was
exposed to cold during the advent of the flow. She

198

UTEEINK SDRGEBY.

suflFered slightly from constipation and hiemorrhoids,
but her great trouble was leiicorrhcca, with pruritus.
An examination showed that there was no granular
erosion of the os, and tliat the irritating secretion was
a puro utorrhcea.

Fig. 73 represents the anatomical pecuHarities of
the OS and cervix and the course of the canal. The
position of the uterus was normal. The intra-vaginal
portion of the cer\'ix was irregularly developed, the
anterior segment being not more than one-fourth as
long as the posterior. In other words, the os tineas
was found, as it were, on the anterior face of the cervix
instead of being central, as at n, in a line with the long
axis of the cervical canal. The os was very small, but
by means of a sponge-tent it
was ascertained that the
anterior face of the c«rvix at
I c was the seat of a granular
I condition of the cervical
membrane evidently giving
rise to the morbid secretion
that irritated the external
parts.

This lady did not consult
me on account of her sterility,
but solely for the relief of
her physical sufferings. Con-
ception would bo absolutely
ti... 73. impossible in such a case as

this. I have seen many like
it, and they are of necessity always sterile. Such
malformations are evidently congenital.

Three months oi' treatment here produced no sort of

i TINCE — AllxVOKMAI..

190

improvement, either of utorrhcea or pruritus. Spouge-
tonts and caustic to the granulations at r combined
with a tonic invigorating course were wholly useless.

The question then arose, " What else can surgery do
for her relief ? " Tiie only way tliat I could see to
cure the utorrhoea, was to open permanently the mouth
of the womb, so as to allow a free outlet to the secre-
tions, which seemed to become acrid, by undergoing
some change while pent up in the pouch formed in the
canal of the cervix.

Two plans of operation were suggested to my mind.
The first to divide the os and cervix bilaterally, and the
other to remove the whole of the posterior lip to ft.
The first plan might relieve the utorrhcea on the
principle that wo adopt in curing a sinus by making a
capacious outlet for its contents, whereby it is kept
constantly drained ; but I folt very sure it would never
relieve tlie sterility, because the redundant posterior
flap would always naturally over-ride and over-lap the
anterior portion, and prevent the upward passage of
the spermatozoa ; and because I had on several occa-
sions tried it under like circumstances without success,
and I feared that there would be no permanent cure if
the sterile condition were not overcome.

I did not then know of the plan of sjilitting open
the posterior lip backwards, as illustrated in figure 63,
page 172, or I would, in all probability, have adopted
it at the time. 1 determined, however, on amputation,
or exscction of the posterior portion of the cervix up
to the dotted hne ft, as being the best method of both
insuring a good outlet for the leucorrhoea and a good
inlet for the somen. The operation was done in April,
1857, with the assistance of Dr. Emmet and Dr.

200 UTERINE SURGERY.

Scudder, then house-surgeon at the Woman's Hospital.
The patient left us in a fortnight, which was entirely
too soon after such an operation, for we were thus
deprived of using all means to prevent an undue
contraction of the os by the granulating process.
However the utorrhoea and the pruritus were even-
tually cured. A conception in due time, and a natural
labour at ftdl term have proved, as far as one case
can, the correctness of the principles of the operation
adopted for the relief of this and analogous cases.

I might go on to enumerate various other modifica-
tions in the size, form, and relations of the os tineas ;
but we have had enough of this to impress upon the
mind of the young surgeon the importance of imitating
nature as much as possible, if we expect to attain the
object of our efforts.

SECTION IV.

THE CERVIX UTERI SHOULD BE OF PROPER
SIZE, FORM, AND DENSITY.

203

SECTION IV.

TAB CERVIX UTERI SHOULD BE OP PROPER SIZE,

FORM, AND DENSITY.

IN 250 married women who have never borne
children, the condition of the cervix was particularly
noticed in 218, the remaining 32 being excluded on
account of other complications, that would mar or
counterbalance any influence that the peculiarities of
the cervix might exercise over the sterile condition.
Of these 218—

The cervix

^nr oS • • •

and indurated

Straight, conical, and indurated in 4

„ „ and elon-
gated „ 109

„ elongated, but not in-
durated „ 7

„ not conical, but hypertrophied

and indurated „ 14

Gi^anular „ 10

[ „ and conical „ 3

ft

»»

147

218

Now of this number we find —

71 flexed, of which 52 had a conical cervix.
147 straight, „ 123 „ „

218

175

204

UTEBINK SURtJEKY.

Thus we have a conoid cervix in nearly 85 per cent).
of all cases of natural stenlity.

This shows very plainly the great influence that this
peculiar abnormal form of the cervix exerts over the
sterile condition ; and when we remember the fact that
it is almost always associated vrith a contracted os, we
are constrained to acknowledge its importance.

Having said that the cervix should be of proper size,:
form, and density, let us consider its variations in si;
from a normal standard.

It is normally about half the length of the uterus,
and projects into the vagina from a fourth to the
third of an inch anteriorly, and a fi-action more
posteriorly. The intra- vaginal portion is rounded,
truncated, and elastic to the touch; but it may vary
from this in many particulars. It may be hypertro-
phied or elongated, or it may not project into the-
vagina at all. It may be flexed, indurated, engorged,
or granular ; but in the sterile, as shown in the table
above, it is most frequently of conical fonn, whether
straight or flexed; and with the indurated conoid
form there is, as before said, almost invariably asso-
ciated a contracted os.

But, independently of its mere form, if the cervix'
projects into the vagina a full half-inch, it is veiy
likely to be associated with the sterile state ; if an
inch, the case is almost necessarily sterile ; if it should
be still more elongated, say one and a half or
two inches, it becomes absolutely so ; and if it does
not project into the vagina at all, it is equall;
sterile.

Elongation of the cervix is very common, while its
defective development is comparatively rare. This

lat

IS, ^^

e
e

1,

y

r

m

CERVIX UTEIU ABNORMAL.

205

elongation is sometimes real and sometimes only
apparent. It is real when the cavity of the uterus
is more than two inches and a half deep, and the
additional depth ia seen to be due to the unnaturally
developed cervix. It is only apjmrently too long when
the depth of the cavity is normal and yet the cervix
evidently projects too far into the vagina, in consequence
of the vagina being inserted too high on the cervix.
But whether really or apparently too long, the same
treatment is necessary. If the elongated cei-vix is
more that an inch, the body of the uterus will almost
of necessity be thrown backwards, because the
Deck projecting so far into the vagina, can only
accommodate itself to the opposite wall, by taking
the direction of its axis. This position of the cervix
must be attended with a retroversion of the body,
or if this be in a normal position, then, as a rule,
the cervix must be flexed anteriorly. Sometimes it
may result in complete procidentia, but we have
only now to deal with the fact, and not its conse-
quences.

Suppose we find the cervix too long, what arc we to
do with it ? Some of our best authorities tell us
melt it down with the potassa c. calce or
potassa flisa when it is gi-eatly hypertrophied. I
never tried to do this, but I have seen cases of
hypertrophy after they were subjected to the process,
and I have no hesitation in saying that it is not the
safest, easiest, and best thing to be done. Wliat is
better then ? Ami)utation ; and for this there are two
methods — the knife and the iScraseur, the former of
which 1 here greatly prefer. The objection to the
fcrasour ia that it makes a lacerated surface to heal by

206

TTEItlNE SUIifiEHy.

granulation, which takes a long time, often leaving
03 tinea' contracted. Another objection to it is the
uncertainty of amputating just where we place the
cliain, wliich often draws in more tissue than we intend,
and removes more than we wish. So great has been
this trouble, that some of the German surgeons have
given up the ccraseur altogether in operations on tho
neck of the womb, because the attachment of the
bladder and, in some instances, the posterior cul-de-sac
of the vagina, have been injured, and even the peritoneal
cavity opened by its
greedy grasp. It might
be supposed that these
accidents are hypotheti-
cal, but unfortunately I
can testify personally to
the truth of, at least, one
of them.

A lady from Connec-
ticut was sent to the
Woman's Hospital in
October, 1860, with a
cancroid tumour of the
cervix, about the size of
a Sicily orange. It grow
from the whole cervix,
Pig. 74 is intended to
represent its relative size and position. There was no
doubt as to the nature of the disease, ncvertheleaa it
was determined to remove it. The jmtient was etherized,
and placed on the left side, as in all such operations.
The speculum was iutraduced, and the chain of the
^craseur was carried around the base of the tumour.

CEEVI^ ITTERI — ABNORMAL.

207

I

jast at the reduplication of the vaginal cul-de-sac
antero-posteriorly, the parts remaining in situ as
represented in the diagram.

The ^craseur was worked in tho usual way ; the late
Professor V. Mott was sitting on my right, watching
the process. He had great objections to the instrument
on philosophic grounds, and I was anxious to prove to
him that it should be accepted as a valuable addition
to our surgical resources, wluch, however, I failed to
do. He was on the eve of lea\-ing before the opera-
tion was finished, when I said, " Please wait a few
minutes. Doctor ; it is almost through." He sat
down again, and in a moment I was surprised by
the sound of air rushing in and out of the vagina,
with all the regularity of, and synchronously with,
inspiration and expiration, at the same time that
the tumour, obeying tho slight traction on the
fcraseur, came without the least resistance to the
mouth of the vagina. Two or three quick turns of
tho chain cut it off entirely, and on its removal I
was horrified to find an immense hole of a semi-
lunar form, in the cul-de-sac of the vagina, through
which we could look for three or four inches
up into the peritoneal cavity, and observe the
movements of the viscera mtb every respiratory
act.

Pig. 75 represents the appearances of the parts,
The uterus adhered anteriorly at /', but posteriorly and
laterally it was completely severed fi'om all vaginal
connections. To have closed tho parts properly,
we should have united tlio edge of the posterior
cul-de-siio " to the posterior portion of the uterus from
which it was separated; but as wo all looked upon

208

ITEIilNt: SCIiriERT.

the case as necessarily and immediately fatal, and at
nice adaptation of the parts would have been tedious,
compelling us to keep
nur patient longer under
tlie influence of ether
than wo wished, we con-
cluded to make quick
work of it. The edges
of the vagina anteriorly,
and all the way around,
were rapidly denuded,
and six silver sutures
were passed, as in tlie
operation for vesico-
FiQ. 75. vaginal fistula, and the

two opposite borders of
the vagina were neatly approximated, leaving the neck
of the uterus within the peritoneal cavity. But for
the drainage of its secretions a catheter was passed
into tbo peritoneal ca'vity at the central point of union
opposite c, which was left sUghtly open for this pur-
pose. A severe peritonitis followed, from which she.
fortunately recovered. %

This operation was witnessed by a large concourse
of medical gentlemen ; amongst whom were the vener-
able Dr. Mott, Dr. Emmot, Dr. Pratt, Dr. Rives, then
house-surgeon, and many others. It is the only
instance in which I have seen any accident from the
use of the ^craseur. Of course the inclosnre of the
cervix within the peritoneal cavity was all wrong, and
should not be done again imder similar circumstances,
and would not have been done then if we had had the
remotest idea of the possible recovery of the patient.

C'EEVIX UTKKI — ABNOUMAL. 209

The peritoneal ca\-ity was kept constantly drained,
by means of the tube, through which wo frequently
injected tepid water, wliich gave great comfort to the
patient.

It was worn for about three weeks, when the
opening became fistulous and remained patent. Greatly
to my surprise, the patient recovered entirely from
the effects of the opeiation, and in a few weeks
returned home in a very comfortable condition; but
soon symptoms of the old cancroid disease began to
manifest themselves, and she died of cancer some
eight or ten months after leaving the Hospital. The
idea of drainage-tubes for the peritoneal ca\'ity, and of
injecting this cavity through them, belongs to my
countryman Dr. Peaslee, who has fully established the
safety and efficiency of the practice, after the operation
of ovariotomy, where thei-o are poisonous secretions
to bo evacuated. The reader wiU find Dr. Peaslee's
cases reported in the Amcn'caii Journol of th; M<'iUfal
Seieiiccs. *

Amputation of the cervix uteri belongs essentially
to French surgery. It was a very frequent operation
in the hands of Lisfranc. He amputated the cervix
in ninety*8even cases, and lost but two patients.

Lately Huguier has brought it more prominently
before the profession iu generalizing it for all cases of
what he terms hypertrophic elongation. His success
is all that could be desired. Huguier's were all pro-
cidentia cases, mostly with elongation of the supra-

• American Jatirnaln/ Ad Haltcut S(Mncea,Jsiimwy, 185fi, p. iO,
Ai.ril, 1863, p. 363; July, 1864, y. 47.

210

UTERINE SURGERY.

vaginal portion of the cervix ; but we are here to ,
consider the operation as applicable only to infra- 1
vaginal elongation, without necessarily a procidentia.

In my early amputations with the ^craseur, the os
tincsB was so often puckered and contracted, that I
adopted the plan of doing the operation at two periods ;
thus, I would with scissors split the cervix bilaterally,
nearly down to the insertion of the vagina, and then
remove one half of it ; for instance, the anterior portion
«,at/^(fig.76);
wait one or
two menstrual
periods for the
parts to heal,
and then re-
move the re-
maining half. J
This was get* ]
s"!"- ™. ting to bo the

method pretty
generally adopted at the Woman's Hospital till
October, 1859, when we hit iipon the following plan
and in the following way. A lady from North Carolina
was Bent to me by her physician for amputation of
the cervix. Her time being bmited, she was very*
anxious to return home as soon as possible. I then
fore determined to remove the whole cervix at one
operation with the ^craaenr. Just as she was ftilly
etherized, Dr. Pratt, the house-surgeon, reported that
om' only ^craseur was broken ; and without any choice ■
in the matter, I was compelled to amputate withl
scissors. By hooking a tenaculum in the anterior lipl
of the OS tincEB, the cervix was pulled gently forwards-']

(_:i;KVIX UTEIU-

and held firmly, while witli scissors it was split
bilaterally nearly to tbo insertion of the vagina, still
holding on mth the tenaculum ; the anterior half was
quickly cut off with scissors and then the posterior half.
I intended to leave the stump to heal over in the usual
way by the granulating process, which would have taken
from three to five or six weeks, but, while examining the
wound, and waiting for the bleeding to cease, the idea
all at once occurred to me to cover over the cut surface
with vaginal mucous membrane, just as we cover over
the sturap of an amputated arm or leg by skin, after
the circular method. I immediately passed four silver
sutures, two on each side of the canal of the cervix,
through the cut edges of the vagina, antero-posteriorly,
which drew this membrane over the stump of the cer-
vix, covering it completely, but leaving a small oval
opening in the centre to correspond with that of the
cervical canal.

The parts healed by the first intention ; the sutures
were removed in nine or ten days, and my patient was
soon on her way home, not having suffered in the least
from the effects of the operation. From that time on
I have adopted this method of amputation, and
have every reason to think that the healing by the
first intention in this oiieration is relatively as
superior to that by granulation as it is in any other
amputation.

Fig. 77 represents the cervix after amputation, with
the wires passed through the cut edges of the vagina
ready for covering over the stump.

Fig. 78 is to represent tlic appearance of the stump
after the sutures are twisted and cut off.

But it may be asked what arc the nsks of the
!■ 2

IITRUINE smiGERY.

operation ? I think they are few. Lisfranc lost tw<M
patients out of ninety-aeven ; Huguier operated thir-
teen timea without any J
bad result. I have ope- |
rated more than fifty I
times, thirty-six by this i
method, and lost one |
patient. This

occurred unfortunately J
just at a time when the |
hospital atraosphei
suddenly became unfa-
vourable to all surgical
operations, and wo bad J
„ __ serious accidents to fol-

low tho slightest opera-
tion, before we were aware that wo were breathing ]
a poisoned air. If wo had known of this epidemic 1
condition, this patient
would not have been
operated upon at that
time, for such was the •
state of our over-
crowded wards that we '
were obliged to thin
them out, and stop all
operations for five or
six weeks. But is there
no danger in the opera-
j,',^ ;y tiou per sc ? The only 1

one that I know of is ]
that of opening the peritoneal cavity by cutting too
high up on the posterior half of the cervix.

VFMVtX UTERI-

This accident happened in the hands of a very
accomplished accoucheur in New York, and his patient
recovered without the least bad symptom. But, not-
withstanding this fortunate escape, it must be looked
upon as a danger to be carefully avoided. Take this
method of amputation all in all, I do not think it is
attended with any more risk than that of incision of
the OS and cervix. Theoretically it should be safer,
inasmuch as the one is healed universally by the first
intention, while the other is an open granulating
surface for fifteen days or more. But if offspring bo
very desirable, and if a long cervix should seem to be
the only or principal barrier, there are but few women
who would not take the slight risks of the operation
for the fidfilment of a hope so precious.

I have jnot as yet had many cases of pregnancy to
follow amputation of the cervix, but I am well satisfied
now, that if amputation had been performed in many
cases in which I simply cut open the cervix, conception
might have occurred, where it has not.

On page 198 is recorded a case of pregnancy fol-
lowing the amputation, or rather exaection of the
posterior portion of the cervix ; and I have another
case where it followed the removal of the anterior half
of the cervix. The circumstances were these. Mrs. A.,
aged thirty ; married seven years ; one child six years
ago ; it died young ; no conception since ; very anxious
for offspring ; exceedingly unhappy. A minute detail
of symptoms is unnecessary. Slie had reti'oversion,
with hypertrophy of the posterior wall of the uterus ;
while the cervix was hypertrophied, elongated, and
indurated. She was under treatment at times from
October, 1857, to the spring of 1859. From the very

214

in'ElllNE ftUBCKUV.

begiimmg I told her I did not see how she could evf
conceive with such a condition of the neck of the"
womb ; and I wished then to amputate it, but she was
afraid of the operation, and could not make up her
mind to it. At last I told her that I could not expend
any more time on her case, unless she submitted to
amputation of the cervix. She consented, and entered
the Woman's Hospital. I was then in the habit of
performing the operation at two periods.

Dr. Francis, Dr. Mott, and Dr. Green, of the con.
suiting board, and Dr. Emmet, were present at the
operation on the 8th July, 1859. The cerrixwas spht
bilaterally with scissors, and the anterior half was
removed. She left the hospital in a fortnight, with tha,
expectation of returning on the 1st of October for thoi
removal of the other half. But fortunately the m
menstruation was followed by conception. She w*
the full term, and was safely delivered.

In 18G2 the greatest number of my amputations
were performed. It was then a question with many
of my medical friends whether the operation would
not in itself prove a barrier to conception. The ca»-i
of half-amputation above related, and the one oaj
page 198, were then my only facts bearing on t]
question. But now X have two cases proving that
in no way interferes with conception. It is true thi
in these the operation was not performed with any
view to conception, but simply for the removal of
disease that baffled all other treatment. One was a<
patient of Professor Metcalfe, of New York. She waa
the mother of one child, and had been in bad healtJi
ever since its Inrth.

The position of the uterus was normal, the cervir

CEBVIX DTEKI — .ONORMAL. 215

was hypertrophied, but not indurated, the os was
lacerated back through the posterior lip, nearly to the
insertion of the vagina, and the cervical mucous mem-
brane projected in voluminous granular folds, giving
rise to constant leucorrhoea. Various remedies had
been used without any improvement ; and as Doctor
Metcalfe had already exhausted our routine of local
treatment, I proposed amputation as the speediest and
surest metliod of getting rid of the diseased condition,
and the operation was done in May, 1802, Dr. Metcalfe,
Dr. T. G. Thomas, and Dr. Emmet assisting. The
operation was performed as already described, and the
stump eovei'ed over with vaginal mucous membrane by
passing the sutures antero-posteriorly. Haemorrhage
came on two or tliree days afterwards, which gave
Dr. Metcalfe and Dr. Thomas a little trouble; but
she soon got well without any other accident ; and
Dr. Emmet wi-ites me that conception occurred four
months after the opei-ation.

The other case was that of a lady who had borne one
child four years before. She is the daughter of an
eminent physician. She had retroversion with enlarge-
ment of the posterior wall, and hypertrophic elongation
of the cervix. This condition of the cervix seemed to
be a barrier to a rectification of the malposition, and it
was determined to amputate it. With the assistance
of Dr. Emmet and Dr. Pratt, the operation was per-
formed in Jime, 1862, and she conceived in October
following.

These facts I present as an answer to any question
in regard to the influence of amputation upon con-
ception, and to show that the operation per m: does
not interfere with it. I have been minute and a UtUe

216 UTERINE SURGERY.

tedious in tletail, because I sliall soon have occasion to
insist on the performance of this operation in a class
of cases where, as yet, it has not been recommended.

An opposite condition of the cervix, viz., defective
development, may be a cause of sterility, aud I may
mention it in this relation. We occasionally find the
womb undeveloped or in quite a rudimentary state, and
here menstruation may be wholly absent, or so slight
as scarcely to attract attention. In such cases little or
nothing is to be done. But now and then we 6nd the
womb large enough, and menstruation abundant, but
the cervix does not project into the vagina. These are
always sterile and usually dysmenon'hceal.* The canal
of the cervix will be very small and usually flexed.

As a type, I may give an illustration. Dr. W. B.i
Johnston called on me in December, 1863, with a
patient of his, who had been married ten years without
issue. She had consulted Volpeau, Nelaton, Ricord,
Trousseau, aud thirty-two other physicians of Paris.
Her dysmenorrhoea was fearful. She usually took
anodynes, and had leeches applied by the speculum
at each menstrual period. The symptoms and sufler-
ings of such cases are too well known to requii
detail here. The finger passed into the vagina, found
only a blind pouch, but it was sufficiently capacious.
No cervix projected into it, but the uterus could be felt
on the right of the mesial line, sitting, as it were, on the
vagina, and attached to it by a narrow crooked isthmus
of fibrous tissue, which was the undeveloped cervix,
along which a probe could be passed to the fundus, a
depth of two inches and a Iialf. On the left of the
uterus was a mass of condensed cellular tissue half
the size of an English walnut, probably the remains of

im

CJiRVIX UTEBI — AllNOnMAL.

217

a pelvic abscess that occurred some four or five years

ago. The circle a h (fig. 79) represents the place

tliat should have been occupied

by the cervix, while the point

c shows the actual opening

leading to the uterus. This

point was once more obscure

than at present, and some one

of her physicians had split up

a bit of vaginal membrane

that overlapped, and made the

canal more valvular and tor- Fig. T9.

tuous than it is now; still

this produced no improvement in her sufferings.

Fig. 80 shows the neck of the womb resting on the
vagina instead of projecting into
it. Ofcourse there would be but
one course here to pursue, viz.,
to cut open the canal of the
cervix, and keep it open after-
wards. But the operation
would require great nicety, on
account of the narrow unde-
veloped state of the cervix just
where it comes in contact with
the vagina. However nothing ^"'' ^■

was attempted in this case ;

she was an only child, and her father was afraid to lot
her submit to a surgical operation.

But let us leave these extreme cases, whether of
hypertrophic or defective development, and pass to the
consideration of such conditions of the cervix a-s we
meet commonly and daily in sterile women.

218

UTEEIKE SUBGERT.

At the beginning of this section I said, " the cervix
should be of proper size, form, and density." Havin;
now spoken of the size and its variations, we may ask
ourselves what is a proper form or shape.

It should be rounded and truncated. Now, if
turn back to the table on page 203, we will see that
of 218 sterile women tbe cervix was flexed in 71. Of
these, 19 were supra-vaginal curvatures complicated
with some version of the fundus from a normal position;
The flexure was associated with a conoid form in 51
cases, in some of which there were also malpositions
of the body. It was straight, conical, and indurated
in 4 ; straight, conical, indurated, and elongated in
109 ; straight, conical, elongated, and not indurat
in 7 ; granular and conical in 3.

It is thus shown that a conoid form of the cervix,
whether flexed, straight, elongated, or not, is found in
the great majority of cases
naturally sterile, being hera
175 out of 218. We must.
discriminate between natural
and acquired, or accidental
sterility; and here let it be
remembered that we speak
only of those married women
who have never conceived.

I know not how I
better describe what I m<
by a conical cervix than bi
diagrams. Let fig. 81 re-i
present a normal type of ft.
rounded, truncated cervix. Now, if we imagine th<
cervix extended in the direction of tlio dotted hne a,

isk ^^_

.ted^^l

CEIiVIX UTKKI — AHN(MiMAI..

219

we sJiall have a not unfrequent form of conoid cervix,
which will almost universally be associated with a con-
tracted OS, and be almost as constantly indurated. A
I moderate degree of conoidity like this may be remedied
very easily, and if everything else is right, we may cal-
culate with a good deal of certainty on the removal of
the sterility. For this purpose the operation of incising
the OS and cervix as for dysraenorrhcea will suffice.
The operation does not alone enlarge the os, but if the
circular filjres of the cervix be properly and thoroughly
divided, the lips of the os tincK, instead of being
puckered to a little round point, evert and roll back
from each other, giving the cervix more of the natural
of a truncated cone than of a pointed one, as
before; and thus while it becomes truncated it also
becomes shorter, or, in other words, while it assumes
a more natural form, it also takes on a more natural
size. This is the mildest and most favourable of the
conoid form. Its type is represented in fig. 6.5, p. 184.
But if the cervix be extended in the direction of the
dotted line l>, then its mere incision will not so easily
I restore it to anything like a normal condition.

We sometimes find the cervix as conical as a mole's
I head, gradually tapering from the insertion of the
vagina almost to a point at the os tincK, being very
much longer than it is broad. Calhng to mind the
I fact that in 218 cases it was straight, conical, and
I elongated in 116, or more than half, I now think that
[ the great mistake I have made in the treatment of
I these cases, was that of simply incising the os and
L cervix ; and the same mistake has been made by all
I other Burgeons.

I now propose to amputate a portion of the cervix

220

HTKRINE SUEGEBY.

in all such cases, for the purpose of giving it as near
a normal form as possible. Tor instance, in fig, 82, let
the cervix be amputated at the point -
designated by the dotted line.

We have all been afraid to trun"
cate the cervix in this way (if any
of us ever thought of it before), and
were satisfied ivith simply splitting
it up for the relief of the pain of
menstruation, thinking that if wo
were successful in this we might
FiQ. 82. hope for success in other things.

I have cut open the neck of the
womb, and often seen conception follow soon after ;
and I have cut open scores, nay, hundreds of others,
sometimes with relief to suffering ; but how often have
I been disappointed in the great object of the operation !
And why ? I now see that, in many cases, more must
be done than to open the canal of the cervix.

When I run my eye over the list of cases in which
the operation has been quickly followed by conception,
I discover that while almost all had a contracted os, all
had also a cervix of no unusual length ; and when I
examine closely all those who have had a division of
the OS and cervix without its being followed by con-
ception, I find almost every one of them either with
an elongated conieul cervix, or with some other com-
plication equally if not more unfavourable. Does not
the inference follow from this, that if we expect to treat
such cases with more certainty and greater success,
we must, other things being equal, approximate a
noi-mal condition as much as possible, by truncating
the cervix to a proper size and form ?

(lEBVUC OTERI — ABNOBMAL.

221

It was but tho other day I had the opportunity of
examining the cervix of an unmarried lady upon whom
I had performed amputation two years ago ; and bo
perfectly normal was the
appearance of the os and
cervix, that there were no
evidences whatever of the
fact that an operation had
ever been done.

Before closing this sub-
ject, I may give a few more
illustrations of the conical
cervix. For instance, it may ~~ —

may be found with a flexure, Fm. B3.

the anterior and posterior

portions being unequally developed, as in fifj. 83 ;
and here we may cut open the cervix bilaterally, or
split the posterior lip directly

backwards ; but I think it

would be much better to
amputate in the direction of
the dotted line, and after-
wards to cut open tho
cerWx bilaterally, if tho prime
object of all treatment be

Again, we may have tho
conical cervix with a sti-aiglit
canal ; the whole organ
having the feel of a hard *'"'■ **^-

inverted cone (fig. 84).

These cases I have always cut open bilaterally, but
I can call to mind few that were followed by conception.

222

LTTERINE SUnCiF.RY.

In all such cases I am now very sure tkat it would be
better to amputate, and restore tlie cervix at once to J
a normal condition.

It is not at all uncommon to find a conoid cervix ]

accompanied witli retroversion. Sometimes the nial- ]

position seemB to '

be the result of tbe

elongated conoid
cervix pressing '
against the poste-
rior wall of the |
F""- 85- vagina. Conception i

is impossiblf

womb of this relative size, form, and position (fig. 85).
These e-tamples of conoidity are enough to impress
upon our minds its general character and apjjcarance ; J
but there are cases that cannot be called conoidjj
and yet are to be treated in the same way, if wei
expect offspring. For example, I saw, in cousultatioii'l
in Paris, in May, 1863, a, lady, about twenty-sevenT
years old, who had been married six or seven years I
without offspring. She had had dysmenorrhcea ever!
since her marriage, and had been treated by very dis-l
tinguished physicians, one of whom told her that sheT
might possibly fall into the. hands of some surget
who might wish to cut open the neck of the woml*
against which he would most seriously protest, as an ^
operation fraught with danger. It is useless for me
to dwell upon her menstrual sufferings, and general
nervous, irritable condition. There was anteversionfl
with hypertrophic enlargement of the fimdus antew
posteriorly, as at rt, h (fig. 86).

The cervix was curved, as shown in the diagrams

CEimX UlTRI— ABNOltMAI,.

The posterior lip overlapped the anterior, giving the
OS a crescentic shape. The
anterior lip was granular.
The cervix was not, pro-
perly speaking, conoid ;
but it was elongated, too
long for easy conception,
even if it had been straight
and patulous. The canal
of the cervix could not be
called contracted, and yet
the flexure was such as to
bring the antero-post«rior

surfaces in close apposition, like laying the bowl of
one spoon in another, which always presents a very
complete obstruction to the egress of the menstrual
flow. As a consequence of this mechanical barrier,
she had a persistent endometritis, as seen by the dark
brownish mucus that was always found hanging from
the cervical canal.

I here proposed to divide the cei-vix bilaterally, at
the same time saying that amputation would give us a
better chance for permanent relief.

Her medical attendant agreed to the operation
of incising the os and cervix. Our object was to
relieve the dysmenorrhcea and endometritis by open-
ing the canal, knowing full well that it would
be a most difficult tiling to render it permanent
unless we could keep tho posterior lip everted or
rolled backwards. However, tho operation was thus
performed, much against the wishes of the patient
herself, who begged for amputation, as affording her
the surest, if not the safest, method of cure. Her

22-i

UTERINE 8URGEBT.

first menstruation after the operation was entirely
painless, but unfortunately it clid not remain so, and
further treatment was necessary. In cases like
this I am sure it would be better to amputate the
cervix first, and then incise it at some subsequent
period.

If experience should prove that I am correct in my
views in regard to the necessity of amputating an
elongated conoid cervix, for the purpose of augmenting
the chances of conception, I feel that it is important
to simplify the operation as much
as possible. The amputation of the
cervix by scissors, as I liave always
done it, is easy enough in the
hands of a practised surgeon, bat
every one will not find it always sa
easy to make a good even stump
by this method. I have not been
able to get a pair of scissors curved
sufficiently to do the work neatly.
But I think I have at last hit upon
.■something better, which I would
term the uterine guillotine. This
instrument is made in Ijondon by
Mayer, and in Paris by Charrifere.
The idea of the uterine guillotini
occurred to mo in this way. In
,July last (18G5) my friend Dr.
Henry Bennet invited me to am-
putate an elongated hypertrophies,
cervix in a patient of his who had
had procidentia for a long timOi
The cervix projected from the vulva about an inoli:

I
I

m

CRHVIX UTEHI — ADNOBMAL.

226

and a half. It waa necessary to remove three-fourths
of an inch of it. Dr. Bennet held the y

uterus firmly with a double tenaculum
forceps (fig. 87), seizing the cervix
antero - posteriorly, just above the
point of election for the amputation.
I then caught hold of the end of the
cervix, and with a bistourie cut it
instantly off. The stump was covered
over with mucous membrane in the
usual way with silver sutures. The
operation was done bo quickly and
withal so neatly, that I immediately
said, "Why should we not have an
instrument, like those for the tonsil.s,
to amputate the cervix all at once,
while the organ is in situ?" This
idea I gave to Mr. Mayer, and fig. 88
represents the instrument. It consists
simply in adding a blade to the
(Scmseur. At first I had a wire to
constrict the part to be amputated,
but I found that it would bend a Httle
from a right line when tightened, and
80 strike the edge of the knife as it
was pushed forwards ; then, at M.
Charrifcre's suggestion, a loop of nar-
row watch spring doubled three or
four times was substituted, giving a
flat surface along which the blade
glides without obstruction. p.n. 88.

In applying the instrument, let the
loop / encircle the cervix where we wish to cut it off;
Q

226 UTERINE SUEGERY.

turn the screw-nut b till the loop embraces the part firmly
and immovably ; transfix the cervix with the needle by
means of the slide d ; then push the blade c quickly for-
wards by forcing down the shaft a, and the part will be
instantly cut through. The dotted lines /, /, j show the
relations of the loop, needle, and knife, when the opera-
tion is finished. The patient is to be, of course, in
the left lateral semi-prone position, and the operation
executed without traction on the uterus. The stump
is to be covered over with mucous membrane, as pre-
viously described and figured (p. 212). There is always
some contraction of the os externum after aU amputa-
tions of the cervix. It is better as a rule to let things
take their course, and in two or three months after-
wards cut open the os and cervix, and treat it just as
we would under ordinary circumstances requiring such
an operation. If we attempt to keep the os normally
open, there is danger of interfering with the covering
of the stump ; and if we resort to the operation
of incising it too soon after the amputation, say
just after the next menstrual flow, we may in our
manipulations tear the vaginal covering of the
stump ft-om the surface to which it has recently
adhered. I have had this accident to happen in
my own hands ; and hence the warning to guard
against it.

Induration of the cervix is so often an attendant
of the sterile condition that it is appropriate to
Bpeak of it here in connection with the size and form
of the cervix. It may be natural or acquired ;
natural when we find a little gristly-feeliug cervix
in a dysmenorrbceal case, where there is often a
small fibroid in the anterior wall of the uterus ;

CERVIX (JTEHI — ABNOEMAL.

227

acquired, when we find it following a clironie
inflammation of tlie cervix, in which the granular
condition disappears after a very long time and
perhaps a long treatment. I have no specific treat-
ment to suggest, and I look upon it as important,
more particularly as it may influence the size, form,
and relations of the os and cervix. If there is a
deposit of fibrous tissue in the cervix, as a result of
inflammatory action, I Isnow of no short way of
causing its absorption, and I deal with it only inci-
dentally, as my attention is directed to the rectification
of the anatomical and mechanical peculiarities already
discussed. I know that physicians give alteratives,
absorbents, and general constitutional remedies, and
apply all sorts of things locally ; that they melt down
the cervix with potassa cum calee ; but even then the
induration remains ; and I would prefer immediate
amputation to this tedious imeertain process. It is
sujiposed that the drain of the caustic issue softens
the parts ; but I have not seen it so, and some years
ago I often used this potent agent. I must say, how-
ever, that Professor Fleetwood Churchill's iodine treat-
ment has in my hands produced a greater amelioration
in these cases than anything else ; but it is tedious.
Dr. Churchill tells me that I have failed with it because
I have not persevered long enough in its use. I beg
leave here to refer the reader to his learned and classic
work on the Diseases of Women for minute infor-
mation on this point.

Dr. Barnes has recently (June 7tb, 1865) presented
a paper to the London Obstetrical Society, in which he
discusses very ably the influence exercised by the conoid
cervix upon the sterile condition. The following sum-
Q 2

228

UTEKINE SDHGEBY.

raary* is extracted from tbo report of the Secretarj^^
Dr. Meadows : — " Dr. Barnes described and figured the^
form of cervix uteri which projected into the vagina as J
a conical body, the vagina appearing to be reflected oSM
at a point nearer the os internum than normal. The I
OS externum was unusnally minute, scarcely adraittingf
the uterine sound. This (the os externum) was thftil
real seat of constriction. The os internum was«
normally a narrow opening, and in these cases (^1
dysmenorrhoea and steriUty it was commonly found tttW
be of normal character. It was therefore unnecessary I
to divide it. It was, moreover, dangerous to divide^l
it, on account of the close proximity of the large 1
vessels and plexuses running into the uterus oa \

a level mth it Discussing the question of I

treatment, Dr. Barnes showed that dilatation was J
unsatisfactory ; that incision of the os internum aS •!
practised by Dr. Simpson's single bistourie cachfi, '
and by Dr. Greenhalgh'g double bistourie cach^, was
unsafe and superfluous. He objected to the latter
instrument, especially that it must cut as it was set,
that it was too much of an automatic machine, nok^
leaving scope for the judgment of the operator.
(Dr. Barnes's) own instrument, constructed like a pai»l
of scissors, acted on the same principle as Dr. Sims's;
it divided only the oa externum, so as to open thol
cavity of the cervix, the part to be cut being first I
seized between the two blades. The operation wasl

* Zaticet, July 15th, 18C5; "On tie Dysnienorrhcea, Metror. J
rhagia, OTaritis, and Sterility associated with a Peculiar Form of ths I
Cervix Uteri, imd the Ti-ejitnieut hv Division." By Rolxirt BaitiM,.!
M.D.

CEEVTX UTEEI— ABNORMAL. 229

perfectly free from risk ; the haemorrhage was usually
slight, and a good os was made. He had performed
the operation many times, both in hospital and private
practice, and was well satisfied with the residts. One
advantage of incision over dilatation was, that it
relieved the engorgement and inflammation."

Dr. Barnes's admirable paper gave rise to a
lengthened discussion ; he and Mr. Baker Brown alone,
amongst all the speakers, holding the same views that
I do in regard to the relative infrequency of con-
traction at the OS internum as compared with that at
the OS externum.

SECTION V.

THE UTERUS SHOULD BE IN A NORMAL POSITION—
ue., NEITHER ANTEVERTED NOR RETROVERTED
TO ANY GREAT DEGREE.

SECTION V.

THE UTEBU8 SHOULD BE IN A NOBMAI, POSITION — I. 6.,
NEITHER ANTBVEETBD NOtt BETEOVEETED TO ANY GREAT

DEUREE.

BEFORE treating of displacements of the uterus,
let us first fix in our minda a correct idea of its
normal position and relations. Not wishing to write
one unnecessary page, I shall, as hitherto, avoid
minute anatomical and histological detail, which can
be better leanied from any of our text-books, I would
say, however, that some of the discrepancies of authors
may be reconciled when we remember that one speaks
of the condition of things in the living subject, and
another in the dead. Thus, one will tell us that the
uterus is about two and a half inches deep, while
another will say it is less. Both are right ; for the
uterus, an erectile organ, full of blood, is larger and
longer in the living body than in the dead. The
knowledge of one is gained in the clinic; of the other
in the dissecting-room.

I do not know of any anatomical plates that repre-
sent correctly the position and relations of the pelvic
organs. The artist has not succeeded perfectly in this
cut (fig. 89), but it is near enough to give us a good
general idea of the subject.

[I was at great pains to get a correct outline of a
vertical section of the pelvic bones as here shown.
For this I am luider special obligations to M. Pdan, of

236

UTEIimE SrRGEKY.

iind retroversions, there was such a proportion ol
flexions, simply because these distinctions will not
modily the general principles of treatment.

Time was, and not very long ago, when the diagnosis|
of uterine displacements was attended with great diffi-
culty, but there ia nothing easier now. Formerly, all
uterine disease was known under the sweeping term of
prolapsus ; a term that has been used so vaguely and
indefinitely that it should be banished from uteiine
technology ; for in this country it is apphed to
descent of the organ through the vulvar outlet, while
in my own it is often applied to its vai-ious intrapelvic
deviations. Formerly, if any woman there bad a Uttle
vesical tenesmus with a constant sense of weight in the
pelvis, and bearing down, it was called a prolapsus;
but now we know very well that these symptoms may^
exist as a sign of engorgement, or granular erosion ol
the OS, without the least displacement of the organ.

To be accurate, then, the malposition should be
certained exactly, and we should apply to it the ti
that would express precisely the deviation from a nor^
mal position. If we use the term retroversion, of
course wo all understand it, because its meaning ia
defined. If we say anteversion, for the same reason^
there can certainly be no misunderstanding. If we say
antero-lateral version, it is equally significant of thi
position, provided we add the quahfying adjectives,
right or left, as the case may be. If we say prociden-
tia, we mean that the cervix uteri has passed beyond
the mouth of the vagina, to a greater or less
but to say there is prolapsus is to hide up the real
condition of the iiterus under a vague generality. I,
therefore use the terms anteversion and retroversion'

liTEUIKE DISPLACliMENTS.

to designate the relative deviations of the body of the
utei'us from a normal position while within the pelvic
cavity, and the term procidentia to designate its passage
out of the pelvis through the mouth of the vagina.

Anteversions are often due to adventitious develop-
ment of some sort in the anterior wall ; retroversions
frequently occur as a sequence of debility, or relaxation
in the ligaments that support the uterus. In both we
often find an enlargement of that portion of the body
which is most dependent. In the first, tbis enlarge-
ment frequently induces the deviation ; in the second,
it is oftener the consequence of it.

When we remember that about every eighth marriage
is sterile, we see the necessity of investigating all par-
ticulars that can by any possibihty bear upon the
elucidation of this important subject. At the begin-
ning (page 2) 1 said that I had, for obvious reasons,
divided my sterile patients into two classes ; viz.,
natural, and acquired steiility. The following table
shows at a glance what an influence mere displacements
of the uterus must exercise over the sterile condition
in each of thi

No. or

IxtCUw... 250
2ndCU»i... 3S6

Total

505

AnteTBTsionB. Betrovor

164

31.1

Tiius we see in 250 married women, who had never
borne children, that 103 had anteversion, and 68 retro-
version ; while in 255 who had once borne children,
but for some reason ceased to conceive before the
natural termination of tlie child-bearing period, 61 had

238

UTEKIVE SCEGEET.

anteversion, and 111 retroversion, the sum total in
each class bearing almost exactly the same relation to
the number observed, being about two-thirds of the
whole, Hence we infer that if the malposition exercises
an influence to prevent conception in the one class, it
is of equal importance in preventing it in the other.
The mere position of the uterus is here stated without
reference to causes or complicatious. I have pm-posely
avoided saying Low many of these bad granulationsj
engorgements, hypertrophies, fibroids, ovarian cysts,
or other complications. The table shows that two-
thirds of all sterile women labour under some form of
uterine displacement, without reference to the particular
cause of such displacement ; and that the anteversions
and retroversions in the two classes are in inverse
proportion : the anteversions in the first being about
equal to the retroversions in the second; and the
retroversions of the first nearly the same as the
anteversions of the second.

Without further general remarks, let us proceed to
consider in turn these various forms of displacement.
I have not thought it worth while to make a distinct
heading for antero-lateral flexions. They comprise but
a small class, and are almost always secondary, being
the result of some other aff'ectiou.

Of Anteversion. — According to the tabulated state-
ment above, nearly one-third of all sterile women have
anteversion. In natural sterility the proportion is 1
in 2'42 ; in acquired, it is 1 in 4'18, being nearly twice
as frequent hi the first as in the second.

It would here be appropriate to lay down the rules
of diagnosis in reference to this particular form of

ANTEVEIiSION.

239

displacement ; but as its principles have been already
amply stated, wliether by bi-manual palpation or
probing (see pages 8, 9, and 100 to 104), it is unneces-
sary to repeat them here. I will now only say that we
are never under any circumstances to probe the uterine
cavity till wc have by the touch first ascertained its
probable direction ; and then the sound is to be curved
or not, according to the suspected curvature of the
canal of the cervix.

Anteversion may depend upon a variety of causes ;
sometimes the uterus seems to he bent upon it.s own
axis, in consequence of an abnormal elongation of the
organ. For instance, suppose the sound passes three
inches and a half into the cavity of the uterus, we
would then say it is at least an inch too long. This
must depend upon one of three things : either an
elongation of the intra- vaginal portion of the cervix ;
elongation of the supra- vaginal portion ; or hypertrophy
of the fundus. If to the first, the touch, sight, and
absolute measurement will at once determine it; if to the
second, the unerring bi-manual palpation will demon-
strate to our sense of touch, a long, delicate, slender,
flexible supra-vaginal cervix ; if to the third, it can be
equally as well measured and judged by the touch
alone, provided we apply the principles of diagnosis
already referred to.

We sometimes find the uterus undeveloped, entirely
too small, often not more than an inch andahalf deep;
and again, it is not uncommon to find it over-developed,
with the supra-vaginal portion of the cervix long and
slender ; and wliun this is the case, the fundus must
of necessity fall one way or another, and most usually
forwards, producing anteversion or flexion.

240

UTERINE SUiiGERY.

Again, anteversion seems to bo occasionally the
result of a shortening of the utero-sacral ligaments ;
or else these ligaments become shortened by the long-
continued malposition. Nothing is more common in
old retroversions than to see the anterior wall of the
Tagina contracted in consequence of the long-contiimed
malposition ; and here it often presents a formidable
barrier to a permanent rectification of the displace-
ment. Now in the same way it is presumable that the
utero-sacral ligaments, if not congenitally too short,
may become shortened by long disuse, just as the round
hgaments may become relaxed and lengthened by long
error of position.

Be this as it may, wo sometimes meet with ante-
versions where we encounter great difficulty, and inflict
great pain in drawing the os tincje forwards. In these
cases the vagina is long and narrow, and the os tineas,
instead of pointing towards the end of the coccyx, may
look directly back towards the hollow of the sacrum.

Now, if we here insert a tenaculum into the anterior
lip of the OS tinca3, and pull it towards the urethra,
feeling at the same time unusual resistance to this
traction, there will be one of two things to account
for it; either the fundus of the uterus is bound down
anteriorly by adhesions, or the cervix is held back
posteriorly by shortened utero-sacral ligaments. If
the first, which is very rare, then it will be impossible
to elevate the fundus to a normal position by the usual
method of elevating the anterior cul-de-sac of the
vagina up behind the inner face of the pubes -with the
left index finger, while the fundus is pushed backwards
by the other hand acting upon it in the hypogastrium
through the parietes of the abdomen ; but if it be due

ANTEVERSION.

241

to the second, then, by introducing the index finger
into the rectum, or even to the posterior cul-dc-sac
of the vagina, at the same time that we draw down
the cervix with the tenaculum, we shall feel the utero-
sacral ligaments as tense and resistent as two well-
stretched guitar-strings. I must admit that such
cases are not very common ; but their infrequcncy
makes it the more important to be able to recognize
them when we meet with them.

One of the most common causes of anteversion is a
FmaJl Bbroid in the anterior wall, as represented in
fig. 90. It is very in-
teresting to obseiwe ,- — —^

the influence of such /^ /_ X

tumours in producing
the variods displace-
ments of the uterus.
If a fibroid not larger
than an Knglish wal-
nut is attached in any ''"'■ ""■
way to the posterior

wall of the uterus above tlie level of the os internum,
it almost invariably pulls the uterus over backwards,
producing retroversion ; but if a similar-sized tumour
is attached to the posterior wall of the uterus below
the level of the os internum, whether it bo pedunculated
or not, it will almost as invariably push the fundus of
tbo uterus over forwards, or produce anteversion. In
other words, a small tumour of the body of the uterus
posteiiorly will produce retroversion, while the same-
sized tumour of the cervix posteriorly will produce
anteversion ; and i"V(^ ik'ritd, a small tumour in the
anterior wall of the body anteverts the uterus, but if

24Sfi CTERINE SDIMiRRY.

it grow anteriorly below tlie level of the os intemtnn,
it invarialily retroverts it. The reasons are anatomical
and most obvious. Let fig. 91 represent the uterus in
ite normal relations with the axis of the vagina. A
small tumour on the poste-
[. rior wall at a wilt, as before
said, retrovert the uterus, but
a similar-sized one attached
low down on the cervix at b
will as invariably antevert it.
In the first instance the
uterus obeys the laws of
gravity, by which an addi-
tional weight on one side of
the fundus must pull it in
*''"• ^1* the direction of said force ;

while in the second instance,
the tumour finds a point d'apimi in the utero-sacral
ligaments, rectum, and cul-de-sac of the vagina, which
oppose its downward pressure ; and thus, as the tumour
grows, it gradually pushes the fundus forwards.

For the same reasons a tumour anteriorly at rf, as a
rule, anteverta, while one at c invariably retroverts
the uterus, because it finds a point of resistance in the
walls of the bladder at its junction with the cervix.
Another reason for this curious law of displacement
in consequence of small growths on the supra-vaginal
cervix may bo found in the fact that the tumour acta
like a splint upon the side of the naturally slender and
flexible cervix. These rules are applicable to small
tumours only, and aU tumours must have had a small
beginning. When they grow large enough to rest
upon the brim of the pelvis, they elevate or depress

ANTEVBRSION.

243

I

tlie body of tlie utenis more by their volume and
relations to the pelvic ca\'ity than by the mere place
of their accidental attachment.

I have in many instances seen the cervix curved
anteriorly where it seemed to be produced by an
amorphous growth on its posterior surface. The
relative position and outline of this anomalous pro-
jection is represented in fig. 92, a. I do not know
what to call it ; it is not a fibroid
tumour. To the touch it has a
fibro-cartilaginous feel : I suppose I
have seen a dozen cases of it. It
is very uniformly of the shape
and form here represented, always
pointed below ; it almost always
projects, as here, a little below the
insertion of the vagina. I have never found anything
like it growing on any other portion of the uterus.
I have seen it in two cases in which there was no
curvature of the cervix. Each of these was sterile,
each had the cervix incised ; one conceived four
months afterwards, the other in eight. Both of
these had had metro-peritonitis some time before I
saw them. From these two cases we may infer
that this growth may possibly be the product of
inflammatory action, and tliat it does not, ^jcr nc,
interfere with conception and child-bearing. In the
other instances I could nut trace its history to any
pi-edisposing cause. The first case of this anomalous
growth that I ever saw was in the Woman's Hospital,
in 1856, in a young Irish girl, who had painful men-
struation as the consequence of a curved contracted
coivical canal. Dr. Eminet and myself called it the
n 2

244

UTERINE SURCERT.

cock's-corab excrescence. We callecl it this merely I
give it a name. The name was suggested l)y the fon
of the growth, by its mobility, by its gi-istly feel,
by the manner of its attachment.

It has a sessile attachment to the neck of the womh)
perhaps half an iuch wide above, growing narrower t
it descends. It can be diagnosed with the great<
facility by the bi-matmal method of palpation. Jndei
I never consider any obscure condition of the uten
thoroughly made out till we manipulate the whole su:
face of the organ almost as completely as if we had it
outside of the body. This affection is not described in
the books, but I have no doubt that others will find it
where they have not, as yet, suspected anything of tliaj
sort ; and the professional mind once directed towardd
it, I have as little doubt that some one will be ablej
sometime or other, to give us its pathological appt
ances from post-obit examinations.

But to return to anteversions. We may have then
from other causes. We often see granuhir engorge-
ment of the anterior lip, accompanied by a correa-^
ponding engorgement, or hypertrophy of the anteria
wall of the uterus. And here there is alwayj
anteversion. Some think that these corresponding
conditions of the cervix and body anteriorly are patho-
logically one and the same thing ; but we often see tin
engorged condition of the os and cervix cured withoud
the least impression being produced, either on tin
hypertrophy of the anterior wall or on the relatiy^
position of the fundus.

We sometimes have the uterus bound down by liga.
mentoua adhesions, the result, most probably, of soms^
former peritoneal inflammation. These cases are coiih|

ANTEVEKSinjU.

245

I
I

parativoly rare ; but that tliey do exist is proved both
by observation on the hving, and by post-mortem
examination. We more frequently find ligamentous
ailhesions in retroversions than in ant-eversions.

Of course we can do nothing for the rectification of
malpositions dependent upon adhesions, nor as a rule
will they require any interference, for the adhesions
naturally sustain and support the uterus in its abnormal
relations, and protect it iigainst the pressure of the
superincumbent viscera, which would otherwise force
it still lower in the cavity of the pelvis. In those
cases in which I havo found the uterus bound down
by adhesions, there was little or no complaint of tlic
symptoms ordinarily attendant upon such displacement.

So far as the treatment of the sterile condition in
connection with auteversion is concerned, I fear that
our efforts must be confined almost wholly to seeing
that the os tiuc^ is opou enough, that the cervix is of
proper form and size, and that the secretions gf the
vagina and of the cervix are suited to the viabiMty of
the spermatozoa.

The introduction of the uterine sound by Simpson
constitutes an era in obstetric surgery. Before this
wo knew as little about the rectification of displace-
ments as we did about their diagnosis. It was, and is
BtiU, used as a redresaer of displacements, in retrover-
sions, with much show of science and precision, if not
of skill and success; but in antcversions with none of
those. As a mere probe, it is, as I have said before,
very valuable, although the practised touch seldom
needs its aid ; but as a redresser, it is capable of doing
great mischief, and should no longer be used as such.
Kven a.s a [jrobe, merely to determine the course,

246

UTERINB SUIUIERY.

curvatiiro, and exact dejitb of the uterine cavity, it is
possible to do harm with it.

In anteversion I now seldom ever use it in the
dorsal decubitus ; but place the patient in the left lat-
eral serai-prone position, as for all uterine operations.
When the cervix ia brought into view, it is pulled
gently forwards by a small tenaculum (6gs, 14 and 53),
and then the annealed probe (fig, 40), more or less curved
to suit the previously ascertained or suspected curvature
of the canalj is to be introduced with great gentleness.
As soon as it passes the os internum, it goes to the
fundus almost by its own weight, simply by elevating
the handle of the instrument towards the sacruin.
We can never do harm or even pro-
duce pain, if we adapt the size and
curvature of the probe to the pecu-
liarities of the individual case. We
may occasionally need one not larger
than that shoivn in fig. 93, and wo
sometimes need to curve it quite as
much in complete anteflexions, such
as are represented in figs. 41 & 60.
Putting the cervix on the stretch
by means of the tenaculum hooked
into the anterior lip of the os greatly
facilitates the use of the probe in
difficult cases, by fixing the uterus
and by straightening the curvature
of the canal. I am sure that much
harm has been done with the sound;
1st, by having it too large ; 2nd, by
having it too straight, or always fixed at the same
curvature, as shown in fig. 39 ; and 3rd, by using

ASTEVEUSIOX.

247

I

too much force. Again let mo repeat that we arc
never to forget that it is simply a probe, and that
we are to liandle it as dehcately as we would a probe
for any other surgical purpose.

While we then accept the sound ae a probe, we must
wholly reject it as a redresser. For diagnosis it is
valuable ; for treatment it is dangerous. During the
learned discussion in the French Academy of Medicine
a few years ago, on the uses and abuses of this instru-
ment, the fact was fully established, that it had,
perhaps more than once, been forced through the
fundus uteri, and that death was the consequonco of
this rude and awkward accident. This coiild only
have happened by using it with violence as a redresser.
There is some show of philosophy to justify it suse in
retroversion, but why it should ever have been used
to replace an anteverted uterus I cannot understand ;
and yet I have seen patients with anteversion, who
had for months been subjected to the introduction of
the sound almost daily ; I need hardly add, without
the least benefit.

To replace in this way, or in any other, an anteverted
uterus with the expectation of its remaining in a
normal position by this means alone, is perfectly futile;
for it invariably falls back into its abnormal position
tho very moment that the force is removed that
replaced it.

For the replacement of an anteverted uterus we
need no instrument whatever. The process is simple
enough, and is effected easier and better by mere
manipulation than by any instrumental aid. The
bladder empty, the patient on the back, introduce the
loft index finger, as shown in fig. 1, to the anterior

248

rTEItlNE SUIUIKRY.

the
idex ^^^

•OW8 ^^n

gera

■ the ^n

cul-de-sac ; make pressure outwardly with the othei
hand, to be sure that the uterus is anteverted ; thei
remove the outer pressure, and with the index finger"^
still resting a little anterior to the cervix, elevate the
08 tincae in the direction of the pubes, by carrying the
anterior wall of the vagina on the point of the index •
finger up behind its inner face ; — this pressure bringin.
the cervix forwards and upwards, necessarily elevat*
the fundus from its bed behind the pubes and throws
it slightly upwards ; — now push the ends of the fingers
of the right hand on the outside from above, do^vu
into the hypogastrium closely behind the pubes,
that the fingers of the two hands shall feel that thei
ia nothing between them but tho thin walls of I
abdomen and the thinner walls of tho vagina and
bladder. While the right hand is thus held firmly,
the fingers occupying, as it were, the place just filled
by the fundus uteri, quickly slide the left index from
tho anterior to the posterior cul-de-sac of the vagina,
and push this before it till tlie finger hes snugly up
behind the cervix uteri ; then elevate it, as it were,
against the points of tlie fingers of the right hand,
with which push back the fundus, and retrovert the
whole organ while we hold it up almost in contact with,
the abdominal parietes.

Thus we are al)Ie not only to stiaighten up th6|
organ, but to manipulate every portion of the exten
surface of tho uterus : the fundus and body, before wa I
attempt to replace it (fig. 1); tho remainder by the J
above mancBUvre.

This js ordinarily easily done, even in very fat women,.]
because nature provides a sulcus between the fatty 1
deposit in tho walls of the abdomen, and the pubiff I

ANTKVEriSloriJ.

249

coveriDg in which the outer hand is readily carried
down behind the pulies as above directed.

AVy only find tvouble in dehcate, nervous, hysterical
women, where there is involuntary spasm of the
abdominal walls, or where the cervix uteri is firmly
held back by shortened utero-sacral ligaments.

It is by thus passing the left index finger behind the
cervix uteri, and then drawing the whole organ directly
forwards, almost against the inner face of the pubea,
and pushing the ends of the fingers of the outer hand
down behind the uterus instead of before it, that we
can diagnose with the greatest accuracy fibroid
tumours, whether sessile or pedunculated, and such
offshoota as are represented in fig. 92, page 243. It
was but the other day that a friend of great eminence
in the profession asked my opinion in reference to a
fibroid suspected to be in the posterior wall of the
uterus. He was hesitating whether to attack it
through the cavity of the uterus or through the cul-
de-sac of the vagina. By this bi-manual method of
palpation alone, I was able in a moment to say that
the tumour, nearly as
large as tiie foetal head
at term, was peduncu-
lated, and that the jie-
dicle, about an inch long
and three-fi)urtlts of an
inch thick, was attached
to the posterior face of
the uterus, about half-
way between the inser-
tion of the vagina and
the fundus uteri (fig. 94),

It is not necessary to say

250

UTHRmt SUIi<iERY.

more about the peculiarities of tbe case here,
tliat in the course of a few minutes my friond was
fectly convinced of the exactness of the diagnosis.

But to return to the subject of anteversion. So
as the mechanical treatment of anteversion 2wr se
concerned, I know of but one instrument that baa
power of rectifying the position perfectly and at once,
and that is the intra-utei-ine stem (with disk) of
Dr. Simpson. But unfortunately the risks of the
instrament are too great ; and I know but three
practitionei's in my own country who have not, after
repeated trials, discarded it altogether. These are B
fessor Beaaleo and Brofeasor Conant, of New Yorl
City, and Professor Mack, of Buffalo.

In the practice of the Woman's Hospital, Dr. Emrai
and myself were long ago compelled to discontini
its use, on account of frequent accidents, such
hcemorrhage, metritis, and pelvic cellulitis. Sometinu
a small Meigs's gutta-percha ring will afford relief, not'
80 much by rectifying the position as by elevating the
organ slightly in the pelvis, and taking some of its
weight from the bladder. Sometimes we derive coi
siderable comfort from a small globe pessary, pai
cularly if it can be made to I'est just antei'ior to
cervix uteri. For this purpose I have now and th(
attached a stem to the globe, which projects exteniall^
and is ciu^'ed up over the pubes, to prevent the ball
from rimning down into the posterior cul-de-sac.

Fig, 95 will represent a very common form of ante-
version. Now, if we introduce a globe pessary
inch and a quarter in diameter, it will ordinarily p!
to the very bottom of the vagina at a, resting
under the cervix, and elevating it, while the fundus

ree
iler^^_

I

the
its I

lOIl;^^^^

thei

ANTEVEBSION.

251

be thereby rather depressed anteriorly than otherwise;
thus aggravating the malposition : Ijut if we attach a
malleable stem to the globe, and
curve it externally at the proper
length to prevent it from jtassing
further than the anterior ciil-de-sac,
its tendency is to throw the fundus
upwards in a normal direction by
its pressure or traction on the an-
terior wall of the vagina at h. Its
action is readily understood by pressing the index
finger forcibly up behind the symphysis pubis, which
easily elevates the anteverted utenis. If the ball be
too large, its pressure here wiU retrovert the uterus,
just as a tumour grooving low down on the cervix
anteriorly will throw the fundus backwards.

But all instruments with external projections annoy
and in-itato a naturally sensitive nervous system,
already rendered more irritable by disease, and are to
be avoided if possible.

It was the fashion a short time ago to use a sponge,
with a string for its removal. To this practice there
are two serious objections : 1st, nothing could be more
disgusting than a sponge thus worn for six or eight
hours ; and 2nd, the sponge always swells consider-
ably by absorbing moisture, and soon patients feel the
need of increasing its size, and they generally get
to introducing two instead of one. The patient that
once contracts the habit of wearing a sponge in the
vagina will find it very difficult to break it up.

But what is better than this, and, indeed, better
than almost anything of the sort, is the appUcation of
a small wad of cotton, not more than an inch in

252 UTERINE SCBGEBy.

diameter when moderately compressed, which may be
used simple or moistened with glycerine, or othenvise
medicated. Instead of expanding, it gets smaller by
the pressure of the parts. A pessary of simple cotton J
should never be retained more than twenty-four hours : J
moistened with glycerine, it may be worn two or threo*
days, or till it cornea away spontaneously. The cottonii
^aeasary secured with a string for ita removal,
be applied by means of a porte-tampon, described i
figured further on.

Id very aggravated cases of anteversion, where thw
whole organ lies flatly down on the anterior wall ofl
the vagina and parallel with it, we often, indceds
almost always, find tlie vagina unusually deep, with I
the anterior wall greatly elongated. For such caseaa
I devised and executed an operation in 1857, which.1
has answered a raost admirable purpose.

It was under these circumstances. A lady was sentJ
to me by Professor Josiah C. Nott, of Mobile, Alabama,,!

in December, 1856, who bad a most complete ante-j
version, the fundus uteri being drawn down behind
the inner face of the pubic symphysis by a fibroid

ANTETEESION.

253

I

tumour on the fiindns anteriorly. Fig. 96 represents
the relative position of the uterus and tumour a. I
have never seen a more complete anteversion. The
diagram does not in any ' way exaggerate any of the
details of the case. She had a cervical leucorrhoDa,
which was
cured in a few
weeks ; but
the cystorhoea,
vesical tenes-
mus, and mal-
position, with
its otherin con-
veniences, per-
sisted. Tor the I
relief of the
displacement I fjh. 97.

tried all sorts

of pessaries, but nothing did any good. The pelvis was
deep, the vagina capacious, the anterior wall unusually
long, and the uterus laid down on and parallel with it.
I discovered that the malposition could be entirely
rectified by hooking a tenaculum in the anterior lip
of the OS tincai, and drawing the cervix down towards
the urethra. By continuing this traction till the cen'ix
was Ijrought fon\ard about an inch and a half, the
fundus rose up in the pelvis into rather a normal posi-
tion, notwithstanding the weight of the tumour on its
anterior portion. When the os tincie was thus drawn
forwards, the elongated, relaxed anterior wall of the
vagina was naturally folded upon itself, presenting the
appearance of an enormous anterior cul-do-sao, as at (/

ag. B7.

254 UTERINE STJKGKHT.

Under tliese circumstancca, could anythinjw hw
been more positively indicated than an operation,
retain the uterus hi tlie position in which it was thii
held by the tenaculum ?

The operation of shortening the elongated antu
rior wall of the vagina, by attaching the cervix ut«
to it at the point c, was therefore most naturally )
aelf-suggested affair. It was very simple, and
a mere operation must always be a successful one^
whether it will, when successful, always produce reli
of suffering, time and further experience can aton(
determine.

Two semilunar surfaces a half-inch wide, and runnix
nearly across the anterior wall of the vagina, the oui
in Juxtaposition with the cervix, and the other
inch and a half or more anterior to it, were cart
fully denuded of the vaginal mucous raombrai
as shown in fig. 98. Thaj
were then closely united by
seven silver suturea, as in
the operation for vesico-
vaginal fistula. The patient
was put to bed, and a self-
retaining catheter worn for
a few days ; after which the
ui'ine was, drawn off wh6n_
necessary. At the end of b
or twelve days the suturi
were removed, the union i
the two surfaces being ]
feet. The patient retaind
the recumbent posture foi
week longer, to allow the cicatrix to get Btrod

aktrvehsion. 255

enongh to resist any traction that might be mado by
the bladder, rectum, or uterus itself.

The utenis was held as nicely in its proper position
by this bridle of vaginal tissue as it was previously
by the tenaculum ; and fortunately she was wholly
relieved of the Buffering aymjitoms, of which she had
so long complained before the operation.

Twelve months afterwards this lady gave birth to a
son. I saw her husband a year after the birth of the
child, and he reported his wife as enjoying most
excellent health, never having felt the slightest
symptoms of her old troubles at any time since the
operation. I am sorry to say I have performed this
operation in but two other instances. I have seen
many cases suitable for it, but they have been satisfied
to put up with some clumsy mechanical contrivance
rather than submit to an operation. As I have not
seen the case above related since the confinement, I
cannot say what effect the labour produced on the
cicatrix, but I should expect to find it intact.

In 1859, a young lady aged twenty-six was sent
to the Woman's Hospital with just such an anteversion
as the one above relat-ed, except that tlie fibroid on the
fundus of the uterus was much larger. She was a
patient off and on for twelve months, and Dr. Emmet
and myself exhausted all our mechanical ingenuity
(and patience too) without producing the least benefit.

At last I proposed to her the operation above
doscril>ed, telling her at the same time that it had
been done but once before. She readily accepted it ;
and the operation wa^ jierforraed in May, 1860, with
perfect success, and with almost entire relief to all her
Bufferings. I havo seen this young lady repeatedly

256 IITERINF, sunriEKT.

since ; the last time in July, 1862, being then twenty-
six months after the operation, and the utenis remained
jiiat as it was when she first left the Hospital.

I performed this operation a third time in 1860, at
the Woman's Hospital ; the patient left soon after-
wards, and as I have not seen or heard from her since,
I cannot say what was its effect upon her health ;
but the operation, as such, was as successful in every
particular as in the other two instances.

I would not be understood as recommending this
operation as a universal one in anteversion. It is to
be resorted to only when the anterior wall of the
vagina is unusually long, and when the uterus lies
down parallel mth it, presenting the fundus just behind
the inner face of the symphysis pubis.

Of Retkoveesion. — While the table on page 237
shows that about one-third of all sterile women have
anteversion from some cause or other, it also shows
that another third suffer from retroversion ; although
these two forms of displacement vary in the two
classes of natural and acquired sterility ; the antever-
sions, as liefore stated, predominating in the fii'st, and
the retroversions in the second.

The uterus is retrovcrted when the fundus falls
backwards under the promontory of the sacrum or
whenever it passes an angle of 45" in that direction
from its normal position. But, as before said, it never
stops at 45°, seldom at 90°, and often goes to 135°.
Thus we may have different degrees of this version .
We can ordinarily diagnose a retroversion by the bi-
manual method of palpation, already more than once
described ; but if at any time we are in doubt, the

RETROVERSION.

257

l^iS!

uterine probe will easily, and with great certainty,
settle the point. If we find a tumour in the retro-
uterine region, and doubt whether it be the fundus of
the uterus or not ; and if we can pass the probe into
it to the depth of two inches and a half, then it is the
fiindus ; but if it pass two inches and a half or more
in some other direction, then it is not the fundus.
There is no need of oar ever being in doubt as to
a retroversion. The physical signs elicited by the
touch and the probe are invariable and indubitable.
I have already said so much on these two methods
of diagnosis, that more is here unnecessary.

Fig. 89, page 234, represents the uterus in a normal
position. Fig. 99 re-
presents the uterus
retroverted from
its normal position
(I to an angle of at
least 90°. In retro-
versions like this
there is ordinarily
a greater degree of
vesical tenesmus
than in antever-
sions. This is ex-
plained by the fact
that in the one the
nock of the bladder
is the seat of pres-
sure, while it is ''"'- '"'■
the fundus in the

other. The diagram roprcaunts the manner in whi<'h
the neck of the bladder may bo jammcl ngainst the

268 ttTEBINE SCTJGERT.

Bymphysis pubis if the utenia is much hypertrophied.
Here it is not relatively augmented in its long
diameter. It also shows how awkwardly the fundus
of the bladder is pulled back by its attachment* to the
cervix uteri, and how the cervix occupies the place,
as it wore, of the has fond of the bladder.

It is possible in many instances to replace a retro-
verted uterus by manipulation alone, simply by push-
ing the cervix back with the index finger till the os
looks in the direction of the hollow of the sacrum, and
as the fundus rolls upwards, grasping it with the oiiter
hand through the walls of the abdomen and pulling
it forwards. We can thus often produce a complete
anteversion of the organ. But it is not always easy
to do this, particularly if the pelvis is deep, the uterua
large, the vagina long, and the patient fat. It is then
necessary to resort to instrumental aid, the simplest of
which are two or three sponge probangs, with sponges
not larger than the ball of the thumb.

For this purpose place the patient on the left side,
as for aB uterine operations, introduce the speculum,
push one of the sponge probangs gently, firmly,
forcibly into the posterior cul-de-sac, holding it there
steadily till the cervix uteri is raised from its contact
with the anterior wall of the vagina; then place the
other sponge against the cervix anteriorly, and gently
push it back towards the posterior cul-de-sac, at the
same time that the pressure is continued by the first
one. This will generally roll the fimdus over forwards,
and elevate it from its bed in the utero-rectal pouch.

Thus let fig. 99 represent a retroverted uterus with
the speculum and the first sponge probang m situ.
The pressure with the probang must be made in the

ItETROVEBSION.

direction of the dotted line h under the ftindus uteri,
directly towards the hollow of the sacrum, or in other
words, in the direction of the proper axis of the vagina.
The tendency of this is at once to throw the fundus
upwards, by tilting the cervix downwards and back-
wards. When this has been carried as far as possible,
then the pressure of the second sponge against the
anterior face of the cervix completes the rectiBcation
of the malposition, — provided we are careful to mako
the pressure in the right direction. If the handle of
the sponge probang be carried far back towards the
perineum or the blade of the speculum, in the direction
of the dotted line r, it will strike against the cervix
uteri or in the anterior cul-de-sac, and of necessity
retrovert the uterus to a greater degiee, by pushing
the cervix upwards and forwards instead of downwards
and backwards. But if the handle of the probang be
kept close to the urethra, the pressure will be made
in the direction of the line h, which necessarily causes
the uterus to revolve on its own axis, the cervix taking
the relative position just occupied by the fundus, while
this rises up above the promontory of the sacrum.
We shall generally, but not always, succeed in this
simple way in restoring the uterus to its proper
position.

If we produce any pain by this process, it will bo
in consequence of pressure against the hypertrophied
tender posterior wall of the uterus, or against a pro-
lapsed supersensitive ovary, or something else abnormal,
in the Douglas cul-de-sac, all of which it ig important
to ascertain by the touch before making efforts at
replacement. Then if we use two sponge probangs
for pressure in the posterior euhde-sac instead of one,
R 2

irrERINE SlTRnEHY.

we avoid the production
pushing the sponges back

of

par

n ; but inst€

n a direct line, centrally

over the os tineas, we cross them, laying one on the left^

side of the cervix, and the other on the right, as shoi

in fig. 100, a b. They will naturally crosa just OV*

or very near the urethra.

I have bad them fastened

together at the crossing,

making one automatic ma-

eliine of the two ; but this

does not answer so well,

because we may sometimes

need to change the point of

pressure of one probang and

not of the other. We may;

not only need to change the

direction of the force, Init

we may also wish to .^se,

more or less, with one than

the other ; and we can do all

this vnth greater facility with

the two sponges as they are.

For instance, suppose wo

wish to change the pressure

of the probang a more to the

Fio. 100. •;p, left., the handle is at once

thrown to the right and it

takes the direction of the dotted line d ; and in like

manner we may act with /'. \Vlien we are satisfied

that the fundus has been rolled up out of its old bed,

which is to be presumed when the os tineas looks

directly back towards the posterior wall of the vagina,

instead of towards the symphysis pubis, then we are

Illy
left^l

ira.^^^

KETBOVEBSION.

261

to apply the probang c against the cervix, and push
this in a straight line backwards.

Fig. 101 shows the uterus somewhat elevated from
its abnormal position, towards the promontory of the
sacrum. We may push the organ up thus far, and
suppose that we have
reduced the disloca-
tion, because the os
and cervix have been
forced back into a
normal relation with
the axis of the vagina.
But the operation
is not yet finished.
Holding the sponges
in position, the specu-
lum is removed, and
the patient requested
to turn from (^ side
on the back ; then
pass the left index fiq. loi.

finger into the vagina,

and place it against the anterior face of the cervix ; hold
it firmly there, and remove the sponges, one at a time ;
then while the cervix is still pushed backwards by the
finger, bring the other hand to make the outer pressure
(bi-manual). If we can with this grasp the fundus of
the uterus, and bring it towards the symphysis pubis,
then we are sure that wo have succeeded ; if not, we
have only crowded the cervix backwards, flexing it
upon itself and leaving the fiindua in its abnormal
position, almost as it was before (fig. 102).

This is more apt to happen when the pelvis is deep,

202

UTEBINE SUBGEEY.

and the supra- vaginal portion of the cervix is long and
Blonder. If our patient is too much fatigued to change
her position to the dorsal decubitus for the bi-manual
examination, we can ascertain the degree of success
of the effort at replacement by passing the uterine
sound while the pa-
tient is still on the
left side. If it pass
easily the proper
distance in the di-
rection of the nor-
mal position of the
uterus, then it is all
right ; but if it pass
back towards the
hollow of the sa-
crum, then it is all
\vrong.

It is better not to
fatigue our patient
too much, and if we
do not succeed to-
day, it will be as well to wait till to-morrow. When
wc attempt anything of this sort, we must always be
sure that the bowels are not constipated ; and we
must not forget to have the bladder emptied before
trying to reduce the dislocated uterus.

Fig. 103 represents a retroverted uterus completely
restored to its normal position by the pressure of two
sponge probangs alone.

We often succeed by the simple process above
detailed;- but suppose we fail in our second effort, or
suppose wo are in doubt about adhesions binding the

EKTROVEESION.

fundus down in its abnormal position, what are we
tlien to do ? Wu then proceed otherwise ; suid it is
here absolutely necessary to use an inti-a-utei-ino force.

Dr. Simpson was the first to teach us how to
diagnose, and how to
rectify a retroversion.
He passes his uterine
sound to diagnose the
position, and then
turning it half a
circle, the retroverted
fundus is necessarily
elevated towards the
promontory of the
sacrum. But as I
have fi'equently said
before, this operation
often produces great
suffering, and some-
times hsemorrhage,

and I have not for many years used Simpson's sound
as a redresser. I have not ^een any more ser-ious
accident from it. Some object to the instrument, and
ostracize it altogether ; because perforation of the fim-
dus and death have followed its injudicioua use. This
is not wise or logical. I object to it only as a redresser.
Its whole principle of action is wrong; and hence the
pain and suffei-ing it produces. I only wonder it has
not done greater miscliiof. Lot us for a moment look
at its modus operandi.

Fig. 104 represents a retroverted utenis with Simp-
son's Bound introduced as a redresser. Now, if we
turn the handle of the instrument a on its own axis

UTEIUNE SUBGBEY.

half a circle, the distal end will elevate the uterus
from its abnormal position to that shown by the dotted

figure c ; but in doing this it will describe a semicircle
of but little less tlian two inches and a half radius,
sweeping tlio fundus round with the whole weight of
the organ, supported pi-incipally on the very end of the
instrument, which in its gyration clianges its point of
pressure from the posterior to the anterior face of the
uterine cavity. To elevate the fundus still more, we
push the handle h back towards tlie perineum, which
thrusts the uterine end upwards. Is it to be wondered
at, then, that we occasionally meet with patients who
look upon the uterine sound with the moat painful
recollections ? Seeing that an intra-uterine force was
occasionally absolutely necessaiy for the rectification of
this malposition, I devised the following instrument in
185G, and have used it ever since. Its whole principle
of action is that of elevatii!<;; the fundus in a straight
lino instead of a circle, and of supporting the weight

RETBOVEBSION.

265

of the oi^an on a disk at the os tines instead of
the distal end of the instrument at the fundus. For
this it is only necessary to make a joint or hinge in the
sound, about two inches from its uterine extremity,
and fix a disk or plate there, as a point of support for
the weight of the uterus. For instance, let fig. 105
represent a retroverted uterus, with a jointed sound a
introduced, the joint being at the os. Now all that
we have to do with such an instrument is to push the
mouth of the womb downwards and backwards into
the posterior cul-de-sac in the direction of the place
which was at the inception of this movement occupied
by the fundus. By
this manoeuvre the
OS tincje describes
the small arc of a
circle . represented
by the dotted line
d, while the fundus,
being elevated in a
right line, describes
a larger one, and
takes the position
b ; the handle or
shaft of the instru-
ment being repre-
sented by the dotted
lino c. If the in-
strument be pro-
perly adjusted, this
operation is efiected

without suffering to the patient or injury to the uterus.
If there are adhesions, we can measure very accurately

266

UTERINE SURGEEY.

their resistance and extensibility. I now remember

^ ^ two cases in which from this cause
it was impossible to elevate the
uterus more than 45° above the
axis of the vagina.

Fig. 106 represents the uterine
elevator with the uterine stem a set
at an angle of 45°, being the proper
angle for an ordinary retroversion :
c is the ball or disk for the support
of the weight of the uterus. It
revolves on its own axis in a line
with the shaft, permitting the stem
A to describe a whole circle, except
90°, — 45° on each side of the shaft.
This ball is perforated with seven
holes (the stem occupying the
eighth), made in a line around its
centre, for the reception of a pointed
rod, concealed in the tubular shaft,
which is pulled down by the ring b,
and flies back again when we let the
ring go, so that the movements of
the uterine stem A can be promptly
arrested at any desired point in its
elevation, simply by letting go the
ring B, which, with the rod, is
driven up by a hidden spiral spring
in the handle below. The little
perforations in the ball are placed
intentionally at the proper distances

to mark off* angles of 45° in the revolutions of the

stem.

8

^

Fig. 106.

UTERINE SDItCEltV.

or whether the two bo entirely separate and independ-
ent of each other. The intra-uterine portion of the
elevator ia malleable, because we may sometimes wish to
curve it a Httle to suit the peculiarities of some special
case.

Ordinarily this stem should not be more than two
inches long. It should never be long enough to touch
the fundus uteri by any possibility. In its use we
should be careful to keep the ball or disk always pressed
well up against the og tineas ; for if it should shp down
half an inch or more, we shall fail to elevate the fundus,
as the whole power of the instrument will then be
expended only in pushing the os tinea; backwards and
doubling the cervix on itself.

I published an account of this uterine elevator in
the January number of the American Journal of the
Medical Sciences for 1858 ; and since then it has been
variously modified by different writers, but not at all
improved. Dr. Gardner and Dr. Dewees, of New
York, and others, have added a screw to move the stem,
wliich is objectionable, because it robs us of the faculty
of determining the power of resistance by the sense
of feehng. When we have a freely movable joint as
in this instrument, it is easy to judge of the weiglit of
the uterus, and to determine the amount and degree
of adhesions, when present, by noting the exact point
at which we feel their resistance.

But suppose we elevate the uterus, whether hy
this means or any other, will it remain in its normal
position simply by placing it there ? Never. I have
known physicians to I'eplace a retroverted uterus day
after day for months, but I never knew a case cured
by it. It is certainly impoi-tant in many cases to

RETIIQVEHSION.

269

I

rectify the malposition, but moi'e than thig remains to
bo done to render it permanent. For this purpose
the organ must be not only replaced, but it must bo
retained in its normal position by some mechanical
means. In old cases, where the utenis is tender and
irritable, it will be well not to resort to a pessary at
once. It ia better to replace the uterus a few times
and apply simply a wad of cotton wet with glycerine,
for the double purpose of supporting the uterus in s-itu
for a while, and of removing engorgement by the
depleting power of the glycerine already described
(pp. 71, 72, 161). Whenever by this means or others
we remove all irritabihty or engorgement that may have
been present, we must adjust a pessary of some sort to
hold the organ in its normal position.

Much has been written on the subject of uterine
displacement, and very opposite views have been
entertained of its treatment. Some look upon it as a
matter of no great importance, while others are ready
to attribute to it every nervous symptom that the
patient may suffer. Some condemn pessaries and
ostracize them altogether, while others advocate them
perhaps too universally. Like most disputed points,
there is some truth on both sides. I have seen much
harm produced by pessaries, and so have I by bleeding,
by purgatives, by opium, by quinine, and by other
powerful remedies ; but I do not see why we should
wholly repudiate remedies or instruments because they
have been used injudiciously. I have also Been much
benefit from the application of the principles of
mechanics to the treatment of uterine displacements,
but I am well aware tliat there ai-e circumstances
nnder which they are inapplicable.

370

DTERINK SUnOBftr.

I have soen cases in wliicli Simpson's intra-nterino

stem (fig. 107) had produced very serious results, such

as metro-peritonitis. I have seen Hodge's

Xopen lever pessary (fig. 110) dig holes in the
anterior wall of the vagina almost through
into the bla^lder. I have often seen Meigs's
ring-pessary (fig. Ill) cut a sulcus in the
posterior cid-de-sac of the vagina deep
enough to burrow the finger in. I have seen
Zwang's pessary (fig. 108) sever the iirethra
from the neck of the bladder, cutting quite
down to the vesical membrane, but not tliroiigh it. I
have known one case where the disk of a .vaginal

rstera-pCRsary (fig. 109) passed
iuto the cavity of the uterus,
and remained incarcerated there
for several days, with the cervix
closely contracted around the
stem, til! it was removed by Pro-
fessor Lewis A. Sayre, of the
Bellevue Hospital College, N&
York ; and I have seen Giarit
Fro, 108. India-rubber bag-possary infiat

till it distCTided the vagina so
enormously that it seemed to occnpy almost the whole
of the pelvic cavity ; and I have heard of other
pessaries producing fistuli
openings into the rectum
\ the bladder.

But notwithstanding
this, I advocate and dl
use pessaries in some form or other; because, if I
not, I should turn away a multitude of cases withi

4

HETOUVERSION. 271

doing anything at alt for tlieir relief. Pessaries are
necessary evils. We should jilways do without them
if possible; but if it be impossible, then it is the part
of wisdom to resort to such appliances as irill best
answer the indications of the individual case.

The man who is not a mechanic should never trust
himself to use a pessary. Even with a correct under-
standing of uterine mechanology, we will often make
mistakes, —

Ist. In resorting to pessaries where there ia metritie
inflammation in some form.

2nd. In selecting an inappropriate instrument.
3rd. In making it too large ; sometimes too small ;
and

4th. In allowing it to remain too long without
, removal.

Even if we feel pretty sure of the form of the

[ instrument as applicable to the case, it is difficult for

I VB to get our ideas of the size of the vagina down to

a proper level. We more frequently make them too

largo than too small. After we succeed in getting the

pessary to fit accurately, we should never send our

I patient ofl" till she is taught to remove and replace it

[ with the same facility that she would put on and pidl

I off an old slipper. A pessary is a thing to be worn like

i glass eye, only when awake. As a rule, it shoidd

be pulled off at night, and put on in the morning, if

needed ; and if every poor woman who is compelled

to use such an aid for the support of the uterus, was

I always taught to understand the principles of its

i action, and to remove and replace it every day or two,

[ there would be none of the accidents alluded to above,

I to damage their reputation for usefiilness. But the

272 DTEltlNE SURGEBT.

greatest mistake that we make is that of taking- a
single model and applying it universally. What woul<i
be thought of the hatter who expected one h,it to fit
every head ? Of the shoemaker who expected one
shoe to fit every foot ? Of the dentist who expected
the cast of one alveolar arch to fit every other ? The
idea ia most preposterous ; and yet wo have been but
little less wise in our mechanical treatment of uterine
displacements.

I have seen the inside of an immense number of
vaginas, and I never saw two that were in all parti-
culars exactly alike. They are as different from each
other as are our faces and noses. In Mr. Pr^terre's
(of Paris) great collection of palatine fissure-casts,
._ numbering now some 600 or more, each one has its
.peculiar anomalies, and each its peculiar apparatus.
I would not be understood as meaning that 600
cases of uterine displacement would need as many
differently constructed instruments ; but I mean this,
that every individual case is a study of itself, and
that its complications and peculiarities must bo in-
vestigated, understood, and respected, if we expect to
treat them safely and successfully. But as I intend
to deal hero with pessaries only in relation with the
sterile condition, further general Remarks arc uncalled
for.

I do not pretend to say that a retroverted or an
anteverted uterus is incapable of conception ; but of
this I am certain, if conception occurs when the uterus
is greatly anteverted or greatly retroverted, it is rather
accidental than otherwise, and would liave occurred
with greater facility if this organ had been in a normal
position, other things being equal.

RETROVERSION. 273

When we call to mind the fact that of 255 cases of
acquired sterility (page 237), 111 had retroversion
and 61 anteversion; and of 250 cases of natural
sterility, 68 had retroversion and 103 anteversion,
we may have a right, as I have said before, to suspect
that the position of the uterus is a matter of some
importance in the treatment of the sterile condition.
Of course many of these cases of malposition were
compUcated with fibroids, or flexures, or engorge-
ments, or hypertrophies, or a conical cervix in those
who have never borne children. But even if all
these be rectified, we may still have sterility as a con-
sequence of malposition alone. At all events, the
frequency of malposition renders it an important
element in the treatment of the sterile condition.

Although I have been for a long time aware of the '
fact that malposition of the uterus had much to do
with sterihty , I never had the slightest idea of treating
this last in connection with the malposition till 1855 ;
and it occurred to me in this way. I was consulted in
July, 1855, by a lady who had been under the treat-
ment of Professor Hodge, of Philadelphia. The
history of her case gave the following facts. She was
twenty- three years old, married at seventeen, in July,
1849 ; had a two months' miscarriage in March, 1851,
from which she slowly recovered, find was sent to
Professor Hodge by her medical attendants in May
following. He found the uteiais retroverted, and
appUed his pessary immediately. She remained in
Philadelphia seven weeks ; had but one menstrual pe-
riod after the pessary was applied ; and returned home
still wearing it. Her physicians there pronounced
her pregnant, but did not remove the instrument till

T

274 UTERINE SURGERY.

September, and her child was born in March follow-
ing, Thia appeared to me at the time a most remark-
able revelation ; and I asked this lady how it happened
that she had sexual intercourse while she wore an
instrument. She replied simply, " It happened so."
"Often?" said I. "Oh, yes; just as if there had
been no instrument there." The idea of adjusting an
instrument that would permit sexual intercourse at
the same time that it held the uterus in silu was to me
a novel one. Since then I have acted upon it, and
think it of great importance.

Hodge's instrument, as first invented by him, is
made of silver and then gilt. It is in the shape of the
letter \J, \vith the two parallel branches curved on the
flat to suit the curvature of the vagina.

Fig. 110 represents the instrument. The cross-bar
connecting the two branches is
to be pushed up behind the
cervix uteri after the organ is
replaced ; the great convexity
of the branches rests on the
posterior wall of the vagina ;
and the open end looks in the
direction of the symphysis
pubis ; while the extremities of
the branches rest anteriorly, one on each side of the
neck of the bladder. Thcoi'etically and practically the
instrument is admirable, when neatly fitted and pro-
perly managed. Its expensiveness was tlie chief
objection to its general use. Dr. Hodge modified his
instrument for ante-versions, by placing a cross-bar
on its front or open end, thus closing it up entirely, and
making a sort of sigmoid parallelogram of ifc (fig. 112.)

RETROVERSION. 275

This form of ttie Hodge instrument is commonly
adopted by the profession in my own country, whether
it be made of silver, block-tin, vulcanite, or gutta-
percha. We seldom use the other one.

Hodge's instrument may be foimd in the shops
variously modified. For instance, they are made of
hard rubber, and sold in great quantities ; but these
are verj- dangerous, for they are generally too large,
and are fashioned into anything but the right shape ;
and I have found it impossible to give them the
proper equilateral curvatures by heating them in
boiling water, as is recommended. What is better
than the hard rubber, but not so cleanly, is a copper
wire covered with giitta-percha. But even hero we
have a right to complain of all our instrument-
makers ; for they have taken the common insulated
telegi'apliic wire, cut it into slips of various lengths,
and most clumsily fastened tho two ends of these
together in a ring, and then curved thera as we
find them. They do this to sell them a few pennies
cheaper. This is poor economy ; for they often get
fractured where they have been joined ; the secretions
then enter the little cracked fissures, and the instru-
ment liecoraes a source of irritation inst-ead of comfort.
Instead of this, the malleable copper wire should bo first
made neatly into a ring or pai'allelogram, and then
smoothly covered with gutta-percha, not varnished.
I have persuaded at least two instruroent-makera
{Mr. Weiss and Mr. Charriire) to remedy this evil.
Away with cheap things 1 whether drugs or instru-
ments, for our sick, especially for our sick women ; and
more especially still when they are afflicted with such
fearful calamities as we are now considering.
T 2

276

DTEFINE SCKGERT.

But my country holds another name equally ns
honoured and respected, and equally as authoritative
as that of Hodge, in advocacy of the mechanical treat-
ment of uterine displacements. In 1853, Professor
Charles D. Meigs published his report on uterine
diseases before the American Medical Association, in
which he promulgates the same views so long taught
by his ilhistrious confrfere,
ProfessorHodgc. Dr. Meigs's
instrument differs from
Hodge's, bnt its principle of
action is the same. While
Hodge's is a curved parallel-
ogram, Meigs's is simply a
ring, acting upon the same
principle of distending the
vagina antero-posteriorly, by
making the posterior cul-de-
sac and the inner face of thoi]
symphysis pubis the poinf
Pro. 111. of support. It, too, hoh

the neck of the womb back
in its proper place, and does not interfere with sexual
intercourse. Meigs's ring pessary is made of watch-
spring, fashioned into a circle, two, two and a half, ti
and three-quarters, and three inches in diameter,
then coated with gutta-percha (fig. 111).

It is introduced with great facility, by compresai
its opposite sides, thus elongating it in one directic
— dotted lino o, while its diameter in the other
diminished. As soon as it passes the arch of
pubes, it recovers its original form, but seldom
becomes perfectly circular again, lonlesa it is a vei

,ck^^

RETIiOVEHSIUN. 277

small instrument. If a large one, it takes on oval form
lifter being worn for any length of time.

These are often worn for a good while ; but in a
general way, as before stated, I am op]x»sed to the
principle. I have often removed the Meigs ring-
pessary after it had been worn continuously for ten or
twelve months. In five or six weeks it becomes coated
with a thick layer of brownisli sordes, having a most
disgusting smell. This, of itself, must irritate the
vaginal mucous membrane, independently of mischief
resulting from prolonged mechanical pressure. I have
seen one case in which the Meigs ring had lUcerated
a sulcus in the poserior cul-de-sac deep enough to
liide the little finger in it. I was surprised that it had
not perforated the peritoneal cavity ; but a close in-
vestigation revealed the wonderfully protective powers
of nature in throwing out lymph, and increasing the
thickness of the tissues through which the instrument
had gradually cut its way. Here the position of the
womb had not been wholly rectified. The pelvis
was deep, and the instrument liad merely pushed the
cervix backwards, while the fimdus was still retro-
verted. Perhaps tliis was well for the patient, for the
cul-de-sac of the vagina and the posterior wall of the
uterus seemed to be agglutinated firmly together, —
doubtless the result of the pressure and idceration of
the ring, for I had examined this case some months
before the ring was applied, and there was nothing of
the sort then.

I saw another case at the Woman's Hospital in
1861, where a Meigs ring had been worn continuously
for nearly twelve months. At first it produced great
relief, but after a while there was an excessive mueo-

278 DTEEINE SURGERY.

pui-ulent discharge from the vagina, and it was i
this that advice was sought at the Hospital.

We often see pessaries of this sort produce mischi
by being too large, but here it was the contra]
The cervix and a portion of the anterior wall of th<
vagina seem to liave gradually descended too far
through the small ring, and to have become almost
strangulated. It had cut a deep circular sulcus all
around the cervix, deeper posteriorly ami on the sides
than anteriorly ; and in this sulcus the ring was entirely
hidden fi'om view except just at the neck of the
bladder, where it was more superficial. On the
removal of the instrument, which was both difficult
and painful, its bed was seen to be a deep suppu-
rating chasm, with granulating edges that had entirely
overlapped the ring behind and on the sides. The
cervix uteri was also very granular, and greatly
engorged, seemingly in consequence of the strangu-
lating pressure of the ring. All of this disappeared
with the filling-up and heahng of the sulcus, which
occurred in the course of a fortnight.

While I advocate, and daily use pessaries of some
sort, it is but just that I should say dl I know
against them, simply as a warning of danger to others.
In this case the fault was with him who appUed the
instrument, and turned his poor patient adrift without
giving her instructions in its use. I have seen more
mischief from the Meigs ring than from Hodge's
instrument. I presume the reason is, that when it was
first introduced it was a cheaper instrument than any
other then in vogue ; was therefore more universally
used ; and, consequently, presented comparative!
larger opportunities for observation.

rethovehsion. 279

If the object be to cure the sterile state while wo
treat the malposition, I always use an instniment on
the same principle as those above described. Besides
the Hodge and Meigs instruments, as we find them
in the shops, I often use rings made of block-tin
softened by the addition of a little lead. These I
introduced in 1856. They are made of different
sizes, varying from two to three inches in diameter.
The material, if tubular, may be a third of an inch
in diameter ; much less if solid. It matters not
whether it be of block-tin or gutta-percha, so it is
malleable. Select a ring to suit the capacity of the
vagina ; compress it gently
between the hands till it
takes an oval form. It
is then in imitation of a
Meigs ring, and may be so
used ; but sometimes it i
better to give it the natural
curvature of the vagina,
after Hodge's plan, by '''"■ "^■

making the distal end b,

g, 112, pass up behind the neck of the womb, while
the proximal end a has a slight counter-curvature
where it presses the neck of the bladder against
the symphysis pubis. Great nicety is necessary in
fitting an instrument so as not to injure by pressure
the neck of the bladder, the posterior cul-de-sac, or
the floor of the vagina, upon which rests the great
curvature. It will be ditBcult to get one instrument
with its exact proportions to fit any two cases ; and it
is often difficult to fit any given case. It has fi-equently
taken me a fortnight, and sometimes much longer, to

CP

280 UTERINE SURGERY.

adjust an instrument accurately ; and sometimes it has
been utterly impossible for me to do it at all. When
I succeed in fitting the case exactly, L e. in supporting
the womb in its normal position without undue pressure
on the vaginal parietes, I usually send the model made
of this malleable material to the instrument-maker, to
be dupUcated in vulcanite or silver, if the patient is
to leave my care wearing an instrument. The block-
tin pessary is quite as good as a silver one ; but then
the patient in removing and replacing it may spoil its
shape, and make it hurtful instead of beneficial. If,
however, the patient lives near enough for me to see
her occasionally, I seldom order any other instrument
than the block-tin one.

As I said before, the case related on p. 272 gave me
new views of practical utility, that were not lost ; for
a lady, twenty-six years old, soon after this came with
her husband to consult me on account of her sterility
(acquired). She had had one child six years before.
It died early, and tliey w^ere exceedingly anxious for
more offspring, She had been treated at different
times by several distinguished physicians, all of whom
put her through ''a coTU'se of caustic,''* but her
symptoms remained the same, and her steriUty per-
sisted. On examination, I found the pelvis deep, the
vagina capacious, the perineum relaxed, and the uterus
completely rotrovcrted, but not difficult to replace.
The posterior wall was, as in all such cases of pro-
longed malposition, somewhat hypertrophied, and there

It was unfortunately the fasliion a few years ago in my own
country to cauterize the neck of the womb, without reference to
conditions or indications.

HETROVEKSlOX. 281

was also some little engorgement of the posterior lip.
Her symptoms of vesical tenesmus, bearing down, &c.,
were evidently the result of the error of position, and
I told them it was quite impossible for her to conceive
with the uterus in its abnormal position. I concluded
to treat the case entirely mechanically, but it was very
difficult, for I did not then possess the tact in adapting
an instrument to the peculiarities of the case, that
observation and enlarged experience can alone give.
It took me nearly a month to adjust it so that it could
bo worn without pain or undue pressure ; but once
fitted, there was no inconvenience from it ; on the
contrary, the greatest comfort. The ring, moulded as
described, was fully three inches and one-eighth in dia-
meter before giving it the form of a sigmoid pai'allclo-
gram. A special injunction was that it should be worn
during sexual intercourse. Conception occurred in three
months. She continued to wear the instrument tiU
after the third month, when the itterus had risen up
above the brim of the pelvis, and then it was removed.
She was delivered, at full terra, of a fine healthy boy,
which was turned over to a wet nurse. She was in
hopes that conception would soon occm* again, but it
did not ; and at the end of eighteen months she re-
turned to ask an investigation of her condition, and,
if necessary to insure an early conception, the reapph-
catioD of the mstrument.

I found the uterus precisely as it was when I first
saw her. It had no self-adjusting power whatever. It
could be replaced with facility, but dropped back as
soon as the finger was removed. I gave it as my
opinion that conception could hardly occur again with
the uterus persistently retrovorted. I therefore re-

I

282 UTERINE SURGERY.

applied the same iustrument with injunctions to weant
as before during coition. Conception occurred in eight
weeks afterwards. About fifteen months after the birth ,
of the second child, she came again, and I found tin
uterus precisely as it was at the first consultatioiuj
I adjusted another instrument to prop it up, and gavfli
the same injunctions, and in ten months atlerwardal
she was again a mother.

Now, in tliis case, I believe that conception coul^
have been brought about as easily five years soonerJ
if the same treatment had been adopted.

To establish the utihty of the pessary during coitioHiJ
in cases of sterUity dependent upon retroversion,
must continue my notes. The case above was uncom-
plicated. There was simple relaxation of all the pelvic
supports of the uterus, and it tilted over backward^
and will remain so always, unless it be propped i
mechanically. Occasionally a malposition of this sort
is cured by a pregnancy, but often it is not.

In 1856, a lady was brought to the Woman's
Hospital, who had been bed-ridden for more than tw
years. She was thirty-two years old ; was married s
twenty ; gave birth to a child in ten months, but sh^i
remained sterile aftenv'ards. She became a widow, '
and married again at thirty. Twelve months after-
wai-ds she ran hurriedly into the garden to bring in
some clothes that had been hung out to dry. On
reaching up quickly, she felt something suddenly give
way in the pelvis ; she had great pain, and immediately
went to bed, sufi'ering also from nausea, vomiting, and
excessive prostration. Her physician was sent for, and
attended her for many months, but ivithout much i
provement. I found the uterus completely retrovert

HETBOVEllSION. 283

and greatly enlarged, with the fundus directed towards
the left sacro-iliac symphysis. The enlargement, or
rather elongation of the organ, was due to a fibrous
tumour growing from the fundua, which explained its
diagonal direction, for it was too long to he retroverted
in the median line. To remove the fibrous tumour was
out of the question ; to allow the uterus to remain
where I found it, was to consign hor to her fato without
an effort for her relief. My only hope of affording her
any permanent benefit was in elevating the uterua,
supporting It in position, and giving her the possibility,
of a conception. When it was so elevated into
position, the tumour could be distinctly felt on the
fundus, above the promontory of the saci-um. But of
course it would fall back into its old position, as soon
as the finger and the uterine elevator were removed.
By repeating this every day for a week, the uterus
became sufficiently tolerant of manipulation to allow
the use of an intra-vaginal support. A malleable
block-tin ring, about two inches and a half in diameter,
was fashioned into the form of a parallelogram, and
cm-ved on its long axis, as already described, so as to
give it a shght sigmoid flexure. The vagina was rather
small, and great care was necessary not to inflict injury
by undue pressure in the posterior cul-de-sac, or against
the neck of the bladder and the symphysis pubis. The
instrument was worn at first for a few hours, but soon
it was worn during the whole day, and after a short
time she waa able to walk. In two or three months
aho returned home, not cured it is true ; but the uterua
was elevated into a proper position, and there supported
by the simple little contrivance already described.
With the hope that conception would take place, she

284

UTEItlNK SUBilERT.

was directod to wear the uturine supporter j
during coition. Six months after leaving the Ho^pitall
she returned for observation, and was found to h0im
pregnant four months and a lialf, having conceived :
six weeks after returning home. She had worn thfly
instrument all the time except when she removed it fat
cleaning.

She WL^nt the full term and was safely dehvered.
saw her some months after the birth of her child. Th^
uterus was in its proper position, but the tumour '
_about the same. Without mechanical aid here, I do uot'"
see how it would have been possible to have done any-
thing at all for this poor sufferer. There was nothing
whatever attempted for her but the replacement of the
dislocated uterus, with this vaginal splint, as it were,
to support it in its proper relations. This case might
be called cared, so far as the mere position of the woml*
was concerned. It is very probable that the fibrouj
tumour had existed a long time on the fundus, and
that it assisted by its weight when the uterus wai
suddenly retroverted in holding it down in its abnormd
position, and I have as little doubt that the same con-1
dition now assists in holding the uterus erect. Th(@
pelvis in this case was of ordinary capacity, while i
the case previously related it was very deep, with i
rather straight sacral promontory.

It might be 8U|)posed a jiriorl that any instrument
in the vagina would interfere with coition. I usually
make it a rule to explain the necessity of the treatment
to the husband as well as the wife. So far as our sea
is concerned, the knowledge of the presence of ,
vagmal support might be an uupoetical association;!
but if it is properly adjusted, it is not at all in the i

IIETRDVERSION.

285

I

I

I

way. Sometimes tlie wife has insisted that it was not
necessary for the husband to know that the uterus
waa thus artifically braced up. The instrument should
be neither too large nor too small, and should fit
snugly up behind the symphysis pubis.

In 1861 I was consulted by a young widow, who had
& proposition of raaiTiiige. During her first marriage
she had had one fiUI term labour, and three or four
miscarriages at about the third month. Her physicians
told her that she would probably always miscarry at
the third month. It was her opmion that few men
would marry if they did not expect to be blessed with
offspring, and she herself looked upon children as
necessary to the complete happiness of married life.
With these views she was unwilling to maiTy unless
she could have some assurance that the habit of
aborting could be broken up ; and upon this point
my opinion was asked. I foimd the uterus completely
retroverted, with some enlargement of the posterior
wall from long error of position. I explained to her
that her miscarriages were almost certainly due to
the retroversion ; that conception would in all pi-oba-
bihty occur with her, and that the pregnancy would
go to its fiUl term, provided the uterus was kept in
its normal position, till it got Itu-ge enough to rise
above the brim of the pelvis. On this assurance the
offer of marriage was accepteil ; and in two months
my patient was ready for its fulfilment.

Having adjusted an instrument to hold the uterus in
proper position, and having instructed her in its man-
agement, the wedding day was fixed at the time she
expected to finish a menstrual period. The marriage
took place early in January, on the very day of the

286

UTEKINE SDEGERT.

cessation of the flow. The happy couple immediate
left for Now Orleans, and in a month afterwards
received a note from my patient saying she '
undoubtedly pregnant.

As she did not wish to consult any other physician/'
and as I was exceedingly anxious for her to pass the
third month ivithout a miscarriage, I directed her to
wear the instrument till she quickened, and then to
remove it. At the full term she was safely delivered, i

Now here was a case in which the husband hai
no idea that there had ever been any uterine diseaf
or any mechanical treatment, and does not '.
to this day. The case is valuable as showing 1
protective power of a normal position against
dangers of abortion. There is no moi-e comn
cause of abortion than retroversion, if we exct
imprudent and excessive coition, and for the simjilffl
of all reasons. A retroverted womb is impregnated S
impregnation only aggravates the malposition ;
uterus and its contents grow apace till it is jamma
with the fundus under the promontory of
sacrum, from which it has no natural tendency l
escajje. When it gets to the third month, it musl
either rise above the brim of the pelvis, or throw i
its contents. If it fail to do the one, the ot
generally takes place. If we do not detect the n
position, and rectify it in time, a miscarriage is
almost inevitable result. I am siu-e I have often pn
vented miscarriage by rectifying a retroverted utcrua.i

Here is an example. A lady, twenty-eight yei
old, had had two labours at ftill term. Afterwards s
had a miscarriage at the third month. She
quently became pregnant, and at the end of

RETROVERSION.

287

raonths and a half she waa a^in violently threatened
with all the symptoraa of a speedy miscarriage. I
found the uterus retroverted, with the cervis against
the pubes, and the fundus jammed under the sacral
promontory. The uterus was gently replaced, and a
Meigs ring three inches in diameter was introduced to
hold it in its proper position. The rectification of the
malposition was immediately followed by a relief of all
uterine symptoms. The instrument was worn for a
month, being changed every three or four days. She
went the full "time, and was safely delivered. This
case serves very well as an illustration, of a principle,
and as an example of its class.

The cases already narrated as exhibiting the in-
fluence of the pessary in facilitating conception, and,
therefore, in curing the maljiosition, were such as had
conceived previously. But I have frequently seen the
same thing in the naturally sterile. In 1858 Dr. Silas
D. Scudder, then house-physician at the Woman's
Hospital, found amongst the out-door patients a
woman married ten years without issue, who was
very desirous of oPFspring. She had retroversion,
but what the complications were, if any, I do not
know. However he fitted a malleable block-tin ring to
the vagina, and she conceived in two months after-
wards. He allowed her to wear the instrument long
enough to guard against a miscarriage (three months),
and she went the full term.

In 1857 a lady from the South consulted me in refer-
ence to her sterility. She had been married fifteen
years without conceiving. Her beautiful physique and
fine general health were all that could be desired ; but
she had painful menstruation. The uterus was retro-

m'KHIN'H SURGEHY.

vertod, ami she had a fil)rous tumour, as large i
English wiilniit, in the posterior wall, while the os i
contracted and the cervix indurated.

The uterine sound, sponge tent, and bi-inanual paJ
pation, showed that the enlargement a (fig. 113) i

a distinct tumour, an^
not a mere hypertrO
phy of tissue,
so often see in old
retroversions. Tb
indications were
Fi'i. 113. same as if there lia<

been no fibroid tu.fl
moiir ; viz., to enlarge the os and cervix by incision,
and then to adjust an instrument to hold the uterus
in sifii during coition. From the conti-actiou of the ,
oa and the induration of the cervix, I was satisRei
that the case would have been sterile even with
normal position of the uterus. Be.sides, given a perfect
state of the os and cervix, the malposition would
militate against the probabilities of conception. There-
fore the OS and cervix were divided bilaterally in April,
1857. The ring was fltt-ed after the next menstruation
in May, and in August she conceived ; but unfor- j
tunately a iaJl, three months afterwards, in November^
produced a miscarriage ; and she had another mis-
carriage in June, 1858, at about the third month.
This, too, was associated witii an accidental fall. It
was accompanied by great loss of blood, and foDowed
by a serious metritic inflammation, from which she did
not recover for several weeks, during which time sh«
was carefully attended by Dr. Grriscom, of New Yorlfi
As soon as she was able to leave the city, we sei

3rus

the^J
ifieCli^H
h al^H

feet ^^
Jd
■e- '

3U J

;h. 1

BETROVEliSION.

her to Saratoga to recuperate, and she returned to
New York in November, her general health being
again very good. It was now eighteen months since
we began to treat her case. She had had two mis-
carriages, which we might have attributed to the
fibroid tumour, if the attending circnmstanees had
not each time been sufficient to liave produced the
unfortunate result. But the worst feature of the case
was that we were now precisely where we started, for
the metritic inflammation follomng the last miscarriage
had reproduced the contracted puckered condition of
the OS, which now looked as if it had never been sub-
jected to a surgical operation ; while the cervix felt,
perhaps, more gi'istly than Ijefore. What was to be
done ? We wei'e all in a hurry for another concep-
tion. Her husband could not remain much longer
away from home. 1 proposed to repeat the operation
of incising the oa and cervix, to which, like a true
woman, she at once assented, and it was done after
the next menstruation. In a few weeks (January,
1859) she was pronounced fit fur the married life.
The OS was o[)en, and the uterus iield erect by a
well-adjusted instrument, which, as before, she was
directed to wear during coition. Conception for-
tunately occurred just after the next men.struation,
and we watched her most carefully during the whole
period of utero- gestation. She wore the instrument
nearly up to the time of quickening, when it was
removed altogether. She now acknowledged to
having removed it as soon as she found out she was
pregnant, each time before, which doubtless had
much to do with the miscarriages that followed the
falls. She went safely the full t<>rm, and was delivered

290

ITTEErUE SURGERY.

by Dr. Griscom, of a son, on the 1st Deeembi
1859.

"We kept this patient in the horizontal position for"
five or sis weeks after confinement, with the hope that
a perfect involution would be effected before she re-
sumed the erect posture, and that the uterus might
stand a good chance of remaining in its proper position
afterwards without instrumental aid. When sho
left for the South, two months after her delivery, the
uterus remained in a normal position ; but the best
evidence of a perfect cure having been effected, is
afforded by the fact that fifteen months after her
confinement in New York, she was safely delivered of
twins at her home in t!ie South.

This case is interesting in many particulars : — ■

1st. It shows, what has been observed by otheT^H
and what I have seen many times before and sine*
that a fibroid tumour does not necessarily impe(
conception, gestation , or delivery, all other thin^
being equal.

2nd. It shows that it is possible, even in verj
difficult cases, to understand the obstacles to concep-l
tion, and to remove them by persistent continue*
effort, if our patient has sufficient fortitude an^
endurance.

3rd. It shows that it is possible to cure a retroversion!
and even to cause the disappearance of a fibroid by tb
modified nutrition of utero-gestation.

I am aware that this reiteration of cases is irksome;
but, as I have said befijre, I write mainly for the young
and inexperienced ; and how am I to impress upon
their minds the truth of ray views but by giving tben
the facts and circumstances that have gradiially led mw

BETltOVERSKlS. 291

own convictions wbere I myself find tliera, without any
prejudices or preconceived opinions on tlie subject?

I could liere detail many, very many cases like those
already related ; but enough has been said, and I leave
this part of the subject by the simple statement of tlie
above facts, which strike me as having an importsmt
bearing on the subject under consideration.

It might be supposed from what I have said about
pessaries, that every case of retroversion is capable of
being rectified by an insti-ument. If so, let me hasten
to correct the error, I am sorry to say that there are
numbers of cases in which a pessary is absolutely out
of the question. In many women the vagina is so
delicately organized that it is perfectly intolerant of
any hard substance, and in a few, about the time of
change of life, it will not bear the presence of a soft
sponge, or even a bit of cotton. In some there is a
chronic metritis, which forbids mechanical means ; and
in others peri-uterine inflammation or a prolapsed
inflamed ovary.

We occasionally find a retroversion conjoined with an
anteflexion. Wlien tins is the case, the infra-vaginal
cervix is almost always too long; and we often find
the supra-vagiual portion indurated, tender, and very
sensitive, just above the insertion of the posterior wall
of the vagina. In such cases it will be impossible for
the patieut to wear a pessary, on account of its pres-
sure behind the cervix. I have not as yet amputated
a cervix under these circumstances, but I am very sure
that it would be better to do this, if we wish to treat
the sterile condition successfully. I have been in the
habit latterly of managing these obstinate cases
simply by introducing a plug of fine cotton, or, as it is

292

UTERINE SURGERY.

I have alluded to tl

called in England, cotton-wool,
before, p. 252.

A pessary of cotton can be worn with great comfoi
if the vagina itself is in a eormal condition. In pi
paring it, we must be careful not to pull the cotton
pieces, but let it be one compact mass of the desired size,
carefuUj tied in the middle with a strong thread for its
ready removal. We may use it simply so, or medicated
with glycerine or tannin, or anything else wo
wish. If it is unmedicated, it must not be worn longw
than twenty-four hours. It is enough to wear it while
awake. If we use glycerine, we may leave this tampon
pessary two or three days, or till it falls out. The
glycerine is disinfectant, and the cotton remains without
odour. It is important for the convenience and comfort
of the patient, to teach hei* to apply and remove tha
cotton pessary herself. For this purpose I hai
invented a porte-tampon, which answers a moat
mirable purpose.

Fig. 114 represents the porte-tampon. The requiaii
quantity of cotton, tied in the middle with a atronj
thread some eight or ten inches long, is placed in tha
porte-tampon ; the lid is shut ; the instrument is
introduced like an ordinary speculum, the patient on
the back ; it is to be pushed firmly and forcibly back-
wards and downwards under the cervix to the posterior
cul-de-sac. Wlien we are satisfied that it can go ni
further ^vitllout jiroducing pain, then tlie piston is to
pushed forwards ; the tampon is left in its place, ai
the instrument is withdrawn. The string previously
attached to the cotton, hangs from the vagina,
with this the tampon is removed when necessary. Oni
and almost the only objection to the cotton nowaday

«

UKTIiOVEnslON.

293

ia its expensivenesa. Tow is much cheaper, and
answers tolerably well. I have had many patients who
could not remain long enough under
treatment to be radically cured of en-
gorgements, &,c., who have gone away
with a porte-taropon and appropriate
remedies, using it themselves, and get-
ting well T\-ithout further aid. I have
had a few who suffered fiom liEemor-
rhages that demanded the tampon,
and who were able to control these by
applying it themselves by means of
this instrument. Of course they had
to charge the porte-tampon four, five,
or sis times, fixing a string to each
bit of cotton. I only recommend this
where the patient ia far removed from
prompt medical aid, and where even a
small loss of blood is to be carefully
avoided.

I have liad lately under my care
two most obstinate cases of retrover-
sion in which no sort of pessary could
be worn except cotton ; without the
cotton pessary, the uterus in each waa
turned back to an angle of more than
100° from a normal line, but with this
pushed snugly up into the posterior
cul-de-sac, the organ was comfoi'tably
sustained in position. Each of these
patients conceived during the time of using this inBtru-
ment. They were taught to apply the tampon on
rising in the morning, and to remove it on going to

5

29-1 UTERJSF, SUiWEKY.

beJ at night. These are the only cases in which as
yet I have seen pregnancy follow the use of this sort
of pessary. One of them was a patient of Sir Joseph
Oiliffe. We tried a variety of pessaries, and were'-
compelled to give up all of them, and resort to thi
cotton pessary, and the result was as stated,

A year ago, I incised the cervix uteri in a case
dysmenorrho3a where there was a retroversion, with!
anteflexion, and elongation of the cervix, with indura-^
tion and great tenderness of its posterior portion, jusfc
above the insertion of the vagina. The dysmenorrhcBa
and the engorgement of the organ were relieved ; but
the retroversion continued, with its attendiint symptoma
of pain across the hips, dragging sensations, &c. On.
account of the tenderness of the cervix when pressed.]
above the posterior cul-de-sac, it was impossible for
her to wear any of the instruments that I am in the
habit of using. But she could wear a small tampon of
cotton with the greatest comfort. She writes : " The
uterine support has, I ara sure, done great things for
me. I now use it about every other day : last month
every day. My idea is that it has quite succeeded in
its purpose, and that I am as well as any one need be." ,
Sometimes the broad, flat port©?'
tampon above figured is difBcult of in.
troduction, even in those who
borne children ; and then I have beei
compelled to resort to one made
this fashion (fig. 115). The cottoi
which must be propei'ly prepared, is
be pushed in at the open end of th)
instrument, and this is to be apphed.''
as before directed.

4

VltOCIDENTIA TJTEEI. 295

Of Prociuentia. — Whenever the cervix uteri passes
through tlie mouth of the vagina, we call it a proci-
. dentia, whether it be to a slight or a great extent.
Thus a procidentia may be complete or incomplete :
complete, when the vagina is inverted and protruded
externally ; incomplete, when the cervix uteri aloDo
passes down without bringing the vagina with it. It
is only occasionally that we see the cervix alone pro-
jecting between the labia for an inch or two, and
remaining thus stationary for a long time ; usually it
goes from bad to worse, till it eventually passes
entirely through the vulva, forming a tumour of great
size, which, at its most dependent part, presents the
OS tincie often ulcerated and bleeding. This tumour is
a veritable hernial "mass, consisting sometimes of the
whole uterus, but oftener of its elongated cervix, the
bus fond of the bladder, and occasionally intestine,
with the inverted vagina as its outer covering.

Fig. 116 represents an incomplete procidentia, and
is a type of its class. — See Dr. Bennet's case, on p. 224.

Fig. 124, p. 313, represents a complete procidentia,
and may be taken as a type of its class.

Several separate and independent conditions must
conspire to produce a result so opposed to the designs
of nature. Thus there must always l)e a broad pubic
arch with very divergent rami and a relaxed perineum ;
and then the axis of the uterus must be turned back
in a lino with that of the vagina and the pelvic outlet;

I in other words, there muat be a retroversion. With the
utenis antcverted, a procidentia is utterly impossible,
be the attendant cu-cumstances what tliey may.
Occasionally we see it as a result of the abnormal
pressure of an irregular mass of fibroid tumours, which

296 riEIilNE SL'llUEHV.

fill the peK-is and crowd the uterus down ; but not even
then without the co-operating conditions above cited.

In very old cases of jirocidentia, the vagina, fi-om
long exposure to the air, becomes dry, and assumes
abnost a dermoid appearance. It is the opinion of
many, that the cervix uteri is the first in the order ofj
exit, that it always comes down, to open like a wedj

the parts through which the whole mass descends. Xl
cannot say that this is not so at first, but I can witiltv
the gi-eatest confidence say that it is not so in the greatj
majority of cases, when they become chronic.

In an old procidentia, the vagina attains enormooj
proportions, in consequence of its being constantlffl
expanded by the distending power of its hemialfl
contents. To observe the order of descent in

rrLOCIDENTU UTERI. 297

case like this, reduce the parts to their normal relations,
and let the patient force them out again, whether in
the erect posture or on the back, and wo shall see the
anterior wall of the vagina, first forced downwards
against the perineum, in the form of a cystocele ; a
slight straining pushes this beyond the vulva, and

the cervix follows immediately, bringing down iEe
posterior wall of the vagina. If we would reduce a
procidentia with ease, wo must invert this order ; push
back the posterior cul-de-sac first ; then the cervix ;
and then the anterior wall of the vagina and bladder
follow as a matter of course.

Fig. 117 is from a photograph of a patient of Dr.

CTERIKE aUllGEKY.

Thierry-Meig, in Paris, and represents a cyBtocele as
the first stage of procidentia. By a little effort she
could effect its complete protrusion. She is a German,
twenty-three years of age, the mother of three children,
the youngest being five months old. She is a street-
sweeper, and has had procidentia ever since her last
confinement. Besides this sho has haemorrhoids,
seen in the cut.

Sometimes wo find the intra-vaginal cervix elongate
but oftener the supra-vaginal. Occasionally we see
complete descent of the whole uterus through tho;
vulva. However I have met with but few cases;
of this sort. One of these was shown to mo by
Dr, Chepmoll, of Paris. It was the case of a maiden
lady, some forty year sold, who had been subject to it
for twelve or fifteen years, and often suffered greatly
from retention of urine, and the other ordinary
attendants of this affection. The doctor tells me that
he has repeatedly found the procidentia girdled by an
ulcerated sulcus at its neck, and seemingly bordering
upon the verge of sphacelus, in consequence of its
obstructed circulation. Its great peculiarity consisted
in the fact that the uterus was but one inch and a half J
deep. Many eminent medical men had seen the case
before, and were of opinion that the utero-cervical
canal was obstructed at this depth by some mechanical
barrier that prevented the further passage of the probe ;
but we were able to settle this point very easily, by
palpation alone, while the uterus was in the pelvis ;
and when it came down, it passed entirely through thai
vulva, and we could easily grasp it between the two.
bands, by passing the index-finger of one hand into th©
rectum, and hooking it forwards over the fundus, while

4

riMXIIDE.NTlA UTERI.

299

pressure was made by the other on the front of the
tumour, just below the urethra. Indeed we could even
tilt the fundus downwards and backwards across the
long axis of the procidentia ; and this movement gave
ns great fiicility in diagnosing the contents of this great
hernial protrusion, which consisted of intestine as well
as of uterus and bladder. In this case the vagina was
immense, the peiineum greatly relaxed, and the pubic
rami unusually divergent.

But while we only occasionally find a procidentia thus
associated with a uterus, under or even of normal size,
we often find it where there is hypertrophy of some
part of this organ. For instance, there may be
hypertrophy of the cervix, or merely elongation of its
iutra-vaginal portion, or of the supra- vaginal portion : if
the former, the body of the uterus may be of normal
proportions ; if the latter, it is more apt to be hyper-
trophied. And sometimes the cervix is elongated in
its two segments, both infra and supra-vaginal.

In these cases of cervical elongation, we often find
the utero-cervical canal four and five inches deep ; the
supra-vaginal portion of the cervix being slender,
attenuated, and, when examined per rectum, feeling
not larger than the finger. This elongation is
evidently secondary. I believe it to be a sequence of
tlio procidentia, for we are more apt to find supra-
vaginal elongation where the fundus uteri is from some
cause or other too largo to pass out of the pelvis. If
tho body of the uterus passes out of the pelvis, there
is no sujira-vaginal elongation ; if not, there is ; and
for the simplest reason. Suppose the cervix uteri
projecting through the vulva, tho fiindus, from some
cause, caimot follow, but remains fixed, as it were,

300 UTEUINE SUHGElty.

within the pelvis by hypertropliic or fibroid enlarge-
ment ; the cervbc once through the viilva, pressure
around it from above soon pushes down the two culs-
de-sac, resulting in a de facto hernia. This gets largeri
and larger, and the uterus retained in the pelvic cavity
becomes one of the principal points of support for this
mass, which hangs by the cervix, and the cervix con-
sequently becomes not hypertrophied but attenuated
and elongated, feeling like a mere cord, not more than ,
lialf its normal size. And this elongation is gradually:
produced by these two antagonistic forces ; one acting
on the body of tho uterus to retain it in the pelvic
cavity, the other on the lower end of the cervix, to push
it downwards.

When the procidentia is due to a mass of tumour«]
filling the pelvic cavity, and crowding the uterus down-
wards, as I have seen in several iustances, we cannol^
I regret to say, promise much relief

Fig. 118 represents a procidentia of more than twenty
years' standing, in a woman nearly seventy years of
age, whose pelvis was filled with a number of small
fibroids of bony hardness. One large tumour is not soi
apt to produce procidentia as several smaller ones,-]
say from the size of an orange to that of the fist,
loosely bound together ; because the single one may
grow large enough to rise above and rest upon the
brim of the pelvis, while the smaller ones accommo-:
date themselves to the polvic cavity, displacing what
over may interfere with their development. The above
was the largest hernial procidentia I have ever Been.
It reached nearly half-way down the thighs, and con-
tained a large quantity of intestine. When it
reduced she felt less comfortable than when it

I

k

raOCIDBnU CTEBI.

301

troded. On tfats aocoont no effort w»s made Iot its
rdief.

Hugaier has wntten eitensirely on procidentia
uteri, azid I betie\« he was the Brsi to point out the

distinctive characteristics of its anatomical peculiarities-
He found elongation of the cervix in all cases, either
above or below the insertion of the vagina; and he
suggested and performed amputation of the neck of
the uteni3 in every case, and ^vitb great success. For
special information in regard to his views, I must refer
the reader to his memoir.*

siir lis AllongtiiiCHta bypertrophiqueB du Col <l<'
s Affectiona d6aign6es sons les noma de DeocMilo.

302

DTEEINE ScmGEBY.

I amputate the cervix only when its lower segment
is too largo or too long, and projects so far into the
vagina as to present a meclianical obstacle to the
retention of the uterus in situ when replaced, Tl
will be sufficient in some cases, such as that met witl
by Dr. A. K. Gardner, of New York, who amputated
a cervix weighing ^iv. gij. 3ij., which is, perhaps, " the
largest on record as having been removed during
life."* Dr. Gardner says, "The organ drefr up far^
into the vagina after the portion was removed, and in]
order to ai'rest a persistent heemorrhage it was neces-
sary to draw it down into view with hooks." Of course
all such cases as this are readily cured by amputation,
and, as a rule, it is the only thing to be done. But,
this is not a type of the gi-eat class of cases that w(
are called upon to treat. If there should be elongatio]
of the infi'a-vaginal cervix, amputation ia the remedy
but we often find procidentia without any extraordinai
elongation of the infra-vaginal portion of the cervix.5
Tliere is then nothing to amputate.

In these cases Mr. Raker Brown, Dr. Savage, and
others, contract the vidvar outlet by the perineal opera-
tion ; but generally I prefer to narrow the vagina abovej
which usually very effectually retains the uterus i
something like a normal position within the pelvis.

The idea of narrowing the vagina is by no meanf

(le Pr&ipitation de cet Organe, et surlour traitcment par la rPHectio%.'
ou I'amputation de U totality du Col, siiivaiit la vuri^t^ de Is
Maladie." Par P. C. Hugiiier, Meuihro de I'AcadSmie Impfriale de
MMecine, iio. Paris : J. B. Bai]li6re et FUa. 1800.

• "Amputation of the Cen-ix Uteri." By A. K. Oardoer, M.D.g
Prof., &c. &c.

PIIOCIDENTU UTERI.

303

new. I suppose we may justly claim it for the great
Marshall Hall. However I do not think the operation
ever succeeded till my own day, — and this success is
due wholly to metallic sutures.

I propose now to give a brief sketch of the steps by
which we arrived at the method of operating herein
advocated.

In 1856, Dr. Warren Stone and Dr. Axson, of New
Orleans, referred a patient of theirs to my care, who
had had procidentia for three years. She was about
thirty years of age, tall, slender, and bony, and had
enjoyed good health till the yellow-fever epidemic of
1853, in New Orleans, The labour, lifting, and fatigue
which she underwent as a nurse during that terrible
epidemic left her with a double inguinal hernia and
a complete procidentia uteri. I have seldom seen
a more distressing case. She wore a double truss for the
hernial protrusions ; and, for the procidentia, the largest
globe-pessary that I ever saw. But notwithstanding
the immense size of the globe, which was nine inches
in circumference, it was impossible for her to retain it
in the vagina by any bandage ; so it was constantly
slipping away, and that too at rather inopportune
moments. I arranged a pessary with a stem and a X
bandage, which kept the parts within the pelvis. In
the course of two months she had regained some 25
pounds of flesh, and was on the eve of returning home
harnessed up with trusses and bandages to a most
uncomfortable degree, when I happened to ask her if
she would be willing to submit to a surgical operation,
if we could promise to get rid of the pessary and its
bandage. She promptly rephed, " Yes."

Previously to this we had been in the habit of per-

304.

UTEEINE SlTRGEItY.

forming the perineal operation after the plan of Mr. i
Baker Brown, and for some reason we had not been J
successful. Dr. Emmet and myself both thought that I
we could hardly promise any better success by it in I
this case tlian we had formerly met with. This was I
the first time that I had had a good opportunity of-1
observing and studying the manner in which the pro- f
cidentia occurred. After replacing it and allowing it J
to descend again, wliich always occurred very quickly J
on assuming the erect posture, I noticed, as before!
described, that the descent was not at first by thoJ
protrusion of the cervix uteri, but invariably by i
prolapse of the anterior wall of the vagina, which'^
always preceded the cervix, and drew down the uterus.
I foimd that this cystocele -was but another hernia (
had double inguinal hernia), and I discovered that she
could not force it down again, when simply the point J
of the index finger was held in the anterior cul-de-sao, f
Then by pinching up the anterior wall of the vagina*
into a longitudinal fold, with two tenacula or a pair c
forceps, I saw that the parts had no tendency whatever^)
to come down ; and that it was impossible for outb
patient to force them down if we thus prevented thea
anterior wall of the vagina from descending. Henw
the idea of wholly removing the redimdant portion of I
the anterior wall of the vagina occurred to me ; but it!
did not occur to me to operate simply by removing
strips of vaginal mucous membrane. I seriously pro-
posed to this lady to make a complete vesico-vaginal .
fistula, by removing at once, as it were, a largi
portion of the base of the bladder with the anterioJ
wall of the vagina. She agreed to it ; and I laid tb^j
plan of operating before the Consulting Board of thai

PItOCIDENTIA DTERI.

305

Hospital, and it waa adopted. Tlie vagina and its
outlet were enormous. When the patient was placed
on the knees, or on the left side, with the perineum
elevated bj the speculum, it presented about the relative
proportion shown in
fig. 119. The mea-
surements made re-
peatedly by Dr.
Emmet and myself,
gave the following
proportions. From
the meatus urinarius
to the perineum, a to
l>, when this was pulled
back by the speculum, f,„. ijg,

was three inches ;

from the meatus urinarius to the posterior cul-de-sac,
a to r., five inches and a quartet"; broadest tnmaversc
diameter, four inches and a quarter ; broadest antero-
posterior, d to p, three inches and a half.

Proposing to excise the anterior wall of the vagina,
I hooked it up with a tenaculum at </, pulled it well
towards the posterior wall, o, and then grasped the
base of the mass thus elevated with a pair of curved
forceps made for the purpose, on the principh* of
Ricord's phymosis forceps, which held the pai'ts
firmly embraced, while with scissors cutting under
the forceps I removed, at once, a very large portion
of the anterior wall of the vagina. The portion
removed measured two inches and a half transversely,
by two inches and five-eighths longitudinally, and was
very thick. Tlio chasm made by this ojieration was
fearful ; the lateral retraction of the divided edges

806 UTERINE SUBGERT.

being BO great as to present at a superficial glance
some difficulty in bringing them together by sutures.
Tliere was, however, no trouble whatever.

Fig. 120 would roproseut a side view of one blade,
a, of the forceps, as it gi-asped the portion c, to be
removed. The bleeding was not profuse ; but I at onco
rapidly filled the chasm with cotton, to stop the
hremon-liage by pressure. A few minutes sufficed
for this ; and then the tampon was removed for the
purpose of closing the edges of the opening by trans-
verse sutures. My surprise was equalled only by my
delight, when I found that I had not succeeded in doing
what I intended ; for instead of excising the base of
the bladder with the anterior wall of the vagina, I had,
by the tenaculum, simply raised the hypertrophied
vaginal tissue up between the blades of the forceps,
lucidly separating it from the lining membrane of the

bladder, which remained intact. Thus by a
accident, the operation was really far better than if I
had succeeded in accomplishing what theoretic^y I
proposed to do.

ntOCIJJKNTIA UTEHI.

Fig. 121 would represent about the relative propor-
tion of vaginal tissue here removed. Tlie lateral edges
were brought together longitudinally by seven or eight
silver sutures passed transversely, as represented in the
diagram. She was
soon well, and is so
to this day. The
operation was done
nine years ago. The
good result in this
case led me to
operate on others
afterwards, by a
simple denudation
of the vaginal epi-
thelium to the same
extent as shown
above. One great
objection to this
method was, that
tlie necessarily te- fig. lii,

dious scarification

permitted the loss of too raucli blood ; anotiier was
the danger of an abscess forming in consequence
of the central part of the scarified portion not being
closely embraced by the sutures. For instance, it will
bo seen by reference to the diagram, that when the
sutures were closed, bringing the outer edges into
apposition, the central portion of denuded tissue not
included by them would necessarily be thrown into a
told that would project the mucous membrane of the
bladder into a sort of longitudinal ridge along the bus
foTid. I was at first aft-aid tliat this li>08e tissue might

308 UTEEINK SURGERY. ^^B

not be held firmly enoug-b together to unite by the ffret
intention ; and in one instance an abscess formed that
gave rise to some constitutional disturbance. But its
nature and seat being detected, the removal of a suture
at the upper angle of the wound, near the cervix uteri,
promptly evacuated the matter,and relieved all suffering.
However this method of operating was continued till
1858, when an elderly woman, with an enormous pro-
cidentia of fifteen or twenty years' standing, was sent
to the Woman's Hospital, by Dr. Duane, of Schenec-
tedy. It was a very bad case indeed. I operated by
the plan of simple denudation of the mucous mem-
brane over a surface extending from the neck of the
bladder to the neck of the uterus, and being two
inches and a half in its largest ti-ansverse diameter ;
the lateral edges were united by silver sutures, and
the parts healed kindly. But I did not remove
tissue enough, and there was a considerable cystocele
left. I felt pretty sure that the original trouble
would be reproduced, unless she should wear con-
stantly some sort of a pessary. Accordingly I fitted
one, and sent her home in a very comfortable condition.
I was quite satisfied, and so was my patient ; but when
she got home, the physician who had had charge of her
case before she consulted Dr. Duane, ridiculed the idea
of her being cured by a surgical operation, if it were
necessai-y for her still to wear an instrument afterwards.
Although she was perfectly comfortable, she returned in
two or three months, and asked to be readmitted to the
Hospital. She said she wished simply to prove to her
physician at home that she could be cured by an
operation, so as not to be compelled to wear a pessary.
Her pluck challenged my inventive faculties, and then

PHOCIDENTU UTEIU.

309

it was that I devised another method of operating.
For instance, instead of the broad scarification of the
anterior wall of the va-
gina, as before, I simply
removed the mucous
membrane in the form
of a V (fig- 122, a h),
the apex being near the
neck of the bladder, and
the two arms extending
up on the sides of the
cervix uteri. These two
denuded surfaces were
brought together by sil-
ver sutures passed trans-
versely, thus making a
longitudinal fold nar-
rowing the vagina and
crowding the cervix Fn.. i.-a.

backwards. This simple

operation was thus repeatedly pcrfoi;med, and always
successfully, by Dr. Emmet and myself, at the
Woman's Hospital, from 1858 to 18G2, when I left
New York.

In Paris I had occasion to perform it for Sir Joseph
Olliffe on an old lady sixty-fivo years of age, who had
had procidentia for twenty years. Tho parts united ;
the utenifl was held in its place, and she returned home
in a fortnight. Her general health was very feeble, in
consequence of a long residence in India ; and in two
months the whole cicatrix gradually gave way, and
the procitlentia was reproduced. This was the first
and only case of failure that I had ever seen Hftor this

310

UTERINK SISROERY.

method. The operation was subsequently repeafa
but thi3 time, instead of a V-shaped scarification, it was
made in the form of a trowel, as represented in fig.
123, the point presenting below, the shoulders above
in the anterior cul-de-sac. The denuded Burfaoes a c
and b d wore brought together by transverse silver
sutures. A small por-
tion of tissue was left
undenuded at e, between
c and d, for the purpose
of jiermitting the escape
uf iiTiy secretions natu-
i;illv forming in the shut

Although she is an
' >|>ium-eater, and fre-
(jueiitly has attacks of
djurrhoea, in conse-
quence of its inordinate
use, as we often Ree, the
operation was success-
ful, and the uterus still
remains in its normal
position. This last ope-
ration was performed with the assistance of Sir Joseph
OtlifFo and Dr. Johnston, of Paris, and Professor Pope,
of St. Louis.

Dr. Emmet* has recently called attention to a source
of trouble when the operation is performed by a simple

• Jfeu) York Medkal, Journal, vol. i., No. I. Api-il, 1865.
Radical O|)eratiou for Pi-ocidcntia TTtori." By Thnmns Ailclia Era
M.D., Surgeon to the Woinan'a UoHpitol.

PKOUIDENTIA CTEBI.

311

V-shaped denudation, as shown in fig. 122. He eaya,
" Previous to the time of Dr. Sims's removal to
Europe in 1862, we both had operated frequently
without the necessity for any modification occurring.

*' In September, 18G2, after three months of great
suffering, one of the first patients operated on by Dr.
Sims in this manner, presented herself at the Hospital,
for relief. She stated that, diu'ing four years, she had
been entirely reheved by the operation, when, suddenly
(while in the afit of lifting) she was seized with a
persistent tenesmus, greatly aggravated in the upright
position.

" On examination, the line of union was foim.d per-
fect, with no prolapse of the vaginal wall. But the neck
of the uterus had slipped behind the septum into the
pouch, thus throwing the fundus into the hollow of the
sacrum, and fixing the organ in this position. With
great difficulty, the neck was disengaged. On return-
ing the uterus to its normal position, immediate relief
was obtained, and she was discharged without further
treatment." This case was subsequently operated
upon by Dr. Emmet.

After this. Dr. Emmet hunted U]j two patients upon
whom he had operated eighteen months before, and he
found the uterus retroverted in each one, with the
cervix resting behind the pouch made by bringing
together the two denuded surfaces a b> fig. 122. To
remedy this defect, in his subsequent operations he
simply denuded the vaginal mucous membrane in a
line across the cul-de-sac between these two points,
as shown by the dotted line c, fig. 122, making a
regular triangle with its apex at the neck of the bladdorj
and base at the cervix uteri. In January, 186-i, Dr.

31-2

UTERINE SURGEKV.

Emmet operated on a very unruly patient, wlio, duringl
tlio niglit after the operation, " got up and walkedl
about tlic ward for several liours, aud continued, in |
spite of all remonstrance, to follow her own inclination.
On the twelfth day, it was discovered tliat four sutures I
(near the neck of the bladder) had torn out, and I
through the gap a portion of the relaxed base of the 1
bladder protruded. The sutures were all removed /
at the time, and every hope of success abandoned.
Before her discharge, it was found on examination that j
the entire line of union had gradually parted, with thoi
exception of the cross scarification, in front of the j
cervix uteri. The fold thus formed (as in a sling) had i
retained the organ perfectly In place, although below,
a cystoCele existed. Future experience must demon-
strate how far the formation of this fold can alone bo I
relied on under other circumstances ; yet it is evident i
that in many cases this will prove all that is necessary J
to retain the uterus in situ.'*

It is always interesting to watch the slow degrees by |
which true principles of treatment are estabUshed.
The idea of narrowing the vagina for the cure of pro-
cidentia was first suggested by Marshall Hall, but I do |
not know that the operation ever succeeded. Then I I
carried out the principle by cutting away the whole of J
the redundant portion of the anterior wall of th»|
vagina (fig. 120). This I afterwards modified by simply I
denuding a large oval surface on the anterior wall, and |
uniting its lateral edges by silver sutures. This was I
further modified by making a V-sh^ped scarificatioa i
(fig. 122), and producing a veritable fold in the wall of 1
the vagina. Then I made the V trowel-shaped, byl
turning its upper ends inwards across the axis of the!

I'ltOCIDENTU DTERI. 313

vagina, in Sir Josept Olliffe's case, fig. 123. Then
Dr. Emmet made this a complete triangle, and even-
tually an accident showed him that merely a narrowing
of the vagina just at the anterior cul-de-eac, at least
in one case, answers every purpose of holding the
uterus in its place.

The mechanical execution of this operation is a
matter of some nicety, but it is by no means difficult.

Suppose we have such a case as the one represented in
fig. 124, which may be taken as a type of its class ; wo
wish to narrow the vagina to keep tlie parts in their
normal relations. We would suppose, if. prioi-i, that
the operation could be done more easily and esact\j
with the uterus thus protnided ; but it is a great mis-
take. The uterus must first be restored to its proper

316

CTEIUNK SOKOEltY.

the curved sound pualung Ijack the cervix and depress-
mg the anterior wall of the vagina.

Dr. Emmet bends the end of the sound into the form _
of a ring, to fit around the cervix uteri. Sir Joseph
Olliffe suggested the same thing to me when I operatf
CD his case in Paris, but instead of this I have hat
simply a Uttle tenaculum fork at the end of the instr
mcnt (fig. 125), to \
hooked into the mttJ
cous membrane, just J
at the junction of the -I
anterior cul -de - sao I
and the vagina. This J
answers the purpose
of fixing the cervix
during the whole time
of the operation, for «
it is to be retained, as I
roiiresented in tho 1
figure, till wo come to j
close up the sutures. I
, A Indeed, the sutures]

are all to be drawn j

J closely before we i-e-a

move it.
Fig. 127 represents^
the instrument super"
ficially transfixing theij
mucous membrane, a
Fio. 127. above described, push

ing the cervix back-a
" wards and depressing the anterior wall of the vagina,S
which rolls over it in voluminous folds, forming

ritOCIDENTlA tTTEltl.

317

deep central sulcus, along the borders of whicb the
denudation is to be made, and which should be more
or less divergent, according to the peculiarities and
necessities of the individual case.

When the operation ia finished, the patient is to be
put to bed, the bowels are to be constipated for a week,
with a dose or two of some form of opium in the
twenty-four hours ; the bladder is to bo emptied by
catheter when needed, for two or three days, and the
recumbent posture is to be enjoined for two or three
weeks. The lower sutures may be removed in eight
or ten days ; the upper should remain a fortnight,
xmless there is some special reason for their earlier re-
moval. The patient is usually discharged at the end of a
month fi'ora the time of the operation, sometimes sooner.
I consider this operation one of the safest in surgery. I
never saw any serious accident from it, and never saw
it fail but once, and that was in the case of Sir Joseph
Ollitfe's patient (page 309), who was subsequently
cured. I have operated repeatedly on patients over
sixty, and on two that were seventy years of age.

Sometimes, as in cases complicated with rectocele,
it ia necessary to narrow the posterior wall of the
vagina, as well as the anterior. If so, I prefer to make
two operations, allowing a period of six or eight weeks
to intervene between them.

It is not my intention to draw a parallel between
this and the perineal operation for procidentia. I only
wish to add another resource to our means of perma-
nent cure in this distressing affection. I may state,
however, that I was first driven to the expedient of
working out this prooees in consequence of repeated
failures of the perineal operation in my hands : not

318

UTERINB SURGEEY.

that the operation, as such, ever failed, but that the
new perineum made by it often gave way, in conse-
quence of the persistent pressure of the parts above. So
far as mere surgical resources are eoncemeil, we have
now three processes from which to choose ; always, of
course, adapting this choice to the peculiar exigences
of the case.

Ist. Amputation of the cervix according to the plan
of Huguier, when its infra-vaginal portion is too long.
I have often seen procidentia cured by this alone.
The case of Dr. Bennett, related on page 224, is an
example.

2nd. The perineal operation, as performed by Mr.
Baker Brown, Dr. Savage, and others.

3rd. The operation of narrowing the vagina by tho
trowel or triangular-shaped denudation on its anterior
wall, as herein illustrated, and as performed by Dr.
Emmet and myself.

But we occasionally meet with those who are so ill-
advised as to object to any surgical operation whatevei".
"What then are we to do ? Meigs's ring, and Hodge's
lever utterly fail to do any good whatever; globes,
disks, and inflated air-bags all fall out ; and Zwang's
pessary is the only mechanical apparatus that promises
any benefit ; and in old women this cannot be tolerated
on account of the excessively delicate condition, after
change of life, of tho vaginal mucous membrane ; for,
as life advances, the vagina becomes more and more
intolerant of any foreign substance. Under these
circumstances, the best pessary is simply a small
tampon of cotton, wet with glycerine, which may bo
introduced in the morning, to be worn all day. With
the porte-tampon, figured on page 293, it is easy

PROCIDENTIA UTERI. 31i)

enough for the patient to do this every day for
herself.

lu April, 1865, Dr. Johnston, of Paris, asked me to
see a case of procidentia, in a French laundress, about
forty years of age, where there was an enormous
hypertrophy of the cervix uteri (two inches in diameter),
due to the development of numerous little cysts in its
Bubstance, varj-ing from the size of a grain of wheat to
that of a garden pea. Some fifteen or twenty of these
were opened, discharging a ropy honey-like fluid ; the
uterus was then replaced, and a tampon of cotton wet
with a solution of tannin in glycerine was applied.
This dressing was repeated every other day for a mont)i
or two, when she became so comfortable that she did
not desire the operation for a radical cure. When she
stops the use of the tampon, the uterus descends on
lifting a heavy weight or taking a long walk, but she
can now protect herself perfectly against this accident
by applying the cotton pessarj' with the porte-tampon.

In 1853, Professor Fordyco Barker, of the Bellevuo
Hospital Medical College, wrote a paper on the treat-
ment of procidentia by the use of tampons wet with a
solution of tannin. Considerable success attended this
method in his hands, but it seemed to fall into disuse.
Perhaps the porte-tami>ou, as in the case above, may
assist to re-instate the practice. When patients will
not submit to a radical operation, I liavo no doubt
that this plan may answer a good purpose, even if it
does not cure the case permanently.

I hjvd the honour of presenting a paper on Proci-
dentia at the November meeting (186&) of the
Obstetrical Society, which formed the basis of an ex-
tended discussion. At this meeting, Mr. Spencer Wells

320 UTERINE SURGERY.

called my attention to the fact, that Marshall Hall's
idea of narrowing the vagina was put into execution
by the late Mr. Heming, and that at least one case
had been successfully operated upon. The report of
this case may be found in Heming's translation of
Boivin and Dugfes (1834), page 53, and is dated
November, 1831. It affords me pleasure to make this
correction.

SECTION VL

THE VAGINA MUST BE CAPABLE OF RECEIVING
AND OF RETAINING THE SPERMATIC FLUID.

^

32S

SECTION VI.

THE VAGINA MUST BE CAPABI^ OP EECErVTNG AND OF
EETAININO TEE SPEttMATIO FLUID.

WE here propose to pass in review the usual
obstacles to the introduction of the semen, and
then the conditions that prevent its retention or sojourn
in the vagina. For it is not enough that the semen
be deposited in the vagina ; it must not be immediately
ejected.

What, then, are the ordinary obstacles to its intro-
duction ? They are mostly anatomical or mechanical,
and may be arranged under the following heads : —

Ist. The hymen may be imperforate or nearly so.

2nd. There may be vaginismus; i. e., hymeneal
hypersesthesia with a spasmodic contraction of the
sphincter vaginae.

3rd. There may be atresia of the vagina.

4th. The vagina may be wanting.

1. Our medical literature contains the histoiy of
many cases in which the hymen was so tough as to
resist all reasonable efforts at penetration. And very
many in which it has been found completely occluded,
with retention of the menstrual flow. It is a little sin-
gular that I have never met with an example of either
of these conditions.

All the cases of impenetrable hymen that I bare seen

were examples of vaginismus, where the obstruction

was not in the mere resisting power of this membrane,

V 2

324

TJTEETNE SUKGEEY.

but in a epasm of the sphincter muscle, the result oi
the irritable condition of the hymen.

Where the hjTiien is hermetically sealed up -mth a
retention of the menses, it is easy enough to open it
and evacuate the imprisoned secretion by a " crucial
incision," as it is termed.

It is against this "crucial incision" that I would
seriously warn the inexperienced ; as, simple as the
operation is, it is fraught with great danger, — not per se,
but in the consequences of a rapid evacuation of the
retained fluid. Whenever it is necessary to perform an
operation for retained menses, whether it be on the
hymen, the os uteri, or at any point along the vagina
between the two, it should always be done by a simple
puncture with an ajq^loring needle, leaving the gradual
evacuation of the fluid to nature and to time. The
object of this is to allow the uterus time to contract
as its contents slowly ooze away. This is a matter of
importance only where there is a considerable amount
of fluid. If there is not more than an ounce or two,
I do not think it makes any diflerence whether we
evacuate it suddenly or slowly.

The probable amount of fluid may be estimated
simply by palpation, which determines with sufficient
accuracy the size of the uterus with its contents.

If the uteinis be but slightly enlarged by the retained
fluid, we may open it fearlessly ; but if it approach the
size of the fcetal head, we should do it with the greatest
caution.

Death has often speedily followed an incision of the
hymen, where there was I'etention of the menses. Of
course, the mere wounding of the hymen baa nothing
whatever to do vrith the fatal result, which seems to be

IMPERFORATE HYMEN.

325

due to pyEcmia. Some think that this is caused by the
admissioTi of air into the cavity of the uterus, which,
having been over-distended, fails to contract as rapidly
as the fluid is evacuated. At the Woman's Hospital
we have had repeatedly to evacuate large quantities of
retained menses, and we have never seen any accident
follow. All our cases were the result of atresia of
some part of the vagina, or of the os tinciB. One only
was seemingly idiopathic, tho others the result of
sloughing from difficult labour.

We havo always punctured the occluded portion with
an exploring needle, or made a very small opening with
the tenotomy knife usually found in our pocket cases ;
and, knowing the dangers of the operation, I must
again insist on this point. If I had now to operate on
the hymen of a delicate young woman, whose uterus
and vagina held six or eight ounces of fluid, I would
give her ergot till its specific action was produced on
tho uterus, and then make a small puncture in the
hymen ; and this for the purpose of insuring uterine
contraction while the fluid was being evacuated. I
cannot do better than to quote here Dr. Graily Hewitt,
the latest and one of tlie best authorities on the
diseases of women,* — " The plan ordinarily adopted
has been, by means of a lancet, or bistoury, or trochar,
to make an opening in the hymen sufficient to allow of
the escape of the chief part of the retained blood at
once, and at the time of the operation. I would
suggest that an opening just large enough to allow of
the escape of a very minute quantity of fluid be made

" "The Diagtio§iH and Treatment of tlie Diwaflea of Women."
Ry (inuly Hewitt^ M.D., lie. &e. Loudon. 1863.

826 UTERINE 8UBGEET.

at first, and tliat this opening should be made obliquelyi
in the obstructing membrane, giving it a valvulai*
character. The fluid should be evacuated guftatim. If
the opening become closed, a second and similar open-
ing to be made tlie following day, or two or three days
later, and a firm but gentle support given to the
abdomen by the aid of a bandage during the whole
period of the evacuation of the fluid ; the patient to be
kept in a state of absolute rest. The aperture in the
hymen should not be increased in size until the uterus
has returned to its proper dimensions, the object being,
at first, simply to allow the fluid to escape in the most
gradual manner possible."

Dr. Arthur Farro lias given me the particulars of a
case of retained menses, which was seen some forty
years ago by his father, an eminent physician of his
time. A young lady in the country had retention of
the menses ; pregnancy was suspected by the fiimUy
physician ; Dr. Farre was sent for to decide the nature
of the case ; but before his arrival the hymen was
ruptured spontaneously ; a large quantity of retained
menses was suddenly evacuated ; irritative fever set in, '
and the patient died in a few days. Although I have '
frequently heard of a fatal result in similar cases, as a
consequence of surgical interference, this is the only
one in which I have known it to happen in this way.

2. Vaginismus. — By the term vaginismus I mean
an excessive hypertesthesia of the hymen and vulvar
outlet, associated with such involuntary spasmodic
contraction of the sphincter vagince as to prevent
coition. This irritable spasmodic action is produced
by the gentlest touch : often the touch of a camel's-

I

I

VAGINISMUS. 327

hair pencil or fine feather will produce such agony as
to cause the patient to shriek out, complaining at the
same time that the pain ia that of thrusting a sharp
knife into the sensitive pai-t. This is worse in some
than in others. In a very large majority, the pain and
spasm conjoined are so great as to preclude the possi-
bihty of sexual intercourse. In some instances it will
bo borne occasionally, notwithstanding the intolerable
suffering ; while in others it will be wholly abandoned,
even after the act has been repeatedly and, as it were,
perfectly performed.

We can hardly make a mistake in the diagnosis of
this affection. It could be confounded only with im-
perforate hymen or atresia of the vagina, the true
nature of which is easily ascertained by examination.
In these there is not necessarily inordinate pain on
being touched. There is only a mechanical impediment
to the passage of a probe or the finger into the vagina,
while in the other the gentlest touch, as said before,
produces excessive suffering, and this is the chief
diagnostic.

To examine a case of suspected vaginismus, place the
patient on the back, with the legs flexed ; separate
gently the labia. The patient will exhibit signs of alarm
and agitation, — not that we hurt her, but she feels an
indescribable insuperable dread of beiug hurt. She is
like a timid, nervoua person who has once had a pointed
instrument thrust into the exposed pulp of an inflamed
nerve in a decayed tooth. The very idea of its repeti-
tion throws her into a nervous rigour. The degree of
general distui-bance will depend upon the peculiar
temperament of the individual. But bo this as it may,
when we come to explore the seat of trouble, the

AJiO UTEKINE SUEtJKItY.

strongest will and stoutest frame will exhibit un
takable signs of excruciating suffering ; for the j
touch with the finger, a probe, even with a 1
produces great agony. The sensitiveness is at
parts of the vaginal outlet. It is very great at i
near the meatus urinarius on each side where the
liymeu takes its origin; and greater still near the
orifice of the vulvo-vaginal gland; but often the most
sensitive point is at the fom-chette, where the hymen
projects upwards. The whole vulval or outer face of
the hymen is sensitive, but it is more so ;
reduplication or base. The touch of a probe or .
carael's-hair pencil is sufficent.

But while the outer face of tlie hymen and the
adjacent parts are so sensitive, if we turn the patient
on the left side and separate the nates and vulva so aa_
to pass a sound through the hymen without toucbii
its outer sui-face, and then make pressure with :
laterally or backwards on the inner or vaginal asp
of this membrane, we will not find there any abnorin
degree of sensitiveness.

Touching the outer surface of the hymen in any
portion of its reduplication, produces not only pain, but
an involuntary spasm of the sphincter muscle both of j
the vagina and anus. In some instances, the sphinctt
ani feels as hard as a ball of ivory; and one of my {
tieats supposed it to be a tumour that would requi
exsection. The snperaensitiveness is diagnostic ;
spasm pathognomonic.

The most perfect examples of vaginismus that I havl
seen were uncomphcated with inflammation; butlhaT^
met with several cases in which there was a redness G
erythema at the fourchetto. Usually, the hymen :

! ot

'1

the
ent

VAOINISMUS.

I

thick and voluminous, and when the finger is forced
through it, its free border often feela as reaistent as if
bound by a fine cord or wire.

By the term blepharismus, or blepharo-spasmus, we
mean an involuntaiy painful spasmodic contraction of
the orbicularis palpebrarum, with great sujierscnsitivc-
ness, or intolerance of light. By the term larjTigisraus,
we mean a spasmodic contraction of the vocal appa-
ratus, producing strididous inspiration ; and, by ana-
logy, I call this painful spasmodic contraction of the
mouth of the vagina, vaginismus.

I presented a paper on this subject to the Obstetrical
Society of London in December, 1861,* from which
I will here extract a few particulars.

In May, 1857, 1 was called to see a lady, aged forty-
five years, who was man-led at twenty, and had been
an invalid ever since. Menstruation, always painful,
had just ceased. She had great irritability of the
bladder, a sense of bearing down, and other symptoms
of uterine derangement. But to mo the most remark-
able thing in her history was the fact that she had
remained a virgin notwithstanding a married state of a
quarter of a century. Some two or three years after
marriage her physician discovered a sanguineous mu-
cous tubercle at the meatus urinariua, which he re-
moved, and then attempted to dilate the vagina with
graduated bougies, which produced great suffering,
without the least permanent improvement. She con-
sulted the most eminent surgeons in tho principal
capitals of America, and subsequently visited London
luid Paris for tlie same pui-pose ; but no one gave a

"Obstetrical TranHBctioas," 1862, vul. H,

330

DTEEINK SUEGEBY.

satisfactory solution of tbo case, nor advised anyfchii
more than the bougie system, whicli had been
fruitlosaly exhausted.

Her nervous system was in a deplorable conditio!
Slie was exceedingly impressible, the shghtest noil
being intensely disagreeable. She was able to wt '
only across her room, but did not often venture on tl
experiment, being confined most of the time to
couch, where she gave herself up to unceasing inl
lectual effort.

I attempted to make a vaginal examination, but
failed completely. The slightest touch at tlie mouth of
the vagina produced intense suffering, throwing her
nervous system into great commotion ; there was a
general muscular agitation ; her whole frame shivered
as if with the rigours of an intermittent ; she shrieked
and sobbed aloud ; her eyes glared wildly ; tears rolled
down her cheeks, and she presented altogether the
moat pitiable appeai'ance of terror and agony. Notn
withstanding all these outward involuntary evidence
of physical suffering, she had the moral fortitude
hold herself on the couch, and implored me not
desist from my efforts if there was the least hope
finding out anytliing about her inexplicable condition.
After pressing with all my strength for some moments,
I succeeded in introducing the index finger into the
vagina up to the second joint, but no further. The
resistance to its passage was so great, and the vaginal
contraction so finu, as to deaden the sensation of the
finger, and thus the examination revealed only an in-
superable spasm of the sphincter vaginiB. I candidly
told her husband I knew nothing whatever about
case, had never seen or heard of anything like it, an*

he

1

VAOINISML'fi.

331

therefore could promise nothing. However, I sug-
gested the propriety of their going to New York, for
further investigation under anaesthesia. Tliej acted
promptly on this suggestion, and I invited the late
Dr. John W. Francis, Dr. Emmet, of the Woman's
Hospital, Professor Van Bureu, and Dr. Kissam to
see her with me. The two latter-named gentlemen
assumed the responsibility of the etherization. Pre-
viously to the ansesthesia I attempted to make a vaginal
examination, when the same train of symptoms was
manifested as on the former occasion. But as soon as
she was fully under the influence of the ether, I found,
greatly to my surprise, the mouth of the vagina com-
pletely relaxed and the vagina itself perfectly normal.
It was not largo, but certainly quite as well developed
as it ought to have been at her time of life and under
the circumstances. The uterus was retroverted, and
there was a small polypoid excrescence about the size
of a pea hanging from the os tinCEB. This was removed,
not with the expectation of its exerting any influence
on her peculiar condition, but to prevent the risk of
its future growth. I gave the opinion that it was a
spasmodic contraction of the sphincter vaginae, result-
ing from an irritable condition of the nerves of the
part, which I could not explain. When asked if it
was possible to cure it, I said — " I do not know, for
the books throw no light on the subject ; but it ap-
pears to me that the only rational treatment would be
surgical." However I declined to do anything, on the
ground that an untried process was not justifiable on
one in her position in society, the hospital being the
legitimate field for experimental observation.

This case is an exaggerated example of its class. I

CTEUINE SURGERY.

have seen several nearly, but not quite, as bad,
liigli intellectual endowments of this lady, her eleg.
culture and fine social position, as well as her 1
suffering, all conspired to make her case one of mud
thought and great anxiety to me; and it was nfl
easily dismissed from my mind. It was the first i
of the sort I had ever seen, and I could not help w
dering if it would be the last. But about fift
months after this. Professor Pitcher, of Detroit, '.
gan, sent me another similar ease, except that the la
had been married but two years. She had the saj
instinctive dread of being touched, the same muscu!
agitation and shivering of the whole frame, and 1
same pain and spasm of the sphincter on attempting
pass the finger into the vagina. As this lady's husbm
threatened to obtain a divorce, I looked upon her c
as a proper one for experiment. Explaining to 1
fuUy our ignorance on the subject, I proposed a f
of experimental incisions, which she readily assented t
Thinking that the division of the initable sposmod
outlet was the only rational operative procedure,
divided first only the edges of the hymeneal membrea
on each side of the fourchette. There was no reli
Waiting for the wounds to heal, I then divided )
parts again at the same points, but extending
incisions deeply through the mucous membrane s
through some of the fibi'es of the sphincter muscle
Tiiis was followed by some improvement ; she c
beai' the introduction of one finger without ver]
great pain, and coidd even tolerate two, but it was
with considerable suffering. I now saw that the
hymen itself was the focus of the excessive irritabilitj
and I then proposed to cut it out entirely, and aft-

VAGINISMUS.

I

wards to repeat the lateral incisions as before, making
them deeper, and rendering the dilatation permanent
by the use of a properly conetmcted bougie. By this
time the mother of my patient came to the conclusion
that I was experimenting on her daughter. I told her
it was true, and attempted to justify the propriety of
the course when a lawsuit and a divorce were in pro-
spect. The mother, however, was inexorable, and un-
fortunately removed her daughter from my care. But
her improvement was so great that I had no doubt of
her ability to fulfil the duties of a wife under some
diflBculties. The experience gained by tbis case was
of great value to me.

A few weeks afterwards, January, 1859, another case
fell into my hands. This patient was the wife of a
clergyman, and had been married six years. Sexual
iutercourse was impossible. Several surgeons had
been consulted, but without any explanation of her
condition, and of course without any relief. On
examination, 1 discovered a sanguineous, mucous,
painful tumour at the meatus urinarius, and notwith-
standing the experience already related, I persuaded
myself tliat this tubercle was alone the source of all
her trouble. It was removed, and its seat cauterized.
Id due time she returned home, but came back to me
in a few days to report a persistence of her former
sufferings. On a more minute examiuation, I found it
to be in all particulars just such a case as those pre-
viously related, but nut quite so intense in its manifes-
tations. The sUghtost touch with a feather or with a
camel' s-hair pencil at the reduplication of the hymeneal
membrane produced as severe suffering as if she were
cut with a knife. While this lady was under observa-

UTERINE SUEGERY.

tion (April, 1859), a fourth

i of the (

esortc

? samesi

under my care, that of a woman who had been married
three years. Sexual intercourse had been imperfectly
accomplished a few times diiriug the first few weeks
after marriage. She innocently supposed that all
women had to suffer as she did, and tried to bear it;
but her sufferings were so severe that at last she looked
with the greatest terror upon the approaches of her
husband. At her earnest entreaties, he ceased all
efforts at sexual intercourse, and they lived together
like brother and sister. But at last the mother of the
poor timid girl began to wonder why, after three years
of married life, her daughter, who seemed to be healthy
and had a healthy vigorous young husband, did not
become pregnant, and ventured to speak of her dis-
appointment; whereupon the daughter hesitatingly
explained it all to the mother, who immediately brought
her to see me, when I found precisely the same con-
dition of things already descHbed. A few weeks after
this. Dr. Harris, of East Thirtieth Street, New York,
sent me another case (the fifth). His patient had been
married two and a half years, and sexual intercourse
was impossible. I now (June 18th, 1859) had three
cases all at one time under observation; but to cut
short this long narrative, I may here say that they
were all, after many experiments and disappointments,
perfectly cured in the following August.

From personal observation I can confidently assert
that I know of no disease capable of producing bo
much uuhappiness to both parties of the marriage
contract, aud 1 am happy to state that I know of no
serious trouble that can be cured so easily, so safely,
and so certainly.

335

Treatment. — The treatment consists in the removal
of the hymen, the incision of the vaginal orifice, and
subsequent dilatation. The last is useless mthout the
first two, but is essential to easy and perfect success
with them. I usually make two operations, but it may
all be done at once.

Placing the patient (etherized) on the left side, I
seize the hymeneal membrane with a dehcate pair of
forceps just at its juncture with the urethra on the left
side, and putting it on the stretch, clip with properly
curved scissors till the whole is removed in one con-
tinuous piece.

In some cases the hsemorrhage requires a compress
of lint. In two instances the bleeding was excessive,
but easily checked with the Liq. Ferri Persulphatis.
The cut surface usually heals entirely in three or four
days, after which the operation for a radical cure may
bo performed. Notwithstanding the removal of the
thick, sensitive hymen, the cicatrix marking its original
place at the mouth of the vagina is exceedingly sensi-
tive, and in some instances feels hard and tense, as if
a wire or small cord were constricting the outlet. This
I divided at various points and in divers ways during
my early experiments, and finally arrived at the fol-
lowing method, as being the surest and best.

Place the patient (fully etherized) as for lithotomy,
on the back; pass the index and middle fingers of the
left hand into the vagina, separate them laterally, so as
to dilate the vagina as widely as possible, putting the
fourchette on the stretch ; then with a common scaliiel
make a deep cut through the vaginal tissue on one side
of the mesial line, bringing it from above downwards,
and terminating at the raph^ of the perineum. This cut

336 UTERINE SCTfJERV.

formB one side of a Y- Then pass the knife agamml
the vagina, still dilating with tlie fingers as before, and
cut in like manner on the opposite side from above down-
wards, uniting the two incisions at or near the raphe,
and prolonging them quite to the perineal integument.
Each cut wiU be about two inches long, i.e. half an inch
or more above the edge of the sphincter, half an inch
over its fibres, and an inch from its lower edge to the
perineal raph^. Of course this will vary in different
subjects according to the development of the pai-ts in
each. To perfect the cure it is necessary for the patient
to wear for a time a properly adapted bougie or dilator.
I use a dilator made usually of glass, sometimes of
metal or ivory. I prefer glass because it is easily kept
clean, and being transparent, it is easy to see the cut
surface, and indeed the whole vagina, without removing
it. If there is much bleeding, I introduce the dilator
at once ; but usually I wait twenty-four hours, when it
is worn one, two, three, or foiu- hours at once. Its
introduction is attended with a sense of soreness,
but with none of the peculiar agonizing suffering so
characteristic of the original disease.

The patient will generally wear the dilator two h<
in the morning and two or three hours in the aftemooJIr
or evening ; sometimes for a longer period. I have
known a few who wore it six or eight hours at a time.
I have often been astonished at the rapidity with which
the cuts sometimes heal, the cure being seemingly
facilitated by the pressure of the glass tube.

I direct the dilator to be worn daily for two or three
weeks, or longer, or till the parts arc entirely cured
and all sensitiveness removed.

The dilator is a tube about three inches long, sligKt

conical, open at one end, closed at the other, and an
inch and a quarter or an inch and a third in diameter
at the largest part, near the open or outer end.

There is a depression or sulcus on one side for the
urethra and nock of the bladder (fig. 128).

The outer open end allows the pressure of the at-
mosphere to assist in retaining it easily in the vagina.

1 an I

L

When closed at both ends, it is much more difficult to
retain it in situ, even with a well-adjusted X bandage.
The depression for the urethra is very important, for I
found that a perfectly round cylinder, worn for three
or four hours, always injured the urethra ; and, more-
over, this urethral depression assists the self-retaining
capacity of the instrument.

Dr. Rottenstein, a celebrated American dentist in
Paris, has recently made for me a dilator of vulcanite,
which answers very well. It is quite as cleanly as
glass, and is not so liable to bo broken.

While those pages were going through the press, I
had occasion to operate on a la<ly fifty-four years of
ago, who was married at eighteen, a widow at twenty,
and married again at forty. During her first marriage
copulation was effected occasionally, biit it was under
most trying circtunstances, and with the most intense
Buffering. During her last marriage it was impossible.

338 UTERINE SUKGERT.

I found the mouth of the vagina a little reddish,
inflamed, and excessively irritable, the sh'ghtcat touch
with a probe producing intense agony. The finger
could be passed into the vagina, but it caused great
Buflering. It was, and had always been, a well-marked
case of vaginismus. The hymen did not present any
undue development, and I simply incised the parts on
each side of the middle line, through to the verge of
the perineum. The whole vulvar outlet was unnaturally
small, and the incisions were extended well through
the outer edge of the perineum. A glass dilator was
worn three or four hours a day for a month ; but at
the end of this time the mouth of the vagina was just
as sensitive and as spasmodic as before the operation,,

I now determined to remove all the hypertrophii
tissue at the fom-chette and divide anew the parts
beneath. Wishing to make pressure with the dilator
more in the direction of the fourchette and perineum
than laterally, I had the instrument made as repre-
sented in fig. 129, which seems to be a great improve-
ment on the purely
cylindrical instru-
ment. Instead of ex-
panding the outer
end of the dilator,
as seen in fig. 128,
it is often necessary
"" to roll its border

inwards to prevent pressure on the labia.

In some instances the instrument is too long, and
produces pain by pressure against the cervix uteri. It
will then be necessary to make it shorter. The do^
ward curvature of the conical extremity, as hi

ist

VAOIXISMDS. 339

represented, prevents it from striking against and
hurting the uterus,

I have now operated on thirty-nine cases of vagi-
nismus, and in every instance with perfect success.
Many of these were complicated with other causes of
a sterile condition, such as painful menstruation, con-
tracted OS, conical cervix, fibroid tumour, or malposi-
tion. But notwithstanding this, six conceptions have
followed the operation. Some others, from whom I
have not heard, have probably conceived, and a few
more of them will almost certainly do so. They have
usually been so well satisfied with the removal of the
vaginismus that they did not care to undergo any
further treatment for a condition that might be
attended to at a more convenient season.

Churchill, Debout, and some others, have thought
that a state of vaginismus could hardly exist long where
the husband possessed strong copidative capacity ; but
I am sure this is an error ; for I have seen several
instances in which the virile power of the husband was
unusually strong, but yet powerless to overcome the
obstruction ; and I have seen two cases that bad been
subjected to the most powerful means of dilatation,
long continued, and to a great degree ; and yet the
spasmodic action remained just the same. One of these
has now been married eighteen years ; and for six
months she submitted, many years ago, to the torture
of a trivalve dilator passed into the vagina, and opened
to its widest extent : and all for no purpose. So great
was her dread of the peculiar paiu of tliis affection
that her husband could not persuade her to submit to
an operation at my hajids, and thus she remains as at
her marriage.

z 2

340 UTEEINE SUEGBRY.

I have operated on ttose who had beea nuunet
seventeen years, fifteen years, twelve years, and so on
down to two years. In a few instances sexual inter-
courao had been imperfectly accomplished, but in the
great majority of cases it had never been consummated.
In two instances, the husbands, though young and
vigorous, wore so excitable that the semen was quickly
lost, but in both of these cases the vaginismus was so
inveterate that I am sure it would have persisted, even
under other circumstances.

Dr. T. G. Thomas, of New York, gave me the
history of a case in which a physician etherized his
patient, and then left her to her husband, who cohabited
with her with the greatest ease ; but he could not repeat
the act when she was not etherize^- Fortunately, the
period was well chosen, for this single act of copula-
tion was followed by conception. I have known other
cases where conception occurred without the introduc-
tion of the virile organ. The seminal fluid was lost
at the mouth of the vagina and a little was, doubtless,
injected through the hymeneal opening, and made its
way to the cavity of the uterus.

Sir Joseph OUiffe has given me the history of a case
of this sort, where conception occurred without pene-
tration of the hymen. It is not imcommon to hear of
a pregnancy at full term where the hymen is un-
ruptured. I presume that all such cases are examples
of vaginismus.

Many surgeons are of opinion, since I first described
this affection, that it is sufficient to forcibly dilate the
mouth of the vagina, or to incise it, and then use
the dilator ; but I am well satisfied that the plan of
removing the hymen entirely is much the best; not

341

only of removing the hymen, but of removine any and
every supersensitive point.

In 18Ij3 I saw a lady with vaginismus who had been
married six years, and during all this time she had
submitted to sexual congress, notwithstanding the
intense suffering that it occasioned her. I found the
hymen unbroken, but dilatable. It was exceedingly
tough, and would stretch almost like an india-rubber
string. I used my speculum, pulling the perineum
far back towards the coccyx, which opened the
mouth of the vagina sufficiently for any purpose. This
was attended with great pain, but the hymen did not
give way. I excised it, divided the fourchette, and
used the dilator till the parts were healed. She went
home, but returned in a few days to say that sexual
intercourse was as unbearable as ever. On a minute
examination, I found a small tubercle of indurated
tissue on the right side of the mouth of the vagina,
not larger than a grain of wheat. It was very sensitive
even to the touch of a camel's-hair pencil. It was
hooked up with a tenaculum, and cut out, and imme-
diately the peculiar sensitiveness of the part was gone.
The relief afforded was as sudden as it would have
been by the removal of a subcutaneous neuromatous
tumour. Indeed it has always appeared to me that the
symptoms of vaginismus were neuromatous. How-
ever, my friend Professor Alonzo Clark, one of the
ablest pathologists in my own country, has frequently
examined the vaginismus hymen for me, and could not
find any enlargeil nerve filaments running through it.

The case above related was cured by the sliglit
operation performed the second time.

Fig. 130 i-epresents the exact size of the hymen in

342

UTEEINE BORGEEY.

this case, immediately after its removal. The indenli
tion on its left side corresponds precisely with the seat
of the little tubercle removed at the second operation,
and which was doubtless the result of the imperfect
excision of the thickened base of the
hymeneal membrane. This case proves
very conclusively how important it ia to
exsect the hymen in its totality ; for here
a small point was left which produced great
suffering afterwards. But to show to a
Fio.i3a greater certainty the propriety of this
course of treatment, I will here relate a
most remarkable case that fell under my observation
a few years ago.

A lady, aged thirty, was married at twenty-one.
Vigorous efforts at copulation wore made fruitlessly for
five or six weeks. The husband and wife were both
young and of course ignorant on the subject, and were
not surprised that there was difficulty at the beginning ;
but soon they began to debate the point of asking
medical advice. At last the wife became worn out
with the oft-repeated and jiainful efforts at coition,
and agreed to a consultation.

The family physician was called, who supposed that
there must be some unusual degree of disproportion in
the relative development of their respective genital
organs, and advised sexual intercourse while the wife
was etherized. This was soon done and the wife knew
nothing of it. But when the act was attempted the
next day and the next, it was found to be utterly impos-
sible. After a week's fi-uitless trial, the physician was
sent for again, and again she was etherized, and coition
effected with the greatest ease. But it was subse-

VAGINISMUS. 343

quently impossible when she was not etherized. The
husband was tall, atliletic, and muscular ; says he is
not subject to hasty ejaculation, and possesses extras
ordinary copulative powers. So that it was not the
fault of the husband that the vaginismus did not yield
to penetration and dilatation. But the subsequent
history of this interesting case bears still more strongly
on this point. Suffice it to say that it became the
business of the physician to repair regularly to the
residence of this couple two or three times a week to
etherize the poor wife for the purpose above alluded
to. They persevered, hoping that she would become
pregnant and that dehvery would cure her. This
etherization was continued for a year, when conception
occurred. But during the whole period of utero-
gestation, etherization was necessary to coition. After
the birth of tho child there were a few copulations
without ether, but it was exceedingly painfid, and soon
the pain became so severe that they were compelled to
resort to ether again. At the end of another year of
ethereal copulation, there was another conception,
which restJted in an abortion at the third month.
After this she was etherized constantly for nearly
another year, when at last they saw no hope of a cure,
and becoming alarmed at tho frequent repetition of the
aniBsthesia, they concluded to give it up altogether.
And when they consulted me there had been no effort
at copulation for three or four years. They had con-
sulted other physicians in the mean time, but no one
explained the case or proposed a remedy.

The mouth of the vagina was barely largo enough to
admit the index finger. The seat of the hymen was
red, inflamed, thickened, indurated, and oxcoodingly

3-y>

UTERINE RUHGEBV.

»

I

senBitive to the slightest touch with the finger, a
or a feather. There waa a redilish blotch, about the
size of half a split pea, at the orifice of each viilvo-
vagiual gland. The perineum had been lacerated
down to the fibres of the sphincter muscle, and
now a tense, inelastic inodular band extended across
the fourchette, and was loat in the thickened tissue
occupying the original seat of the hymen. This
entire ring was quite as sensitive to a gentle touch
as the most marked case of vaginismus could be;
indeed, it was a vaginismus at the beginning, and it
was a vaginismus now, notwithstanding the fact that
coition had been accomplished scores, nay, hundreds of
times, and tliat a labour at full term and a miscarriage
had also occurred to break up the morbid condition, if
it could be done by the mere mechanical action of dis-
tension. I would not pretend to deny that we can dilate a
case of vaginismus so as t>o permit sexual intercourse,
but in most of the cases so treated the act is very painful.
In every case that I have operated upon by removal of
the hymen, and then by division and dilatation, sexual
intercourse has been accomplished without pain.

The course to be pursued in the case we are de-
scribing was very plain, viz., to remove the whole ring
of thickened tissue tliat encircled the mouth of the
vagina, and particularly the cicatricial portion at the
fourchette. This was done, and then the septum
between the fourchette and the rectum was divided on
each side, down through the fibres of the sphincter
muscle and the fourchette to the perineal raphe. This
left a very thin partition between the two outlets.
After this a glass vaginal dilator was introduced, and
worn almost constantly. A larger one was used in a

ATEESIA VAGIN,G. 345

day or two, and in a fortnight sexual intercourse was
accomplisbed for the first time without pain. Where
there is cicatricial tissue, as in this case, there is danger
of a relapse, and hence greater necessity for a prolonged
use of the dilator. This remarkable case presents
many points of interest, not the least of which is the
fact tiiat the two conceptions took jilace while she
was in a state of complete anesthesia.

3. Atresia VAGiNiE. — Thia,ofcourae,forms an obstacle
to the reception of the seminal fluid. It may be con-
genital or accidental, — more frequently the hitter, and
oftener the result of tedious labour, followed by slough-
ing. The records of the Woman's Hospital present a
number of cases of atresia, a few of which will servo
as examples.

I have seen but one case that might bo called con-
genital; and that was in a young girl aged eighteen, who
entered the Hospital in October, 1857, complaining of
great pain every month without ever having liad the
slightest show. Slie had taken aloetic purgatives and
other emmenagogues without benefit.

On examination, a rounded tumour, half as large as
a fojtal head, supposed to be the uterus, could be felt in
the hypogastriura. The finger passed through the
hymen, which was very rigid, detected a hard inelastic
tumour, three-quarters of an inch beyond it, the vagina
seemingly ending there in a cul-do-sac. By passing
the finger into the rectum, it came in contact with the
tumour felt through the vagina, and which appeared
to be the upper two-thirds of the vagina distended
with something hai^d and inelastic, and continuous
with the tumour that rose above the symphysis pubis.

346 UTEEINE SURGKliy.

Tbe rational symptoms and anatomical relations i
pointed to retention of the menses by occliiaion of the
lower third of the vagina. But to the sense of touch
per rectum, \vith supra-pubic pressure or palpation, it
felt exactly like an osteo-fibroid tumour. The lower
or vaginal part of the tumour was quite as unyielding
to pn^ssure as the upper or uterine portion.

Fig. 131 represents the relations of the utero-
vaginal tumour,
formed by the
occlusion of the
walla of the va-
gina. A very
small puncture
wasmadeintothe
tumour, through
the occluded va-
gma where the
tissue seemed to
be about a liaK-
inch thick. The
fluid gradually oozed away. There was no constitu-
tional disturbance; and the patient experienced only
relief from its evacuation. When the uterus was
found diminished to its normal size, we ventured to
enlarge the opening sufficiently to pass the index
finger up to the os tincse, and we kept it dilated
to this moderate extent till the divided parts were
covered with mucous membrane. The os and cervix
uteri presented a remarkable state of granular erosion,
extending over the adjacent portion of vagina, and
giving rise to a profuse albuminoid leucorrhceai dis-
charge, which yielded to appropriate treatment in the

ATRESIA VAGINA. 347

course of a month. The next menstruation was normal,
and she left the Hospital with the vagina slightly
naiTowed at the oiiginal seat of occlusion.

This case might have been congenita!, or the oppos-
ing sides of the vagina might have formed adhesions
by inflammatory action during childhood.

We have seen at the Woman's Hospital atresia in
great variety from sloughing of the soft parts and
consequent cicatrization. Sometimes the mouth of the
vagina is closed, or nearly so ; again, we may have a
contraction and closure of its middle portion ; and,
again, the upper part of the vagina and the neck of the
uterus may be agglutinated together in one dense mass
of fibro-ccUular tissue, while we may occasionally find a
complete obliteration of this canal, from the neck of
the bladder quite to the os tincae. In all cases the
treatment is the same; viz., to restore the canal, if
possible, and to keep it open, by tlie use of the glass
dilator, till the newly exposed surfaces become covered
with mucous membrane. In some instances this will
be done in three or four weeks. The constant wearing
of the dilator greatly facilitates the healing of the
raw surfaces and the conversion of mere cellular into
mucous tissue. There is always such a tendency to
contraction that I have directed the dilator to be used
every day for a long period of time.

I have seen a groat many cases of occlusion of the
vaginal outlet, whore there was an opening perhaps
not larger than a small probe for the passage of the
menstrual flow. I have seen several in which it was
impossible to find this small opening till the occurrence
of the flow indicated it. From these I will select but
one to illustrate the treatment. A lady, forty-six

348

UTEltlNK SUBGEET.

years old, was placed under my care in April, 1858, to
be treated for atresia. She was maiTied at fourteen ;
became a mother at fifteen ; labour tedious ; bead
impacted ; delivery instrumental ; child still-bom ;■
slouf^bing of aoft parts ; slow recovery ; atresia Taginae ;
Bexual intercourse impossible afterwards. Eminent
surgeons were consulted, amongst others, tlie distin>
guished Drs. Physic and Dewees, of Philadelphia, in
1828. Nothing was done. No attempt even was ever
made to open the passage. In a few years afterwards
her husband died, Strango as it may seem, tliis
lady married again in three years. In three years
more she was a widow for the second time. But the
most unaccountable thing is, that she married again,
after remaining a ividow for nearly eighteen years and
knowing at the same time that she had had perfect
occlusion of the vagina for nearly thirty years. She
had been married the third time about twelve months
when I saw her. The mouth of the vagina was sealed
up, as it wore, by a cartilaginous barrier, quite un-
yielding to the strongest pressure. But there was a
small valvular opening through which the menses made
their exit.

This little opening barely admitted a small probe ;
but this could be passed the whole depth of the vagina,
audits point could be felt by the finger in the rectimi
depressing the recto-vaginal septum, as it was pushed
onwards to the os tincK. Menstruation was normal,
and the uterus, of natural size, was in proper position.
The vagina was normal above the point of occlusion,
which was a little anterior to the neck of the bladder,
as shown by fig. 132.

This case was operated on in Juno, 1858, the late

ABSENTIA VAGINJE.

349

Dra, V. Mott and John W. Francis, with Dr. Emmet,

assisting, A small bliint-pointeil bistoury was passed

through the little opening into the vagina, and the

gristly structure was divided

from side to side, and then the

blade of the knife was turned

downwards and backwards,

cutting outwards, parallel, as

it were, with the ascending

ischial ramus, first on the right

and then on the left, keeping

the index finger in the rectum,

to avoid making a recto- vaginal fistula.

In this way the mouth of the vagina was made quite
large enough, and when the finger was passed in, it
was found to be sufficiently capacious above. The
glass dilator was introduced, and I had the happiness
of sending this lady away in the course of a month
perfectly fitted for the married life.

I directed her to wear the instrument a while every
day for an indefinite period, to guard against the com-
mon accident of relapse.

I might relate many more very curious and interesting
cases illustrating this point, but I forbear, as enough
has been said to establish the principles that are to
guide us in practice.

4. Congenital Absence of the Vagina. — I have
seen five cases of congenital absence of the vagina,
and in all of them there was "no uterus. One of
these, shown to me by Dr. Livingston, of New York,
had been married seven or eight years. She was
married young, and, of course, had no idea of her

350

UTERINE SimOEnY.

peculiar condition. The labia were normally developet
anil tliG mombranons tissue between the meatus uri- "
narius and the fourchette had by constant use been
pushed up between the base of the bladder and the
rectum till it was developed into a blind pouch, into
which the finger could be passed to the depth of nearlyJ
two inches.

As it would serve no practical purpose to dilate oij
this subject, I shall leave it here, simply saying thail
tlie diagnosis in such cases is easy enough with a fing
in the rectum, and a sound in the bladder, altematir
the latter with supra-pubic pressure.

At the beginning of this section, I said that " thfl^
vagina must be capable of receiving and of retaininj
the spermatic fluid."

Having now considered such obstacles as would
prevent the deposit of the seminal fluid in the vagina,
we may turn to such conditions as prevent its retention
there when once introduced.

It has only been about three or four years since |
foimd out that some vaginas would not for a momei
hold a drop of semen.

There are no two vaginas exactly alika They diffei
in length, in their various diameters, in their relationi
with the bladder and rectum, in their course wit^
regard to the pelvian axes, and in then- relation witifr*
the axis of the uterus. They sometimes refuse to retain
the semen when they are very capacious; again, when
they are too short. In this last instance, there will
probably be found a disproportion between the sizes
of the respective genital organs of the two sexes.

A young woman, married five years, without iasui
consulted me on account of her sterility. The <

SHORT VAGINA.

351

was rather indurated ; the os waa small. I cut it
open, and the ob afterwards presented quite a noi-mal
appearance. As there waa nothing other^vise ab-
normal about the uterus, I told her she would almost
cei-tainly conceive in four or five months. She
patiently waited eighteen months, and then came to
rae again in despair. The condition of the uterus
was now all that I could have wished it to bo; but
the vagina, as before said, was rather short. For
the first time I now suspected that perhaps the fault
lay here. I requested her to come to roe at some early
day, two or three hours after sexual intercourse. She
came the next morning. I did not find any signs of
spermatozoa in the mucus of the vagina, or in that of
the cervix uteri. I then began to suspect that the fault
lay with her strong, vigorous husband. I asked her if
she seemed to retain anything after coition. She said
it all appeared to pass off instantly. In such a case,
all false delicacy must be laid aside; it is a matter of
the gravest scientific importance, and must be treated
as such.

I told her and her husband that I must see her just
aft«r sexual intercourse. The time was appointed ; I
was at the house, and in four or five minutes after the
act I saw my patient ; and the vagina did not contain
a drop of semen, but it was on her person and napkin
in the greatest quantity. The microscope showed that
it waa perfectly normal. What was to be done ? The
vagina was short — too short; it could not be made
longer. When the finger was pushed forcibly against
the posterior cul-de-sac, in the direction of the dotted
line a, fig. 133, it yielded to the pressure, and
as the finger was withdrawn, the cul-de-sac sprang

352

UTBEINK SUEQERT.

forward, almost aa if it were made of a thin sheet
ludia-nibber. This reaction of the distended vagina
evidently ejected all the semen that did not at once
regurgitate in the very act of ejaculation. Of course
the remedy was self-suggestive. As we could do no-
tliing to change the size or form of the vagina, we had
only to order what was so evidently indicated — some-
thing to prevent the forcible impingement of the male
organ against the posterior cul-de-sac. This had the
desired effect ; the semen in sufficient quantities was
retained, and conception occurred in three months,
after a sterile mairiage of nearly seven years. I now
think it probable that the operation performed on the
cervix uteri was not at all necessary ; for never till I
saw this case liad I the remotest idea of such a state
of things as I have here described.

I'ig. 133 would represent about the relations of the
vagina and uterus in the case
described above.

But it must not be inferred
that all short vaginas are neces-
sarily associated with a sterile
condition. I have seen several
cases in which the vagina had
been almost whoDy destroyed by
the sloughing process, and in which the neck of the
uterus had also sloughed away to a great extent :
where, in fact, the vagina was not more than two
inches deep, and yet conception occurred with the
greatest facility ; but in ever)' one of these cases the
upper part of the vagina was fixed with the open 03
presenting at its bottom ; it was unyielding, inelastic,
did not give before pressure, and, of course, did no;^

;tof I

SHOUT VAfJINA.

rebound on its removal. Thus it was poaaible for tlie
semen to enter at once into the canal of tbe cervix.

Amongst several eases of this sort, I now call to
mind one of vesico-vaginal fistula, sent to tbe Woman's
Hospital, in 1857, by Dr. Dimond of Aubiiru, New
York, in which almost the whole anterior wall of the
vagina, a lai'ge part of tbe cervix, and the posterior
cul-de-sac, and a large portion of tbe posterior wall
of the vagina, were lost. There was but a small
strip of the anterior wall, just at the neck of tbe
blatlder ; the fistulous opening was two inches wide,
reaching fi-om one pubic ramus across to the other,
through which the inverted fimdus of the bladder
fell into the vagina, presenting at its posterior border
the open mouths of the m-eters, from which we could
see the urine passing off aa it was secreted. This
case was cured, but the vagina was not more than two
inches deep. I had but little thought that she would
ever conceive again ; but in ten months after returning
home she became a mother; and again, in about fifteen
months after this, she gave birth to twins. In four
other cases hke this, the vagina was quite as short, and
in all it was fixed and inelastic at its upper part ; and
in all, the intra-vaginal portion of tbe cervix uteri had
been destroyed by the sloughing process, and tbe os
presented itself as a Uttle gaping slit in the centre of
the fibrous structure that formed the upper boimdary
of tbe vagina, which stretched across the pelvis like
a cord of cartilage.

In all those cases but one, the shortening of the vagina
tilted the fundus uteri backwards, and placed the axis of
the uterus in a direct lino -with that of the vagina, so that
the meatus urethnB nmst, at the moment of ejaculation,

2 A

854 ■ UTERINE SUROERT.

have been in direct contact, and in a straight line with
the open end of the canal of tho cervix uteri. I have
Been many sterile wombs, where I thought the sterile
condition could be overcome if it wore possible to
imitate artificially the unfortunate state of things here
produced accidentally, i. e., fixing immovably the open
03 in a direct line with the ejaculative force. This
would lead me now to enquire into the rationale of
the entrance of the semen into the cavity of tlie uterus ;
but I shall leave this for the next section.

But sometimes the vagina does not retain the semen
even when it is of large proportions. When this is tlie
case we almost al-
ways find the utenis
retroverted.

I have now but
little doubt that, in
many cases of re-
ti-oversion, iu which
I have seen preg-
nancy follovr the
rectification of the
malposition, the
sterile state was
due to the fact tliat
the vagina did not
retain the semen.
I do not mean to
fio. 131. say tliat in all cases

of retroversion the
semen is not retained : far from it ; for I know that it
is often retained in ample quantities, in even tho worst
cases of retroflexion, such as that shown in fig. 134.

VAGINA NON-BETAININO. 355

Tlie pliiloaophy of this is plain enough ; for the
vagina is here almost in its normal relations, with what
should be the proper axis of the utt^i-us, although this
is flexed out of its normal position. The uterine
malposition that is most unfavourable to the retention
of the semen by the vagina is that of retroversion,
with the OS tincie lying close up behind the inner
face of the pubes, and the fundns, of course,
thrown backwards below the level of the vaginal axis.
I made this discovery of the ejecting power of the
vagina, where there is retroversion, only within the
last few years, It occurred in this way. A sterile
patient, in good general health, had painful menstrua-
tion, a contracted os, and a retroverted uterus. The
indications were to enlarge the os and to rectify the
malposition. Accordingly I cut open the os and cen'ix,
and then, wishing to see if the semen entered the cervix,
I directed her to come to me some morning after
sexual intercourse. She did so, but I found no traces
of spermatozoa.

I tlien said, " I must see you soon after the act of
coition ;" and told her to remain quietly, in the
horizontal position, till I should arrive, I saw her
in six or eight minutes aftei-wards, and there was not a
vestige of semen in the vagina, but it was found in the
greatest abundance outside and on the napkins. The
vagina was very capacious, far above the average size ;
and I could hardly believe my senses when I found
that it contained nothing. It was then aiTanged that

II should see my patient in fifty or sixty seconds after
coition, and I found precisely the same state of things,
viz., not a sign of semen in the vagina. Now, let
us see why this was so. But 6rat it might have been
2 A 2

:i56

I-TICKINF. SVltnKRV,

Biipposed that it wa3 due to hasty ejaculation. Proper
inquiry settled that question in the negative by the
evidence of both man and wife. Why, then, was there
no semen in this very capacious vagina immediately
afler a normal copulation? Let us look at its ana-
tomical relations. The uterus was retroverted, but
anteflected ; the cervix was long and pointed, and
rested against the urethra ; the body of the uterus was
somewhat hypertrophied ; the anterior wall of the
vagina rather short, in consequence of long error of
position ; the vagina was otherwise very large, and the
perineum relaxed. The finger carried to the bottom of
the vagimi, at its redupli-
cation, 1, fig. 135, could
push this back towards
the hollow of ,the sacrum
relatively as far as /' ; this
would necessarily thraw
the fundus upwards; the
withdrawal of the finger
would let it fall down
again, but its momentum would carry it a little lower
than the point at which it rested in equilibrio. There
was nothing easier of demonstration than this see-saw
movement of the uterus by jnishin^ the posterior
cul-de-sac backwards. Now the tendency of this falling
of the organ by the sudden removal of a force thus
impinging against the point ti, is to depress the fimdus
still more, which tliereby proportionally elevates the
cervix; this draws up also the cul-dc-sac of the vagina,
and rolls out, as it were, whatever has been deposited
in it. In this particular case, the vagina would spring
back from b to o, and this of itself would eject the fluid.

VACISA^NON-nETAINiSii. 40/

Besides, in all cases when we examine the condition of
the uterus inimediately after coition we shall find the
organ ])resenting signs of exhaustion, if I may be
allowed such an expression ; for instance, if the uterus
ia in a normal position, or even moderately anteverted,
we shall find the upper part of the vagina relaxed, and
passively holding a large quantity of semen, in which
the cervix uteri is submerged ; the uterus itself seems
to be fatigued, and drojjs by ita o\vu gravity down
towards the rectum, where it lazily sinks to the bottom
of the little pool of semen.

Nothing has surprised mo more than the difference
in the relative condition of the uterus and vagina
before and after sexual congress. I have had occasion
to examine many cases under these circumstances, and
I have uniformly found this as I have here described
it ; and when there ia retroversion the fundus sinks
still lower after coition than before, and this neces-
sarily elevates the os tinciB still farther from the
seminal fluid, if any of it have been retained. 1
have seen many cases of retroversion latterly where
the semen was not retained. I could give some most
interesting details on this point, but enough has been
said to show the importance of the subject, to illustrate
its philosophy, and to indicate the proper treatment ;
which, of course, would be to place the uterus in its
normal position, and to retain it there by means of a
properly-fitted instrument to be worn during sexual
congress. In the case figured aliovc, amputation of
the cervix at the point indicated by the dotted lino
would be advisable before attempting fui-thcr treat-
ment.

/

I

SECTION VII.

•Ct

FOR CONCEPTION, SEMEN WITH LIVING SPERMA-

TOZOA SHOULD BE DEPOSITED IN THE

VAGINA AT THE PROPER TIMK

361

SECTION VII.

FOR CONCEPTION, SEMEN WITH LIVING SPEBMATOZOA SHOULD
BE DEPOSITED IN THE VAGINA AT THE PROPER TIME.

THIS proposition naturally involves three considera-
tions : —

Ist. The nature and properties of semen.

2nd. Its passage to the cavity of the uterus ; and

3rd. The proper time for this.

The seminal fluid, as ejected in the act of copu-
lation, is composed of the secretion of the testes, mixed
with that of the vesicute seminales, prostate and
Cowper's glands.

The oflBce of the testes is to secrete the semen, which
is composed of the liquor seminis, granules, and
spermatozoa.

If we take a drop of semen from the vagina im-
mediately after sexual intercourse, and place it under
the microscope, we shall see the hurried movements
of seemingly thousands of spermatozoa. But this is
not the best way of studying the phenomena of their
movements. The best plan is take a drop of mucus
from the canal of a perfectly normal cervix uteri some
fifteen or twenty hours after sexual intercourse. We
shall then be better able to examine the spermatozoa ;
for we shall see them in the fluid that serves as the
means of their finding their way towards the ovum. We
shall find them moving more slowly, more cautiously,
if the term may be allowed. Suppose we select any

nTEltlNF, srRaEKY.

ono Bpormatozoon for observation, and note par-
ticularly its various actions and movements. It will
Bwirn first one way and then another, or move in a
straight line across the field of \-ision ; and perhaps turn
abruptly to retrace the path already traversed. If it
encounters a large epithelial scale it stops, places its
head aginst it, as though trying to push it forwards ;
and when it fails so to do, it turns and moves ofi'
slowly in another direction, perliaps to encounter
another opposing obstacle, to pause a moment and
make another etfort to overcome
it, and then to turn again in search
of some new field of exploration.

Fig. 136, a, represents the a.p-
pearanco of spermatozoa in a
normal state. With the sperma-
tozoon motion is life, and as
long as it lives it moves. When
the tail ceases its movements, the
organism is dead. The alternate
lateral movements of the caudiil portion drive the
head forwards. If by any accident this be injured,
then the movements of the body or head are in
accordance with the nature of the power exerted by
the inJHi-ed part.

For instance, if the extreme point of the tail sliould
be curled up, either by an injury or bo held so by in-
spissated mucus, as is represented in fig. 13G, b, then
the movements of the spermatozoon will be in a straight
lino, as shown by the arrow. If the injury be sneh as
to give a permanent gentle curvature to the middle of
the tail, .is shown in fig. 137, then its movements will
be in a circle, because the extremity drawing constantly

8P£BHAT0Z0A.

363

\

Fig. 137.

against the resisting fluid always in one direction,
will, of course, drive the head always in a corres-
ponding direction. For instance,
if the tail be permanentLy turned
to the left, as here represented,
then, with every contraction of it,
the head will be driven round to
the left ; and if to the right (fig.
138), then it will turn in a circle
to the right. But when we find a
spermatozoon injured so as to be
doubled on itself in the middle, with the tail reach-
ing up by or beyond the head, as shown in fig.
] 39, then its movements will be in
the opposite direction to the curva-
ture, because the moving power
will be expended at the very end
of the caudal portion, and this
force necessarily drives the head in
an opposite direction.

Spermatozoa cease to move only
when life is extinct. Under favourable circumstances,
they live many hours; but under unfavourable cir-
cumstances they die quickly. For
instance, any great variation in tem-
perature is fatal to their existence.

For impregnation, the semen must
contain living spermatozoa. It has
been pretended by some that it may
t/ake place without them. They are
to be found in aU animated nature. I
should as soon think of conception without the presence
of semen, as to suppose it possible without spermatozoa.

Fio. 138.

/

N

Fio. 139.

304 V TKK1>E SUKGEKY.

A sliort time ago it was generally supposed that
stoi-ility was a thing that belonged almost wholly to
the opposite sex. Mr. Curling* has recently brought
this subject prominently before the profession, and
has estal)lished very conclusively that sterility in the
male does positively exist, and that it may depend
upon —

1st. Congenital malj)Osition of the testes.

2n(l. Chronic inflammation of these glands ; and

'Jrd. Stricture.

In the first and second, the testes fail to produce
spermatozoa ; in the third, the semen regurgitates into
the bladder.

When the testes are retained in the abdomen, they
seem to remain in a inidimentary state, and never
attain the power of secreting semen with spermatozoa.

Mr. Curling's admirable paper contains a number of
cases illustrating this fact, and he arrives at the very
just conclusion that the semen of such testes being
devoid of the fructifying pnnciple, is wholly incapable
of procreation. Mr. Curling says that Mr. Poland and
Mr. Cock have each seen cases of procreation where
llie testes never descended into the scrotum; but in
neither of these cases had the semen been examined
microscopically. The inference in both instances is
plain : either that there are exceptions to the rule that a
retained testis does not furnish spermatozoa ; or that
tlie claims to paternity in their cases were entirely out

"* "0))st'rviilions on Sterility in ^lan," with nist^. By T. B.
Curling, F.K.S., Siirge(»n t<) tho London Hospital, Arc. Ro|»nntiHl
iVom the Biilish mid Futciyn Mtdicu-Chiriiryicid Heviav.

MITIKMATOZOA.

of the question. The latter the most probable, us
there are no facts to substfintiate the former.

In the Fi-ench school this subject has been very
thoroughly investigated. The ivritings of Goubaux,
of FoUin, of Gosselin, and Godard all go to prove that
a retained testicle is, as a rule, whether in man or
animal, incapable of producing spermatozoa, and that
semen without spermatozoa is incapable of procreation.
In some instances, one testis has been found in the
abdomen, and the other in its normal position in the
scrotum ; and here, the one has invariably been
deficient, and tlie other prolific in spermatozoa.

But while the presence of spermatozoa is essential
to fecundation, their absence has no sort of influence
upon im()otence. By impotence, we under.stand an
incapacity for copulation ; by sterility, an incapacity
for fructification. Thus a man may be impotent and
not sterile ; and sterile but not impotent. I have
known many men who performed the act of coition
witli tlie greatest \-igour, whose semen was perfectly
devoid of tlie slightest trace of spermatozoa ; and on
the other hand, how often do we encounter tliose who
are incapable of the least eflbrt at copulation, but whose
somen is loaded with spermatozoa. In the first class,
ignorance of their real condition is bhss ; whUe in tho
second, the certain knowledge of their infirmity pro-
duces the greatest misery.

The seminal fluid may be destitute of spermatozoa
in consequence of an obstruction of the excretory
duets of tho testes. This is tho result usually of acute
inflammation of theso organs. GonorrhtEa has been
regarded as a disease of no very serious importance ;
hut when we see it often producing a double orchitis.

L

366

DTERJNE SCKOEnY.

iction
ation.^^n

which may leave the subject of it sterile for €fver after-
wards, we should look upon it rather as an affection
likely to be attended with the most disastrious coDse-,
quences.

I now call to mind three young men whom I tn
for double orchitis, following gonon-hoeal inflammation,
about twenty-five years ago, which left in each a
chronic double epididymitis. They have been married
many years without issue. It is true their wives may
have been sterile. On this point I cannot do better
than to quote from Mr. Curling,* who says : —

" In 1853, M. Gossehn made known some curious
researches in relation to this subject. He cai-efuUy
examined tlie semen in twenty men who had been
attacked with double epididymitis after gonoiThoea.
In fifteen of these cases which were comparatively
recent, a callosity existed in the tail of the epididymis
at the time they seemed to be cured. In all, the genital
functions appeared fuUy restored and the sperm normal.
The semen was repeatedly examined at intervals of
several weeks, but no spermatozoa were detected, M.
Gosselin lost sight of all but two cases, and in these
the return of spermatozoa in the semen occurred after
some months, and coincidently with the complete dis-
appearance of the induration in the epididymis on one
side. In the remaining five of the twenty cases the
double epididymitis had occurred several years pre-
viously. One man, aged forty -five, had been attacked
twenty years before, but the left callosity no longer
existed, and spermatozoa were found in the semen. In
another man the disease dated back five years, and had

SPERMATOZOA.

307

L

left a considerable induration at the lower part of each
epididymis. Tiie general health was good. No sperma-
tozoa could be detected. In the three other cases
the disease had occurred ten, six, and four years before.
There was hardness on both sides. The testicles were
othermse unaltered. The indications of virility were
quite satisfactory, and the semen jjresented its usual
appearance. The individuals had all been married
several years, but had no children. The sperm was
carefully examined and found destitute of spermatozoa.
One of them hatl had children by a former wife before
the attack of double epididymitis. Since the publica-
tion of the preceding observations, M. Gosselin has
met with two cases of men who, after suffering from
bilateral epididymitis during their youth, had retained
an induration on each side. They had been married
several years and had no children. In both the virile
powers were not, apparently, weak, but the sperm was
entirely wanting in spermatozoa."

Thus it will be seen that inflammation of the testes is
a matter of grave importance. And tins is so whether it
be the result of specific causes, of accident, of cold, or
of translated parotitis. I have known one case of epidi-
dymitis fi-om mumps, where the testes lost the power
of generating spermatozoa. It is a curious and fortu-
nate circumstance that epididymitis, by whatever cause
produced, in no way weakens the sexual appetite, or
the power of gratifying it.

Semen destitute of spermatozoa has the usual sni
generis odour, but lacks the appearance of uniformity
that belongs to the normal secretion. Wlion viewed
by a transmitted light, we usually see little whitish
flakes of mucus flouting through it. But I have seen

CTKRINli SI'llUKEY.

lUt U)

and
i tiid

two instances in which it hud tlie colour and app
ance of good eemen, although wanting spermatozoa
It is insoluble in hot or cold water, and floats about iq
it iimniscibly in cloudy flakes like ordinary mucus.
is more translucent than good semon, Itiss milky,
less ojiaque. Under the microscope it presenta
appearance of ordinary mucu8. I have seen samplei
of semen fiill of spermatozoa, l)ut loaded vritU
mucus, which probably came from tho glaudulim
api)aratu8 at tlie neck of the bladder. I know of end
case illustrating the fact that a man is not necesgarilw
sterile because his semen possesses too large a proporJ
tion of mucosity. m

Normal semen will drop from the end of the synngoj
in drops as easily as water. A small quantity fiillingi
into a glass of water is, by slight agitation, inimeti
diately diffused or dissolved in it. Abnormal semonj
full of mucus will not leave the mouth of the syringJ
quickly or suddenly, but ropes off for an inch or morn
before it breaks into a drop; and when it falls Jntoi
water it preserves its tenacity, and but a small part on
it is dissolved. It floats about in shreds, and eventuaUyi
settles at the bottom of the glass in the form of an
whitish sediment. i^

Sometimes sterility in the male depends upon Bn
stricture obstructing the outward passage of the semend
which consequently in the act of copulation regiirgyd
tates into the bladder. This condition of things is, oH
couree, cui'able by the proper treatment for stricture. I

At tho beginning of tliis section I said that, to ensure.]
conception, "semen with living spermatozoa should boj
deposited in the vagina at the proper time." j

It is the vulgar opinion, and the opinion of mauyJ

SEXUAL CONGttESS. 369

savants, that, to ensure conception, sexual intercourse
sliould be performed with a certain degree of complete-
ness, that would give an exhaustive satisfaction to both
parties at the same moment. Even Roubaud" has
devoted many pages to the consideration of frigidity
iu the woman. How often do we hear husbands com-
plain of coldness on the. part of wives; and attribute
to this the failure to procreate. And sometimes wives
are disposed to think, though they never complain,
that the fault lies with the hasty ejaculation of the
husband. Both are wrong.

God has given us appetites and desires, and endowed
the act of copulation with a pleasurable eretliism,
simply that we might be forced to " multiply and
replenish." But for this, the human family might,
long ago, have been numbered with the fossils that
represent extinct species. No; it matters not how
awkwardly and unsatisfactorily the act of coition may
be performed, so that semen with the proper fructi-
fying principle be placed in the vagina at the right
moment ; and, on the contrary, it matters not how
perfectly and satisfactorily it may be done, if the semen
laxtks this fecundating power. I have known many
men who knew but little of mere animal sensuality,
and whose wives knew less, and yet they were blessed
with large families ; and, on the contrary, I have known
some who were differently constituted, and yet they
were perfectly sterile.

It miglit be thought that I am here overstepping the

* " Trati6 do I'lmpuisaanoe et de la St£rilit6 chez t'Homme et chei
lit Fpinme." Par le Dr. F*5Iix Rotibftud. Paria ; J. B.- BailliSre.

370 DTEIUNE SUEGEBT.

bounds of propriety, even in a work purely sa
but I justify myself by the fact, that a false philosopbj
has gained almost universal credence; and that young
medical men, with a correct knowledge of facts at
they truly exist, may do much to render many familie^
happier) by setting them right on a point of more vital
importance to domestic happiness than many of ufl
have ever dreamed of. |

Let ua turn to pages 340 and 342, and read ovca?
the cases in which conception took place wliile thai
wives were etherized, and ask ourselves what agency
mere sensual enjoyment could have had in bringing!
about the result. Our literature furnishes many cases
where the seminal fluid has been lost at the mouth of
the vagina; where the hymen has remained intact;;
and where, nevertheless, conception readily occun-ed.

I have seen cases of this sort ; so has Sir Joseph
OlHffe; and so has Dr. Campbell, of Paris. Most <
these were cases of vaginismus, where the pai
and spasm of the sphincter vaginte were such as toi
preclude penetration, and the semen was lost at the:
ostium vaginai, a little passing through the hymen. |

M. Tardieu,* Dean of the Faculty of Paris, relate^
a remarkable instance of conception following lascivious;
titillations under most unnatural and unfortunate eir-!
cumstances. Here the semen was habitually lost afe
the ostium vaginae, with the belief that conception could;
not occur unless the act of coition was fully consiun-'
mated. But the sequence proved otherwise ; and M. '

sephj
st<]l
paiw

• "litude M6Jico-16gale sur les Attentata anx M.eiiw." Par'
AmWoisG Tanlieii, Professeur, 4c. Pum : J. B. BniJli^reet Fils, 1859,i
l«ge 99,

L

SEXUAL fONGBESS.

Legrand, who delivered her, found the young gii'1'8
vagina virginal.

I once requested the husband of a lady who had
vaginismus, to let me see his wife an hour after sexual
intercourse, for the purpose of determining whether any
semen ever entered the vagina. He had not attempted
it for ten days or more, and he said he was so nervous
at the idea that he lost the semen at the moment of
contact, and hence the effort amounted to nothing.

In consequence of this accident, I did not see the
patient at the appointed time ; but visited her a few
hours later for some other purpose, and removed about
ten drops of clear translucent mucus from the canal of
the cervix. The attempt at copulation was made at
eight a.m,, the patient did not rise from bed till eleven.
At twelve I saw her, and then removed the cervical
mucus. I intended to make a microscopic examina-
tion of it at once, but circumstances put it out of
my power, and I did not do this till midnight, being
twelve hours atler its removal, and sixteen hours after
the attempt at intercourse.

In this cervical mucus I found a solitary spermatozoon,
which manifested the greatest activity. I examined
the whole of the ten drops of mucus, but could not
discover another one, nor was there any in the vaginal
mucus. How did only one spermatozoon and no more
find its way into the canal of the cervix ? Perhaps
not more than a drop, or a half a drop, of semen passed
through the little hymeneal opening. The patient
lay iu bed three hours afterwards. During this time
this stray sperraatoaoon had travelled three inches and
a half from the hymen to the os tincie (for the vagina
was very long and narrow), and had entered into
2 B 2

872

UTERTNE SUUOEHY.

the canal of the cervix, while the remaiader of On
seminal fluid passed ofi" in resuming the erect posture, i
The case is curious, as showing —

Ist. That semen can be thrown into the va^na
without penetration.

2nd. That a spermatozoon can, in a comparatively
short time, move over a considerable distance ; and

3rd. That it can live a long time out of the body,
provided the temperature is not too low. This obser-;
vation was made on one of the hottest days in July.

We know very well that the semen, or rather its
fructifying principle, the spermatozoa, must pass into ;
the cavity of the uterus, if not further, to render con-
ception possible. How is this done ? Does it enter
the canal of the cervix in the act of ejaculation ? or do '
the spermatozoa afterwards, by their locomotive
powers, gradually wend their way up the canal of the i
cervix ? \

I am not aware that any observations on the living ^
subject have before been made upon this point. A few '
jmst-inoriem examinations, made in cases of sudden death j
after coition, have demonstrated the presence of sper- ;
matozoa in the cavity of the uterus ; but this does !
not settle the questions raised above. The fact that ■
pregnancy has frequently occurred without penetration,
proves very conclusively that the spermatozoa can and ,
do traverse the whole length of the vagina ; that they
then can and do enter the canal of the cervix, and ^
passing along this narrow strait, that they can and do.
pass on till they reach the ovum, and fertilize it. But ■
this is not the usual way in which this is done. i

I have, over and over again, examined the condition!
of the uterus after coition, and often in four or five

SEXflAI. C-ONGBESS.

minutes after it; and I have usually found the state
of things described on page 357. I have also fre-
quently removed the mucus of the cervical canal im-
mediately after sexual intercourse, first a drop from
the OS tincffi, and then a drop or two from an inch
higher. If the neck of the womb is in a normal con-
dition, with an open os tincse filled with healthy mucus,
we shall always find . spermatozoa in it, in greater or
less numbers, if we examine it immediately after
coition.

Thus we see that they enter the cervix, as it were,
suddenly. My explanation of this physiological phe-
nomenon is, that the cervix is pressed forcibly against
the glans by a contraction of the superior con-
strictor vaginae ; that this pressure necessarily forces
out the contents of the canal of the cervix ; that the
parts subsequently become relaxed, the uterus returns
suddenly to its normal condition, and the seminal fluid
filling the vagina necessarily rushes into the canal of
the cervix by a process similar to that by which a
fluid would pass into an India-rubber bottle slightly
compressed, so as to expel a portion of its contents
before placing its mouth in a fluid of any sort.

If the uterus is in a normal condition, we shall
always, as a rule, find spermatozoa in the canal of the
cervix immediately after coition. If the uterus is
greatly retroverted, we sliall not; and if it is greatly
anteverted we shall not. And why ? Because,
in the first instance, the os tincsB will be too close
to the symphysis pubis, and if it is subjected to
any such pressure as tliat alluded to above, it
will, for anatomical reasons, be such as to com-
ju'oss the posterior lip of the os ttncai " up against

374 UTERINE SUliGEET.

the anterior, which will have no effect in exhaastiB^ '
the canal of the cervix ; and in the second instance,
where there is a complete anteversion, with the 03
looking in the direction of the hollow of the sacrum,
the same act and the same pressure would only force
the anterior lip of the os tincae up against the posterior,
creating no vacuum, and making no room for the newly
introduced fluid.

From this it will be seen that I believe the cervix
uteri to be shortened in the erethismal climax of
coition, by pressure exerted upon it in the direction of
its long axis when its position is normal, which is
impossible in any greatly abnormal position. I have
spoken of a superior constrictor vaginas, arid attributed
to it a certain ofBce — that of compressing the glans
forcibly against the os tincre at a certain moment. I
have made no dissections to prove tlie existence of such
a special muscle ; but that it does exist, and that some
anatomist will dissect and describe it, I feel perfectly
confident, for I have seen the manifestations of its
presence hundreds of times. In uterine examinations
with the patient on the left side and my speculum
introduced, we may now and then see the posterior
wall of the vagina just opposite the oa tincce gradually
contracted and corrugated, till it is brought almost in
contact with the cervix, evidently by circular bands of
muscular fibres that occupy the superior portion of the j
vagina. I

We are more apt to see this in patients that are ;
alarmed, and manifest some degree of general nervous
a^tation. I have witnessed this over and over again,
and what one man sees, another will be sure to discover
when his auention is turned in the proper direction.

ARTIt'lCUL FERTILIZATION.

375

It matters not whether this explanation is correct or
not, provided other observers estabHsh the fact that
the semen finds its way at once into the canal of the
cervix.

We have ab-eady discussed many of the mechanical
obstructions that prevent the passage of the semen to
the cavity of the uterus ; and we have seen that the
great difficulty is to be found almost uniformly in the
cervix.

It has, hence, occurred to many philosophic minds,
to overleap this barrier at once, by throwing the
fructifying agent right into the cavity of the uterus.
But the practical execution of this is surrounded by
many difficulties. For instance, how delicate and diffi-
cult would it be to arrange everything preparatory
to such a procedui-e. Then, as to the temperature of
instruments; for the slightest variations of this,
whether of heat or cold, are inimical to the life of
the spermatozoa. Then as to the quantity of semen to
be introduced, whether much or little ; the delicacy of
the apparatus for this, and the proper time for the
operation. Wlien all these circumstances are taken
into consideration, we can appreciate the difficulties of
the practical execution of a thing tliat would at first
appear to be theroretically so simple. Ever since the
days of Spallanzani and Rossi, who, with a syringe,
injected the semen of the dog into the vagina of the
bitch, and saw impregnation follow, it has been
supposed by many that in the human subject this
mechanical process might be carried still further, by
injecting the semen into the cavity of the uterus from
L the canal of the vagina. But I know of no published
I account of any pxperiments of this sort.

376 UTEEINE aURQEHT.

Some years ago, I made a series of this kind, and
actually saw conception follow this process in one
instance. Dr. George Harley, Professor, &c., in
University College, London, informs me that he has
repeatedly performed the experiment of injecting the
semen into the cavity of the uterus, but with no result.
I have given up the practice altogether, and do not
expect to return to it again ; but as others may feel
disposed to try further experiments in this direction,,
shall here give them the advantage of my experience.!

Before undertaking this we must satisfy ourselves'
that the semen is perfectly normal, and that it does
not and cannot enter the canal of the cervix in the
natural way.

In all my cases there was a contraction of the canal
of the cervix, and in two there was quite a flexure at
the 08 internum ; and experimental observations proved
that the semen never entered the canal of the cervix
in any one of them. In all of them the operation of
incising the os and cervix would have been the proper
course to pursue ; but my patients were too timid, would
not submit to it, and accepted the uncertain alternative
of uterine injection. In ray first experiments this was
often more painftil than any operation, for it frequently
produced severe uterine colic. I had no data to guide
me, and I began by slowly injecting three or four drops
of the seminal fluid, which produced very severe
symptoms ; then two drops, and then one, till finally
I determined that a half a drop was quite enough.
Indeed, I have no idea that this quantity ever gets into
the cavity of the uterus in Nature's own way, and I
now wonder why I should have begun these experi-
ments in such a heroic manner. Suffice it to say that

ot
es^^n

ARTIFICIAL FEHTlLtZATKlN.

377

L

I have seen conception follow this artificial ft-uctification
once, and once only. The case is of sufficient import-
ance to give it in detail.

My patient was twenty-eight years old ; had been
married nine years without issue ; and had had more or
less dysmenorrhcea all her menstrual life. It was often
attended with great constitutional disturbance, such as
nausea, vomiting, and sick headache. She had retro-
version, with hypertrophy of the posterior wall, an
indurated conical cervix, a contracted canal, which was
particularly contracted at the os internum, in conse-
quence of the flexure incidental to the malposition ;
and, superadded to all these mechanical obstructions,
the vagina never retained the semen. I examined
this case several times very soon after sexual inter-
course, and I never found a drop of semen in tlie
vagina, although it was jjlaced there in the greatest
abundance.

This patient was willing to submit to anything but a
surgical operation. Could any case have presented a
greater number of difficulties to be overcome t" The
first thing to be done was, of course, to rectify the
malposition, and to keep the uterus in its normal
relations by means of a properly adjusted pessary, with
the hope that the vagina would retain the semen.
Tliis point has been so fully discussed in Section V.,
that it is unnecessary to say more here than that 1
fortunately succeeded in doing this, and a sufficient
quantity of semen was retained, though tlie most of it
passed ofiF. This part satisfactorily arranged, we wei-e
now ready for the uterine injections. These extended
over a period of nearly twelve months. Some of thetn
(two) were made just before monstniation ; the othci-s

378

UTEKINE StmOEBY.

(eight) were made at different periods, varying from
two to aeven days after it ceased. Beginning mth
three drops, I at last injected half
^^^ a drop.

Y Fig- 140 represents the instni-

mont with wiiich tlieae experiments
were condueted, with the exception
of the bulb at the end of the tube,
it is made of glass. The piston can
be drawn out easily for the purpose
of taking up the semen ; but for the
])urpose of graduating exactly the
quantity to be injected, there was
a little screw nut, a, which coidd be
tiuTied against the piston-rod, upon
which a screw was cut. This pro-
vented the piston from being forced
down, except hy the action of the
screw. When we wished to force
out the contents of the syringe, half
a revolution of the piston forced out
half a drop, a whole revolution a
whole drop, and so on, just as
does Pravaz's instrument for the
endermic injection of morphine.
The greatest care was necessary in
managing the temperature of the
syringe. I placed it in a bow! of
P,y 1^, warm water, with a thermometer

to mark 98° Fab., taking care to
have it no more and no less. But as the i-emoval
of the instrument from the Iiowl of water to the
vagina would be necessarily attended with a diminu-

AUTIFICIAL FERTILIZATION.

tion of temperature, I adopted the plan of allowing
it to remain about a minute in the vagina before
drawing up any of the semen into it ; and thia
for the purpose of insuring it to bo the same tempera-
ture as the fluid in which the spermatozoa disported.

rig. 141 represents the exact size of the glass-tube,
used the last time in thia case ; n is the point at which
a string was tied, as a guide and a
guard to prevent its being introduced
too far into the cavity of the uterus.
This was exactly one inch and nine-
sixteenths from the end, which I think
is quite as far as we should introduce
the instrument. Thus it was not cai-ried
so far as to injure the lining membrane
of the uterus, or to mar the vitality of
the ovum, if it had already reached this
cavity. I feared that I might have
done one or both of these in some of
my earlier experiments. In this par-
ticular case, about four drops of semen
were taken up ; the instrument was
cautiously carried into the canal of the
cervix, till the point was in close contact
with the OS tineas ; then the piston-rod
was slowly turned half a revolution,
which as slowly forced out half a drop of semen ;
the instrument was held m situ for ten or fifteen
seconds and then withdrawn, and the patient lay
quietly in bed for two or three hours afterwards.

Under these circumstances, at this, the tenth, trial,
conception took jjlace, and everything went on favour,
ably till the fourth inoutli, when a fiUl and a i'right

UTEKINE SURGEBT.

unfortunately produced a miscarriage, from whicb the
motlior recovered with the greatest difficulty. I have
related thia case minutely, because I presume it is the
first and only authentic case in which artificial fertiliza-
tion haa been successful in the human species ; and
because it furnishes about the sum and substance of
my knowledge on the subject which may be of any
possible service as a guide to future observers, who
may have the curiosity, leisure, courage, and perse-
verance to experiment further in this direction.

The experiments above alluded to were made on
half a dozen different patients. During the two years
that I was engaged in them, I made fifty-five uterine in-
jections. I think I am entitled to subtract about half the
number as having been badly done, or having been made
with badly constructed instruments, or under injudicious
circumstances. If so, then they show one conception out
of about twenty-seven trials. I have very little doubt
that we shall learn still more about embryology ; and
some years hence, when we shall better understand the
laws of conception, I doubt as little that some one will
be able to apply the principles sought to be estflblished
by these experiments with more exactitude than I have.
If we understood more about the propei" period for
conception, this mechanical fertilization might become
exact enough to depend upon it in such cases as
would bo otherwise impracticable.

Science, even in our own day, demonstrates now and
then the wisdom of laws given under the Mosaic dis-
[icnsation. As an instance, I have only to refer to the
recent discovery of TrichinBe in swine, as showing not
only its occasional unfitness, but its positively poisonous
(luahties as an article of diet uii<kT some circumstances.

rEinon fob conckption.

381

Then, again, tlie laws bearing on the uncleanness and the
purification of women in menstruation, are in accord-
ance \vith the accepted doctrines of the day, in regard
to the period of fitness for conception. " But if she
be cleansed of her issue, then she shall number to
herself seven days, and after that she shall be clean."
— Levit. XV. 28.

It is pretty well established that menstruation is the
sign of ovulation ; that it is preparatory to the re-
ception of the ovum ; that the ovum reaches the cavity
of the uterus in from two to ten days after menatnia-
tion ; and that it must be fertilized at some point
between the ovary and the os internum, by coming
in contact with the spermatozoa. Dr. Ritchie * of
Glasgow believes, with many other modern Physio-
logists, that the uterus itself is the normal seat of
conception.

Now, if all this be so, it follows that the best time
to insure this fructification is within the ten days
following menstruation. This is the generally accepted
doctrine in regard to the most fitting time for con-
ception. 1 have no doubt that conception may take
place at any period whatever, relatively to the retimi
of menstruation ; but there is hardly a question that
it occurs more frequently within the ten days following
this period. I know of several instances in which it
undoubtedly occurred within the week preceding the
expected return of the flow.

Sir Joseph Olliffe and 1 sent a patient of ours to

* " ContribntionB to Aanst the Shidy of Ovuriati Physiology and
Pathftlogy." ByCharWO. Ritcliip, M.D., 4c. &c. ]>. U>I. Joliu
Churchill .Ir Soiih, 186.).

L

J

882 DTEEINE SUBOERT.

Spain, in the spring of 1 864. She had been on^^
treatment for raenorrhagia for three or four months,
and lived entirely apart from her husband during the
whole of this time. They were ordered to live apart
till she should pass over one period in Spain. Every-
thing went on according to oiir prescription till about
forty-eight hours before the expected appearance of the
flow, when by accident, as sometimes happens, the
injunction of the doctors was momentarily forgotten,
and the period did not come at the expected time.
Indeed, she conceived, and in due time was delivered of
a daughter.

The husband of a lady of great eminence, aged
thirty, tlie mother of three sons, the youngest three
years old, was absent in the Holy Land for five months,
and returned exactly five days before the expected
recurrence of his wife's menses. He spent but one
night at home, being suddenly called ofl" for several
days by some tirgent business. His wife conceived,
and bore him a daughter.

I had a lady, aged twenty-eight, nearly two months
under treatment for some cervical disease. The case
was treated entirely with tampons of cotton-wool, wet
with glycerine, hoUfing in solution various remedies,
such as tannin. When she was thought to be well
enough to return home, her husband came for her. I
wished to see if tlie secretions were normal. Sexual
intercourse took place, at my request, two days before
the expected return of menstruation. It did not
appear. She had conceived, and in due time a son
was bom.

I can vouch for the reliability of the parties alluded
to above. I have related these three cases to illustrate

PERIOD FOE CONCEPTIIiN.

383

the fact, that conception can and does take place just
on the eve of the approach of menstruation ; a tiling,
by the bye, that ia not denied. I could give several
reliable cases where the circumstances wore such as to
prove that conception could only have occurred within
a week or ten days following the cessation of the flow.
^Vhen I was engaged in the philosophic esperiments
of artificially introducing the semen into the cavity of
the womb, I had to make some fifteen or twenty essays
before I was satisfied of the quantity of semen to be
introduced, but as to the proper time for this I never
felt entirely sure. For those who are very anxious for
offspring, I usually order sexual intercourse on the
third, fifth, and seventh days after the flow has ceased ;
and on the fifth and third before its expected return ;
and but once on each day. For the most obvious
reasons this should always be on going to bed at night,
instead of just before rising iu the morning. The
horizontal posture favours the retention of the semen ;
the erect its expulsion. I am satisfied that too
frequent sexual indulgence is fraught with mischief to
both parties. It weakens the semen. In other wortla,
this is not so rich in spermatozoa aft^r too great
indulgence, and when carried to the extent of a
debauch, the fluid ejected may be wholly destitute of
spermatozoa. Thus it will be seen that it ia much
better to husband the resources of both man and wife.
Tlio sexual act should never be done except at the
spontaneous prompting of nature. It is very curious
to contemplate the bounties of nature when we come
to view the provisions made for fructification, whether
in the veget^able or animal kingdom. We know that
but little semen and but few spermatozoa are needed

384

UTERINE SPBQEET.

for fertilizing the ovum. We see this
culture, and we may infer it in all creation. I do uot
know that any one has ever thought of measuring the
quantity of semen ejected in the act of copulation, nor
do I know that it would be possible to arrive at this
point accurately ; but accident led me to make some
observations on this subject, which I here place on
record as a matter of physiological iuterest, if not of
therapeutical importance.

In most women a considerable part of the semen
passes off with the completion of the copulative act,
and the separation of the sexes, while a large part of
it remains iu the vagina to gradually ooze away. It
has so happened that I had two patients whose vaginas
seemed to hold almost all that they received. It has
been my duty to examine them a few minutes after coi-
tion, and the perineum and nates appeared to be almost
as dry as if nothing of the kind had taken place. The
quantity of semen retained by the vagina seemed to me
to be so great, that I was induced on several occasions
to remove it with a syringe, and to measure it sub-
sequently, and I found that ordinarily there was about
a drachm and ten minims. Of course, this did not
comprise all that was deposited there, for a very con-
siderable portion must of necessity always be removed
by the male, merely by the attraction of cohesion.

It would be important to determine how long sper-
matozoa can live in the matrix. On this point we
need more extended experiments, for I do not tliiak that
their duration of life lias yet been fully established.
Dr. S. R. Percy, * of New York, reports a case in which

TEEIOD FOB CONCEITION.

385

he found " liying spermatozoa, and many dead ones,"
issuing from the os uteri, eight and a half days after
the last sexual connection. During this time the
husband of the patient had been from home.

I have examined the semen many times with the
view of determining this point, and think I can safely
say that spermatozoa never live more than twelve hours
in the vaginal mucus. But in the mucus of the cervix
they live much longer. At the end of twelve hours,
while all are dead in the vagina, there are but few dead
ones to be found in the cervix. When the cervical
mucus is examined from thirty-six to forty hours after
coition, we shall ordinarily find as many spermatozoa
dead as alive. But my observations on this point
could not, under the nature of things, be accepted as
the rule, for they were all made upon those who were,
or had been, the subjects of uterine disease in some
form or other.

Here is the report of an observation made upon a
patient who is perfectly reliable : — " Sexual intercourse
at eleven p.m. on Saturday. A microscopic examina-
tion of the secretions was made on Monday, at three
p.m., just forty hours aftenvards. The vaginal mucus
contained a few dead spermatozoa — none alive ; the
cervical mucus contained great numbers very active^
a few dead."

The above is copied from notes made at t)io time.
I saw no reason why many of these active spermatozoa
should not have lived for a still longer time. Many of
them lived six hours after their removal. This was in
July.
■ Before closing this aubject, I shall give a few

UTEEINE PUEGERT.

examples illuatrating the host time for aexiial congreaa
after menstruation, to insure conception.

A menstruation took place on the 7th and ended
on the 10th of the month. Sexual intercourse
happened once on the 11th. On the morning of the
12th, the lady went to a sea-side watering-place,
where she remained more than a month, leaving her
husband at home. She had always been regular, but
her period did not appear on the Sth of the following
month as she expected. Fearing that the sea bathing
had something to do with the non-appearance of the
menses, she sent for a physician, who ordered her to
stop the baths, and gave hor some strong emmena-
gogues to provoke the flow, but it did not come. The
next period passed, and it was found, greatly to her
surprise, that she was pregnant. She went the full
time, and a son was bom.

I operated on a lady, thirty years old, wlio had been
married fifteen years without offspring. I directed
her to have sexual intercourse on the third, fifth, and
seventh days aft«r the cessation of the menses. She
menstruated on the 8th of the month, ceased on the
12th, had sexual intercourse on the 17th, and a son
was bom on the 16th nine months afterwards.

In the case of uterine injection spoken of on page
379, menstruation began on the 2nd of the month,
finished on the 6th, sexual intercourse took place on
the 12th, the uterine injection was only five or six
minutes afterwards, and conception dated from that
time.

Here, then, is one case where conception occurred
on the day after the flow ceased, and only four days

PERIOD FOR CONCEPTION. 387

from the time it began ; another in which it probably
took place five days after the flow ceased, and nine
days from the time it began ; and another in which it
took place six days after the flow ceased, and ten days
after it began. I might give other facts like the last
two, but I forbear. They accord very well with the
received doctrines of the day as to the proper time for
conception, viz., about a week, more or less, after the
cessation of the flow.

I hope I have said enough to show that, for the
purpose of conception, « semen with living spermatozoa
should be deposited in the vagina at the proper
time."

2 c 2

SECTION VIIL

THE SECRETIONS OF THE CERVIX AND VAGINA
SHOULD NOT POISON OR KILL THE

SPERMATOZOA.

r

f

i

f '

r

SECTION VIII.

TQE SECRETIONS OP THE CERVIX AND VAGINA SHOULD
MH POISON OR KILL THE SPERMATOZOA.

THE vagina and the canal of the cervix each secrete
a mucus peculiar to itself. That of the vagina is
acid ; that of the cervix very slightly alkaline. These
secretions become changed in character and consistence
by any inflammatory action set up in the glandular
apparatus that gives rise to them. We shall consider
their deviations from a normal condition,

Ist. Of the vaginal secretions ; and

2nd. Of the cervical.

1. The vagina is subject to an inflammatory action,
which may arise from a specific cause or not.

Vaginitis is a most troublesome affection ; it matters
not from what cause it originates. It usually lias a
specific origin, but it may arise spontaneously ; some-
times it is secondary to some irritating discharge from
the uterus. Sir Charles Locock* saya : " There is one
material point connected with leucorrhcea, and
especially where the discharge is purulent or of
an acrid character. In such instances it is well known

Cyfliipiciliu of Pmcticul Mtilicine,"' uilielti Lout

CTEEINB SUHGEBT.

that sexual intercourse wiU often bring on
Byniptoms very mucb resembling gonorrlicea in tlie
male. Tliis, when occnm'ng between bnaband and
wife, has often led to much domestic imhappinese, from
the supposition of one party or the other faaring con-
tracted gonorrhoBa from impure connection."

I am unhappily able to substantiate fully all that ia
here stated on this point by this distinguished authority;
for I have seen many cases of urethral inflammation ^
in the husband, that wore imquestionably contracted i
from the wife, who, however, had merely a !eucorrha?a -
of an acrid character.

The treatment of vaginitis is now reduced to great
simplicity. I have found Demarquay's plan to
answer admirably. It consists in introducing a
tampon of cotton or lint saturated with a solution of
tannin in glycerine, from two to four drachms to the
ounce. Tliis dressing may be retained three or four
days. According to Demarquay, the average time of
treatment by this method is about a fortnight.

Recently Dr. John J. Black,* of the Philadelphia
Hospital, Blockley, has made some experiments in the
treatment of vaginitis with medicated suppositories
that produced most satisfactory results. He experi-
mented with persulphate of iron, alum, tannin, copaiba,
and a variety of other remedies, and anived at the
conclusion that the suppository plan of treatment was
superior to all other methods in efficiency, cleanliness,
portability, and ease of application at any time, and

Journal of t/ie Medkal Sciences, No. XCIX.

without the aid of instruments. Subjoined is one of
Dr. Black's formuIa3 for their preparation ; —
y^ 01. Tlieolji-oinfe, 5x11.

Morjiliiie Siilpk, gi'. vi.

Liq. Feni Persuljili., gtt. csliv.

Cerat. Adijiis, ^iij sa.

Et fiant Suppositoria xii

Of these, one is to be introduced into the vagina
every other day, except during ^menstruation. Dr.
Black says, " The average number of days required
for the cure was as follows : — Liq. ferri persulph., nine
days; alum and tannin, nine days and a half; ol.
copaibse, twelve days ; comp. iodine ointment, thirteen
days ; citrine ointment, fourteen days ; chloride of
zinc, nineteen days." The very strong preparations
were inferior to the milder.

This is certainly far better than the old plan by
nitrate of silver and vaginal washes, which was always
tedious and most unsatisfactoiy. I do not know that
vaginitis, properly speaking, is absolutely opposed to
the vitality of the spermatozoa. According to Donn^
they live in pus and blood, and a variety of other
fluids, I liave fi-equently seen conception to happen
whero the cervix uteri was the seat of profuse
suppuration, so that pus, per ne, is no hindrance
of this. The most troublesome obstacle of this
sort is to be found, not in the quantity but in the
character of the vaginal secretion. This, as before
stated, should be slightly acid ; if it is very acid it
kills the spermatozoa instantly. I have seen many
cases in which they wore all dead within five or six
minutes sifter coition. In all these case.s the vaginal

394

CTEKINE SURGERY.

I

mucus was by no means abundant, but the surface^H
the vagina always had a reddish look, and its papillae
wore prominent.

By simply inspecting the surface of the vagina, and
testing the degree of acidity with litmus-paper, I have
sometimes been able to say that the vaginal mucus
would jirobably poison the spermatozoa. The blue
litmus should be slowly turned to a faint pink when
the secretion is normal ; but when it is abnormal, the
litmus-paper turns quickly to a deeper pink colour. I
have seen conception twice where the vaginal mucus
poisoned the spermatozoa. One was remedied by
slightly alkaline washes used before sexual congress. In
the other It occurred in this way. A lady, aged twenty-
eight, was married six years without issue. She had
a contracted os. It was incised ; but she did not con-
ceive. She had an indurated cervix, the consequence
of cystic disease. For this she was under treatment
for nearly two months. It was cured ; and her hus-
band came to take her home. Wishing to see the
character of the semen, I examined the vaginal mucus
four or five hours after coition. The spermatozoa
were all dead. On the next day I examined them in
five or six minutes afterwards, and could not find one
alive. I then placed in the vagina a small tampon of
cotton moistened with a httle glycerine, which held
in solution some of the bicarbonate of soda (twenty
grains to the ounce). This apphcation was repeated
on the next day. The cotton was tied with a string
for its easy removal. This was worn from about two
o'clock p.m. till eight the next morning. Its removal
was followed by connection. Living spermatozoa were

m

LEPCOKimiEA.

395

afterwards found in the greatest abundance. Indeed,
there were no dead ones at all. Conception dated from
that moment, being just two days before the expected
return of the menses, which, however, did not recur.
There had been no sexual intercourse for nearly two
months before. Labour came on at the fubiess of
time ; and the delivery was safe.

According to KoUiker, the phosphate of soda is
peculiarly favourable to the movements of spermatozoa ;
and this would probably be a good application in such
cases as the above. But as yet I have had no experi-
ence with it.

2. Of cervical leucorrhoea.

Dr. Bennet has done much for the treatment of the
diseases of the cervix uteri ; and Dr. Tyler Smith's
contributions to the Pathology of Leucorrhoea* are
of the greatest importance. With these and the com-
prehensive treatises of West, of Churchill, of Hewitt,
and of McChntock now before us, and all fi-esh from
the press, I can here afford to pursue pretty much
the same course as that which I have followed all
along, viz., to give a few clinical illustrations of merely
surgical and manipulatory processes.

Cervical leucoiThoea may be a hyper-secretion from
the lips of the os, or from tlie cavity of the cervix.
It is almost always of albuminous consistence, and
very difficult of removal. Under the microscope it
presents the characteristics of rauco-pus. Sometimes
it is merely an exaggerated secretion seemingly without

" The Patholo^ imd Tnwtiiic-ut of Leuwrrhceu."
Siiiilh, Mil.. Profesaor, Ac. ISR5.

By W. Tyler

396 UTEIilNE SrilGERY.

aiiy abnormal qualities. It interferes with cODC^ti
in two ways — mechanically and chemically. Mechani-
cally in blocking up the canal of the cervix, and pre-
venting the passage of the spermatozoa ; chemically,
by poisoning or killing them. I have frequently seen
conception happen while using the nitrate of silver for
granular erosion of the os and cervLx uteri. Unless
there is some special reason for it, I never interdict
sexual congress during the treatment of ordinary cases of
cervical engorgement. Where conception has taken place
imder these circumstances, I am satisfied that sexual
intercourse must have occurred within ten or twelve
hours after the use of the remedy, or at least before
its eschar began to separate, which is always attended
with a secretion of muco-pua that would be fatal to
the spermatozoa.

Nitrate of silver will probably retain the good repu-
tation it has acquired in the treatment of granular
erosions of the cervix. In some cases it unfortunately
provokes hajmorrhage, and this is one of the objections
to its use. Dr. Wright, * of the Samaritan Hospital,
has recently called the attention of the profession to
the use of a compound of the iodide and nitrate of
silver as they exist in "an old photogi'aphic nitrate-
bath, stUl bright and clear, but which had been so long
worked that it had become saturated with iodide of
silver, and contained a considerable amount of ether."
Accident led him to the use of this preparation, and
he has found it far more efficacious in the various

* I'/ie Lancet, Mureh 18, It^G.'i, |>. iSi : "Thi.- Topical Uae of
Silver SohitioiiH." By Henry (_i. W'l-ij^lit, W.D.

LEOCORRHiEA.

397

forms of storaatitia and analogona affections of tho
uterus than the more concentrated solutions of tho
pure nitrate of silver. Dr. Gibb has also used it
topically with marked benefit in affections of the
throat and larynx. This " old batli solution " may be
obtained of any respectable photogi-apher.

I know of no caustic application of more value in
these cervical engorgements than the chromic acid,
as already set forth on page 44.

Potassa cum calce I now seldom employ, and think
it should be used with great caution. In the practised
hands of such men as Bennet and Tilt I have no fear
of it. We know very well that we can by long ex-
perience acquire a tact in the management of powerful
remedies whereby they are perfectly harmless. Any
one must have been struck with this fact who has
followed the distinguished surgeon Job^rt (de Lamballe)
through his wards in the Hotel Dieu, and seen with
what skill he wielded the potential cautery in the
kind of cases that we are now considering.

There are many hypertrophied and granular con-
ditions of the cervi.t that obstinately resist all local
stimulating, or escharotic applications. Scanzoni
recommends excision or amputation of the affected por-
tion when this is the case. For many years I have
been in the habit of doing this, and have thus often
cured cases in a week or a fortnight that had been
under treatment for months without improvement.

Vaginal washes are of some importance in the
conditions of the cervix that give rise to leucorrhosal
discharges. They are to be made with a syringe
that is capable of throwing in a suflBcient quantity

IJTBRINE SUnlERT.

of water without fatigue to the patient. Solutions
of ahira, of zinc, of lead, of iron, of tannin, and
of other astringent remedies, may be used from
time to time. We shoukl never use cold vagim
washes. I am sure I have seen great harm product
by them. They are valuable in controlling loucorrhceal*
discharges, but they favour to a great degree the pro-
duction of an indurated condition of the cervix, which
is to be avoided if possible. Vaginal injections should
always be tepid, let tliem contain what they may i
solution.

It has been thought tliat they could produce but litti
effect on the condition of the cervix ; but this is agrei
mistake. Remedies thus applied act by osmosis, and pro-
duce not only a local, but, in some instances, a constitu-
tional effect. I have oft<?n heard patients complain of
the taste of tannin a few minutes after its application tl
the cervix uteri. It might be supposed that this was a
effect of imagination, or that the odour of it was con-"
founded with the taste. But this could not be so, when
the application was made without the patient knowing
what it was ; and if the scent of it was mistaken
the taste, the mother, or aunt, or nurse present wou!
have been as liable to bo thus deceived as the patient"
which was never the case. I am perfectly satisfied
that I have known patients to experience the taste of
tannin in the mouth only two or three minutes i
was applied to the cervix uteri.

Great care is necessary in the use of the s
How often have I seen vaginal injections given w
their ever reaching the posterior cul-de-sac ;
sionally not oven the anterior. Why any one shou!

and

from ^^J
^ini^l^H

UCQJ^^H

hceal^^^
pro-

hich I

oul^^ri

littl^H

pro- li

itu-

3on- [I
hen
ivin g II

"Ih

ient,^^^

) after I

3 synng

VAGIflAL INJECTIONS.

399

erer tave made a curved vaginal tube I cannot under-
stand ; and yet we find them in all the shops. If a
curved tube be introduced into the vagina with ita
concavity upwards the distal end wiU strike against the
anterior wall of the vagina before it reaches the cervix
uteri ; if, on the contrary, it be turned backwards, it
will as invariably rest upon the posterior wall of the
vagina without passing under the cervix, and in either
case it fails totally in the object of its use. A vaginal
syringe tube should bo about the size of the little finger,
and full four inches long. The patient should be
taught to use it for herself. It should be passed into
the vagina, and directed downwai'ds and backwards as
if it were to be passed in the direction of the os
coccygis. It should be pushed gently on almost by
its own gravity, if the patient is in the recumbent
posture, tiU it seems to be arrested by an elastic
resistance, which is the posterior cul-de-sac. We shall
then know that the end of the tube is under and
beyond the cervix uteri.

When wo, then, begin to inject the water, we shall
feel confident that it will in its regurgitation bring
away whatever secretions may be lying in the
vagina, whether high up or low down. We cannot
be too careful in our directions about the use of va-
ginal washes, for if not properly apphed they may not
only fail to accomplish all that we expect from them, but
they may produce most painful if not dangerous con-
sequences. We all know what a serious matter it once
was to throw the blandest fluid into the cavity of the
uterus ; indeed, many of us had altogether given up the
practice of injecting tins cinnty with any Hui<l whatever

400

IITERINE SDIiGEBY.

till Dr. Savage showed how safe it was after tlw
dilatation of the os iutemum by sponge tents. Tl
accident that I allude to as sometimes happening from
the use of the vaginal syringe is that of suddenly
throwing a jet of water forcibly into the cavity of the
uterus, which produces a dreadful uterine colic, at-
tended with the most distressing symptoms of prostra-
tion. No man who has unfortunately witnessed the per-
fect collapse following such an occurrence, whether by
accident or design, can ever forget the feeling of dread
tliat seized his own soul as he saw his patient launched
in a moment from a comparative state of ease and
comfort into the very jaws of death, as it were. I have
never known any one to die as a consequence of uterinft:
injection, but he is a rash man who runs the risic
of his patient's life after once witnessing the painful
results of such a thing under the old ri^gime.

The uterine cohc accidentally produced by the aelf-
injecting syringe has always happened under my
observation in cases of retroversion. In these, the os
tincre presented in the line of the axis of the vagina
the end of the tube entered the open os, and the wati
was tin-own directly into the cavity of the uterus. It
is, therefore, most important in cases of retroversion,
to teach the patient the art of using the syringe pre
perly and safely as well as efficiently. To prevent any
accident it would be well to close the little hole in thw
end of the tube, leaving the lateral ones open.

Amongst other vaginal washes for cervical secretionSy'
I must not omit to mention Dilute Hydrochloric Acid.
I gave Mr. Swann, of Paris, several samples of muco-
purulent albuminoid-looking secretionsfrom the cervici

1

VAGINAL INJECTIONS.

401

cavity, for experimental observation, and he found that
dilute hydrochloric acid was the only chemical capable
of dissolving it, that could be used locally as a wash.
Where there is no vaginal irritation or epithelial
abrasion, this may be used with advantage according
to the following formula : —

{t Dilute HydiwJilorie Acid, Jj.
I>iHtilled water, Jvij.

m

A tableapoonfiil in a pint of tepid water to be thrown into tho
vttgina niglit and moruing.

But vaginal injections are only adjuvants of treat-
ment. We cannot depend upon them wholly for
curative results. They are valuable in their way, and
not to be ignored. I know of nothing more difficult
of cure than an old cervical leucorrhoea ; and notwith-
standing the vaunted success of this or that remedy,
I fear that the young practitioner will often be dis-
appointed in their application.

Professor Courty, of Montpelier, foiled in the treat-
ment of cervical leucorrhcea by the ordinary routine,
resorted to the expedient of leaving a bit of nitrate of
silver in the canal of the cervix for several days, and
describes good results from It. Dr. Simpson has lately
been applying various remedies in the vagina in the form
of suppositories, made of tho butter of cocoa. I have
recently had made little suppositories of cocoa butter, an
inch and a quarter long, and small enough to pass along
the cervix, medicated with various remedies so as to
bring these into permanent contact with the diseased
surface. For instance, T have had them made, contain-
ing severally morphine, atropine, alum, tannic acid,
2 P

402 DTERINE aUROEEY,

peraulphate of iron, &c., in appropriate doses, and think
tliey promise very satisfactory results.

A very convenient way of applying remedies topically
to the cervix uteri is that introduced, I Relieve, by
Kiwisch, of using a tampon of cotton or lint, satm-ated
with a solution of the remedy to be so used. I have
for a long time adopted this plan, and have every
reason to be satisfied with it.

If I were asked what next to mere mechanical
obstruction of the cervix uteri constitutes the greatest
obstacle to conception, I would have no hesitation in
saying that it was an abnormal secretion 6-om the
cervix.

We often see the cervical mucus in such large
quantities that its mere abundance will mechanically
prevent the passage of the semen to the cavity of the
uterus. Sir Joseph OUifTe has informed me of the
case of the wife of a medical man, who had been sterile
for many years, and whose cei-vix uteri always pre-
sented a little mass of ropy mucus hanging from the
OS that obstructed mechanically this canal. At last,
the doctor had the rational surgical idea to exhaust
the cervix of its inspissated mucus, and sexual con-
gress with his wife immediately afterwards was
followed by conception.

I knew but little about the effects of the mucus
secretion of the vagina and the cervix upon the vitality
of the spermatozoa until within the last three or four
years; and I am now satisfied that the cervical secre-
tion is often poisonous to the spermatozoa, even when it
would seem to be almost normal in appearance. This
must depend upon some other quality tlian mere i

ENro-CEEVicrns. 403

Unity, for I have often found all the spermatozoa in the
cervical mucus dead while it manifested no unusual
degree of alkalinity when tested by litmus-paper. But
when placed under the microscope it showed an uncom-
mon number of epithelial scales. This demonstrated
an abnormal action in the glandular apparatus that
gave rise to this secretion, which seemed to kill the
spermatozoa more by its density than by its chemical
action ; for I have noticed that they Hved longer in
that portion of the mucus that had the fewest number
of epithelial scales ; and, vice versa, died quicker in
that portion that had the most ; and that, too, when
htmus-paper showed no difference in the chemical
character of the two.

In these cases, in almost every instance after the use
of a sponge-tent, for six or eight hours I have been
able to detect by the sense of touch a small gristly
growth at some point in the course of the canal of the
cervix that was evidently the seat of this abnormal
hyper-secretion. Sometimes this is confined to a
single spot ; again, it may be spread over a surface of
greater or less extent. Occasionally the whole of the
lining membrane of the canal may be a muco-pyogenic
surface. What are we to do when this is the case ?
As said before, I know of nothing more difficult to
remedy. Professor Courty's plan of prolonged cauteriza-
tion may hold out some hopes of a cure ; or the method
of intra-cervical suppositories already alluded to may
be of service. But I am disposed to believe that we
shall do bettor by ignoring caustics and caustic appli-
cations altogether, and resorting to some method of
modifying this secretory surface by pressure. My
2p2

404

UTERINE SUKGERY.

countryman, Professor Bj'ford* speaking of Endocer-
vicitls, says : " A bougie of slippery elm large enough to
fill the cervical cavity, introduced as high as the in-
flammation extends, and allowed to remain for twenty-
four or thirty-six hours, not only prepares the way for
other applications, but favourably modifies the disease
by its pressure upon the capillaries. The use of the
stem pessary proves beneficial, too, I think, in some
instances, on account of the stem pressing upon the
inflamed part inside the cavity of the cervix, and thus
changing the character of the capillary action."

I am quite prepared to accept Professor Byford'a
teachings on this point, for I have known many cases
of conception to follow the use of the intra-uterine
stem, and I have now but little doubt that its curative
action was more in reheving that condition of the
cervical membrane that gave rise to abnormal secre-
tions, than in merely mechanicaUy dilating the os
internum.

I have, in the early part of this volume, objected to
the use of the intra-iiterine stem ; but there is
a modification of it by Dr. Greenhalgh that I have
occasionally used with good results. Its advantage
over its prototype is, that it is tubular and self-retain-
ing. It allows the secretions from the cavity of the
uterus

I pass ■

ugh

not so liable to slip out.

• " The Practice of Medicine and Surgory, applied to the Diseases'
and Accidents incident to Women," By Wm. H, Byford, M.A.,
M.D., Pi-ofessor, Ac. Philadelphia : Lindsay A Blakiaton. 1865.
Page 263.

ENDO-CEBVICITIS. 405

Fig. 142 represents the inatrument of full size. It
is from two to two inches and an eighth long. It is
introduced with the w*ing8 drawn into a straight
line by means of a stilet, as shown in the figure. As
soon as it is passed to the requisite
depth, the stilet is withdrawn ; the
wings spring back within the cavity
of the uterus ; the os internum grasps
the inatrument at its bifurcation, and
the lower end rests against the os
tincsB. Of course, this instrument
can only bo used after an incision of
the cervix or a dilatation of it by a
sponge or a sea-tangle tent. It may
be made of steel and silver plated ;
but I prefer it of vulcanite.*

I have seen cases in which this in-
strument was worn with great com-
fort ; and again I have seen others
that could not tolerate its presence
for a moment. In these last we shall
find the cause of intolerance to be an
eudo-metintia which had not, perhaps,
been auspected before. Dr. Coghlan'st
plan of using a tube of sheet-lead I have found I
answer a very good purpose.

I have not been able to arrange any apparatus fi

i

■ Made by Mnyer, of Great Portland Street ; alao by Weis*.
+ " On Dysnienorihcpa and Btorility ; witli Wood-cubi of New
Iiiitruuit'uliB." By Jului 0(i(;liliui, M.D, Malicai Timet luul O'uuUlt,
iSCl, '02, Mui "04.

406 UTEEfffB SUHOERY.

withdrawing in an isolated form the secretions
cavity of the uterus for microscopic and chemical ex-
amination. It is highly probable that this will be doni
at some time or other, and we shall then be able
determine more about the condition of it8 secretioi
as influencing the life or death of the spermatozoa. We'
have already made great advances in studying the
effects of the vagiual and cervical secretions upon
them; and I belong to that sanguine class of medical
men who look forward with great hope to enlarged
views and more certain methods, not only in this but
in every depai-traent of medicine.

I have said a good deal about semen and its exi
tion, and it is time that I should say something about
the meaaiu'es prejjaratory to this. Suppose we wish
to examine the vaginal mucus soon after coition-
say within an hour ; we direct the patient to empty the
bladder before the act, and to retain quietly the recum-
bent posture after it. The dorsal decubitus is the best.
To remove a few drops of the contents of the vagina,
pass the index finger into it, press the posterior wall
downwards and backwards, just under the cervi
uteri ; hold it so for a minute or two ; the semen
necessarily gravitate to the pouch made by this prei
sure ; then introduce the nozzle of the syringe alonj
the finger ; let it project slightly over the end of th(
finger-nail, and it will be easy enough to obtain what
we want if there is any semen in the vagina. I am thug
minute in explaining this simple operation, because we
may fail in it entirely, even when the vagina contains
large quantities of semen, if we neglect these minutije.
And in this way. If we pass in the syi-inge in

m

-he
on
cal

his but ^m

:amina-^^^B

CERVICAL MUCUS. 407

hazard manner, and begin to draw the piston, the
mucous membrane of the vagina is sucked up into the
end of the tube, and thus it is possible for us to slide
it around in various directions, without getting a drop
of mucus of any sort. But suppose we fail even with
properly directed efforts ; then the left lateral position
and my speculum will in a moment show us the whole
of the contents of the vagina, and we can with the
syringe remove what we want.

When we wish to examine the cervical mucus, we
should resort at once to the speculum and the proper
position. It is well enough, then, to sponge away all the
mucus from the vagina, and especially from about the
cervix uteri. We then pass the nozzle of the syringe just
within the os tinCEB, and draw up a drop of its mucna.
To do this it is necessary first to puU the cervix for-
wards, BO as to be able to look into it and to see exactly
what we are doing. If the cervical mucus is very
tenacious we may fail to get it away. Then it will at
the next attempt be necessary, after introducing the
syringe, and dramng up the mucus, to pass the left
index finger to the edge of the os tinea;, and sHde the
end of the syringe on to the end of the finger without
raising it from the surface of the cervix, or breaking
its suction power. This may seem to be a Httle thing
to describe so minntely, but really it is a most im-
portant matter to know and to do, if we expect to be
exact in our investigations. The nicety of this maui-
pidation renders it the more important for us to clear
away all the vaginal mucus before we undertake it, lest
we get some of this di'awn up into the syringe, which
would, of course, mar the precision of our observations.

408 UTERINE SUBGERY.

Suppose we succeed in this ; then we may wish to
pass the Byringe up for an inch into the cervix to get
a portion of mucus nearer the cavity of the uterus.
This operation is quite as delicate and quite as im-
portant as the first, and is to be conducted in the same
way. There is an object in having the end of the
syringe bulb-shaped, as represented in fig. 140. This
bulb fills up the os or the canal of the cervix, and pre-
vents the air from being drawn into the instriunent, as
sometimes happened with me when it was slender and
more pointed. For carrying a fluid of any sort into the
cavity of the uterus, of course we need the nozzle of the
syringe more like that represented in fig. 141 ; bub for
removing anything fi'om the cervix the bulb form is
the best.

As illustrating the exactness and the importance of
this method of investigation, I will give an example.

Dr. Fauvel, the distinguished laryngoscopist, of
Paris, requested me to see a patient of his, who had been
married twice, and had had one child by the first
marriage; none by the second. She was thirty-five
years of age, the picture of good health, and men-
struated regularly and normally. The uterus was
slightly anteverted. She had no leucorrhoea properly
speaking ; but the cervical mucus seemed to be shghtly
in excess of a normal quantity. What was the cause
of her persistent sterility for the last eight years, and,
indeed, for the last four years of her first marriage ?

The questions to be answered were, Was the semen
normal? Did the secretions of the vagina or cervix
poison the spermatozoa ? Did these enter the canal of
the cervix ?

INTEA-DTEKINR AB8CE3S.

The vagina was examined an liour after sexual inter-
course. Its mucus contained living spermatozoa in
abundance. The cervical mucus was full of them, but
they were all dead.

On anothei- occasion, a microscopic examination
made but a few minutes (eight or ten) after coition,
proved that the mucus of the cervical canal was full
of dead spermatozoa, while in the vagina they were
living. Here the litmus test was valueless ; but the
microscope demonstrated a superabundance of epithe-
lial castSj the result of a slightly congested condition
of some portion of the lining membrane of the cervix.

As said before, all abnormal secretions from the
vagina have been classed under the generic tenn
leucorrlioea, whether they emanate from the vagina,
from the canal of the cervix, or (roin the caWty of the
uterus. Having already hurriedly glanced at the con-
ditions of the first two that ordinarily give rise to
such discharges, it only remains to notice those of the
third, — viz., the cavity of the womb. We all know that
jnuco-pus is the almost constant accompaniment of
polypus, but as this has already been the subject of
discussion we have here nothing more to say on it.

The cavity of tho uterus sometimes becomes a
regular abscess, as it were. This condition has been
particularly described by Dr. J. Matthews Duncan, of
Edinburgh.

Dr. West* (p. 137) says, " A peculiar form of uterine
leucorrhoea, limited in its occurrence to the aged, and

* '■ lectures or
M.D., Fdlo«-, Ac.

< DiiMwat« of Women."
iid E.lm..ii. lt*Gl.

By Cburbx Vwl,

410

UTERINE SDRGERY.

aaaociated with dilatation of the cavity and atrophy of
the walls of the uterus, has been described by Dr.
Matthews Duncan, in the Edinburgh Medical Journal,
March, 1860. Its characteristic symptoms appear to
be peculiar lumbar and pelvic pain, accompanied by a
sense of constriction, and the discharge of muco-pus.
Its euro seems to require the dilatation of the con-
tracted internal os by the sound, and the application of
nitrate of silver to the interior of the womb. 1 beUeve
that I have met with this condition on one or two
occasions ; but the patients, having their minds relieved
with reference to the existence of uterine cancer, pre-
ferred putting up with the discomfort to submitting to
treatment for its cure."

I have seen one well-marked case of this sort. The
patient was about sixty years of age, and had had a
purulent discharge from the vagina for twelve months or
more. She was the mother of a large family of grown-
up children, and had ceased to menstruate at about
forty-five. The discharge from the vagina was pure
pus ; and it had almost a cancerous odour. On ex-
amination, I found the vagina fall of pus, and its whole .
surface and that of the cervix were excoriated and
granular. The uterus was retroverted, and of rather
imusual size for the period of life. I did not detect
the true nature of the disease for some time ; not till I
had succeeded in restoring the vagina and the cervix
to a perfectly healthy condition. Then I discovered
that the OS, which was very small, gave issue to a
slight though constant discharge of pus, and that this
was the cause of the vaginitis, which I had mistaken
for and treated as the original disease. The cervical

ENDO-METRITIS.

411

can^ was very narrow, flexed, and contracted at the
OS intermira, bo that the uterus, as it was bent back-
wards, always held about an ounce of pus. As the
first step in the treatment, the cervix was dilated ; the
pus was then evacuated ; the cavity of the uterus was
washed out with warm water, injected through a tube
small enough for the stream of water to i-egiu-gitate
easily by its side ; and then the pyogenic cavity was
injected sometimes with the Tr. of Iodine, and some-
times with a solution of the Persulphate of Iron. The
patient soon began to improve, and was finally cured.

We can thus medicate the cavity of the uterus with
the greatest safety, if we are only careful to provide an
easy retrogression of the injected fluid, either by the
sponge-tent, or by forcible instrumental dilatation
with Priestley's or Ellis's dilator, or some modification
of these.

Endo-metritis has recently been the subject of con-
siderable investigation. Scanzoni, Routh, and others,
have written much upon it ; Dr. Hall Davis has ex-
hiliited, at the Pathological Society, the uterus of a
woman who died of this affection; and Dr. Oldham
has shown me a number of valuable specimens in the
extensive Museum of Guy's Hospital, illustrative of
the varieties of this disease, which may exist in various
degrees of intensity, from a merely congested and
eroded state of the uterine mucous membrane to the
extent of great disorganization.

General constitutional remedies are, of course, in-
dicated, but are here never of any groat value ^vithout
local treatment. Nothing in uterine disease is more
difficult to remedy than eudo-metritis. The first gi-eat

L

412 UTEHINE SUROERT.

principle to guide us is that of insuring a very free
exit from the cavity of the uterus for the Becretiona
therein generated. The second is that of appropriate
local applications to this cavity for the purpose of
modifying or healing, as it were, its diseased surface.
Where the canal of the cervix is contracted, I have
freely divided it, as in cases of dysmenorrhcea depen-
dent upon mechanical obstruction ; and this with great
relief. Indeed, while menstruation continues, it is
almost impossible to treat successfully a case of endo-
metritis, without adopting this principle of practice in
some form. The uterine secretions must not remain
pent up in its cavity. With a patulous cervut, we may
use medicated injections, or apply nitrat-e of silver in
ointment, as recommended and successfully done by
Professor Fordyce Barker, of New York. There is a
mild form of endo-metritis that seemingly gives rise to
no secretions whatever, which, nevertheless, is attended
with great suffering, and often passes unnoticed, or
rather undetected for a long time. Dr. Eouth has
particularly noticed this form, and calls it fundal endo-
metritis. We can diagnose this with great accuracy.
Place the patient in the left lateral semi-prone position ;
introduce the lever speculum, hook a tenaculum slightly
in the anterior lij) of the os tincBe ; draw this gently
forwards, pulling the os open so as to be able to look
i-iglit into it ; then pass the sound, previously wanned,
gently along the cervix, using no force whatever, but
almost letting it go by its own gravity, as it were, to
the fundus. This is attended with no pain whatever till
the sensitive point be reached, when it praduces the most
intense agony, a pain that does not cease sometimes for

EN DO- METRITIS.

413

hours after the experiment. I have seen many cases of
this sort. And I now call to mind a most accom-
pliahed lady from one of the Southern States who had
been married six or seven years without issue ; and
who, soon after marriage, passed into a state of chronic
bad health, and became a confirmed invalid. For three
or four years she did not jjretend to walk ; and was
always carried from the house to the carriage whenever
she drove out. Indeed, her time was spent mostly in bed,
or on a lounge. Fortunately she was able to oat, and
so her strength and embonpoint were kept up in spite
of her sufferings. Her greatest agony was to be
found in a never-ceasing pain in the left hip about the
joint. She had a granidar erosion of the os and cervix,
attended with a leucorrhoeal discharge, which were
cured in the course of two months. But the pain in
the left hip, and her utter inabihty to walk continued
in spite of all we did. Thinking that the diseased
condition of the cervix was the principal source of all
her troubles, and that the pain in the hip furnished
merely an example of Sir Benjamin Brodio'a hysterical
joint, I had made no further uterine explorations,
and was quite surprised to find my patient no better in
any particular after the cervical erosion and its dis-
charge were cured. And now, for the first time, I
explored the cavity of the uterus. When the sound
passed the os internum my patient complained of in-
tense agony, but almost the whole of it was referred
to the left hip.

Dr. Alonzo Clark was called in consultation, and
a^eed to the line of treatment to be adopted, viz.,
that of applying remedies to the uterine cavity. The

414

UTEEINE SURGEBY.

canal of the cervix was dilated, and the diseSSS, i
its painful symptoms, was perfectly cured in a few
weeks, simply by injecting the cavity of the uterus
with a few drops of glycerine two or three times a
week. This was in 1858. In the course of a year
after this, our patient became a mother, and has had
other children since.

Mr. Holmes Coote and Dr. Greenhalgh are at this
moment att<?nding a case of endo-metritis with me,
where the pain is almost wholly in the left hip and left
inguinal region. By touching even the canal of the
cervix with the sound in the gentlest manner possible,
a most intense pain shoots at once to the left hip and
groin. Here there is not only pain but tumefaction of
the affected parts, as we often see in some forms of
hysterical hyperaesthesia.

A short time ago, I saw a patient with Dr. Thierry-
Meig, in Paris, who, besides other evidences of uterine
trouble, complained greatly of pain in the left ovarian,
left mammary, and epigastric regions. Her symptoms,
as a whole, all pointed to the uterus as their origin ;
but a super6cial examination failed to demonstrate their
relationship. The position of the organ was normal ;
there was apparently no hypertrophy of the fiindus ;
there was no leucorrhoea, and no engorgement of the
cervix ; but by placing the patient in the proper
position, and making the exploration of the cavity as
above directed, the gentle passage of the sound along
the canal of the cervix was attended by a sudden ex-
udation of blood in small quantity, and a severe pain,
which became more severe as the sound reached the
fundus uteri, from which point the pain radiated '-

ENDO-METRITIS. 415

the other foci of suflTering above indicated. The exuda-
tion of a small quantity of blood, by the passage of the
sound along the canal of the cervix, is a common sign
of subacute inflammation of the utero-cervical canal.

In this case a single sponge-tent, followed by the
injection of half a drachm of the oflBcinal Tr. of Iodine,
produced almost complete relief at once. A repetition
of the same, ten or twelve days afterwards, produced
a perfect cure. For the past two years this patient
had been imder thet reatment of several other physi-
cians, without the least benefit.

I think it highly probable that many unexplained
neuralgic pains may yet be found out to be symptomatic
of some slight endo-metritic affection ; of which the
case last mentioned may be taken as a type.

It is very probable that when we shall turn our
attention more to the investigation of the condition of
the cavity of the womb, we shall be able to detect, to
explain, and to remedy its abnormal states with as
much certainty as we now treat many affections of the
cervix and its canal.

In many cases in which the spermatozoa are found
to die quickly in the canal of the cervix, the real
source of the mischief may yet be found to exist in
the cavity of the uterus.

1/

'hr

•»■

IH^

)■

»;-.

INDEX.

AfiXORMAL elongation of the uterus

and anteversioD, 239.

cervical secretion, 402.

hyper-secretion from the canal of

the cervix, 403.

OS tincffi, 191, 198.

position of the uterus, 235.

semen, 368.

Abortion and retroversion, 286.

Meigs's ring, 287.

Absence of uterus, 349.

of the vagina, congenital, 849.

Absentia vaginsd, 349.
Accidental atresia vaginsEt, 345.
Accident in amputating the cervix by

the dcraseur, 207.
Acid, chromic, as an escharotic, 43, 45.

chromic, in granular erosion, 397.

secretions kill spermatozoa, 393.

vaginal secretions, bicarbonate of

soda for, 394.
Acquired sterility, 2, 185, 193.

— fibroid tumours in, 95.
Acrid leucorrhcBa, 391.
Action of sponge tents, 59.
Actual cautery, 397.
Advanced life, conception in, 30.
Aged women, difficulty of dilating

OS tineas in, 89.
Air-bag, india-rubber, 138.

pessary, Gariers, 270.

pessary in inversion, 130.

Albuminms leucorrhosay 395.

Alkaline injections for acid vaginal

secretions, 394.
Althaus (Dr.), Faradization, 41.
Alum suppositories, 401.

suppositories in vaginitis, 392.

American lithotomist, 90«
Amputation, contracted os tincse after,

226.
of the inverted uterus, 128, 138.

of the cervix uteri, -201, 209,

211, 212, 220, 301, 318.

of the cervix, conception after

it, 213.

of the cervix, ^craseur objected

to, 206.
of inverted uterus, hemorrhage

after, 131.

of inverted uterus, objected to,139.

Anaesthesia, conception under it, 348.

for copulation in vaginismus, 348.

in yaginismus, 330, 840.

Anatomy of the uterus, 181.

Animal sensuality not essential to pro.

creation, 369.
Anteflexion from a fibroid, 104.
Anterior wall of uterus, seat of polypui,

84.
of vagina removed in procidentia,

304.
Antero-lateral version, 236.
Anteversion, 238.
from abnormal elongation of the

2b

Uterus, 289.

418

UTERINE SURGERY.

AntevenioD, short utero-saoral liga-
ments, 240.
what oonstitntes it> 285.

— with a long narrow vagina^ 240.

■ with tumour in the Douglas

cul-de-sao, 100.
Appearance of semen, 867.
Arg. iod. in granular erosion, 896.
^— nit. producing hiemorrhage, 896.

nitr. ung. in endo-metritis, 412.

Argenti nit in granular erosion, 896.
Artificial enucleation of a fibroid, 117.
——fertilization producing conception,

877, 878, 879.
Astringent vaginal injections, 898.
Atlee, Dr., 109, 110.
^-— plan of enucleation. 111.
Atresia yaginse, 828, 845.
— - from sloughing, 847.

— operation for, 849.

remarkable case of, 848.

treatment of, 847.

varieties, 847.

Atropine suppositories, 401.
Attenuated cervix in procidentia, 800.
Author's amende honorable — Marshall

Hall's operation for procidentia, 320.

curette, 61.

double tenaculum, 225.

experiments in mechanical ferti-
lization, 376, 377, 378, 379, 380.

kneeling position for use of specu-

lum, 12.

— lateral semi-prone position for
use of speculum, 23.

— method of amputating the cervix

uteri, 211, 212.

— method of fixing the cervix in
procidentia operations, 816.

— method of incising os and cervix

uteri, 158, 169.

— method of introducing speculum,

23.

— method of operating for vaginis-
mus, 335, 336.

— method of reducing inversion,

137.

Author'a method of reducing retrover-
sion, 258.

method of using glycerine, 71.

method of uterine examination,

6,9.

operation tor anteversion, 258,254.

operation for procidentia, 808,

818 to 817.

— porte-chaine dcraseur, 79.

— porte-tampon, 298.

— speculum, 11 to 20.

— sponge probang, 70, 160.

— tenaculum, 24.

— uterine elevator, 264, 265.

— uterine depressor, 24.

— uterine guillotine, 224.

— uterine syringe, 878.

— utero-tome, 159, 171.
vaginal dilator, 837.

Aveling, polyptrite, 98.
Average time of trelitment for vagi-
nitis, 892.
Axson's (Dr.) case of procidentia^ 803.

B.

Baden-Baden, a case at, 35.

Barker, Prof. Fordyce, sloughing of

cervix uteri, 195.

treatment of procidentia, 319.

ointment of nitrate of silver, 412.

nit. arg. ung., 412.

Barnes, Dr., conoid cervix, 227.

— « instrument for dividing the os

and cervix uteri, 228.
Barry, Martin, — conception, 4.
Batchelder, Dr., compressed sponge,

47.
Belladonnain painful men8truation,145.
Bennet, Dr. Henry, case of procidentia,

818.

objection to hysterotomy, 173.

painful menstruation, 143.

procidentia, 225, 224.

sponge tents, 147.

treatise, 395.

potassa cum calce, 397.

INDEX.

419

Best time for aezual intercourae^ 886.
Bicarbonate of soda for acid vaginal

secretions, 897.
Bichloride of mercury in dysmenorrhoea,

145.
Bickersteth — enucleation, 117, 118.
Bi-lateral epididymitis, 867.

incision of the os uteri, 45, 174.

Bi-manual examination, 261.

palpation, 9, 102.

Bischoff— conception, 4,

Black's (Dr. John J.) method of treating

vaginitis, 892.
Blepharismus, 829.
Blood and pos, spermatozoa live in,

898.

Bougie, gum elastic, 111.

uterine cavity, 106.

Bougies of slippery elm, 404.
Brady, Dr. John A., inversion, 127.
Breaking the ^craseur, 78.
Brodie's (Sir Benjamin) hysterical joint,

418.
Bromide of potassium, 84, 109.
Brown, Mr. Baker, 109, 110.
contraction of the ob tincse,

229.

division of cervix, 174.

gouging process in fibroids, 114.

incision of os and cervix for fibroid,

121, 128.

operation for procidentia, 802.

perineal operation, 804.

perineal operation for procidentia,

818.
Byford, Prof., on endo-cervicitis, 404.

C.

Campbell, Dr., vaginismus, 870.
Cancer of rectum removed by Chassaig-

nac*s ^cniseur, 77.
of tongue removed by Chassaig-

nac*s ^mseur, 77.
Cancroid tumour of cervix, 206.
Canula, Gooch's, 86, 87.
Case of atresia vaginae, 848.

Case of conception after artificial ferti-
lization, 877.

of inversion of the uterus, 129.

of retroversion producing sterility,

280.

Cases of chronic inversion successfully
reduced, 186, 187, 188.

Causes of inversion, 125.

of painful menstruation, 141 —

143.

of sterility in man, 864.

Cauterization, prolonged, 408.
Cavity, peritoneal, drainage o( 209.

of uterus, secretions fix>m, 406.

Cellulitis, pelvic, 147, 148-152.
Cervical elongation in procidentia,
299.

leucorrhcoa, 895.

mucus, alkaline, 891.

mucus, after coition, 885.

mucus sometimes poisons sperma-
tozoa, 409.

secretion, poisonous to sperma*

tozoa, 402.

suppositories, 401.

2 E

Cervix uteri, action of in procidentia,
296.

amputation of, 205, 206, 209, 220.

— — amputation of in procidentia, 801.

attenuation of in procidentia, 800.

cancroid tumour of, 206.

cancroid, 204, 218, 227.

defective, 216.

elongation of, 204.

hypertrophy, 205.

indurated, 226.

normal, 182, 218.

sloughing of, 195.

— spermatozoa in, 885.

— — undeveloped, 216.

Chair for the consulting-room, 21 .

Change of life, false quickening at, 85.

Channing's (Dr.) amputation of the in-
verted uterus, 188.

Channiug, Prof., 109.

Chapman, Dr., on cold and heat, 41.

Charri^re, Mr., 224, 225.

2

^M 400 UTGBINE

^^^^^^M

^^^^^BnOhMMigMli'* fcrmwar,

■ Jnst before menBtruation, S95. ^^^^|

^^^^^FfAuMlgDM. remoiUof caDoerofrec-

not Iiindoied by poi, 393. ^^^H

^^^^^^ tniD with Ills fortueur, 77.

only during menettual life, 29. ^^^H

~ period for, ^^H

^^M Cblaroforn] puiuoaing, 115.

prevented b; Bbroids, 94. ^^H

^H CbroiDic acid u an eichuvtic, <3-4S,

prevented bj leuoorrhcea, 3M, ^^^1

^H

seat ^^^1

^H Chronic epididymitia, 3M. 367.

^H iDTenion of tba Dterug, 12S.

without roenxtruation, SO. ^^^|

^H melritiB, Torbida peisarieii, 2B1.

without penetration, 34(1, 870. ^^^^^

^V Ohurohiil'B (Prof. Fleetwood) works, 41.

with nnraptured hymeu, 370. ■

Coogenilol absence of Uie otBrus, 84». a

^m tn«tise, 895.

absence of the vagiua, S49. J^^^J

atresia vagina, 345. ^^H

^H Clark, Prof. Alonin— BDdo-Qietritia,413.

— iuveraion of the nUnn, 130. ^^^H

^H ngimainnB bymen, 841.

Congren, seinal, S69. ^^^^|

^H Cock's (Mr.) ciu« oF prwireUiaK, 304.

— -einal, best ti>ne for, 386. ^^H

^H CoghUd'i (Dr.) lendeu tube, 405.

Conoid cervix, SIS. ^^^H

^H CoitJoD >Dd peffinrieo, 2S4.

in natunl oteriUty, £04. ^^H

^H oerrioi] muoud after, 335.

^H during the usa o{ a peaary, 283.

Constrictor vngins, superior, 3T3, 3T4. '

^^H during treatment uf oerrical

^H di*eaM. SSe.

Cntraotioo of o« after incUioo, 162.

^H

Coote, Mr. HolmcB-caw «f endo.

^H . the act uf. SG9.

inetritiB, 414. |

^H -^ without spermaloEoa, 3B5,

^H sparmntozDa in thfl VErvii ateri

Costs — conception, 4. ^^^^H

^M aaer, 8S5.

Cotton, glyccrole, 71, 102. ^^^|

^M Cold vaginal injectioDB not to ba uaeJ.

pessary in retrovermon, !93, ^^^H

^H

Cotton-wool as a pessary, 292, SI». ^^H

^H Coldnea* of wives, SSB.

Court;'B (Dr.) prolopged cauteriMti«^^H

^V Colie, ntarine, 124.

^^^1

^H Collapn foUowing uterine injections.

cervical leuoorrbcea, 401. . ^^^H

^M

Cowper's glandfl, 361. _^^^H

^H Complete prooidentia, 205.

Crucial inciaioo of hymen oI^eOtafl^^^^^|

^H CompresEcd aponge, 47.

^^H

CuI'de-sM, DouglaB, drainage-tntf^^H

^^^H

^^1 after eauclcation of fibroids, 110.

Curette of Author, 0] . ^^^1

of Idcamier, S5. 00. ^^^H

^B^ 139.

Curlbg, Mr., on sterility in nutn, S^^H

^^^H

^H ragential conilitioDs of, S.

INDEX.

421

Caired ▼agioal tube should never be

used, 899.
Cysto-cele, in relation to procidentia,

297, 298, 804.

D.

Dangxb of opening peritoneal cavity
in amputating the cervix, 212.

of vaginal syringe in cases of

retroversion, 400.

Datngers of ^craseur in amputation of
the cervix, 206.

of sponge tents, 57.

Davis, Dr. Hall, on endo-metritis, 411.

Dead spermatozoa, 885.

Death from haemorrhage after incision
of the OS and cervix, 151.

from incision of occluded hymen,

324.

from operation on fibroid tumours,

113, 114.

from spontaneous evacuation of

retained menses, 326.

Debauch weakens semen, 883.

D^bout— vaginismus, 839.

Defective cervix uteri, 216.

Deleau — perchloi-ide of iron, 68.

Deleau*8 sol. perchl. of iron, 160.

Deligation of polypi dangerous, 92.

Delivery, fibroid tumours complicat-
ing, 116.

Demarquay — glycerine in surgery, 71.

Demarquay*s treatment of vaginitis,
892.

Depressor, uterine, 24.

Dermoid appttarance of vagina in proci-
dentia, 296.

Deweos, Dr.,— Tr. guaiacum, 144.

uterine elevator, 268.

Professor, 848.

Diagnosis and treatment of intra-
uterine polypus, 85.

of fibroids, 114.

of fibroid tumours, 98.

of fungoid granuUtions, 47, 55.

«»f fundal oudu-motritis, 412.

Diagnosis of uterine displacements, 236.

of intra- uterine fibroids — sponge

tents, 107.

of polypi, 72.

Difficulty of dilating os tineas in aged

women, 89.
Dilatation of os internum for uterine

injections, 400.
Dilator for vaginismus, 836.

uterine, Priestley's, 163.

Dilute hydrochloric acid in leucorrhoaa,

401.
Dimond, Dr., 853.
Disgusting discharge from sponge tents

remedied by glycerine, 65.
Dislocated uterus, 262.
Displacements of the uterus, 233, 269.
Division of the cervix, 174.

of cervix in endo-metritis, 412.

Donn^ — spermatozoa in pus and blood,

893.
Double epididymitis, 866.

tenaculum forceps, 225.

Douglas cul-de-sac, tumour in, 100.
Drainage of peritoneal cavity through

the Douglas cul-de-sac, 209.
Drayton's (Elizabeth) early pregnancy,

29.
Dressings of glycerine, 269.
Duane*s (Dr.) cases, 189, 190, 191,

192, 308.

Duchenne (de Boulogne), Faradization,

41.
Duncan, Dr. J. Matthews, on uterine

abscess, 409.
Dysmenorrhcea, a symptom of disease,

143.

from flexure of the cervix, 170.

from polypus or from flexure, 165.

its pathology, 142.

neuralgic pains in, 165.

treatment, 144.

£.

Eablt montlia of pregnancy, iuversioi)
in, 127.

422

UTERINE SURGBBT.

Early pregnancy, 29.

EcraBour, acddent in amputation, 207-

Chasougnao's, 76, 87.

for amputation of inverted utems,

181.

for polypi, 68.

for removing cancer of rectum or

tongue, 77.

— its dangers in amputation of the
cervix, 206.

— manner of using it, 78.
porte-chaine of Author, 79.

Ecraseur-breaking, Dr. Hewitt and
Dr. McGlintock on, 78.

Electricity, an emmenagogue, 41.

Elevator, uterine, 265, 266.

Elixir of opium, 164.

Elliot, Prof., 108.

Elli8*8 (Dr.) dilator, 411.

Elm bougies, 404.

Elongation of the cervix, 204.

of cervix in procidentia, 299.

Emmenagogue — electricity, 41.

Emmet, Dr., 107, 109, 129, 182, 349.

bi-lateral incision, 174.

hysterotomy, 171.

measurements of vagina, 805.

method of fixing the cervix in

procidentia operations, 316.

operations, 199. 208, 214, 215, 818.

procidentia, 304, 309.

remarkable case, 80, 81.

removal of polypi, 92.

sponge tents, 62, 63, 64.

triangular denudation for proci-
dentia, 811.

uterine sound, 163, 169.

vaginismus, 331.

Endo- cervicitis, 404.
Endometritis, 186, 223, 411.

diflBcult to remedy, 411.

division of cervix in, 412.

prevents the use of the intra-
uterine stem, 405.
• producing neuralgia, 415.

treated by uteriue injections, 414.

without abnormal secretions, 412.

Engorgement, fibrous, of the cervix,

monorrhagia from, 48.
Enjoyment, sensual, not essential to

procreation, 869, 870.
Enormous intra-uterine fibroid, 105.

- procidentia from fibroid tumours,
801.

Enucleation of fibroids, 109, 111.

of fibroid, conception after, 116.

Epididymitis after gonorrhoea, 866.

does not weaken sexual power,

867.
Epithelial scales in cervical mucus, 408.
Erethism of sexual congress, 869.
Erethismal climax of coition, 874.
Ergot, 86.

in operation for retention of

menses, 825.

Erosion, granular,menorrhagiafrom,43.

granular, arg. nit. in, 896.

Erroneous opinions about sexual inter-
course, 869.

Escharotic, chromic add as, 48,45, 897.

Essential conditions for conception, 5.

Ethereal copulation, 848.

Etherization in vaginismus, 340.

Evil effects of sponge tents, 57.

Examination, bi-manual, 261.

by rectum, 100.

of semen, 406.

with speculum, 23.

of secretions after coition, 406.

Examples of best time for sexual con-
gress, 386.

Experimental operations — vaginismus,
332.

Experiments on seminal injections into
the uterus, 376.

Exploring needle for occluded hymen,
324.

for puncturing occlusion of vagina,

325.

Extract of belladonna in painful men-
struation, 145.

Exuberant granulations, 46.

Exudation of blood by passing the
sound, a sign of endo-mctritis, 414.

INDEX.

423

F.

Fall producing miscarriage, 288.

False qaickeuing at change of life, 85.

Faradization, 41.

Farre, Dr. Arthur, case of death from
spontaneous evacuation of retained
menses, 826.

Fauvel's (Dr.), case of sterility, 408.

Fecundation, spermatozoa essential to,
865.

Fenestrated forceps, 74.

Fenner's (Dr. E. D.) treatment of pain-
ful menstruation, 145.

Fetor of sponge- tent discharge re-
medied by glycerine, 65.

Fibro-oellular polypus, 74.
Fibro-cystic tumour, 108.
Fibroid, enucleation of. 111.

intra-uterine, large, 106, 110.

intra-uterine monorrhagia, 105.

producing anteflexion, 104.

tumours, 93.

tumours, complicating delivery,

116.

tumour, death from, 113, 114.

tumours, diagnosis, 98.

tumoura, iutramural, 94.

tumours, intra-uterine, 94,

tumours in acquired sterility, 95.

tumour, in retroversion, 288.

tumours, clasitification of, 95.

— tumour, no impediment to child-
bearing, 290.

— tumour, pedunculated, 94.

— tumours, prevent conception, 94.

— tumours producing procidentia.

295.

tumour producing retroversion.

283.

tumours, sessile, 94.
tumours, treatment, 109.
tumours in virgins, 96.

Fibroids, diagnosis, 114.

enucleation, 109.

gouging process, 114.

intra-uterine, diagnosis, 107.

Fibrous engorgement of the cervix,
monorrhagia from, 43.

Fibrous polypus, destroyed by a sponge
tent, Qd.

Fistula, vesico-vaginal, a case of,
853.

Flexed cervix, cause of dysmenor-
rhoea, 170.

Flexure, cause of dysmenorrbcea, 165.

of the cervix and painful men-
struation, 142.

Follin, Dr., 865.

Forceps, double tenaculum, 225.

Formula for suppositories for vaginitis,
893.

Francis, Dr. John W., 181, 214, 849.

vaginismus, 881.

Fructification, artificial, producing con-
ception, 377.

Fundal endo-metritis, its diagnosis,
412.

Fundus uteri, polypi attached to, 86.

Fungoid granulations, monorrhagia
from, 46.

their diagnosis, 47, 55.

G.

Galvanio pessary, Dr. Simpson's, 40.
Gardner's (Dr.) case of amputation in
procidentia, 302.

monograph, 4.

uterine elevator, 268.

sponge tents, 147.

Gariel's pessary, 270.
German-silver uterine sound, 103.
Gibb, Dr., use of iodide of silver in

throat affections, 397.
Globe pessary, its failure in procidentia,

303.
Glycerine, 161, 162.

a remedy for the fetor of tha

sponge-tent discharge, 65.

and tannin in vaginitis, 892.

dressings, 269.

in surgery, Demarquay, 71.

in endo-metritis, 414.

424

UTEHTNE SUEOEBT.

GIjoeriDe. iU effects aa a dresring, 71.

oemosiB, 72.

Price's, 70, 71.

tampon, 70,

Glycerioed cotton, 161.

Glycerole cotton, 71.

Godard, Ernettt, 365.

Gonorrhcea, a serious disease, 865, 366.

— — produced by acrid leucorrhosa,

392.
Gooch's canula, 86, 87.
Gosselin, Dr., 365, 366, 367.
Goubaux, Dr., 865.
Gouging process in fibroids — Mr. Baker

Brown's, 114.
Granular erosion, iodide of silver in, 896.

chromic acid in, 397.

menorrbagiafrom, 43.

often resists local treatment, 397.

nitrate of silver in, 896.

Granulations, exuberant, 46.

fungoid, menorrhagia from, 46.

uterine, 124.

Gream (Dr.), opposed to hysterotomy,

173.
Green, Dr., 214.
Greeiihalgh (Dr.)— polypus, 73.

case of endometritis, 414.

hysterotome, 156, 157.

■ intra-utcrine Btem, 163, 404.

raetro'ome, 176, 177.

sea-tingle tents, 65, 66.

uterine injections, 123.

Grimsdale'fl artificial enucleation of a

fibroid, 117.
Griscom's ^Dr.) case of abortion, 288,

290.
Guillotine, uterine, Author's, 224.
Gum-elastic bougie, 111.
to measure the uterine cavity, 106.

H.

HiKMORRHAOE after incision of 08 and !

cervix, 149.
j.r.Mlucod by nitrate of silver, 390. I

Hall's (Marshall) idea of narrowing the
vagina for procidentia, 303, 320.

Harley, Prof. — seminal injection, 376.

Harris's (Dr.) case of vaginismus, 834.

Hasty ejaculation, 356, 869.

Head, sloughing from impacted, 194.

Heming (Mr.) on Marshall Hall's opera-
tion for procidentia, 320.

Hewitt, Dr. Graily, book, 41.

on operation for retention of the

menses, 325.

opposed to deligation of polypi, 92.

polypus, 78.

treatise, 395.

Hicks's (Dr. Braxton) wire #craseur,

77, 79.
Higgins— inversion, 126.
History of a case of vaginismus, 329,

830.
Hodge's (Prof.) case of retroversion, 273.

lever pessary, 270.

pessary, 278, 318.

pessary during coition, 274, 281.

pessary in anteversion, 274.

pessary, of what made, 275.

Holmes, Mr. James, inventor of the

invalid chair, 21.
How to introduce sponge tents, 49.
■ to make sponge tents, 48.

to reduce a procidentia, 297.

to remove semen from the vagina

for microscopic examination, 406.
to remove semen from the cerv'x

uteri for microscopic examination,
407.

Hiijpjier, amputation of the cervix for
procidentia, 318.

on procidentia, 301.

Hugier's hypertrophic elongation of the
cervix, 209.

Hydrarg. bi-chloride in painful men-
struation, 145.

Hymen, imperforate, 323.

Hyperresthesia of hymen, 326.

Hypertrophy of the cervix uteri, 205.

of the uterus, sponge tents in, 64.

of uterus in procidentia, 290.

INDEX.

425

Hyper-seoretion from tbe canal of the
cervix, 403.

Hysterical bTpersesthesia, 414.

joint, often symptomatic of endo-
metritis, 413.

Hysterotoraes, 156.

Hysterotomy, 171.

its rationale, 176.

objections to, by Dr. Henry

Bennet, 173.

objections to, by Dr. Gream, 173.

opposed by N^laton, 153.

I.

Illustrations of beat time for sexual

intercourse, 386.
Impacted head, sloughing from, 194.
Impenetrable hymen, 323.
Imperforate hymen, 323.
Imperfect involution, 40.
Impotence, 365.

Incision, bilateral, of the os uteri, 45.
of occluded hymen tlie cause of

death, 324.

of the OS and cervix, 147.

of OS and cervix. Author's method.

168.

— of OS and cervix, hsBmorrhage
after, 149.

— of OS and cervix, its risks, 149,
161, 152, 163.

— of OS, contraction after, 162.

— of OS and cervix uteri, deatb
from haemorrhage after, 151.

— of OS an<l cervix for fibroid
tumour, 121, 128.

— of OS and cervix, rationale, 176.

Incomplete procidentia, 295.
India-rubber air-bag, 138.

air-pessary, 130.

Indurated cervix, 188, 193, 226.

produced by cold vaginal washes,

8P8.
Induration of epididymis, 366.
Inflammation of the teMtcs, 365, 367.
of the utero-cervical canal, 115.

Influence of uteiine displacement upon

the sterile condition, 237.
Injecting semen into the uterus, 376.
Injection of uterine cavity for abscess,

411.
Injections of iodine for nienorrhagia,

121.
of perchloride of iron for me-

norrhagia, 122.

vaginal, 397.

Inspissated mucus, an obstacle to con-
ception, 402.
Instrument for artificial fertilization,

878.
(Dr. Barnes's) for dividing the oa

and cervix uteri, 228.
Intercourse, sexual, 369.

best time for, 386.

under etherization, 342.

Intolerance of pessaries, 291.
Intra cervical supp>ositorie8, 403.
Intra-uterine fibroids, diagnosis, 107.

large, 110.

injections of iodine. 121.

injections of iron, 122.

monorrhagia, 106.

polypi, attached to anterior wall

of uterus, 84.

polypi, case illustrating diagno-

sis and treatment, 86.
stem, 163, 270, 404.

Intra- vaginal cervix in procidentia,

298.
Invalid-chair invented by Mr. Holmes,

21.
Invention of Author's speculum, 1 1 —

20.
Inversion, cause of, 125.

congenital, 126.

^craseur— haemorrhage, 131.

efforts at replacement, 130, 131.

in early months of pregnancy, 127.

of the uterus, 124.

of twelve months, reduced, 186.

partial, 127.

rationale of its reduction, 137.

- — removed by t^cia^eur, 128.

426

UTEEINB SUEGERY.

lo version, replacement, 127.

spontaneouB, 184.

Involution, imperfect, 40.

Iodide of silver in granular erosion,
396.

Iodine injections for menorrhagia, 121.

in induration of the cervix, 227.

Iron, perch loride, 68.

perchloride — Deleau, 160.

perchloride, injections for me-
norrhagia, 122.

persulphate of, 68, 129.

persulphate — Squibb, 160.

suppositories in vaginitis, 892.

Irritable condition of hymen, 824.

J.

JoBERT (de Lamballe)on actual cautery,

397.
Johnson, Dr., case, 216.

polypus, 88.

case of procidentia, 810, 819.

K.

Kennedy, Dr., obstetric auscultation^

33.
Kissani, Dr., vaginismus, 831.
Kiwisch on medicated tampons, 402.
Kolliker — movements of upermatozoa,

3^5.

L.

Laminaria DiGiTATA tents, 65.

I^^rge intra-uterine fibroid, 110.

Larriboihiere Hospital, 77.

Laryngismus, 329.

Lateral semi-prone position for specu-
lum, 23.

Leaden tube, Dr. Cogblan'a, 405.

Lee, Prof. Charles A., inversion, 124,
126.

Lee, Dr. Robert, inversion of the
uterus, 125.

l>o]ypi, 92.

Left lateral semi -prone position for
removal of semen, 407.

for the speculum, 23.

JiCgrand, M., 371.

Leucorrhcea, acrid, 891.

a hyper secretion, 895.

albuminous, 895.

cervical, 895.

chemically prevents conception.

896.

mechanically prevents conception.

896.

— producing symptoms of gonor-
rhoea, 892.

— purulent, 891.
muco-pus, 895.

Lever pessary, Hodge's, 270.

Life of spermatozoa in vaginal mucus,
384.

Ligation of polypi dangerous, 76, 92.

Liq. ferri persulphatis, 129.

Liquor seminis, 361.

Lisfrano — amputation of the cervix, 209.

Lithotomist, American, 90.

Litmus-paper, test for vaginal secre-
tions, 894.

Livingston, Dr., 849.

Local treatment of endo-inetritis, 412.

Locock, Sir Charles, onleucorrhaca,391.

Locomotion of spermatozoa^ 871.

M.

McClintock, Dr., on amputation of
the inverted uterus, 138.

on inversion, 125.

opposed to deligation of polypi,92.

on polypus, 83.

polypus forceps, 75.

treatise, 395.

Mcintosh — contracted os, 4.

uterine bougie, 145.

McMunn's elixir of opium, 164.

Maisonneuve's wire ecraseur, 77, 79 .

Manner of using ecraseur, 78.

Man, sterility in, 364.

Marshall Hall— procidentia, 312, 320.

Maxwell's (Dr.) case of inversion, 129.

Mayer, Mr., instrumeut-makcr, 224,
225, 405.

Mechanical causes of painful menstrua-
tion, 111-143.

INDEX.

427

Medicated rappositories for cervical

caDal, 401.
suppositories in vaginitis, 392.

injections in endo-metritis, 412.

Meigs's ring in abortion, 287.
Meigs's ring pessary, 270, 276, 818.

objections to its prolonged use,

277, 278.

Menorrhagia from fibroid tumours, 93.

from fibrous engorgement of the

cervix, 43.

from fungoid granulations, 46.

from granular erosion, 43.

from inversion, 124.

from organic causes, 43.

from polypus, 67.

iodine injections in, 121.

intra-uterine fibroid, 105.

quantity, 42.

treatment of, 42.

Menses, retention of, 346.
Menstrual fluid, 89.

life, time for conception, 29.

Menstruation, normal, 39.

painful, 139.

profuse, 41.

scanty, 89.

sign of ovulation, 40.

Metallic sutures in procidentia, 303.
Metcalfe, Dr., amputation of the cervix,

nohindrauce to conception, 214, 215.

on dysmenorrbopA, 145.

polypus, 87, 92.

Method of amputating the cervix uteri,

211, 212.
of incising the 08 and cervix uteri,

150.

of introducing the speculum, 23.

of operating for procidentia, 313-

317.

of operating for vaginismus, 835.

of uterine examination, 6.

of uterine exploration in endo-
metritis, 412.

Methods of treating vaginitis, 392.

Metro-peritonitis from a sponge tent,
58.

Metro-peritonitis from uterine bougie,

146.
Metrotome cach^, 174.
Microscopic appearance of semen, 361,

868.
Migration of spermatozoa, 871.
Miscarriage and retroversion, 285, 286.

from a fall, 288.

Mistakes from carelessness, 33.
Modification of Chassaignao's ^raseur,

77.

Modus operandi of uterine sound as a
redresser, 263.

Morpain, Dr., polypus, 82, 83, 84.

Morphine suppositories, 401 .

Mosaic law in reference to menstrua-
tion, 880.

Mott, Prof, v., 131, 849.

on ^craseur, 207.

operations, 208, 214.

Movements of spermatozoa, 861, 362,

863.
Muco-puB an attendant of polypus,

409.

fatal to spermatozoa, 396.

Muco-pyogenic lining of the cervix,

403.
Mucous polypus destroyed by sponge

tents, 61.
Mucus, vaginal, life of spermatozoa in,

384.
Mumps, cause of epididymitis 867.
Mushroom polypus, 73.

N.

Nabothban polypi, 74.
Narrowing of the vagina fur proci-
dentia, 302, 318.
Natural sterility, 2.

conoid cervix in, 204.

fibroid tumours in, 95.

Nature of semen, 361.
Nt^laton — case, 216.

opiMMed to hysterotomy, 153.

Neuralgic pains indy»menorrhcBa,167.
produced by endo-metritis, 415.

428

UTERINE SUEGERY.

NeuromatouB hymen, 841.

Nitrate of silver in cervical leacorrboea,
401.

in granular eroeion, 896.

producing bsemorrhage, 896.

in uterine abscess, 410.

Noeggeratb, Dr., 135.

on an inversion of thirteen years,

128.

Non-descent of testes, 364.

Non-retention of semen by the vagina,
250, 351.

of semen by the vagina in retro-
version, 856, 857.

Normal cervix, 182, 218.

menstruation, 89.

08 tincsB, 182.

position of the nterus, 234.

semen. 868.

Nott, Professor J. C, — polypus, 86,

O.

Objections to amputation of Ibe in-
verted uterus, 139.

to the dcraseur for amputating

the cervix, 206.

Obstetric auHCulation, Dr. Kennedy on,
33.

Obstetrical Society, paper on proci-
dentia before it, 319.

paper on vaginiHmus before it, 329.

Occluded vagina, 346.

Occlu^jion of hymen producing reten-
tion of the menses, 324.

of the 08 tincse, 185, 187, 188.

of the vagina, 346.

Odour of semen, 367.

Office of tlie testes, 361.

Ointment of nitrate of silver in endo-
metritis, 412.

Oldham, Dr., on inversion, 126.

endometritis, 411.

Oldham's (Dr.) pathological specimens,
411.

Olliffe, Sir JoReph, 370.

OUiffe, Sir Joseph, hsemorrhage after
incision of cervix, 155.

polypus, 88.

procidentia operation, 810.

vaginismus, 840.

OlliflPe's (Sir Joseph) cases, 154, 168,
186, 809, 813, 317.

case of cervical obstruction, 402*

snggestions for procidentia opera-
tions, 816.

Opeiation for atresia vaginse, 349.

for procidentia, Author's method,

813-817.

for retention of the menses, 324,

825.

for vaginismus, 835.

unsuccessful, for polypus, 87.

of incising OS and cervix. Author's

method, 158, 159.

Operations in Paris, 154.

Opinions about sexual intercourse,
erroneous, 869.

Orchitis, 365.

Organic causes, menstruation from, 43.

Os and cervix, incision for fibroid tu-
mours, 121, 123.

and cervix uteri, Author's method

of incising, 158, 159.

and cervix uteri, incision of, its

risks, 147, 149, 151, 152, 153.
Os, contracted, 141, 155.
Odmosis — glycerine, 72.

by vaginal medication, 398.

Os tincae, abnormal, 191, 198.

contracted after amputation, 226.

in aged women, difficulty of

dilating, 89.

normal, 182.

occlusion, 185, 187, 188.

Os uteri, bilateral incision, 45.
Ovarian tumour, pregnancy mistaken

for, 32.
Ovary, prolapsed, 259.
Ovulation, a sign of menstruation, 40.

Painful menstruation, 139.

INDEX.

429

Paiuful menstraation and flexure of
the cervical canal, 142.

menstruation and sterility, 140.

menstruation due to mechanical

causes, 141, 143.

Painful effects sometimes produced by
vaginal injections, 399.

Pain in endo-metritis, 412.

Pains, neuralgic, in dysmenorrhoea, 165.

Palatine fiasure-casts, Pr^terre's, 272.

Palpation, bi-manual, 9, 102.

Paper on vaginismus before Obstet-
rical Society, ^29.

Parotitis, translated, 367.

Partial inversion of the uterus, 127.

Pathology of dysmenorrhcea, 142.

P^n, M., Prosecteur des Hdpitaux,
Paris, 234.

Peaslee, Dr., drainage- tubes, 209.

Pelvic cellulitis, 147, 148, 162.

Penetration, conception without it,
340.

Perchloride of iron, 68.

injection for menorrhagia, 122.

Percy, Dr. S. R., spermatozoa, 384.

Perineal operation for procidentia,
302, 317.

Period for conception, 380 386..

Peritoneal cavity, danger of opening
it in amputation of the cervix, 212.

drainage through Douglas cul-de-
sac, 209.

Peri-uterine inflammation opposed to
the use of pessaries, 291.

Persulphate of iron, 68, 129.

solution in uterine alMcess, 411.

Per-sulph. of iron in vaginitis, 392.

suppositories, 402.

Pessaries, 270.

importance of fitting, 279.

in relation to coition, 284.

intolerance of, 291.

necessary evils, 271.

of block -tin and gutta-percha,

279.

of cotton-wool, 292.

Pessary, galvanic, 40.

Pessary, Dr. Meigs's, 276.

Dr. Hodge's, 274.

stem, 404.

Phosphate of soda, influence of on

spermatozoa, 395.
Photographic nitrate bath, 396.
Physic, Dr., 348.
Pisciculture, 383.
Pitcher's (Prof.) case of vaginismus,

332.
Plan of enucleation, 111.
Poisoning by chloroform, 115.
Poland, Mr., case of procreation, 364.
Polypi attached to fundus uteri, 86.

destroyed by sponge tents, 62, 63.

intra-uterine, attached to anterior

wall of uterus, 84.

Nabothean, 74.

position for operation, 69.

varieties, 67.

Polyptrite, Aveling's, 93.

Polypus, attached to posterior wall, 88.

cause of dysmenorrhoea, 165.

diagnosis, 72.

fibro-cellular, 74.

fibrous, destroyed by a sponge

tent, 63.

forceps, 75.

ligation, dangerous, 76.

menorrhagia from, 67.

mucous, destroyed by sponge

tents, 61.

muco-pus from, 409.

mushroom, 73.

removed by dcraseur, 68.

removed by scissors, 69.

removal by torsion, 75.

unsuccessful operation, 87.

Pope, Prof., procidentia operation,

310.
Porte-chaine for ^raseur, Author's, 79.
Porte-tampon, 293.

how used, 292.

in procidentia, 319.

Position for removing (>olypi, 69,

for speculum examination, 23.

of uterui, noimal, 234.

430

UTEEINB SUBGEEY.

Posterior wall of uienu, polypas at-
tached to, 88.

Potassa cum oalce, 185, 188, 189, 205,
227.

in cervical disease, 897.

Potassiam, bromide of, 84, 109.

Potential cautery, 897.

Poucbet — conception, 4.

Pratt, Dr., 107, 208, 210, 215.

Pravaz — perchloride of iron, 68.

Pravaz's syringe, 878.

Pregnancy, early, 29.

inyeraion in the early months of,

127.

mistaken for a tomonr, 81, 82.

Preparations' of iron, 68.
Presenoe of spermatozoa in the aterus,
872.

Pressure to modify the cervical secre-
tions, 403.
Pr^terre, M., palatine fissure-casts,272.

polypus, 90.

Price's glycerine, 70, 71.
Priestley, Prof., galvanic pessary, 41.

uterine dilator, 163, 411.

dilator for washing out a uterine

abscess, 411.

Probangs, sponge, 70, 160.

for retroversion, 268.

Procidentia, a hernia, 299.

amputation of the cervix in, 818.

complicated by recto-cele, 817.

complicated with hernia, 803.

definition, 236.

Dr. Bonnet's case, 224, 225.

Dr. Duane's case, 308.

enormous, 805.

excision of anterior wall of vagina,

305.

from fibroids, 295.

from fibroid tumours, 800.

how to reduce it, 297.

idea of removing the anterior

wall of vagina in, 304.

impossible with ante version, 295.

Mr. Baker Brown's operation for,

Procidentia operation by V-shaped

scarfiication, 309.
operation of excising anterior wall

of vagina, 306.

order of descent in, 297.

perineal operation for, 317.

progress of the operation for, 312.

rationale of its descent, 304.

^the method of operating for, 813-

318.

317.

treated with tannin tampons, 319.

trowel-shaped scarification, 310.

uteri, 295.

with elongation of the cervix, 299.

with uterine hypertrophy, 299.

Procreation without spermatozoa im-

posfflble, 364.

Profuse menstruation, 41.

Prolapsed ovary, 259, 291.

Prolapsus, a term to be ignored, 236.

Prolonged cauterization, 403.

retention of sponge tent, 56.

Properties of semen, 361.

Proper time for sexual intercourse, 383.

Prostate gland, 361 .

Proud flesh, 46.

Pruritus, 198, 200.

Purulent leacorrhcea, 891, 392.

Pus and blood, spermatozoa live in,

393.
Pus, no hindrance to conception, 393.

Pyaemia, 115.

Pyogenic membrane in uterine abscess,

410.

Q.

Quantity of semen in artificial ferti-
lization, 376.

in man, 383.

Quickening, false, at change of life, 85.

R.

Rationale of hysterotomy, 176.

of non-retention of semen by the

vagina, 356.
of replacing an inverted uteru8,137.

Rdcamier's curette, 55, 60.
uterine granulations, 124.

INDEX.

431

'Recio-cele complicaiiog procidentia,
817.

Rectum, cancer of, removed by the
dcraseur, 77.

examination by, 100.

Kedresser, sound as, 262.

Reduction of an inverted uterus, its
rationale, 137.

of inversion, conception after, 189.

Remarkable case of atresia vaginse, 348.

Removal of cervical mucus for micro-
scopical examination, 378.

of polypi by torsion, 75.

of sponge tents, 51, 52.

of vaginal secretions for micro-
scopic examination, 406.

Replaced retroverted uterus, 258, 259,
268.

Replacement of inversion, efforts at,
127, 130, 181.

Retained testes, 364.

Retention of menses, 846. *

by occlusion of hymen, 824.

Retroverted uterus, 257.

repUced, 258, 269, 268.

Retroversion and miscarriage, 285,286.

and sponge probangs, 258.

case treated, 280.

conjoined with anteflexion, 291.

cured by child-bearing, 290.

danger of vaginal syringe in, 400.

due to a fibroid, 288.

in relation to non-retention of

semen, 356, 357.

produced by a fibroid tumour, 283.

producing sterility, 280.

what constitutes it, 235.

with conoid cerfix, 222.

Ricord — case, 216.

forceps, 305.

Rigby — inversion, 126.

Ring pessary of Meigs, 270, 276.

Risks of incising the os and cervix

uteri, 149, 151, 152, 153.
Ritchie, Dr., seat of conception, 881.
Rives, Dr., operation, 208.
Roberta, Dr., oompreeied sponge, 47.

Rossi — seminal injection, 375.
Rottenstein, Dr., vulcanite vaginal

dilator, 837.
Roubaud on frigidity in woman, 869.
Routh, Dr., on endo-metritis, 411.

on fundal endo-metritis, 412.

uterine injections, monorrhagia,

122.

vaginoscope, 33.

Rudimentary testes, 364.

S.

Savage's (Dr.) diagram, 175.

operation for procidentia, 302,

318.

— dilatation of cervix for uterine
injection, 400.

— uterine injections of iodine in

monorrhagia^ 121, 122, 123.

Sayre's (Dr. Lewis A.) inversion, 125.

stem pessary, 270.

Scanzoni — excision of granulations, 397 .

on endo-metritis, 411.

Scanty menstruation, 39.

Scudder, Dr. S. D., 200.

case of retroversion and sterility,

287.

Sea-tangle tents, 65.

Seat of conception, 881.

Secretions, cervical, 391.

from the uterine cavity, 406.

— vaginal, 391.

Self-injecting syringe for vaginal injec-
tions, 400.

Semen, abnormal, 368.

appearance o^ 367.

in epididymitis, 366.

its examination, 406.

nature and properties of, 361.

non-retention of, 351.

normal, 868.

odour of, 867.

quantity in man, 883.

under microscope, 361.

weakened by excess, 383.

with mucosity, 867, 368.

without spermatozoa, 864.

432

UTEEINE SUEGERY.

Seminal flaid, 861.

iDJections into the utenu, 875.

Sami-prone position for the 8pecalam,28

Sensnality, animal, not easential to
procreation, 869.

Sexoal oongren, effecta of on the
ntems, 857.

not interdicted daring treatment

of cervical disease, 896.

best time for, 886.

Sexual intercoarse, 869.

doriog the ose of pessaries, 284.

erroneous opinions on, 869.

proper time for, 888.

ander etherisation, 842.

Short utero-sacral ligaments in ante-
version, 240.

Short vagina, 851.

Silver uterine sound, 108.

solutions in uterine disease, 896.

Simpson, Dr., 102, 109.

compressed sponge^ 47.

contracted os, 4.

hemorrhage after incision of the

OS and cervix, 149.

— hyBterotome, 166.

— metliod of incising

the OS and

cervix, 150.

retroversion, 263.

uterine probe, 98.

vaginal suppoBitories, 401.

Sketch of author's operation for pro*
cidentia, 303.

Slippery elm bougies, 404.

Sloan, Dr., sea-tangle tents, 65.

Sloughing from impacted head, 194.

of cervix uteri, 195.

Smith, Dr. Tyler— conception after in-
version, 139.

— air-bag, 130.

— India-rubber air-bag, 138.

— inversion of twelve years, 128.

— inversion of the uterus, 125, 135,
130.

on leucorrhoea, 395.

Sodn, ])hosphate of, influence on sperma-
tozoa, 895.

Solution of the perchloride of iron, 160.

of the persulphate of iron, 160.

Solutions of silver in uterine disease,
896.

SoL of persulph. of iron in uterine
abscess, 411.

Solvents of leucorrhoeal secretions, 401.

Souchon, Mr. Edward, uterine dissec-
tions, 284.

Spae, Dr. — inversion, 127.

Spallanzaui — seminal injection, 875.

Spasm of sphincter vagine, 824.

Speculum examination, 28.

— * its invention and modus operandi,
11—20.

method of introducing it, 28.

and position for removal of

semen from cervical canal, 407.

Sperm, destitute of spermatozoa, 867.
Spermatozoa after epididymitis, 866.
dead, 885.

— duration of life in vaginal muont,
884.

' how do they enter the canal of the

cervix ? 372, 873, 374.
in cervix immediately after sezuAl

intercourse, 373.

— in cervix uteri after coition, 885.

— in the uterus, 372.

— in vaginal mucus, 385.

— killed by muco-pus, 396.

— killed by too acid mucus, 893,894.

— live in blood and pus, 893.

— living, 385.

— locomotion of, 371.

— necessary to procreation, 365.

— not essential to coition, 365.

— philosophy of their entrance into
the cervix, 373, 874.

— their movements, 361, 862, 363.

Sphincter vagime, spasm of, 824.
8{K>ngc, compressed, 47.

probangs, 70, 160.

probangs for retroversion, 268.

Sponge tent, a necessary evil, 57.

destroys a fibrous polypus, 63.

diagnosis of fibroids, 114.

INDEX.

433

Sponge tent, diagnosis of intra-uterine
fibroids, 107.

destroys mucous polypi, CI.

Sponge tents ,47, 99, 147.

before uterine injections, 400.

disgusting effects, 65.

bow to introduce thera, 49.

bow to make them, 48.

in bypertropby of tbe uterus, 64 .

in uterine disease, 67.

metro-peritonitis from, 68.

prolonged retention, 56.

the time for introducing them, 50.

tbeir dangers, 67.

their removal, 61, 52.

their action, 69.

Spontaneous evacuation of retained
menses producing death, 320.

inversion, 134.

Squibb*s(Dr.) Liq. ferri persulph., 129.

persulphate of iron, 68.

sol. persulph. of iron, 160.

Stem, intra-uterino, 163, 2/0.

Stem pesmnry, 404.

vaginal, 270.

Sterile condition influenced by mal-
position of uterus, 273.

Sterility, a case of, due to retroversion,
280.

acquired, 185, 103.

acquireil, fibroid tumours in, 95.

and painful menstruation, 140.

incident to uterine di.sease, 2.

in man, 364.

in the male from stricture, 368.

natural and acquired, 2.

nntur.ll, fibroid tumours in, 95.

Stevens, Dr. Alex. H., inversion,
126.

Stomatitis treated by iodide of silver,
396.

St(>no*R (Dr. Warren) case of prociden-
tia, 303.

Stricturo, cause of sterility in man, 364,
368.

Superior conMlrictor vntrina*. 378, 874.

SuppoHitorics, iotra-ccrvical, 403.

Suppositories, medicated, in vaginitis,
892.

Suppository formula for vaginitis, 393.

Supra- vaginal cervix in prooidentiB,298.

elongation of cervix in procidentia;

299.

Sutures, metallic, in procidentia, 803.

Swann, Mr., prepiirations of iron, 68.

solvents of leucorrhceal secre-
tions, 400.

Swine, trichinoB in, 380.

Symptoms of uterine abscess, 410.

T.

Tampon of glycerine, 70.

Tampons of tannin in procidentia, 319>

Tangle-tents, 65.

Tannin and glycerine in vaginitis
392.

Tannin suppositories, 401.

— suppositories in vaginitis, 392.

taste of. Boon after its application*

to the cervix uteri, 398.

Tardieu, M., conception without pene-
tration, 370.

Taste of tannin soon after its applica-
tion to the cervix, 398.

Taylor, Prof. Isaac E., sloughing of
the cervix, 195.

Tenaculum forceps, doublo, 22.').

Tents of sea-tangle. 65.

sjwnge, how to make them, 48.

Tepid vaj^inal injections, 398.

Testes, inflammation of, 365, 367.

malposition of, 364.

retiined, 364.

their office, 361.

Thierry-Mieg*8 (Dr.) case of endo-
metritis, 414.

case of procidentia, 298.

Thomas, Dr. T. G., 214.

on vaginismoH, 340.

Tilt. Dr., sponge tents, 147.

potassa cum calfo, 307.

Tim** for sexujil intercourse, 383.

of conception, 881.

2 F

I

4U

UTEKINE ftURfJERY.

Time for sezual congress, S86.

to in trod ace sponge tents, 50.

Tongue, cancer of, remoFed by the
<<craseur, 77.

Torsion for removing polypi, 75.

Tough hymen, 823.

Translated parotitis, 867.

Treatment of dysmenorrhoea, 144.

of fibroid tumours, 109.

of roenorrhagia, 42.

of procidentia with tannin tam-
pons, 319.

of vaginismus, 335, 392.

Trichime in swine, 380.

Tr. of iodine in uterine abscess, 411.

Tr. of iodine in endo-metritis, 415.

Trocar, 108.

Trousseau, case of dysmenorrhcea, 216.

Trowel- shaped scarification for proci-
dentia, 310.

Tube of lead, Dr. Coghlan's, 405.

Tubes, drainage, of peritoneal cavity,
209.

Tumonr, cancroid, of the cervix uteri,
206.

fibro cvstic, 108.

in tlio Douglas" cul-de-pac, 100.

intra-uterine, fihr /id, 10r».

ovarian, pregnancv mistaken for,

32.

I

Tumours, fibroid, 93. j

fibroid, and retroversion, 288. j

fibroid, complicatincj deliv(iry,l 16. '

fil>roid, dini]fnosifl, 98. I

fibroid, enucleation of, 109, 111, I

117. I

fibroid, in acquired sterility, 0/). I

fibroid, in natural sterility, 95.

fibroid, in virgins, 96.

fibroid, incision of the os and

cervix for, 121, 123.

— fibroid, intra- mural, 94.

— fibroid, intra-uterine, 94.

— fibroid, no impediment to child-
bearing, 290.

— fibroid, pedunculated, 94.

— fibroid, prevent conception, 94.

Tumours, fibroid, producing anteflexion,

104.

fibroid, producing procidentia, 295.

fibroid, producing retroversion,

283.

fibroid, sessile, 94.

fibroid, treatment, 109.

U.

ITxcLEANNESS and purification. Mosaic
law on, 381.

Undeveloped cervix, 216.

uterus, 216.

Ung. arg. nitr. in endo-metritis, 412.

Unruptured hymen, with conception,
370.

Unsuccessful operation for polypus, 87.

Urethral inflammation, produced by
acrid leucorrhcea, 392.

Use of vaginal syringe, 899.

Uterine abscess, its symptoms, 410.

bougie, 145, 146.

cavity, measured by the elastic

bougie, 106.

cavity, secretions from, 406.

colic, 124, 876. 400.

colic, .sometim<*8 produced by va-
ginal injections, 400.

depressor, 24.

dilator, 163.

disease, sponijo tents in. .')7.

disease, sterility incident to, 2.

displacement, 233, 260.

displacement, influence of upon

>terile condition, 273.
displacements influenced by utero-

pestation, 200.

displacements, their diagnosis, 23(5.

elevator, 265, 206.

elevator to diagnose small tumours.

267.

— examination, method, 6.

— exploration in endo metritis, 412.
- granulations, 124.

— guillotine, 224.

— hypertrophy in procidentia, 299.

INDEX.

435

Uterine injections of iodine in me-
norrhagia, 121, 122, 123.

injections, producing collapse, 400.

leucorrhoea, 409.

probe, 98, 102, 105, 257.

sound, 111, 163.

sound, a probe, 102.

sound as a redresser, 263.

sound, German silver, 103.

sound, modus operandi, 263,

sound, silver, 103.

surgery, 1. '

Utero-cervical canal, inflammation of,
415.

Utero-gestation, its influence upon mal-
positions of the uterus, 290.

Utero-sacral ligaments in anteversion,
240.

Uterus, abnormal position, 235.

anatomy, 181.

and vagina after sexual congress.

367.

and vagina before sexual inter-

conme, 357.

congenital absence of, 349.

dislocated, 262.

displacement of, 233.

hypertrophy of, sponge tents in,64.

influence of position on sterile

condition, 273.

— injecting semen into it, 375.

— inversion of, 124.

— normal position of, 234.
retrovertetl, 257.

seat of conception, 381.

spermatozoa in, 372.

— - undeveloped, 216, 239.
ITtility of pessaries, 281.
lHorrha3a, 198, 199, 200.

V.

Vagina and uterus in sexual congress,

357.
Vagina, atresia of, 34.'>.

- - dermoid appearance of in pro-
cidentia, 296.

ejecting the semen, 855.

Vagina, its varieties, 850.

long and narrow in anteTSrsion,

240.

narrowed for procidentia, 302.

non-retention of semen by, 850.

no two alike, 850.

size of in procidentia, 296.

2^ superior constrictor of, 373, 374.

too short, 351.

varies in size, 272.

Vaginal dilator in atresia vaginae, 347.
dilator for vaginismus, 336, 337,

388.

injections, not to be used cold,398.

injections, sometimes produce

uterine colic, 399.

mucus, life of spermatozoa in, 884.

mucus, spermatozoa in, 385.

mucus, test for acidity of, 394.

mucus, too acid, kills spermatozoa.

393.
secretions, tested by litmus-paper,

394.

stem pessary, 270.

suppositories for lencorrhcea, 401.

syringe, how to be used, 399.

syringe, 397.

touch, 9, 102.

tube should be straight, 399.

washes, 397.

Vaginismus, 323, 326.

complications, 339.

diagnosin, 327.

etherization in, 331, 840.

history of a case, 329.

method of examining, 327, 328.

operations for, 335, 34 1 .

treatment of, 335.

Vaginitis, 391.

caused by uterine abscess, 410.

its influence on spermatozoa, 8i^8.

secon<lary, 891 .

specific, 391.

treatment of, 392.

Vaginoscope, Dr. Routh's, 83.

Van Buren, Prof., caaa of vaginismus,

881.

436

UTERINE SURGERY.

Vanderpoel*!! (Dr.) case of dysmenor-
rhoEM^ 148.

Tarietiefi of atresia yaginsB, 347.

of polypi, 67.

VariouR conditions of the Tagina, 850.

Yelpean — case, 216.

inversion, 128.

Version, antero-Iateral, 236.

Versions become flexionSi 235.

Vesicnlic seminalcs, 861.

Vesico- vaginal fistula, a case of, 353.

Vien, Mr., 234.

Virginp, fibroid tumours in, 96.

V-shaped scarification for procidentia,
809.

Vulcanite vaginal dilator for vagi-
nismus, 837.

intra-uterine stem, 404.

W.

Wells, Mr. Spencer— hysterotomy,
173, 174.
^ operation for procidentia, 316. |

West, Dr. Charles, on inversion of

twelve months' duration, 128.

on uterine abscess, 409.

West's (I)r.) works, 41, 395.

White, Prof., 135,136,137.

inversion of fifteen years' duration,

128.

inversion of the uterus, 125.

Williams, Dr. — congenital inversion,

126.
Wire <^ra.seur of Dr. Braxton Hicks,

77, 79.

of Maisonneuve, 77, 79.

Woman's hospital, 30, 63, 64, 86, 92,

97, 109, no, 113, 128, 129, 185, 195,

200, 206, 214, 308, 345.
Woodson, Dr. — invendon, 127.
Wright, Dr. H. G., on silver solutions

396.

Z.

Zwang'8 pessary, 270, 318.

(!i\ ^M» W^MAN, rRIMKRS. GRRAT Q^F.K^ hTR Kl- I . I.I >(<OI.>'S-l % N- Fi Rl D-.

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